Current Research and Scholarly Interests
Quality improvement (QI) efforts seek to make medical care the best it can be rather than merely good enough to avoid censure. Focus on improving the average performance usually produces more net benefit than eliminating outliers, often by simplification, standardization, and specification. We have worked with electronic medication monitors, clinical databases, and computerized physician order entry systems for better clinical outcomes. We have also developed training modules for students, house officers, and clinicians for enhanced professionalism and accountability.
Recent work has emphasized optimizing among cost, quality and access, using examples of common internal medicine problems (e.g., community acquired pneumonia, diabetes mellitus, blood product transfusion). QI project teams arose in both inpatient and outpatient settings. The optimal results occur from combining didactic training and practical applications via projects with plan-do-study-act rapid cycles of change. We have also examined the relative impact of patient versus physician behaviors as well as system factors in determining clinical outcomes for control of elevated cholesterol.
In prior work, we explored medication adherence. Medication-taking represents a complex behavior integral to optimal outcomes in much of ambulatory medical care. We have helped develop and test electronic medication monitors capable of dynamic tracking of medication dispensing events over time. The technology offers a time-based matrix by which to interpret, understand, and improve clinical outcomes that depend on patients' medication-taking behavior.
Using the electronic monitor technology, we have studied
a) Normative patterns of medication-taking among subgroups of patients on chronic cardiovascular medications
b) Dose-response relationships among established and investigational antihypertensive medications for misinterpretations of optimal dosing recommendations
c) Critical evaluation of reported adverse drug reactions, based on dosing errors that involve omission, commission, or misscheduling
d) Clinical protocols useful for assessing apparent secondary resistance to treatment after initial clinical responsiveness
e) Cost-effectiveness of the incremental information about precise medication-taking events, patterns, and distortions.