Patients continue to suffer preventable harm from the omission of evidence-based therapies. To remedy this, The Joint Commission developed core measures for therapies with strong evidence and, ...through the Top Performer on Key Quality Measures program, recognize hospitals that deliver those therapies to 95% of patients. The Johns Hopkins Medicine board of trustees committed to high reliability and to providing > or = 96% of patients with the recommended therapies.
The Armstrong Institute for Patient Safety and Quality coordinated the core measures initiative, which targeted nine process measures for the 96% performance goal: eight Joint Commission accountability measures and one Delmarva Foundation core measure. A conceptual model for this initiative included communicating goals, building capacity with Lean Sigma methods, transparently reporting performance and establishing an accountability plan, and developing a sustainability plan. Clinicians and quality improvement staff formed one team for each targeted process measure, and Armstrong Institute staff supported the teams work. The primary performance measure was the percentage of patients who received the recommended process of care, as defined by the specifications for each of The Joint Commission's accountability measures.
The > or = 96% performance goal was achieved for 82% of the measures in 2011 and 95% of the measures in 2012.
With support from leadership and a conceptual model to communicate goals, use robust improvement methods, and ensure accountability, The Johns Hopkins Hospital achieved high reliability for The Joint Commission accountability measures.
During the last 25 years, National Cancer Institute (NCI) cooperative trial groups have extended trial networks from academic centers to include certain community and Veterans Health Administration ...(VHA) centers. We compared trial patients' attributes and outcomes by these enrollment settings.
Studying 2,708 patients on one of 10 cooperative group, randomized lung trials at 272 institutions, we compared patient attributes by enrollment setting (ie, academic, community, and VHA affiliates). We used adjusted Cox regression to evaluate for survival differences by setting.
Main member institutions enrolled 44% of patients; community affiliates enrolled 44%; and VHAs enrolled 12%. Patient attributes (ie, case-mix) of age, ethnicity, sex, and performance status varied by enrollment setting. After analysis was adjusted for patient case-mix, no mortality differences by enrollment setting were noted.
Although trial patients with primarily advanced-stage lung cancer from nonacademic centers were older and had worse performance statuses than those from academic centers, survival did not differ by enrollment setting after analysis accounted for patient heterogeneity. An answer for whether long-term outcomes for patients at community and VHA centers affiliated with cooperative trial groups are equivalent to those at academic centers when care is delivered through NCI trials requires additional research among patients with longer survival horizons.
Early success in reading is predicated on a child's ability to accurately and effectively master core literacy constructs (e.g., phonological awareness, alphabet knowledge, concept of word, and ...grapheme-phoneme correspondence) and to exercise these understandings in a comfortable sociocultural context. In recent years, educators, legislators, and policymakers have shown great interest in creating an effective and instructionally useful diagnostic screening tool for identifying children at risk for early reading difficulties. In response to this charge, the Phonological Awareness and Literacy Screening-Kindergarten (PALS-K) was developed. Through Fall 2003, more than 430,000 kindergarten students in Virginia had been screened using PALS-K. The purposes of this paper are to (a) describe the PALS-K instrument, (b) examine its effectiveness in screening for poor beginning literacy skills, and (c) discuss the educational and policy implications of the results of statewide literacy screening efforts.
A large-scale survey of the Central Arizona-Phoenix Long-Term Ecological Research study area was conducted in which many kinds of samples were collected (e.g., plant, insect, soil). The plant samples ...were of a smaller size than typical herbarium accessions due to limitations in personnel, storage space, available plant materials, and time. The vouchers were identified in the field if possible. The vast majority of the rest were identified in the herbarium morphologically after the survey; less than 5% of the vouchers remained unidentified. Of these, a subset were subjected to molecular analysis using sequences of the nuclear ribosomal ITS region and to a BLAST search of sequences in GenBank to find closely related taxa. The close relatives along with the unknown specimens were subjected to maximum parsimony analysis to identify the potential phylogenetic relationships of the unknown specimens. Through this analysis nine unknown plant accessions were identified to family, tribe, genus, and species. Once this level of identification was established, some specimens were re-examined morphologically and compared with potentially related taxa in the herbarium to confirm or improve identifications. We outline an efficient method for surveying and collecting plant vouchers for a large sampling area. We also demonstrate that one can combine morphological and molecular data in the identification process to produce more complete datasets.
