Vitamin D and incident urinary incontinence in older adults.

BACKGROUND/OBJECTIVES: The aim of this study is to determine whether vitamin D status is associated with incident urinary incontinence (UI) among community-dwelling older adults. SUBJECTS/METHODS: The University of Alabama at Birmingham Study of Aging is a prospective cohort study of community-dwelling Medicare enrollees. Standardized assessment of UI was conducted using the validated Incontinence Severity Index. The analysis of 25-hydroxyvitamin D [25(OH)D] levels was performed on stored baseline sera. UI was assessed every 6-12 months for up to 42 months. The analyses included multivariable logistic regression and Cox proportional hazard models. RESULTS: Of 350 participants (175 male, 147 black, mean age 73.6±5.8), 54% (189/350) were vitamin D deficient (25(OH)D <20 ng/ml) and 25% (87/350) were vitamin D insufficient (25(OH)D: 20 ng/ml to <30 ng/ml). Among the 187 subjects with no UI at baseline, 57% (107/187) were vitamin D deficient and 24% (45/187) were vitamin D insufficient. A total of 175 of the 187 subjects had follow-up evaluation for incident UI over 42 months, and incident UI occurred in 37% (65/175). After adjustment, cumulative incident UI at 42 months was associated with baseline vitamin D insufficiency (P=0.03) and demonstrated a trend association with deficiency (P=0.07). There was no association between baseline vitamin D status and the time to incident UI. CONCLUSIONS: These preliminary results support an association between vitamin D and incident UI in community-dwelling older adults. Future studies may target specific at-risk groups, such as men with BPH or women with pelvic floor disorders for evaluation of the impact of vitamin D supplementation on urinary symptoms.

Dietary patterns and diet quality among diverse older adults: the University of Alabama at Birmingham Study of Aging.

OBJECTIVES: To characterize dietary patterns among a diverse sample of older adults (≥ 65 years). DESIGN: Cross-sectional. SETTING: Five counties in west central Alabama. PARTICIPANTS: Community-dwelling Medicare beneficiaries (N=416; 76.8 ± 5.2 years, 56% female, 39% African American) in the University of Alabama at Birmingham (UAB) Study of Aging. MEASUREMENTS: Dietary data collected via three, unannounced 24-hour dietary recalls was used to identify dietary patterns. Foods were aggregated into 13 groups. Finite mixture modeling (FMM) was used to classify individuals into three dietary patterns. Differences across dietary patterns for nutrient intakes, sociodemographic, and anthropometric measurements were examined using chi-square and general linear models. RESULTS: Three dietary patterns were derived. A "more healthful" dietary pattern, with relatively higher intakes of fruit, vegetables, whole grains, eggs, nuts, legumes and dairy, was associated with lower energy density, higher quality diets as determined by healthy eating index (HEI)-2005 scores and higher intakes of fiber, folate, vitamins C and B6, calcium, iron, magnesium, and zinc. The "western-like" pattern was defined by an intake of starchy vegetables, refined grains, meats, fried poultry and fish, oils and fats and was associated with lower HEI-2005 scores. The "low produce, high sweets" pattern was characterized by high saturated fat, and low dietary fiber and vitamin C intakes. The strongest predictors of better diet quality were female gender and non-Hispanic white race. CONCLUSION: The dietary patterns identified may provide a useful basis on which to base dietary interventions targeted at older adults. Examination of nutrient intakes regardless of the dietary pattern suggests that older adults are not meeting nutrient recommendations and should continue to be encouraged to choose high quality diets.

The association of nocturia with incident falls in an elderly community-dwelling cohort.

OBJECTIVE: The aim of this study was to examine the association of nocturia with incident falls in a population-based sample of community-dwelling elderly persons. METHODS: The University of Alabama at Birmingham Study of Aging is a prospective cohort study of 1000 community-dwelling older adults in the USA designed to examine factors associated with impaired mobility. Subjects were recruited from a stratified, random sample of Medicare beneficiaries to include equal numbers of black women, black men, white women and white men. Nocturia was assessed at baseline and falls were assessed at baseline and every 6 months for a total of 36 months of follow-up. RESULTS: A total of 692 individuals (mean age 74.5 +/- 6.2, 48% female, 52% black) did not fall in the 12 months prior to baseline. Of these 692, 214 (30.9%) reported falling at least once during the subsequent 3 years. In unadjusted analysis, three or more nightly episodes of nocturia were associated with an incident fall [RR = 1.27, 95% CI (1.01-1.60)]. After multivariable logistic regression, three or more episodes of nocturia were associated with an increased risk of falling [RR = 1.28, (1.02-1.59)]. DISCUSSION: In a racially diverse, community-based sample of older men and women who had not fallen in the previous year, nocturia three or more times a night was associated in multivariable analysis with a 28% increased risk of an incident fall within 3 years. While this study has several advantages over previous reports (longitudinal follow-up, performance-based measures of function, population-based sampling), causality cannot be ascertained. Further research is needed to ascertain the impact of treatments to reduce nocturia as part of a multi-component programme to reduce fall risk.

