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Biomedical subjects

David W Bates

Publications and source records attributed to David W Bates.

At least 55 records · Page 3Linked to original sources
PubMed2005

Antibiotic treatment of children with sore throat.

CONTEXT: Of children with sore throat, 15% to 36% have pharyngitis caused by group A beta-hemolytic streptococci (GABHS). Performance of a GABHS test prior to antibiotic prescribing is recommended for children with sore throat. Penicillin, amoxicillin, erythromycin, and first-generation cephalosporins are the recommended antibiotics for treatment of sore throat due to GABHS. OBJECTIVES: To measure rates of antibiotic prescribing and GABHS testing and to evaluate the association between testing and antibiotic treatment for children with sore throat. DESIGN, SETTING, AND PARTICIPANTS: Analysis of visits by children aged 3 to 17 years with sore throat to office-based physicians, hospital outpatient departments, and emergency departments in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1995 to 2003 (N = 4158) and of a subset of visits with GABHS testing data (n = 2797). MAIN OUTCOME MEASURES: National rates of antibiotic prescribing, prescribing of antibiotics recommended and not recommended for GABHS, and GABHS testing. RESULTS: Physicians prescribed antibiotics in 53% (95% confidence interval [CI], 49%-56%) of an estimated 7.3 million annual visits for sore throat and nonrecommended antibiotics to 27% (95% CI, 24%-31%) of children who received an antibiotic. Antibiotic prescribing decreased from 66% of visits in 1995 to 54% of visits in 2003 (P = .01 for trend). This decrease was attributable to a decrease in the prescribing of recommended antibiotics (49% to 38%; P = .002). Physicians performed a GABHS test in 53% (95% CI, 48%-57%) of visits and in 51% (95% CI, 45%-57%) of visits at which an antibiotic was prescribed. GABHS testing was not associated with a lower antibiotic prescribing rate overall (48% tested vs 51% not tested; P = .40), but testing was associated with a lower antibiotic prescribing rate for children with diagnosis codes for pharyngitis, tonsillitis, and streptococcal sore throat (57% tested vs 73% not tested; P<.001). CONCLUSIONS: Physicians prescribed antibiotics to 53% of children with sore throat, in excess of the maximum expected prevalence of GABHS. Although there was a decrease in the proportion of children receiving antibiotics between 1995 and 2003, this was due to decreased prescribing of agents recommended for GABHS. Although GABHS testing was associated with a lower rate of antibiotic prescribing for children with diagnosis codes of pharyngitis, tonsillitis, and streptococcal sore throat, GABHS testing was underused.

Adolescent↗
PubMed2005

Acute infections in primary care: accuracy of electronic diagnoses and electronic antibiotic prescribing.

OBJECTIVE: To maximize effectiveness, clinical decision-support systems must have access to accurate diagnostic and prescribing information. We measured the accuracy of electronic claims diagnoses and electronic antibiotic prescribing for acute respiratory infections (ARIs) and urinary tract infections (UTIs) in primary care. DESIGN: A retrospective, cross-sectional study of randomly selected visits to nine clinics in the Brigham and Women's Practice-Based Research Network between 2000 and 2003 with a principal claims diagnosis of an ARI or UTI (N = 827). MEASUREMENTS: We compared electronic billing diagnoses and electronic antibiotic prescribing to the gold standard of blinded chart review. RESULTS: Claims-derived, electronic ARI diagnoses had a sensitivity of 98%, specificity of 96%, and positive predictive value of 96%. Claims-derived, electronic UTI diagnoses had a sensitivity of 100%, specificity of 87%, and positive predictive value of 85%. According to the visit note, physicians prescribed antibiotics in 45% of ARI visits and 73% of UTI visits. Electronic antibiotic prescribing had a sensitivity of 43%, specificity of 93%, positive predictive value of 90%, and simple agreement of 64%. The sensitivity of electronic antibiotic prescribing increased over time from 22% in 2000 to 58% in 2003 (p for trend < 0.0001). CONCLUSION: Claims-derived, electronic diagnoses for ARIs and UTIs appear accurate. Although closing, a large gap persists between antibiotic prescribing documented in the visit note and the use of electronic antibiotic prescribing. Barriers to electronic antibiotic prescribing in primary care must be addressed to leverage the potential that computerized decision-support systems offer in reducing costs, improving quality, and improving patient safety.

