The role of compliance in the treatment of chronic heart failure and the ways to improve it

Despite the development and implementation of clinical guidelines, emergence of modern effective drugs for the treatment of chronic heart failure (CHF), this pathology is characterized by stable progression, directly worsening the quality of life and decreasing the life expectancy. With that, treatment efficacy directly depends on high treatment compliance in patients with CHF both at the treatment start and upon its subsequent correction. One should also not underestimate the value of patient readiness to modify their lifestyle. Besides, the complete physician compliance with clinical guidelines also plays a significant role. The absence of correspondence between principles defined in the guidelines and really administered drugs excludes the possibility of achieving control over CHF symptoms and positive impact on the prognosis. This review is aimed at evaluating treatment compliance among both patients with CHF and their physicians with a focus on Russian studies and good clinical practice (GCP) compared to studies of foreign authors. Unfortunately, the problem of compliance in CHF in the Russian Federation has not been sufficiently analyzed in large-scale studies up to the present time: CHF patient registries mainly allow to detect clinical and epidemiological disease features, while almost not covering compliance issues. It should also be noted that the problem of compliance in both physicians and patients is undoubtedly up-to-date, as it often defines further prognosis in patients with CHF, which explains the scientific practical value of large trials with subsequent thorough analysis and searches regarding increasing its efficiency.

Improving physician compliance with mammography screening by implementing a breast cancer screening guideline at a hospital in Bahrain

BackgroundFrom a health and safety perspective, it is critical to use adequate, evidence-based breast screening guidelines. The aim of this quality improvement project was to improve physicians’ compliance with breast cancer screening guidelines to enhance the mammography screening rate among eligible women; this was achieved through the implementation of multifaceted changes to the hospital’s processes and the improvement of physicians’ attitudes towards the guidelines.MethodsThe project used the Plan-Do-Study-Act method to implement the changes. This was a pre-post evaluation study. The data were collected from patients’ charts. The primary outcome of interest was the rate of physician compliance with mammography screening guidelines before and after the implementation of the process changes. A literature review was conducted to determine which women should be identified as eligible for mammography screening.InterventionThe interventions targeted physician knowledge and hospital processes. Improving doctors’ expertise was achieved by implementing the US Preventive Service Task Force recommendation for mammography screening every 2 years for women aged 50–74 years. The process modifications included the establishment of a system that would be effective in identifying at-risk patients and reminding physicians at the point of care.ResultsOver the course of this study, 825 patients met the criteria for breast cancer screening. The rate of physician compliance with the breast cancer screening guideline increased from 2% to 69% after 23 weeks, and the control charts demonstrated a reliable process.ConclusionThis project examined the relationship between different interventions (identification of the eligible patient, reminder alerts and physician knowledge) and physician compliance with mammography screening guidelines. The results suggest a positive link between the study variables and physicians’ compliance with mammography screening guidelines.

Improving physician handover documentation process for patient transfer from paediatric intensive care unit to general ward

BackgroundInadequate handover communication is responsible for many adverse events during the transfer of care, which can be attributed to many factors, including incomplete documentation or lack of standardised documentation process. The quality improvement project aimed to standardise the handover documentation process during patient transfer from paediatric intensive care unit (PICU) to the general paediatric ward.MethodsData analysis revealed lack of proper handover documentation with the omission of vital information when transferring patients from PICU to general ward. The quality improvement team assessed the current handover documentation practice using a brainstorming technique during multiple meetings. The team evaluated the process for possible causes of incomplete handover documentation, framed the existing challenges, and proposed improvement interventions, including a standardised handover form and conducting education sessions for the new proposed process. The main quality measures included physician’s compliance with handover documentation elements, physician’s satisfaction and PICU emergency readmission rate within 48 hours.ResultsPhysician compliance to handover documentation improved from 29.5% to 95.5% before and after implanting the improvement interventions, respectively. The level of physician satisfaction with the quality of communicated information during the handover process improved from 47.5% to 84%, and the PICU emergency readmission rate declined from 3.8% to zero after all improvement interventions were implanted.ConclusionImplementation of standardised handover form is essential to improve physician compliance for clear handover documentation and to avoid data omission during the patient transfer process. Documented handover in patient’s medical record has positive impact on physician satisfaction when managing patients recently discharged from PICU.

The Amsterdam Wrist Rules to reduce the need for radiography after a suspected distal radius fracture: an implementation study

Purpose While most patients with wrist trauma are routinely referred for radiography, around 50% of these radiographs show no fracture. To avoid unnecessary radiographs, the Amsterdam Wrist Rules (AWR) have previously been developed and validated. The aim of the current study was to evaluate the effect of the implementation of the AWR at the Emergency Department (ED). Methods In a before-and-after comparative prospective cohort study, all consecutive adult patients with acute wrist trauma presenting at the ED of four hospitals were included. Primary outcome was the number of wrist radiographs before and after implementation of the AWR. Secondary outcomes were the number of clinically relevant missed fractures, the overall length of stay in the ED, physician compliance regarding the AWR, and patient satisfaction and experience with the care received at the ED. Results A total of 402 patients were included. The absolute reduction in wrist radiographs after implementation was 15% (p < 0.001). One clinically irrelevant fracture was missed. Non-fracture patients without wrist radiography due to the AWR spent 34 min less time in the ED compared with non-fracture patients who had a wrist radiograph (p = 0.015). The physicians adhered to the AWR in 36% of patients. Of all patients who did not receive a radiographic examination of the wrist, 87% were satisfied. Conclusion Implementation of the AWR safely reduces the amount of wrist radiographs in selected patients and consequently reducing the length of stay in the ED.

