Browsing by Subject "Practice Patterns, Physicians'"
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Item The antibiotic era: historical and ethical reflections on seven decades of reform efforts(2017-11-14) Podolosky, Scott H.Today, as we increasingly turn our attention to antibiotic resistance and the possibility of a post-antibiotic era, it is important to consider the historical evolution of attempts to implement the "rational" use of antibiotics. Throughout such history, important ethical considerations-from debates in the 1950s over conflict of interest and the role of industry in the "education" of clinicians, through contemporary concerns over our obligations to present versus future patients-have continually simmered under the surface of such broader medical and regulatory concerns. In this talk, Scott Podolsky examines seven decades of reformers who have attempted to change how antibiotics are developed, marketed and prescribed. Tensions between antibiotic development and conservation, and between education and regulation, continue to play out today in medical offices, hospitals, industry, agricultural enterprises, and the halls of government alike.Item Assess Effectiveness of Opioid Prescription Policies for Acute Pain Management(2022-05-01T05:00:00.000Z) Machchhar, Arti; Reed, W. Gary; Phelps, Eleanor; Kandil, EnasBACKGROUND: In 2017, the Department of Health and Human Services (HHS) declared the Opioid Crisis a public health emergency. Regulatory agencies and institutions have adopted several guidelines to ensure opioids are prescribed appropriately. In October 2014, the DEA changed the schedule of hydrocodone combination products (HCPs) from schedule III to schedule II narcotics. This led to a substantial rise in Tylenol 3 prescriptions at the University of Texas at Southwestern Medical Center (UTSW) due to the institutional guideline that prevents residents from prescribing schedule II narcotics without documented approval from an attending physician. OBJECTIVE: We sought to evaluate whether the UTSW guideline preventing residents from prescribing schedule II narcotics serves to improve patient safety and pain management. METHODS: Prescription data and associated patient demographic data was pulled directly from the UTSW electronic medical record (EMR) for one year prior to and following the rescheduling of HCPs. Additional data was pulled for the 2019 and 2020 calendar years. The proportion of T3 and schedule II narcotic prescriptions was calculated for all time periods and stratified for age, race, provider type, and department. RESULTS: One year before the rescheduling of hydrocodone, the vast majority of prescriptions were schedule II narcotics at 98.92% and T3 was very rarely prescribed at 1.08%. In 2014 - 2015 following the rescheduling of HCPs, there was an overall decrease in opioid prescriptions and the proportion of T3 prescriptions rose to 49.94%. In 2019 and 2020, the overall number of opioid prescriptions increased to 17,297 in 2019 and 15,395 in 2020 and the proportion of T3 prescriptions decreased to 37.12% and 33.89% respectively. CONCLUSION: The rescheduling of HCPs led to the dramatic shift in Tylenol 3 prescriptions, indicating that regulatory agencies and institutional guidelines are driving prescribing habits. Tylenol 3 is being prescribed at a significant rate however, information regarding its addictive potential, metabolic effects, and potential adverse effects remains relatively unknown. The drug policies and institutional guidelines discussed disproportionately affect people of color and lower socioeconomic class.Item Decision Fatigue in Primary Care Opioid Prescribing(2020-05-01T05:00:00.000Z) Hughes, Jordan Gregory; Kandil, Enas; Reed, W. Gary; Greilich, PhilipBACKGROUND: Decision fatigue -- a psychological phenomenon describing the depletion of mental resources as one makes a series of decisions -- affects primary care physicians as they treat patients and prescribe medications throughout the course of the clinical day. This results in more inappropriate treatments being ordered as the day goes on. Because the United States faces an unprecedented epidemic of opioid abuse, we must understand the extent to which decision fatigue affects opioid prescribing, as the prescription of these drugs has been associated with both long-term use and overdose deaths. Additionally, we are unaware of the effect various national interventions to stem the tide of the opioid epidemic have had on decision fatigue in opioid prescribing. LOCAL PROBLEM: We are unaware of whether decision fatigue is playing a role in opioid prescribing, and if it is, how great the variation in prescription likelihood is throughout the clinical day in UT Southwestern's primary care clinics. The aim of this study is to measure PCPs' varying likelihoods of prescribing opioids throughout the clinical day, before and after major interventions were implemented to combat the epidemic, as this can serve as an indication of both the presence of decision fatigue and the impact of concerted interventions. METHODS: We used the years 2014 and 2017 to represent the pre- and post-intervention periods for study, as many major interventions to combat the opioid epidemic took place in 2016. Next, we analyzed the percentage of appointments in which opioids were prescribed in