Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis.

CONTEXT: Studies suggest little benefit in relief of acute sinusitis symptoms from the use of newer and more expensive (second-line) antibiotics instead of older and less expensive (first-line) antibiotics. However, researchers have failed to include development of complications and cost of care in their analyses. OBJECTIVE: To compare the effectiveness and cost of first-line with second-line antibiotics for the treatment of acute uncomplicated sinusitis in adults. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study using a pharmaceutical database containing demographic, clinical (International Classification of Diseases, Ninth Revision), treatment, and charge information for 29 102 adults with a diagnosis of acute sinusitis receiving initial antibiotic treatment between July 1, 1996, and June 30, 1997. MAIN OUTCOME MEASURES: Absence of additional claim for an antibiotic in the 28 days after the initial antibiotic, presence of a claim for a second antibiotic, serious complications of sinusitis, and direct charges and use for the acute sinusitis treatment. RESULTS: There were 17 different antibiotics prescribed in this study. The majority (59.5%) of patients received 1 of the first-line antibiotics. The overall success rate was 90.4% (95% confidence interval [CI], 90.0%-90.8%). The success rate for the 17 329 patients who received a first-line antibiotic was 90.1% and for the 11 773 patients who received a second-line antibiotic was 90.8%, a difference of 0.7% (95% CI, 0.01%-1.40%; P<.05). There were 2 cases of periorbital cellulitis, one in each treatment group. The average total direct charge for patients receiving a first-line antibiotic was $68.98 and a second-line antibiotic was $135.17, a difference of $66.19 (95% CI, $64.95-$67.43; P<.001). This difference was due entirely to the difference in charge of antibiotics and not other charges, such as professional fees, laboratory tests, or emergency department visits. CONCLUSIONS: Patients treated with a first-line antibiotic for acute uncomplicated sinusitis did not have clinically significant differences in outcomes vs those treated with a second-line antibiotic. However, cost of care was significantly higher for patients treated with a second-line antibiotic.

Healthcare in a networked world.

In this essay a medical informatics expert reflects on what the history and future of the Internet means to the way we do business and how we relate to each other. It is not just a matter of more of the same faster; the nature of work changes, the value of services change, and participation in community becomes natural. Ironically, the informality and impersonal nature of the Internet is making it that much more important to know who one is dealing with.

Impact of a Web-based clinical information system on cisapride drug interactions and patient safety.

BACKGROUND: Most commercially available drug-interaction screening systems have important limitations that fail to protect patients from dangerous drug combinations. We attempted to overcome the limitations of our commercial program by developing a Web-based clinical information system to serve as a safety net. This system identifies drug interactions with newly marketed medications not screened by our commercial program, and generates a second alert on dangerous interactions that were overridden during order processing. METHODS: The Web-based system uses patient-specific pharmacy, laboratory, and demographic data to generate detailed alerts on patients receiving potentially dangerous drug combinations. The system's impact on the use of dangerous drug combinations and related adverse events was evaluated by a retrospective analysis of patients receiving cisapride with contraindicated medications in the 2 years before and after implementation. RESULTS: The rate of dangerous drug combinations declined by 66% after implementing the system, from 9.0% of cisapride orders in 1994 and 1995 to 3.1% in 1996 and 1997 (P<.001). The mean [SD] duration of contraindicated therapy (4.1 [3.8] vs 1.6 [1.4] days, P<.001) and proportion of patients being discharged under treatment with a dangerous drug combination (36.2% vs 7.7%, P<.001) was also significantly reduced during the study period. Three patients (1.7%) during the control period experienced serious adverse events that may have been related to the targeted drug interactions. No symptomatic cardiac events were identified during the study period (P = .21). CONCLUSIONS: An automated system running as a safety net can be an efficient method of detecting contraindicated drug combinations and serves an important role in the avoidance of potentially serious adverse drug events.

Computers and productivity: is it time for a reality check?

