Quality of Care and Preventive Screening Use in the CareFirst Patient-Centered Medical Home Program Despite their value, comprehensive diabetes care and screening for common cancers remain underutilized. We examined the association between participation in a patient-centered medical home (PCMH) program with strong financial incentives and receipt of preventive care in the first 5 years after program launch. Using multivariate regression analysis, we compared outcomes for adults under the care of participating primary care providers (PCPs) with adults under the care of nonparticipating PCPs. Outcomes were breast, cervical and colorectal cancer screenings, and elements of diabetes care. The analytic sample included 818,623 adults living in Maryland, Virginia, or the District of Columbia, and enrolled with CareFirst for at least 1 year during 2010–2015. By Year 5, enrollees in the intervention group were 7.9 (95% confidence interval [CI]: 2.8–13.0), 6.1 (95% CI: 1.4–10.7), 3.1 (95% CI: 2.1–4.0), and 7.6 (95% CI: 7.0–8.2) percentage points more likely to undergo HbA1c tests, nephropathy examinations, breast, and cervical cancer screenings, respectively. We found no significant change in the propensity to receive colorectal cancer screening or an eye examination. Our study shows that a PCMH program with strong financial incentives can raise the provision of preventive care but could require additional adjustment.

Using Lean Performance Improvement for Patient-Centered Medical Home Transformation at an Academic Public Hospital Although Lean performance improvement (PI) has been used in health care for more than 15 years, little is known about how Lean has been used in Patient-Centered Medical Home (PCMH) transformation. We describe our experience implementing Lean in our safety-net, primary care teaching clinic. To advance high value care, a culture of systematic, sustainable PI methods needed to be integrated into primary care and taught to resident physicians. Clinic leadership were trained in Lean methods, protected time was dedicated to PI for a stable, interdisciplinary team, then visual management was introduced, and resident physicians were integrated into the clinic's PI initiatives. Self-assessment using the PCMH Assessment tool demonstrated improvement in core features of the PCMH model. Process outcomes also revealed successful, sustainable integration of Lean into our primary care clinic and resident training, and early findings show improvements in clinical quality outcomes. Patient survey outcomes demonstrate improvement in patient experience. Lean can be used successfully to promote PCMH transformation and create a culture of continuous PI in an academic, safety-net primary care setting.

Text Message Quality Improvement Project for Influenza Vaccine in a Low-Resource Largely Latino Pediatric Population Children with asthma are targeted for influenza vaccine because of their vulnerability to complications, particularly those with low income or family preference for Spanish language. We used text messaging to encourage caregivers to vaccinate. Participants were children (aged >6 months), predominantly low income and Latino, with an asthma diagnosis attending a pediatric clinic. Interactive text messages that described the vaccine and how to make an appointment were sent to parents in English or Spanish, January 2016 to April 2017. Year 1 messages were evaluated by the investigators considering vaccination results and evidence in the literature. Improvements for Year 2 included timing of message, clarity of message, and using the family language of preference. Messages went to 398 (Year 1) and 485 (Year 2) families. Sixty-four percent of families preferred English; 35% preferred Spanish. Children in Spanish-speaking families were significantly more likely than children in English-speaking families to be vaccinated, 66% versus 46%. Text messaging is a straightforward, low-cost health promotion strategy with potential to improve child health. Quality improvement efforts in outpatient settings with low-income and limited English proficiency families are needed. mHealth strategies may help address the needs of vulnerable populations. SQUIRE V.2.0 guidelines were used for manuscript writing and reporting.

A Quality Improvement Project to Improve Sepsis-Related Outcomes at an Integrated Healthcare System Hospitals are encouraged to take steps to improve outcomes for patients with sepsis, a leading cause of morbidity and mortality. A retrospective analysis examined data (n = 4,475) from three health systems to better determine the impact of a 10-month sepsis quality improvement program that consisted of clinical alerts, audit and feedback, and staff education. Compared with the control group, the intervention group significantly decreased length of stay and costs per stay. The intervention group increased sepsis bundle compliance by more than 40%. A sepsis quality improvement program may improve sepsis health outcomes and decrease costs.

Preoperative Blood Management Strategy for Elective Hip and Knee Arthroplasty To improve quality and outcomes, a preoperative anemia clinic (PAC) was established to screen, evaluate, and manage preoperative anemia. A retrospective review of primary and revision hip and knee arthroplasty patients from August 2013 to September 2017 was conducted. Patients at “high risk” for transfusion were referred to PAC for treatment with iron, erythropoietin, or both based on anemia type. Preoperative anemia clinic referred patients were compared with a 1:3 historic propensity-matched control set of patients to help determine impact of PAC. Forty PAC patients were compared with 120 control patients. Among PAC patients, 26 (63.41%) received iron only, 3 (7.32%) received erythropoietin (EPO) only, and 12 (29.27%) received both. Preoperative hemoglobin significantly increased in the treatment group (median [interquartile range] 10.9 g/dl [10.3–11.2] vs. 12.0 g/dl [11.2–12.7]; p < .001). Four PAC patients (10.00%) received red blood cell transfusions compared with 29 (24.17%) from matched controls (p = .055). In addition, the PAC cohort had higher postoperative nadir hemoglobin levels (mean [SD] 9.7 g/dl [1.31] vs. 8.7 g/dl [1.25]; p < .001). High-risk patients appropriately treated with iron and/or EPO before surgery demonstrate a significant increase in preoperative hemoglobin, trend toward decrease perioperative transfusion, and increased hemoglobin levels postoperatively compared with matched controls.

