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Biomedical subjects

David W Bates

Publications and source records attributed to David W Bates.

At least 91 records · Page 5Linked to original sources
PubMed2005

Improving override rates for 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. We developed a selective knowledge base of only clinically significant drug alerts and designated only critical-high severity alerts to be interruptive to clinician workflow (a tiered approach). Using this approach, we were able to achieve a 67% clinician accept rate for ambulatory computerized prescribing alerts.

Ambulatory Care Information Systems↗
PubMed2004

Adherence with osteoporosis practice guidelines: a multilevel analysis of patient, physician, and practice setting characteristics.

PURPOSE: The diagnosis and treatment of patients at risk of fragility fractures is uncommon. We examined the patient, physician, and practice characteristics associated with adherence to local osteoporosis guidelines. METHODS: Data were obtained from electronic medical records from one academic medical center. Local guidelines suggest screening and consideration of treatment for at-risk patients, including women aged > or =65 years, women aged 50 to 64 years who smoke cigarettes, persons who used more than 5 mg of oral prednisone for >3 months, and those with a history of a fracture after age 45 years. Clinical notes, medication lists, and radiology records were reviewed to determine whether patients had undergone bone mineral density testing or received any medications for osteoporosis. Possible correlates of guideline adherence, including patient, physician, and practice site characteristics, were assessed in mixed multivariable models. RESULTS: We identified 6311 at-risk patients seen by 160 doctors at 10 primary care sites during 2001 to 2002. Of these patients, 45% (n = 2820) had a prior bone mineral density test and 30% (n = 1922) had received a medication for osteoporosis; 54% (n = 3401) had one or the other. After adjusting for patient case mix, 17% to 71% of patients had been managed according to local guidelines and had undergone at least bone mineral density testing or received a medication. Patient variables that significantly lowered the probability of guideline adherence included age >74 years (odds ratio [OR] = 0.49; 95% confidence interval [CI]: 0.43 to 0.55), age <55 years (OR = 0.34; 95% CI: 0.28 to 0.42), male sex (OR = 0.17; 95% CI: 0.12 to 0.23), black race (OR = 0.40; 95% CI: 0.34 to 0.47), and having more than one comorbid condition (OR = 0.79; 95% CI: 0.69 to 0.89). Patients seen by male physicians were less likely to have care that was adherent with guidelines (OR = 0.70; 95% CI: 0.55 to 0.89). CONCLUSION: Rates of adherence with local osteoporosis guidelines for patients at risk of fragility fractures vary by patient, physician, and practice site characteristic.

Aged↗
PubMed2004

Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study.

Despite benefits associated with the use of electronic health records (EHRs), one major barrier to adoption is the concern that EHRs may take longer for physicians to use than paper-based systems. To address this issue, we performed a time-motion study in five primary care clinics. Twenty physicians were observed and specific activities were timed during a clinic session before and after EHR implementation. Surveys evaluated physicians' perceptions regarding the EHR. Post-implementation, the adjusted mean overall time spent per patient during clinic sessions decreased by 0.5 min (p=0.86; 95% confidence interval [-5.05, 6.04]) from a pre-intervention adjusted average of 27.55 min (SE=2.1) to a post-intervention adjusted average of 27.05 min (SE=1.6). A majority of survey respondents believed EHR use results in quality improvement, yet only 29% reported that EHR documentation takes the same amount of time or less compared to the paper-based system. While the EHR did not require more time for physicians during a clinic session, further studies should assess the EHR's potential impact on non-clinic time.

Attitude of Health Personnel↗
PubMed2004

Understanding of drug indications by ambulatory care patients.

PURPOSE: Patients' knowledge of the indications of their prescription medications was studied and those medications that were most likely to be taken without patients understanding the correct indication were identified. METHODS: Adult patients who received care at four primary care practices were surveyed. Patients were eligible to participate if they were over 18 years old and had received a prescription from a participating physician at a clinic visit. Patients were telephoned and asked to retrieve the bottles of all medications they were currently taking, identify their medications, and state the reason they took each medicine. The primary outcome was absent or incorrect knowledge of a drug's indication. RESULTS: A total of 2340 prescription medications were used by the 616 patients whose data were analyzed. Eighty-three patients (13.5%) lacked knowledge of the indication for at least one of their prescription medications. They did not know the indication for 148 medications (6.3%). After multivariable adjustment, lack of knowledge was more common for cardiovascular drugs (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.03-2.19) and less common for diabetes medications (OR, 0.37; 95% CI, 0.16-0.84) and analgesics (OR, 0.23; 95% CI, 0.05-1.01) compared with all other medications, and more common if the patient taking these medications was older, black, or had a high school education or less. CONCLUSION: More than 13% of patients in primary care practices did not know the indication of at least one of their prescription medications. Lack of knowledge was most prevalent for cardiovascular medications.

