Impact of an Electronic Template on Documentation of Obesity in a Primary Care Clinic.
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SUBMITTER: Thaker VV
PROVIDER: S-EPMC4909579 | biostudies-literature | 2016 Oct
REPOSITORIES: biostudies-literature
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Impact of an Electronic Template on Documentation of Obesity in a Primary Care Clinic.
Thaker Vidhu V VV Lee Felix F Bottino Clement J CJ Perry Cassandra L CL Holm Ingrid A IA Hirschhorn Joel N JN Osganian Stavroula K SK
Clinical pediatrics 20151215 12
Identification of obesity at well-child care (WCC) examinations is a step toward intervention. Studies have shown suboptimal documentation in primary care clinics that can improve with the use of electronic health records (EHRs). This study investigated the impact of a standardized EHR template on documentation of obesity at WCC visits and its impact on physician behavior. A cohort of 585 children with severe early onset obesity (body mass index >99th percentile, age <6 years) was identified wit ...[more]
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Project description:Physicians who more intensively interact with electronic health records (EHRs) through their documentation style may pay greater attention to coded fields and clinical decision support and thus may deliver higher quality care. We measured the quality of care of physicians who used three predominating EHR documentation styles: dictation, structured documentation, and free text.We conducted a retrospective analysis of visits by patients with coronary artery disease and diabetes to the Partners Primary Care Practice Based Research Network. The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after primary care visits.During the 9-month study period, 7000 coronary artery disease and diabetes patients made 18?569 visits to 234 primary care physicians of whom 20 (9%) predominantly dictated their notes, 68 (29%) predominantly used structured documentation, and 146 (62%) predominantly typed free text notes. In multivariable modeling adjusted for clustering by patient and physician, quality of care appeared significantly worse for dictators than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation, and diabetic eye exam); better for structured documenters for three measures (blood pressure documentation, body mass index documentation, and diabetic foot exam); and better for free text documenters on one measure (influenza vaccination). There was no measure for which dictators had higher quality of care than physicians using the other two documentation styles.EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.ClinicalTrials.gov Identifier: NCT00235040.
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Project description:PurposeWe sought to evaluate sexual history documentation and corresponding Chlamydia trachomatis screening practices across a large pediatric primary care network in the context of patient and clinic characteristics.MethodsDemographic, chlamydia screening, and provider note data were collected via electronic health record and manual chart audit for females aged 15-19 years attending annual well-adolescent visits, from February 1 to 28, 2019. Inductive qualitative textual analysis evaluated sexual history documentation as informative (containing clear indication of patient as sexually active or not) or noninformative and identified documentation subtypes. We examined patient and clinic characteristics by sexual history documentation type (informative or noninformative) and chlamydia screening status and documentation subtypes across clinic types using chi-square and Fisher's exact tests. A multilevel logistic regression model considering clinic-specific random effects evaluated predictors of informative sexual history documentation.ResultsChart notes were examined for 1,062 patients across 31 unique clinics. Only 34.7% of chart notes were found to have informative sexual history documentation. Older patients (odds ratio: 1.51, 95% confidence interval: 0.99-2.31) and patients seen at clinics receiving U.S. Department of Health and Human Services Title-X funding (odds ratio: 11.05, 95% confidence interval: 1.34-90.86) had higher rates of informative documentation. The overall Chlamydia screening rate was 13.1%.ConclusionSexual history documentation varied widely across clinics, and the majority of chart notes were found to have noninformative documentation. Understanding and addressing barriers to informative sexual history documentation and comprehensive sexual health care is fundamental to improve adolescent sexual health outcomes, particularly given recently enacted federal electronic health record transparency policies.
