and physicians: how to get them together
Salemi C, Canola MT, Eck EK. Infect Control Hosp Epidemiol
To determine the motivating and behavioral factors responsible for improving
compliance with hand washing among physicians.
Five unobtrusive, observational studies recording hand washing after
direct patient contact, with study results reported to physicians.
A 450-bed hospital in a health maintenance organization with an 18-bed
medical-surgical intensive care unit (ICU) and a 12-bed cardiac care
An infectious disease physician met individually with participants to
report study results and obtain a commitment to hand washing guidelines.
Follow-up interviews were conducted to evaluate behavioral factors and
educational programs. Hand washing study results were presented to all
staff physicians by live and videotaped inservice presentations and
electronic mail (e-mail) newsletters. The importance of influencing
factors and the educational effectiveness of the hand washing program
Five observational hand washing studies were conducted in the ICU between
April 1999 and September 2000. Rates of physician compliance with hand
washing were 19%, 85%, 76%, 74%, and 68%, respectively. There were 71
initial encounters and 55 follow-up interviews with the same physicians.
Physician interviews revealed that 73% remembered the initial encounter,
70% remembered the hand washing inservice presentations, and 18% remembered
the e-mail newsletters. Personal commitment and meeting with an infectious
disease physician had the most influence on hand washing behavior. Direct
inservice presentations (either live or videotaped) had more influence
than did e-mail information. Rates of ventilator-associated pneumonia
did not significantly change before and during the study periods. A
decrease in the rate of central-line-related bloodstream infections
from 3.2 to 1.4 per 1000 central-line days was found, but could not
be solely attributed to improved physician compliance with hand washing.
Physician compliance with hand washing can improve. Personal encounters,
direct meetings with an infectious disease physician, and videotaped
presentations had the greatest impact on physician compliance with hand
washing at our medical center, compared with newsletters sent via e-mail.
Local data on compliance with hand washing and physician involvement
are factors to be considered for physician hand washing compliance programs
in other medical centers.
implication: On the basis of information in this article, the
National Kaiser Permanente (KP) Hand Hygiene Program has been instituted.
All KP Medical Centers are required to have a hand hygiene program
with continuous education, assessment of hand washing compliance,
and feedback to the physicians and health care workers. We show
in our study that strong motivating factors to improve physician
hand washing require local compliance data and a personalized approach.
From the Northwest:
of asthma control with health care utilization: a prospective evaluation
Vollmer WM, Markson LE, O'Connor E, Frazier EA, Berger M, Buist AS.
Am J Respir Crit Care Med 2002 Jan 15;165(2):195-9
disease management should be enhanced by good risk assessment models
and instruments. We prospectively evaluated the ability of a simple
measure of short-term asthma control (scored 0 to 4) to predict asthma
12-month health care utilization (HCU). A total of 5172 adult asthma
patients completed a brief questionnaire in fall 1997 to assess current
level of asthma control. We then evaluated HCU for calendar year 1998.
Ninety-three percent had health plan eligibility in 1998 and were included
in this analysis. Both acute and routine asthma utilization increased
with increasing numbers of asthma control problems. Rates of acute care
episodes were 3.5 (95% confidence interval [CI] = 2.9, 4.3) times more
likely for those with three to four control problems versus those with
no control problems. Lesser, but statistically significant, increases
were seen for those with two (relative risk [RR] = 1.7, 95% CI = 1.4,
2.2) or one (RR = 1.4, 95% CI = 1.1, 1.8) control problem. These patterns
were similar for men and women, and diminished with increasing age.
The asthma control index contributed significantly to prospective prediction
models even after adjusting for administrative data such as medication
use and prior HCU. These data reinforce the usefulness of measures of
short-term asthma control both for the individual clinician and for
those interested in population-based asthma management.
Journal of the American Thoracic Society. (c)American Thoracic Society.
implication: The article shows that the Asthma Therapy Assessment
Questionnaire (ATAQ) index of asthma control, which can be readily
administered and scored in the clinic setting, can be used to identify
asthma patients who are at increased risk for future hospital-based
care due to acute exacerbation of their disease. We believe this
simple index can be a useful clinical vital sign for patients with
asthma and that those scoring three to four on the index should
be evaluated closely concerning their medication regimen, inhaler
use technique, possible adherence problems, and allergen avoidance.
