Comprehensive electronic medical record implementation levels not associated with 30-day all-cause readmissions within Medicare beneficiaries with heart failure.

BACKGROUND: Regulatory standards for 30-day readmissions incentivize hospitals to improve quality of care. Implementing comprehensive electronic health record systems potentially decreases readmission rates by improving medication reconciliation at discharge, demonstrating the additional benefits of inpatient EHRs beyond improved safety and decreased errors. OBJECTIVE: To compare 30-day all-cause readmission incidence rates within Medicare fee-for-service with heart failure discharged from hospitals with full implementation levels of comprehensive EHR systems versus those without. METHODS: This retrospective cohort study uses data from the American Hospital Association Health IT survey and Medicare Part A claims to measure associations between hospital EHR implementation levels and beneficiary readmissions. Multivariable Cox regressions estimate the hazard ratio of 30-day all-cause readmissions within beneficiaries discharged from hospitals implementing comprehensive EHRs versus those without, controlling for beneficiary health status and hospital organizational factors. Propensity scores are used to account for selection bias. RESULTS: The proportion of heart failure patients with 30-day all-cause readmissions was 30%, 29%, and 32% for those discharged from hospitals with full, some, and no comprehensive EHR systems. Heart failure patients discharged from hospitals with fully implemented comprehensive EHRs compared to those with no comprehensive EHR systems had equivalent 30-day readmission incidence rates (HR = 0.97, 95% CI 0.73 - 1.3). CONCLUSIONS: Implementation of comprehensive electronic health record systems does not necessarily improve a hospital's ability to decrease 30-day readmission rates. Improving the efficiency of post-acute care will require more coordination of information systems between inpatient and ambulatory providers.

High oleic/stearic fatty-acid desaturation index in cord plasma from infants of mothers with gestational diabetes.

OBJECTIVE: Enhanced fatty-acid desaturation by stearoyl-CoA desaturase enzyme-1 (SCD1) is associated with obesity. This study determined desaturation in the cord plasma of newborns of mothers with and without gestational diabetes (GDM). STUDY DESIGN: Newborns of mothers with GDM (n=21) and without (control, n=22) were recruited. Cord plasma fatty-acid desaturation indices (palmitoleic/palmitic, oleic/stearic ratios) were compared, and correlated with anthropometrics and biochemical measures. A subset of very low-density lipoprotein (VLDL) desaturation indices were determined to approximate the liver SCD1 activity. RESULT: The total oleic/stearic index was higher in GDM, despite adjustment for cord glucose concentrations. Among GDM and controls, the oleic/stearic index correlated with cord glucose concentrations (rs=0.36, P=0.02). Both palmitoleic/palmitic and oleic/stearic indices correlated with waist circumference (r=0.47, P=0.001; r=0.37, P=0.01). The VLDL oleic/stearic index was higher in GDM. CONCLUSION: The elevated total oleic/stearic index suggests increased lipogenesis in GDM newborns. Factors in addition to glucose supply may influence fetal SCD1 activity.

Associations between the concurrent use of clinical decision support and computerized provider order entry and the rates of appropriate prescribing at discharge.

INTRODUCTION: Electronic health record systems used in conjunction with clinical decision support (CDS) or computerized provider order entry (CPOE) have shown potential in improving quality of care, yet less is known about the effects of combination use of CDS and CPOE on prescribing rates at discharge. OBJECTIVES: This study investigates the effectiveness of combination use of CDS and CPOE on appropriate drug prescribing rates at discharge for AMI or HF patients. METHODS: Combination use of CDS and CPOE is defined as hospitals self-reporting full implementation across all hospital units of CDS reminders, CDS guidelines, and CPOE. Appropriate prescribing rates of aspirin, ACEI/ARBs, or beta blockers are defined using quality measures from Hospital Compare. Multivariate linear regressions are used to test for differences in mean appropriate prescribing rates between hospitals reporting combination use of CDS and CPOE, compared to those reporting the singular use of one or the other, or the absence of both. Covariates include hospital size, region, and ownership status. RESULTS: Approximately 10% of the sample reported full implementation of both CDS and CPOE, while 7% and 17% reported full use of only CPOE or only CDS, respectively. Hospitals reporting full use of CDS only reported between 0.2% (95% CI 0.04 - 1.0) and 1.6% (95% CI 0.6 - 2.6) higher appropriate prescribing rates compared to hospitals reporting use of neither system. Rates of prescribing by hospitals reporting full use of both CPOE and CDS did not significantly differ from the control group. CONCLUSIONS: Although associations found between full implementation of CDS and appropriate prescribing rates suggest that clinical decision tools are sufficient compared to basic EHR systems in improving prescribing at discharge, the modest differences raise doubt about the clinical relevance of the findings. Future studies need to continue investigating the causal nature and clinical relevance of these associations.

Hearing impairment caused by intratympanic pressure changes during general anesthesia.

Hearing impairment is not often considered a potential complication of general anesthesia; however, four patients who sustained hearing loss following nitrous oxide inhalation anesthesia have recently come to the authors' attention. The cases are presented and middle ear pressure measurements taken during endotracheal inhalation anesthesia with various agents are reported. Factors predisposing to hearing loss during anesthesia are discussed.