Many clinicians and administrators in academic medical centers have eagerly embraced the idea of a comprehensive computer-based patient record (CPR), and either are contemplating implementing such a system or have already begun implementing one. Most believe that CPR systems will lead to greater productivity and clinical efficiency, and ultimately to better patient outcomes at lower cost. But there is a gamble in all of this. It is possible that in some settings a CPR system's potential will not be realized because of poor implementation, poor organization, or excessive and unanticipated costs. Given the high stakes associated with CPR implementations, it is important that medical centers move more cautiously, always asking the question "What if these systems do not work?" The author of this article considers worst-case scenarios of CPR deployment as well as evidence from industry and government that undermines claims that CPR deployment will inevitably confer greater productivity and efficiency. He challenges readers to think hard about the cost-benefit ratios of both CPR systems and paper-based systems, and to commit to an institutional "bill of rights" before forging ahead with CPR deployment.

Scaling an expert system data mart: more facilities in real-time.

Clinical Data Repositories are being rapidly adopted by large healthcare organizations as a method of centralizing and unifying clinical data currently stored in diverse and isolated information systems. Once stored in a clinical data repository, healthcare organizations seek to use this centralized data to store, analyze, interpret, and influence clinical care, quality and outcomes. A recent trend in the repository field has been the adoption of data marts--specialized subsets of enterprise-wide data taken from a larger repository designed specifically to answer highly focused questions. A data mart exploits the data stored in the repository, but can use unique structures or summary statistics generated specifically for an area of study. Thus, data marts benefit from the existence of a repository, are less general than a repository, but provide more effective and efficient support for an enterprise-wide data analysis task. In previous work, we described the use of batch processing for populating data marts directly from legacy systems. In this paper, we describe an architecture that uses both primary data sources and an evolving enterprise-wide clinical data repository to create real-time data sources for a clinical data mart to support highly specialized clinical expert systems.

Re-imagining the medical informatics curriculum.

Most physicians in academics, administration, and private practice are insufficiently trained to cope with the current challenges facing medicine. Although information technology, and medical informatics in particular, has been considered to be part of the solution to this problem, the philosophical underpinnings of informatics remain a source of much discussion. Too often, new technology is seen as a new way to do the same things, rather than as an opportunity for a radical reenvisioning of the processes and practices themselves. As a consequence, practitioners and educators fail to make the best uses of new technologies, and fail to offer medical students the comprehensive training in medical informatics that they will need as they move into the real worlds of practice and academics. In this paper, the author describes an imaginary informatics curriculum made up of six core courses: Introduction to Complexity, Decisions and Outcomes, Scarcity and Conflict, Teamwork and Organizations, Representing Knowledge and Action, and Groupware and Collaboration. He does not recommend that these hypothetical courses actually be implemented, but presents them in the hope that they may serve as a starting point for discussions of how informatics can be incorporated into the curriculum in a more substantive way.

What is the Internet learning about you while you are learning about the Internet?

Privacy, confidentiality, and security are largely taken for granted in physicians' offices. However, increasingly, physicians and insurance providers will be obtaining and exchanging information through the sophisticated resources available on the Internet and the World Wide Web (WWW, or the Web). Some of these resources will maintain the same privacy experienced in the office of a trusted clinician or in the reading room of a great library, but more often than not, while people are learning from the Web, the Web will be learning about them. The author describes a new type of file used by Web browsers (the "cookies" file) that may enable users to browse the Web more efficiently but that may also compromise the user's privacy. He then discusses exactly how abuses might occur if information obtained through cookies files is misused, particularly by health insurance providers. Finally, he considers privacy and confidentiality issues raised by computer-based medical records, and the role of the health care provider in maintaining confidential and helpful doctor-patient relationships in the face of rapid technological change and the pressures of managed care.

The commerce of ideas: Internets and Intranets.

Academic physicians pride themselves on their intelligent use of medical technology, their innovativeness, and their ability to market their excellence to the public. Although this pride is extraordinarily justified in the areas of clinical medicine, biomedical research, and health sciences education, academic physicians have less reason to be proud of their accomplishments in the area of information management. In years past, a lack of attention to coherent information management had few consequences so long as there were foci of excellence in clinical disciplines, libraries, core research laboratories, and selected training programs. But the widespread adoption of network-based communications has changed both the priorities of faculty and the information infrastructure necessary to maintain a competitive advantage. In the arena of health care information technology, many medical centers have chosen indiscriminate consumption over focused leadership. This essay speculates on how technologies based on the World Wide Web (WWW) may affect academic medicine through both the greater penetration of the Internet and a wider use of internal "intranets." The Internet is transforming the landscape of biomedical publishing, biomedical education, and the hospital library. The intranet is becoming a vital means of providing documents to support the administration of academic medicine and, in many circumstances, the delivery of patient-specific information. Although there is great potential for transformation, many academic medical centers have not yet fully demonstrated either the wisdom to advance a great information-technology vision or the will necessary to turn a vision into a coherent plan of action.

