Adverse drug events in pediatric outpatients.

OBJECTIVE: To determine rates and types of adverse drug events (ADEs) in the pediatric ambulatory setting. METHODS: A prospective cohort study at 6 office practices in the greater Boston area was conducted over 2-month periods. Duplicate prescription review, telephone surveys 10 days and 2 months after visit, and chart reviews were done. A 2-physician panel classified the severity, preventability, and ability to ameliorate (ie, if the severity or duration of the side effect could have been mitigated by improved communication) ADEs. RESULTS: We identified 57 preventable ADEs (rate 3%; 95% confidence intervals [CI], 3%-4%) and 226 nonpreventable ADEs (rate 13%; 95% CI, 11%-15%) in the medical care of 1788 patients. Of the ADEs, 152 (54%) were able to be ameliorated. None of the preventable ADEs were life threatening, although 8 (14%) were serious. Forty (70%) of the preventable ADEs were related to parent drug administration. Improved communication between health care providers and parents and improved communication between pharmacists and parents, whether in the office or in the pharmacy, were judged to be the prevention strategies with greatest potential. CONCLUSIONS: Patient harm from medication use was common in the pediatric ambulatory setting. Errors in home medication administration resulted in the majority of preventable ADEs. Approximately one fifth of ADEs were potentially preventable and many more were potentially able to be ameliorated. Rates of ADEs due to errors are comparable in children and adults despite less medication utilization in children.

Assessment of education and computerized decision support interventions for improving transfusion practice.

BACKGROUND: Overuse of blood products is common, but prior efforts to improve transfusion decisions have met with limited success. STUDY DESIGN AND METHODS: This study examines transfusion practices before and after a conventional educational intervention followed by a randomized controlled trial of a decision support (DS) intervention with computerized physician order entry (CPOE) for red blood cell, platelet, and fresh-frozen plasma orders. The study was conducted in an academic medical center between April 2003 and June 2004. Orders originating from units not using CPOE with DS (e.g., the emergency department) were excluded. Junior housestaff were randomly assigned into a control group and an intervention group who received DS for transfusion orders. Transfusion orders were initially classified according to guideline rules as DS-agree or DS-disagree. Chart reviews assessed inappropriateness for all DS-disagree orders and a sample of DS-agree orders. The total of inappropriate transfusion orders included chart review confirmed DS-disagree orders and DS-agree orders reclassified as inappropriate. RESULTS: The percentages of inappropriate nonemergent transfusion orders during the baseline phase for the entire staff and randomly assigned junior housestaff were 72.6 percent (2154/2967) and 71.9 percent (1259/1752) and improved after conventional education to 63.8 percent (1699/2663; p < 0.0001) and 63.3 percent (1263/1996; p < 0.0001), respectively. The percentage of inappropriate orders in the DS intervention group continued to improve (59.6%, 804/1350; p < 0.0001). Physicians accepted 14 percent (133/939) of new DS-recommended orders, especially recommendations to increase transfusion doses (73%). CONCLUSIONS: Education and computerized DS both decreased the percentage of inappropriate transfusions, although the residual amount of inappropriate transfusions remained high.

Assessing the level of healthcare information technology adoption in the United States: a snapshot.

BACKGROUND: Comprehensive knowledge about the level of healthcare information technology (HIT) adoption in the United States remains limited. We therefore performed a baseline assessment to address this knowledge gap. METHODS: We segmented HIT into eight major stakeholder groups and identified major functionalities that should ideally exist for each, focusing on applications most likely to improve patient safety, quality of care and organizational efficiency. We then conducted a multi-site qualitative study in Boston and Denver by interviewing key informants from each stakeholder group. Interview transcripts were analyzed to assess the level of adoption and to document the major barriers to further adoption. Findings for Boston and Denver were then presented to an expert panel, which was then asked to estimate the national level of adoption using the modified Delphi approach. We measured adoption level in Boston and Denver was graded on Rogers' technology adoption curve by co-investigators. National estimates from our expert panel were expressed as percentages. RESULTS: Adoption of functionalities with financial benefits far exceeds adoption of those with safety and quality benefits. Despite growing interest to adopt HIT to improve safety and quality, adoption remains limited, especially in the area of ambulatory electronic health records and physician-patient communication. Organizations, particularly physicians' practices, face enormous financial challenges in adopting HIT, and concerns remain about its impact on productivity. CONCLUSION: Adoption of HIT is limited and will likely remain slow unless significant financial resources are made available. Policy changes, such as financial incentivesto clinicians to use HIT or pay-for-performance reimbursement, may help health care providers defray upfront investment costs and initial productivity loss.

