CD8+ T-cell mediated anti-malaria protection induced by malaria vaccines; assessment of hepatic CD8+ T cells by SCBC assay.

Malaria is a severe infectious disease with relatively high mortality, thus having been a scourge of humanity. There are a few candidate malaria vaccines that have shown a protective efficacy in humans against malaria. One of the candidate human malaria vaccines, which is based on human malaria sporozoites and called PfSPZ Vaccine, has been shown to protect a significant proportion of vaccine recipients from getting malaria. PfSPZ Vaccine elicits a potent response of hepatic CD8+ T cells that are specific for malaria antigens in non-human primates. To further characterize hepatic CD8+ T cells induced by the sporozoite-based malaria vaccine in a mouse model, we have used a cutting-edge Single-cell Barcode (SCBC) assay, a recently emerged approach/method for investigating the nature of T-cells responses during infection or cancer. Using the SCBC technology, we have identified a population of hepatic CD8+ T cells that are polyfunctional at a single cell level only in a group of vaccinated mice upon malaria challenge. The cytokines/chemokines secreted by these polyfunctional CD8+ T-cell subsets include MIP-1α, RANTES, IFN-γ, and/or IL-17A, which have shown to be associated with protective T-cell responses against certain pathogens. Therefore, a successful induction of such polyfunctional hepatic CD8+ T cells may be a key to the development of effective human malaria vaccine. In addition, the SCBC technology could provide a new level of diagnostic that will allow for a more accurate determination of vaccine efficacy.

Addressing Disparities in Stroke Prevention for Atrial Fibrillation: Educational Opportunities.

Disparities in atrial fibrillation (AF)-related stroke and mortality persist, especially racial disparities, within the US "Stroke Belt." This study identified barriers to optimal stroke prevention to develop a framework for clinician education. A comprehensive educational needs assessment was developed focusing on clinicians within the Stroke Belt. The mixed qualitative-quantitative approach included regional surveys and one-on-one clinician interviews. Identified contributors to disparities included implicit racial biases, lack of awareness of racial disparities in AF stroke risk, and lack of effective multicultural awareness and training. Additional barriers affecting disparities included patient medical mistrust and clinician-patient communication challenges. General barriers included lack of consistency in assessing stroke and anticoagulant-related bleeding risk, underuse of standardized risk assessment tools, discomfort with novel anticoagulants, and patient education deficiencies. Effective cultural competency training is one strategy to reduce disparities in AF-related stroke and mortality by improving implicit clinician bias, addressing medical mistrust, and improving clinician-patient communication.

A community-based collaborative approach to improve breast cancer screening in underserved African American women.

Although African American women in the United States have a lower incidence of breast cancer compared with white women, those younger than 40 years actually have a higher incidence rate; additionally, African American women are more likely to die from breast cancer at every age compared with white women. Racial disparities in breast cancer mortality rates are especially significant in Maryland, which ranks fifth in the nation for breast cancer mortality, and in Baltimore City, which has the second highest annual death rate for African American women in Maryland. To address this disparity in care, Med-IQ, an accredited provider of CME, collaborated with Sisters Network Baltimore Metropolitan, Affiliate Chapter of Sisters Network® Inc., the only national African American breast cancer survivorship organization, to sponsor their community-based educational outreach initiative. The collaborative mission was to engage at-risk African American women, their families, local organizations, healthcare professionals, and clinics, with the goals of increasing awareness, addressing fears that affect timely care and diagnosis, and encouraging women to obtain regular mammograms. Intervention strategies included (1) a "Survivor Stories" video, (2) patient outreach consisting of neighborhood walks and an educational luncheon, and (3) a community outreach utilizing direct mailings to local businesses, community groups, and healthcare professionals. Trusted and well-known community resources were presented as mediums to promote the initiative, yielding achievement of broader and more effective outcomes. As a result of this patient-friendly initiative, two (2) of the women who sought screening were diagnosed with breast cancer and underwent treatment.

A clinician performance initiative to improve quality of care for patients with osteoporosis.

