OBJECTIVE -Hypertension increases micro-and macrovascular complications of diabetes. The goal for blood pressure is Ͻ130/80 mmHg. In primary care, however, blood pressure in many patients exceeds this goal. In this study, we evaluated the clinical decision-making process when a patient with diabetes presents with elevated blood pressure.RESEARCH DESIGN AND METHODS -Twenty-six primary care practices in two practice-based research networks in Colorado participated. Questionnaires were completed after each encounter with an adult with type 2 diabetes. Data obtained from the survey included 1) demographic information, 2) blood pressure results, 3) action taken, 4) type of action if action was taken, and 5) reasons for inaction if action was not taken. Bivariate and multivariate analyses were performed to identify predictors of action.RESULTS -Completed surveys totaled 778. Blood pressure was 130/74 Ϯ 18.8/12.0 mmHg (mean Ϯ SD). Sixty-two percent of patients exceeded goals. Action was taken to lower blood pressure in 34.9% of those. Predictors of action were 1) blood pressure level, 2) total number of medicines the patient was taking, and 3) patient already taking medicines for blood pressure. As blood pressure rose, providers attributed inaction more often to "competing demands" and reasons other than "blood pressure being at or near goal." CONCLUSIONS -No evidence was found for patterns of poor care among primary care physicians. Providers balance the clinical circumstances, including how elevated the blood pressure is, and issues of polypharmacy, medication side effects, and costs when determining the best course of action. Knowledge deficit is not a common cause of inaction. Diabetes Care 29:2580 -2585, 2006T here is extensive clinical evidence linking hypertension with microand macrovascular complications of diabetes, including randomized controlled trials and a meta-analysis (1-6). Until 2000, the target blood pressure for individuals with diabetes was the same as that for individuals without diabetes (Ͻ140/90 mmHg). However, because of the demonstrated clinical benefit of lower blood pressure specifically for diabetes, national guidelines, established by the American Diabetes Association and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), call for more intensive management, with a target of Ͻ130/80 mmHg (7,8).Of the care provided to patients with type 2 diabetes, ϳ90% takes place in primary care practices (9). Unfortunately, blood pressure control in these settings is frequently suboptimal (10 -12) and may be even worse in those with diabetes and hypertension compared with those with hypertension alone (13).An essential component of lowering blood pressures to goal is the clinical decision made by the primary care provider at the visit in which blood pressure is elevated. Multiple factors may influence this decision. For example, it has been found that optimal blood pressure control often requires three or more medications (8), leading to increas...
Objective: The aim of this study was to learn about community members' definitions and types of harm from medical mistakes.Methods: Mixed methods study using community-based participatory research (
PURPOSE Observational studies that collect patient-level survey data at the pointof-care are often called card studies. Card studies have been used to describe clinical problems, management, and outcomes in primary care for more than 30 years. In this article we describe 2 types of card studies and the methods for conducting them. METHODSWe undertook a descriptive review of card studies conducted in 3 Colorado practice-based research networks and several other networks throughout the United States. We summarized experiences of the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP). RESULTSCard studies can be designed to study specifi c conditions or care (clinicians complete a card when they encounter patients who meet inclusion criteria) and to determine trends and prevalence of conditions (clinicians complete a card on all patients seen during a period). Data can be collected from clinicians and patients and can be linked.CONCLUSIONS Card studies provide cross-sectional descriptive data about clinical care, knowledge and behavior, perception of care, and prevalence of conditions. Card studies remain a robust method for describing primary care. INTRODUCTIONO bservational and survey research continues to be an important source of information about primary care. Among the numerous methods available for gathering data about clinicians, patients, and their care, one method has persisted for more than 30 years and is considered by some to be the hallmark of practice-based research: the card study. A card study is a fi eld-tested method for gathering data in the location where patients receive care by those who provide the care.The card study method is designed to gather data at the point of care about such observable phenomena as disease incidence/prevalence, practice patterns, or clinical behaviors. Pioneered in the United States by the Ambulatory Sentinel Practice Network (ASPN) 30 years ago, card studies use short questionnaires that participating clinicians complete for patients with a specifi c condition. 1 The name card study derives from a weekly return card introduced by the Sentinel Stations in the Netherlands and later modifi ed by ASPN. The pocketsized card, which was designed to take fewer than 60 seconds to complete, allowed clinicians to carry it from room to room as they saw eligible patients. Although a card study is essentially a survey, it is designed to be completed as patients are seen by those who provide the care. Card studies have undergone signifi cant development by numerous researchers during the past 30 years and represent a wide array of data collection tools and methods. C A R D S T UDIES F OR OBSERVAT IONA L R ESE A RCHand otitis media. [7][8][9][10][11][12] For example, the publication of ASPN's card study on spontaneous abortion contributed to the evidence that uncomplicated spontaneous abortion could be managed safely without surgery. Using data from this study, Green et al found that card studies are as accurate as medical record review for identifying p...
Findings suggest that health care personnel perceive they are effective at providing palliative care in their rural health care facilities, yet face barriers to providing optimal end-of-life care. Results of this study suggest that differences in training and experience may influence health care personnel's perceptions of the existing barriers. It may be important in rural areas to customize interventions to both the professional role and the site of care.
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