Physician Compliance With Bronchiolitis Guidelines in Pediatric Emergency Departments

An online survey was administered through the American Academy of Pediatrics (AAP) Section of Emergency Medicine Survey Listserv in Fall, 2017. Overall compliance was measured as never using chest X-rays, viral testing, bronchodilators, or systemic steroids. Practice compliance was measured as never using those modalities in a clinical vignette. Chi-square tests assessed differences in compliance between modalities. t tests assessed differences on agreement with each AAP statement. Multivariate logistic regression determined factors associated with overall compliance. Response rate was 47%. A third (35%) agreed with all 7 AAP statements. There was less compliance with ordering a bronchodilator compared with chest X-ray, viral testing, or systemic steroid. There was no association between compliance and either knowledge or agreement with the guideline. Physicians with institutional bronchiolitis guidelines were more likely to be practice compliant. Few physicians were compliant with the AAP bronchiolitis guideline, with bronchodilator misuse being most pronounced. Institutional bronchiolitis guidelines were associated with physician compliance.

Relationship between physician financial incentives and clinical pathway compliance: a cross-sectional study of 18 public hospitals in China

ObjectivesMany strategies have been either used or recommended to promote physician compliance with clinical practice guidelines and clinical pathways (CPs). This study examines the relationship between hospitals’ use of financial incentives to encourage physician compliance with CPs and physician adherence to CPs.DesignA retrospectively cross-sectional study of the relationship between the extent to which patient care was consistent with CPs and hospital’s use of financial incentives to influence CP compliance.SettingEighteen public hospitals in three provinces in China.ParticipantsStratified sample of 2521 patients discharged between 3 January 2013 and 31 December 2014.Primary outcome measuresThe proportion of key performance indicators (KPIs) met for patients with (1) community-acquired pneumonia (pneumonia), (2) acute myocardial infarction (AMI), (3) acute left ventricular failure (heart failure), (4) planned caesarean section (C-section) and (5) gallstones associated with acute cholecystitis and associated cholecystectomy (cholecystectomy).ResultsThe average implementation rate of CPs for five conditions (pneumonia, AMI, heart failure, C-section and cholecystectomy) based on 2521 cases in 18 surveyed hospitals was 57% (ranging from 44% to 67%), and the overall average compliance rate for the KPIs for the five conditions was 69.48% (ranging from 65.07% to 77.36%). Implementation of CPs was associated with greater compliance within hospitals only when hospitals adopted financial incentives directed at physicians to promote compliance.ConclusionCPs are viewed as important strategies to improve medical care in China, but they have not been widely implemented or adhered to in Chinese public hospitals. In addition to supportive resources, education/training and better administration in general, hospitals should provide financial incentives to encourage physicians to adhere to CPs.

Meeting Physician Compliance Recommendations in the Management of Opioids in Chronic Pain: The Chronic Pain Management Registry (CPMR)

In a recent commentary in INNOVATIONS in Pharmacy, details were given on a recently released Chronic Pain Management Registry (CPMR). The CPMR was designed to provide a tracking and audit framework for evaluating claims made for therapy interventions in chronic pain management. At the same time, the CPMR was seen as a key element in monitoring physician and practice compliance with requirements for the prescribing of opioids and other scheduled substances. The purpose of the present commentary is to expand upon the role of the CPMR in the management of opioids in detailing the concordance of the CPMR data collection requirements with the latest recommendations of the American Society of Interventional Pain Physicians (ASIPP) for responsible, safe and effective opioid prescribing in chronic non-cancer pain. Given ongoing concerns with opioid misuse and abuse, the opioid epidemic, physician practices are at risk for what may be judged as poor therapy decisions in evaluating medical necessity and a failure to monitor effectively response to therapy. Adoption of a platform such as the CPMR may, through providing a comprehensive evidence base and tracking capability, support more effective prescribing decisions and adherence to therapy. At the same time, the ability to justify decisions through a CPMR documentation audit may not only alleviate physician concerns if their decisions are challenged but also lead to improved outcomes in the treatment of chronic pain. Article Type: Commentary

Physician compliance with quality and patient safety regulations: The role of perceived enforcement approaches and commitment

The implementation of a quality and patient safety accreditation system is crucial for hospitals. Although control systems—such as accreditation—can contribute to quality improvements, they also run the risk of unintended consequences. As a result, ways should be found to avoid or reduce these undesirable consequences. This study aims to answer this call by exploring the association of different approaches to the enforcement of rules (punishment, based on monitoring and threats of sanctions; and persuasion, based on dialog and suggestion) with compliance. To test the relation between perceived enforcement and compliance, this study used survey data collected from medical specialists (N = 92) of a large academic medical center. The findings indicate that the same system is interpreted differently and that only a perceived persuasion approach is related to higher levels of compliance. This effect is fully mediated by affective commitment. No direct or indirect effects on compliance were found for a perceived coercive approach. These results suggest that control systems can be perceived in different ways and that the implementation of a control system does therefore not automatically lead to negative and unintended outcomes.