Chronic obstructive pulmonary disease is missed in asthmatics in specialty care in Trinidad, West Indies.

SETTING: Underdiagnosis of chronic obstructive pulmonary disease (COPD) in asthmatics attending specialty care in Trinidad, West Indies. OBJECTIVE: To determine the prevalence of COPD in diagnosed asthmatics receiving specialty respiratory care. DESIGN: In a cross-sectional study, 258 asthmatics were screened for lung function measures to examine forced expiratory volume after 1 second (FEV1), forced vital capacity (FVC) and post-bronchodilator FEV1/FVC (COPD was defined as FEV1/FVC < 70 per cent). RESULTS: Of 165 patients evaluated (response rate 64.0 per cent), 53 (32.1 per cent, 95 per centCI 25.0-39.2) had a study diagnosis of COPD and a mean FEV1/FVC of 60.12 +/- 1.2. Proportionally, more males had COPD (50.9 per cent) than asthma (24.1 per cent, P < 0.001). Patients with COPD were 10 years older than asthmatics (P < 0.001). Persons with asthma who smoked were more likely to have COPD (56.0 per cent) (OR 3.26, 95 per cent CI 1.36-7.80, P = 0.006). In both sexes, FEV1/FVC was lower among older people (P < 0.001), with a greater effect (OR 2.75, 95 per cent CI 1.00-7.56, P < 0.01) seen among men in this cross-sectional study. CONCLUSIONS: One third of diagnosed asthmatics in specialty care also have COPD. Lung function was lower among older persons. Early spirometric evaluation of elderly asthmatics who smoke can determine the presence of COPD and facilitate appropriate management.

Chronic obstructive pulmonary disease is missed in asthmatics in specialty care in Trinidad, West Indies.

SETTING: Underdiagnosis of chronic obstructive pulmonary disease (COPD) in asthmatics attending specialty care in Trinidad, West Indies. OBJECTIVE: To determine the prevalence of COPD in diagnosed asthmatics receiving specialty respiratory care. DESIGN: In a cross-sectional study, 258 asthmatics were screened for lung function measures to examine forced expiratory volume after 1 second (FEV1), forced vital capacity (FVC) and post-bronchodilator FEV1/FVC (COPD was defined as FEV1/FVC < 70%). RESULTS: Of 165 patients evaluated (response rate 64.0%), 53 (32.1%, 95%CI 25.0-39.2) had a study diagnosis of COPD and a mean FEV1/FVC of 60.12 +/- 1.2. Proportionally, more males had COPD (50.9%) than asthma (24.1%, P < 0.001). Patients with COPD were 10 years older than asthmatics (P < 0.001). Persons with asthma who smoked were more likely to have COPD (56.0%) (OR 3.26, 95%CI 1.36-7.80, P = 0.006). In both sexes, FEV1/FVC was lower among older people (P < 0.001), with a greater effect (OR 2.75, 95%CI 1.00-7.56, P < 0.01) seen among men in this cross-sectional study. CONCLUSIONS: One third of diagnosed asthmatics in specialty care also have COPD. Lung function was lower among older persons. Early spirometric evaluation of elderly asthmatics who smoke can determine the presence of COPD and facilitate appropriate management.

Learning from malpractice claims about negligent, adverse events in primary care in the United States.

BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985-2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49345 primary care claims, 26126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

Quality of care and the National Practitioner Data Bank: are the two related?

As the National Practitioner Data Bank (NPDB) approaches its tenth year of operation, it is time to review Data Bank operations in comparison to the goals set forth in the legislation that created it, the Health Care Quality Improvement Act of 1986. The goal of the enabling legislation was to improve the quality of health care rendered in this country. The NPDB was created as one step in the achievement of that goal by identifying problem practitioners who may move from one geographic location to another, thus leaving a poor performance record behind. The premise of this article is to review the contributions of the NPDB in terms of accurately identifying practitioners who pose a quality problem.

Litigious consequences of open and laparoscopic biliary surgical mishaps.

Three hundred six injuries or complications coincident to 296 laparoscopic cholecystectomies were analyzed for the nature and extent of injuries and litigious outcomes that followed. The data were drawn from 31 member companies of the Physician Insurers Association of America, a trade association that initiated the study. The outcomes were compared to 261 contemporaneous open cholecystectomy claims. Biliary tract injuries were the most common, accounting for almost two thirds of all injuries. The spectrum of cases, originally selected for indemnity potential, reflected relative incidences in the medical literature. Laparoscopic injuries were significantly more severe, more likely to result in indemnity, and more apt to involve higher mean +/- standard deviation dollar values (160 dollars +/- 154 x 10(3)) to surviving claimants than injuries resulting from open procedures (106 dollars +/- 122 x 10(3), P = 0.01). Injury recognition at the time of the original procedure had no discernible mitigating effect because 80% of recognized injuries required an additional operative procedure. Risk-aversive behavior should include paying particular attention to placement of the first port, more liberal use of the Hasson technique, placement of all other ports under direct vision, elimination of intraoperative anatomic uncertainty, programmed inspection of the abdomen before withdrawing the laparoscope, and acquiring sufficient knowledge of electrosurgical principles to ensure the safe use of this potentially dangerous modality.