From the Northwest:
pylori eradication in dyspeptic primary care patients: a randomized
controlled trial of a pharmacy intervention
VJ, Shneidman RJ, Johnson RE, Boles M, Steele PE, Lee NL. West J Med
To determine the effectiveness of structured adherence counseling
by pharmacists on the eradication of Helicobacter pylori when
using a standard drug treatment regimen.
Randomized controlled clinical trial.
Nonprofit group-practice health maintenance organization (HMO).
participants: HMO primary care providers referred 1393 adult dyspeptic
patients for carbon 14 urea breath testing (UBT).
interventions: Those whose tests were positive for H pylori
(23.3%) were provided a standard antibiotic regimen and randomly assigned
to receive either usual-care counseling from a pharmacist or a longer
adherence counseling session and a follow-up phone call from the pharmacist
during drug treatment. All subjects were given the same seven-day course
of omeprazole, bismuth subsalicylate, metronidazole, and tetracycline
hydrochloride (OBMT). Dyspepsia symptoms were recorded at baseline and
outcomes: The main outcome was eradication of H pylori as
measured by UBT at three-month follow-up. Secondary outcomes were patient
satisfaction and dyspepsia symptoms at three-month follow-up.
results: Of the 333 participants randomly assigned to treatment,
90.7% completed the three-month follow-up UBT and questionnaires. Overall
eradication rate with the OBMT regimen was 80.5% with no significant
difference in eradication rates between the two groups (p = 0.98).
conclusions: In this study, additional counseling by pharmacists
did not affect self-reported adherence to the treatment regimen, eradication
rates, or dyspepsia symptoms but did increase patient satisfaction.
with permission from the BMJ Publishing Group.
implication: We found that Helicobacter pylori was not
as prevalent in this sample of dyspeptic patients as recent studies
would suggest. A good eradication rate was achieved with the use
of pharmaceutical treatment (OBMT). Special added counseling by
pharmacists did not affect medication adherence or eradication rates
in this sample, but additional counseling did increase patient satisfaction
with treatment. H pylori eradication did not affect symptoms
of dyspepsia. --VS
From the Northwest:
of intrathoracic sarcoidosis in referral vs population-based settings:
influence of stage, ethnicity, and corticosteroid therapy
Reich JM. Chest 2002 Jan;121(1):32-9
objectives: To compare the sarcoidosis mortality in referral settings
(RS) and population-based settings (PS), and to identify the contribution
of stage, ethnicity, and corticosteroid therapy (CST) to their disparate
All observational studies identified in a MEDLINE search and bibliographic
review published in the English language since 1960 dealing with the
course and prognosis of sarcoidosis in large, unsorted, adult, ambulatory
RS and PS providing long-term follow-up were reviewed and subjected
and results: Sarcoidosis mortality in RS (4.8%), in which 17% of
patients had the most unfavorable prognosis as judged by stage (stage
III), was ten-fold that reported in PS (0.5%), in which 11% of patients
were identified at this stage. The magnitude of this disparity could
not be accounted for solely by adverse selection, as indicated by stage
or by ethnicity. Patients in RS received CST with sevenfold the frequency
of PS, and its provision was highly correlated with stage-normalized
The prognosis of patients with intrathoracic sarcoidosis in PS is far
more favorable than that obtained in RS. Sarcoidosis mortality is largely
independent of ethnicity. The possibility cannot be excluded that excessive
employment of CST may unfavorably influence the long-term course of
the disease in some individuals.
