Pursuing integration of performance measures into electronic medical records: beta-adrenergic receptor antagonist medications.

OBJECTIVE: Electronic medical records seldom integrate performance indicators into daily operations. Assessing quality indicators traditionally requires resource intensive chart reviews of small samples. We sought to use an electronic medical record to assess use of beta-adrenergic antagonist medications (beta-blockers) following myocardial infarction, to compare a standardized manual assessment with assessment using electronic medical records, and to discuss potential for future integration of performance indicators into electronic records. DESIGN: Cross-sectional data analysis. SETTING: An urban academic medical center. PARTICIPANTS: US Medicare beneficiaries 65 years of age or older, admitted to hospital with myocardial infarction between 1995 and 1999. MEASUREMENTS AND MAIN RESULTS: Manual chart review was compared with a computer driven assessment of electronic records. Administration of beta-blockers and cases excluded from use of beta-blockers were measured, based on Medicare criteria. Among 4490 older adults, 391 (4%) of 9018 hospital admissions contained codes for myocardial infarction. In 323 (83%) of the 391 hospital admissions, criteria for excluding beta-blockers were met; 235 (60%) were excluded due to heart failure. Of 68 hospital admissions for myocardial infarction that did not meet exclusion criteria, physicians prescribed beta-blockers in 49 (72%) on admission and 42 (62%) at discharge. Compared with manual chart review, electronic review had a sensitivity of 83-100% and led to fewer false negative findings. CONCLUSIONS: An electronic medical records system can be used instead of chart review to measure use of beta-blockers after myocardial infarction. This should lead to integration of real time automated performance measurement into electronic medical records.

Epilepsy and associated psychopathology in young people with intellectual disability.

OBJECTIVE: This study aimed to investigate the role of epilepsy in psychopathology among an epidemiological sample of young people with intellectual disability (ID). The study also compared behavioural and emotional problems in young people on medication to control their epilepsy with those not on medication, and young people with epilepsy who were having current seizure activity with those with no current seizure activity. METHODOLOGY: An epidemiological cohort of 392 participants, representative of the general Australian population of young people with ID, were used in the study. One hundred and fifteen individuals from this cohort were identified as suffering from epilepsy. The Developmental Behaviour Checklist was used to measure symptoms of behavioural and emotional disturbance. RESULTS: Results confirmed that young people with ID and epilepsy did not differ from controls without epilepsy on measures of psychopathology. Furthermore, those with epilepsy on medication had no difference in levels of problem behaviours than epileptics not on medication. CONCLUSIONS: The results suggest that epilepsy has little or no influence on problem behaviours for young people with ID. Our attempt to understand the pathogenesis of behaviour problems in persons with ID may be better directed towards understanding genetic mechanisms than epilepsy pathologies.

Improving appropriate selection of radical prostatectomy for prostate cancer.

Men 70 and older should usually not have radical prostatectomies to treat prostate cancer. Using Medicare claims data, 10 hospitals were identified that performed 29% of the radical prostatectomies in men 70 and older in Kentucky and Indiana. A quality improvement project was conducted with the purpose of decreasing the performance of radical prostatectomy in men 70 and older. On the advice of an expert committee, the peer review organization and the 10 hospitals collaborated in developing and implementing improvement plans that included institutional review of practices and informed consent policies. The project was associated with significant improvement in the use of radical prostatectomy. In addition, substantial savings in Medicare payments were observed, and improvement in the quality of life for Medicare men was anticipated.

Quality improvement in the diagnosis and treatment of heart failure by participating Indiana and Kentucky hospitals.

Acute-care hospitals in Kentucky and Indiana collaborated with Health Care Excel, the Medicare peer review organization, to improve the care of patients admitted with heart failure. Current guidelines for the treatment of heart failure support a focus on quality indicators including confirmation of diagnosis, choice of therapeutic agents, education of patients and their caregivers, and discharge planning. Significant improvement occurred in use of diagnostic tests to confirm diagnosis and in patient education and discharge planing. Improvement in use of therapeutic agents was minimal or lacking in most hospitals. This project demonstrated an opportunity and need for continued improvement efforts in the care of heart failure patients.

Geographic distribution of AIDS patients diagnosed at eight Baltimore hospitals.

Since the beginning of the AIDS (acquired immunodeficiency syndrome) epidemic in Baltimore, the university hospitals, particularly Johns Hopkins, have diagnosed and treated a disproportionate share of Baltimore patients. Many Baltimore community hospitals are now treating AIDS patients. These hospitals will have an increasing role in providing primary and secondary care as the epidemic expands.

Occurrence of erythema chronicum migrans and Lyme disease among children in two noncontiguous Connecticut counties.

In May-November 1977 erythema chronicum migrans of Lyme arthritis occurred in at least 12 children in New London County, Connecticut, east of the original 3-town epidemic focus. The attack rate (0.15 cases per 1,000 persons under 18) was considerably lower than within the focus itself but similar to the rate in towns west of the focus. No cases were identified in Litchfield County in northwest Connecticut. Observed rates of Lyme disease varied markedly within Connecticut in 1977.

Shigellosis in day-care centres.

Increasing numbers of outbreaks of shigellosis in day-care centres have been reported to the Center for Disease Control since 1972. Investigations reveal certain unique epidemiological features of shigellosis in this setting. Attack-rates tend to be higher than in outbreaks in primary schools, and epidemiologically these outbreaks resemble those in custodial institutions. Person-to-person transmission is the usual mode of spread; secondary spread within households is common, and there may also be significant spread to the community at large. Preventive measures should be directed at children, staff, and the day-care centre environment. Control of outbreaks may require closing the centre and must include separation of infected and uninfected persons, judicious use of antibiotics, and correction of deficiencies in hygiene and health education. Improved surveillance of shigellosis in day-care centres will be an aid in efforts toward controlling this increasingly important public-health problem.