A Systematic Review of Interventions to Follow-Up Test Results Pending at Discharge.

BACKGROUND: Patients are frequently discharged from the hospital before all test results have been finalized. Thirty to 40% of tests pending at discharge (TPADs) return potentially actionable results that could necessitate change in the patients' management, often unbeknownst to their physicians. Delayed follow-up of TPADs can lead to patient harm. We sought to synthesize the existing literature on interventions intended to improve the management of TPADs, including interventions designed to enhance documentation of TPADs, increase physician awareness when TPAD results finalize post-discharge, decrease adverse events related to missed TPADs, and increase physician satisfaction with TPAD management. METHODS: We searched Medline, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Database of Controlled Clinical Trials and Medline (January 1, 2000-November 10, 2016) for randomized controlled trials and prospective, controlled observational studies that evaluated interventions to improve follow-up of TPADs for adult patients discharged from acute care hospitals or emergency department settings. From each study we extracted characteristics of the intervention being evaluated and its impact on TPAD management. RESULTS: Nine studies met the criteria for inclusion. Six studies evaluated electronic discharge summary templates with a designated field for documenting TPADs, and three of six of these studies reported a significant improvement in documentation of TPADs in discharge summaries in pre- and post-intervention analysis. One study reported that auditing discharge summaries and providing feedback to physicians were associated with improved TPAD documentation in discharge summaries. Two studies found that email alerts when TPADs were finalized improved physicians' awareness of the results and documentation of their follow-up actions. Of the four studies that assessed patient morbidity, two showed a positive effect; however, none specifically measured the impact of their interventions on downstream patient harm due to delayed follow-up of TPADs. Three studies surveyed physicians' attitudes towards the interventions, of which two studies reported improved physician satisfaction with TPAD management with the implementation of an enhanced discharge template and a notification system when TPADs finalize. DISCUSSION: Discharge summary templates, educational interventions for discharging physicians, and email alerts when TPAD results are finalized show promise in improving management of TPADs. Given the complexity of the processes necessary to ensure follow-up of TPADs, rigorous evaluations of multifaceted interventions (e.g., improved discharge documentation of TPADs combined with email alerts when results become available) is needed.

Making health care safer II: an updated critical analysis of the evidence for patient safety practices.

OBJECTIVES: To review important patient safety practices for evidence of effectiveness, implementation, and adoption. DATA SOURCES: Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders. REVIEW METHODS: The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption. RESULTS: From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption. CONCLUSIONS: The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.

What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.

BACKGROUND: Little is known about adverse events (AEs) that occur between physician visits for ambulatory chronic disease patients. An automated telephone self-management support programme for a diverse population of diabetes patients was implemented to capture AEs, describe the self-management domains from which they emanate and explore contributing causes. METHODS: AEs and potential AEs (PotAEs) were identified among 111 ethnically diverse diabetes patients. An AE is an injury that results from either medical management or patient self-management; a PotAE is an unsafe state likely to lead to an event if it persists without intervention. Medical record reviews were conducted to ascertain which self-management domain was involved with the event and to explore contributing causes. RESULTS: Among the 111 patients, 86% had at least one event detected over the 9-month observation period. 111 AEs and 153 PotAEs were identified. For all events, medication management was the most common domain (166 events, 63%). Only 20% of events reflected a single contributing cause; in the remaining 80%, a combination of system, clinician and patient factors contributed to their occurrence. Patient actions were implicated in 205 (77%) events, systems issues in 183 (69%) events and inadequate physician-patient communication in 155 (59%) events. Aside from communication, primary care clinician actions contributed to the occurrence of the event in only 16 cases (6%). CONCLUSIONS: Our findings reveal a complex safety ecology, with multiple contributing causes for AEs and PotAEs among ambulatory diabetes patients. Moreover, patients themselves seem to be key drivers of safety and of AEs, suggesting that patient-level self-management support and patient-centred communication are critical to AE prevention.

Dual energy computed tomography in tophaceous gout.

OBJECTIVE: To evaluate the potential utility of a dual energy CT (DECT) scan in assessing urate deposits among patients with tophaceous gout, and obtain computerised quantification of tophus volume in peripheral joints. METHODS: 20 consecutive patients with tophaceous gout and 10 control patients with other arthritic conditions were included. DECT scans were performed using a renal stone colour-coding protocol that specifically assessed the chemical composition of the material (ie, urate coloured in red, calcium coloured in blue). An automated volumetric assessment of DECT was used to measure the volume of urate deposits in all peripheral joint areas. RESULTS: All 20 patients with gout showed red colour-coded urate deposits on their DECT scans, whereas none of 10 controls showed urate deposits. DECT scans revealed a total of 440 areas of urate deposition in 20 patients, whereas physical examination showed 111 areas of urate deposition (mean 22 vs 6 per patient, respectively, p<0.001). Total urate volume in a given patient ranged from 0.63 cm(3) to 249.13 cm(3), with a mean of 40.20 cm(3). CONCLUSIONS: DECT scans can produce obvious colour displays for urate deposits and help to identify subclinical tophus deposits. Furthermore, tophus volume can be measured by DECT scans through an automated volume estimation procedure.

