Clinical inertia: a common barrier to changing provider prescribing behavior
ABSTRACT A cross-sectional content analysis nested within a randomized, controlled trial was conducted to collect information on provider responses to computer alerts regarding guideline recommendations for patients with suboptimal hypertension care.
Participants were providers who cared for 1,017 patients with uncontrolled hypertension on a single antihypertensive agent within Veterans Affairs primary care clinics. All reasons for action or inaction were sorted into a framework to explain the variation in guideline adaptation.
The 184 negative provider responses to computer alerts contained explanations for not changing patient treatment; 76 responses to the alerts were positive, that is, the provider was going to make a change in antihypertensive regimen. The negative responses were categorized as: inertia of practice (66%), lack of agreement with specific guidelines (5%), patient-based factors (17%), environmental factors (10%), and lack of knowledge (2%). Most of the 135 providers classified as inertia of practice indicated, "Continue current medications and I will discuss at the next visit." The median number of days until the next visit was 45 days (interquartile range, 29 to 78 days).
Clinical inertia was the primary reason for failing to engage in otherwise indicated treatment change in a subgroup of patients. A framework was provided as a taxonomy for classification of provider barriers.
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ABSTRACT: This dissertation focuses on quality assessment of cardiometabolic treatment in patients with type 2 diabetes in general practice. First, methods are developed for collecting data related to diabetes care from electronic medical records. Important elements include a uniform procedure for patient selection and the extraction of relevant data from records without burdening practices with extra registration requirements. These methods were successfully implemented in the Groningen Initiative to Analyse Type 2 diabetes Treatment (GIANTT) project to build a longitudinal observational database for monitoring diabetes care. The second part concerns quality indicators for diabetes management. A comparison is made between commonly used cross-sectional indicators and newly developed “sequential” indicators which shows the value of these new indicators. A systematic review on prescribing indicators is presented, describing different types of existing indicators and their validity. Furthermore, an overview of the quality of cardiometabolic risk factor management is given, showing contrasting results for the various indicators. The third part focuses on factors mentioned as reasons not to modify cardiometabolic treatment when indicated. Some of these, e.g. using higher thresholds than recommended, waiting for the next risk factor measurement, competing demands, and medication non-adherence were found to be related to treatment decisions for hypertension and hyperglycaemia. Polypharmacy, however, was not a factor of influence. This dissertation provides new methods of obtaining information from medical records for quality assessment and scientific research. Furthermore, the usefulness of sequential indicators for quality assessment is shown. Finally, the studies on determinants of treatment modifications show targets for interventions.
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ABSTRACT: The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care. To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus. Retrospective cohort study Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice. Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care. Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7-5.7), urine microalbumin (OR 3.3, 95% CI 2.1-5.5), blood pressure (OR 1.8, 95% CI 1.1-2.8), retinal examination (OR 1.9, 95% CI 1.3-2.7), foot monofilament examination (OR 4.2, 95% CI 3.0-6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0-9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02-3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1-4.5) compared to controls. A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved processes of care and some clinical outcomes for diabetic patients. This study provides a model for further hypothesis generation and more rigorous testing of the quality benefits of structured chronic illness care in diverse outpatient practices.Journal of General Internal Medicine 09/2008; 23(11):1749-56. DOI:10.1007/s11606-008-0751-5 · 3.42 Impact Factor
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ABSTRACT: The efficacy and safety of an olmesartan medoxomil (OM)-based treatment algorithm was tested in a double-blind, randomized, placebo-controlled titration study in 276 patients with stage 1 or 2 hypertension. After placebo run-in, patients were randomized to placebo (12 weeks) or OM 20 mg/d (weeks 1-3). OM was up-titrated to 40 mg/d (weeks 4-6), then OM/hydrochlorothiazide (HCTZ) 40/12.5 mg/d (weeks 7-9) and OM/HCTZ 40/25 mg/d (weeks 10-12) were started if blood pressure (BP) remained > or =120/80 mm Hg at each time interval. End points were change from baseline in mean systolic BP (primary) and mean diastolic BP (secondary). OM-based treatment was well tolerated and changed BP by -22.3/-12.1 mm Hg from baseline vs -0.1/+0.8 mm Hg for placebo (P<.0001). Cumulative goal BP (<140/90 mm Hg) was achieved in 74.1% and 30.7% of OM- compared with placebo-treated patients, respectively (P<.0001). BP normalized (<120/80 mm Hg) in 44.8% of OM- vs 1.4% of placebo-treated patients with stage 1 hypertension (P<.0001).Journal of Clinical Hypertension 12/2008; 10(12):911-21. DOI:10.1111/j.1751-7176.2008.00045.x · 2.96 Impact Factor