Dietary factors and cognitive impairment in community-dwelling elderly.

BACKGROUND: Diet may play a role in cognitive impairment. OBJECTIVE: To examine the relationship between dietary factors and cognitive impairment. DESIGN AND METHODS: All subjects (n=1056) were participants in the State-wide Survey of Alabama's Elderly (1986-87). Basic demographic information, Mental Status Questionnaire (MSQ) score, and dietary intake frequency of meat (pork, beef, lamb), fish, chicken or turkey, vegetables, fruit, milk, cheese, desserts, bread or cereal, and dried beans and peas were ascertained during an inhome interview. RESULTS: Most participants were female (67%) and white (73%) with a mean age of 69 years (SD 8.9, min 55 max 94) and mean years of education of 10.7 (SD 3.8, min 1 max 18). Intake of cheese was found to be inversely associated with cognitive impairment in a simple logistic regression analysis, (OR = 0.59; 95% CI: 0.42, 0.84; p=0.003) and in a multiple logistic regression analysis (OR=0.68; 95% CI: 0.47, 0.99; p=0.04), after adjusting for basic socio-demographic factors and for other dietary factors. Increased frequency of cheese intake was associated with decreased cognitive impairment (p=0.0034). In the multiple logistic regression analysis bread or cereal (OR= 0.37, 95% CI: 0.14, 0.97; p=0.044) was inversely associated with, and dessert intake (OR= 1.70, 95% CI: 1.12, 2.59; p=0.013) positively associated with cognitive impairment. CONCLUSION: Dietary intake of cheese is associated with a lower prevalence of cognitive impairment, with a dose-response effect, while intake of dessert is associated with a higher prevalence of cognitive impairment. Possible reasons for a potential protective effect of cheese ingestion are discussed.

Religiosity and mental health in southern, community-dwelling older adults.

This study considers potential interaction effects of three measures of religiosity, organized (OR), non-organized (NOR), and intrinsic religiosity (IR), on depression and general mental health, controlling for socio-demographic characteristics and mobility. In-home interviews were conducted among a stratified random sample of Medicare beneficiaries from five central Alabama counties (the University of Alabama at Birmingham Study of Aging). Those who were high on all three dimensions of religiosity reported having fewer symptoms of depression and better mental health than did those who were low on all three dimensions of religiosity. Subjects who scored high on OR reported lower levels of depression (F (1,981) = 3.97, p<0.05). Neither IR nor NOR had salutary effects on the measure of depression nor on the general measure of mental health.The interpretation of the relationships of religiosity with the Geriatric Depression Scale (GDS) and the general mental health (Mental Component Score of the SF-12; MCS) measures was complicated by the presence of three way interactions (F (1,981) = 9.02, p<0.01 and F (1, 981) = 5.46, p<0.05, for GDS and MCS respectively). The presence of interaction effects between the different dimensions of religiosity and mental health affirms the importance of remaining sensitive to the multidimensional nature of religiousness and its relationships with measures of mental health.

Alabama coronary artery bypass grafting project: results of a statewide quality improvement initiative.

