Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports.

Importance: Antibiotic resistance is a global health issue. Up to 50% of antibiotics are inappropriately prescribed, the majority of which are for acute respiratory tract infections (ARTI). Objective: To evaluate the impact of unblinded normative comparison on rates of inappropriate antibiotic prescribing for ARTI. Design: Non-randomised, controlled interventional trial over 1 year followed by an open intervention in the second year. Setting: Primary care providers in a large regional healthcare system. Participants: The test group consisted of 30 primary care providers in one geographical region; controls consisted of 162 primary care providers located in four other geographical regions. Intervention: The intervention consisted of provider and patient education and provider feedback via biweekly, unblinded normative comparison highlighting inappropriate antibiotic prescribing for ARTI. The intervention was applied to both groups during the second year. Main outcomes and measures: Rate of inappropriate antibiotic prescription for ARTI. Results: Baseline inappropriate antibiotic prescribing for ARTI was 60%. After 1 year, the test group rate of inappropriate antibiotic prescribing decreased 40%, from 51.9% to 31.0% (p<0.0001), whereas controls decreased 7% (61.3% to 57.0%, p<0.0001). In year 2, the test group decreased an additional 47% to an overall prescribing rate of 16.3%, and the control group decreased 40% to a prescribing rate of 34.5% after implementation of the same intervention. Conclusions and relevance: Provider and patient education followed by regular feedback to provider via normative comparison to their local peers through unblinded provider reports, lead to reductions in the rate of inappropriate antibiotic prescribing for ARTI and overall antibiotic prescribing rates.

Recruiting primary care physicians to teach medical students in the ambulatory setting: a model of protected time, allocated money, and faculty development.

PROBLEM: Medical schools face barriers to recruiting physicians to teach in the ambulatory setting for many reasons, including time required to teach, loss of productivity when learners are present, and physicians' uncertainty about how to teach. APPROACH: In 2012, the primary care department of the University of Queensland-Ochsner Clinical School (UQ-OCS) implemented an innovative model for recruiting primary care physicians to teach students in their clinics. The model's three-pronged approach allows protected teaching time, allocates tuition money to reimburse physicians for teaching via educational value unit (EVU) tracking, and includes a faculty development program. OUTCOMES: In the first two years of EVU tracking (academic years 2012 and 2013), 5,530 EVUs were provided by 48 primary care faculty teaching 60 students at 11 sites. In academic year 2013, the first year in which tuition dollars were available to fund teaching by primary care faculty, over $120,000 in tuition money was transferred to the department to pay for EVUs. No faculty in 2012 or 2013 experienced a change in salary as a result of teaching activities. Faculty development workshops have been well attended. The general practice clerkship has been the top-rated third-year clerkship by students for the first three years of clinical rotations at the UQ-OCS. NEXT STEPS: A qualitative study to describe the barriers to and solutions for recruiting physicians to teach students in ambulatory settings is planned. Other studies will evaluate the effectiveness of faculty development efforts and the impact of students' presence on patients' access to clinic appointments.

Long-term effects of a diabetes boot cAMP on measures of diabetic care.

BACKGROUND: Diabetic patients should receive self-management education to improve self-care and quality of life but are frequently unable to attend such programs because of the time commitment. We instituted an intensive 2-hour Diabetes Boot Camp to provide this education in a condensed time frame. The objective was to determine the long-term effect of the boot camp on mean hemoglobin A1c (HgA1c) levels in patients with diabetes compared to diabetic patients receiving the standard of care. METHODS: The Diabetes Boot Camp population was defined as all diabetic patients referred to the boot camp from the 10 highest utilizing physicians between August 2009 and August 2010. A control population was randomly selected from these same physicians' diabetic patients during the same period. Baseline and postintervention HgA1c measurements on the same patients in both groups were extracted from the electronic medical record. Subpopulations studied included those with HgA1c ≥9% and <9% at baseline. To evaluate long-term effects, we compared HgA1c levels 3 years later (between July 1, 2012 and December 31, 2012) for all groups. RESULTS: Using comparison-over-time analysis, the overall boot camp group (n=69) showed a mean decrease in HgA1c from 8.57% (SD ± 2.32%) to 7.76% (SD ± 1.85%) vs an increase from 7.92% (SD ± 1.58%) to 8.22% (SD ± 1.82%) in the control group (n=107, P<0.001). Mean length of follow-up was 3.2 (SD ± 0.54) years. CONCLUSION: An intensive 2-hour multidisciplinary diabetes clinic was associated with significant long-term improvements in glycemic control in diabetic participants of the clinic.

Effects of a diabetes boot cAMP on hemoglobin a1c levels.

BACKGROUND: Diabetic education can have significant effects in improving glycemic markers in patients with diabetes. This study sought to determine if the Diabetes Boot Camp, a novel 2-hour, intensive educational program by a multidisciplinary team, was effective in lowering mean hemoglobin A1c (HgA1c) levels in diabetic patients when compared to the standard of care. METHODS: The research design was that of a retrospective cohort study. The Diabetes Boot Camp population was defined as all diabetic patients referred to the boot camp clinic from the 10 physicians referring the most patients to the clinic from August 2009-August 2010. Three control populations were randomly selected from the same physicians' diabetic patients identified in the Ochsner primary care diabetes database during the same period. Pre- and postintervention HgA1c measurements on the same patients in all groups were analyzed. Control populations studied included an overall group, patients with HgA1c >9%, and patients with HgA1c ≤9%. RESULTS: Overall, the Diabetes Boot Camp cohort showed a significant decrease in mean HgA1c of 1.25% versus 0.11% compared to the control cohort (P<0.001). In the other analyses, Diabetes Boot Camp patients with HgA1c >9% and those with HgA1c ≤9% had statistically significant reductions in HgA1c compared to the control groups (P<0.001). CONCLUSION: An intensive 2-hour multidisciplinary diabetes clinic demonstrated significant improvements in glycemic control as measured by HgA1c compared to standard care.