Acute Disease↗
PubMed2005

KnowledgeLink: impact of context-sensitive information retrieval on clinicians' information needs.

OBJECTIVE: Infobuttons are message-based content search and retrieval functions embedded within other applications that dynamically return information relevant to the clinical task at hand. The objective of this study was to determine whether infobuttons effectively answer providers' questions about medications or affect patient care decisions. DESIGN: The authors implemented and evaluated a medication infobutton application called KnowledgeLink. Health care providers at 18 outpatient clinics were randomized to one of two versions of KnowledgeLink, one that linked to information from Micromedex (Thomson Micromedex, Greenwood Village, Co) and the other to material from SkolarMD (Wolters Kluwer Health, Palo Alto, CA). MEASUREMENTS: Data were collected about the frequency of use and demographics of users, patients, and drugs that were queried. Users were periodically surveyed with short questionnaires and then with a more extensive survey at the end of one year. RESULTS: During the first year, KnowledgeLink was used 7,972 times by 359 users to look up information about 1,723 medications for 4,961 patients. Clinicians used KnowledgeLink twice a month on average, and during an average of 1.2% of patient encounters. KnowledgeLink was used by a wide variety of medical staff, not just physicians and nurse practitioners. The frequency of usage and the questions asked varied with user role (primary care physician, specialist physician, nurse practitioner). Although the median KnowledgeLink session was brief (21 seconds), KnowledgeLink answered users' queries 84% of the time, and altered patient care decisions 15% of the time. Users rated KnowledgeLink favorably on multiple scales, recommended extending KnowledgeLink to other content domains, and suggested enhancing the interface to allow refinement of the query and selection of the target resource. CONCLUSION: An infobutton can satisfy information needs about medications. Although used infrequently and for brief sessions, KnowledgeLink was positively received, answered most users' questions, and had a significant impact on medical decision making. The next steps would be to broaden the domains that KnowledgeLink covers to more specifically tailor results to the user type, to provide options when queries are not immediately answered, and to implement KnowledgeLink within other electronic clinical applications.

Analysis of Variance↗
PubMed2005

Improving acceptance of computerized prescribing alerts in ambulatory care.

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians.

Adult↗
PubMed2005

Acute kidney injury, mortality, length of stay, and costs in hospitalized patients.

The marginal effects of acute kidney injury on in-hospital mortality, length of stay (LOS), and costs have not been well described. A consecutive sample of 19,982 adults who were admitted to an urban academic medical center, including 9210 who had two or more serum creatinine (SCr) determinations, was evaluated. The presence and degree of acute kidney injury were assessed using absolute and relative increases from baseline to peak SCr concentration during hospitalization. Large increases in SCr concentration were relatively rare (e.g., >or=2.0 mg/dl in 105 [1%] patients), whereas more modest increases in SCr were common (e.g., >or=0.5 mg/dl in 1237 [13%] patients). Modest changes in SCr were significantly associated with mortality, LOS, and costs, even after adjustment for age, gender, admission International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis, severity of illness (diagnosis-related group weight), and chronic kidney disease. For example, an increase in SCr >or=0.5 mg/dl was associated with a 6.5-fold (95% confidence interval 5.0 to 8.5) increase in the odds of death, a 3.5-d increase in LOS, and nearly 7500 dollars in excess hospital costs. Acute kidney injury is associated with significantly increased mortality, LOS, and costs across a broad spectrum of conditions. Moreover, outcomes are related directly to the severity of acute kidney injury, whether characterized by nominal or percentage changes in serum creatinine.

