Improving Evidence-Based Care in Cystic Fibrosis Through Quality Improvement

Abstract

To increase clinician adherence to prescribing guidelines for pulmonary medications in children with cystic fibrosis (CF). Design: Quality improvement project with multiple time series design. Setting: The CF center at a tertiary care pediatric hospital in the United States. Patients: Children with CF who were eligible to receive oral azithromycin, nebulized dornase alfa, or inhaled tobramycin sulfate based on prescribing guidelines for CF lung disease. Intervention: Evidence-based prescribing guidelines were designed by a local committee to reflect consensus recommendations from the CF Foundation. Clinicians and families were educated about guidelines. Adherence to prescribing guidelines was tracked using a local CF database and record reviews. Weekly meetings were used to highlight adherence failures and promote clinician accountability. Main Outcome Measure: The rate of clinician adherence to prescribing guidelines. Results: One hundred seventy patients with CF were included. At the start of the project, the rate of clinician adherence to prescribing guidelines was 62%. After 3 months of the project, the rate of clinician adherence to prescribing guidelines was 87% (odds ratio=4.6; 95% confidence interval, 3.0-7.0). The improvements in adherence to prescribing guidelines were sustained for 21 months of follow-up. Conclusions: Educating clinicians about prescribing guidelines, sharing guidelines with families, and monitoring clinician adherence improve prescribing adherence to evidence-based recommendations.

Inhaled Tobramycin Effectively Reduces FEV1 Decline in Cystic Fibrosis. An Instrumental Variables Analysis

“…CF centers with larger numbers of eligible patients have more opportunities for individual providers to prescribe tobramycin, which may lead to more variation among physician practices. Physician information is undocumented in the CFFPR, but annual reporting has focused on center-specific outcomes with the assumption that physicians within a center collectively participate in quality improvement initiatives (8,37,38). Methodological advancements in instrumental variables approaches are needed to examine longer-term treatment effectiveness, time-varying exposures, and more flexible model fitting.…”

“…Inhaled tobramycin has been established as an efficacious, well-accepted therapy for treating chronic P. aeruginosa infection in CF through several randomized clinical efficacy trials and expert evidence review (5)(6)(7)(8). Chronic use of inhaled tobramycin received the highest grading in the CF Pulmonary Guidelines (5) and has been recommended by the Cystic Fibrosis Foundation (CFF) for patients 6 years of age and older with chronic P. aeruginosa infection.…”

The impact of transforming healthcare delivery on cystic fibrosis outcomes: a decade of quality improvement at Cincinnati Children’s Hospital

“…Adherence successes and failures were highlighted at weekly team meetings to promote clinician accountability. At the start of the project, the rate of clinician adherence to prescribing guidelines was 62%, which quickly improved to 87% after just 3 months 5. We continued to monitor prescribing guideline adherence for 21 months and found it to be sustained.…”

Constrictive Bronchiolitis in Cystic Fibrosis Adolescents with Refractory Pulmonary Decline

“…Mean total Brody score was 47.5 (range, 17-78), with a bronchiectasis subscore of 19.1 (range, 5-40) and a total hyperinflation subscore of 17.0 (range, [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. The mean hyperinflation score of the biopsied lobe was 3.0 (range, 2-4.5).…”

“…The Cystic Fibrosis Center at Cincinnati Children's Hospital Medical Center (CCHMC) has incorporated a comprehensive, multidisciplinary treatment algorithm for patients with persistent decline in lung function (18). This algorithm includes a focus on evidencebased care programs, enhanced medication adherence, screening for CF-related diabetes, bronchoalveolar lavage, and lung computed tomography (CT) imaging.…”