Comparison of use of medications after acute myocardial infarction in the Veterans Health Administration and Medicare.

BACKGROUND: There is concern that care provided in the Veterans Health Administration (VA) may be of poorer quality than non-VA health care. We compared use of medications after acute myocardial infarction in the VA with that in non-VA healthcare settings under fee-for-service (FFS) Medicare financing. METHODS AND RESULTS: We used clinical data from 2486 VA and 29 249 FFS men >65 years old discharged with a confirmed diagnosis of acute myocardial infarction from 81 VA hospitals and 1530 non-VA hospitals. We reported odds ratios (ORs) for use of thrombolytics, beta-blockers, ACE inhibitors, or aspirin among ideal candidates adjusted for age, sample design (hospital academic affiliation, availability of cardiac procedures, and volume), and within-hospital clustering. Ideal VA candidates were more likely to undergo thrombolytic therapy at arrival (OR [VA relative to Medicare] 1.40 [1.05, 1.74]) or to receive ACE inhibitors (OR 1.67 [1.12, 2.45]) or aspirin (OR 2.32 [1.81, 3.01]) at discharge and equally likely to receive beta-blockers (OR 1.09 [1.03, 1.40]) at discharge. CONCLUSIONS: Ideal candidates in VA were at least as likely as those in FFS to receive medical therapies of known benefit for acute myocardial infarction.

Preventable medical injuries in older patients.

Injuries associated with hospitalization are more common in older (>/=65 years) than in younger patients (<65 years), and they may be more severe and more often preventable. The increasing age of the population magnifies the importance of this problem. In this review, we first consider medical injuries in general and then review the literature for 6 categories: adverse drug events, falls, nosocomial infections, pressure sores, delirium, and surgical and perioperative complications. For each of these categories, older patients appear to be at higher risk, ranging from a 2.2-fold increase for perioperative complications to a 10-fold increase for falling, based on Harvard Medical Practice Study rates. The main cause of these increased risks appears to be the diminished physiological reserve of elderly patients; however, age alone is a less important predictor of adverse events than comorbidities and functional status. Furthermore, many of these complications appear to be preventable, although the proportion preventable varies by type of complication. While some prevention strategies are specifically beneficial in older patients, many apply to all age groups. Geriatric care units and consultation systems have improved outcomes in some instances, although the data are mixed. The success of intervention varies by type of complications. For medications, various interventions have been successful, and fall prevention programs have been demonstrated to be effective in the nursing home and home.

The appropriateness of use of cardiovascular procedures in women and men.

OBJECTIVE: To determine whether there are differences between women and men in the appropriateness of use of cardiovascular procedures. DESIGN: Retrospective chart review. SETTING: Thirty hospitals located in New York State. PATIENTS: Random sample of 3979 patients undergoing coronary angiography, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery in 1990. MEASURES: We evaluated two measures: (1) the percent of women and men who underwent cardiovascular procedures for appropriate, uncertain, and inappropriate indications and (2) for coronary angiography patients, the prognostic exercise stress treadmill score that predicts before the coronary angiogram the 5-year probability of death from a cardiovascular event. RESULTS: The inappropriate rate of use of cardiovascular procedures was low and not significantly different for men and women (4% vs 5% for coronary angiography; 4% vs 3% for percutaneous transluminal coronary angioplasty; and 2% vs 3% for coronary artery bypass graft surgery, respectively), and the use of these procedures for uncertain reasons also did not vary significantly by gender. There was also no significant gender difference in the predicted risk of death from a cardiovascular event for coronary angiography patients: 24% of men and 22% of women were at high risk (ie, < 75% 5-year survival rate) and 20% and 16%, respectively, were at low risk (ie, > or = 95% 5-year survival rate). CONCLUSION: Based on two indicators, the RAND appropriateness score and the Duke prognostic exercise treadmill score, we were unable to find any evidence of a difference in the clinical appropriateness of use of these three cardiovascular procedures between women and men.

Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group.