Development and validation of the Spondyloarthritis Research Consortium of Canada (SPARCC) Enthesitis Index.

BACKGROUND: Enthesitis is a recommended core domain for assessment of ankylosing spondylitis (AS), but no measurement has yet been validated according to Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) criteria. OBJECTIVE: The purpose of this study was to seek to validate an enthesitis index for patients with AS according to OMERACT criteria. METHODS: An enthesitis index was validated in two AS patient cohorts: (1) a longitudinal cohort (n = 223) and (2) 22 patients from three Canadian sites participating in a 24-week randomised placebo-controlled trial of adalimumab in AS. Construct validity was evaluated by correlation analysis with the Bath AS Disease Activity Index (BASDAI), the Bath AS Functional Index (BASFI) and quality of life instruments. Reproducibility was assessed by intraclass correlation coefficient (ICC), and responsiveness was assessed by Guyatt's effect size and standardised response mean. RESULTS: The most frequently affected sites were the greater trochanter and supraspinatus insertion ( approximately 20%). Patients with enthesitis had significantly greater scores for the BASDAI, BASFI, patient global, AS-specific quality of life index (ASQOL) and the Short Form 36 (SF-36) General Health Survey (p<0.001). The enthesitis score contributed significantly to variance in the BASDAI and BASFI. Interobserver ICCs were 0.96 in the longitudinal cohort and 0.89 and 0.77 in the adalimumab clinical trial cohort (for status and change score, respectively). Significant differences in change scores were evident for all patients after 24 weeks of adalimumab treatment, (p = 0.04), this being more significant when a subset of the most commonly affected entheses were analysed (p = 0.01). CONCLUSION: AS patients with enthesitis constitute a more severe subset of disease, and the Spondyloarthritis Research Consortium of Canada (SPARCC) Enthesitis Index is feasible and reliable for measurement of this condition. Discrimination requires further study in larger trials.

Overestimation of clinical diagnostic performance caused by low necropsy rates.

BACKGROUND: Diagnostic sensitivity is calculated as the number of correct diagnoses divided by the sum of correct diagnoses plus the number of missed or false negative diagnoses. Because missed diagnoses are generally detected during clinical follow up or at necropsy, the low necropsy rates seen in current practice may result in overestimates of diagnostic performance. Using three target conditions (aortic dissection, pulmonary embolism, and active tuberculosis), the prevalence of clinically missed cases among necropsied and non-necropsied deaths was estimated and the impact of low necropsy rates on the apparent sensitivity of antemortem diagnosis determined. METHODS: After reviewing case series for each target condition, the most recent study that included cases first detected at necropsy was selected and the reported sensitivity of clinical diagnosis adjusted by estimating the total number of cases that would have been detected had all decedents undergone necropsy. These estimates were based on available data for necropsy rates, time period, country (US v non-US), and case mix. RESULTS: For all three target diagnoses, adjusting for the estimated prevalence of clinically missed cases among non-necropsied deaths produced sensitivity values outside the 95% confidence interval for the originally reported values, and well below sensitivities reported for the diagnostic tests that are usually used to detect these conditions. For active tuberculosis the sensitivity of antemortem diagnosis decreased from an apparent value of 96% to a corrected value of 83%, with a plausible range of 42-91%; for aortic dissection the sensitivity decreased from 86% to 74%; and for pulmonary embolism the reduction fell only modestly from 97% to 91% but was still lower than generally reported values of 98% or more. CONCLUSIONS: Failure to adjust for the prevalence of missed cases among non-necropsied deaths may substantially overstate the performance of diagnostic tests and antemortem diagnosis in general, especially for conditions with high early case fatality.

Making health care safer: a critical analysis of patient safety practices.

OBJECTIVES: Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety. SEARCH STRATEGY AND SELECTION CRITERIA: Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions. Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation. This process resulted in the identification of 79 practices for review. The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients. Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice. Pertinent studies were identified using various bibliographic databases (e.g., MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts. DATA COLLECTION AND ANALYSIS: Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature." For most practices, the project team required that the primary outcome consist of a clinical endpoint (i.e., some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality. This criterion was relaxed for some practices drawn from the non-health care literature. The evidence supporting each practice was summarized using a prospectively determined format. The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries. A separate ranking was developed for research priorities. MAIN RESULTS: Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery. Many patient safety practices drawn primarily from nonmedical fields (e.g., use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment. The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections. CONCLUSIONS: An evidence-based approach can help identify practices that are likely to improve patient safety. Such practices target a diverse array of safety problems. Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care.

