A Retrospective Analysis of Adverse Events in Hyperbaric Oxygen Therapy (2012-2015): Lessons Learned From 1.5 Million Treatments.

OBJECTIVE: To describe the distribution and occurrence of adverse events recorded during hyperbaric oxygen (HBO) therapy from 2012 to 2015. In this analysis, events are defined as otic/sinus barotrauma, confinement anxiety, hypoglycemia, oxygen toxicity, pneumothorax, seizure, and shortness of breath. DATA AND ANALYSIS: The data for the analysis were drawn from a proprietary electronic health data system that contained information on 1,529,859 hyperbaric treatments administered during 53,371 treatment courses from 2012 to 2015 in outpatient wound care centers across the United States managed by Healogics, Inc, Jacksonville, Florida. RESULTS: Of the 1.5 million treatments included in the analysis, 0.68% were associated with an adverse event. Barotrauma and confinement anxiety were the most frequently reported events. Medically severe events were extremely uncommon, with fewer than 0.05 instances of oxygen toxicity per 1000 treatments and only 1 confirmed case of pneumothorax. CONCLUSIONS: Results indicate that the occurrence of adverse events associated with HBO therapy is infrequent and typically not serious. The findings of this study suggest that when administered according to the appropriate therapeutic protocols HBO therapy is a safe and low-risk intervention.

Doxycycline as a modulator of inflammation in chronic wounds.

 Doxycycline is a semisynthetic, chemically modified tetracycline compound that is rapidly absorbed and exerts biological effects independent of its antimicrobial activity. One such effect includes the inhibition of matrix metalloproteinases. Doxycycline has a long history as a collagenase inhibitor. This article will describe its mode of action and review its effectiveness in significantly reducing inflammation and elevated levels of proinflammatory cytokines within chronic wounds. .

Synthetic membrane neo-pericardium facilitates total artificial heart explantation.

BACKGROUND: In the past, explantation of the Cardio West total artificial heart (TAH) has been technically challenging because of the presence of dense adhesions and extremely thickened pericardium. To prevent this, we constructed a synthetic neo-pericardium in 14 patients. METHODS: Using expanded polytetrafluoroethylene (e-PTFE) membrane, we constructed a pericardium within the pericardium, or "neo-pericardium," completely covering the Cardio West TAH separating the native atria from the native pericardium, and wrapping the ascending aorta from the outflow conduit distally for about 5 to 7 cm. RESULTS: Of the 14 patients, 9 were transplanted and could be evaluated, 3 died on device support, and 2 are currently on device support. In each case, we attained faster (by 25 minutes) and easier reentry through the sternum. Surgical planes around the aorta, over the right and left atria, and throughout the pericardial space became apparent immediately after e-PTFE membrane removal. The pericardium and related tissues although slightly thickened (<2 mm) were pliable compared with our previous 36 patients, with very thick adherent pericardium over the device and native atria. CONCLUSIONS: The plastic materials forming the ventricular housing and drivelines of the Cardio West TAH and the Dacron outflow conduits have in the past caused profound local inflammatory reactions, resulting in extremely dense adhesions and thickened adherent pericardium. Using e-PTFE membrane to fashion a complete neo-pericardium and to wrap the ascending aorta at the time of Cardio West implantation dramatically reduces adhesions and pericardial thickening and facilitates explantation.

Hospital resources used to treat the injured elderly at North Carolina trauma centers.

OBJECTIVE: The purpose of this paper is to compare the hospital resources used by elderly, adult, and pediatric patients treated in hospitals reporting to the North Carolina Trauma Registry (NCTR). DESIGN: We analyzed data on all patients entered into the NCTR from 1 January 1988 to 31 December 1990. SETTING: The NCTR is a statewide registry of all trauma patients admitted for at least 24 hours or dead on arrival at the eight Level I and II trauma center hospitals in North Carolina. PATIENTS: The total number of patients included in the study was 21,214; elderly adults included those age 65 and older (n = 2808), adults included those 15 to 64 years old (n = 15,776), and pediatric patients included those 0 to 14 years old (n = 2630). MAIN OUTCOME MEASURES: We examined hospital resources using three measures: overall length of hospital stay in days, intensive care unit (ICU) length of stay in days for those admitted to the ICU, and total hospital charges billed during the hospitalization. RESULTS: Controlling for injury severity, we found that elderly adults had longer mean hospital and ICU lengths of stay and higher mean hospital charges than adults or children. Whereas only 22% of injuries to elderly adults were transportation-related, transportation injuries generated 38% of their hospital charges. Sixty-eight percent of their injuries were caused by falls, generating total hospital charges of $17.6 million, an average of 15 days in hospital stay and 9 days in ICU stay. CONCLUSION: A 10% reduction in both transportation injuries and falls among the elderly could save $3.5 million in this population over 3 years.