BACKGROUND: Osteoporosis is a widespread but largely preventable disease. Improved adherence to screening and treatment recommendations is needed to reduce fracture and mortality rates. Additionally, clinicians face increasing demands to demonstrate proficient quality patient care aligning with evidence-based standards. METHODS: A three-stage, clinician-focused performance improvement (PI) continuing medical education (CME) initiative was developed to enhance clinician awareness and execution of evidence-based standards of osteoporosis care. Clinician performance was evaluated through a retrospective chart analysis of patients at risk or with a diagnosis of osteoporosis. RESULTS: Seventy-five participants reported their patient practices on a total of 1875 patients before and 1875 patients after completing a PI initiative. Significant gains were made in the use of Fracture Risk Assessment Tool (FRAX) (stage A, 26%, n=1769 vs. stage C, 51%, n=1762; p<0.001), assessment of fall risk (stage A, 46%, n=1276 vs. stage C, 89%, n=1190; p<0.001), calcium levels (stage A, 62%, n=1451 vs. stage C, 89%, n=1443; p<0.001), vitamin D levels (stage A, 79%, n=1438 vs. stage C, 93%, n=1439; p<0.001), and medication adherence (stage A, 88%, n=1136 vs. stage C, 96%, n=1106; p<0.001). CONCLUSIONS: Gains in patient screening, treatment, and adherence were associated with an initiative promoting self-evaluation and goal setting. Clinicians must assess their performance to improve patient care and maintain certification. PI CME is a valid, useful educational tool for accomplishing these standards.

Enhancing the quality of care for patients with multiple sclerosis through performance improvement CME.

Multiple sclerosis (MS) is an inflammatory neurodegenerative disease marked by a heterogeneous clinical presentation and disease course. Although improvements in the recognition and management of MS have been made in recent years, challenges remain due to the complex nature of the disease. Clinicians must remain current with their skills as knowledge surrounding MS care continues to advance. Here we report results of a performance improvement (PI) continuing medical education (CME) activity that was designed to promote evidence-based care of patients with MS. Participants demonstrated significant improvements in assessing disease-related complications, treating cognitive dysfunction, assessing adherence, and providing disease-related educational materials. These data support the role of PI CME in improving clinician practices that align with quality MS patient care.

Crew resource management and VTE prophylaxis in surgery: a quality improvement initiative.

Despite the availability of safe and effective prophylaxis, appropriate use of venous thromboembolism (VTE) prophylaxis in surgical patients remains suboptimal. Multifaceted quality improvement (QI) activities are needed for sustained improvement at the individual institution level. This work describes a QI initiative for VTE prophylaxis in surgery that combined clinical education with Crew Resource Management (CRM)--a set of principles and techniques for communication, teamwork, and error avoidance used in the aviation industry. Surveys of clinicians participating in the initiative demonstrated immediate and retained confidence and increased knowledge in identifying process-related factors leading to errors, applying CRM to patient care, and identifying VTE prophylaxis candidates and guideline-recommended prophylaxis regimens. Reviews of patient charts preinitiative and postinitiative demonstrated performance improvement in meeting guideline recommendations for the timing, inpatient duration, and use of VTE prophylaxis beyond discharge. This new model joins continuing medical education with CRM to improve the appropriate use of VTE prophylaxis in surgery.

A report of quality improvement in the care of patients with acute coronary syndromes.

Despite the existence and wide acceptance of guidelines for the treatment of patients with acute coronary syndromes, gaps in patient care still remain. To improve clinical processes of acute coronary syndromes care, a performance improvement (PI) continuing medical education (CME) program, a CME format approved by the American Medical Association, was developed. Clinician participants underwent a 3-stage process: (1) an initial patient chart review for self-assessment purposes, (2) the development and implementation of a personalized PI plan focusing on strategies to enhance processes of care, and (3) a second patient chart review to assess the changes in practice. Although participants provided a high baseline level of guideline-recommended care, there was an improvement in the documentation of the use of risk scores and a trend towards improved treatment times including many participants reaching a door-to-needle time of within 30 minutes. Participants were also more likely to measure cardiac biomarkers and document electrocardiogram performance times. These results demonstrate that PI is a valid and effective means of CME that has the potential to positively affect patient outcomes.

Physician practice patterns in acute coronary syndromes: an initial report of an individual quality improvement program.

The American College of Cardiology and the American Heart Association guidelines are the nationally accepted standards for the treatment of patients with acute coronary syndromes. Despite this recognition, adherence to guideline recommendations remains suboptimal with 25% of opportunities to provide guideline appropriate care missed. To address performance gaps related to acute coronary syndrome care and improve patient outcomes, a performance improvement (PI) initiative was designed for cardiologists and emergency department physicians. As an American Medical Association-approved, standardized continuing medical education initiative, participating physicians can earn up to 20 American Medical Association-PRA Category 1 Credits by completing 2 phases of self-assessment in addition to developing and implementing a PI plan to address self-identified areas where improvement in patient care is needed. As the second in a series of 3 articles, this article describes the initial data submitted by 101 participating physicians and how their treatment practices compared with American College of Cardiology/American Heart Association guidelines as well as with current national standards. Overall, participating physicians meet guideline expectations with performance and documentation of a 12-lead electrocardiography, measurement of cardiac biomarkers, and administration of aspirin. Identified areas of improvement were the standardization of treatment protocols, use of risk assessment scores, appropriate dosing of anticoagulants, and improvement in patient treatment times. A noted challenge of this PI initiative is the low rate of physician participation, with fewer than 10% of registered physicians actively submitting patient data. This fact may reflect several barriers to PI, such as: (1) lack of time to collect and submit data, (2) the belief that current practices do not need to be improved, and (3) the need for system-based improvements.

