Does determining serum alcohol concentrations in emergency department patients influence physicians' civil suit liability?

Emergency physicians may incur liability when impaired patients who have been treated and released are subsequently involved in traffic crashes. We surveyed attorneys to assess their perception of how serum alcohol determinations might influence their liability in civil suits. Overall, 63.9% of the attorneys surveyed would advise patients that they received potentially negligent care if they were impaired following treatment in the emergency department and were involved in a traffic crashes. Perceived liability was altered by physician behavior as follows: 43.1% of attorneys would advise clients that they received potentially negligent care when impairment was documented by a test for serum alcohol concentration and no advice was given regarding drunk driving, and 17.3% of attorneys would give similar advice when impairment was not documented by a test for serum alcohol concentration and no advice was given regarding drunk driving. In contrast, only 3.5% of attorneys would suggest possible negligence when impairment was documented by a test for serum alcohol concentration and with advice subsequently given not to drive. The coupling of diagnosing impairment by the serum alcohol concentration and driving advice is medically sensible and might result in minimal civil liability.

Screening for pseudohypertension. A quantitative, noninvasive approach.

We studied 36 hypertensive men, aged 60 years or older, and compared direct intra-arterial diastolic blood pressure (BP) measurements, indirect cuff mercury sphygmomanometer measurements, and automatic infrasonic recorder (IR) measurements. We used a receiver operating characteristic curve to determine whether a difference between the cuff and IR diastolic BP could identify patients likely to have pseudo-hypertension (cuff-intra-arterial diastolic BP difference of 10 mm Hg or greater). We found that a cuff-IR difference of 4 mm Hg could identify the majority of patients with pseudo-hypertension (sensitivity, 93%; specificity, 64%; positive predictive value, 62%; negative predictive value, 93%). We concluded that the IR is an accurate, quantitative, noninvasive substitute for intra-arterial measurements and may be the preferred technique for screening and monitoring of blood pressure in elderly hypertensive patients.

Observer error in systolic blood pressure measurement in the elderly. A case for automatic recorders?

Measurement of systolic blood pressure (BP) in the elderly can be inaccurate due to observer errors such as terminal digit preference and expectation bias. Efforts to reduce these errors include use of trained observers, random-zero sphygmomanometers, and automatic BP recorders. To evaluate the value of an infrasonic recorder, the infrasonde, we compared simultaneous systolic BP determinations obtained directly by intra-arterial measurements, and indirectly by a standard cuff-mercury sphygmomanometer using clinic nurses (casual and serial measurements), a trained physician assistant (PA), and the Infrasonde in 36 elderly hypertensive men. All the indirect measurements correlated positively with the direct measurement. A terminal digit preference for zero occurred more frequently in the casual and serial readings compared with the Infrasonde and PA cuff readings: 45% and 51% vs 21% and 22%, respectively. Our data suggest that the Infrasonde is a reliable, alternative device for systolic BP measurement that eliminates observer biases associated with standard cuff BP recordings.

Erythrocyte anisocytosis. Visual inspection of blood films vs automated analysis of red blood cell distribution width.

An improved anemia classification may be available by combining measures of red blood cell size variability with mean corpuscular volume. Visual inspection of the peripheral blood film allows semiquantitative description of anisocytosis while quantitative measures are determined from electronic cell counter analyzers' red blood cell distribution width. We evaluated correlations between semiquantitative and quantitative measures of anisocytosis for different groups of observers. Hematologists', medical students', and medical residents' semiquantitative assessment of anisocytosis correlated with the quantitative red blood cell distribution width. The interobserver variability demonstrated that all observers correlated with each other, while the intraobserver variability of semiquantitative anisocytosis demonstrated that observers were more precise than could be predicted by chance. However, the extreme precision of the red blood cell distribution width strongly suggests that it should be the "gold standard" for measuring red blood cell size variability.

Spurious hypertension in the obese patient. Effect of sphygmomanometer cuff size on prevalence of hypertension.

