Use of interpreters by physicians for hospitalized limited English proficient patients and its impact on patient outcomes.

BACKGROUND: Few studies have examined the impact of inpatient interpreter use for limited English proficient (LEP) patients on length of stay (LOS), 30-day post discharge emergency department (ED) visits and 30-day hospital readmission rates for LEP patients. METHODS: A retrospective cohort analysis was conducted of all hospitalized patients admitted to the general medicine service at a large academic center. For patients self-reported as LEP, use of interpreters during each episode of hospitalization was categorized as: 1) interpreter used by non-MD (i.e., nurse); 2) interpreter used by a non-Hospitalist MD; 3) interpreter used by Hospitalist; and 4) no interpreter used during hospitalization. We examined the association of English proficiency and interpreter use on outcomes utilizing Poisson and logistic regression models. RESULTS: Of 4,224 patients, 564 (13 %) were LEP. Of these LEP patients, 65.8 % never had a documented interpreter visit, 16.8 % utilized an interpreter with a non-MD, 12.6 % utilized an interpreter with a non-Hospitalist MD and 4.8 % utilized an interpreter with a hospitalist present. In adjusted models, compared to English speakers, LEP patients with no interpreters had significantly shorter LOS. There were no differences in readmission rates and ED utilization between LEP and English-speaking patients. Compared to LEP patients with no interpreter use, those who had a physician use an interpreter had odds for a longer LOS, but there was no difference in odds of readmission or ED utilization. CONCLUSION: Academic hospital clinician use of interpreters remains highly variable and physicians may selectively be using interpreters for the sickest patients.

Establishing a Causal Relationship between Interventions to Promote Self-Determination and Enhanced Student Self-Determination.

Promoting the self-determination of adolescents with disabilities has become best practice in secondary education and transition services, but to date there have been no studies establishing a causal relationship between efforts to promote self-determination and enhancement of the self-determination of youth with disabilities. This article reports a randomized trial, placebo control group study of 371 high school students receiving special education services under the categorical areas of mental retardation or learning disabilities. Students were randomly assigned to an intervention or control group (by high school campus), with students in the intervention condition receiving multiple instructional components to promote self-determination. Latent growth curve analysis showed that although all students in the study showed improved self-determination over the three years of the study, students in the intervention group showed significantly greater growth, though specific intra-individual variables impacted this growth. Implications for research and intervention are discussed.

Nerve-sparing technique and urinary control after robot-assisted laparoscopic prostatectomy.

OBJECTIVES: To characterize determinants of 4-, 12-, and 24-month urinary control after robot-assisted laparoscopic prostatectomy (RALP). METHODS: Adjusted comparative study using prospectively collected, patient self-reported urinary control for 602 consecutive RALPs. Urinary control defined as: (1) EPIC urinary function (UF) scored from 0 to 100 and (2) continence (zero pads per day). RESULTS: Both UF (62.8 vs. 42.4, P<0.001) and continence rates (47.2 vs. 26.7%, P=0.043) were better for bilateral nerve-sparing (BNS) vs. non-nerve-sparing (NNS) at 4 months, but only UF scores were significantly better at 12- (80.9 vs. 70.7, P=0.014) and 24-month (89.2 vs. 77.4, P=0.024) post-RALP. No difference in positive margin rates was observed. In multivariate analysis, older age (parameter estimate -0.42, 95% CI -0.80 to -0.04) and increasing gland volume (-0.13, CI -0.26 to -0.01) resulted in lower UF scores at 4 months, while higher pre-operative UF (0.25, CI 0.05-0.46), bladder neck-sparing technique (10.1, CI 3.79-16.35), BNS (19.1, CI 9.37-28.82), and unilateral nerve-sparing (19.00, CI 7.88-30.11) resulted in higher UF scores at 4 months. At 12 months, higher pre-operative UF (0.24, CI 0.083-0.40) and BNS (9.54, CI 1.92-17.16) resulted in higher UF scores. At 24 months, higher pre-operative UF (0.20, CI 0.06-0.33), bladder neck-sparing technique (7.80, CI 3.48-12.10), and BNS (7.86, CI 1.04-14.68) resulted in higher UF scores. CONCLUSIONS: BNS, bladder neck-sparing technique, and higher pre-operative UF score result in improved 24-month urinary control after RALP.

