Use of Preoperative Testing and Physicians’ Response to Professional Society Guidance

Sigmund, Alana; Stevens, Elizabeth R.; Blitz, Jeanna; Ladapo, Joseph A.

doi:10.1001/jamainternmed.2015.2081

Cited by 45 publications

(38 citation statements)

References 28 publications

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“…Both are crucial when trying to assess the impact of an educational program. 15 , 16 Without an adequate control group and a method that accounts for the change in knowledge over time for other reasons, any observed findings might be due to unmeasured confounding factors. In our study, the inclusion of this control group was important since we expected that knowledge related to antimicrobial prescribing might increase over the course of an internal medicine rotation, even without access to an app.…”

Section: Discussionmentioning

confidence: 99%

Can a smartphone app improve medical trainees’ knowledge of antibiotics?

et al. 2017

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ObjectivesTo determine whether a smartphone app, containing local bacterial resistance patterns (antibiogram) and treatment guidelines, improved knowledge of prescribing antimicrobials among medical trainees. MethodsWe conducted a prospective, controlled, pre-post study of medical trainees with access to a smartphone app (app group) containing our hospital’s antibiogram and treatment guidelines compared to those without access (control group). Participants completed a survey which included a knowledge assessment test (score range, 0 [lowest possible score] to 12 [highest possible score]) at the start of the study and four weeks later. The primary outcome was change in mean knowledge assessment test scores between week 0 and week 4. Change in knowledge assessment test scores in the app group were compared to the difference in scores in the control group using multivariable linear regression. ResultsSixty-two residents and senior medical students participated in the study. In a multivariable analysis controlling for sex and prior knowledge, app use was associated with a 1.1 point (95% CI: 0.10, 2.1) [β = 1.08, t(1) = 2.08, p = 0.04] higher change in knowledge score compared to the change in knowledge scores in the control group. Among those in the app group, 88% found it easy to navigate, 85% found it useful, and about one- quarter used it daily. ConclusionsAn antibiogram and treatment algorithm app increased knowledge of prescribing antimicrobials in the context of local antibiotic resistance patterns. These findings reinforce the notion that smartphone apps can be a useful and innovative means of delivering medical education.

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Section: Discussionmentioning

confidence: 99%

Can a smartphone app improve medical trainees’ knowledge of antibiotics?

et al. 2017

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“…(15) We used visit diagnoses and reasons for visit from our prior work to identify patients with other risk factors for adverse cardiovascular events, including hypertension, dyslipidemia, cigarette smoking, obesity, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, CAD, and stroke (16,17). We were unable to validate our PAD diagnosis codes but they were extracted from an American Heart Association Scientific Statement, and the NAMCS/NHAMCS uses rigorous methods to review and classify data reported on Patient Record Forms.…”

Section: Methodsmentioning

confidence: 99%

Underuse of Prevention and Lifestyle Counseling in Patients With Peripheral Artery Disease

Berger

Ladapo

2017

Journal of the American College of Cardiology

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154

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Background Little is known about patterns of medication use and lifestyle counseling in patients with peripheral artery disease (PAD) in the United States. Objective We sought to evaluate trends in both medical therapy and lifestyle counseling for PAD patients in the United States from 2005 through 2012. Methods Data from 1,982 outpatient visits among patients with PAD were obtained from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, a nationally representative assessment of office-based and hospital outpatient department practice. We evaluated trends in the proportion of visits with medication use (antiplatelet therapy, statins, ACE-inhibitors [ACE-I] or angiotensin receptor blockers [ARB], and cilostazol) and lifestyle counseling (exercise or diet counseling and smoking cessation). Results Over the 8-year period, the average annual number of ambulatory visits in the U.S. for PAD was 3,883,665. Across all visits, mean age was 69.2 years, 51.8% were female and 56.6% were Non-Hispanic white. Comorbid coronary artery disease (CAD) was present in 24.3% of visits. Medication use for cardiovascular prevention and symptoms of claudication was low: any antiplatelet therapy in 35.7% (standard error [SE] 2.7), statin 33.1% (SE, 2.4), ACE-I/ARB 28.4% (SE, 2.0), and cilostazol in 4.7% (SE, 1.0) of visits. Exercise or diet counseling was used in 22% (SE, 2.3) of visits. Among current smokers with PAD, smoking cessation counseling or medication was used in 35.8% (SE, 4.6) of visits. There was no significant change in medication use or lifestyle counseling over time. Compared to visits for patients with PAD alone, comorbid PAD and CAD were more likely to be prescribed antiplatelet therapy (OR 2.6 [1.8–3.9]), statins (OR 2.6 [1.8–3.9]), ACE-I/ARB (OR 2.6 [1.8–3.9]), and smoking cessation counseling (OR 4.4 [2.0–9.6]). Conclusions The use of guideline-recommended therapies in patients with PAD was much lower than expected, which highlights an opportunity to improve the quality of care in these high-risk patients.

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“…5 Despite strong evidence that performing diagnostic testing such as laboratory tests, electrocardiograms (EKG) and chest x-rays provide limited benefit in routine preoperative care, this practice remains widespread. 6 …”

Section: Introductionmentioning

confidence: 99%

Choosing Wisely: A Quality Improvement Initiative to Decrease Unnecessary Preoperative Testing

Matulis

Liu

Mecchella

et al. 2017

BMJ Qual Improv Report

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Dartmouth-Hitchcock Medical Center is a rural, academic medical center in the northeastern United States; its General Internal Medicine (GIM) division performs about 900 low and intermediate surgical risk preoperative evaluations annually. Routine preoperative testing in these evaluations is widely considered a low-value service. Our baseline data sample showed unnecessary testing rates of approximately 36%. A multi-disciplinary team used a micro-systems approach to analyze the existing process and formulate a rapid cycle improvement strategy. Our improvement efforts focused on implementation of a Nurse Practitioner and Physician Assistant (Associate Provider) clinic to incorporate standardized protocols for preoperative assessment. Plan-Do-Study-Act (PDSA) cycles included creation of a dedicated Associate Provider run preoperative clinic, modifying and operationalizing a scheduling scheme, and creating and implementing Electronic Health Record (EHR) tools. We used Statistical Process Control (SPC) methods to analyze time ordered data for the usual care process and to compare performance with the novel preoperative clinic. The Associate Provider preoperative clinic showed unnecessary testing rates of 4% compared with 23% in the usual care cohort (p<.001) within 3 months of implementation. When testing rates across the entire division were analyzed, there was no significant change. In our GIM division this preoperative clinic was effectively staffed with Associate Providers. Dedicated leadership support, incorporating input from a diverse improvement team, and balancing innovation with other clinical needs are important elements for success. We hypothesize that protecting clinical time to focus on preoperative care, monitoring and modifying scheduling processes, and improving support for electronic health record tool implementation would have yielded further performance improvements. Our experience provides valuable learning for other primary care practices with similar challenges. Identifying appropriate patients for inclusion in these clinic visits while optimizing primary care provider collaboration are important future challenges.

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Use of Preoperative Testing and Physicians’ Response to Professional Society Guidance

Cited by 45 publications

References 28 publications

Can a smartphone app improve medical trainees’ knowledge of antibiotics?

Can a smartphone app improve medical trainees’ knowledge of antibiotics?

Underuse of Prevention and Lifestyle Counseling in Patients With Peripheral Artery Disease

Choosing Wisely: A Quality Improvement Initiative to Decrease Unnecessary Preoperative Testing

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