Drug Therapy Problem Severity Following Hospitalization and Association With 30-Day Clinical Outcomes.

BACKGROUND: Improved understanding of how drug therapy problems (DTPs) contribute to rehospitalization is needed. OBJECTIVE: The primary objectives were to assess the association of DTP likelihood of harm (LoH) severity score, as measured by comprehensive medication management (CMM) pharmacist after hospital discharge, with 30-day risk of hospital readmission, observation visit, or emergency department visit, and to determine whether resolution of DTPs reduces 30-day risk. Secondary objectives were to determine if any eventswere associated with DTPs and preventability of events. METHODS: Data were collected for 365 patients who received CMM following hospitalization and had at least 1 DTP identified. Retrospective chart reviews were completed for 80 patients with subsequent events to assess associationg with a DTP and its preventability. RESULTS: For each 1-point increment in maximum LoH score, there was 10% higher risk of the composite end point (hazard ratio [HR]=1.10; 95% CI:0.97-1.26; P=0.13). When DTPs were resolved by the CMM pharmacist, the association was attenuated, with a HR of 1.15 (95% CI:0.96-1.38; P=0.12) when the DTP was unresolved and HR of 1.09 (95% CI:0.96-1.25; P=0.52) when resolved; for hospital readmission alone, the corresponding HRs were 1.23 (95% CI:1.00-1.53; P=0.05) and 1.05 (95% CI:0.87-1.27; P=0.60). Of 80 subsequent events, 44 were associated with a medication; 22 were considered preventable. Conclusion and Relevance: The LoH severity score was associated with risk of 30-day events. The strength of association was attenuated when DTPs were resolved by the CMM pharmacist. However, because of statistical uncertainty, larger studies are needed to confirm these patterns.

Use of automated reminder letters to improve diabetes management in primary care: outcomes of a quality improvement initiative.

BACKGROUND: Effective management of patients with diabetes mellitus (DM) can be time-consuming and costly. One patient-centred quality improvement strategy is to generate reminder letters to prompt patient action(s), but this strategy's effect on DM outcomes is uncertain. AIM: To determine whether using the electronic medical record to automatically generate reminder letters for patients not meeting recommended DM targets is associated with improvement in practice level quality metrics for DM management. METHODS: Over 15 months, letters were sent monthly to all patients with DM in a large, urban, primary care teaching practice whose records for haemoglobin A1c (HbA1c), low-density lipoprotein (LDL) or blood pressure (BP) indicated non-compliance with recommended levels and testing intervals. Logistic regression was used to analyse cross-sectional, practice-level differences in the proportion of patients meeting DM quality metrics (HbA1c < 7%, LDL < 100 mg/dl and BP < 130/80 mmHg; rates of checking each value within the last 12 months; and a composite of these five measures) across four time points: six months before the intervention, start of the intervention, end of the 15-month intervention period and six months after the intervention. RESULTS: The number of letters sent per month ranged from 284 to 392, representing 28-38% of all patients with DM. At the end of the intervention, patients' odds of being at goal were higher than before the intervention began for LDL < 100 mg/dl, and for HbA1c and LDL tested once within the last 12 months (or 1.24, P = 0.005; or 1.35, P = 0.03; or 1.48, P < 0.001, respectively). Post intervention, declines were seen in LDL checked within the last 12 months (or 0.76, P = 0.003) and in the composite endpoint (or 0.78, P = 0.005). CONCLUSIONS: The automated patient-reminder letter intervention was associated with modest improvements in several, but not all DM measures. This approach may be an effective tool for improving quality of care for patients with DM.

Comparative effectiveness of bariatric surgery and nonsurgical therapy in adults with type 2 diabetes mellitus and body mass index <35 kg/m2.

BACKGROUND: Outcomes of bariatric surgery in patients with a body mass index (BMI) <35 kg/m(2) have been an active area of investigation. We examined the comparative effectiveness of Roux-en-Y gastric bypass (RYGB) to routine medical management (nonsurgical controls; NSCs) in achieving appropriate targets defined by the American Diabetes Association for type 2 diabetes mellitus (T2DM) in patients with class I obesity (BMI 30.0-34.9 kg/m(2)) T2DM at 1 year. METHODS: We identified patients undergoing RYGB (N = 17) with both class I obesity and T2DM and compared them to similar NSC (N = 17) treated in the Primary Care Center. Data were collected at baseline and 1 year for systolic blood pressure (SBP), as well as blood levels for low-density lipoprotein (LDL) cholesterol and hemoglobin A1c (HbA1c). RESULTS: After RYGB, BMI decreased from 34.6 ± 0.8 kg/m(2) to 25.8 ± 2.5 kg/m(2) (P < .001) and HbA1c decreased from 8.2 ± 2.0% to 6.1 ± 2.7% (P < .001). The NSC cohort had no significant change in either BMI or HbA1c. SBP and LDL did not significantly change in either group. The RYGB group had a decrease in medication use compared to the NSC group (P < .001). The RYGB group ceased the use of antihypertensive and antihyperlipidemia medications by 1 year despite abnormal values. CONCLUSION: RYGB can be performed in patients with both a BMI <35 kg/m(2) and T2DM with better weight loss, glycemic control, and fewer antihyperglycemic medications than NSC. Inappropriate cessation of medications may partially explain the persistent increase in both SBP and LDL after RYGB.

Effects of Accreditation Council for Graduate Medical Education work hour restrictions on medical student experience.

BACKGROUND: Residents have a major role in teaching students, yet little has been written about the effects of resident work hour restrictions on medical student education. OBJECTIVE: Our objective was to determine the effects of resident work hour restrictions on medical student education. DESIGN: We compared student responses pre work hour restrictions with those completed post work hour restrictions. PARTICIPANTS: Students on required Internal Medicine, Surgery, and Pediatric clerkships at the University of Minnesota. MEASUREMENTS: Two thousand eight hundred twenty-five student responses on end-of-clerkship surveys. RESULTS: Students reported 1.6 more hours per week of teaching by residents (95%CI 0.8-2.6) in the post work hours era. Students' ratings of the overall quality of their teaching on the ward did not change appreciably, 0.05 points' decline on a 5-point scale (P = .05). Like the residents, students worked fewer hours per week (avg. 1.5 hours less, 95%CI 0.4-2.6). There was no change in quality or quantity of attending teaching, students' relationships with their patients, or the overall value of the clerkships. CONCLUSIONS: Whereas resident duty hour restrictions at our institution have had minimal effect on students' ratings of the overall teaching quality, they do report being taught more by their residents. This may be a factor of decreased resident fatigue or an increased sense of well-being; but more study is needed to clarify the causes of our observations.