Effects of an Intensive Discharge Intervention on Medication Adherence, Glycemic Control, and Readmission Rates in Patients With Type 2 Diabetes.

OBJECTIVES: Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes. METHODS: We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician. RESULTS: One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = -1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = -0.98, 95% confidence interval = -2.03 to -0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant. CONCLUSIONS: The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.

Did the 1997 balanced budget act reduce use of physical and occupational therapy services?

OBJECTIVE: To investigate whether use of physical therapy (PT) and occupational therapy (OT) services decreased after the passage of the 1997 Balanced Budget Act (BBA). DESIGN: Data from the nationally representative Medicare Current Beneficiary Survey (MCBS) were merged with Medicare claims data. We conducted cross-sectional analyses of data from 1995 (n=7978), 1999 (n=7863), and 2001 (n=7973). All analyses used MCBS sampling weights to provide estimates that can be generalized to the Medicare population with 5 common conditions. SETTINGS: Skilled nursing facilities (SNFs), home health agencies, inpatient rehabilitation facilities (IRFs), and outpatient rehabilitation settings. PARTICIPANTS: Medicare beneficiaries who participated in the MCBS survey in each of the study years and had 1 or more of the following conditions: acute stroke, acute myocardial infarction, chronic obstructive pulmonary disease, arthritis or degenerative joint disease, or mobility problems. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Percentage of persons meeting our inclusion criteria who received PT or OT in each setting, and total units of PT and OT received in each setting. RESULTS: Multivariable logistic regression revealed no statistically significant differences in the proportion of people who met our inclusion criteria who used PT or OT from home health agencies across the 3 time points. For SNFs, an increase in the odds of receiving PT was statistically significant from 1995 to 1999 (odds ratio [OR]=1.42; 95% confidence interval [CI], 1.19-1.69) and 1995 to 2001 (OR=1.69; 95% CI, 1.39-2.05). For IRF and outpatient settings, a significant increase was observed between 1995 and 2001 (OR=1.71, OR=1.27, respectively). For OT, a statistically significant increase was observed for IRF and outpatient rehabilitation settings from 1995 to 2001. For SNF, the increase was statistically significant from 1995 to 1999 and 1995 to 2001. Mean total PT and OT units received also increased across all settings from 1995 to 2001 except for IRFs. CONCLUSIONS: Despite BBA mandates restricting postacute care expenditures, this nationally representative study showed no decreases in the percentage of Medicare beneficiaries with 5 common diagnoses receiving PT and/or OT across all settings and no decreases in units of PT and/or OT services received between 1995 and 2001 except for those in IRFs. This study suggests that the delivery of PT and OT services did not decline among persons with conditions for which rehabilitation services are often clinically indicated.

Is hospital service associated with racial and ethnic disparities in experiences with hospital care?

PURPOSE: Little is known about the influence of processes of hospital care on racial and ethnic differences in experiences with hospital care. SUBJECTS AND METHODS: To determine whether patient experiences differed by race and ethnicity and whether these differences were associated with hospital care characteristics, we analyzed survey and hospital administrative data from 2664 adult patients after hospitalization at an urban teaching hospital during 1998-1999. We assessed the association of patient race and ethnicity with reporting problems in multiple dimensions of patient experience, using logistic regression to adjust for sex, age, self-reported health status, insurance status, income, route of hospital admission, and hospital service. We then stratified adjusted analyses by hospital service. RESULTS: After adjustment for demographic and hospital characteristics, black (odds ratio (OR): 1.8; 95% confidence interval [CI]: 1.3-2.6) and Latino (OR: 2.0; 95% CI: 1.3-3.0) patients reported more problems with respect for their preferences compared to whites. Blacks reported more problems with respect for their preferences (OR: 1.7; 95% CI: 1.0-3.0) among patients discharged from surgical services, and Latinos reported more problems with respect for their preferences (OR:3.6; CI: 1.6-8.2) among patients discharged from obstetrical services when compared to whites. Patient experiences did not significantly differ by race among patients discharged from medical services. CONCLUSIONS: We found significant racial and ethnic differences in patients' experiences with hospital care, particularly in respect for patient preferences. Our findings suggest physicians and hospital staff should strive to understand and address the expectations of black and Latino patients, particularly those who are hospitalized for surgical or obstetrical issues.

Quality dimensions that most concern people with physical and sensory disabilities.