BACKGROUND: Adverse drug events (ADEs) are common in hospitalized patients, but few empirical data are available regarding the strength of patient risk factors for ADEs. METHODS: We performed a nested case-control study within a cohort that included 4108 admissions to a stratified random sample of 11 medical and surgical units in 2 tertiary care hospitals during a 6-month period. Analyses were conducted on 2 levels: (1) using a limited set of variables available for all patients using computerized data available from 1 hospital and (2) using a larger set of variables for the case patients and matched controls from both hospitals. Case patients were patients with an ADE, and the matched control for each case patient was the patient on the same unit as the case patient with the most similar prevent length of stay. Main outcome measures were presence of an ADE, preventable ADE, or severe ADE. RESULTS: In the cohort analysis, electrolyte concentrates (odds ratio [OR], 1.7), diuretics (OR, 1.7), and medical admission (OR, 1.6) were independent correlates of ADEs. Independent correlates of preventable ADEs in the cohort analysis were low platelet count (OR, 4.5), antidepressants (OR, 3.3), antihypertensive agents (OR, 2.9), medical admission (OR, 2.2), and electrolyte concentrates (OR, 2.1). In the case-control analysis, exposure to psychoactive drugs (OR, 2.1) was an independent correlate of an ADE, and use of cardiovascular drugs (OR, 2.4) was independently correlated with severe ADEs. For preventable ADEs, no independent predictors were retained after multivariate analysis. CONCLUSIONS: Adverse drug events occurred more frequently in sicker patients who stayed in the hospital longer. However, after controlling for level of care and preevent length of stay, few risk factors emerged. These results suggest that, rather than targeting ADE-prone individuals, prevention strategies should focus on improving medication systems.

Wilm's Tumor: An Update.

Major advances have been made against Wilms' tumor as a result of treatment methods developed by single institutions that then have been confirmed and extended by national cooperating groups. Better survival rates have been achieved, and therapy has been refined so that treatment can be reduced in early stage disease without jeopardizing tumor control. This results in fewer short- and long-term complications, an especially important consideration in children. Their organs and tissues are vulnerable to anti-mitotic treatments such as chemo- and radiotherapy, that can produce disabling if not lethal dysfunctions. This progress has been the result of the cooperative efforts by multiple specialists, and provides evidence of the value of such integrated studies. They have changed the outlook from a 90% death rate in the early years of this century to the 90% survival rate now possible with modern management.

Underuse and overuse of diagnostic testing for coronary artery disease in patients presenting with new-onset chest pain.

PURPOSE: To determine the extent of overuse and underuse of diagnostic testing for coronary artery disease and whether the socioeconomic status, health insurance, gender, and race/ethnicity of a patient influences the use of diagnostic tests. SUBJECTS AND METHODS: We identified patients who presented with new-onset chest pain not due to myocardial infarction at one of five Los Angeles-area hospital emergency departments between October 1994 and April 1996. Explicit criteria for diagnostic testing were developed using the RAND/University of California, Los Angeles, expert panel method. They were applied to data collected by medical record review and patient questionnaire. RESULTS: Of the 356 patients, 181 met necessity criteria for diagnostic cardiac testing. Of these, 40 (22%) failed to receive necessary tests. Only 7 (3%) of the 215 patients who received some form of cardiac testing had tests that were judged to be inappropriate. Underuse was significantly more common in patients with only a high school education (30% vs 15% for those with some college, P = 0.02) and those without health insurance (34% vs 15% of insured patients, P = 0.01). In a multivariate logistic regression model, only the lack of a post-high school education was a significant predictor of underuse (odds ratio 2.2, 95% confidence interval 1.0 to 4.4). CONCLUSION: Among patients with new-onset chest pain, underuse of diagnostic testing for coronary artery disease was much more common than overuse. Underuse was primarily associated with lower levels of patient education.

Laparoscopy in children.

Laparoscopy has been performed in 120 infants and children for a variety of indications including chronic abdominal pain, debatable appendicitis, liver biopsy, biliary atresia, and abdominal trauma. A specific diagnosis was made in 71% of patients and 59% were spared laparotomy. There were one complication and four errors in interpretation (3.3%). Laparoscopy represents a considerable advantage over laparotomy in the diagnosis and management of a number of pediatric disorders and deserves wider application.

