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Improving OSA screening and diagnosis in patients with hypertension in an academic safety net primary care clinic: quality improvement project.

ABSTRACT: Obstructive sleep apnoea (OSA) is more prevalent in patients with hypertension (HTN), and associated morbidities include stroke, heart failure and premature death. In the Internal Medicine Clinic (IMC), over 70% of the patients had a diagnosis of HTN and obesity. We identified a lack of OSA screening in patients with HTN. The aim of this quality improvement (QI) was to increase OSA diagnosis to 5% from the baseline rate of less than 1% in patients with HTN between the ages of 18 and 75 years over 6 months at IMC. We used the Plan-Do-Study-Act (PDSA) method. The QI team performed root cause analysis to identify materials/methods, provider and patient-related barriers. PDSA cycle included: (1) integration of customised workflow of loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (BANG) OSA screening tool in the electronic health record (EHR); (2) physician education of OSA and EHR workflow; and (3) completion of STOP survey by patients, which was facilitated by nursing staff. The outcome measure was the percentage of OSA diagnosis in patients with HTN. The process measures included the percentage of patients with HTN screened for OSA and the increase in sleep study referrals in hypertensive patients with STOP-BANG score of ?3. Increase in patient wait time and cost of sleep study were the balance measures. Data analysis was performed using weekly statistical process control chart. The average increase in OSA screening rate using the STOP-BANG tool was 3.88%. The significant variation seen in relation to PDSA cycles was not sustainable. 32% of patients scored ?3 on the STOP-BANG tool, and 10.4% had a confirmed diagnosis of OSA. STOP-BANG tool integration in the EHR and a team approach did not result in a sustainable increase in OSA screening. OSA diagnosis was increased to 3.3% in IMC patient population within the 6-month period. The team identified multiple barriers to screening and diagnosis of OSA in the IMC.

SUBMITTER: Bakhai SY

PROVIDER: S-EPMC5717931 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Improving OSA screening and diagnosis in patients with hypertension in an academic safety net primary care clinic: quality improvement project.

Bakhai Smita Y SY Nigam Mansi M Saeed Musa M Krishnan Amita A Reynolds Jessica L JL

BMJ open quality 20171125 2

Obstructive sleep apnoea (OSA) is more prevalent in patients with hypertension (HTN), and associated morbidities include stroke, heart failure and premature death. In the Internal Medicine Clinic (IMC), over 70% of the patients had a diagnosis of HTN and obesity. We identified a lack of OSA screening in patients with HTN. The aim of this quality improvement (QI) was to increase OSA diagnosis to 5% from the baseline rate of less than 1% in patients with HTN between the ages of 18 and 75 years ove ...[more]

PMID: 29435504

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Project description:Blood tests are a seemingly basic investigation, but are often a vital part of directing patient management. Despite the importance of this everyday process, we indentified the potential for improvement of the current phlebotomy service in our hospital, as both junior doctors and phlebotomists reported a lack of communication and standardised practice across the wards. Resulting delays in obtaining blood test results can impact detrimentally on patient safety and management. We designed a survey which highlighted inefficient handovers and discrepancies between wards as driving factors behind this. We therefore aimed to improve communication between phlebotomists and doctors, as well as the overall organisation of the service. This took the form of the "Phlebotomy Box," a box file system offering a set location for blood stickers to be situated. The box concept was optimised on a series of medical and surgical wards, incorporating multidisciplinary feedback from relevant teams. We measured how many untaken bloods were handed over to medical staff continuously, both pre- and post implementation of the phlebotomy box. Our baseline ward demonstrated poor handover rates of untaken bloods, ranging from 0% to 40%. This increased to a consistent 100% following introduction of the Phlebotomy Box and ongoing staff education. Once optimised, the box was trialled on a further two medical wards and one surgical ward, achieving 100% handover from an initial 0% to 67%. Quantitative improvement was also reflected qualitatively in widespread staff surveys, with overwhelmingly positive support and acceptance. In summary, the Phlebotomy Box innovation has led to 100% of untaken bloods being effectively handed over. We have demonstrated a significant improvement in communication and efficiency within the phlebotomy service, with tangible benefits to patient care, as minimising time lags can prevent delays in clinical decisions. The phlebotomy box represents a simplistic, sustainable intervention that could be easily replicated in other Trusts.