each hour of physicians' clinical days, at three exclusively primary care clinics at UT Southwestern. Scheduled appointment times were used as substitutes for visit times. We then excluded patients with cancer and those who had surgery within six weeks of an appointment, in order to minimize the number of appointments in which opioids may be prescribed by clear clinical indication. Finally, we employed logistic regression analysis to determine the predictive relationship between appointment time and opioid prescriptions, using physicians' prescription rates in their first clinic hour as the reference for calculating hourly odds ratios in each year. INTERVENTIONS: New legislation, updated healthcare guidelines, and national media coverage in 2016, including: the CDC's "Guideline for Prescribing Opioids for Chronic Pain—United States", the FDA's "General Principles for Evaluating the Abuse Deterrence of Generic Solid Oral Opioid Drug Products: Guidance for Industry, 2016", the Comprehensive Addiction and Recovery Act of 2016, the Surgeon General's call to providers to end the opioid crisis, and the opioid crisis becoming top health news story of 2016. RESULTS: 34,972 clinic visits in 2014 and 42,313 clinic visits in 2017 met our inclusion criteria. In 2014, patients were prescribed an opioid at 5.34% of all primary care appointments, while in 2017, they were prescribed at a rate of 4.34% (2014 vs 2017 OR=1.290; 95% CI, 1.217-1.367). While the overall rates of opioids decreased from 2014 to 2017, the hourly likelihoods of patients being prescribed opioids steadily increased throughout the clinical day in both years (p<0.01 in 2014 and 2017). In fact, each year had hours in which physicians' opioid prescription odds ratio was over 1.6, when compared to their first clinical hour. DISCUSSION: While there was a significant decrease in the overall likelihood of being prescribed opioids in 2017 compared to 2014, the variation in hourly prescription likelihoods is similar in both years. The results show that while interventions to combat the opioid epidemic were successful in reducing the overall amount of opioids prescribed, they had minimal impact on the effect of decision fatigue. Clinical decision support tools, integrated into the electronic medical record, have been proven to reduce the clinical variation that indicates the presence of decision fatigue. In light of this, this project should be continued, and decision fatigue measured, after implementation of such tools.Item Deprescribing Unnecessary Pantoprazole Prescribed by Hospitalists on Parkland Hospital Non-ICU Inpatient Floors(2020-05-01T05:00:00.000Z) Jain, Shailavi; Chu, Eugene; Reed, W. Gary; Kannan, SubhasriBACKGROUND: Proton pump inhibitors are one of the most prescribed classes of drugs in the United States. Their efficacy and relatively low adverse event profile has resulted in their significant overuse both inpatient and at discharge. Long-term proton pump inhibitor use has been associated with many health consequences and any unnecessary prescribing leads to unnecessary expenses. OBJECTIVES: The primary aim of this project was to achieve a 25% relative reduction in inappropriate inpatient pantoprazole prescribing by the hospital medicine physicians and advanced practice providers who account for the majority of the unnecessary proton pump inhibitor prescribing in non-critical patients at Parkland during the period of January 2018-May 2020. METHODS: The baseline scope of the problem was determined using chart review and provider surveys. The chart review study population was any non-critical, medicine patient admitted to Parkland Memorial Hospital and prescribed inpatient pantoprazole by a hospitalist in June of 2017 (n=319 patients). This chart review helped quantify the pantoprazole use problem and identify the reasons for inappropriate prescription of inpatient pantoprazole. The hospitalists were surveyed to understand their prescribing practices and their perspective on the causes of unnecessary inpatient pantoprazole use. Using this information, a fishbone diagram outlining the causes of inappropriate inpatient pantoprazole use was created. Interventions addressing these causes were rated using a prioritization matrix and the best interventions were implemented. The interventions included removal of proton pump inhibitors from order sets, group and individual provider education, individual provider audit and feedback report cards, and changes to the proton pump inhibitor prescription auto-fill refill numbers in the electronic medical record. The 15 hospitalists accounting for 56% of the unnecessary prescribing at baseline were the study cohort. Prescribing data for these 15 hospitalists was then assessed post-intervention to determine the impact of the interventions. Chi squared analysis was performed. A p-value of <0.05 was considered significant. RESULTS: In June of 2017, in all non-critical patients cared for by hospitalists, 58.3% of pantoprazole prescriptions were unnecessary. Of the patients that were started on inpatient pantoprazole, 52.4% of the 66.5% of patients discharged on pantoprazole had no indication and, six months later, 46.8% of those patients continued to use pantoprazole. At baseline, the study cohort of 15 providers prescribed 45% of the total inpatient pantoprazole prescriptions