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Project description:It is known that the management of chronic gout in relation to serum uric acid (SUA) monitoring, allopurinol dosing, and lifestyle advice is often sub-optimal in primary care.[1] A quality improvement project in the form of a criterion based audit was carried out in an urban general practice to improve the care of patients being treated for gout. Baseline searching of EMIS confirmed that management of patients with gout who were taking allopurinol was not in line with current guidance. 51(40%) had a SUA checked in the past 12 months, 88(25%) had a SUA below target level, and gout lifestyle advice was not being recorded. An audit was performed to measure and improve the following criteria: Monitoring of SUA levels in the past 12 monthsTitration of urate lowering therapy to bring the SUA below target levelLifestyle advice in the past 12 months An audit standard of 60% achievement at 2 months and 80% achievement at 4 months was set. The intervention consisted of a custom electronic template within EMIS which allowed guidance of gout management to be displayed and for data to be entered. All members of the team including GPs and administrative staff were educated regarding the intervention. This resulted in a sustained improvement over a 6 month period in all 3 components of the audit with 112(84%) having a SUA level checked, 79(51%) having a SUA below target level and 76(57%) receiving lifestyle advice. Although the improvement did not reach the audit standard in 2 of the criteria it would be expected that outcomes would continue given the systems changes which have been made.
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Project description:IntroductionAnaphylaxis is a potentially life-threatening allergic reaction. Common allergy clinic procedures, including oral food challenges and subcutaneous immunotherapy, carry a risk of anaphylaxis, the treatment for which is epinephrine. Our goal was to develop a standardized process for the management and documentation of allergic reactions that occur in a tertiary care pediatric allergy clinic.MethodsThis was a single institution quality improvement pilot study. A multidisciplinary team from the allergy department designed, implemented, and studied the use of a standardized form for the documentation and treatment of allergic reactions within the clinic.ResultsA standardized form was developed based on evidence-based guidelines for the management of allergic reactions and included space for documentation. Both clinic providers and staff approved the form. One year after the introduction, we reached 100% adherence for the use of the form in visits during which a patient experienced a severe allergic reaction requiring epinephrine. Two patients required transfer to the emergency room; the quality improvement form was utilized in these cases to document treatment and assist with the hand-off to emergency room personnel before transfer.ConclusionsWe successfully implemented a standardized form for the treatment and documentation of anaphylaxis within our allergy clinic. The next steps focus on further integrating this form into the electronic medical record, determining compliance with evidence-based management of anaphylaxis, and formally assessing the use of the form as a handoff tool in the event of patient transfer.
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Project description:BACKGROUND:Primary care providers' (PCPs) attitude toward obesity is often negative, and their confidence level for helping patients manage their weight is low. Continuing professional development (CPD) on the subject of obesity is often based on a single activity using a traditional passive approach such as lectures known to have little effect on performance or patient outcomes. The aim of this study was to evaluate the impact of an educational intervention for obesity management on PCPs' attitude, self-efficacy, practice changes and patient-related outcomes. METHODS:Prospective interventional study with 12?months follow-up. A two-day clinical obesity preceptorship was offered where participants were actively involved in competence building using real-life situations, in addition to electronic networking tools, including a discussion forum and interactive monthly webinars. Thirty-five participants (12 nurses and 23 physicians) from seven Family medicine groups were enrolled. Questionnaires were used to evaluate the impact on primary care nurses' and physicians' attitudes and self-efficacy for obesity management. Practice changes and patient outcomes were evaluated using clinical vignettes, de-identified electronic patient records and qualitative analyses from group interviews. RESULTS:Physicians' general attitude towards patients with obesity was improved (61?±?22?mm vs 85?±?17?mm, p?<? 0.001). Self-efficacy for obesity management and lifestyle counselling were also improved immediately and 1 year after the intervention (all Ps?<? 0.05). De-identified patient records and clinical vignettes both showed improvement in recording of weight, waist circumference and evaluation of readiness to change lifestyle (all Ps?<? 0.05) that was confirmed by group interviews. Also, 15% of patients who were prospectively registered for weight management had lost more than 5% of their initial weight at the time of their last visit (P?<? 0.0001, median follow-up of 152?days). CONCLUSION:A multimodal educational intervention for obesity management can improve PCPs'attitude and self-efficacy for obesity management and lifestyle counselling. This translates into beneficial practice changes and patient-related outcomes. TRIAL REGISTRATION:clinicaltrials.gov Identifier: NCT01385397 . Retrospectively registered, 28 June 2011.
