Influencing physician practice patterns

Influencing physician practice patterns

the operative procedure performed. The resident either viewed the CD-ROM or read the text model the evening before the surgery and then filled out a q...

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the operative procedure performed. The resident either viewed the CD-ROM or read the text model the evening before the surgery and then filled out a questionnaire afterward. Operations included TAH/BSO, TVH/BSO, cold knife conization, anterior colporrhaphy, perineorrhaphy, and Burch retropubic urethropexy. Helpfulness with indications, pelvic anatomy, understanding of techniques/methods, learning the names and uses of surgical instruments, and completing dictation were assessed in a rating system of 0 (not helpful) to 7 (extremely helpful). Results: During the study period, six residents completed questionnaires in both groups (CD-ROM, text group). The mean differences in resident evaluation of the surgical indications were 2.67 (Mann-Whitney rank sum, P ⫽ 0.0022); pelvic anatomy, 3.0 (Mann-Whitney rank sum, P ⫽ 0.0065); surgical techniques, 1.83 (Mann-Whitney rank sum, P ⫽ 0.0082); knowledge and use of instruments, 3.0 (Mann-Whitney rank sum, P ⫽ 0.0022); aid in completing surgical dictations, 3.167 (Mann-Whitney rank sum, P ⫽ 0.0022); and overall usefulness: 2.33 (Mann-Whitney rank sum, P ⫽ 0.0022). Conclusion: One of the biggest complaints from junior residents has been the lack of good photographs in traditional surgical textbooks. The residents in this study felt that the photographs shown on the CD-ROM better aided their knowledge of the indications, techniques, and surgical anatomy of the aforementioned procedures. We believe that the CD-ROM medium is underused and that it could provide better resident education, especially if combined with the traditional surgical textbook.

Care of the Dying Newborn: Perinatal Hospice, Research, and Practice Anita J. Catlin, DNSc Napa Valley College, Napa, CA

Byron C. Calhoun, MD, and Brian S. Carter, MD Purpose: To inform providers of the state of the nation in the provision of neonatal palliative care. Methods: A practicing maternal–fetal medicine specialist will describe efforts to create a hospice setting for newborns. The primary investigator of the Internet-based national Delphi study to create a neonatal end-of-life palliative care protocol will review the methodology and outcomes of the protocol developed by neonatologists, obstetricians, maternal–fetal physicians, parents, nurses, ethicists, hospice specialists, social scientists, lawyers, policy makers, and others, using sequential questionnaires. Results: Research findings will include: 1) candidates for comfort care; 2) transfer to Level III versus local community hospital care; 3) best location for provision of comfort care— eg, NICU, postpartum ward, hospice, home; 4) essential components of an optimally supported neonatal dying process, including needs of parents and needs of staff; 5) step-by-

VOL. 97, NO 4 (SUPPLEMENT), APRIL 2001

step process for ventilator withdrawal, including protocol for managing the infant who does not expire as expected when life support is withdrawn; and 6) family and staff follow-up needs. Conclusions: Physicians have reported a need for clinical and ethical guidelines for the care of the neonate with a lifelimiting condition. Nationally created guidelines are now available.

Comparison of Osteoporosis Knowledge in Menopausal Women Who View a Teaching Video Versus Those Who Don’t Martin Martino, MD UMDNJ–Robert Wood Johnson Medical School, New Brunswick, NJ

Gloria Bachmann, Jennifer Kulp, and Sarika Rane Objective: To determine the effectiveness of enhancing osteoporosis education for menopausal patients via a video. Methods: Data were collected from 194 menopausal, ambulatory patients: 98 patients observed an educational osteoporosis video before their office visit, and 96 patients did not view the video. After their gynecologic visit, all patients answered a standardized osteoporosis questionnaire. Results: No statistically significant differences were noted as to the demographics of the patients, including level of education. Test scores for the control group were 82%, versus 94% for the video group. The most notable differences: two-thirds of those who did not view the video did not know the role of hormone replacement therapy in osteoporosis treatment and prevention and did not understand the role of family history and the role of weight-bearing exercise. The video group answered these questions correctly. Conclusion: The study objectively demonstrated that the use of educational materials in addition to physician counseling improves patient understanding of osteoporosis.

Influencing Physician Practice Patterns J. Patrick Lavery, MD Bronson Hospital, Kalamazoo, MI

Mary Kindle, BSN, Linda Hutchinson, RN, and Jane Janssen, MBA, RN Objective: A program was initiated to change physician ordering patterns to reduce routine postpartum blood count (CBS) determinations and ensure cost-effective quality care.