From the Northwest:
assessment of usefulness and appropriate presentation mode of alerts
and reminders in the outpatient setting
MA, Sittig DF. Proc AMIA Symp 2001:334-8
is very little known about the limits of alerting in the setting of
the outpatient Electronic Medical Record (EMR). We are interested in
how users value and prefer such alerts. One hundred Kaiser Permanente
primary care clinicians were sent a four-page questionnaire. It contained
questions related to the usability and usefulness of different approaches
to presenting reminder and alert information. The survey also contained
questions about the desirability of six categories of alerts. Forty-three
of 100 questionnaires were returned. Users generally preferred an active,
more intrusive interaction model for "alerts" and a passive,
less intrusive model for order messages and other types of reminders
and notifications. Drug related alerts were more highly rated than health
maintenance or disease state reminders. Users indicated that more alerts
would make the system "more useful" but "less easy to
with permission from the American Medical Informatics Association.
implication: Mature Electronic Medical Records (EMR) deliver,
in part, on their promise of decreasing medical errors and increasing
the quality and cost-effectiveness of care via electronic alerts
and reminders. Primary care clinicians indicate that alerts are
not all "created equal." Specific characteristics contribute
to user acceptance, and users have preferences for alert style and
topic. EMR developers and implementers should seek to understand
and encompass these important usability and usefulness lessons.
of clinical outcome studies among cholesterol-lowering agents
Lousberg TR, Denham AM, Rasmussen JR. Ann Pharmacother 2001 Dec;35(12):1599-1607
To review and compare clinical
trials of cholesterol-lowering agents that evaluated clinical end points
as the primary outcome
measure; specifically, to determine whether all agents that decrease
cholesterol impact clinical outcomes similarly.
sources: Primary articles were identified through a MEDLINE search
(1966-February 2001) and through secondary sources.
study selection and data extraction: All of the articles identified
from the data sources were evaluated. Articles that included clinical
end points as the primary outcome measure were included in this review.
data synthesis: Clinical trials were assessed according to study
population (primary vs secondary prevention of coronary artery disease),
baseline and follow-up lipid profiles, and clinical outcome data. Both
cardiac and noncardiac morbidity and mortality were evaluated. The differences
in study populations, study methods, and changes in lipid values were
compared and contrasted between trials to evaluate their effect on outcomes.
conclusions: Niacin and bile acid sequestrants should be considered
as add-on therapy when therapeutic goals cannot be attained with a hydroxymethyl
glutaryl-coenzyme A reductase inhibitor (statin). Estrogen therapy cannot
be recommended solely for cardioprotection. Fibrates are most effective
in patients with high baseline triglycerides, low baseline high-density
lipoprotein cholesterol, and low to average low-density lipoprotein
cholesterol (LDL). Statins are considered first line for the treatment
of elevated LDL in both the primary and secondary prevention of coronary
heart disease. They are well tolerated, have the strongest data to support
their use, and have been shown to decrease total mortality.
From the Northwest:
hearing impairment on use of health services among the elderly
Green CA, Pope CR. J Aging Health 2001 Aug;13(3):315-28
To assess the effects of hearing impairment on health-service use in
an elderly population, controlling for factors associated with hearing
difficulties known to affect utilization.
Diagnoses of hearing impairment, depression, and chronic illnesses were
used in hierarchical regression procedures to pre
dict the volume and probability of any service use among 1436 randomly
selected 65-year-old health maintenance organization members.
Hearing impairment substantially increased the likelihood of making
at least one visit to a health care provider (OR = 3.31, 95%; CI = 1.55-7.06).
Among those who made such visits, however, hearing impairment did not
lead to use of additional services despite expectations to the contrary.
Further research should explore whether underutilization of services
exists, and, if so, whether it stems from clinician or patient attitudes
about the seriousness of hearing impairment, from a paucity of available
treatment strategies, or from some combination of these and other factors.
2001 by Sage Publications, Inc. Reprinted by Permission of Sage Publications,
implication: Our results suggest that elderly individuals who
report hearing impairment to clinicians may not receive needed follow-up
treatment. The negative functional consequences and potential harmful
sequelae of such impairment (eg, depression) suggest that clinicians
should pay particular attention to addressing, and following, hearing
among diabetics in a group model Health Maintenance Organization (HMO)
Fong DS, Sharza M, Chen W, Paschal JF, Ariyasu RG, Lee PP. Am J Ophthalmol
To report the management of diabetic retinopathy in one group model
health maintenance organization and assess the quality of care.
methods: Cross-sectional study. A chart review of 1200 randomly
identified patients with diabetes mellitus, continuously enrolled for
three years in Kaiser Permanente (KP) Southern California, the largest
provider of managed care in Southern California, was performed. A total
of 1047 patients were included in the analyses. Patient characteristics
as well as information from the last eye examination were abstracted.