CONTEXT: Efforts to improve quality of care in the cardiac surgery field have focused on reducing the risk-adjusted mortality associated with common surgical procedures, such as coronary artery bypass grafting (CABG). However, the best methodological approach to improvement is under debate. OBJECTIVE: To test an intervention to improve performance of CABG surgery. DESIGN AND SETTING: Quality improvement project based on baseline (July 1, 1995-June 30, 1996) and follow-up (July 1-December 31, 1998) performance measurements from medical record review for all 20 Alabama hospitals that provided CABG surgery. PATIENTS: Medicare patients discharged after CABG surgery in Alabama (n = 5784), a comparison state (n = 3214), and a national sample (n = 3758). INTERVENTION: Confidential hospital-specific performance feedback and assistance with multimodal improvement interventions, including the option to share relevant experience with peers. MAIN OUTCOME MEASURES: Duration of intubation, reintubation rate, aspirin therapy at discharge, use of the internal mammary artery (IMA), hospital readmission rate, and risk-adjusted in-hospital mortality. RESULTS: Proportion of extubation within 6 hours increased from 9% to 41% in Alabama, decreased from 40% to 39% in the comparison state, and increased from 12% to 25% in the national sample. Use of IMA increased from 73% to 84%, 48% to 55%, and 74% to 81%, respectively, in the 3 samples, but aspirin use increased only in Alabama (from 88% to 92%). The amount of improvement in all 3 of these process measures was greater in Alabama than in the other samples (IMA use for Alabama vs comparison state was P =.001 and for Alabama vs national sample, P =.02; and P<.001 for all other comparisons). Risk-adjusted mortality decreased in Alabama (4.9% to 2.9%), but this decrease was not statistically significantly different from mortality changes in the other groups (odds ratio, 0.76; 95% confidence interval, 0.54-1.07 vs national sample). CONCLUSION: Confidential peer-based regional performance feedback and process-oriented analysis of shared experience are associated with some improvement in quality of care for patients who underwent CABG surgery.

Prophylactic value of preincision intra-aortic balloon pump: analysis of a statewide experience.

OBJECTIVE: The objective of this study was to determine whether preincision use of an intra-aortic balloon pump improves survival and shortens postoperative length of stay in hemodynamically stable, high-risk patients undergoing coronary artery bypass grafting. METHODS: A post hoc analysis of the Alabama CABG Cooperative Project database was performed by using propensity scores to model the likelihood of receiving a prophylactic preincision intra-aortic balloon pump. Every patient receiving a prophylactic preincision balloon pump was matched with another patient of similar propensity score who did not receive one. We then compared outcomes for matched pairs. RESULTS: There were 7581 patients of whom 592 received a prophylactic preincision balloon pump. Patients with preoperative renal insufficiency, heart failure, or left main coronary artery disease, or who had undergone previous bypass grafting were significantly more likely to receive a prophylactic preincision balloon pump. By using propensity scores, we matched 550 patients who received a prophylactic preincision balloon pump with 550 who did not. Survival did not significantly differ by whether a prophylactic preincision balloon pump was used. However, surviving patients who received a preincision balloon pump had a significantly shorter postbypass length of stay (7 +/- 7.3 days) than did matched patients not receiving a balloon pump (8 +/- 6.2 days; P <.05). CONCLUSIONS: No survival advantage was found for use of a prophylactic intra-aortic balloon pump in hemodynamically stable, high-risk patients undergoing bypass grafting, as opposed to placing a balloon pump on an "as needed" basis during or after the operation. However, the patients receiving the balloon pump had improved convalescence as shown by significantly shorter length of stay.

Relation of low body mass to death and stroke in the systolic hypertension in the elderly program. The SHEP Cooperative Research Group.

BACKGROUND: There are scant data on the effect of body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) on cardiovascular events and death in older patients with hypertension. OBJECTIVE: To determine if low body mass in older patients with hypertension confers an increased risk of death or stroke. PATIENTS: Participants were 3975 men and women (mean age, 71 years) enrolled in 17 US centers in the Systolic Hypertension in the Elderly Program trial, a randomized, double-blind, placebo-controlled clinical trial of lowdose antihypertensive therapy, with follow-up for 5 years. MAIN OUTCOME MEASURES: Five-year adjusted mortality and stroke rates from Cox proportional hazards analyses. RESULTS: There was no statistically significant relation of death or stroke with BMI in the placebo group (P = .47), and there was a U- or J-shaped relation in the treatment group. The J-shaped relation of death with BMI in the treated group (P = .03) showed that the lowest probability of death for men was associated with a BMI of 26.0 and for women with a BMI of 29.6; the curve was quite flat for women across a wide range of BMIs. For stroke, men and women did not differ, and the BMI nadir for both sexes combined was 29, with risk increasing steeply at BMIs below 24. Those in active treatment, however, had lower death and stroke rates compared with those taking placebo. CONCLUSIONS: Among older patients with hypertension, a wide range of BMIs was associated with a similar risk of death and stroke; a low BMI was associated with increased risk. Lean, older patients with hypertension in treatment should be monitored carefully for additional risk factors.

Exploratory study of incident vehicle crashes among older drivers.

