Clinical decision support: making the transition from the hospital to the community network.
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Community Networks↗
Biomedical subjects
D W Bates
Publications and source records attributed to D W Bates.
The appropriateness of coronary artery bypass graft surgery in academic medical centers. Working Group of the Appropriateness Project of the Academic Medical Center Consortium.
OBJECTIVE: To compare the appropriateness of use of coronary artery bypass graft (CABG) surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases. DESIGN: Retrospective, randomized medical record review. SETTING: 12 Academic Medical Center Consortium hospitals. PATIENTS: Random sample of 1156 patients who had had isolated CABG surgery in 1990. MAIN OUTCOME MEASURES: 1) Percentage of patients with indications for which CABG surgery was classified as appropriate, Inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review. RESULTS: Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02). The Academic Medical Center Consortium cardiac surgeons revised 568 (24%) of the indications used by the expert panel. However, because those revisions altered the appropriateness ratings in both directions and affected only 50 cases (4%), the net effect of the revisions was slight: The rate of inappropriate CABG surgery increased from 1.6% to 1.9%. Local review found that data collection errors had caused erroneous ratings in 12.5% of 64 cases in which surgery had been classified as inappropriate or uncertain. CONCLUSIONS: The Academic Medical Center Consortium hospitals had low rates of inappropriate and uncertain use of CABG surgery, regardless of the criteria used for assessment. Even though surgeons from the Consortium revised the appropriateness ratings extensively, their revisions had a negligible effect on the overall assessment of appropriateness. However, because of potential data collection errors, appropriateness criteria should be used for individual case audits only if supplemented by subsequent physician review.
Academic Medical Centers↗
A piece of my mind. A cyberday in the life.
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Computer Communication Networks↗
Health status in patients with chronic fatigue syndrome and in general population and disease comparison groups.
PURPOSE: To measure the functional status and well-being of patients with chronic fatigue syndrome (CFS), and compare them with those of a general population group and six disease comparison groups. PATIENTS AND METHODS: The subjects of the study were patients with CFS (n = 223) from a CFS clinic, a population-based control sample (n = 2,474), and disease comparison groups with hypertension (n = 2,089), congestive heart failure (n = 216), type II diabetes mellitus (n = 163), acute myocardial infarction (n = 107), multiple sclerosis (n = 25), and depression (n = 502). We measured functional status and well-being using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), which is a self-administered questionnaire in which lower scores are indicative of greater impairment. RESULTS: Patients with CFS had far lower mean scores than the general population control subjects on all eight SF-36 scales. They also scored significantly lower than patients in all the disease comparison groups other than depression on virtually all the scales. When compared with patients with depression, they scored significantly lower on all the scales except for scales measuring mental health and role disability due to emotional problems, on which they scored significantly higher. The two SF-36 scales reflecting mental health were not correlated with any of the symptoms of CFS except for irritability and depression. CONCLUSION: Patients with CFS had marked impairment, in comparison with the general population and disease comparison groups. Moreover, the degree and pattern of impairment was different from that seen in patients with depression.
Activities of Daily Living↗
Can comorbidity be measured by questionnaire rather than medical record review?
Comorbidity generally is measured by medical record abstraction, which is expensive and often impractical. The aim of this study was to assess the reproducibility and validity of a comorbidity questionnaire. The authors developed a brief comorbidity questionnaire that included items corresponding to each element of the medical record-based Charlson index. The questionnaire was administered to 170 inpatients. Charlson scores were abstracted from these patients' medical records. We assessed test-retest reliability of the questionnaire and the Charlson index, the correlation between the questionnaire and the Charlson index, and correlations between each comorbidity measure and indicators of health resource utilization including medication use, hospitalizations in the past year, and hospital charges. Test-retest reliability, assessed with the intraclass correlation coefficient, was 0.91 for the questionnaire and 0.92 for the chart-based Charlson index. The Spearman correlation between these two measures was 0.63. The correlation between comorbidity measures was weaker in less educated patients. Correlations with indicators of resource utilization were similar for the two comorbidity instruments. The authors found that a questionnaire version of the Charlson index is reproducible, valid, and offers practical advantages over medical record-based assessments.
Aged↗
Medication errors. How common are they and what can be done to prevent them?
Medication errors are common in hospitals, but only about 1 in a 100 actually results in harm to the patient. Conversely, only about 30% of injuries due to drugs in hospitals are associated with a medication error, and are thus preventable. Nonetheless, drugs are used so frequently that the total number of preventable drug injuries that occur is substantial, and these injuries are costly. Changing the systems by which drugs are ordered and administered holds substantial potential for reducing the number of drug-related injuries. Computerised ordering systems, in which orders are written on-line by a physician and the physician can receive feedback on the suitability of the order during the process of making it, appear likely to have an especially large impact on reducing medication errors.