We used standard, large adult, and thigh-size cuffs in random order to take BPs in 470 patients. The prevalences of definite high BP [( HBP]), greater than or equal to 160/95 mm Hg) and borderline HBP [( BHBP ], greater than or equal to 140/90 less than 160/95 mm Hg) were the same with all three cuffs in patients with an arm circumference less than 35 cm, a body mass index less than 34, and a weight of less than 95 kg. The large adult and thigh cuffs did not underestimate the prevalence of HBP in these nonobese patients. The prevalences of HBP and BHBP were twofold greater with the standard cuff than with the large adult or thigh cuffs in obese patients (arm circumference greater than or equal to 35 cm or body mass index greater than or equal to 34 or weight greater than or equal to 95 kg). Routine use of the large adult cuff will provide accurate BP measurement and avoid unneeded evaluation and treatment.

Need for insulin therapy in type II diabetes mellitus. A randomized trial.

To identify patients with type II diabetes mellitus for whom insulin therapy is most beneficial, we conducted a randomized controlled trial in the general medicine clinic of a university hospital. Asymptomatic, obese, insulin-treated patients were given diet and diabetes education and, in half of these patients, insulin therapy was withdrawn. Over six months, patients developing hyperglycemic symptoms or acetonemia were counted as study failures. Failure criteria developed in 13 of 25 insulin-withdrawal patients, at a median of four weeks after withdrawal, compared with two of 24 control subjects. Elevated stimulated glucose levels predicted the need for insulin therapy. Hyperglycemia worsened in insulin-withdrawal patients who did not meet study failure criteria, but it improved in control patients. Study patients were insulin deficient as shown by low baseline C peptide values (0.43 +/- 0.05 nmol/L). The prompt metabolic decompensation precipitated by insulin withdrawal suggests that insulin-deficient patients may benefit from insulin therapy and may need it to prevent symptomatic hyperglycemia.

BP control. Improvement in a university medical clinic by use of a physician's associate.

Many hypertensive patients, especially those in outpatient clinics at large teaching hospitals, do not achieve BP control. We incorporated a physician's associate into an existing house staff medical clinic and evaluated whether this improved BP control. In patients with moderate or severe hypertension, BP control was achieved in 56% of patients observed by both the physician's associate and the house staff and in 32% of patients observed solely by house staff. Possible contributing factors were more frequent follow-up, simplification of drug regimens, reduced waiting time, more time spent with the patients, and overall greater satisfaction with the physician's associate. We conclude that the addition of a physician's associate to an outpatient clinic is an effective method for enhancing BP control. This can be achieved without establishing a separate hypertension clinic or depriving house staff of experience in the management of hypertension.

Impact of glucose self-monitoring on non-insulin-treated patients with type II diabetes mellitus. Randomized controlled trial comparing blood and urine testing.

The goal of this study was to compare the relative efficacy and cost of self-monitoring of blood glucose (SMBG) with routine urine testing in the management of patients with type II (non-insulin-dependent) diabetes mellitus not treated with insulin. Fifty-four patients with type II diabetes mellitus, not treated with insulin, who had inadequate glucose control on diet alone or diet and oral hypoglycemic agents were studied. Patients performed SMBG or urine glucose testing as part of a standardized treatment program that also included diet and exercise counseling. During the 6-mo study, both the urine-testing and SMBG groups showed similar improvement in glycemic control; within each group, there were significant improvements in fasting plasma glucose (reduction of 1.4 +/- 3.2 mM, P less than 0.03) and glycosylated hemoglobin (reduction of 2.0 +/- 3.4%, P less than 0.01) levels. Seventeen (31%) of 54 patients actually normalized their glycosylated hemoglobin values, 9 in the urine-testing group and 8 in the SMBG group. Comparisons between the urine-testing and SMBG groups showed no significant differences in mean fasting plasma glucose (P greater than 0.86), glycosylated hemoglobin (P greater than 0.95), or weight (P greater than 0.19). In patients with type II diabetes mellitus not treated with insulin, SMBG is no more effective, but is 8-12 times more expensive, than urine testing in facilitating improved glycemic control. Our results do not support widespread use of SMBG in diabetic patients not treated with insulin.