BACKGROUND: People with physical and sensory disabilities face important challenges in obtaining high-quality health care. We examined whether persons who are blind or have low vision, who are deaf or hard of hearing, or who have mobility impairments or manual dexterity problems are satisfied with the technical and interpersonal aspects of their care. METHODS: By using a 1996 nationally representative survey of 16 403 community-dwelling elderly and disabled Medicare beneficiaries, we identified persons with disabling conditions. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) controlled for demographic characteristics and managed care membership in predicting dissatisfaction with 12 dimensions of care. RESULTS: Of an estimated 33.58 million noninstitutionalized Medicare beneficiaries, 64.1% (an estimated 21.51 million) reported at least 1 potential disability and 29.5% (an estimated 9.89 million) reported more than 1 potential disability. Roughly 98% of people with and without disabilities believed their physicians were competent and well trained. But statistically significantly more people with disabilities reported dissatisfaction with care for 10 of the 12 quality dimensions. Persons reporting any major disability were more likely to be dissatisfied with physicians completely understanding their conditions (AOR, 2.4; 95% CI, 1.9-3.1), physicians completely discussing patients' health problems (AOR, 2.4; 95% CI, 1.9-2.9), physicians answering all patients' questions (AOR, 2.3; 95% CI, 1.7-3.1), and physicians often seeming hurried (AOR, 1.6; 95% CI, 1.4-1.9). CONCLUSIONS: Persons with disabilities generally reported positive views of their care, although they were significantly more likely to report poor communication and lack of thorough care. These findings held regardless of the disabling condition. Thoughtful systematic approaches are required to improve communication and to reduce time pressures that might compromise the health care experiences of people with disabilities.

Physical and sensory functioning over time and satisfaction with care: the implications of getting better or getting worse.

OBJECTIVE: To determine whether those persons whose sensory or physical functioning improved or worsened over one year are more or less satisfied with their health care. DATA SOURCES: 1996 and 1997 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN: The MCBS surveys a nationally representative, longitudinal panel of Medicare beneficiaries about their sociodemographic attributes; vision, hearing, and various mobility functions; and 10 items representing satisfaction with and access to health care. Using multivariable logistic regression and controlling for sociodemographic factors, we computed adjusted odds ratios of dissatisfaction with care, examining the effects of changes in sensory or physical functioning. Analyses accounted for MCBS sampling weights. DATA EXTRACTION METHODS: We identified 9,974 community-dwelling respondents, 18 years old and over who answered the 1996 and 1997 MCBS. We assessed five categories of sensory or physical functioning (vision; hearing; walking; reaching overhead; and grasping and writing) and compared 1996 and 1997 responses to identify those whose functioning improved or worsened. PRINCIPAL FINDINGS: Worsened functioning was strongly associated with older age, low income, and low educational attainment. Improved functioning was rarely significantly associated with satisfaction; an exception involved substantially lower rates of dissatisfaction with "ease and convenience" of getting to physicians. Worsened functioning was often statistically significantly associated with dissatisfaction, always with adjusted odds ratios >1.0. Across all five functional categories, persons whose functioning worsened displayed significantly greater dissatisfaction with overall quality, ease, and costs or care. CONCLUSIONS: Persons whose functioning improved rarely reported better satisfaction than did those whose functioning did not improve, while those whose functioning worsened expressed more systematic reservations about their care.

Preventive care for low-income women in massachusetts post-health reform.

BACKGROUND: Before enacting health insurance reform in 2006, Massachusetts provided free breast, cervical cancer, and cardiovascular risk screening for low-income uninsured women through a federally subsidized program called the Women's Health Network (WHN). This article examines whether, as women transitioned to insurance to pay for screening tests after health reform legislation was passed, cancer and cardiovascular disease screening changed among WHN participants between 2004 and 2010. METHODS: We examined claims data from the Massachusetts health insurance exchange and chart review data to measure utilization of mammography, Pap smear, and blood pressure screening among WHN participants in five community health centers in greater Boston. We conducted a longitudinal analysis, by insurance type, using generalized estimating equations to examine the likelihood of screening at recommended intervals in the postreform period compared to the prereform period. RESULTS: Pre- and postreform, we found a high prevalence of recommended mammography (86% vs. 88%), Pap smear (88% vs. 89%), and blood pressure screening (87% vs. 91%) that was similar or improved for most women postreform. Screening use differed by insurance type. Recommended mammography screening was statistically significantly increased among women with state-subsidized private insurance (odds ratio [OR] 1.58, p<0.05). Women with unsubsidized private insurance or Medicare had decreased Pap smear use postreform. Although screening prevalence was high, 31% of women required state safety-net funds to pay for screening tests. CONCLUSION: Our results suggest a continued need for safety-net programs to support preventive screening among low-income women after implementation of healthcare reform.