BACKGROUND: As the number of older adult drivers increases, distinguishing safe from unsafe older adult drivers will become an increasing public health concern. We report on the medical and functional factors associated with vehicle crashes in a cohort of Alabama drivers, 55 years old and older. METHODS: This prospective study involved 174 older adults, on whom demographic, medical, functional, and physical performance data were collected in 1991. Subjects were then followed through 1996 for incident vehicle crashes. RESULTS: Sixty-one subjects experienced between one and four police-reported vehicle crashes during the study period. Following adjustment for age, race, days driven per week, and gender, Cox proportional-hazards models showed the following variables to be associated with crash involvement: reported difficulty with yardwork or light housework (relative risk [RR] = 2.1; 95% confidence interval [CI] 1.1, 4.0; p = .02), or opening ajar (RR = 3. 1; 95% CI 1.4, 6.7; p = .004); at least one crash before 1991 (RR = 2.1; 95% CI 1.2, 3.7; p = .008); using hypnotic medication (RR = 2.9; 95% CI 1.3, 6.6; p = .01); self-reported stroke or transient ischemic attack (RR = 2.7; 95% CI 1.1, 6.6; p = .03); scoring within the depressed range on the Geriatric Depression Scale (RR = 2.5; 95% CI 1.1, 6.0; p = .03), and failing the useful field-of-view test (RR = 1.9; 95% CI 1.0, 3.5; p = .05). CONCLUSIONS: Variables related to function, medication use, affect, neurological disease, and visuocognitive skills were associated with vehicle crash involvement in this cohort. Our findings suggest that multifactorial assessments are warranted to identify at-risk older drivers.

Alabama coronary artery bypass grafting Cooperative Project: baseline data. Alabama CABG Cooperative Project Study Group.

BACKGROUND: The Alabama Cooperative CABG Project is a statewide process-oriented analysis of coronary artery bypass grafting (CABG). The purpose of this report is to present the first information generated by this analysis, which will serve as a baseline for subsequent quality improvement projects. METHODS: Medical records of Medicare beneficiaries from Alabama, a comparison state, and a national random sample who had isolated CABG between July 1, 1995, and June 30, 1996, were examined. Fifty-six demographic, procedural, and outcome variables were abstracted. Quality indicators identified by the Alabama Quality Assurance Foundation Study Group included: internal mammary artery use, prescription of aspirin at discharge, duration of postoperative intubation, use of intraaortic balloon pump, readmission to intensive care unit, hospital readmission within 30 days, return to the operating room for bleeding, and in-patient mortality. Benchmark performance rates for quality indicators reflecting care processes were calculated. RESULTS: Alabama, the comparison state, and the national sample consisted of 4,092, 2,290, and 1,119 patients, respectively. The processes of care and outcome, including risk-adjusted mortality, for CABG across the state of Alabama are generally similar to other states and nationwide samples. However, there was considerable variation at the local hospital level in Alabama for each quality indicator. CONCLUSIONS: The data provide a "snapshot" of practice patterns for CABG in Alabama. A specific quality indicator (duration of intubation) was identified as a focus for statewide improvement. Hospital-specific variations in quality indicators suggested opportunities for improvement in other indicators at a number of hospitals.

Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay.