A telephone-delivered intervention for patients with NIDDM. Effect on coronary risk factors.

OBJECTIVE: To examine whether a telephone-delivered intervention (TDI), designed to improve glycemic control in patients with non-insulin-dependent diabetes mellitus (NIDDM), improved coronary risk factors in high-risk patients. RESEARCH DESIGN AND METHODS: This randomized controlled trial involved 275 veterans with NIDDM followed in a general medical clinic. Intervention (TDI) patients were telephoned at least monthly by a nurse. Calls emphasized compliance with the medical regimen (diet, medications, and exercise), encouraged behavioral changes, and facilitated referrals to a dietitian or smoking cessation clinic. Control patients received no such calls. Baseline and 12-month follow-up measurements included fasting lipid profiles, weight, smoking status (self-reported; cessation verified by measurement of exhaled CO), adherence to diet and exercise (self-reported), appointments, and medications (hospital computerized data base). RESULTS: After 12 months, equal numbers of obese patients in the two groups reported adhering to a diabetic diet and exercising, although more obese TDI patients had seen a dietitian (30 vs. 7%, P = 0.003). Weight loss was not seen in either group (-0.9 +/- 5.3 vs. -0.1 +/- 3.6 kg, P = 0.202). Hyperlipidemic TDI patients were more likely to see a dietitian (31 vs. 6%, P = 0.003) and receive lipid-lowering medications (22 vs. 9%, P = 0.096), but serum cholesterol reduction was similar between groups (-11.7 +/- 33.4 vs. -4.3 +/- 32.7 mg/dl, P = 0.270); comparable results were seen for high-density lipoprotein, low-density lipoprotein, and triglyceride levels. More TDI group smokers reported quitting (26 vs. 0%, P = 0.033), but the difference was not significant for CO-verified abstention (10 vs. 0%, P = 0.231). CONCLUSIONS: The TDI improved self-reported adherence to regimens that might reduce coronary risk, but had little effect on objective measures of risk.

Double-blind, placebo-controlled trial of potassium chloride in the treatment of mild hypertension.

Epidemiological and experimental data suggest blood pressure-lowering effects of dietary potassium. A randomized, double-blind clinical trial was used to assess blood pressure response to orally administered potassium, 120 mEq/day, and to placebo in 101 adults with mild hypertension. Blood pressure was measured with a random-zero sphygmomanometer every 2 weeks of this 8-week trial. Systolic blood pressure in the potassium-treated group decreased by 6.4 +/- 13.7 (SD) mm Hg (p less than or equal to 0.025) compared with 0.11 +/- 13.0 mm Hg in the placebo-treated group (p = 0.96). Diastolic blood pressure in the potassium-treated group decreased by 4.1 +/- 8.3 mm Hg (p less than or equal to 0.05) compared with a 1.6 +/- 6.5 mm Hg decrease in placebo-treated subjects (p = 0.09). Baseline blood pressure of potassium-treated subjects was unexpectedly higher than that of controls. After correcting for baseline variation, blood pressure still decreased 3.4/1.8 mm Hg more in potassium recipients than in placebo recipients (p = 0.14 and 0.24, respectively). Blood pressure decreased by 19/13 mm Hg in five blacks taking potassium versus a 1/0 mm Hg increase in seven blacks taking placebo. Compliance with the potassium regimen was 91.5% by pill count; only one subject discontinued treatment because of side effects. In conclusion, 120 mEq/day of microencapsulated potassium chloride was well tolerated in adults with mild hypertension. An antihypertensive effect of potassium cannot be ruled out despite the fact that there was no statistically significant difference between potassium-treated and placebo-treated subjects after adjustment for differences in baseline blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term survival of veterans with traumatic spinal cord injury.