Patient awareness of health precautions after splenectomy.

Sepsis after splenectomy is a lifelong risk, and patients who have had splenectomy should be educated about this risk. This study examines patient knowledge after splenectomy. We reviewed hospital records of 118 patients who had splenectomies performed between 1982 and 1988 at New Hanover Memorial Hospital. Twenty-four patients have died since their surgery; one death was suspected to be due to postsplenectomy sepsis. Of the 89 patients alive and eligible for follow-up, we were able to query 63. Only 16% were aware of any health precautions. After prompting, patient awareness improved to 40%. We also surveyed 11 of the 14 surgeons who performed the splenectomies. They indicated that they always discuss with their patients the immunologic consequences of spleen removal and the increased risks of infection, although they do not always recommend pneumococcal vaccine. We conclude that splenectomy patients have a low level of knowledge about postsplenectomy infection risks and precautions. We developed an educational pamphlet to aid the surgeon in patient education.

Results of staged bilateral carotid endarterectomy.

To determine differences in outcome between unilateral and staged bilateral carotid endarterectomies, we reviewed 850 carotid endarterectomies done by 14 surgeons in a community hospital. Results of 528 unilateral procedures were compared with those of 161 bilateral procedures. Data were abstracted from records for an 11-year period. Twelve of the patients in the unilateral group had nonfatal strokes, and 14 died within 30 days of surgery (stroke + death rate, 4.9%). There were no nonfatal strokes among patients in the bilateral group, and nine died (stroke + death rate, 5.6%). Seven of 14 deaths in the unilateral group and six of nine deaths in the bilateral group were due to neurologic events. In the bilateral group, death was associated with postoperative hypertension and a short intersurgical interval. The stroke + death rate was not significantly different between unilateral and bilateral procedures and compared favorably with North American Symptomatic Carotid Endarterectomy Trial guidelines and other published reports. Staged bilateral carotid endarterectomy can be safely performed in a community hospital.

A statewide, hospital-based analysis of frequency and outcomes in carotid endarterectomy.

BACKGROUND: For more than 40 years carotid endarterectomy (CE) has been used in the treatment of extracranial carotid disease for the prevention of stroke. Recent prospective clinical trials have confirmed the benefit of CE for both symptomatic and asymptomatic patients. Our purpose was to examine statewide trends in the numbers of CE over a 6-year time period and to evaluate outcomes. METHODS: Using data from the North Carolina Medical Database Commission (NCMDC) all CE procedures from 1988 to 1993 were identified. Numbers of CE were compared with the population and hospital admissions. Variables of length of stay, hospital charges, discharge disposition, and occurrence of stroke and death were analyzed. RESULTS: A total of 11,973 CE were performed in 6 years. Compared by admissions, population, and the proportion of elderly, the number of CE increased yearly. The stroke rate was 1.7% and the death rate 1.2% for an overall in-hospital stroke plus mortality rate of only 2.7%. CONCLUSIONS: From a diverse group of hospitals and a large number of surgeons and patients, this hospital-based study documents the acceptance and safety of CE in the treatment of extracranial carotid disease.

Breast conservation surgery for breast cancer at a regional medical center.

BACKGROUND: This study examined trends in breast conservation surgery (BCS) at our hospital and factors associated with BCS. METHODS: We retrospectively reviewed breast cancer surgeries in patients eligible for BCS (size <4 cm, N0, N1) from 1990 through 1996 (n = 634). We calculated the yearly prevalence of BCS and used multiple logistic regression (MLR) to determine tumor, patient, and surgeon factors associated with BCS. RESULTS: BCS increased from 17% in 1990 to 41% in 1996. Women with T1a and T1b tumors were 3.8 and 2.0 times, respectively, as likely to have BCS compared with those who had T2 tumors. Other factors associated with BCS included nonpalpable tumors, age <50, Medicare, Medicaid, or self-pay patients, and women whose surgeons graduated since 1961, with odds ratios of 1.8, 1.9, 2.4, and 2.3, respectively. CONCLUSION: Women with small, nonpalpable tumors, age <50, without private insurance, operated on by younger surgeons were more likely to receive BCS.

Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography.

The administration of oral contrast (OC) is widely recommended for computed tomography (CT) of the abdomen in patients with blunt trauma. The purpose of this study was to determine whether routine abdominal CT scans performed without OC were associated with diagnostic error in patients with blunt trauma. Four hundred ninety-two patients were identified from our Trauma Registry who had CT scans for the evaluation of blunt abdominal trauma between January 1988 and December 1991. Seventy-six percent (372) of the CT scans were interpreted as negative, and 24% (120) were considered positive. OC was used in 8 (1.6%) of 492 patients. Only 1 of 372 patients whose initial non-OC--enhanced scan was negative subsequently required surgery. There were 5 bowel injuries among the 42 patients who underwent an abdominal operation; in none would the use of OC have ensured the preoperative diagnosis. We found that the omission of OC did not represent a disadvantage to patients with blunt trauma undergoing a routine abdominal CT scan. Potential time delays and the hazards associated with the use of OC were minimized.

Community hospital carotid endarterectomy in patients over age 75.

We compared the prevalence of stroke and death in 133 patients aged 75 and older in whom 170 carotid endarterectomies were performed with that in 501 patients less than age 75 in whom 640 carotid endarterectomies were performed. There were three strokes (2%) in patients aged 75 and older and nine strokes (1%) in younger patients (p = 0.7). There were 8 deaths (5%) in patients aged 75 and older and 14 deaths (2%) in younger patients (p = 0.1). After controlling for the possible confounding effects of diabetes, prior stroke, history of angina, prior carotid artery disease, previous vascular surgery, history of myocardial infarction, preoperative hypertension requiring medication, and female gender, a logistic regression model showed that patients aged 75 and older were no more likely to have a stroke or death than patients under age 75. We conclude that age alone is not a contraindication to the safe performance of carotid endarterectomy in the community hospital.

Fine-needle aspiration cytology and thyroid surgery in the community hospital.

BACKGROUND: To assess the use and usefulness of fine-needle aspiration cytologic biopsy (FNAB) of the thyroid in our hospital. METHODS: All cytology slides and charts of patients who had FNAB of the thyroid done in our hospital in 1993 were reviewed. Charts of all patients having thyroid surgery in our hospital in 1993 were reviewed to determine the pathological diagnosis and whether FNAB had been performed preoperatively. Finally, we reviewed all consecutive thyroid surgery cases for an 8-year period, and we calculated the yearly percentage of malignancy. RESULTS: Fifty-five FNAB were done in 53 patients. In 21 patients the FNAB gave indication for thyroid surgery, yet surgery was done in only 12 (57.1%). Forty-two patients had surgery for a thyroid nodule, but only 20 patients (47.6%) had a preoperative FNAB. There were 3 malignancies among the 20; 2 were correctly predicted by FNAB. The FNAB was correct in 18 of 20. In all, 378 thyroid operations were done from 1987 to 1994. The yearly proportion of thyroid malignancy ranged from 11% to 29%, but showed no change corresponding with increasing diagnostic sophistication. CONCLUSIONS: Fine-needle aspiration cytologic biopsy in the workup of patients with thyroid masses is strikingly underutilized in our institution. While accurate in 90% of cases where used, FNAB appears to play a minor role in the surgeon's decision regarding surgery. As a result of these findings, we developed a grading system for better communication of the FNAB report and a clinical guideline to improve the evaluation of patients with thyroid masses.

Cholecystectomy in patients aged 80 and older.

BACKGROUND: We assessed whether the increase in performance of laparoscopic cholecystectomy has affected patients aged 80 and older and if outcomes of a laparoscopic approach in this population would show improvement over those for open surgery. METHODS: We analyzed an 11-state discharge database obtained from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Release 1 contains a 20% sample of United States hospitals for the period 1988 to 1992. Diagnosis-related group (DRG) codes 197 and 198 were searched, and demographics, type of surgery, and outcome measures were analyzed. RESULTS: In 5 years, 350,451 patients underwent cholecystectomy with the DRG codes listed. Of those, 18,500 patients were aged 80 to 105. The total number of cholecystectomies increased each year. Performance of laparoscopic cholecystectomy rose rapidly and that of open cholecystectomy decreased. Overall mortality with laparoscopic cholecystectomy was 1.8%, was lower than that of open cholecystectomy, was lower in women, and decreased with time. CONCLUSIONS: Patients aged 80 and older have participated in the increased performance of cholecystectomy and the switch to laparoscopic cholecystectomy. This has a low mortality, low length of stay, and higher proportion of patients being discharged to home compared with patients having open cholecystectomy.