Humans↗
Diagnosis-based risk adjustment for Medicare capitation payments.
Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multiple coexisting medical conditions. Prospective models predict average costs of individuals with chronic conditions nearly as well as concurrent models. All models predict medical costs far more accurately than the current health maintenance organization (HMO) payment formula.
Aged↗
Detecting alerts, notifying the physician, and offering action items: a comprehensive alerting system.
We developed and evaluated a system to automatically identify serious clinical conditions in inpatients. The system notifies the patient's covering physician via his pager that an alert is present and offers potential therapies for the patient's condition (action items) at the time he views the alert information. Over a 6 month period, physicians responded to 1214 (70.2%) of 1730 alerts for which they were paged; they responded to 1002 (82.5% of the 1214) in less than 15 minutes. They said they would take action in 71.5% of the alerts, and they placed an order directly from the alert display screen in 39.4%. Further study is needed to determine if this alerting system improves processes or outcomes of care.
Attitude to Computers↗
Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group.
OBJECTIVES: To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. DESIGN: Prospective cohort study. PARTICIPANTS: All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. MAIN OUTCOME MEASURES: Adverse drug events and potential ADEs. METHODS: Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. RESULTS: Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. CONCLUSION: Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process.
Boston↗
Systems analysis of adverse drug events. ADE Prevention Study Group.
OBJECTIVE: To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs. DESIGN: Systems analysis of events from a prospective cohort study. PARTICIPANTS: All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6-month period. MAIN OUTCOME MEASURES: Errors, proximal causes, and systems failures. METHODS: Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts. RESULTS: During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems. CONCLUSIONS: Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely.
Boston↗
How bad are bacteremia and sepsis? Outcomes in a cohort with suspected bacteremia.
BACKGROUND: To evaluate the short-term and long-term outcomes of patients with suspected bacteremia, we performed a prospective cohort study. METHODS: Clinical data were collected within 24 hours of initial culture from a random sample of 1516 episodes in which blood cultures were performed in an urban tertiary care hospital. One hundred forty-two patients with bacteremia were compared with two comparison groups: (1) 142 randomly selected patients with negative cultures, matched in age within 5 years, gender, severity of underlying disease, and presence of major comorbidity, and (2) all 155 patients with contaminant cultures. The main outcome measures were death, death secondary to bacteremia, and major complications. RESULTS: In the 439 patients, there were 142 deaths (32%), 114 at 1 year (26%) and 46 within 30 days (11%). Mortality at 30 days was most highly correlated with predicted fatality of underlying disease: 48% for the 65 patients with a rapidly fatal disease, 9% for the 156 patients with an eventually fatal disease, and 0.5% for the 217 patients with no fatal disease. In a Cox survival analysis, the risk ratio associated with bacteremia was 1.6 (95% confidence interval, 1.0 to 2.4) vs the comparison groups. When we performed time-dependent Cox analyses in which the hazard ratio was allowed to change at 30 days, we found that the risk ratios associated with bacteremia were 2.3 (95% confidence interval, 1.2 to 4.4) for the first 30 days, and 1.3 (95% confidence interval, 0.76 to 2.1) after 30 days. CONCLUSIONS: We conclude that this population has a high mortality, which is strongly correlated with severity of underlying disease. Short-term mortality was higher in patients with bacteremia even after controlling for severity of illness, but the increase in risk was present only during the first month and most deaths occurred in patients with a rapidly fatal disease.
Adult↗
Clinical laboratory test findings in patients with chronic fatigue syndrome.
BACKGROUND: Results of readily available clinical laboratory tests in patients with chronic fatigue syndrome were compared with results in healthy control subjects. METHODS: Cases consisted of all 579 patients who met either the Centers for Disease Control and Prevention, Atlanta, Ga, British, or Australian case definition for chronic fatigue syndrome. They were from chronic fatigue clinics in Boston, Mass, and Seattle, Wash. Control subjects consisted of 147 blood donors who denied chronic fatigue. Outcome measures were the results of 18 clinical laboratory tests. RESULTS: Age- and sex-adjusted odds ratios of abnormal results, comparing cases with control subjects, were as follows: circulating immune complexes, 26.5 (95% confidence interval [CI] 3.4-206), atypical lymphocytosis, 11.4 (95% CI, 1.4-94); elevated immunoglobulin G, 8.5 (95% CI, 2.0-37); elevated alkaline phosphatase, 4.2 (95% CI, 1.6-11); elevated total cholesterol, 2.1 (95% CI, 1.2-3.4); and elevated lactic dehydrogenase, 0.30 (95% CI, 0.16-0.56). Also, antinuclear antibodies were detected in 15% of cases vs 0% in the control subjects. The results of these tests were generally comparable for the cases from Seattle and Boston. Although these tests served to discriminate the population of patients from healthy control subjects, at the individual level they were not as useful. CONCLUSIONS: Patients with chronic fatigue syndrome who were located in two geographically distant areas had abnormalities in the results of several readily available clinical laboratory tests compared with healthy control subjects. The immunologic abnormalities are in accord with a growing body of evidence suggesting chronic, low-level activation of the immune system in chronic fatigue syndrome. While each of these laboratory findings supports the diagnosis of chronic fatigue syndrome, each lacks sufficient sensitivity to be a diagnostic test. Furthermore, the specificity of these findings relative to other organic and psychiatric conditions that can produce fatigue remains to be established.
