Routine, single-item screening to identify abusive relationships in women.

BACKGROUND: Abusive relationships are associated with several demographic factors and many clinical problems in women. However, practices often do not screen for abuse. METHODS: This is a descriptive study of 1526 women aged 19 to 69 years who completed a health survey in 31 office practices. The 53-item survey included a question designed to screen for an abusive relationship. Our analysis compared self-reported measures of symptoms (N = 13) and functional limitations (n = 6) of women who had abusive relationships with those who did not. We also examined the utility of using a constellation of clinical problems to identify risk for abuse. RESULTS: Women in abusive relationships were more likely to be poor (37% vs 14%; P < .001) and young (87% were younger than 51 years versus 69% of those who were not in such relationships; P < .001). They had twice as many bothersome symptoms (3.1 vs 1.7; P < .001) and functional problems (1.6 vs 0.8; P < .001). Approximately 40% (36/89) of low-income women with emotional problems were at risk for abuse versus only 6% (64/1025) of women with adequate financial resources and no emotional problems. However, because so many women were at low risk, almost twice as many in this group (n = 64) reported abusive relationships than in the high-risk group (n = 36). CONCLUSIONS: Women in abusive relationships have many symptoms and functional limitations. However, symptoms and clinical problems provide insufficient clues for abuse. It is better just to ask. A single-item screening question appears adequate for this purpose.

Improving efficiency in office practices.

Office practices are very busy places. However, a large degree of inefficiency and wasted effort is embedded in all of that activity. Improving efficiency enhances an office's ability to provide care in a more organized, comfortable environment for clinicians, staff, and patients alike. It improves access to care and allows more time to be spent on important clinical issues. Improving efficiency improves an office's work capacity without adding resources and, therefore, improves its financial performance as well.

Improving access to clinical offices.

Optimal access to office care requires a detailed understanding of a practice's capacity to provide care and demand for services. Once capacity and demand are known, they can be effectively managed to provide care today for those needs that arise today. Such a system of "open access" benefits clinicians and patients alike. This article describes specific steps a practice can take to achieve open access.

Rethinking incentives.

Financial incentives focused on individuals represent a naive understanding of the complexity of human motivation. This article recommends rethinking monetary incentives and moving toward the creation of workplaces that enable and allow the natural excellence that most individuals desire to achieve. Despite their wide use and superficial logic, monetary incentives have features that are toxic to systemic improvement and high performance. They often erode opportunities for true improvement, breed an atmosphere of expectation, decrease innovation, injure intrinsic motivation, and damage teamwork. When monetary "incentives" are used, we suggest directing them to a whole group or team of individuals to inspire teamwork, learning, and greater productivity.

Improving care through collaboration.

The opportunity to improve health care using existing scientific knowledge is immense. Much is known that is not being used in routine care, leading to a large gap between knowledge and practice. Collaborative improvement models bring health care professionals together to focus on this gap and to accelerate the pace of improvement in their organizations. This article describes one such model, the Institute for Healthcare Improvement's Breakthrough Series Collaborative model. Lessons are drawn to help inform future collaborative efforts that focus on the improvement of care.

From resistance to attraction: a different approach to change.

How can physician executives interested in promoting change be more effective at the task? This article explores how to create an attraction towards change, as opposed to viewing change as overcoming resistance. Learning to recognize naturally occurring change, identify attractors, explore the rationality of others' points of view, and reduce risk are clear and constructive insights from research and emerging systems science. Other ideas to consider are: Understand the issues of those you wish to change, create changes that are "exothermic," produce system changes, accept responsibility, learn from failed efforts, and focus on building relationships of trust.

Beyond survival: toward continuous improvement in medical care.

Using the scientific method, continuous improvement strives to attain unprecedented levels of performance - improved patient outcomes while maintaining or reducing costs. The needs for, and benefits of, continuous improvement are discussed along with a description of its basic elements. The approaches outlined can serve to greatly increase the pace of improvement in health care.

A report card on continuous quality improvement.

Efforts to incorporate the principles of continuous quality improvement (CQI) into health care have been underway for about ten years. In order to understand the lessons of this decade of experience, senior organizational leaders and experts in the field of health care were interviewed. This select group agreed that there have been concrete accomplishments: the tactic of assigning blame for mistakes to individuals is gradually giving way to an emphasis on detecting problems with process; there is a new focus on the health care customer; and many valuable projects have been inaugurated. Nevertheless, the interviews underlined the reality that the movement has not yet made a sizable impact on the U.S. health care system. Until there is a profound, organization-wide recognition of the need for change, universal commitment to CQI principles will not be achieved.

A framework for collaborative improvement: lessons from the Institute for Healthcare Improvement's Breakthrough Series.

The article describes the Breakthrough Series, a collaborative improvement model developed by the Institute for Healthcare Improvement. The model adapts and applies existing knowledge to multiple, similar sites to accomplish common aims. It has been used to address several of the most pressing issues in health care today. The article outlines key elements of the Breakthrough Series to provide a framework for future collaborative improvement efforts.