Sensitivity and specificity of the RAND/UCLA Appropriateness Method to identify the overuse and underuse of coronary revascularization and hysterectomy.

There is no empirical evidence on the sensitivity and specificity of methods to identify the possible overuse and underuse of medical procedures. To estimate the sensitivity and specificity of the RAND/UCLA Appropriateness Method. Parallel three-way replication of the RAND/UCLA Appropriateness Method for each of two procedures, coronary revascularization and hysterectomy. Maximum likelihood estimates of the sensitivity and specificity of the method for each procedure. These values were then used to re-calculate past estimates of overuse and underuse, correcting for the error rate in the appropriateness method. The sensitivity of detecting overuse of coronary revascularization was 68% (95% confidence interval 60-76%) and the specificity was 99% (98-100%). The corresponding values for hysterectomy were 89% (85-94%) and 86% (83-89%). The sensitivity and specificity of detecting the underuse of coronary revascularization were 94% (92-95%) and 97% (96-98%), respectively. Past applications of the appropriateness method have overestimated the prevalence of the overuse of hysterectomy, underestimated the prevalence of the overuse of the coronary revascularization, and provided true estimates of the underuse of revascularization. The sensitivity and specificity of the RAND/UCLA Appropriateness Method vary according to the procedure assessed and appear to estimate the underuse of procedures more accurately than their overuse.

Reducing the frequency of errors in medicine using information technology.

BACKGROUND: Increasing data suggest that error in medicine is frequent and results in substantial harm. The recent Institute of Medicine report (LT Kohn, JM Corrigan, MS Donaldson, eds: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999) described the magnitude of the problem, and the public interest in this issue, which was already large, has grown. GOAL: The goal of this white paper is to describe how the frequency and consequences of errors in medical care can be reduced (although in some instances they are potentiated) by the use of information technology in the provision of care, and to make general and specific recommendations regarding error reduction through the use of information technology. RESULTS: General recommendations are to implement clinical decision support judiciously; to consider consequent actions when designing systems; to test existing systems to ensure they actually catch errors that injure patients; to promote adoption of standards for data and systems; to develop systems that communicate with each other; to use systems in new ways; to measure and prevent adverse consequences; to make existing quality structures meaningful; and to improve regulation and remove disincentives for vendors to provide clinical decision support. Specific recommendations are to implement provider order entry systems, especially computerized prescribing; to implement bar-coding for medications, blood, devices, and patients; and to utilize modern electronic systems to communicate key pieces of asynchronous data such as markedly abnormal laboratory values. CONCLUSIONS: Appropriate increases in the use of information technology in health care- especially the introduction of clinical decision support and better linkages in and among systems, resulting in process simplification-could result in substantial improvement in patient safety.

The new medical marketplace: physicians' views.

The transformation of the medical marketplace has major implications for the physician workforce. Findings are reported here from national surveys of physicians, hospitals, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and medical group practices conducted in 1995 to measure the impact of those changes. Physicians in higher HMO penetration states were more likely to report serious problems with several aspects of medical practice and patient care and were more likely to perceived oversupply in their specialty areas and changes in their practice arrangements. Some divergence is noted in views of supply between physicians and those that employ them. The majority of physicians would still recommend medicine and their specialty as a career.

Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991.

BACKGROUND: As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. METHODS: We reviewed 30121 randomly selected records from 51 randomly selected acute care, non-psychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. RESULTS: Adverse events occurred in 3.7% of the hospitalizations (95% confidence interval 3.2 to 4.2), and 27.6% of the adverse events were due to negligence (95% confidence interval 22.5 to 32.6). Although 70.5% of the adverse events gave rise to disability lasting less than 6 months, 2.6% caused permanently disabling injuries and 13.6% led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test chi(2) = 21.04, p<0.0001). Using weighted totals we estimated that among the 2671863 patients discharged from New York hospitals in 1984 there were 98609 adverse events and 27179 adverse events involving negligence. Rates of adverse events rose with age (p<0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (p<0.01). There were significant differences in rates of adverse events among categories of clinical specialties (p<0.0001), but no differences in the percentage due to negligence. CONCLUSIONS: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.

