Changing clinical practice. Prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism

OBJECTIVE: To determine the effect of continuing medical education (CME) with and without a quality assurance component (CME+QA) on physician practices in the prevention of venous thromboembolism. METHODS: A communitywide study was performed in 15 short-stay hospitals in central Massachusetts. The study population included 3158 patients in acute-care hospitals with multiple risk factors for venous thromboembolism. Study hospitals were randomly assigned to one of two educational strategies or to a control group that received no intervention. RESULTS: The proportion of patients at high risk for venous thromboembolism who received effective methods of prophylaxis increased significantly from 29% in 1986 to 52% in 1989 (P < .001). This increase was seen in all study groups: control hospitals, 40% to 51% (P < .001); CME hospitals, 21% to 49% (P < .0001); and CME+QA hospitals, 27% to 55% (P < .0001). The increase in prophylaxis use from 1986 to 1989 was significantly greater among patients cared for in hospitals whose physicians participated in a formal CME program (an increase of 28%) than in control hospitals (an increase of 11%) (P < .001). There was no significant difference in the use of prophylaxis in hospitals whose physicians received CME+QA interventions compared with hospitals whose physicians received CME interventions alone (identical increases of 28%). CONCLUSION: A formal CME program significantly increased the frequency with which physicians prescribed prophylaxis for venous thromboembolism. We believe the key factor in our CME interventions that motivated clinicians to change their practices was the provision of hospital-specific data demonstrating a compelling need for improvement. Despite the substantial investment by hospitals in QA, traditional QA intervention appeared to provide no additional benefit. Even after extensive CME/QA interventions, prophylaxis for venous thromboembolism remained underutilized, suggesting the need to develop new approaches to changing clinical practice.     

The development of an interdepartmental audit as part of a physics quality assurance programme for external beam therapy

A cost-effective audit system has been developed that will both detect systematic error in data and procedures and evaluate the quality assurance programme provided by a physics department for radiotherapy. The audit has been developed for external beam radiotherapy and assesses one modality and one treatment machine per year. The audit is carried out on an interdepartmental basis and can be undertaken by two physicists from each department in one working day. The method of assessing the quality assurance programme and the schedule of measurements are described. The process is illustrated using the results of trial audits between the medical physics departments at Coventry and Leicester.     

Interpreting hospital admissions data across the K?rner divide: the example of diabetes in the north western region

Hospital admission rates and hospital bed utilization rates are presented for all admissions assigned to diabetes mellitus as principal cause in the North Western Region from 1980/81 to 1990/91. Data are derived from Hospital Activity Analysis (1980/81-1986/87) and from the Regional Information System (1988/89-1990/91). Admission rates for all categories of diabetes combined showed little change until 1986/87 after which they rose progressively each year. Hospital bed utilization rates fell progressively from 1986/87 onwards, the number of bed days attributed to diabetes falling from 1.9% to 0.8% of the total for all causes. Most of the rise in admission rates from 1988/89 onwards was attributable to diabetes with ophthalmic complications (ICD 250.4). This was heavily influenced by the enumeration of day cases in the Regional Information System. When these are discounted, admission rates for the more recent years are stable. Diabetes without mention of complications (ICD 250.0) showed the most dramatic decline in its contribution to hospital bed utilization. This may be the result of increasing outpatient support from diabetes specialist nurses whose numbers increased in inverse proportion to the fall in bed utilization attributed to ICD 250.0.     

The routine use of radiography and arterial blood gases in the evaluation of blunt trauma in children

STUDY OBJECTIVE: To evaluate the usefulness of routine radiographs and arterial blood gases in children with blunt trauma. DESIGN: Retrospective chart review. TYPE OF PARTICIPANTS: Ninety patients who met triage criteria for our trauma team evaluation and who were less than 15 years old were evaluated. Patients with a Glasgow Coma Scale score (GCS) of 15 (lie, mild to moderately injured children) were the focus of this study. METHODS: Children seen from May 1991 through August 1992 had charts reviewed systematically and within 24 hours of emergency department evaluation. Standard radiologic evaluation, including cervical-spine, chest, and pelvic radiographs, as well as arterial blood gas analysis, were obtained. The severity of injury was graded according to the Modified Injury Severity Scale. RESULTS: The mean age of patients was 6.4 years, and the injuries observed were exclusively extremity fractures. The correlation between physical examination findings and radiologic evaluation was assessed. Forty-three patients had an abnormal physical examination (ie, gross deformity, limitation of motion, or pain), and 26 had a fracture identified on radiograph. Forty-seven patients had a normal physical examination and none had a fracture identified on radiograph (P < .001; sensitivity of positive signs and symptoms, 100%; false-negative findings, 0%). Four patients with abnormal blood gases are described. No patient had any vascular or solid organ injury identified. CONCLUSION: In children with a GCS score of 15, selected radiologic and laboratory tests based on clinical findings are recommended. Careful observation and repeat examinations by trained clinicians can select a group of children at low risk for occult injury.     

Type I, II, and III inositol 1,4,5-trisphosphate receptors are unequally susceptible to down-regulation and are expressed in markedly different proportions in different cell types

The type I inositol 1,4,5-trisphosphate (InsP3) receptor can be rapidly depleted from cells during stimulation of phosphoinositide hydrolysis because its degradation is accelerated (Wojcikiewicz, R. J. H., Furuichi, T., Nakade, S., Mikoshiba, K., and Nahorski, S. R. (1994) J. Biol. Chem. 269, 7963-7969). The present study examines the regulatory properties of type II and III InsP3 receptors. Initially, the relative abundance of InsP3 receptors was defined in a range of cell types by quantitative immunoblotting. These studies showed that the proportions in which type I, II, and III InsP3 receptors are expressed differs greatly and that some cells (for example, AR4-2J rat pancreatoma cells) express all three receptors. Analysis of the effects of cholecystokinin and bombesin on AR4-2J cells showed that each of the InsP3 receptors could be down-regulated during activation of phosphoinositide hydrolysis, but that depletion of the type II receptor was limited. Such a discrepancy was also seen in rat cerebellar granule cells and was found to result from the type II receptor being relatively resistant to degradation. In conclusion, type I, II, and III receptors can all be down-regulated, but with different characteristics. As the relative abundance of InsP3 receptors is extremely variable, the extent to which activation of the down-regulatory process alters intracellular signaling will vary depending on which InsP3 receptors are expressed.     

G1 cyclin-dependent activation of p34CDC28 (Cdc28p) in vitro

In Saccharomyces cerevisiae, transient accumulation of G1 cyclin/p34CDC28 (Cdc28p) complexes induces cells to traverse the cell cycle Start checkpoint and commit to a round of cell division. To investigate posttranslational controls that modulate Cdc28p activity during the G1 phase, we have reconstituted cyclin-dependent activation of Cdc28p in a cyclin-depleted G1 extract. A glutathione S-transferase-G1 cyclin chimera (GST-Cln2p) efficiently binds to and activates Cdc28p as a histone H1 kinase. Activation of Cdc28p by GST-Cln2p requires ATP, crude yeast cytosol, and the conserved Thr-169 residue that serves in other organisms as a substrate for phosphorylation by cyclin-dependent protein kinase-activating kinase. This assay may be useful for distinguishing genes that promote directly the posttranslational assembly of active Cln2p/Cdc28p kinase complexes from those that stimulate the accumulation of active complexes via a positive-feedback loop that governs synthesis of G1 cyclins.