Burden of illness for children and where we stand in measuring the quality of this health care.

CONTEXT: Measures of health care quality for children are not as well developed as those for adults. It is also unclear the extent to which the current pool of measures address common causes of illness and health care utilization for children. OBJECTIVE: The goal of this study was to create lists of high-priority conditions for children based on different vantage points for defining burden relative to both inpatient and outpatient care for children. These high-priority conditions were then cross-tabulated with all known existing quality measures for pediatric health care. DATA: High-prevalence conditions for children were identified by using the 2000 National Ambulatory Medical Care Survey, 2000 National Hospital Ambulatory Medical Care Survey, 1999 Medical Expenditure Panel Survey, 2000 Healthcare Cost and Utilization Project's State Inpatient Databases, and 2000 Healthcare Cost and Utilization Project's State Ambulatory Surgery Databases. Burden assessments were done using frequencies of visits, charges, in-hospital deaths. Existing quality measures for children were identified from a recent compendium of such measures and a search of the National Quality Measures Clearinghouse. RESULTS: There are numerous and large gaps in existing quality-of-care measures for children relative to high-burden conditions in both the inpatient and outpatient setting. With the ever increasing efforts to measure and even publicly report on health care, efforts for children need to include focus on building a representative repertoire of quality measures for the high-burden conditions children experience.

Acute kidney injury, mortality, length of stay, and costs in hospitalized patients.

The marginal effects of acute kidney injury on in-hospital mortality, length of stay (LOS), and costs have not been well described. A consecutive sample of 19,982 adults who were admitted to an urban academic medical center, including 9210 who had two or more serum creatinine (SCr) determinations, was evaluated. The presence and degree of acute kidney injury were assessed using absolute and relative increases from baseline to peak SCr concentration during hospitalization. Large increases in SCr concentration were relatively rare (e.g., >or=2.0 mg/dl in 105 [1%] patients), whereas more modest increases in SCr were common (e.g., >or=0.5 mg/dl in 1237 [13%] patients). Modest changes in SCr were significantly associated with mortality, LOS, and costs, even after adjustment for age, gender, admission International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis, severity of illness (diagnosis-related group weight), and chronic kidney disease. For example, an increase in SCr >or=0.5 mg/dl was associated with a 6.5-fold (95% confidence interval 5.0 to 8.5) increase in the odds of death, a 3.5-d increase in LOS, and nearly 7500 dollars in excess hospital costs. Acute kidney injury is associated with significantly increased mortality, LOS, and costs across a broad spectrum of conditions. Moreover, outcomes are related directly to the severity of acute kidney injury, whether characterized by nominal or percentage changes in serum creatinine.

Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study.

Despite benefits associated with the use of electronic health records (EHRs), one major barrier to adoption is the concern that EHRs may take longer for physicians to use than paper-based systems. To address this issue, we performed a time-motion study in five primary care clinics. Twenty physicians were observed and specific activities were timed during a clinic session before and after EHR implementation. Surveys evaluated physicians' perceptions regarding the EHR. Post-implementation, the adjusted mean overall time spent per patient during clinic sessions decreased by 0.5 min (p=0.86; 95% confidence interval [-5.05, 6.04]) from a pre-intervention adjusted average of 27.55 min (SE=2.1) to a post-intervention adjusted average of 27.05 min (SE=1.6). A majority of survey respondents believed EHR use results in quality improvement, yet only 29% reported that EHR documentation takes the same amount of time or less compared to the paper-based system. While the EHR did not require more time for physicians during a clinic session, further studies should assess the EHR's potential impact on non-clinic time.

Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope.