Unnecessary surgery.

The extent of unnecessary surgery has been the object of considerable speculation and occasional wild accusation in recent years. Most evidence of the existence of unnecessary surgery, such as information from studies of geographic variations and the results of second surgical opinion programs, is circumstantial. However, results from the few studies that have measured unnecessary surgery directly indicate that for some highly controversial operations the fraction that are unwarranted could be as high as 30 percent. Most unnecessary surgery results from physician uncertainty about the effectiveness of an operation. Elimination of this uncertainty requires more efficient production and dissemination of scientific information about clinical effectiveness. In the absence of adequate data from scientific studies, the use of a consensus of expert opinion, disseminated by means of comprehensive practice guidelines, offers the best opportunity to identify and eliminate unnecessary surgery.

Coronary angiography and revascularization: defining procedural indications through formal group processes. The Canadian Revascularization Panel, the Canadian Coronary Angiography Panel.

OBJECTIVES: To summarize the process and extent of interphysician agreement within two panels convened to derive indications for the appropriate use of coronary angiography and for coronary revascularization procedures. PARTICIPANTS: Two panels, each with nine practitioners. METHODS: Panelists rated the appropriateness of intervention for a comprehensive set of indications for each procedure. Indications were brief profiles created by combining and permuting clinical characteristics pertinent to case selection for intervention. Ratings were first made at home, with a second round at the panel meeting following open discussion. Final rankings of indications as 'appropriate', 'uncertain' or 'inappropriate' were based on the pattern of panelists' responses on a nine-point scale, including the median rating and extent of agreement among panelists. Agreement was defined as at least seven panelists' ratings within the three-point region containing the median rating. Panelists were later mailed a much-reduced list of indications for which there was agreement on appropriateness. These were re-rated on a necessity scale. A procedure was rated 'necessary' only if a physician was ethically obligated to recommend it as the preferred treatment option. RESULTS: For appropriateness of angiography, agreement occurred in 38.2% of indications in round 1 and 64.4% in round 2 (P < 0.0001). For coronary artery bypass graft (CABG) versus medical therapy, the corresponding increase was from 43.5 to 54.0% (P < 0.0001). Agreement on necessity of angiography occurred for 44.3% of scenarios. For indications where CABG alone was appropriate, agreement on necessity was 56%. However, for indications where percutaneous transluminal coronary angioplasty (PTCA) could be regarded as the first-line intervention, agreement on necessity was only 5%. CONCLUSIONS: A two-step panel process permitted considerable convergence of panelists' ratings, highlighting the importance of formal panel methods in setting utilization management criteria. However, the extent of continuing disagreement on ratings underscores the need to avoid a forced consensus; instead, divergent opinions should be taken as indicative of uncertainty about the appropriateness of intervention. Interpanelist agreement on necessity ratings was modest, but may help in setting benchmarks to assess possible underprovision of invasive cardiac services in Canada.

Waiting for coronary revascularization: a comparison between New York State, The Netherlands and Sweden.

OBJECTIVE: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. METHODS: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals (n = 1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands (n = 1980) or to one of seven hospitals in Sweden (n = 1486). We measured the median waiting time between coronary angiography and PTCA or CABG. RESULTS: The median waiting time for PTCA in New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden (P < 0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively (P < 0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. CONCLUSIONS: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved.

Rickets in low birth weight infants receiving total parenteral nutrition.

Development of rickets in association with parenteral nutrition is described in four premature infants having gestational ages of 26-31 wk. In the first two infants there was a documented deficiency of vitamin D, but in the second two adequate supplementation was achieved. Vitamin D, whose primary action is to facilitate intestinal absorption of calcium, may also be a hormone of prime necessity in infant bone formation. Conversion of precursor cholecalciferol to the active form of hormone, 1,25-DHCC, requires intermediate hydroxylation by the liver. The premature infant liver may be deficient in its ability to carry out this step of metabolism, and in normal intrauterine existence the fetus may receive 1,25-DHCC, the active metabolite, from the mother. Calcium intake in these infants was far below that achieved by fetuses of comparable age in utero, even though in excess of that provided by usual premature infant oral formulas. Although calcium deficiency has not been incriminated as a cause of rickets in the past, it is possible that in very tiny premature infants rapid growth requirements lead to a relative calcium deficiency which may be manifested as uncalcified osteoid. Until the mechanism of the formation of rickets in small premature infants is clarified it is recommended that supplemental calcium and vitamin D be given to all premature infants receiving parenteral nutrition, and that periodic x-rays be obtained to detect the development of rickets.