Project description:In recent years medical handover has been identified as an increasingly important area for hospitals to improve upon, in light of the changes in shift patterns for doctors. Significant changes to weekday handover had recently been successfully introduced at Broomfield hospital. Weekend handover remained a concern, with an electronic and paper system being used simultaneously. Our objectives were to introduce a new electronic handover system for weekend handover at Broomfield Hospital and improve the organisation of the weekend handover meeting to promote patient safety. Doctors involved in weekend handover were surveyed using a questionnaire, to establish insufficiencies in the weekend handover process; where both the electronic ExtraMed system and paper were being used inconsistently. A new weekend handover system was introduced together with a new user-friendly electronic handover database, addressing the identified difficulties in the current system. These changes met the medical handover guidelines set by the Royal College of Physicians. Three months after the launch of the new system, doctors were re-surveyed using a modified questionnaire to assess the impact our changes had made. Before changes were implemented only 12% of doctors surveyed used the electronic system for weekend. Eighty-nine percent found sorting through jobs time consuming and 67% were handed jobs to them meant for a different grade of doctor. Only 41% were aware who to hand weekend discharges to. Subjective assessment of safety was 3.18 out of 5. The electronic system was felt to be time consuming and complicated. After execution of the new weekend handover process, 100% of doctors reported using the electronic system for weekend handover. Only 47% of doctors felt sorting through jobs was time consuming and 89% of doctors were aware who to handover weekend discharges to. Subjective assessment of the safety of weekend handover improved to 3.84 out of 5. Informal interviews on the ward revealed a high degree of satisfaction with the new weekend handover system. In conclusion we found that a structured, well organised weekend handover meeting together with an effective electronic handover system improves the quality of medical weekend handover.

Project description:BackgroundMailed fecal immunochemical testing (FIT) can increase colorectal cancer (CRC) screening rates, including for vulnerable patients, but its cost-effectiveness is unclear.ObjectiveWe sought to examine the effectiveness and cost-effectiveness of the initial cycle of our mailed FIT program from November 2017 to July 2019 in a federally qualified health center (FQHC) system in Central Texas.DesignSingle group intervention and economic analysis PARTICIPANTS: Eligible patients were those ages 50-75 who had been seen recently in a system practice and were not up to date with screening.InterventionThe program mailing packet included an introductory letter in plain language, the FIT itself, easy to read instructions, and a postage-paid lab mailer, supplemented with written and text messaging reminders.Main measuresWe measured effectiveness based on completion of mailed FIT and cost-effectiveness in terms of cost per person screened. Costs were measured using detailed micro-costing techniques from the perspective of a third-party payer and expressed in 2019 US dollars. Direct costs were based on material supply costs and detailed observations of labor required, valued at the wage rate.Key resultsOf the 22,838 eligible patients who received program materials, mean age was 59.0, 51.5% were female, and 43.9% were Latino. FIT were successfully completed by 19.2% (4395/22,838) patients at an average direct cost of $5275.70 per 500-patient mailing. Assuming completed tests from the mailed intervention represent incremental screening, the direct cost per patient screened, compared with no intervention, was $54.83. Incorporating start-up and indirect costs increases total costs to $7014.45 and cost per patient screened to $72.90. Alternately, assuming 2.5% and 5% screening without the intervention increased the direct (total) cost per patient screened to $60.03 ($80.80) and $67.05 ($91.47), respectively.ConclusionsMailed FIT is an effective and cost-effective population health strategy for CRC screening in vulnerable patients.

Project description:ImportanceThe patient-centered medical home (PCMH) model holds promise for improving primary care delivery, but it has not been adequately tested in teaching settings.Design, setting, and participantsWe implemented an intervention guided by PCMH principles at a safety-net teaching clinic with resident physician providers. Two similar clinics served as controls.Main outcomes and measuresUsing a cross-sectional design, we measured the effect on patient and resident satisfaction using the Consumer Assessment of Healthcare Providers and Systems survey and a validated teaching clinic survey, respectively. Both surveys were conducted at baseline and 1 year after the intervention. We also measured the effect on emergency department and hospital utilization.ResultsFollowing implementation of our intervention, the clinic’s score on the National Committee for Quality Assurance’s PCMH certification tool improved from 35 to 53 of 100 possible points, although our clinic did not achieve all must-pass elements to qualify as a PCMH. During the 1-year study period, 4676 patients were exposed to the intervention; 39.9% of these used at least 1 program component. Compared with baseline, patient-reported access and overall satisfaction improved to a greater extent in the intervention clinic, and the composite satisfaction rating increased from 48% to 65% in the intervention clinic vs from 50% to 59% in the control sites (P = .04). The improvements were particularly notable for questions relating to access. For example, satisfaction with urgent appointment scheduling increased from 12% to 53% in the intervention clinic vs from 14% to 18% in the control clinics (P < .001). Resident satisfaction also improved in the intervention clinic: the composite satisfaction score increased from 39% to 51% in the intervention clinic vs a decrease from 46% to 42% in the control clinics (P = .01). Emergency department utilization did not differ significantly between the intervention and control clinics, and hospitalizations increased from 26 to 27 visits per 1000 patients per month in the intervention clinic vs a decrease from 28 to 25 in the control clinics (P = .02).Conclusions and relevanceOur PCMH-guided intervention, which represented a modest but substantive step toward the PCMH vision, had favorable effects on patient and resident satisfaction at a safety-net teaching clinic but did not reduce emergency department or hospital utilization in the first year. Our experience may provide lessons for other teaching clinics in safety-net settings hoping to implement PCMH-guided reforms.

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Improving OSA screening and diagnosis in patients with hypertension in an academic safety net primary care clinic: quality improvement project.

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Improving OSA screening and diagnosis in patients with hypertension in an academic safety net primary care clinic: quality improvement project.

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