Acute Disease↗
PubMed2005

Results of a survey on medical error reporting systems in Korean hospitals.

BACKGROUND: Recent data suggest that medical injuries, or adverse events, represent an important international problem, and that many are caused by errors. Spontaneous reporting is the main tool used to detect errors and adverse events in most countries, and reporting systems are believed to be important for improving patient safety. Increasingly, such reporting can be done using information systems, and information systems are widely used in Korea. However, few data are available regarding the use of electronic medical error reporting systems in Korea. OBJECTIVES: The objectives of this study were to investigate the present status of reporting system of Korean hospitals, and to compare the current status of medical error reporting systems with that of other health information sub systems. METHODS: The chairs of nursing departments of all 283 hospitals nationwide with more than 100 beds were surveyed using a structured questionnaire. The response rate was 35%. In addition, two reports on the national use of health information systems in Korea from 1999 and 2003 were analyzed. RESULTS: Among reporting hospitals (n=99), medical errors were reported on paper in 75 hospitals (77%), verbally in 30 hospitals (30%), using word processing in 13 hospitals (13%), and using the hospital information system in only three hospitals (3%). In contrast, there was widespread and increasing use of health information technology (HIT) in areas such as medication administration, inpatient and outpatient order entry, and radiology. CONCLUSIONS: While HIT is increasingly widely used in Korea in many areas, it is not being used for error reporting. Increasing the use of electronic reporting systems, and systemically evaluating the medical errors and adverse events reported, represent essential steps for reducing systemic errors and improving patient safety.

Health Care Surveys↗
PubMed2005

The costs of a national health information network.

BACKGROUND: The use of information technology may result in a safer and more efficient health care system. However, consensus does not exist about the structure or costs of a national health information network (NHIN). OBJECTIVES: To describe the potential structure and estimate the costs of an NHIN. DESIGN: Cost estimates of an NHIN model developed by an expert panel. SETTING: U.S. health care system. MEASUREMENTS: An expert panel estimated the existing and the expected prevalence in 5 years of critical information technology functionalities. They then developed a model of an achievable NHIN by defining key providers, functionalities, and interoperability functions. By using these data and published cost estimates, the authors determined the cost of achieving this model NHIN in 5 years given the current state of information technology infrastructure. RESULTS: To achieve an NHIN would cost 156 billion dollars in capital investment over 5 years and 48 billion dollars in annual operating costs. Approximately two thirds of the capital costs would be required for acquiring functionalities and one third for interoperability. Ongoing costs would be more evenly divided between functionality and interoperability. If the current trajectory continues, the health care system will spend 24 billion dollars on functionalities over the next 5 years or about one quarter of the cost for functionalities of a model NHIN. LIMITATIONS: Because of a lack of primary data, the authors relied on expert estimates. CONCLUSIONS: While an NHIN will be expensive, 156 billion dollars is equivalent to 2% of annual health care spending for 5 years. Assessments such as this one may assist policymakers in determining the level of investment that the United States should make in an NHIN.

Health Expenditures↗
PubMed2005

Do emergency department blood cultures change practice in patients with pneumonia?