OBJECTIVE: To determine the diagnostic utility of neurovascular ultrasonography (transcranial Doppler and carotid ultrasonography) in patients with syncope. PATIENTS AND METHODS: We retrospectively identified consecutive patients who underwent neurovascular ultrasonography for the diagnosis of syncope or presyncope at an academic hospital in 1997 and 1998. From medical records we abstracted patient demographic and clinical information, results and consequences of testing, and follow-up data for 3 years. RESULTS: A total of 140 patients participated in the study. The median age of the study patients was 74 years (interquartile range, 66-80 years), and 49% were male. Severe extracranial or Intracranial cerebrovascular disease was found on neurovascular ultrasonography in 20 patients (14%; 95% confidence interval [CI], 9.5%-21%). Focal neurologic signs or symptoms or carotid bruits were found in 19 (95%) of 20 patients with positive test results compared with 46 (38%) of 120 patients without severe disease (P<.001). Ultrasonography identified cerebrovascular lesions that may have contributed to the syncopal process in only 2 (1.4%) of 140 patients (95% CI, 0.39%-5.1%), but the lesions were unlikely to have been the primary cause of syncope in either patient. CONCLUSION: In this predominantly stroke-age population, neurovascular ultrasonography had a low yield for diagnosing vascular lesions that contributed to the pathophysiology of syncope. However, in patients with focal signs or symptoms or carotid bruits, it detected incidental lesions that typically require treatment or follow-up. In patients with syncope, neurovascular ultrasonography should be reserved for this subset. The data suggest enhancements to the American College of Physicians guideline for the use of neurovascular ultrasonography in patients with syncope.

Analysis of familial and sporadic restless legs syndrome in age of onset, gender, and severity features.

Restless Legs Syndrome is characterized by the irresistible, often indescribable unpleasant urge to move the limbs while resting. It has an estimated prevalence of approximately 29.3 % in US private practice. Restless Legs Syndrome often has a familial component; whether the familial and non-familial forms differ in terms of clinical features has previously been investigated, with the only significant factor emerging as younger age at onset in familial cases. Our study further explores a possible underlying difference between familial and sporadic forms of RLS by comparing familial RLS with sporadic RLS in terms of demographic and clinical features including subject gender, age of onset, and severity measures based an the IRLSSG severity scale. Both gender and family history are significant predictors of onset age in an overall model and also significant when analyzed independently. Participants who reported more severe RLS symptoms were significantly younger in age and progressed more rapidly. Two variables from the IRLSSG severity scale were significantly associated with age of onset when tested independently: discomfort and the urge to move the limb for relief. Our analysis supports the prevailing hypothesis that RLS is divided into earlier onset disease with a clear genetic component and later onset disease with unclear etiology, and that one or more endophenotypes might exist within the disorder which could further characterize these subjects for future genetic studies.

Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals.

Few U.S. hospitals have implemented computerized physician order entry (CPOE) in spite of its effectiveness at preventing serious medication errors. We interviewed senior management at twenty-six hospitals to identify ways to overcome barriers to adopting and implementing CPOE. Within the hospital, strong leadership and high-quality technology were critical. Hospitals that placed a high priority on patient safety could more easily justify the cost of CPOE. Outside the hospital, financial incentives and public pressures encouraged CPOE adoption. Dissemination of data standards would accelerate the maturation of vendors and lower CPOE costs. These findings highlight several policy levers to speed the adoption of this important patient safety technology.

Relation of family history of prostate cancer to perceived vulnerability and screening behavior.

Men with a positive family history of prostate cancer are known to be at increased risk for the disease; however, relatively little is known about their risk perceptions or screening behavior. To address these issues, the current study examined the relationship of family history of prostate cancer to perceived vulnerability of developing prostate cancer and prostate cancer screening practices. Participants were 83 men with a positive family history of prostate cancer and 83 men with a negative family history of prostate cancer. As predicted, men with a positive family history reported greater (p< or =0.05) perceived vulnerability of developing prostate cancer and stronger intentions to undergo screening (p< or =0.05). They also reported greater past performance of prostate-specific antigen screening and were more likely to request information about prostate cancer (p< or =0.05). Additional analyses indicated that perceived vulnerability mediated the relation between family history and intentions to undergo prostate cancer screening. Findings confirm the increased likelihood of men with a positive family history to undergo prostate cancer screening and suggest that heightened concerns about developing the disease are an important motivating factor.

Overcoming the barriers to the implementing computerized physician order entry systems in US hospitals: perspectives from senior management.

We sought to identify the barriers to CPOE implementation and the strategies for overcoming them. By analyzing 57 transcripts of interviews with management officials at 25 US hospitals, we identified costs and physician resistance as the two most significant barriers. Hospitals often overcome the high cost of CPOE implementation by placing patient safety at the top of their agenda. Other hospitals manage physician resistance by leveraging strong leadership, external influence, vendor commitment and the presence of house staff and hospitalists. Efforts to promote the adoption of CPOE should therefore focus on these strategies.