A case control study to improve accuracy of an electronic fall prevention toolkit.

Patient falls are a serious and commonly report adverse event in hospitals. In 2009, our team conducted the first randomized control trial of a health information technology-based intervention that significantly reduced falls in acute care hospitals. However, some patients on intervention units with access to the electronic toolkit fell. The purpose of this case control study was to use data mining and modeling techniques to identify the factors associated with falls in hospitalized patients when the toolkit was in place. Our ultimate aim was to apply our findings to improve the toolkit logic and to generate practice recommendations. The results of our evaluation suggest that the fall prevention toolkit logic is accurate but strategies are needed to improve adherence with the fall prevention intervention recommendations generated by the electronic toolkit.

An Evaluation of the Beyond High School Model on the Self-Determination of Students with Intellectual Disability.

Students with intellectual disability are often served in community-based services to promote effective adult outcomes in employment, community inclusion, and independent living (Gaumer, Morningstar & Clark (2004). Beyond High School (Wehmeyer, Garner, Lawrence, Yeager, & Davis, 2006), a multi-stage model to promote student involvement in educational planning, was effectively used by 109 students with mild and moderate levels of intellectual disability between 17.8 and 21 years of age to increase student abilities. Results are discussed in regard to improved transition opportunities for individuals with intellectual disability such as those afforded through post-secondary education.

Lack of access due to costs remains a problem for some in Massachusetts despite the state's health reforms.

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer. The state needs to implement new strategies to build on the promise of universal coverage and address specific needs of vulnerable populations, such as limiting out-of-pocket spending for this group. Also, more data are needed on the social determinants of health to identify specific barriers related to cost and access for vulnerable groups that general insurance reforms may not address.

Case management intervention in cervical cancer prevention: the Boston REACH coalition women's health demonstration project.

BACKGROUND: The Boston REACH Coalition developed a case management intervention for Black women in primary care settings to identify and reduce medical and social obstacles to cervical cancer screening and following up abnormal results. METHODS: The 5-year intervention was evaluated among 732 Black women aged 18 to 75 who were at high risk for inadequate Pap smear screening and follow-up. Case managers provided social services referrals to address patient-identified social concerns (e.g., transportation, housing), as well as navigation to prompt screening and follow-up of abnormal tests. The three study aims were to (1) identify the social factors associated with Pap smear screening at baseline before intervention, (2) evaluate the correlation between exposure to case management intervention and achieving recommended Pap screening intervals, and (3) evaluate the correlation between exposure to case management intervention and having timely follow-up of abnormal Pap smear tests. RESULTS: We found that a lack of a regular clinical provider, concerns communicating with providers, poor self-rated health, and having less than a high school education were important correlates of recent Pap smear screening before the case management intervention. During the case management intervention, we found a significant increase in achieving recommended Pap smear screening intervals among women with a recent Pap smear at study entry (increasing from 52% in the first year to 80% after 4 or more years; p < .01), but not among women who entered the study without a recent Pap smear (increasing from 31% in the first year to 44% after 4 or more years; p = .39). During case management intervention, having social support for childcare was associated with regular screening among women without a recent Pap smear (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.28-9.69). Insurance status was the key factor in timely clinically indicated follow-up of abnormal results (uninsured OR, 0.27; 95% CI, 0.08-0.86), rather than case management intervention. CONCLUSIONS: Exposure to case management was associated with regular Pap smear screening among women who recently engaged in screening. Future research should focus on systems changes to address social determinants of health, including strategies to facilitate screening for Black women without social support for childcare. To improve follow-up of abnormal results, financial access to care should be addressed.

Mammography use among Black women: the role of electronic medical records.