STUDY OBJECTIVE: Although it is considered standard of care to obtain blood cultures on patients hospitalized for pneumonia, several studies have questioned the utility and cost-effectiveness of this practice. The objective of this study is to determine the impact of emergency department (ED) blood cultures on antimicrobial therapy for patients with pneumonia. METHODS: We performed a prospective, observational, cohort study of consecutive adult (age > or =18 years) patients treated at an urban university ED between February 1, 2000 and February 1, 2001. Inclusion criteria were radiographic evidence of pneumonia, clinical evidence of pneumonia, and blood culture obtained. Blood cultures were classified as positive, negative, or contaminant based on previously established criteria. Additionally, data were collected on antimicrobial sensitivities, empiric antibiotic therapy, antibiotic changes, and reasons for changes. RESULTS: There were 3,926 ED visits with blood cultures obtained for any reason, of which 3,762 (96%) were available for review. Of these, 414 of 3,762 (11%) patients met pneumonia study inclusion criteria, and blood cultures identified 29 of 414 (7.0%) patients with true bacteremia. In the 414 patients, blood culture results altered therapy for 15 patients (3.6%) with suspected pneumonia, of which 11 (2.7%) patients had their coverage narrowed; only 4 (1.0%) patients had their coverage broadened because of resistance to empiric therapy. For the 11 patients with bacteremia whose therapy was not altered, culture results actually supported narrowing therapy in 8 (1.9%) cases, but this was not done. CONCLUSION: Blood cultures rarely altered therapy for patients presenting to the ED with pneumonia. More discriminatory blood culture use may potentially reduce resource utilization.

Aged↗
PubMed2005

Determinants of racial/ethnic differences in blood pressure management among hypertensive patients.

BACKGROUND: Prior literature has shown that racial/ethnic minorities with hypertension may receive less aggressive treatment for their high blood pressure. However, to date there are few data available regarding the confounders of racial/ethnic disparities in the intensity of hypertension treatment. METHODS: We reviewed the medical records of 1,205 patients who had a minimum of two hypertension-related outpatient visits to 12 general internal medicine clinics during 7/1/01-6/30/02. Using logistic regression, we determined the odds of having therapy intensified by patient race/ethnicity after adjustment for clinical characteristics. RESULTS: Blacks (81.9%) and Whites (80.3%) were more likely than Latinos (71.5%) to have therapy intensified (P = 0.03). After adjustment for racial differences in the number of outpatient visits and presence of diabetes, there were no racial differences in rates of intensification. CONCLUSION: We found that racial/ethnic differences in therapy intensification were largely accounted for by differences in frequency of clinic visits and in the prevalence of diabetes. Given the higher rates of diabetes and hypertension related mortality among Hispanics in the U.S., future interventions to reduce disparities in cardiovascular outcomes should increase physician awareness of the need to intensify drug therapy more agressively in patients without waiting for multiple clinic visits, and should remind providers to treat hypertension more aggressively among diabetic patients.

Black or African American↗
PubMed2005

Guided prescription of psychotropic medications for geriatric inpatients.

BACKGROUND: Inappropriate use or excessive dosing of psychotropic medications in the elderly is common and can lead to a variety of adverse drug events including falls, oversedation, and cognitive impairment. METHODS: We developed a database of psychotropic medication dosing and selection guidelines for elderly inpatients. We displayed these recommendations to physicians through a computerized order entry system at a tertiary care academic hospital. The system was activated for 2 of 4 six-week study periods in an off-on-off-on pattern. Main outcome measures were agreement with the recommended daily dose for the initial drug order, incidence of dosing at least 10-fold greater than the recommended daily dose, prescription of nonrecommended drugs, inpatient falls, altered mental status as measured by a brief nursing assessment, and hospital length of stay. RESULTS: A total of 7456 initial orders for psychotropic medications were prescribed for 3718 hospitalized elderly patients with a mean +/- SD age of 74.7 +/- 6.7 years. The intervention increased the prescription of the recommended daily dose (29% vs 19%; P<.001), reduced the incidence of 10-fold dosing (2.8% vs 5.0%; P<.001), and reduced the prescription of nonrecommended drugs (10.8% vs 7.6% of total orders; P<.001). Patients in the intervention cohort had a lower in-hospital fall rate (0.28 vs 0.64 falls per 100 patient-days; P = .001). No effect on hospital length of stay or days of altered mental status was found. CONCLUSION: A geriatric decision support system for psychotropic medications increased the prescription of recommended doses, reduced the prescription of nonrecommended drugs, and was associated with fewer inpatient falls.