and 71.7% of those prescriptions were inappropriate (n= 145 patients). After the interventions, the rate of their pantoprazole prescribing decreased from a mean of 145 prescriptions to 89 prescriptions per month. The proportion of inappropriate pantoprazole prescriptions decreased from 71.7% to 47.9% (n= 178 patients). Of those inappropriate prescriptions post-intervention, a majority were continuations of outpatient proton pump inhibitors; not new pantoprazole prescriptions as before. The percentage of the study cohort's patients inappropriately discharged on pantoprazole decreased from 62.9% to 50.8%. The percentage of their patients still on a proton pump inhibitor six months after discharge decreased from 32.4% to 26.4%. CONCLUSIONS: The interventions achieved a 33% relative reduction in inappropriate inpatient pantoprazole prescriptions in non-critical, medicine patients by the 15 worst prescribing hospitalists at Parkland. Further analysis will help elucidate if the audit and feedback received by these 15 hospitalists resulted in any additional benefit beyond the group education all the hospitalists received. Future directions would include continued re-education, audit and feedback and accountability for the proper utilization of proton pump inhibitors. As the opportunity for reducing unnecessary inpatient prescribing of proton pump inhibitors diminishes, resources may be redirected to decreasing inappropriate discharge prescriptions and improving outpatient prescribing practices.Item Five things every internist should know about lung cancer ... and why(2015-04-24) Schiller, JoanItem Health Information technology: has its adoption been worth it?(2016-01-29) Kazi, SalahuddinItem Institutional corruption & off-label drug use(2015-04-14) Rodwin, Marc A.Although sometimes reasonable, off-label drug use typically is unsupported by substantial evidence of effectiveness and safety. At the root of inappropriate off-label drug use lies institutional corruption of pharmaceutical practice. Institutional corruption involves perverse incentives for pharmaceutical firms, the lack of evaluation of off-label prescribing and conflicts of interest in the design, oversight, and reporting of clinical trials. Typical reform proposals such as increased sanctions for manufacturers, education for physicians, registration of clinical trials, and disclosure of conflicts of interest do not remove the source of the problem. The speaker explores alternative reform options. These include: 1) tracking off-label prescriptions to monitor the risks and benefits of off-label uses and the manufacturers' conduct; 2) changing pharmaceutical firm reimbursement to remove incentives to encourage off-label prescribing; and 3) independent clinical trials to evaluate drugs.Item Pre-oping wisely: a guide to more judicious pre-operative testing(2015-12-18) Burton, MichaelItem The short history and tenuous future of "professionalism"(2022-12-13) Wynia, Matthew[Note: The slide presentation is not available from this event.] The concept of professionalism in health care is both newer and more fragile than many assume. The history, strengths, risks, and alternatives to professionalism should be understood if we hope to create a future in which health professionals work well together in teams to effectively and ethically serve our patients and communities.Item Simple Measures to Reduce Opioid Prescriptions Following Pediatric Spinal Fusion Surgery: A Multidisciplinary Quality Improvement Project(2022-02-01) Winsauer, Andrew; Charu, Sharma; Bukowsky, Stacie; Greenberg, Sandi; Birch, Craig; Ramo, BrandonBACKGROUND: The opioid epidemic is one of the biggest challenges facing modern healthcare. Among the adolescent and young adult populations opioid overdose is one of the leading causes of death. LOCAL PROBLEM: Within pediatric orthopaedics, spinal fusion is a common procedure making up 7% of the surgical volume at our institution. Spinal fusion also has high postoperative opioid prescribing rates. Review of baseline data showed that there was wide variability in prescribing habits. The goal of this quality initiative was to reduce and standardize post-operative opioid prescribing following spinal fusion procedures. METHODS: Data, including opiate-prescribing habits and a patient survey to assess patient and parent satisfaction with pain control, was collected retrospectively in the pre-intervention phase for 99 consecutive Adolescent and Juvenile Idiopathic Scoliosis patients undergoing spinal fusion surgery. This was followed with 2 PDSA cycles following implementation of a new protocol during which prospective surveys were administered to a total of 273 patients. Physician prescribing data was collected for 150 patients during the sustain phase. INTERVENTIONS: A multi-pronged approached was utilized consisting of the following aspects: 1) Instruction to orthopaedic trainees to limit opioid prescriptions to 45 and 40 for PDSA cycles 1 and 2, respectively. 2) A pharmacy-led education program with an opioid tapering handout given to families and encouragement of usage of non-opioid pain control. 