Adult↗
Relationship between medication errors and adverse drug events.
OBJECTIVE: To evaluate the frequency of medication errors using a multidisciplinary approach, to classify these errors by type, and to determine how often medication errors are associated with adverse drug events (ADEs) and potential ADEs. DESIGN: Medication errors were detected using self-report by pharmacists, nurse review of all patient charts, and review of all medication sheets. Incidents that were thought to represent ADEs or potential ADEs were identified through spontaneous reporting from nursing or pharmacy personnel, solicited reporting from nurses, and daily chart review by the study nurse. Incidents were subsequently classified by two independent reviewers as ADEs or potential ADEs. SETTING: Three medical units at an urban tertiary care hospital. PATIENTS: A cohort of 379 consecutive admissions during a 51-day period (1,704 patient-days). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Over the study period, 10,070 medication orders were written, and 530 medications errors were identified (5.3 errors/100 orders), for a mean of 0.3 medication errors per patient-day, or 1.4 per admission. Of the medication errors, 53% involved at least one missing dose of a medication; 15% involved other dose errors, 8% frequency errors, and 5% route errors. During the same period, 25 ADEs and 35 potential ADEs were found. Of the 25 ADEs, five (20%) were associated with medication errors; all were judged preventable. Thus, five of 530 medication errors (0.9%) resulted in ADEs. Physician computer order entry could have prevented 84% of non-missing dose medication errors, 86% of potential ADEs, and 60% of preventable ADEs. CONCLUSIONS: Medication errors are common, although relatively few result in ADEs. However, those that do are preventable, many through physician computer order entry.
Boston↗
Serious falls in hospitalized patients: correlates and resource utilization.
PURPOSE: To evaluate the correlates of serious falls in hospitalized patients and the resource utilization associated with such falls. PATIENTS AND METHODS: This retrospective case-control study was performed in an urban tertiary care hospital. The 62 cases included all inpatients with available charts who were reported as having fallen with a resulting fracture (n = 22), dislocation (n = 1), or laceration or hematoma (n = 39) after being admitted between January 1987 and March 1991. The 62 controls were matched by date of hospitalization (within 3 months), age (within 5 years), gender, and length of stay up to the time of the fall. RESULTS: Univariate correlates of falls (P < 0.05) included severity of underlying disease, Charlson comorbidity score, and Confusion Assessment Method (CAM) score. In multivariate conditional logistic regression analyses, only the Charlson index (P < 0.006) and the CAM score (P < 0.03) were independent correlates of a fall. Exposure to any of a number of drugs did not predict falls, but the power to detect drug effects was limited. A combination of the Charlson comorbidity and CAM scores identified a population at substantially increased risk of fall, including 50% (31/62) of fallers, versus 16% (10/62) of controls (odds ratio 5.2; 95% confidence interval, 2.4 to 12). In multivariate analyses, falls were also independently correlated with increases in length of stay (P < 0.004) and total charges (P < 0.008). Fallers stayed 12 days longer and had charges $4,233 higher than controls, after adjustment for potential clinical and nonclinical confounders. CONCLUSION: Falls during hospitalization are commoner in confused patients and those with greater comorbidity. This profile differs from that of fallers in the community, probably because hospitalized patients are sicker. Injurious falls are associated with substantially increased resource utilization.
Accidental Falls↗
The incident reporting system does not detect adverse drug events: a problem for quality improvement.