Accidental Falls↗
PubMed2005

A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease.

OBJECTIVE: The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system. DESIGN: We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care. MEASUREMENTS: The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system. RESULTS: Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01-1.67) and CAD (OR 1.25, 95% CI 1.01-1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care. CONCLUSION: An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist.

Algorithms↗
PubMed2005

Patient-reported medication symptoms in primary care.

BACKGROUND: Little is known about the prevalence and character of medication-related symptoms in primary care and their relationship to adverse drug events (ADEs) or about factors that affect patient-physician communication regarding medication symptoms. METHODS: The study included 661 patients who received prescriptions from physicians at 4 adult primary care practices. We interviewed patients 2 weeks and 3 months after the index visit, reviewed patients' medical records, and surveyed physicians whose patients identified medication-related symptoms. Physician reviewers determined whether medication symptoms constituted true ADEs. We used multivariable regression to examine factors associated with patients' decision to discuss symptoms with a physician and with physicians' decision to alter therapy. RESULTS: A total of 179 patients identified 286 medication-related symptoms but discussed only 196 (69%) with their physicians. Physicians changed therapy in response to 76% of reported symptoms. Patients' failure to discuss 90 medication symptoms resulted in 19 (21%) ameliorable and 2 (2%) preventable ADEs. Physicians' failure to change therapy in 48 cases resulted in 31 (65%) ameliorable ADEs. In multivariable analyses, patients who took more medications (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.04-1.08; P<.001) and had multiple medication allergies (OR = 1.07; 95% CI = 1.03-1.11; P = .001) were more likely to discuss symptoms. Male physicians (OR = 1.20, 95% CI = 1.09-1.26; P = .002) and physicians at 2 practices were more likely to change therapy (OR = 1.24; 95% CI = 1.17-1.28; P<.001; and OR = 1.17; 95% CI = 1.08-1.24; P = .002). CONCLUSION: Primary care physicians may be able to reduce the duration and/or the severity of many ADEs by eliciting and addressing patients' medication symptoms.

Adult↗
PubMed2005

Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity.

CONTEXT: Somatoform disorders are an important determinant of medical care utilization, but their independent effect on utilization is difficult to determine because somatizing patients frequently have psychiatric and medical comorbidity. OBJECTIVES: To assess the extent of the overlap of somatization with other psychiatric disorders; to compare the medical utilization of somatizing and nonsomatizing patients; and to determine the independent contribution of somatization alone to utilization. DESIGN: Patients were surveyed with self-report questionnaires assessing somatization and psychiatric disorder. Medical care utilization was obtained from automated encounter data for the year preceding the index visit. Medical morbidity was indexed with a computerized medical record audit. SETTING: Two hospital-affiliated primary care practices. PARTICIPANTS: Consecutive adults making scheduled visits to their primary care physicians on randomly chosen days. In all, 2668 questionnaires were distributed, and 1914 (71.7%) were returned. Of these, 1546 (80.8%) contained complete data and met eligibility criteria. MAIN OUTCOME MEASURES: Medical care utilization and costs within our hospital system in the preceding 12 months. RESULTS: Two hundred ninety-nine patients (20.5%) received a provisional diagnosis of somatization; 42.3% of these patients had no comorbid depressive or anxiety disorder. Somatizing patients, when compared with nonsomatizing patients, had more primary care visits (mean [SE], 4.90 [0.32] vs 3.43 [0.11]; P<.001); more specialty visits (mean [SE], 8.13 [0.55] vs 4.90 [0.21]; P<.001); more emergency department visits (mean [SE], 1.29 [0.15] vs 0.52 [0.036]; P<.001); more hospital admissions (mean [SE], 0.32 [0.051] vs 0.13 [0.014]; P<.001); higher inpatient costs (mean [SE], USD 3146 [USD 380] vs USD 991 [USD 193]; P<.001); and higher outpatient costs (mean [SE], USD 3208 [USD 180] vs USD 1771 [USD 91]; P<.001). When these results were adjusted for the presence of comorbid anxiety and depressive disorders, major medical morbidity, and sociodemographic characteristics, patients with somatoform disorder still had more primary care visits (P = .04), more specialist visits (P = .002), more emergency department visits (P<.001), more hospital admissions (P<.001), more ambulatory procedures (P<.001), higher inpatient costs (P<.001), and higher outpatient costs (P<.001). When these findings are extrapolated to the national level, an estimated USD 256 billion a year in medical care costs are attributable to the incremental effect of somatization alone. CONCLUSIONS: Patients with somatization had approximately twice the outpatient and inpatient medical care utilization and twice the annual medical care costs of nonsomatizing patients. Adjusting the findings for the presence of psychiatric and medical comorbidity had relatively little effect on this association.