BACKGROUND AND AIMS: Accurately documenting mammography use is essential to assess quality of care for early breast cancer detection in underserved populations. Self-reports and medical record reports frequently result in different accounts of whether a mammogram was performed. We hypothesize that electronic medical records (EMRs) provide more accurate documentation of mammography use than paper records, as evidenced by the level of agreement between women's self-reported mammography use and mammography use documented in medical records. METHODS: Black women aged 40-75 were surveyed in six primary care sites in Boston, Massachusetts (n = 411). Survey data assessed self-reported mammography prevalence within 2 years of study entry. Corresponding medical record data were collected at each site. Positive predictive value (PPV) of self-report and kappa statistics compared data agreement among sites with and without EMRs. Logistic regression estimated effects of site and patient characteristics on agreement between data sources. RESULTS: Medical records estimated a lower prevalence of mammography use (58%) than self-report (76%). However, self-report and medical record estimates were more similar in sites with EMRs. PPV of self-report was 88% in sites with continuous access to EMRs and 61% at sites without EMRs. Kappa statistics indicated greater data agreement at sites with EMRs (0.72, 95% CI 0.56-0.88) than without EMRs (0.46, 95% CI 0.29-0.64). Adjusted for covariates, odds of data agreement were greatest in sites where EMRs were available during the entire study period (OR 4.31, 95% CI 1.67-11.13). CONCLUSIONS: Primary care sites with EMRs better document mammography use than those with paper records. Patient self-report of mammography screening is more accurate at sites with EMRs. Broader access to EMRs should be implemented to improve quality of documenting mammography use. At a minimum, quality improvement efforts should confirm the accuracy of paper records with supplemental data.

Use of physical and occupational therapy by Medicare beneficiaries within five conditions: 1994-2001.

OBJECTIVE: To examine the use of physical therapy and occupational therapy among Medicare beneficiaries nationwide before and after the 1997 Balanced Budget Act, which introduced prospective payment for rehabilitation services. DESIGN: We analyzed responses from the longitudinal Medicare Current Beneficiary Survey, merged with Medicare claims, to track physical therapy and occupational therapy rates and intensity (units of service) from 1994 through 2001. This observational study focused on elderly and disabled Medicare beneficiaries within five conditions: stroke, acute myocardial infarction, chronic obstructive pulmonary disease, arthritis, and lower-limb mobility problems. We used cubic smoothing spline functions to describe trends in service intensity over time and generalized estimating equations to assess changes in service intensity. RESULTS: Controlling for demographic characteristics, adjusted mean level of physical therapy and occupational therapy intensity rose significantly between 1994 and 2001 for all five conditions. Service intensity leveled off in 1999 for occupational therapy and 2000 for physical therapy. With few exceptions, physical therapy and occupational therapy intensity was not significantly associated with patients' demographic characteristics. CONCLUSIONS: Medicare beneficiaries with conditions that can potentially benefit from physical therapy or occupational therapy or both continued to get these services at similar-and sometimes increasing-intensity during years after passage of the Balanced Budget Act.

Addressing social determinants of health to improve access to early breast cancer detection: results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women's Health Demonstration Project.

BACKGROUND: The Boston Racial and Ethnic Approaches to Community Health (REACH) 2010 Breast and Cervical Cancer Coalition developed a case management intervention for women of African descent to identify and reduce medical and social obstacles to breast cancer screening and following up abnormal results. METHODS: We targeted black women at high risk for inadequate cancer screening and follow-up as evidenced by a prior pattern of missed clinic appointments and frequent urgent care use. Case managers provided referrals to address patient-identified social concerns (e.g., transportation, housing, language barriers), as well as navigation to prompt screening and follow-up of abnormal tests. We recruited 437 black women aged 40-75, who received care at participating primary care sites. The study was conducted as a prospective cohort study rather than as a controlled trial and evaluated intervention effects on mammography uptake and longitudinal screening rates via logistic regression and timely follow-up of abnormal tests via Cox proportional hazards models. RESULTS: A significant increase in screening uptake was found (OR 1.53, 95% CI 1.13-2.08). Housing concerns (p < 0.05) and lacking a regular provider (p < 0.01) predicted poor mammography uptake. Years of participation in the intervention increased odds of obtaining recommended screening by 20% (OR 1.20, 95% CI 1.02-1.40), but this effect was attenuated by covariates (p = 0.53). Timely follow-up for abnormal results was achieved by most women (85%) but could not be attributed to the intervention (HR 0.95, 95% CI 0.50-1.80). CONCLUSIONS: Case management was successful at promoting mammography screening uptake, although no change in longitudinal patterns was found. Housing concerns and lacking a regular provider should be addressed to promote mammography uptake. Future research should provide social assessment and address social obstacles in a randomized controlled setting to confirm the efficacy of social determinant approaches to improve mammography use.