Interval sterilizations. A substitute for postpartum procedures, an example from Southeast Brazil.

From December 1979 to February 1980, data were collected on access to postpartum sterilization for all obstetric patients at a large maternity hospital in Campinas, Brazil. Of the 827 women wanting no additional children and having knowledge of sterilization, 481 (58%) reported that they wanted to be sterilized. Of these women, 226 (47%) were sterilized postpartum. One year following their deliveries, follow-up forms were administered to the women desiring sterilization, but who had not been sterilized postpartum, to determine if they had been sterilized over the course of the year. Only 13% of the women had been sterilized, but almost 75% of the women not sterilized said they were still interested in getting sterilized. Of the women interviewed, 18% either had become pregnant again since the initial survey or were currently pregnant.

Factors affecting number of prenatal care visits during second pregnancy among adolescents having rapid repeat births.

PURPOSE: To examine factors associated with the number of prenatal care visits during second pregnancy for adolescents having a short interval between pregnancies. METHODS: The sample includes all adolescents aged 13 to 17 years whose first pregnancy resulted in a birth at a regional medical center in southeastern North Carolina from January 1983 to December 1989 and who had a repeat pregnancy within 24 months which resulted in a birth. We abstracted data from medical records and birth certificates. We fit a negative binomial regression model to determine the effects of various factors on the number of prenatal care visits during second pregnancy. RESULTS: The number of prenatal care visits during the first pregnancy, poor first birth outcome, interval between first and second pregnancy, and care provided by health department staff during first pregnancy were all positively associated with number of prenatal care visits during second pregnancy when controlling for gestation age of second birth. Other independent variables in the model included maternal age, education, black race, and being unmarried at the time of second birth. CONCLUSIONS: Because prenatal care is important for healthy mothers and babies, adolescents should be encouraged to seek prenatal care early in the first pregnancy. This could be an important time to implement interventions aimed at increasing prenatal care utilization in this and subsequent pregnancies.

PIP: Researchers analyzed data on 287 adolescents who delivered their first child between January 1983 and December 1989 at a regional medical center in southeastern North Carolina and had a repeat pregnancy within 24 months of the first birth to identify factors linked to the number of prenatal care visits during the second pregnancy for these adolescents. They were 13-17 years old during the first pregnancy and 15-19 years old during the second pregnancy. The interval between pregnancies was no more than 12 months for about 50% of the teens and no more than 18 months for more than 80%. The mean interval between pregnancies was 11.1 months. The teens were more likely to have received no prenatal care during their second pregnancy than their first pregnancy (7.9% vs. 2.9%; p 0.001). They also had fewer prenatal visits (7.5 vs. 9.2; p 0.0001). After controlling for gestation age of second birth, factors positively associated with the number of prenatal care visits during the second pregnancy were poor first birth outcome, number of prenatal care visits during first pregnancy, pregnancy interval, and care provided by the county health department. A poor first birth outcome had the greatest impact on the number of prenatal care visits during second pregnancy. These findings indicate the need to encourage teens to seek prenatal care early in their first pregnancy so clinicians can implement interventions which increase prenatal care use during this and subsequent pregnancies.

Severity, manifestations, and consequences of violence among pregnant adolescents.

PURPOSE: To examine the severity, manifestations, and consequences of prenatal violence among adolescent and adult participants in a county health department prenatal care coordination program. METHODS: The prospective cohort study design included all Medicaid-eligible program participants from 1994 to 1996. Care coordinators screened participants for prenatal violence using a validated, systematic violence assessment protocol at three times during pregnancy. This protocol was linked with prenatal care and hospital delivery records to document pregnancy outcomes. The main outcome variables were low birth weight (<2500 g) and preterm delivery (before 37 weeks' gestation). RESULTS: Among teens, 16.1% reported prenatal violence, including 9.4% who reported severe violence such as hitting, kicking, or stabbing. Among adults, 11.6% reported prenatal violence, including 4.8% who reported severe violence. Teens were more likely than adults to report abdominal trauma (56% vs. 22%) and violence perpetrated by a relative (23% vs. 5%). Teens who reported severe prenatal violence were more likely to report alcohol use. They were significantly more likely to deliver preterm than teens who reported "other" or "no" prenatal violence (odds ratio 3.5, 95% confidence interval 1.1-10.8) when adjusting for race, adequacy of prenatal care, prior preterm delivery, and alcohol use. For adults, the relationship between prenatal violence and preterm delivery was not statistically significant. The relationship between prenatal violence and low birth weight was not significant for either age cohort. CONCLUSIONS: Prenatal violence was a significant risk factor for preterm birth in this population, especially among teens.