The commerce of ideas: copyright in the digital era.

Copyright law concerns the rights of an individual to make copies of published works. Changes in technology, be they the introduction of the printing press or the proliferation of photocopy machines, affect how these "copy rights" are interpreted. The transmission of published works over digital networks and the introduction of new and relatively inexpensive ways to conduct commerce over the same networks will have a profound effect on how medical school faculty protect their own published works and how they make use of the published works of others. When copyright law moves from tangible objects such as books and journals to intangible bits carried over a network, many historic notions about the nature of publications and libraries will be called into question. The authors review the history of copyright law and some basic concepts of copyright, particularly "first sale" and "fair use." They also discuss the effects past technological changes have had on the law and on the often-competing concerns of authors, publishers, and readers/users. Finally, they discuss the implications for medical schools of digital publications, digital libraries, and the proposed changes to copyright law.

Managing information in the academic medical center: building an integrated information environment.

The strategic importance of integrated information systems and resources for academic medical centers should not be underestimated. Ten years ago, the National Library of Medicine in collaboration with the Association of Academic Medical Centers initiated the Integrated Advanced Information Management System (IAIMS) program to assist academic medical centers in defining a process for addressing deficiencies in their information environments. The authors give a brief history of the IAIMS program, and they describe both the characteristics of an integrated information environment and the technical and organizational structures necessary to create such an environment. Strategies some institutions have used to implement integrated information systems are also outlined. Finally, the authors discuss the role of librarians in integrated information system design.

Educating physicians to use the digital library.

Skill in creating, finding, managing, and using biomedical information is a vital component of modern medical practice. Medical schools recognize the revolutionary implications of computing technology and use a number of different strategies to integrate "informatics education" into their curricula. In many institutions, leadership for this effort rests with the health sciences library and/or the department of medical informatics. Examples are presented of how nine medical schools have implemented informatics education; no single informatics-education strategy prevails, and these schools' strategies do not exhaust the possibilities. Informatics education programs will require better planning and integration in the future because of the need to keep pace with curriculum reform, the changing context of medical practice, and the speed of technological innovation.

Informatics and medical libraries: changing needs and changing roles.

Medical librarians play a crucial role in the evolution of institutional information policy. As information professionals, they share many similarities with their medical informatics counterparts. Both groups emphasize information delivery to the point of decision making; both groups serve as curators of institutional knowledge bases. If the term "publication" encompasses the delivery of clinical information relevant to individuals or populations, both librarians and medical informaticians have an immediate interest in the nature of biomedical publishing, particularly in areas of intellectual ownership, confidentiality, distribution, and access. Both groups also have been early leaders in applying information technology to solve pressing knowledge-management problems, and both groups have a strong commitment to educating colleagues in the effective use of information. Although the challenges faced by librarians and medical informaticians are sometimes different, the evolution of information technology and new forms of biomedical communication suggest that there is now a greater convergence between the two disciplines.

An Internet primer: resources and responsibilities.

The ease with which individuals can access the Internet and with which institutions can make information available on the Internet explains the exponential growth of this national resource. Once one accomplishes the difficult task of installing network services and establishing an ongoing mechanism for their support, it is relatively simple to use software systems such as those described in this article to gainfully traverse the Internet for a wide range of professional activities. But, as we have discussed, every step of the process, from simple naming conventions to organizations and ongoing maintenance of network-based information services, should proceed only after careful consideration of a network growing hourly in complexity. Despite the power of the technology available on one's desktop, one can often be frustrated by the small decisions: what is my colleague's email address? How can I most effectively find relevant information on home health care software? How should I organize a gopher server? When is WAIS preferable to Gopher or W3? Who will help me learn more? The process comes full circle back to academic medical institutions. The usefulness of the Internet hinges upon the policies these institutions create to aid the organization and dissemination of medical information, and in the means they use to make their constituents aware of the pitfalls and potentials of various technologies.(ABSTRACT TRUNCATED AT 250 WORDS)