OBJECTIVE: To investigate the long-term survival of veterans with traumatic spinal cord injury (SCI). DESIGN: Survival in a retrospective inception cohort of veterans suffering service-connected traumatic SCI is compared with survival among veterans disabled by other conditions, survival among nondisabled veterans, and a population-based life table. SETTING: Subjects were identified from a national census of veterans with service-connected disabilities, using a selection algorithm based on disability codes. PATIENTS: A retrospective cohort of 5545 male veterans with traumatic SCI, surviving at least 3 months after injury, is compared with a stratified random sample of 7077 disabled veterans without SCI, a stratified random sample of 6967 nondisabled veterans, and a life table formed from similarly aged American males. MAIN OUTCOME MEASURE: Survival curves, extending from 3 months to 40 years after injury. RESULTS: The mean life expectancy of veterans suffering traumatic SCI and surviving at least 3 months is an additional 39 years after injury, 85% that of similarly aged American males. Although survival with traumatic SCI was comparable to that of the disabled control subjects for approximately 20 years after onset, a clear deficit occurred beyond this point. Older age at injury is a stronger predictor of poorer long-term survival than is complete quadriplegia. CONCLUSIONS: Among patients who survive the acute phase of their traumatic SCI, long-term survival is relatively good. Health care planners, providers, and communities should anticipate an increasing number of persons aging with SCI.

Teaching cardiovascular examination skills: results from a randomized controlled trial.

PURPOSE: To evaluate the effectiveness of a teaching program designed to improve interns' cardiovascular examination skills. PARTICIPANTS: All 56 interns rotating on a mandatory 4-week inpatient cardiology service during 1 academic year (July 1989-June 1990). METHODS: We randomly assigned interns to receive either an eight-session physical diagnosis course ("teaching group") taught on the cardiology-patient simulator ("Harvey") or to receive no supplemental teaching ("control group"). Before and immediately after the teaching or control period, the interns were evaluated on three preprogrammed simulations (mitral regurgitation, MR; mitral stenosis, MS; aortic regurgitation, AR). Immediately after the control or the intervention period, the interns also evaluated patient volunteers. RESULTS: There were no baseline differences in the interns' ability to correctly identify the disease simulations. Both the intervention and the control interns showed similar, moderate improvement in their diagnostic ability on the simulator. The intervention interns improved on MR from 42% correct to 54% correct; on MS from 8% correct to 23% correct; and on AR from 46% correct to 58% correct. The intervention and the control interns performed similarly on patient volunteers: for MR, 20% correct versus 31%; for AR, 29% correct versus 33%; and for aortic sclerosis, 64% correct versus 33%, respectively. CONCLUSIONS: The interns had difficulty correctly identifying three valvular heart disease simulations before and after an educational intervention employing a cardiovascular-patient simulator. At no time did the proportion of correct responses exceed 64%. Our teaching intervention during internship was either of insufficient intensity or of insufficient duration to produce significant improvement in cardiovascular diagnostic skills.

Contrasting methicillin-resistant Staphylococcus aureus colonization in Veterans Affairs and community nursing homes.

PURPOSE: To compare the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) nares colonization, the patterns of MRSA acquisition, and the risk for subsequent MRSA infection between a hospital-based, Department of Veterans Affairs (VA) nursing home care unit (NHCU) and community-based nursing homes. PATIENTS AND METHODS: In this prospective study, 148 residents of three community nursing homes and 55 residents of a VA NHCU had their anterior nares swabbed; repeat cultures were obtained from hospitalized patients and/or individuals colonized with MRSA. Subjects were followed up prospectively for 1 year to note hospitalizations and the development of MRSA infections. RESULTS: The prevalence of MRSA colonization was significantly higher in the VA NHCU than in the community nursing homes (mean +/- SD 30.3% +/- 11% versus 9.9% +/- 4%). The rate of MRSA nares colonization was similar in the two settings. Acquisition of MRSA took place in both the long-term care facilities and hospitals, with 23.8% of incident cases occurring during a hospitalization. Only 3 of the 27 individuals colonized at baseline developed an MRSA infection. A trend toward an increased rate of infection was seen in colonized individuals residing in the community nursing homes versus those in the VA NHCU (relative risk 4.67; 95% Cl 0.55 to 39.9). Forty-seven percent of the 55 subjects hospitalized were colonized at some point during the study. In contrast to residents of the VA NHCU, MRSA colonization in the community facilities was a marker for high mortality. CONCLUSIONS: Outcomes from colonization may be different in the VA NHCU population and the community nursing home population.