3) A call to the prescribing physician from pharmacy if the prescribed dosage was greater than the maximum allowed. RESULTS: There was a significant reduction in opioid prescriptions from a preintervention mean of 48.5 doses to a PDSA 1 mean of 39.0, PDSA 2 mean of 37.5, and a sustain phase mean of 36.4 (p=0.000). This represented an estimated reduction of 22.8% over the course of the study. During this time, there was no significant change in patient and parent reported postoperative pain. CONCLUSIONS: Through simple measures, our institution was able to significantly reduce total opioid prescriptions following spinal fusion surgeries while maintaining good pain control.Item Standardizing Treatment for Acute Exacerbations of COPD (AECOPD) at a Large Academic Hospital(2024-01-30) Peraka, Veena; Wootton, Taylor; Irving, AnnetteBACKGROUND: Acute exacerbations of COPD (AECOPD) are a common problem faced by patients with chronic obstructive pulmonary disease (COPD). There are discrepancies in AECOPD treatment that impact patient outcomes. Despite evidence of improved or non-inferiority outcomes and reduced cost with short oral regimens, steroid prescribing patterns remain variable. Furthermore, there is confusion regarding antibiotic choice that contributes to the problem. LOCAL PROBLEM: The local problem is the lack of standardization of care for AECOPD at Clements University Hospital (CUH). Data from 6/1/2021-5/31/2023 shows that AECOPD treatment at CUH has been variable despite the availability of evidence-based medications. AIM: The aim of this project is to improve the adherence to evidence-based selection of steroids and antibiotics for AECOPD at CUH by 75% at 1 year after the intervention along with a 10% decrease in length of stay and readmissions. METHODS: The intervention is an order set containing guidelines and treatments for AECOPD that can be implemented into Epic electronic health records. Emergency department physicians, hospitalists, and pulmonologists were consulted for insight about treatment recommendations. This advice along with the GOLD guidelines and additional research were used to create the order set. RESULTS: The order set is now ready for implementation into Epic after being presented to physicians and respiratory therapists for feedback. After implementation, data will be collected on the usage and effectiveness of the order set and analyzed for up to one-year post-intervention. CONCLUSION: AECOPD is a complex disease that is treated with various medications that can lead to the different outcomes. Insight from various physician specialties was helpful to understand methods at CUH at different stages of the AECOPD journey. Due to the complexity, the order set can be a helpful resource for physicians when choosing treatments to improve adherence to evidence-based medications and patient outcomes.Item The State of Anesthesia Practice in Sub-Saharan Africa: Statistics, Case Studies, and Ways Forward(2020-03-12) Choo, Vincent; Mihalic, Angela; Ambardekar, Aditee; Tao, WeikeBACKGROUND: There is substantial need for additional anesthesia resources in Sub-Saharan Africa. In this region of the world, maternal and surgical mortality are high. Non-coincidentally, the number of anesthesiologists and anesthesia providers is low and provision of medications and other basic supplies is lacking. This thesis aims to describe anesthesia practice in Sub-Saharan Africa using statistics and case studies, present current initiatives already in place to improve access to care, and suggest other strategies that may improve anesthesia capacity in the future. OBJECTIVE: Non-adherence to minimum guidelines from the World Federation of Societies of Anaesthesiologists (WFSA) for anesthesia practice in the areas of staffing and physical resources is associated with poor anesthesia and surgical outcomes, which could be improved by improving training programs and increasing available physical resources. METHODS: A Pubmed literature search was performed using key words. Relevant articles from these searches were retrieved and references from these articles were also examined. Websites for organizations mentioned in the articles were queried. Websites containing factual information about individual Sub-Saharan African countries were consulted. The information found was grouped by themes and presented. RESULTS: The numbers of anesthesiology providers in Sub-Saharan Africa are insufficient to provide safe anesthesia care. A lack of medications and supplies and inadequate technology, including monitoring equipment, contribute to the problem. The situation in Ghana, Mozambique, Liberia, and Rwanda helps to illustrate this problem. Initiatives such as the founding of the World Federation of Societies of Anaesthesiologists and Lifebox, as well as formalizing task-sharing, have attempted to improve the situation. Continuing to ensure that equipment adapted to the reality of the practice environment in the region and careful planning and coordinating of future humanitarian projects can help improve anesthesia care provided in the region. CONCLUSION: The current state of anesthesia in Sub-Saharan Africa is insufficient to meet population needs. The causes are multi-factorial and include issues providing adequate human and material resources. Establishing strong, coordinated humanitarian efforts on the ground is critical to addressing the problem. Reorganizing manpower to best utilize precious human resources is another way forward. Providing appropriate resources in the form of equipment and