Improving detection of violence among pregnant adolescents.

PURPOSE: The purpose of this study was to determine whether a systematic assessment protocol could increase reporting of violence among pregnant adolescents compared with a routine prenatal assessment. This study also sought to examine issues related to violence assessment among maternity care coordinators. METHODS: The Maternity Care Coordination (MCC) program in a health department prenatal clinic in North Carolina routinely screened all clients for violence at their first visit. This assessment was not standardized. In 1994, the MCC program implemented a systematic violence assessment protocol for all adolescents (n = 117). The protocol assessed violence at three points during pregnancy by asking one direct question: "Have you been hit, slapped, kicked, or hurt during this pregnancy?" To examine the effectiveness of the system, we retrospectively reviewed the 1993 MCC records in which the coordinators routinely screened clients for violence (n = 129). To examine issues related to screening, we conducted in-depth interviews with the maternity care coordinators. RESULTS: The routine pre-intervention assessment indicated that 5.4% of adolescents 12-19 years of age reported prenatal violence. The systematic assessment protocol resulted in a significant increase in reported violence from 5.4% to 16.2% (odds ratio = 2.9, 95% confidence interval = 1.6, 5.6, adjusted for race). Maternity care coordinators identified five factors related to increased reporting using the standardized protocol: (a) written protocol and data collection form; (b) asking direct, specific questions; (c) not labeling the victim; (d) not naming the perpetrator; and (e) conducting multiple assessments. CONCLUSIONS: Multiple, direct, systematic assessments throughout prenatal care resulted in increased reporting of prenatal violence among adolescents compared to single, routine, nonstructured assessments.

PIP: This study tested the hypothesis that use of a direct, systematic assessment protocol applied throughout the course of prenatal care rather than a one-time, nonstructured, routine assessment would increase the reporting of prenatal violence among adolescents. Data from a retrospective assessment of the records of all 142 adolescents aged 12-19 years enrolled during 1993 (when the assessment was nonstructured) in the Maternity Care Coordination program of a health department prenatal clinic in North Carolina were compared to data from all 130 adolescents enrolled during 1994-95 when the systematic protocol was in place. The 13 adolescents with repeat pregnancies were excluded from analysis. The assessment protocol asked the direct question "Have you been hit, slapped, kicked, or hurt?" at three points during pregnancy. It was found that the standardized assessment protocol resulted in almost twice as many reports of violence at initial assessment, but this result was not statistically significant. However, multiple assessments using the systematic protocol increased reporting of prenatal violence significantly and consistently documented the perpetrator of the violence (68% partners, 14% parents, 9% siblings, and 9% friends). In-depth interviews with the seven maternity care coordinators confirmed that the new intervention tool was useful and effective because it used a written protocol and data collection form; asked direct, specific questions; did not label the victim; did not require the perpetrator's name; and involved multiple assessments.

Carotid endarterectomy reoperations in a regional medical center.

Large, randomized prospective clinical trials have not addressed the safety of reoperation for recurrent carotid disease. Our purpose was to determine whether outcomes for carotid endarterectomy for recurrent disease were different from those for primary or contralateral carotid endarterectomy. We reviewed all carotid endarterectomies done in our regional medical center hospital from 1979 through 1997. We analyzed 1656 primary procedures, 377 contralateral carotid procedures, and 63 reoperations. Operation for recurrent disease was done in 3 per cent of those having primary operations. Patients in the three groups did not differ significantly with regard to age, race, or sex. Seventy per cent of patients were symptomatic with transient ischemic attacks, amaurosis, and reversible ischemic neurological deficit being most prominent. There were no deaths and three strokes in the reoperation group for a combined stroke and death rate of 4.8 per cent. This was not significantly different from that of 3.2 per cent for the stroke and death rate for the primary group and 3.5 per cent for the contralateral group. Carotid endarterectomy is a safe treatment for recurrent carotid artery disease.