Charts from patients with visual acuity less than 20/200 in their better
eye (legal blindness) were
selected for extensive chart review to determine the cause of visual
loss and the antecedent process of care. T tests or the Wilcoxon rank
sum test was used to compare continuous variables. The chi(2) test or
the Fisher exact test was used to compare categorical variables. All
analyses were performed on the Statistical Analyses System (SAS Institute,
results: Our study population of 1047 diabetic patients was 51.7%
male, had a mean age of 60.4 years, a mean duration of diabetes of 9.6
years, and a mean hemoglobin A1c of 8.3%. During the study period, 77.5%
of patients received a screening eye examination with examination by
an ophthalmologist, an optometrist, or review of a retinal photograph.
Of those with a visual acuity assessment (n = 687, 65.6% of 1047), 1.5%
had visual acuity of 20/200 or worse (legally blind) in the better eye,
while 8.2% had this level of visual acuity in the worse eye. Of eyes
with new onset clinically significant macular edema and visual acuity
< 20/40, 40% had documentation of focal laser performed within one
month of diagnosis. Of eyes with vitreous hemorrhage and visual acuity
< 20/40, 50% had documentation of vitrectomy. Among eyes that had
vitrectomy, over 80% had this procedure within one year of diagnosis
of vitreous hemorrhage.
The current report is the largest study of diabetic retinopathy outcomes
among patients enrolled in a prepaid health plan. Further research is
necessary to investigate the impact of managed care on health outcomes.
from American Journal of Ophthalmology, Vol 133, Fong DS, Sharza M,
Chen W, Paschal JF, Ariyasu RG, Lee PP, Vision loss among diabetics
in a group model Health Maintenance Organization (HMO), 236-41. Copyright
2002, with permission from Elsevier Science.
From the Northwest:
trial of a brief dietary intervention to decrease consumption of fat
and increase consumption of fruits and vegetables
Stevens VJ, Glasgow RE, Toobert DJ, Karanja N, Smith
KS. Am J Health Promot 2002 Jan-Feb;16(3):129-34
This study tested the efficacy of a computer-assisted counseling intervention
to reduce diet-related cancer risk.
design: Randomized controlled trial.
subjects: Healthy women HMO members (n = 616) aged 40 to 70.
intervention: Participants were randomly assigned to nutrition
intervention or an attention-control intervention unrelated to diet.
Intervention consisted of two 45-minute counseling sessions plus two
five- to ten-minute follow-up telephone contacts. Counseling sessions
included a 20-minute, interactive, computer-based intervention using
a touchscreen format. Intervention goals were reducing dietary fat and
increasing consumption of fruit, vegetables, and whole grains.
Twenty-four hour diet recalls and the Fat and Fiber Behavior Questionnaire
Four-month follow-up data were collected from 94% of the intervention
participants and 91% of the controls. Testing with a multivariate general
linear models analysis showed improvements on all dietary outcome variables.
Compared to the control, intervention participants reported significantly
less fat consumption (2.35 percentage points less for percentage of
energy from fat), significantly greater consumption of fruit and vegetables
combined (1.04 servings per day), and a significant reduction in a behavioral
measure of fat consumption (.24 point change in the FFB).
These four-month results are comparable to several other moderate-intensity
studies showing that, in the appropriate circumstances, moderate-intensity
dietary interventions can be efficacious. Study limitations include
the short follow-up period and the use of self-reported outcome measures.
or switching selective serotonin-reuptake inhibitors
SA, Hunkeler EM, Lee JY, et al. Ann Pharmacother 2002 Apr;36(4):578-84
To describe reasons for discontinuing or switching selective serotonin-reuptake
inhibitors (SSRIs) at three and six months after starting treatment,
and to identify information provided to patients that may help prevent
premature discontinuation of medication.