medications, as well as encouraging local research, can help provide innovative solutions for the region.Item Understanding Institutional Physician Chronic Opioid Prescription Practices for the Improved Implementation of Newly Developed EMR Tools(2021-03-12) Gagrani, Sonal; Reed, W. Gary; Phelps, Eleanor; Kandil, EnasBACKGROUND: Chronic non-cancer pain (CNCP) affects a significant portion of the United States population each year and is often treated with chronic opioids. There has been a rise in prescription opioids over the past 20 years, accompanied by a rise in overdose deaths as well. In order to improve patient safety related to opioid prescribing, several state and national policies including the 2016 "CDC Guidelines for Prescribing Opioids for Chronic Pain" have been developed recently to guide CNCP management. These recommendations include the use of pain management agreements, urine drug screening, prescription monitoring programs (PMP) and risk and pain assessments among others. LOCAL PROBLEM: In Texas, several recent policies have made CNCP practices mandatory, requiring support in order to enforce them. At the University of Texas Southwestern Medical Center (UTSW), there is no current reliable measure of CNCP policy adherence. Preliminary chart review by students at our institution showed low adherence overall, which may be secondary to poor documentation. METHODS: A set of surveys were developed to subjectively measure physician barriers to policy adherence, attitudes toward the policy components and current opioid prescribing practices. This survey was administered via electronic communication before and after the intervention to any physician at our academic medical center prescribing chronic opioids to at least one patient. Implementation science outcomes of appropriateness, adoption and acceptability were targeted by these surveys in order to inform implementation strategies for the intervention. INTERVENTIONS: A multi-faceted intervention including an electronic medical record (EMR) navigator tool, chronic opioids registry and physician education was developed by the institutional opioid task force to improve accessibility, documentation and understanding of opioid prescribing guideline recommendations. RESULTS: Physicians who had used the EMR navigator tool reported overall greater use of several guideline-concordant treatment components compared to those who had not used it (p < .05). Physicians who received opioid prescribing training were more aware and familiar with the policy (p < .0001). Those who were more familiar with the policy were more likely to use pain management agreements, urine drug screens and pain assessments. No specific barriers to policy adherence stood out as a remediable concern. Only a small percentage of respondents reported co-prescribing naloxone for high-risk CNCP individuals. CONCLUSION: An EMR navigator tool to improve accessibility of treatment components is effective in improving policy adherence at an academic medical center. Physician education is also effective in improving awareness and familiarity with the policy. Future steps include the study of patient-centered outcomes surrounding the intervention. There is also room for the support of other CNCP guidelines including co-prescription of naloxone for high-risk individuals and decreasing chronic opioid prescription strengths at our institution.Item Using the Electronic Medical Record to Ensure Compliance with Opioid Prescription Laws in Texas(2019-03-28) Bender, Christopher McLean; Reed, W. Gary; Kandil, Enas; Fish, JasonBACKGROUND: The American population currently finds itself in the midst of a prescription drug overdose epidemic. This crisis has been fueled by an overreliance on opioid medications for the treatment of chronic pain. The state of Texas medical board (TMB) enacted a law change that restricts and regulates the prescribing and dispensing of controlled substances with respect to patients experiencing chronic pain. LOCAL PROBLEM: At the onset of this project, the University of Texas Southwestern (UTSW) system had no comprehensive measures in place to ensure compliance with these rules, and the current state of compliance was unknown. METHODS: Three clinics were chosen for observation to help understand the process of opioid prescribing for chronic pain treatment and the steps necessary to comply with the new law. Multiple Plan, Do, Study, Act (PDSA) cycles were applied to the process of baseline data measurement culminating in a final estimate of 3.1% ± 0.4% of applicable patient records written by UTSW providers in compliance with the law. INTERVENTIONS: Tools in the electronic medical record system (EMR) for tracking the use of scheduled medications in the treatment of chronic pain as well as for ensuring compliance with the new law have been developed and are in the process of implementation at the clinics with the largest populations of opioid-prescribed chronic pain patients. RESULTS: A chronic opioid registry was created, containing about 200 patients. Data retrieval is in process to determine the current rate of compliance. CONCLUSION: This project has successfully created a registry of the patients at UTSW on chronic opioid therapy and built an EMR structure that will ensure that these patients are cared for in a fashion compliant with TMB laws.