Abstract only Background: Although current cholesterol performance measures define good quality as low density lipoprotein cholesterol (LDL-C) levels < 100mg/dl in cardiovascular disease (CVD) ...patients, they provide a snap shot at one time point and do not inform whether an appropriate action was taken to manage elevated LDL-C levels. We assessed frequency and predictors of this appropriate response (AR). Methods: We used administrative data to assess 22,902 CVD patients receiving care in a Veterans Affairs network of 7 hospitals and affiliated clinics. We determined the proportion of CVD patients at LDL-C goal <100 mg/dl, and the proportion of patients with uncontrolled LDL-C levels (>100 mg/dl) who had an AR defined as the initiation or dosage increase of a lipid lowering medication (LLM), addition of a new LLM, receipt of maximum dosage or >1 LLM, or LDL-C reading <100 mg/dl at 45 days follow-up. Logistic regression was performed to evaluate facility, provider and patient characteristics associated with AR. Results: LDL-C levels were at goal in 16,350 (71.4%) patients. An additional 2,110 (9.2%) had an AR at 45 days of follow-up. Controlling for clustering between facilities and patient's illness severity, history of diabetes (OR 1.18, 95% CI 1.03-1.35), hypertension (OR 1.21, 95% CI 1.02-1.44), patients showing good medication adherence (medication possession ratio > 0.8) OR 2.29, 95% CI 1.99-2.64 were associated with AR. Older CVD patients (age >75 years) were less likely to receive AR (OR 0.60, 95% CI 0.52-0.70). Teaching vs. non-teaching facility (p=0.40), physician vs. non-physician provider (p=0.14), specialist vs. non-specialist primary care provider (p=0.12), and patient's race (p=0.12) were not predictors of AR. Conclusion: Among patients with CVD and LDL-C above guideline recommended levels, only one-third receive AR. Diabetic and hypertensive CVD patients are more likely to receive AR, whereas older Veterans with CVD receive AR less often likely reflecting providers' belief of lack of efficacy from treatment intensification in older CVD patients. Our findings are important for quality improvement and policy making initiatives as they provide more actionable information compared with isolated LDL-C goal attainment as a quality indicator.
Early success in reading is predicated on a child's ability to accurately and effectively master core literacy constructs (e.g., phonological awareness, alphabet knowledge, concept of word, and ...grapheme-phoneme correspondence) and to exercise these understandings in a comfortable sociocultural context. In recent years, educators, legislators, and policy-makers have shown great interest in creating an effective and instructionally useful diagnostic screening tool for identifying children at risk for early reading difficulties. In response to this charge, the Phonological Awareness and Literacy Screening-Kindergarten (PALS-K) was developed. Through Fall 2003, more than 430,000 kindergarten students in Virginia had been screened using PALS-K. The purposes of this paper are to (a) describe the PALS-K instrument, (b) examine its effectiveness in screening for poor beginning literacy skills, and (c) discuss the educational and policy implications of the results of statewide literacy screening efforts.
To report a case of QT prolongation associated with concomitant cyclobenzaprine and fluoxetine administration followed by torsade de pointes potentiated by droperidol.
A 59-year-old white woman who ...had been receiving long-term fluoxetine and cyclobenzaprine therapy was admitted for Achilles tendon repair. Baseline QTc was prolonged at 497 msec. Prior to surgery, the patient received droperidol, an agent known to prolong the QT interval. During surgery the patient developed torsade de pointes, which progressed into ventricular fibrillation. On postoperative day 1, after cyclobenzaprine discontinuation, the QTc decreased toward normal (440 msec).
Cyclobenzaprine shares anticholinergic effects, tachycardia, and dysrhythmic potential with the tricyclic antidepressants (TCAs). Fluoxetine is a known inhibitor of the CYP2D6 isoenzyme (along with CYP3A4 and CYP2C) and has been shown to increase TCA serum concentrations. The combination of cyclobenzaprine and fluoxetine resulted in significant QT prolongation in our patient that progressed to torsade de pointes after preoperative droperidol administration. Resolution of QT abnormalities after cyclobenzaprine discontinuation provided further evidence of a drug-induced etiology. Other possible medical and drug-related causes of torsade de pointes are reviewed and ruled out.
Clinicians should be aware of the dysrhythmic potential of cyclobenzaprine and fluoxetine, monitor for other cytochrome P450 inhibitors, and avoid concomitant drugs known to prolong the QT interval.
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