Age Factors↗
PubMed2004

Psychological effects of a suspicious prostate cancer screening test followed by a benign biopsy result.

PURPOSE: To evaluate the psychological implications of an apparently false-positive screening result for prostate cancer. METHODS: The sample comprised 167 men with a benign biopsy result in response to a suspicious screening test result (biopsy group) and 233 men with a normal prostate-specific antigen (PSA) test result (control group). The men responded to a questionnaire within about 6 weeks of their biopsy or PSA results. They were asked about demographic characteristics, medical history, psychological effects, biopsy experience, and prostate cancer knowledge. RESULTS: The survey response rate was 85% (400/471). The mean (+/- SD) age of respondents was 60 +/- 9 years (range, 40 to 88 years); 88% (n = 350) were white. Forty-nine percent (81/167) of men in the biopsy group reported having thought about prostate cancer either "a lot" or "some of the time", compared with 18% (42/230) in the control group (P < 0.001). In addition, 40% (67/167) in the biopsy group reported having worried "a lot" or "some of the time" that they may develop prostate cancer, compared with 8% (18/231) in the control group (P < 0.001). CONCLUSION: Men who underwent prostate biopsy more often reported having thought and worried about prostate cancer, despite having received a benign result. This underrecognized human cost of screening should be considered in the debate about the benefits and harms of prostate cancer screening.

Adult↗
PubMed2004

"I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care.

BACKGROUND: Failure to review and follow up on outpatient test results in a timely manner represents a patient safety and malpractice concern. Therefore, we sought to identify problems in current test result management systems and possible ways to improve these systems. METHODS: We surveyed 262 physicians working in 15 internal medicine practices affiliated with 2 large urban teaching hospitals (response rate, 64%). We asked physicians about systems they used and the amount of time they spent managing test results. We asked them to report delays in reviewing test results and their overall satisfaction with their management of test results. We also asked physicians to rate features they would find useful in a new test result management system. RESULTS: Overall, 83% of respondents reported at least 1 delay in reviewing test results during the previous 2 months. Despite reporting that they spent on average 74 minutes per clinical day managing test results, only 41% of physicians reported being satisfied with how they managed test results. Satisfaction was associated with fewer self-reported delays in reviewing test results. Physicians who actively tracked their test orders to completion were also more likely to be satisfied. The most highly desired features of a test result management system were tools to help physicians generate result letters to patients, prioritize their workflow, and track test orders to completion. CONCLUSIONS: Delays in test result review are common, and many physicians are not satisfied with how they manage test results. Tools to improve test result management in office practices need to improve workflow efficiency and track test orders to completion.

Adult↗
PubMed2004

Effect of reducing interns' work hours on serious medical errors in intensive care units.

BACKGROUND: Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors. METHODS: We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an "every third night" call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident. RESULTS: During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001). CONCLUSIONS: Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.

Humans↗
PubMed2004

Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion.

After the first session of the American College of Medical Informatics 2004 retreat, during which the history of electronic health records was reviewed, the second session served as a forum for discussion about the state of the art of EHR adoption. Adoption and diffusion rates for both inpatient and outpatient EHRs are low for a myriad of reasons ranging from personal physician concerns about workflow to broad environmental issues. Initial recommendations for addressing these issues include providing communication and education to both providers and consumers and alignment of incentives for clinicians.

Diffusion of Innovation↗
PubMed2004

Improving completion of advance directives in the primary care setting: a randomized controlled trial.

BACKGROUND: Since 1991, hospitals have asked patients whether they have advance directives, but few patients complete these documents. We assessed two simple interventions to improve completion of advance directives among elderly or chronically ill outpatients. METHODS: We conducted a cluster randomized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center. Patients were either > or =70 years of age or > or =50 years old with a chronic illness. The study comprised three arms: physician reminders recommending documentation of advance directives, physician reminders plus mailing advance directives to patients together with educational literature, or neither intervention (control). The main outcome measure was completion of an advance directive. RESULTS: After 28 weeks, 1.5% (5/332) of patients in the physician reminder group, 14% (38/277) in the physician reminder plus patient mailing group, and 1.8% (5/286) in the control group had completed advance directives. In multivariate analyses, patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives (odds ratio [OR] = 5.9; 95% confidence interval [CI]: 1.5 to 22), whereas patients in the physician reminder-only group were no more likely than controls to have completed advance directives (OR = 0.88; 95% CI: 0.21 to 3.7). CONCLUSION: Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents. A physician reminder alone did not have an effect.

Adult↗
PubMed2004

Determinants of JNC VI guideline adherence, intensity of drug therapy, and blood pressure control by race and ethnicity.