Thromboprophylaxis After Hospitalization for Joint Replacement Surgery Venous thromboembolism (VTE) is a leading cause of mortality during the perioperative period, with individuals who have undergone hip and knee arthroplasty at the highest risk for VTE. The American College of Chest Physicians recommends 35 days of postoperative thromboprophylaxis and the use of intermittent pneumatic compression (IPC) therapy for mechanical compression after major orthopedic surgery. However, little research has described adherence to these recommendations during recovery at home. The purpose of this cross-sectional descriptive study was to describe thromboprophylaxis prescription, use, and education among patients discharged home after major orthopedic surgery. We surveyed patients within 2 years of major orthopedic surgery. A total of 388 subjects completed the survey. More than three-quarters of respondents reported a thromboprophylaxis duration <35 days. Most (93.8%) respondents were prescribed a pharmacologic agent, while 55.9% were prescribed mechanical compression therapy. Of the respondents who were prescribed mechanical compression therapy, 13.4% were prescribed IPC. Adherence to mechanical compression therapy was moderate, with 63% of respondents wearing mechanical compression therapy ≥75% of the time. The results of this study suggest a need for increased duration of thromboprophylaxis and increased use of IPC in the outpatient setting. Additional research describing prescribers' perceptions of thromboprophylaxis is also needed.

Diabetic Ketoacidosis Management in the Emergency Department: Implementation of a Protocol to Reduce Variability and Improve Safety Emergency departments (EDs) are the primary venue for diagnosis and initiation of treatment of diabetic ketoacidosis (DKA). Typically managed in an intensive care unit (ICU), in many medical centers, limited ICU bed availability necessitates DKA-extended ED management until sufficient improvement for admission to a non-ICU bed. Although DKA treatment is well established, coordinating safe and effective extended care in a busy ED is complex. Recurrent problems in this high-risk transition of care led us to improvement efforts. We studied the impact of a standardizing ED DKA management in two phases: rollout of a DKA pathway in our computerized order entry system followed by audit and feedback. We evaluated adherence, clinical process, operational, and safety measures following these interventions. Adherence to the pathway was initially slow, improving significantly after audit and feedback. We observed mixed improvements in clinical processes, no changes in operational metrics (as expected), and reductions in variability for several measures. There were no deteriorations and improvements in measures of safety, and a reduction in the number of adverse event reports in the postimplementation periods.

Meaningful Use: Does Physician Participation Move the Needle on Quality Metrics? Introduction: To determine the association between pattern of participation in the Meaningful Use (MU) initiative and self-reported clinical quality metrics. Methods: We used state-level Medicaid electronic health record (EHR) incentive program data to categorize physicians based on receipt of MU payments (single year vs. multiple years) and self-reported quality metrics from 2011 to 2016. Results: Among 4,198 participating physicians, only 36% received more than one EHR incentive payment. Physicians participating for a single year had better cancer-screening metrics. By comparison, physicians who participated for multiple years reported better medication-related metrics and chronic disease management metrics. Conclusions: Nature of participation may have varying degrees of influence on types of clinical quality metrics. Sustained participation may support management of chronic conditions. Administrative claims data will help to elucidate our findings.

Effectiveness of Implementing a Predischarge Order to Discharge Patients Before 11 a.m. Barriers to early discharges include poor communication among the healthcare team and families, pending laboratory test results, delays in discharge orders, medical reconciliation list, and patient transport. The baseline data at our hospital in October 2017 (N = 1,021) showed that 5% of patients were discharged before 11 a.m., with the mean discharge processing time being 145 minutes. The goal of this study was to assess the effectiveness of using an electronic predischarge order to discharge more than 40% of patients before 11 a.m. A predischarge order set was created in the electronic record, which notified the nurses, pharmacists, and case and social workers to complete all tasks related to discharge (medication reconciliation, complete laboratory test results and imaging, and arrange transport with family and nursing homes). The resident teaching service group (N = 381) from November 2017 to September 2018 discharged 22% of their patients before 11 a.m. (baseline: 5%, p value = 3.38638E-22), and the mean total discharge time was 77 minutes (baseline: 145 minutes; p value = 1.12013E-19). Our inability to discharge more than 40% of patients from the resident teaching service group before 11 a.m. was attributed to 3 limitations. We propose three viable recommendations to meet our goal in a future intervention.