Adult↗
PubMed2005

Antivirals and antibiotics for influenza in the United States, 1995--2002.

PURPOSE: To measure the rates of antiviral and antibiotic prescribing for patients diagnosed with influenza in the United States. METHODS: We performed a retrospective analysis of visits to ambulatory clinics and emergency departments in the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) with a diagnosis of influenza that occurred in seven influenza seasons between 1 October 1995 and 31 May 2002 (n=1216). RESULTS: There were an estimated 22 million visits (95%CI, 17--26 million visits) with a diagnosis of influenza to community ambulatory clinics (88% of visits), hospital ambulatory clinics (3%) and emergency departments (9%) in the United States between the 1995--1996 and the 2001--2002 influenza seasons, inclusive. The sample was 63% adults, 44% male and 84% white. Physicians prescribed antivirals in 19% of visits and antibiotics not associated with an antibiotic-appropriate diagnosis in 26% of visits. In multivariable modeling, independent predictors of antiviral prescribing were adult age (OR, 2.1; 95%CI, 1.1--4.0) and Medicare insurance (OR, 0.1 compared to private insurance; 95%CI, 0.0--0.6). Antiviral prescribing was marginally associated with influenza season (OR, 1.2 per influenza season; 95%CI, 1.0--1.4). Independent predictors of antibiotic prescribing were influenza season (OR, 0.8 per influenza season; 95%CI, 0.7--0.9), male sex (OR, 0.6; 95%CI, 0.4--0.9), adult age (OR, 2.3; 95%CI, 1.2--4.2) and emergency department visits (OR, 0.5 compared to community ambulatory visits; 95%CI, 0.3--0.8). CONCLUSIONS: Physicians prescribed antiviral medications to 19% of patients they diagnosed with influenza; the proportion that would have been clinically appropriate is unknown. In contrast, physicians prescribed apparently inappropriate antibiotics to 26% of these same patients, a rate that, encouragingly, decreased over time.

Adolescent↗
PubMed2005

Frequency of potential azole drug-drug interactions and consequences of potential fluconazole drug interactions.

PURPOSE: To assess the frequency of potential azole-drug interactions and consequences of interactions between fluconazole and other drugs in routine inpatient care. METHODS: We performed a retrospective cohort study of hospitalized patients treated for systemic fungal infections with an oral or intravenous azole medication between July 1997 and June 2001 in a tertiary care hospital. We recorded the concomitant use of medications known to interact with azole antifungals and measured the frequency of potential azole drug interactions, which we considered to be present when both drugs were given together. We then performed a chart review on a random sample of admissions in which patients were exposed to a potential moderate or major drug interaction with fluconazole. The list of azole-interacting medications and the severity of interaction were derived from the DRUGDEX System and Drug Interaction Facts. RESULTS: Among the 4,185 admissions in which azole agents (fluconazole, itraconazole or ketoconazole) were given, 2,941 (70.3%) admissions experienced potential azole-drug interactions, which included 2,716 (92.3%) admissions experiencing potential fluconazole interactions. The most frequent interactions with potential moderate to major severity were co-administration of fluconazole with prednisone (25.3%), midazolam (17.5%), warfarin (14.7%), methylprednisolone (14.1%), cyclosporine (10.7%) and nifedipine (10.1%). Charts were reviewed for 199 admissions in which patients were exposed to potential fluconazole drug interactions. While four adverse drug events (ADEs) caused by fluconazole were found, none was felt to be caused by a drug-drug interaction (DDI), although in one instance fluconazole may have contributed. CONCLUSIONS: Potential fluconazole drug interactions were very frequent among hospitalized patients on systemic azole antifungal therapy, but they had few apparent clinical consequences.