Taking advantage of the explosion of systematic reviews: an efficient MEDLINE search strategy.

CONTEXT: Systematic reviews of the literature are an important resource for clinicians. Unfortunately, the few published strategies for identifying these articles involve MEDLINE interfaces not widely available outside of academic medicine. In addition, the performance of these strategies is unknown. OBJECTIVE: To develop and evaluate a search strategy for identifying systematic reviews by using a publicly available MEDLINE interface (PubMed). DESIGN: Diagnostic test assessment. DEFINITION OF SENSITIVITY: The proportion of recognized systematic reviews (indexed in the Cochrane Library's Database of Abstracts of Reviews of Effectiveness [DARE] or in ACP Journal Club) that are identified by the search strategy. DEFINITION OF POSITIVE PREDICTIVE VALUE: The proportion of articles identified in one of three sample searches (screening for colorectal cancer, thrombolytic therapy for venous thromboembolism, and treatment of dementia) that meet a minimum definition of systematic review. RESULTS: Our PubMed search strategy identified 93 of 100 DARE-indexed systematic reviews, a sensitivity of 93% (95% CI, 86% to 97%). For the sample of systematic reviews drawn from ACP Journal Club (n = 103), the PubMed strategy achieved a sensitivity of 97% (CI, 91% to 99%). When the three sample search strings were used, approximately 50% of retrieved articles met our minimum definition of systematic review. In contrast, the similar precision of a PubMed search restricted to review-type articles (as indexed by MEDLINE) was less than 10%. CONCLUSIONS: This search strategy identified most systematic reviews without over-whelming users with numerous false-positive results. A "single-click" filter based on this strategy is now available as part of the Clinical Queries feature of PubMed.

Hypoglycemia induced by hydroxychloroquine in a type II diabetic treated for polyarthritis.

A 77-year-old man with type II diabetes taking a stable dose of subcutaneous, twice daily human insulin developed symmetrical, inflammatory, rheumatoid factor positive polyarthritis. Within 2 weeks of starting therapy with prednisone 5 mg daily and hydroxychloroquine 400 mg daily he had 2 episodes of severe hypoglycemic coma requiring emergency care. His blood glucose became controlled again when his insulin was decreased by 37%. There are no reported cases of hypoglycemia in diabetic or nondiabetic patients treated with hydroxychloroquine. Hydroxychloroquine has been reported to reduce insulin requirements in refractory type II diabetes by an average of 30%. When hydroxychloroquine is initiated for the treatment of polyarthritis in a type II diabetic requiring insulin or sulfonylurea treatment, blood glucose levels should be monitored closely and the insulin dose may need to be reduced.

Reducing vancomycin use utilizing a computer guideline: results of a randomized controlled trial.

BACKGROUND: Vancomycin-resistant enterococci represent an increasingly important cause of nosocomial infections. Minimizing vancomycin use represents a key strategy in preventing the spread of these infections. OBJECTIVE: To determine whether a structured ordering intervention using computerized physician order entry that requires use of a guideline could reduce intravenous vancomycin use. DESIGN: Randomized controlled trial assessing frequency and duration of vancomycin therapy by physicians. PARTICIPANTS AND SETTING: Three hundred ninety-six physicians and 1,798 patients in a tertiary-care teaching hospital. INTERVENTION: Computer screen displaying, at the time of physician order entry, an adaptation of the Centers for Disease Control and Prevention guidelines for appropriate vancomycin use. MAIN OUTCOME MEASURES: The frequency of initiation and renewal of vancomycin therapy as well the duration of therapy prescribed on a per prescriber basis. RESULTS: Compared with the control group, intervention physicians wrote 32 percent fewer orders (11.3 versus 16.7 orders per physician; P = 0.04) and had 28 percent fewer patients for whom they either initiated or renewed an order for vancomycin (7.4 versus 10.3 orders per physician; P = 0.02). In addition, the duration of vancomycin therapy attributable to physicians in the intervention group was 36 percent lower than the duration of therapy prescribed by control physicians (26.5 versus 41.2 days; P = 0.05). Analysis of pharmacy data confirmed a decrease in the overall hospital use of intravenous vancomycin during the study period. CONCLUSION: Implementation of a computerized guideline using physician order entry decreased vancomycin use. Computerized guidelines represent a promising tool for changing prescribing practices.

Cyclosporin A in the treatment of adult Still's disease.

Cyclosporin A (CyA) has been used successfully in the treatment of rheumatoid arthritis. There is one case report of CyA used successfully in the treatment of severe systemic onset Still's disease. To our knowledge, there are no reports of CyA used in adult Still's disease. We present the first report of a patient with refractory adult Still's disease successfully treated with CyA. We submit that cyclosporine treatment may induce remission of symptoms in patients with adult Still's disease and reduce the steroid requirements.