Publications
Department of Medicine faculty members published more than 3,600 peer-reviewed articles in 2024.
2010
BACKGROUND & AIMS
Cirrhosis is a prevalent and expensive condition. With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with cirrhosis, we established a set of explicit quality indicators (QIs) for their treatment.
METHODS
We organized an 11-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for cirrhosis. We provided the panel with a report that summarized the results of a comprehensive literature review of data linking candidate QIs to outcomes. The panel performed independent ratings of each candidate QI by using a standard 9-point RAND appropriateness scale (RAS) (ranging from 1 = not appropriate to 9 = most appropriate). The panel members then met, reviewed the ratings, and voted again by using an iterative process of discussion. The final set of QIs was selected; QIs had a median RAS >7, and panel members agreed on those selected.
RESULTS
Among 169 candidate QIs, the panel rated 41 QIs as valid measures of quality care. The selected QIs cover 6 domains of care including ascites (13 QIs), variceal bleeding (18 QIs), hepatic encephalopathy (4 QIs), hepatocellular cancer (1 QI), liver transplantation (2 QIs), and general cirrhosis care (3 QIs). Content coverage included prevention, diagnosis, treatment, timeliness, and follow-up.
CONCLUSIONS
We developed an explicit set of evidence-based QIs for treatment of cirrhosis. These provide physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in any setting where care for patients with cirrhosis is provided.
View on PubMed2010
2010
2010
2010
BACKGROUND
Little is known about adverse events (AEs) that occur between physician visits for ambulatory chronic disease patients. An automated telephone self-management support programme for a diverse population of diabetes patients was implemented to capture AEs, describe the self-management domains from which they emanate and explore contributing causes.
METHODS
AEs and potential AEs (PotAEs) were identified among 111 ethnically diverse diabetes patients. An AE is an injury that results from either medical management or patient self-management; a PotAE is an unsafe state likely to lead to an event if it persists without intervention. Medical record reviews were conducted to ascertain which self-management domain was involved with the event and to explore contributing causes.
RESULTS
Among the 111 patients, 86% had at least one event detected over the 9-month observation period. 111 AEs and 153 PotAEs were identified. For all events, medication management was the most common domain (166 events, 63%). Only 20% of events reflected a single contributing cause; in the remaining 80%, a combination of system, clinician and patient factors contributed to their occurrence. Patient actions were implicated in 205 (77%) events, systems issues in 183 (69%) events and inadequate physician-patient communication in 155 (59%) events. Aside from communication, primary care clinician actions contributed to the occurrence of the event in only 16 cases (6%).
CONCLUSIONS
Our findings reveal a complex safety ecology, with multiple contributing causes for AEs and PotAEs among ambulatory diabetes patients. Moreover, patients themselves seem to be key drivers of safety and of AEs, suggesting that patient-level self-management support and patient-centred communication are critical to AE prevention.
View on PubMed2010
2010
OBJECTIVES
Quality indicators (QIs) for the assessment of care of patients with systemic lupus erythematosus (SLE) have been proposed. We evaluated care according to these proposed QIs for osteoporosis and cardiovascular disease (CVD) in patients with SLE in our rheumatology practice.
METHODS
We selected 200 patients with SLE according to American College of Rheumatology Criteria and ≥2 visits to our practice in 2007 to 2008. We performed a structured medical record review and collected demographics, SLE and past medical history, medications, laboratories and data concerning osteoporosis, and CVD management. We employed univariable analyses and multivariable regression analyses to test for factors associated with care meeting the proposed QIs.
RESULTS
Ninety-four percent of patients were female and 64% were white. Mean age was 46.3 years and mean lupus duration was 15.3 years. Twenty-nine percent were taking ≥7.5 mg prednisone per day for ≥3 months. The proportions of patients for whom care met the proposed QIs were as follows: 59% for bone mineral density testing, 62% for calcium and vitamin D supplementation, and 86% for antiresorptive or anabolic osteoporosis medications. Only 3% had 5 cardiac risk factors assessed within the year and 26% had 4 cardiac risk factors assessed annually. Smoking, fasting lipid panels, and diabetes mellitus were rarely assessed annually. Having a primary care physician within our health care network increased care meeting QIs.
CONCLUSIONS
Care according to newly proposed QIs for osteoporosis and CVD was suboptimal in our academic center. To standardize and improve care of patients with SLE, we suggest specific changes to the proposed QIs.
View on PubMed2010