OBJECTIVE: To determine whether or not the development of a Stage II or greater pressure ulcer in-hospital is associated with increased hospital costs and length of stay after adjusting for admission severity of illness, comorbidities, nosocomial infections, and other hospital complications. DESIGN: Prospective, inception cohort study. SETTING: Tertiary care, urban, university teaching hospital. PARTICIPANTS: 286 patients identified within 3 days of admission to a tertiary care, urban teaching hospital were enrolled in a prospective, inception cohort study. Patients were age 55 or greater; expected to be confined to bed or chair or with a hip fracture; and expected to remain in hospital at least 5 days. MEASUREMENTS: Baseline data were collected within 3 days of admission. Weekly skin assessments were performed by study nurses to document the development of pressure ulcers. Medical record reviews, patient exams, and physician and nurse interviews were used to obtain baseline demographic, medical, functional, nutritional, and global measures of disease severity. The incidence of nosocomial infections and the number of other hospital complications were monitored by medical record reviews. Hospital costs were estimated using category-specific cost-to-charge ratios. Diagnostic-related group (DRG) adjusted length of stay was calculated by subtracting the mean length of stay for assigned DRGs from actual stays. RESULTS: Incident pressure ulcers were associated with significantly higher mean unadjusted hospital costs ($37,288 vs $13,924, P = 0.0001) and length of stay (30.4 vs 12.8 days, P = 0.0001). In addition to pressure ulcers, other independent predictors of hospital costs and length of stay after multivariable analyses included: admission to an intensive care unit or surgical service, younger age, nosocomial infection, the physician assessment of disease severity, and the number of other hospital complications. Compared with those who did not develop pressure ulcers, patients who developed pressure ulcers also were more likely to develop nosocomial infections (45.9% [17/37] vs 20.1% [50/249], P = 0.001) and other hospital complications (86.5% [32/37] vs 43.0% [107/249], P < 0.001). After adjusting for only the admission predictors of costs and length of stay by multivariable analyses, hospital costs, and length of stay for those who developed pressure ulcers remained significantly greater than for those who did not develop pressure ulcers ($14,260 vs $12,382, P = 0.03, and 16.9 vs 12.9 days, P = 0.02, respectively). The differences in costs and length of stay for those with and without incident pressure ulcers were even greater when adjusted for admission predictors and also the occurrence of nosocomial infections and other complications ($29,048 vs $13,819, P = 0.002, and 20.9 vs 12.7 days, P = 0.0001, respectively). CONCLUSION: Incident pressure ulcers are associated with substantial and significant increases in hospital costs and length of stay. Nosocomial infections and other hospital complications are additional significant independent predictors of health care utilization among patients at risk for pressure ulcers.

Effects of timely antibiotic administration and culture acquisition on the treatment of urinary tract infection.

The purpose of this study was to assess the timeliness of initial antibiotic administration and culture acquisition for Medicare patients discharged with a principal diagnosis of urinary tract infection. The main outcome measurement was reduced length of stay. Data were collected retrospectively from 24,389 randomly selected discharged Medicare patients from September 1, 1994, to August 31, 1995. Only 61% of the cases as urinary tract infection had adequate criteria to confirm the diagnosis. Of these cases, antibiotics were administered within 4 hr after presentation in 40.9% patients. Urine cultures within 24 hr of presentation were noted more frequently (94%)than blood cultures (66%). Urine cultures obtained before antibiotic administration were noted more frequently (82%) than were blood cultures (58%). Timely antibiotic administration and the acquisition of urine cultures in the first 24 hr of hospitalization were independently associated with shorter length of stay.

A preliminary assessment of the medical and functional factors associated with vehicle crashes by older adults.

OBJECTIVES: To examine associations between medical and functional variables and at-fault car crashes in a cohort of older drivers. DESIGN: A case-control study. SETTING: A tertiary care medical center. PARTICIPANTS: Older drivers (ages 55-90 years) residing in Jefferson County, Alabama (n = 174). Cases were drivers who had at least one at-fault crash in the previous 6 years; controls were crash-free during the same period. MEASUREMENTS: Self-reported medical conditions, reported and observed functional measures, and urinary drug screens. The occurrence of one or more at-fault car crashes in the 6 years preceding the 1991 assessment date represented the outcome measure. RESULTS: Ninety-nine older drivers experienced between one and seven at-fault vehicle crashes during the period 1985 through 1991, whereas 75 drivers did not. Logistic regression models indicated that the following variables were independently associated with crash involvement: A 40% or greater reduction in the useful field of view (OR = 6.1; 95% CI, 2.9 to 12.7; P < 0.001), black race (OR = 6.6; 95% CI, 1.7 to 26.2; P = .007), a history of falling in the previous 2 years (OR = 2.6; CI, 1.1 to 6.1; P = .025), and not taking a beta-blocking drug (OR = 4.3; CI, 1.2 to 15.0; P = .023). CONCLUSIONS: Functional assessments, such as a comprehensive test of visual processing, a falls history, and a review of current medications may be of greater relevance than specific medical conditions in the identification of older at-risk drivers. If prospective studies determine that falling and crashing share risk factors, a unified approach to the prevention of these mobility disorders could result. The finding of an independent association of black race with at-fault crashing is in need of further clarification because of the low representation of black drivers in this sample.

Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project.