A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy.

PURPOSE: To evaluate the effect of sustained clinical pharmacist interventions involving elderly outpatients with polypharmacy and their primary physicians. PATIENTS AND METHODS: Randomized, controlled trial of 208 patients aged 65 years or older with polypharmacy (> or = 5 chronic medications) from a general medicine clinic of a Veterans Affairs Medical Center. A clinical pharmacist met with intervention group patients during all scheduled visits to evaluate their drug regimens and make recommendations to them and their physicians. Outcome measures were prescribing appropriateness, health-related quality of life, adverse drug events, medication compliance and knowledge, number of medications, patient satisfaction, and physician receptivity. RESULTS: Inappropriate prescribing scores declined significantly more in the intervention group than in the control group by 3 months (decrease 24% versus 6%, respectively; P = 0.0006) and was sustained at 12 months (decrease 28% versus 5%, respectively; P = 0.0002). There was no difference between groups at closeout in health-related quality of life (P = 0.99). Fewer intervention than control patients (30.2%) versus 40.0%; P = 0.19) experienced adverse drug events. Measures for most other outcomes remained unchanged in both groups. Physicians were receptive to the intervention and enacted changes recommended by the clinical pharmacist more frequently than they enacted changes independently for control patients (55.1% versus 19.8%; P <0.001). CONCLUSIONS: This study demonstrates that a clinical pharmacist providing pharmaceutical care for elderly primary care patients can reduce inappropriate prescribing and possibly adverse drug effects without adversely affecting health-related quality of life.

A randomized controlled trial comparing quantitative informed consent formats.

Informed consent has been indirectly studied only in settings that do not replicate the actual consent process. We designed a sham study and randomly allocated adult ambulatory patients to receive one of two consent forms: Consent A (n = 52) described a randomized trial of usual treatment vs a new medication that "may work twice as fast as the usual treatment"; or Consent B (n = 48) that described a randomized trial of a new medication that "may work half as fast as the usual treatment". Patients randomized to Consent A were more likely to consent than those randomized to Consent B (consent rate A = 67%, consent rate B = 42%, p less than 0.01). Among patients who cited quantitative information, the difference in consent rate was even more marked (95% vs 36%, p less than 0.001); patients who did not cite quantitative information had equivalent consent rates. Patients who perceived minimal or severe symptoms had lower consent rates than those with mid-range symptom scores (chi 2(2) = 8.35, p = 0.015). Patients who recognize quantitative information will use it to make informed consent decisions.

Observer variability of Osler's maneuver in detection of pseudohypertension.

Pseudohypertension in the elderly occurs when blood pressure is overestimated because of inelastic, sclerotic arteries. Osler's maneuver (OM), the palpability of a pulseless artery, is recommended as a non-invasive test to detect pseudohypertension, despite limited data concerning its reproducibility. We assessed the maximum achievable inter-and intra-observer agreement of OM among 6 examiners: cardiologists, geriatricians and general internists. Each examiner performed OM twice on 65 elderly hypertensive men attending the general medicine and geriatric clinics. The inter-observer agreement for brachial and radial examinations was 79 and 70%, while intra-observer agreement was 82 and 75%, respectively. After adjusting for chance agreement the kappa values for inter-observer agreement for brachial and radial arteries were 0.38 (95% confidence interval (CI): 0.21-0.55) and 0.37 (0.28-0.46), respectively. Similarly, the kappa values for intra-observer agreement were 0.45 (95% CI: 0.35-0.55) and 0.49 (0.39-0.59). Kappa values never exceeded 0.6 in any time period, suggesting no training effect. OM cannot be recommended as a screening test for pseudohypertension given this low inter- and intra-observer agreement.

A method for assessing drug therapy appropriateness.

