Developing a culture of safety is a core element of many efforts to improve patient safety and care quality. This systematic review identifies and assesses interventions used to promote safety culture or climate in acute care settings. The authors searched MEDLINE, CINAHL, PsycINFO, Cochrane, and EMBASE to identify relevant English-language studies published from January 2000 to October 2012. They selected studies that targeted health care workers practicing in inpatient settings and included data about change in patient safety culture or climate after a targeted intervention. Two raters independently screened 3679 abstracts (which yielded 33 eligible studies in 35 articles), extracted study data, and rated study quality and strength of evidence. Eight studies included executive walk rounds or interdisciplinary rounds; 8 evaluated multicomponent, unit-based interventions; and 20 included team training or communication initiatives. Twenty-nine studies reported some improvement in safety culture or patient outcomes, but measured outcomes were highly heterogeneous. Strength of evidence was low, and most studies were pre–post evaluations of low to moderate quality. Within these limits, evidence suggests that interventions can improve perceptions of safety culture and potentially reduce patient harm.

IntroductionPatient-centeredness is central to healthcare. Hospitals should address patients’ unique needs to improve safety and quality. Patient engagement in healthcare, which may help prevent adverse events, can be approached as an independent patient safety practice (PSP) or as part of a multifactorial PSP.ObjectivesThis review examines how interventions encouraging this engagement have been implemented in controlled trials.MethodsWe searched Medline, CINAHL, Embase and Cochrane from 2000 to 2012 for English language studies in hospital settings with prospective controlled designs, addressing the effectiveness or implementation of patient/family engagement in PSPs. We separately reviewed interventions implemented as part of selected broader PSPs by way of example: hand hygiene, ventilator-associated pneumonia, rapid response systems and care transitions.ResultsSix articles met the inclusion criteria for effectiveness with a primary focus on patient engagement. We identified 12 studies implementing patient engagement as an aspect of selected broader PSPs. A number of studies relied on patients’ possible function as a reporter of error to healthcare workers and patients as a source of reminders regarding safety behaviours, while others relied on direct activation of patients or families. Definitions of patient and family engagement were lacking, as well as evidence regarding the types of patients who might feel comfortable engaging with providers, and in what contexts.ConclusionsWhile patient engagement in safety is appealing, there is insufficient high-quality evidence informing real-world implementation. Further work should evaluate the effectiveness of interventions on patient and family engagement and clarify the added benefit of incorporating engagement in multifaceted approaches to improve patient safety endpoints. In addition, strategies to assess and overcome barriers to patients’ willingness to actively engage in their care should be investigated.

Patients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns.

2225) for general payments, respectively. Receipt of research payments was associated with increased prescribing for mRCC but not CML. Similarly, when treating payments as a continuous variable, increasing amounts of general payments were associated with increased prescribing. Considering individual drugs, we found increased prescribing when receiving vs not receiving general payments for sunitinib (50.5% vs 34.4%, P = .01), dasatinib (13.8% vs 11.4%, P = .02), and nilotinib (15.4% vs 12.5%, P = .01) (Figure) but found decreased prescribing of imatinib (72.4% vs 75.5%, P = .02). Differences for sorafenib and pazopanib were not statistically significant. Research payments were not associated with statistically significant differences in prescribing for any individual drug. Results were similar when including payments specifically attributed to the drug of interest rather than all payments from the corresponding manufacturer and when changing the exposure to receipt of payments in both 2013 and 2014 (vs 2013 without respect to 2014). Our study had some limitations. These include the observational design precluding causal assessment, potential inaccuracies with Open Payments data, 5 lack of generalizability to other cancers, absence of information about the indications for the drugs, and small sample sizes for comparisons in the research payments analysis, notably for physicians receiving CML research payments. Conclusions | For 3 of the 6 cancer drugs studied, physicians who received general payments were more likely to prescribe the drug marketed by the company that made the payments. Imatinib was a notable exception; this may reflect a strategy by the manufacturer of imatinib (which also produces nilotinib) to promote switching to nilotinib before the patent expiration of imatinib in 2015.

Communication in the care of patients with advanced and serious illness can be improved using quality improvement interventions, particularly for healthcare utilization as an outcome. Interventions may be more effective using a consultative approach.

knee. The knee arthroplasty rate increased, but most of the increase preceded the decline in arthroscopy rates.Between 1999 and 2014, the prevalence of osteoarthritis in the US adult population more than doubled from 6.6% to 14.3%. 6 Trends in per capita knee surgical procedures, which are not adjusted for the increase in the prevalence of osteoarthritis, likely understate the degree to which use of arthroscopic surgery as a treatment for knee pain has declined.Some private insurers have started to require physicians to obtain authorization before an arthroscopic knee procedure. The fee-for-service Medicare program does not require prior authorization. Private insurers covered 72% of knee arthroscopies in patients younger than 65 years, and Medicare covered 83% of these procedures in patients aged 65 years or older. I could not observe the impact of prior authorization requirements directly, but trends in arthroscopy rates in these age groups were similar, indicating that the requirements may not be a major factor behind the decline in rates.The results suggest that the accumulating evidence on the lack of benefit associated with knee arthroscopy, compared with medical management, has altered treatment decisions. Despite the lower use rates, knee arthroscopy is still a common procedure. There may be additional opportunities to reduce the use of knee arthroscopy without adversely affecting patient outcomes.

Background-While studies suggest most women have little regret regarding their breast cancer treatment decisions immediately following treatment, to date no studies have evaluated how regret may change over time.

BACKGROUND AND OBJECTIVES: Respiratory tract infections (RTIs) are a common reason for direct-to-consumer (DTC) telemedicine consultation. Antibiotic prescribing during video-only DTC telemedicine encounters was explored for pediatric RTIs. METHODS: Encounter data were obtained from a nationwide DTC telemedicine platform. Mixed-effects regression was used to assess variation in antibiotic receipt by patient and physician factors as well as the association between antibiotic receipt and visit length or patient satisfaction. RESULTS: Of 12 842 RTI encounters with 560 physicians, antibiotics were prescribed in 55%. The provider was more likely to receive a 5-star rating from the parent when an antibiotic was prescribed (93.4% vs 80.8%). A 5-star rating was associated with a prescription for an antibiotic (odds ratio [OR] 3.38; 95% confidence interval [CI] 2.84 to 4.02), an antiviral (OR 2.56; 95% CI 1.81 to 3.64), or a nonantibiotic (OR 1.93; 95% CI 1.58 to 2.36). Visit length was associated with higher odds of a 5-star rating only when no antibiotic was prescribed (OR 1.03 per 6 seconds; 95% CI 1.01 to 1.06). Compared with nonpediatricians, pediatric providers were less likely to prescribe antibiotics (OR 0.44; 95% CI 0.29 to 0.68); however, pediatricians received higher encounter satisfaction ratings (OR 1.50; 95% CI 1.11 to 2.03). CONCLUSIONS: During DTC telemedicine consultations for RTIs, pediatric patients were frequently prescribed antibiotics, which correlated with visit satisfaction. Although pediatricians prescribed antibiotics at a lower rate than other physicians, their satisfaction scores were higher. Further work is required to ensure that antibiotic use during DTC telemedicine encounters is guideline concordant.