Laparoscopic cholecystectomy in octogenarians.

Performance of laparoscopic cholecystectomy (LC) is increasing, and patients age 80 and over comprise an increasingly larger proportion of the LC population. This study documents that the increase is accompanied by safe outcome in this patient population. However, the evidence also suggests that cholelithiasis appears to have been a neglected condition in this age group. The prevalence of nonelective procedures, the conversion rate to an open operation, more intraoperative complications, and the percentage having evidence of common bile duct stone passage all support this assertion. With the technology of LC, we are now appropriately addressing the problem with a treatment that allows less surgical trauma to the patient and shorter recovery time. Same-day LC surgery for the octogenarian appears to be very safe and would justify a decision to perform earlier LC in these patients. Surgery done before the appearance of comorbid conditions that increase the surgical and anesthetic risks may result in improved outcomes for the elderly at lower cost. Even when necessary in the already hospitalized patient, LC can be accomplished with morbidity and mortality comparable to those of elective abdominal procedures in younger populations.

Splenic salvage in adults at a level II community hospital trauma center.

Recognition of the important role of the spleen within the immune system has prompted surgeons to regularly consider splenic preservation. We studied our experience at a Level II trauma center to determine whether this trend is reflected in our management. We reviewed 81 adult blunt trauma patients with splenic injury admitted between January 1988 and December 1993. We examined age, race, and clinical data including mechanism of injury, trauma and injury severity scores, organ injury scale (OIS) grade, admitting blood pressure, operations, length of stay, hospital charges, and outcome. Thirty-nine patients underwent immediate splenectomy. Nonoperative treatment was successful in 31 of 37 patients (83.7%). Mean OIS grade (American Association for the Surgery of Trauma) was significantly different between patients treated nonoperatively (1.6 +/- 0.9) and patients treated with immediate splenectomy (3.9 +/- 1.1), (P = <0.001). American Association for the Surgery of Trauma OIS grade correlated well between CT classification and classification at operation (r = 0.7, P = 0.0001) but did not predict success in nonoperative management. Hemodynamic stability, injury severity, and abdominal CT scan findings determine choice of therapy. Splenorrhaphy is frequently discussed but infrequently performed. Splenectomy remains the most commonly performed operation for splenic injury in adults with blunt splenic trauma. Nonoperative management is the most common method of splenic salvage at the Level II community hospital trauma center.

An analysis of trends, perceptions, and use patterns of electronic medical records among US family practice residency programs.

BACKGROUND AND OBJECTIVES: This study intended to quantify electronic medical record (EMR) use in family practice residencies, associate program characteristics with EMR use, and identify perceptions and issues about the use of EMRs. METHODS: A survey was mailed to all 454 US family practice residency programs, with a 72% response rate. The survey, which was pretested and revised, was designed to identify benefits, problems, perceptions, and trends regarding the use of EMRs. RESULTS: Fifty-five of 329 programs (17%) were using an EMR, while 10 (3%) had used an EMR but discontinued. Programs in the South reported the highest EMR use (21%, 21/99), and those in the North Central region reported the lowest use (11%, 11/102). EMR use was highest in university settings (19%, 15/81), programs offering fellowships (26%, 24/92), new programs (36%, 18/48), and programs that require research (22%, 20/91). Of the 329 programs that responded, 43% (143 programs) reported having information systems (IS) committees. Of the 55 programs currently using EMRs, 78% had at least one full-time equivalent IS technician. Of programs that discontinued use, software inadequacy was the most frequently cited reason (40%, 4/10). Programs that had never used EMR systems (n = 264) were more likely than those that had used EMRs (n = 65) to favorably perceive EMRs with respect to 1) meeting program requirements (44% versus 34%), 2) documenting improved patient care (65% versus 43%), 3) providing a reliable research database (94% versus 55%), and 4) documenting resident experience (92% versus 53%). Of the 264 (80%) programs that had never used an EMR, 172 (65%) plan to implement one. CONCLUSIONS: EMR use is low among US family practice residency programs, but some success in implementation of EMRs has been achieved. Based on the responses to this survey, use will likely increase from 55 of 329 programs (17%) to 153 of 329 (47%) by 2000.