This study evaluated the reliability of a new medication appropriateness index. Using the index, independent assessments were made of chronic medications taken by 10 ambulatory, elderly male patients by a clinical pharmacist and an internist-geriatrician. Their overall inter-rater agreement for medication appropriateness (ppos) was 0.88, and for medication inappropriateness (pneg) was 0.95; the overall kappa was 0.83. Their intra-rater agreement for ppos was 0.94 overall, for pneg was 0.98 overall while the overall kappa was 0.92. The chronic medications taken by 10 different ambulatory elderly male patients were independently evaluated by two different clinical pharmacists. Their overall inter-rater agreement for ppos was 0.76, and for pneg was 0.93, while the overall kappa was 0.59. This new index provides a reliable method to assess drug therapy appropriateness. Its use may be applicable as a quality of care outcome measure in health services research and in institutional quality assurance programs.

Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions.

OBJECTIVE: To determine clinical and patient-centered factors predicting non-elective hospital readmissions. DESIGN: Secondary analysis from a randomized clinical trial. CLINICAL SETTING: Nine VA medical centers. PARTICIPANTS: Patients discharged from the medical service with diabetes mellitus, congestive heart failure, and/or chronic obstructive pulmonary disease (COPD). MAIN OUTCOME MEASUREMENT: Non-elective readmission within 90 days. RESULTS: Of 1378 patients discharged, 23.3% were readmitted. After controlling for hospital and intervention status, risk of readmission was increased if the patient had more hospitalizations and emergency room visits in the prior 6 months, higher blood urea nitrogen, lower mental health function, a diagnosis of COPD, and increased satisfaction with access to emergency care assessed on the index hospitalization. CONCLUSIONS: Both clinical and patient-centered factors identifiable at discharge are related to non-elective readmission. These factors identify high-risk patients and provide guidance for future interventions. The relationship of patient satisfaction measures to readmission deserves further study.

Geriatric evaluation and management units: experimental methods for evaluating efficacy.

A multi-site randomized controlled trial could most conclusively establish the efficacy of geriatric evaluation and management units, but many questions must be answered to design such a trial. First, the research questions needs to be rigorously specified. This will facilitate decisions concerning the types of patients to be included in the study. Second, the intervention requires a clear definition, including its component parts, to improve replication across multiple sites. Third, the type of randomization (ie, by hospital or by patient) and the timing of randomization (ie, at admission or at some later point during care) need to be considered. Fourth, because this type of intervention cannot be administered in a blind fashion, bias is a critical concern. Outcome measures must be selected carefully so that those least susceptible to bias are given the highest priority. Despite the need to address all of these questions, the time is upon us to conduct a multi-site trial of geriatric evaluation and management programs.

Overestimation of diastolic blood pressure in the elderly. Magnitude of the problem and a potential solution.

Indirect sphygmomanometric blood pressure measurement is the established method of diagnosing and monitoring hypertension, but it may overestimate the true blood pressure in certain elderly patients leading to unnecessary or excessive treatment. The authors studied 36 elderly (aged 60 years or older) hypertensive men and compared direct intraarterial diastolic blood pressure (DBP) measurements with indirect DBP measurements obtained concurrently by a standard mercury sphygmomanometer and also by an automatic blood pressure recorder to: assess the presence and degree of overestimation of DBP by indirect cuff measurement, and evaluate an alternative noninvasive method. The difference between sphygmomanometric and intraarterial DBP was 10 mmHg or greater in 14 of 36 patients, whereas that between the automatic recorder and intraarterial DBP was 10 mmHg or greater in 14 of 36 patients, whereas the between the automatic recorder and intraarterial DBP was 10 mmHg or greater in only three of 36 patients (P less than 0.05). Fourteen patients (39%) had a DBP of greater than or equal to 90 mmHg by the mercury sphygmomanometer compared with five patients (14%) by intraarterial measurement (P less than 0.05); only seven patients (19%) had a DBP of greater than or equal to 90 mmHg by the automatic recorder (P = .7). Thus, in the authors' patient population: indirect sphygmomanometer overestimated the frequency of elevated DBP by nearly threefold compared with intraarterial measurements, and the automatic recorder closely approximated intraarterial values offering a more accurate, noninvasive measure of DBP in the elderly.