CONTEXT: Medicare has a legislative mandate for quality assurance, but the effectiveness of its population-based quality improvement programs has been difficult to establish. OBJECTIVE: To improve the quality of care for Medicare patients with acute myocardial infarction. DESIGN: Quality improvement project with baseline measurement, feedback, remeasurement, and comparison samples. SETTING: All acute care hospitals in the United States. PATIENTS: Preintervention and postintervention samples included all Medicare patients in Alabama, Connecticut, Iowa, and Wisconsin discharged with principal diagnoses of acute myocardial infarctions during 2 periods, June 1992 through December 1992 and August 1995 through November 1995. Indicator comparisons were made with a random sample of Medicare patients in the rest of the nation discharged with acute myocardial infarctions from August 1995 through November 1995. Mortality comparisons involved all Medicare patients nationwide with inpatient claims for acute myocardial infarctions during 2 periods, June 1992 through May 1993 and August 1995 through July 1996. INTERVENTION: Data feedback by peer review organizations. MAIN OUTCOME MEASURES: Quality indicators derived from clinical practice guidelines, length of stay, and mortality. RESULTS: Performance on all quality indicators improved significantly in the 4 pilot states. Administration of aspirin during hospitalization in patients without contraindications improved from 84% to 90% (P< .001), and prescription of beta-blockers at discharge improved from 47% to 68% (P < .001). Mortality at 30 days decreased from 18.9% to 17.1% (P = .005) and at 1 year from 32.3% to 29.6% (P < .001). These improvements in quality occurred during a period when median length of stay decreased from 8 days to 6 days. Performance on all quality indicators except reperfusion was better in the pilot states than in the rest of the nation in 1995, and the differences were statistically significant for aspirin use at discharge (P < .001), beta-blocker use (P < .001), and smoking cessation counseling (P = .02). Postinfarction mortality was not significantly different between the pilot states and the rest of the nation during the baseline period, although it was slightly but significantly better in the pilot states during the follow-up period (absolute mortality difference at 1 year, 0.9%; P = .004). CONCLUSIONS: The quality of care for Medicare patients with acute myocardial infarction has improved in the Cooperative Cardiovascular Project pilot states. Performance on the defined quality indicators appeared to be better in the pilot states than in the rest of the nation in 1995 and was associated with reduced mortality.

A congestive heart failure project with measured improvements in care.

This project was designed to improve the in-hospital management of Medicare beneficiaries with congestive heart failure (CHF). Eleven hospitals were studied using two indicators: (a) assessment of left ventricular (LV) function, and (b) use of angiotensin converting enzyme (ACE) inhibitors in patients with systolic dysfunction. Baseline performance rates were obtained for 990 cases with the Diagnosis Related Group (DRG) 127 for CHF discharged January 1994 to December 1994. Baseline data feedback presentations in 1995 spurred quality improvement plans with interventions such as physician education, critical care maps, and standing orders. Follow-up abstractions were performed on 612 discharges October 1995 through April 1997. The study demonstrated 12% improvement (53% to 65%, p < .01) in assessing LV function and 20% improvement (54% to 74%, p < .01) in appropriate ACE inhibitor use. Projects emphasizing Health Care Quality Improvement Program (HCQIP) principles can successfully affect health care management for the Medicare population.

Pressure ulcer prevalence, incidence, risk factors, and impact.

Pressure ulcers are a common problem among older adults in all health care settings. Prevalence and incidence estimates vary by setting, ulcer stage, and length of follow-up. Risk factors associated with increased pressure ulcer incidence have been identified. Activity or mobility limitation, incontinence, abnormalities in nutritional status, and altered consciousness are the most consistently reported risk factors for pressure ulcers. Pain, infectious complications, prolonged and expensive hospitalizations, persistent open ulcers, and increased risk of death are all associated with the development of pressure ulcers. The tremendous variability in pressure ulcer prevalence and incidence in health care settings suggests that opportunities exist to improve outcomes for persons at risk for and with pressure ulcers.

Effect of computerized requisition of radiology examinations on the transmission of clinical information.

RATIONALE AND OBJECTIVES: The authors developed a method to evaluate the availability and accuracy of clinical data proffered by clinicians when ordering radiologic examinations with a computer order-entry system. METHODS: Two thousand consecutive clinical indications for a spectrum of pediatric imaging studies were scrutinized for accuracy by means of computerized chart review, verbal communication with clinical attending staff, and reference to surgical and laboratory results. The indications were classified as appropriate, incorrect, misleading, or incomplete. RESULTS: Of the 2,000 stated indications, 1,464 (73%) provided a reasonable, if minimal, amount of clinical information; however, in 376 (19%) cases the diagnosis or proximate indication was incorrect, in 108 (5%) cases the data were incomplete, and in 52 (3%) cases the information was misleading. CONCLUSION: Computer order-entry systems can improve the transmission of clinical information but they allow misinformation to be provided.