Card studies for observational research in practice.

PURPOSE: Observational studies that collect patient-level survey data at the point-of-care are often called card studies. Card studies have been used to describe clinical problems, management, and outcomes in primary care for more than 30 years. In this article we describe 2 types of card studies and the methods for conducting them. METHODS: We undertook a descriptive review of card studies conducted in 3 Colorado practice-based research networks and several other networks throughout the United States. We summarized experiences of the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP). RESULTS: Card studies can be designed to study specific conditions or care (clinicians complete a card when they encounter patients who meet inclusion criteria) and to determine trends and prevalence of conditions (clinicians complete a card on all patients seen during a period). Data can be collected from clinicians and patients and can be linked. CONCLUSIONS: Card studies provide cross-sectional descriptive data about clinical care, knowledge and behavior, perception of care, and prevalence of conditions. Card studies remain a robust method for describing primary care.

Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN) Study.

OBJECTIVE: The aim of this study was to learn about community members' definitions and types of harm from medical mistakes. METHODS: Mixed methods study using community-based participatory research (CBPR). The High Plains Research Network (HPRN) with its Community Advisory Council (CAC) designed and distributed an anonymous survey through local community newspapers. Survey included open-ended questions on patients' experiences with medical mistakes and resultant harm. Qualitative analysis was performed by CAC and research team members on mistake descriptions and types of reported harm. Patient Safety Taxonomy coding was performed on a subset of surveys that contained actual medical errors. RESULTS: A total of 286 surveys were returned, with 172 respondents (60%) reporting a total of 180 perceived medical mistakes. Quantitative analysis showed that 41% of perceived mistakes (n = 73) involved only unanticipated outcomes. Reported types of harm included emotional, financial, and physical harm. Reports suggest that perceived clinician indifference to unanticipated outcomes may lead to patients' loss of trust and belief that the unexpected outcome was a result of an error. DISCUSSION: CBPR methodology is an important strategy to design and implement a community-based survey. Community members reported experiencing medical mistakes, most with harmful outcomes. The response they received by the medical community may have influenced their perception of mistake and harm.

Action or inaction? Decision making in patients with diabetes and elevated blood pressure in primary care.

OBJECTIVE: Hypertension increases micro- and macrovascular complications of diabetes. The goal for blood pressure is <130/80 mmHg. In primary care, however, blood pressure in many patients exceeds this goal. In this study, we evaluated the clinical decision-making process when a patient with diabetes presents with elevated blood pressure. RESEARCH DESIGN AND METHODS: Twenty-six primary care practices in two practice-based research networks in Colorado participated. Questionnaires were completed after each encounter with an adult with type 2 diabetes. Data obtained from the survey included 1) demographic information, 2) blood pressure results, 3) action taken, 4) type of action if action was taken, and 5) reasons for inaction if action was not taken. Bivariate and multivariate analyses were performed to identify predictors of action. RESULTS: Completed surveys totaled 778. Blood pressure was 130/74 +/- 18.8/12.0 mmHg (mean +/- SD). Sixty-two percent of patients exceeded goals. Action was taken to lower blood pressure in 34.9% of those. Predictors of action were 1) blood pressure level, 2) total number of medicines the patient was taking, and 3) patient already taking medicines for blood pressure. As blood pressure rose, providers attributed inaction more often to "competing demands" and reasons other than "blood pressure being at or near goal." CONCLUSIONS: No evidence was found for patterns of poor care among primary care physicians. Providers balance the clinical circumstances, including how elevated the blood pressure is, and issues of polypharmacy, medication side effects, and costs when determining the best course of action. Knowledge deficit is not a common cause of inaction.

Barriers to quality care for dying patients in rural communities.

CONTEXT: Barriers to providing optimal palliative care in rural communities are not well understood. PURPOSE: To identify health care personnel's perceptions of the care provided to dying patients in rural Kansas and Colorado and to identify barriers to providing optimal care. METHODS: An anonymous self-administered survey was sent to health care personnel throughout 2 rural practice-based research networks. Targeted personnel included clinicians, nurses, medical assistants, chaplains, social workers, administrators, and ancillary staff, who worked at hospice organizations, hospitals, ambulatory clinics, public health agencies, home health agencies, and nursing homes. FINDINGS: Results from 363 completed surveys indicated that most health care personnel were satisfied with the palliative care being provided in their health care facilities (84%) and that most were comfortable helping dying patients transition from a curative to a palliative focus of care (87%). Yet, many reported that the palliative care provided could be improved and many reported that family members' avoidance of issues around dying (60%) was a barrier to providing optimal care in rural health care facilities. CONCLUSIONS: Findings suggest that health care personnel perceive they are effective at providing palliative care in their rural health care facilities, yet face barriers to providing optimal end-of-life care. Results of this study suggest that differences in training and experience may influence health care personnel's perceptions of the existing barriers. It may be important in rural areas to customize interventions to both the professional role and the site of care.

Triage and diagnosis of chest pain in rural hospitals: implementation of the ACI-TIPI in the High Plains Research Network.

PURPOSE: The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) has been shown to improve diagnostic accuracy of acute cardiac ischemia (ACI) and decrease coronary care unit admissions in urban emergency departments. The purpose of this study was to determine the impact of the ACI-TIPI on triage and diagnosis of patients with chest pain in rural hospitals. METHODS: We undertook a controlled trial of the impact ACI-TIPI use in the High Plains Research Network (HPRN). Main outcome measures were the triage of patients in emergency departments (admission, transfer, or discharge home) and diagnostic accuracy. RESULTS: There were 1,861 patients seen during a 10-month period. Forty-five percent of all patients complaining of chest pain were discharged home from the emergency department. Eight percent were transferred from the emergency department, and another 10% were transferred later after admission. Among patients with acute myocardial infarction or unstable angina, 22.2% were transferred directly from the emergency department and only 3% were discharged home when ACI-TIPI was available, compared with 18.7% transferred and 5.2% discharged home when not available (P = .4). Diagnostic accuracy was high and not statistically different with the addition of the ACI-TIPI score (86.8% ACI-TIPI off vs 89.0% ACI-TIPI on, P = .15), CONCLUSIONS: Physicians in the HPRN provided appropriate diagnosis and triage to patients with chest pain. Routine addition of the ACI-TIPI score did not improve diagnostic accuracy or significantly change triage. Further research on ACI-TIPI in rural hospitals is necessary before recommending routine use of the ACI-TIPI.