Telephone surveys were conducted at three and six months after patients
(n = 672) were started on an SSRI for a new or recurrent case of depression.
Significantly more patients discontinued or switched their SSRI because
of an ad
verse effect within the first three months of starting (43%) compared
with the second three months (27%; p = 0.023). The adverse effect most
frequently reported as the reason for early discontinuation or switching
was drowsiness/fatigue (10.2%), followed by anxiety, headache, and nausea--all
at just over 5%. The odds ratio for discontinuation was 61% less in
patients who recalled being told to take the medication for at least
six months compared with those who did not (OR 0.39; p < 0.001).
Patients who recalled being informed of potential adverse effects increased
their reported incidence of mild to moderate adverse effects by 55%
(OR 1.55; p < 0.05) without affecting rates of premature discontinuation
(OR 1.06; p = 0.77).
conclusions: Adverse effects are the most frequent reason for discontinuing
or switching SSRIs within the first three months of treatment. Patients
are more likely to continue taking their antidepressant if they fully
understand how long to take the medication. Informing patients of potential
adverse effects does not appear to prevent premature discontinuation,
but may increase the patient's awareness and reporting of mild to moderate
implication: The study reinforces the knowledge that patients
need a clear explanation of the fact that they are expected to continue
with antidepressant treatment for a minimum of six months. Patients
who understand the reasons for this expectation are more likely
to stick it out and continue with treatment. --SB
in multiple gestation: the role of assisted reproductive technologies
Lynch A, McDuffie R Jr, Murphy J, Faber K, Orleans M. Obstet Gynecol
To estimate the relationship of assisted reproductive technologies and
ovulation-inducing drugs with preeclampsia in multiple gestations.
This historical cohort study was conducted on 528 multiple gestations
from a Colorado health maintenance organization. Using univariate and
logistic regression analysis, we determined if women who conceived a
multiple gestation as a result of assisted conception were at a greater
risk of preeclampsia than those who conceived spontaneously.
Between January 1994 and November 2000, there were 330 unassisted and
198 assisted multiple gestations. Sixty-nine multiple gestations followed
assisted reproductive technologies (in vitro fertilization and gamete
intrafallopian transfer). Human menopausal gonadotropins and clomiphene
citrate were associated with 38 and 91 of the multiple gestations, respectively.
Compared with unassisted multiple gestations, the relative risk of mild
or severe preeclampsia among mothers who received assisted reproductive
technologies was 2.7 (95% confidence interval [CI] 1.7, 4.7) and 4.8
(CI 1.9, 11.6), respectively. Adjusted for maternal age and parity,
women who received assisted reproductive technologies were two times
more likely to develop preeclampsia (odds ratio 2.1, CI 1.1, 4.1) compared
with those who conceived spontaneously. The adjusted odds ratios of
nulliparity and maternal age for preeclampsia were 2.1 (CI 1.3, 3.4)
and 1.1 (CI 1, 1.1), respectively. Although the incidence of preeclampsia
was greater in mothers who received clomiphene citrate and human menopausal
gonadotropins, this association did not reach statistical significance
at the p < .05 level.
Women who conceive multiple gestations through assisted reproductive
technologies have a 2.1-fold higher risk of preeclampsia than those
who conceive spontaneously.
with permission from the American College of Obstetricians and Gynecologists
(Obstetrics and Gynecology, 2002, 99, 445-51).
implication: This study, distinguished by careful definition
of preeclampsia and adjustment for the confounding effect of other
risk factors, found that assisted reproductive technologies, nulliparity,
and advancing maternal age were independent risk factors for preeclampsia.
Furthermore, the risk of severe preeclampsia was increased almost
fivefold among mothers receiving assisted reproductive technologies
compared with mothers having unassisted multiple births. The results
suggest that women with multiple gestations resulting from assisted
reproductive technologies should be carefully monitored for preeclampsia
by their health care providers. --AL