Laparoscopy in infants and children.

Laparoscopy has been performed in 60 infants and children over a 32-mo period. Indications included: the problem of possible appendicitis, chronic abdominal pain, possible regional enteritis, possible biliary atresia, and liver biopsy. Fifty-two per cent of patients were spared laparotomy, while in 32% the need for operation was established. There were 2 errors in diagnosis, 3 failures, and 1 complication. Laparoscopy is considered to be a safe, effective, and economical diagnostic procedure that deserves wider application in the pediatric patient.

Anterior ectopic anus: a common cause of constipation in children.

Anterior ectopic anus is increasingly being recognized as a cause of constipation in infancy. Experience is reported with surgical treatment of 20 patients with anterior ectopic anus. This form of anal ectopia is associated with a syndrome of constipation that begins at birth, straining on defecation, and anterior displacement of an otherwise normal anus and sphincter. It is seen almost exclusively in females. Posterior anoplasty with sphincterotomy is curative.

Esophageal biopsy in the diagnosis of reflux esophagitis.

Esophagitis in infancy and childhood produces characteristic histologic changes in the mucosa and lamina propria of the distal esophagus. The use of biopsy in addition to endoscopic evaluation considerably enhances the accuracy of the diagnosis of esophagitis, particularly when the degree of inflammatory change is mild. In the absence of severe inflammatory changes, such as ulceration or mucosal slough, esophageal biopsy appears to be essential for the accurate diagnosis of esophagitis. In children of any age with GER who have symptoms of esophagitis, antacid therapy and vigorous efforts to control reflux are indicated. Failure to respond to this program is an indication for esophageal biopsy to confirm or rule out the presence of esophagitis. The degree of inflammatory change in the biopsy is a reliable guide to expected response to antiacid therapy.

Bronchogenic cyst.

Two recent patients with bronchogenic cysts, presenting in an atypical manner, stimulated our review of this subject. Twenty patients with bronchogenic cysts have been treated at the Boston Floating Hospital over the past 20 yr. Of these patients, 19 out of 20 were symptomatic, the most common symptom being fever (6 out of 20). Half of our patients had no respiratory symptoms but only one was found to have an asymptomatic mass on chest x-ray. The majority of theses cysts were found within the pulmonary parenchyma, the right lung being affected three times more commonly than the left. These facts are at odds with the reports in the literature. Three were found in the neck. Bronchogenic cysts are generally thought to be small, solitary, and limited in area. However, a significant number in our series (8 out of 20) were large, multiple or multicystic, and involved segments, lobes, multiple lobes, and, on one occasion, an entire lung. The correct pre-operative diagnosis was made in only 30% of the cases. The fact that the diagnosis was often missed led to long delays in treatment resulting in recurrent infectious complications and repeated hospitalizations. The most common cause of error in diagnosis was failure to follow a pneumonia to complete resolution. Despite the frequent delays in diagnosis, surgical treatment was curative in all patients.

Total thyroidectomy for occult familial medullary carcinoma of the thyroid in children.

Experience with 17 children in one kindred with familial medullary carcinoma of the thyroid and pheochromocytoma has demonstrated the utility and validity of periodic provocative testing by calcium infusion or pentagastrin injection in the identification of children with early medullary carcinoma of the thyroid or its premalignant precursor, C-cell hyperplasia. In these 17 patients with two consecutive elevations of calcitonin levels greater than 0.55 ng/ml after stimulation all but one have had MTC or CCH at operation. Total thyroidectomy has been well tolerated and can be performed with an acceptably low incidence of complications in this group of patients.