The costs and savings associated with prevention of adverse events by critical care nurses.

PURPOSE: The aim of the study was to determine the costs and savings associated with prevention of adverse events (AEs) by critical care nurses. MATERIALS AND METHODS: We performed a secondary analysis of data from 2 coronary care unit (CCU) studies that determined the incremental cost of AEs and the rate of near misses recovered by nurses during weekday, daytime shifts. For this study, we determined the nurse staffing costs and savings by averting AEs. Physicians judged the likelihood that observed near misses would have resulted in actual AEs if not initially intercepted. A sensitivity analysis was performed on the savings from preventing AEs and the costs of different nurse staffing ratios and experience levels. RESULTS: We observed 66 recovered near misses during 308 observation hours, with 34 (51.5%) judged to likely have reached and harmed the patient resulting in an AE if not intercepted. The annual incidence of prevented AEs extrapolated to 2296 events. Savings from prevented AEs ranged from $2.2 million to $13.2 million. Nurse staffing costs for the same time frame was $1.36 million. CONCLUSIONS: Although CCU nursing staffing costs are significant, the potential savings associated with preventing AEs is far greater. Further research is needed to identify the optimal nurse staffing ratios.

Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes.

BACKGROUND: Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted despite a daunting learning curve with bladder neck dissection as a challenging step for newcomers. OBJECTIVE: To describe an anatomic, reproducible technique of bladder neck preservation (BNP) and associated perioperative and long-term outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: From September 2005 to May 2009, data from 619 consecutive RALP were prospectively collected and compared on the basis of bladder neck dissection technique with 348 BNP and 271 standard technique (ST). SURGICAL PROCEDURE: RALP with BNP. MEASUREMENTS: Tumor characteristics, perioperative complications, and post-operative urinary control were evaluated at 4, 12 and 24 months using (1) the Expanded Prostate Cancer Index (EPIC) urinary function scale scored from 0-100; and (2) continence defined as zero pads per day. RESULTS AND LIMITATIONS: Mean age for BNP versus ST was 57.1±6.6 yr versus 58.9±6.7 yr (p=0.033), while complication rates did not vary significantly by technique. Estimated blood loss was 183.7±95.8 ml versus 224.6±108 ml (p=0.938) in men who underwent BNP versus ST. The overall positive margin rate was 12.8%, which did not differ at the prostate base for BNP versus ST (1.4% vs. 2.2%, p=0.547). Mean urinary function scores for BNP versus ST at 4, 12, and 24 mo were 64.6 versus 57.2 (p=0.037), 80.6 versus 79.0 (p=0.495), and 94.1 versus 86.8 (p<0.001). Similarly, BNP versus ST continence rates at 4, 12, and 24 mo were 65.6% versus 26.5% (p<0.001), 86.4% versus 81.4% (p=0.303), and 100% versus 96.1% (p=0.308). CONCLUSIONS: BNP versus ST is associated with quicker recovery of urinary function and similar cancer control.

Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients.

PURPOSE: Rates of serious medication errors in three pediatric inpatient units (intensive care, general medical, and general surgical) were measured before and after introduction of unit-based clinical pharmacists. METHODS: Error rates on the study units and similar patient care units in the same hospital that served as controls were determined during six- to eight-week baseline periods and three-month periods after the introduction of unit-based clinical pharmacists (full-time in the intensive care unit [ICU] and mornings only on the general units). Nurses trained by the investigators reviewed medication orders, medication administration records, and patient charts daily to detect errors, near misses, and adverse drug events (ADEs) and determine whether near misses were intercepted. Two physicians independently reviewed and rated all data collected by the nurses. Serious medication errors were defined as preventable ADEs and nonintercepted near misses. RESULTS: The baseline rates of serious medication errors per 1000 patient days were 29 for the ICU, 8 for the general medical unit, and 7 for the general surgical unit. With unit-based clinical pharmacists, the ICU rate dropped to 6 per 1000 patient days. In the general care units, there was no reduction from baseline in the rates of serious medication errors. CONCLUSION: A full-time unit-based clinical pharmacist substantially decreased the rate of serious medication errors in a pediatric ICU, but a part-time pharmacist was not as effective in decreasing errors in pediatric general care units.