The relationship between blood pressure control and racial differences in the processes of hypertension care have not been well examined. We reviewed medical records of 15 768 visits to 12 general internal medicine clinics during July 1, 2001 to June 30, 2002 to determine whether visits were adherent to the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) by identifying medications selected for hypertension therapy. We compared JNC adherence, blood pressure control, and intensification of therapy by patient characteristics. Using repeated measures logistic regression, we determined the adjusted odds of obtaining blood pressure control when therapy was intensified the visit before, and tested the interaction of intensification of therapy and patient race/ethnicity in predicting blood pressure control. JNC adherence was more frequent among blacks (83.7%) and Hispanics (83%) than whites (78.4%) (P<0.001). Blood pressure was controlled most often among whites (38.7% versus 34.8% for blacks and 33.3% for Hispanics; P<0.001). Blacks (81.5%) and whites (80.9%) were more likely than Hispanics (70.8%) to have therapy intensified (P=0.02). After adjustment for baseline blood pressure, intensifying therapy was associated with higher odds of subsequent blood pressure control (odds ratio, 1.55; P<0.001). There were no significant interactions between race/ethnicity and intensification in predicting control. We found that therapy intensification is associated with subsequent blood pressure control in all racial/ethnic groups and that Hispanics were least likely to have their therapy intensified. Interventions to reduce disparities in cardiovascular outcomes should consider the need to intensify drug therapy more aggressively among all high-risk populations.

Adult↗
PubMed2004

Organization and representation of patient safety data: current status and issues around generalizability and scalability.

Recent reports have identified medical errors as a significant cause of morbidity and mortality among patients. A variety of approaches have been implemented to identify errors and their causes. These approaches include retrospective reporting and investigation of errors and adverse events and prospective analyses for identifying hazardous situations. The above approaches, along with other sources, contribute to data that are used to analyze patient safety risks. A variety of data structures and terminologies have been created to represent the information contained in these sources of patient safety data. Whereas many representations may be well suited to the particular safety application for which they were developed, such application-specific and often organization-specific representations limit the sharability of patient safety data. The result is that aggregation and comparison of safety data across organizations, practice domains, and applications is difficult at best. A common reference data model and a broadly applicable terminology for patient safety data are needed to aggregate safety data at the regional and national level and conduct large-scale studies of patient safety risks and interventions.

Humans↗
PubMed2004

Characteristics and consequences of drug allergy alert overrides in a computerized physician order entry system.

OBJECTIVE: The aim of this study was to determine characteristics of drug allergy alert overrides, assess how often they lead to preventable adverse drug events (ADEs), and suggest methods for improving the allergy-alerting system. DESIGN: Chart review was performed on a stratified random subset of all allergy alerts occurring during a 3-month period (August through October 2002) at a large academic hospital. MEASUREMENTS: Factors that were measured were drug/allergy combinations that triggered alerts, frequency of specific override reasons, characteristics of ADEs, and completeness of allergy documentation. RESULTS: A total of 6,182 (80%) of 7,761 alerts were overridden in 1,150 patients. In this sample, only 10% of alerts were triggered by an exact match between the drug ordered and allergy listed. Physicians' most common reasons for overriding alerts were "Aware/Will monitor" (55%), "Patient does not have this allergy/tolerates" (33%), and "Patient taking already" (10%). In a stratified random subset of 320 patients (28% of 1,150) on chart review, 19 (6%) experienced ADEs attributed to the overridden drug; of these, 9 (47%) were serious. None of the ADEs was considered preventable, because the overrides were deemed clinically justifiable. The degree of completeness of patients' allergy lists was highly variable and generally low in both paper charts and the CPOE system. CONCLUSION: Overrides of drug-allergy alerts were common and about 1 in 20 resulted in ADEs, but all of the overrides resulting in ADEs appeared clinically justifiable. The high rate of alert overrides was attributable to frequent nonexact match alerts and infrequent updating of allergy lists. Based on these findings, we have made specific recommendations for increasing the specificity of alerting and thereby improving the clinical utility of the drug allergy alerting system.

Decision Support Systems, Clinical↗
PubMed2004

Strategies for detecting adverse drug events among older persons in the ambulatory setting.

OBJECTIVE: To examine various strategies for the identification of adverse drug events (ADEs) among older persons in the ambulatory clinical setting. DESIGN: A cohort study of Medicare enrollees (n = 31,757 per month) receiving medical care from a large multispecialty group practice during a 12-month observation period (July 1, 1999 through June 30, 2000). MEASUREMENTS: Possible drug-related incidents occurring in the ambulatory clinical setting were detected using signals from multiple sources. RESULTS: During the tracking period, there were 1,523 identified ADEs, of which 421 (28%) were considered preventable. Across all sources, 23,917 signals were found; 12,791 (53%) were potential incidents that led to review of a patient's medical record and 2,266 (9%) were presented to physician reviewers. Although the positive predictive value (PPV) for reports from providers was high compared with other sources (54%), only 11% of the ADEs and 6% of the preventable ADEs were identified through this source. PPVs for other sources ranged from a low of 4% for administrative incident reports to a high of 12% for free-text review of electronic notes. Computer-generated signals were the source for 31% of the ADEs and 37% of the preventable ADEs. Electronic notes were the source for 39% of the ADEs and 29% of the preventable ADEs. There was little overlap in the ADEs identified across all sources. CONCLUSION: Our findings emphasize the limitations of voluntary reporting by health care providers as the principal means for detection of ADEs and suggest that multiple strategies are required to detect ADEs in geriatric ambulatory patients.