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Project description:BackgroundHealthcare costs attributable to obesity have previously involved estimations based on costs of diseases commonly considered as having obesity as an underlying factor.AimTo quantify the impact of obesity on total primary care drug prescribing.Design of studyReview of computer generated and handwritten prescriptions to determine total prescribing volume for all drug classes.SettingTwenty-three general practice surgeries in the UK.MethodStratified random selection of 1150 patients who were obese (body mass index [BMI]>30 kg/m(2)) and 1150 age and sex-matched controls of normal weight (BMI 18.5-<25 kg/m(2)). Retrospective review of medical records over an 18-month period.ResultsA higher percentage of patients who were obese, compared with those of normal weight, were prescribed at least one drug in the following disease categories: cardiovascular (36% versus 20%), central nervous system (46% versus 35%), endocrine (26% versus 18%), and musculoskeletal and joint disease (30% versus 22%). All of these categories had a P-value of <0.001. Other categories, such as gastrointestinal (24% versus 18%), infections (42% versus 35%), skin (24% versus 19%) had a P-value of <0.01, while respiratory diseases (18% versus 21%) had a P-value of <0.05. Total prescribing volume was significantly higher for the group with obesity and was increased in the region of two- to fourfold in a wide range of prescribing categories: ulcer healing drugs, lipid regulators, beta-adrenoreceptor drugs, drugs affecting the rennin angiotensin system, calcium channel blockers, antibacterial drugs, sulphonylureas, biguanides, non-steroidal anti-inflammatories (NSAIDs) (P<0.001) and fibrates, angiotensin II antagonists, and thyroid drugs (P<0.05). The main impact on prescribing volumes is from numbers of patients treated, although in some areas there is an effect from greater dosage or longer treatment in those who are obese including calcium channel blockers, antihistamines, hypnotics, drugs used in the treatment of nausea and vertigo, biguanides, and NSAIDs (P<0.05) reflected in significantly increased defined daily dose prescribing.ConclusionsThis large study of contemporary practice indicates that obesity more than doubled prescribing in most drug categories.
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Project description:BackgroundThe Veterans Health Administration (VA) implemented the comprehensive life-sustaining treatment (LST) Decisions Initiative to provide training and standardize documentation of goals of care and LST preferences for seriously ill Veterans to improve end-of-life (EOL) outcomes. LST documentation is expected for all Home-Based Primary Care (HBPC) Veterans because they are at high risk of hospitalization and mortality.MethodsA retrospective, cross-sectional analysis compared associations between Bereaved Family Survey (BFS) EOL care ratings and LST documentation. Participants were Veterans who died August 1, 2018 through September 30, 2019 in one of 55 VA HBPC programs. Regression modeling generated odds for key BFS outcomes. LST template completion rate was plotted by month to understand the interaction between time, LST completion rate, and EOL care family ratings.ResultsLST preferences were documented for 39% of HBPC Veterans. Family members rated overall EOL care as excellent for 53% of Veterans but significant divergence in BFS ratings occurred during the last 7 months of the study with 60% of family members of LST completers rating care as excellent compared with 48% for Veterans lacking LST documentation (p = 0.003). The adjusted odds of rating overall care in the final month of life as excellent was higher among those with a completed LST template (1.64 95% CI 1.19, 2.26).ConclusionsHigher rates of LST documentation were associated with more favorable ratings of EOL but not in initial months following implementation of the comprehensive initiative; however, LST documentation rates were lower than expected among HBPC Veterans. Following an initial period of implementation of a comprehensive national initiative to promote Veteran choice about care during serious illness, documented LST preferences were associated with better family ratings of EOL care. HBPC clinicians may improve the bereaved family experience by using LSDTI tools and training to elicit and document preferences.
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Project description:This study addresses the prevalence and characteristics of leg cramps in 294 primary care patients (mean age = 46.5 years), with 51.7% reporting leg cramps. Patients who experience resting or exercise-induced leg cramps were more likely to be older and female. Cramp severity averaged 5.6 on a scale of 1-10 and disturbed sleep "sometimes" or "often" in 55% of patients. Most patients did not discuss cramps with their clinician. Our study reveals a possible shift in patients who experience leg cramps to younger age and chronicity. Resting leg cramps should be reviewed by clinicians as a symptom of declining health and advancing aging.
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