Adverse Drug Reaction Reporting Systems↗
PubMed2005

Prediction of missed myocardial infarction among symptomatic outpatients without coronary heart disease.

BACKGROUND: Missed diagnoses of acute myocardial infarction (AMI) in the ambulatory setting can cause patient suffering and malpractice litigation. Multiple algorithms have been developed to detect the presence of coronary heart disease (CHD) or acute coronary ischemia. METHODS: We performed a case-control study of patients with no prior history of CHD presenting to outpatient practices with potential cardiac ischemia. Malpractice claims files were used to identify 18 cases of patients with missed AMIs. For each case, we identified 3 control patients who had office visits for chest pain during the same month and assessed the association of 4 different prediction tools with missed AMI. RESULTS: The 18 cases of missed AMI had a 39% 1-month mortality rate. Cases were more likely than controls to be men (67% vs 26%, P = .001), to be smokers (88% vs 39%, P < .001), and to have low HDL cholesterol (39 mg/dL vs 59 mg/dL, P < .001) and elevated total cholesterol (236 mg/dL vs 213 mg/dL, P = .01). A Framingham risk score predicting a 10-year risk of CHD > or =10% and a positive score using the Goldman risk predictor were associated with an increased risk of missed AMI (odds ratio 5.7, 95% CI 1.8-18.4 for Framingham risk score; odds ratio 7.2, 95% CI 1.4-36.8 for Goldman risk predictor). CONCLUSIONS: Among ambulatory patients with possible cardiac ischemia and no prior CHD, multiple algorithms may be useful for improvement of risk stratification.

Algorithms↗
PubMed2005

The incidence of adverse drug events in two large academic long-term care facilities.

PURPOSE: To assess the incidence of and risk factors for adverse drug events in the long-term care setting. METHODS: We performed a cohort study of all long-stay residents of two academic long-term care facilities over a period of up to 9 months during 2000 to 2001. We assessed the number of adverse drug events, the severity of events (classified as less serious, serious, life threatening, or fatal), and whether the events were preventable. A case-control study was nested within the prospective study to identify resident-level risk factors for the occurrence of adverse drug events. RESULTS: There were 815 adverse drug events, of which 42% were judged preventable. The overall rate of adverse drug events was 9.8 per 100 resident-months, with a rate of 4.1 preventable adverse drug events per 100 resident-months. Errors associated with preventable events occurred most often at the stages of ordering and monitoring. Residents taking medications in several drug categories were at increased risk of a preventable adverse event. In multivariate analyses, the adjusted odds ratio was 3.4 (95% confidence interval [CI]: 2.0 to 5.9) for those taking antipsychotic agents, 2.8 (95% CI: 1.6 to 4.7) for those taking anticoagulants, 2.2 (95% CI: 1.2 to 4.0) for those taking diuretics, and 2.0 (95% CI: 1.1 to 3.7) for those taking antiepileptics. CONCLUSION: Our findings reinforce the need for a special focus on the ordering and monitoring stages of pharmaceutical care for preventing adverse drug events in the long-term care setting. Patients taking antipsychotic agents, anticoagulants, diuretics, and antiepileptics are at increased risk.

Aged↗