Adverse Drug Reaction Reporting Systems↗
PubMed2004

A consensus action agenda for achieving the national health information infrastructure.

BACKGROUND: Improving the safety, quality, and efficiency of health care will require immediate and ubiquitous access to complete patient information and decision support provided through a National Health Information Infrastructure (NHII). METHODS: To help define the action steps needed to achieve an NHII, the U.S. Department of Health and Human Services sponsored a national consensus conference in July 2003. RESULTS: Attendees favored a public-private coordination group to guide NHII activities, provide education, share resources, and monitor relevant metrics to mark progress. They identified financial incentives, health information standards, and overcoming a few important legal obstacles as key NHII enablers. Community and regional implementation projects, including consumer access to a personal health record, were seen as necessary to demonstrate comprehensive functional systems that can serve as models for the entire nation. Finally, the participants identified the need for increased funding for research on the impact of health information technology on patient safety and quality of care. Individuals, organizations, and federal agencies are using these consensus recommendations to guide NHII efforts.

Health Policy↗
PubMed2004

Patient characteristics and experiences associated with trust in specialist physicians.

BACKGROUND: Nearly half of all medical visits are to specialist physicians, yet little is known about patients' outpatient experiences with specialists or how patients' characteristics and experiences are related to trust in specialist physicians. METHODS: We surveyed patients who had a new patient visit with a cardiologist, neurologist, nephrologist, gastroenterologist, or rheumatologist practicing in hospital-based practices (response rate, 73%; N = 417) and inquired about their experiences with care and trust in the specialist physician. We used multivariable models to assess associations of patients' characteristics and experiences with trust. RESULTS: Most patients reported good experiences, and 79% reported complete confidence and trust in the specialist. Black patients were less trusting than white patients (risk ratio [RR], 0.5; 95% confidence interval [CI], 0.2-0.8). Patients were more trusting if they reported that the consultant listened (RR, 1.8; 95% CI, 1.0-2.5), received as much information as they wanted (RR, 1.6; 95% CI, 1.1-1.9), were told what to do if problems or symptoms continued, got worse, or returned (RR, 1.4; 95% CI, 1.2-1.5), were involved in decisions as much as they wanted (RR, 1.5; 95% CI, 1.2-1.8), and spent as much time as they wanted with the specialist (RR, 1.8; 95% CI, 1.3-2.2). CONCLUSIONS: Patients reported high levels of trust in specialist physicians after an initial visit. Several specific experiences were associated with higher trust, suggesting that efforts to improve patient-physician interactions may be successful at achieving trust. Such efforts should especially aim to optimize physicians' interactions with black patients, who were less trusting of specialist physicians.

Adult↗
PubMed2004

The Internet as a vehicle to communicate health information during a public health emergency: a survey analysis involving the anthrax scare of 2001.

BACKGROUND: The recent public health risks arising from bioterrorist threats and outbreaks of infectious diseases like SARS (Severe Acute Respiratory Syndrome) highlight the challenges of effectively communicating accurate health information to an alarmed public. OBJECTIVE: To evaluate use of the Internet in accessing information related to the anthrax scare in the United States in late 2001, and to strategize about the most effective use of this technology as a communication vehicle during times of public health crises. METHODS: A paper-based survey to assess how individuals obtained health information relating to bioterrorism and anthrax during late 2001. We surveyed 500 randomly selected patients from two ambulatory primary care clinics affiliated with the Brigham and Women's Hospital in Boston, Massachusetts. RESULTS: The response rate was 42%. While traditional media provided the primary source of information on anthrax and bioterrorism, 21% (95% CI, 15%-27%) of respondents reported searching the Internet for this information during late 2001. Respondents reported trusting information from physicians the most, and information from health websites slightly more than information from any traditional media source. Over half of those searching the Internet reported changing their behavior as a result of information found online. CONCLUSIONS: Many people already look to the Internet for information during a public health crisis, and information found online can positively influence behavioral responses to such crises. However, the potential of the Internet to convey accurate health information and advice has not yet been realized. In order to enhance the effectiveness of public-health communication, physician practices could use this technology to pro-actively e-mail their patients validated information. Still, unless Internet access becomes more broadly available, its benefits will not accrue to disadvantaged populations.

Ambulatory Care Facilities↗