Tuberculin skin testing of hospitalized patients.

OBJECTIVES: We sought to define the prevalence of tuberculin skin test (TST) positivity in a group of newly hospitalized patients, to identify risk factors for positive tests, and to examine the impact of testing on infection control practices. DESIGN: Unblinded cohort study over 5 days in July 1992. SETTING: A 1,000-bed university-affiliated hospital. PATIENTS: All patients admitted (excluding obstetric patients and newborns) were interviewed. Patients without a history of tuberculosis (TB) or a positive TST were offered a TST with Candida and tetanus controls. RESULTS: Of 346 patients offered the test, 21 (6%) had a prior history of TB or a positive TST, and 36 (10%) declined to participate; 279 of the remaining 289 completed the study. Anergy was demonstrated in 94 (33.7%) of 279 patients. New positive TSTs were identified in 19 (10.3%) of 185 nonanergic patients. Of the 19 TST-positive patients, 6 (32%) had infiltrates on chest radiographs and were evaluated for active TB. One patient was treated empirically for active TB, and five received isoniazid prophylaxis. Risk factors for a new positive TST included age (odds ratio [OR], 1.56 per decade of life; P = .021), African American race (OR, 4.81; P = .008), alcohol abuse (OR, 5.53; P = .005), and peptic ulcer disease (OR, 4.53; P = .017). Risk factors for anergy included admission to a surgical service (OR, 2.1; P = .006), current use of steroids (OR, 2.65; P = .005), and human immunodeficiency virus (HIV) infection (OR, undefined; P = .034). CONCLUSIONS: Despite a high rate of anergy, routine tuberculin skin testing identified a substantial number of patients with TB infection who might otherwise have gone unrecognized.

Metformin: a safe and effective treatment in the management of NIDDM.

The oral antihyperglycemic drug metformin has a unique mechanism of action and controls glycemia in both obese and normal-weight NIDDM patients without inducing hypoglycemia, insulin stimulation or hyperinsulinemia. Metformin used in combination with sulfonylureas has a synergistic effect in lowering fasting and postprandial glucose and hemoglobin A1c levels, and improving the lipid profile. Metformin does not increase lactate production from skeletal muscle and has little clinically significant effect on vitamin B12 and folic acid absorption. Lactic acidosis associated with metformin use is extremely rare (reported incidence of 0.03/1,000 patient-years exposure) and has occurred predominantly in patients for whom the drug was contraindicated. Observance of prescribing guidelines will greatly minimize risk, since risk factors have been identified. Metformin can be safely used in the elderly, provided prescribing precautions are followed. Dosing in the elderly should be conservative, with dose adjustment designed to achieve normal blood sugar levels.

Interactions between the sorbitol pathway, non-enzymatic glycation, and diabetic vascular dysfunction.

BACKGROUND: Many lines of evidence attest to a multifactorial pathogenesis of diabetic complications in humans and in animal models of diabetes. Increased sorbitol pathway metabolism and non-enzymatic glycation products have been implicated by many investigators in the pathogenesis of vascular and neural dysfunction as well as early vascular structural changes in animal models of diabetes. The present studies were undertaken to assess the mechanisms that mediate vascular dysfunction associated with these biochemical imbalances. METHODS: Three different animal models of diabetes were used: (1) rats with diabetes induced by injection of streptozotocin; (2) non-diabetic rats with acute hyperglycaemia of 5 h duration induced by i.v. glucose infusion at a rate sufficient to produce plasma glucose levels comparable to those in diabetic rats; and (3) the skin chamber granulation tissue model in which vessels in the chamber are exposed to buffer containing 5 or 30 mM glucose +/- pharmacological agents or 0.1 microM glycated rat serum albumin +/- pharmacological agents. Vascular function was assessed by injection of 11.3 microns 46Sc microspheres for quantification of blood flow and by injection of [125I] and [131I]bovine serum albumin for quantification of vascular albumin permeation. RESULTS: Vascular dysfunction induced by elevated glucose levels (increased blood flow and increased albumin permeation) in all three models was prevented by inhibitors of sorbitol pathway metabolism, inhibitors of nitric oxide synthesis and inhibitors of prostaglandin synthesis. In the skin chamber model vascular dysfunction induced by elevated glucose levels and by glycated rat serum albumin was prevented by superoxide dismutase, probucol and inhibitors of nitric oxide synthase. CONCLUSIONS: These observations suggest that vascular dysfunction induced by increased sorbitol pathway metabolism (caused by elevated glucose levels) and by products of non-enzymatic glycation (at normal glucose levels) is mediated by a common final pathway consistent with a scenario in which: increases superoxide production-->increases intracellular calcium levels-->increases nitric oxide synthesis-->increases blood flow and increases vascular permeability.