Objective. Despite the significant health impact of gout, there is no consensus on management standards. To guide physician practice, we sought to develop quality of care indicators for gout management.Methods. A systematic literature review of gout therapy was performed using the Medline database. Two abstractors independently reviewed each of the articles for relevance and satisfaction of minimal inclusion criteria. Based on the review of the literature, 11 preliminary quality indicators were developed and then reviewed and refined by an initial feasibility panel of community and academic rheumatologists. A twelfth indicator was added at the request of the first panel. Using a modification of the RAND/University of California at Los Angeles appropriateness method (bridging teleconference and white-board Internet technology were added), a second expert panel rated each of the proposed indicators for validity using a 9-point scale, in which ratings of 1-3, 4-6, and 7-9 were considered "invalid," "indeterminate," and "highly valid," respectively. Indicators were considered valid if the median panel rating was >7 and there was no evidence of panel disagreement (defined to occur when 2 of 6 panelists provided a validity rating of 1-3 and 2 panelists provided a validity rating of 7-9).Results. Ten of the 12 draft indicators were rated to be valid by our second expert panel. Validated indicators pertained to 1) the use of urate-lowering medications in chronic gout, 2) the use of antiinflammatory drugs, and 3) counseling on lifestyle modifications.Conclusion. Using a combination of evidence and expert opinion, 10 indicators for quality of gout care were developed. These indicators represent an important initial step in quality improvement initiatives for gout care.Preliminary evidence suggests that medical errors in the treatment of gout are common. An older age at onset of gout and the presence of serious comorbid conditions render patients vulnerable to medicationrelated errors and substandard quality of care. Indomethacin, a nonsteroidal antiinflammatory drug (NSAID) routinely used in gout treatment, is among the most commonly prescribed inappropriate medications among the elderly (1). In a prospective investigation involving a large cohort of elderly patients who presented to an emergency room (1), gout was among the treatment indications most commonly associated with selection of inappropriate medications. Such medication-related errors have been reported as a complication in more than one-fourth of all orders for intravenous colchicine administered to inpatients (2) and approximately one-half of orders for administration of allopurinol (3), both of which are drugs that are commonly used in the treatment of gout.Although gout has a substantial health impact and although its treatment appears to be characterized by preventable medical errors, quality of care in gout has not been well studied. A barrier to such research has been a lack of consensus regarding the standards of care in gout therapy. To address this is...
Objective. To examine the effects of physician specialty and comorbidities on cyclooxygenase 2-selective nonsteroidal antiinflammatory drugs (NSAIDs; coxibs) utilization. Methods. Medical records of 452 patients from a regional managed care organization with >3 consecutive NSAID prescriptions from June 1998 to April 2001 were abstracted. Multivariable adjusted associations between coxib initiation and discontinuation and patient and provider characteristics were examined. Results. A total of 1,142 NSAID prescriptions were written over 9,398 total patient-months of followup. Compared with patients seeing family or general practitioners, patients seeing rheumatologists (odds ratio [OR] 3.4, 95% confidence interval [95% CI] 2.1-5.7) and internists (OR 2.3, 95% CI 1.5-3.6) were significantly more likely to receive a coxib, as well as patients with a history of osteoarthritis (OR 2.6, 95% CI 1.7-3.8), gastrointestinal disease (OR 2.3, 95% CI 1.2-4.5), and congestive heart failure (OR 4.1, 95% CI 1.0 -16.4). Although specialists were more likely than generalists to prescribe coxibs, only family or general practitioners were significantly more likely to selectively use coxibs among their patients with a history of gastrointestinal disease. Fifty-four percent of NSAID prescriptions were discontinued, and coxibs were significantly less likely to be discontinued than were traditional NSAIDs (OR 0.6, 95% CI 0.5-0.8). Conclusion. Our findings suggest significantly greater, but perhaps less selective use of coxibs among specialists, even after accounting for important covariates. The initiation and discontinuation of coxibs was influenced by physician specialty and by patient risk factors.
Background: Despite dramatic increase in Internet-based CME activities, little is known about physician Internet CME preferences. Aims: To identify the education format and resource preferences among registrants of a pediatric-focused CME website. Methods: Preferences of physician registrants at PedsEducation.org between July 2000-November 2007 (n ¼ 1388) were assessed via survey. A secondary analysis of respondent demographics vs. reported preferences was conducted. Results: A total of 345 physicians participated (25% response rate). The majority (73%, n ¼ 252) identified free CME as a highly important feature of an Internet CME resource; monthly case series was identified as the least important. Seventy-five percent of respondents (n ¼ 260) identified practice guideline updates as a highly useful practice resource; practice feedback was identified as the least useful. Respondents with 10 years practice experience were more likely to identify case-based CME as highly useful to their daily practice (p50.001); respondents who spend 90% working time on patient care were more likely to identify Internet CME as a highly useful CME format (p50.001). Conclusion: Internet CME preferences of PedsEducation.org registrants differ from those typically associated with knowledge gains and behavior changes. Demographic characteristics may influence these preferences.
For adult learners, educational experiences should be targeted to the learners' perceived needs but should also address unrecognized deficits. Collectively, physicians, nurses, and respiratory therapists were most interested in participating in simulations addressing "codes" (emergency resuscitations) and airway management; these perceptions may provide a focus for designing simulation events that appeal to diverse learning styles. Prior experience with medical simulation seems to increase interest in subsequent simulation activities and offers the optimistic possibility that first-hand experience with simulation may help overcome structural and cultural barriers. Future research should seek to better understand potential obstacles for the participation of healthcare providers, especially physicians, in simulation-enhanced learning.
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