The use of antithrombotic therapies in the prevention and treatment of arterial and venous thrombosis: a survey of current knowledge and practice supporting the need for clinical education.

Arterial and venous thrombosis are serious health threats. Patients with atrial fibrillation (AF), acute coronary syndromes (ACS), and venous thromboembolism (VTE) can reduce their risk of thrombosis through proper anticoagulation. Multiple evidence-based guidelines exist regarding the proper use of antithrombotic therapy, yet previous studies have shown the prevalence of inconsistent practices with respect to guideline recommendations. Here, we describe a survey of 647 practicing physicians and their current beliefs, behaviors, and knowledge surrounding the use of antithrombotic therapies in the treatment of their patients with AF, ACS, and VTE. Results show that while most physicians are confident in their abilities to treat patients with these conditions, specific knowledge of guideline recommendations for the optimal use of antithrombotic agents use is low. In addition, physician concerns over bleeding risks and complicated monitoring procedures associated with antithrombotic use were reported as barriers to their use in patients. Survey results also demonstrated that physicians have little knowledge of investigational antithrombotic agents, but would like education about them. These data suggest a need for education on guideline recommendations regarding the appropriate use of current antithrombotic therapies, as well as a need for information on the potential benefits and limitations of investigational drugs that may be used in the future to manage thrombosis in patients with AF, ACS, and VTE.

Individual quality improvement in acute coronary syndromes: a performance improvement initiative.

Although treatment guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) have been published and widely accepted, barriers to the optimal management of patients with acute coronary syndromes (ACS) still exist. Adherence to guidelines has been correlated with improvements in patient outcomes in ACS, including reduced mortality, yet data demonstrate that 25% of opportunities to provide guideline-recommended care are missed. This article describes a performance improvement (PI) initiative designed to address gaps in process-related ACS care and improve patient outcomes. PI is an American Medical Association-approved, standardized continuing medical education format in which physicians can earn up to 20 American Medical Association PRA category 1 credits by completing 2 phases of self-assessment and developing and implementing a PI plan to address self-identified areas in which patient care can be improved. In this ACS PI initiative, physicians will assess their practice using performance measures defined by the 2007 ACC/AHA ST-segment elevation myocardial infarction and unstable angina or non-ST-segment elevation myocardial infarction guideline updates within 3 general benchmark areas: (1) patient risk assessment, (2) initial pharmacologic management, and (3) time-to-treatment (ie, "door-to-needle," "door-to-balloon," and "door-in-door-out" times). After completing a self-assessment and identifying 1 or more areas of improvement, participants can complete educational interventions and access benchmark-specific tools that provide guidance on improving adherence with the ACC/AHA guidelines. This PI initiative supplements other ongoing quality improvement initiatives in ACS, but is unique in that it is the first to use individual physician self-assessment, benchmark-focused continuing medical education, and self-developed PI plans to improve process-related ACS care.

Pharmacy informatics syllabi in doctor of pharmacy programs in the US.

OBJECTIVES: To assess pharmacy informatics education, identify current competencies, and develop a foundational set of recommendations. METHODS: Accredited pharmacy programs were contacted. Data were collected using a mixed-mode procedure. Didactic and experiential syllabi were analyzed for compliance with informatics competencies in Accreditation Council for Pharmacy Education (ACPE) Standards 2007. RESULTS: Thirty-two of 89 schools responded; 25 provided syllabi (36% response rate, 28% submission rate). Twenty-seven didactic and 9 experiential syllabi were received. The syllabi contained a diverse mix of educational content, some of which represented pharmacy informatics content as defined by ACPE. Schools are teaching clinical system terminology, applications, and evaluation. CONCLUSIONS: Many professional programs are not providing instruction in pharmacy informatics. There may be confusion within the academy/profession between pharmacy informatics and drug information practice. Much work is required for programs to become compliant with the ACPE 2007 pharmacy informatics competencies.