Quality improvement (QI) plays a vital role in practice management, patient care, and reimbursement. The authors implemented a 3-year longitudinal curriculum that combined QI didactics, intervention development, and implementation at university-based, community-based, and Veterans Administration–based practices. Highlights included Plan-Do-Study-Act cycle format, team-based collaboration to brainstorm interventions, interdisciplinary QI council to select and plan interventions, system-wide intervention implementation across entire clinic populations with outcome monitoring, and intervention modifications based on challenges. A pre–post survey assessed residents’ confidence in QI skills and interdisciplinary team participation, while quarterly quality data assessed patient outcomes. All 150 internal medicine residents participated. Confidence in QI and interdisciplinary team participation improved significantly ( P < .001). Patient outcomes improved for 6 of 9 targeted projects and were sustained at 1 year. This curriculum is a systems-based innovation designed to improve patient care and encourage interdisciplinary teamwork and can be adopted by residencies seeking to improve engagement in QI.
A woman in her 50s with idiopathic dilated cardiomyopathy (ejection fraction, 15%-20%), quiescent celiac disease, chronic diarrhea due to active lymphocytic colitis, and treated hypothyroidism presented with malaise and anorexia of several weeks' duration.She did not have abdominal pain, nausea, vomiting, weight loss, or fever. Given her age and nonspecific symptoms, the clinician was concerned for possible cancer. As part of her initial workup, levels of carbohydrate antigen 19-9, carcinoembryonic antigen, and cancer antigen (CA)-125 were measured. The CA-125 level was elevated, at 210 U/mL (normal, Յ35 U/mL). The patient was referred to a gynecologist owing to concern for ovarian cancer. Pelvic ultrasonography and abdominal computed tomography did not reveal evidence of ovarian cancer.Several months later, the CA-125 level remained elevated, at 188 U/mL. A consulting oncologist believed that given the downtrending CA-125 level, a nonmalignant cause of the symptoms was more likely. Three months later, a third measurement found the CA-125 level to be 66 U/mL, thus negating the need for further testing. The patient's malaise and anorexia were subsequently attributed to her worsening heart failure. The elevated CA-125 level was thought to be secondary to gut edema from heart failure and inflammation from lymphocytic colitis. The use of CA-125 measurement in this clinical setting led to a delay in diagnosing worsening heart failure and to patient harm through radiation exposure and anxiety about a potential cancer diagnosis.
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