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Methods: A retrospective review showed that routine CBS determinations after vaginal deliveries did not affect patient care. Subsequently, a review of 1,618 charts was made over an 11-month study period. Three periods were studied: first, a baseline period assessing routine CBS use; second, after a physician education program about the negligible benefit of routine postpartum CBS use; third, after the routine order for ‘CBS in am postpartum was deleted from the preprinted order sheet. Maternal complications, including readmission and anemia-associated events, also were assessed. Results: Study Period—Patients

% Routine postpartum CBS

1st— 463 2nd—256 3rd— 899

65.8% 50.0% ⫺ P ⬍ 0.05 from 1st* 14.3% ⫺ P ⬍ 0.005 from 2nd*

Rogers’ theory, and frustrations correlated with failure to adhere to these concepts. Methods: A multidisciplinary team designed three guidelines that were presented at departmental meetings. A feedback reporting system was designed, consisting of quarterly reports with overall cesarean delivery rates and detailed individual and aggregate data about utilization of the guidelines. A retrospective analysis of the 4-year effort compared the actions taken with the four elements of Rogers’ theory. Conclusion: CQI efforts can be more effective with a better understanding of factors that lead some ideas to be adopted more quickly than others. Rogers’ theory holds great promise to streamline CQI efforts, increase their efficacy, and improve patient outcomes.

* X-analysis

The cost savings from reduced lab testing were projected to be $22,112, based on an annual delivery rate of 2,639 births. Conclusion: Physician practice patterns were modified somewhat by education but to a greater degree by influencing ordering habits. In this case, modification of preprinted orders had the greatest impact. Cost-effectiveness of this program was demonstrated, and quality of care was maintained.

Optimizing Quality Improvement in Obstetrics: An Application of the Diffusion of Innovations Theory David P. Johnson, MD Providence St. Vincent Medical Center, Portland, OR

Nancy R. Davis, MP, Diane Waldo, RN, MBA, CPHQ, and Katherine Criswell, RN, MSN Purpose: To enhance understanding of why continuous quality improvement (CQI) efforts in obstetrics often fail and why well-researched practice guidelines do not achieve widespread adoption, to review a recent CQI project to reduce cesarean delivery rates, and to gain a better understanding of the factors that lead some ideas to be adopted more quickly than others. Results: At the start of the project, the overall cesarean delivery rate was 19.4%, with wide variation among individual providers. At the conclusion, cesarean delivery rates were virtually unchanged. After considerable efforts by the obstetrics department and hospital quality management, there was minimal utilization of the practice guidelines. A retrospective analysis using Everett Rogers’ diffusion of innovations theory showed an apparent correlation between the project’s successes and failures and the concepts of Rogers’ theory, successes correlated with actions that had inadvertently followed

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Patient Vaccine Awareness in an Ob-Gyn Setting Bernard Gonik, MD Wayne State University School of Medicine, Detroit, MI

Mark Tomlinson, MD Objective: To better understand patient vaccine awareness, a survey was tested in ob-gyn continuity teaching clinics to evaluate patient preferences and their knowledge about their immunization status. Methods: Masked questionnaires were offered to ob-gyn patients attending two geographically distinct clinic sites. The survey contained 12 yes/no or multiple-choice questions exploring demographic, recollection, and preference items concerning vaccine-preventable diseases. Chi-square analysis was used for categoric data, and the Student t test was used for continuous data. Results: A total of 228 surveys were completed (Site 1 ⫽ 101; Site 2 ⫽ 127). No significant differences were seen between the two clinics for any of the variables tested. The mean (⫹ SD) patient age for the study population was 27.4 (⫾10.6) years. Prenatal care was the most frequent clinic visit indication (57.0%). Only 25.6% of the subjects reported having documentation of their childhood vaccine information, and only 15.5% had documentation of adult vaccine information. Of the vaccine-preventable diseases surveyed, fewer than half of the respondents reported adequate protection (either by vaccination or prior exposure) against measles (30.5%), varicella (48.5%), hepatitis B (36.1%), or tetanus (43.1%). Annual vaccination against influenza was uncommon (23.6%). Family medicine/internist office was the most frequently reported site of vaccine administration (28.6%), followed by ob-gyn (21.7%) and health department (10.3%). The remaining 39.4% reported having no designated vaccination site. Of note, the overwhelming majority (84.0%) expressed the desire to use their ob-gyn for such services if they were available. Conclusions: The majority of patients surveyed have no documentation of their vaccination history. By patient recall, most are not adequately immunized against a number of

Obstetrics & Gynecology