OBJECTIVES: The objectives of this study were 1) to determine the frequency with which adverse drug events result in an incident report (IR) in hospitalized patients; and 2) to determine if there were differences between quality assurance administrators, nurse leaders in quality assurance, and staff nurses as to whether an incident report should or would be filed for each adverse drug event. STUDY DESIGN: All patients admitted to five patient care units (one medical intensive care unit, two surgical intensive care units, and two medical general care units) in one academic tertiary care hospital were studied between February and July 1993. The main outcome measures used were adverse drug events (ADEs) and IRs. Consensus voting was used by senior hospital administrators, nursing leaders, and staff nurses to determine whether an adverse drug event should have been reported and would have been reported. RESULTS: Of 54 adverse drug events identified by the study, only 3 patients (6%) had a corresponding incident report submitted to the hospital's quality assurance program or called into the pharmacy hotline. One additional ADE was identified by an IR, but not by the ADE study. Of the 55 ADEs, 15 were preventable, and 26 were serious or life-threatening, yet only 2 of the 26 led to an incident report. The three voting groups agreed that most ADEs justified an IR, but judged that in actual practice, an IR would infrequently have been filed. CONCLUSIONS: Voluntary reporting identified only a small fraction of ADEs. Using IRs for quality assurance/quality improvement will lead to significant bias when assessing quality of care.
Adverse Drug Reaction Reporting Systems↗
Evaluation of screening criteria for adverse events in medical patients.
The goals of this study were to evaluate the sensitivity and specificity of 15 screening criteria for adverse events, preventable adverse events, and severe adverse events in medical patients, and to evaluate combinations of these criteria, including those available through hospital billing data, to determine whether a small subset of generic screens might efficiently identify adverse events. The authors studied 3,137 consecutive admissions to a medical service over a 4-month period at an urban tertiary care hospital. Chart reviews were performed after discharge by reviewers blinded to the eventual determination of presence of an adverse event. Judgments regarding presence, severity, and preventability of adverse events were made using guided implicit reviews by physicians. Of all admissions, 341 (11%) were judged to include an adverse event, of which 274 were severe and 145 were preventable. Sensitivity and specificity of individual screens varied widely, with prior hospitalization the most sensitive (68%) but least specific (56%). Death was specific (97%) but not sensitive (9%); readmission was intermediate (sensitivity 28%, specificity 80%). In analyses using severe and preventable adverse events as the outcome, results were generally similar. Combinations of screens also were compared, including some using only screens available through billing data; the most sensitive billing strategy detected just 47% of adverse events, but cost only $3 per admission reviewed and $57 per adverse event, versus $13 per admission and $116 per adverse event for a strategy in which all records were reviewed. It is concluded that no small subset of screens identified a high percentage of adverse events. Using screens available through billing data, although insensitive, would be much less costly.
Boston↗
Representing hospital events as complex conditionals.
We have developed an approach to medical knowledge representation whereby simple medical concepts are combined to yield complex statements of testable medical logic. The logic is created from a small number of generic medical concepts that are instantiated and combined to create the rules. Rule writing is done through a rule editor and requires knowledge of the system's data dictionaries, though no programming is required. We have used the approach to create a large knowledge base including panic lab alerting rules, drug-laboratory interaction alerting rules, an adverse drug event monitor, and a drug-age interaction detection program. The rules have been used as part of an alerting system and for data collection to determine the frequency of events of interest. The scheme is extensible and yields a readable form of the created knowledge. The scheme holds great promise as a durable form of medical knowledge representation.
Artificial Intelligence↗
Projected impact of monoclonal anti-endotoxin antibody therapy.
BACKGROUND: The goals of this study were to evaluate the criteria for administration of HA-1A monoclonal antibody therapy from the HA-1A trial in patients with suspected gram-negative bacteremia and to evaluate the accuracy with which Bone's criteria for sepsis syndrome identify patients with gram-negative bacteremia. METHODS: This prospective cohort study included 1509 episodes in which hospitalized patients had blood cultures performed in an urban tertiary-care hospital. The main outcome measures were gram-negative bacteremia and gram-negative sepsis. RESULTS: Of 1509 episodes, 115 (8%) represented bacteremia and 40 (3%) included gram-negative rods. Of these 40 patients, nine died in the hospital, including five patients who had gram-negative sepsis; all five had another rapidly fatal disease. Using criteria for treatment and exclusions from the HA-1A trial, three of the patients with gram-negative bacteremia would have been treated, while at least 52 patients without gram-negative bacteremia might have received HA-1A therapy (positive predictive value of criteria, 5.5%). Of the 1509 episodes, sepsis syndrome as defined by Bone was present in 34 (2.3%). While 32 of the 34 patients had suspected gram-negative bacteremia, only five had blood cultures positive for gram-negative bacteria. CONCLUSIONS: In this population, current criteria for administration of monoclonal anti-endotoxin antibody therapy were not sensitive or specific for gram-negative bacteremia, and many patients with gram-negative sepsis were too ill from other conditions to benefit. Indiscriminate use of these therapies could thus be costly yet yield few benefits. To identify patients who should receive novel therapies, better risk-stratification methods and cost-effectiveness analysis are needed.
Antibodies, Monoclonal↗