Medication Allergy and Adverse Drug Reaction Documentation Discrepancies in an Urban, Academic Emergency Department.

INTRODUCTION: Medication histories, including knowledge of allergies and adverse drug reactions (ADRs), are a nationally recognized quality measure. Medication histories in the emergency department (ED) are often inaccurate or incomplete. Our objective was to determine the prevalence and nature of medication allergy and ADR discrepancies in an urban ED. METHODS: This was a prospective observational descriptive study, enrolling a convenience sample of adults over 7 months at a single academic urban ED. Trained personnel recorded patient demographics and number of daily medications. Patients listed any prior drug allergies or non-allergic ADRs. Following the ED encounter, the patients' self-reported allergies and ADRs were compared to the electronic medical record (EMR) to identify and describe discrepancies. RESULTS: A sample of 1014 patients, predominantly black (81%), female (60%), and in the 18- to 59-year-old range (69%), was recruited. Most patients were taking at least one daily medication (74%). Three hundred fifteen patients reported at least one allergy (31%), and 252 (25%) at least one ADR. Four hundred sixteen patients (41%) had a discrepancy between their self-report of allergy or ADR and the EMR. Omissions were the most frequent discrepancy. Full descriptions of allergies or ADR were present in 18.4% of charts. Fifty-seven patients (5.6%) were administered a medication which could have interacted with a documented allergy or ADR; none of the allergy EMR records were updated to reflected this. CONCLUSIONS: In this cross-sectional ED study, drug allergies and ADRs were both highly prevalent. There were significant discrepancies in documentation of allergies and ADRs between patient self-report and the EMR.

Mean HEART scores for hospitalized chest pain patients are higher in more experienced providers.

BACKGROUND: The HEART score has been validated as a predictor of major adverse cardiac events (MACEs) in emergency department patients complaining of chest pain. Our objective was to determine the extent of physician variation in the HEART score of admitted patients stratified by years of experience. METHODS: We performed a retrospective medical record review at an academic tertiary care emergency department to determine HEART score, outcome of hospitalization, and 30-day MACE. Electrocardiograms were graded by consensus between 3 physicians. We used analysis of variance to determine the difference in mean HEART scores between providers, Fisher's exact test to determine difference in MACE by duration of training, and logistic regression to determine predictors of low-risk admission (HEART score≤3). RESULTS: The average mean HEART score for 19 full-time physicians was 4.41 (SD 0.43). Individually, there was no difference in mean scores (P=.070), but physicians with 10-15 years of experience had significantly higher mean scores than those with 0-5 years of experience (mean HEART score 4.65 vs 3.93, P=.012). Those with 10-15 years of experience also had a significantly higher proportion of MACE in their admitted cohort (15.3%, P=.002). CONCLUSIONS: More experienced providers admitted higher-risk patients and were more likely to admit patients who would experience a MACE. More research is needed to determine whether adding the HEART score for clinical decision making can be used prospectively to increase sensitivity for admitting patients at high risk for MACE and to decrease admissions for chest pain in lower-risk patients by less experienced providers.

Different Measures, Different Outcomes? A Systematic Review of Performance-Based versus Self-Reported Measures of Health Literacy and Numeracy.

BACKGROUND: Health literacy (HL) and numeracy are measured by one of two methods: performance on objective tests or self-report of one's skills. Whether results from these methods differ in their relationship to health outcomes or use of health services is unknown. METHODS: We performed a systematic review to identify and evaluate articles that measured both performance-based and self-reported HL or numeracy and examined their relationship to health outcomes or health service use. To identify studies, we started with an AHRQ-funded systematic review of HL and health outcomes. We then looked for newer studies by searching MEDLINE from 1 February 2010 to 9 December 2014. We included English language studies meeting pre-specified criteria. Two reviewers independently assessed abstracts and studies for inclusion and graded study quality. One reviewer abstracted information from included studies while a second checked content for accuracy. RESULTS: We identified four "fair" quality studies that met inclusion criteria for our review. Two studies measuring HL found no differences between performance-based and self-reported HL for association with self-reported outcomes (including diabetes, stroke, hypertension) or a physician-completed rheumatoid arthritis disease activity score. However, HL measures were differentially related to a patient-completed health assessment questionnaire and to a patient's ability to interpret their prescription medication name and dose from a medication bottle. Only one study measured numeracy and found no difference between performance-based and self-reported measures of numeracy and colorectal cancer (CRC) screening utilization. However, in a moderator analysis from the same study, performance-based and self-reported numeracy were differentially related to CRC screening utilization when stratified by certain patient-provider communication behaviors (e.g., the chance to always ask questions and get the support that is needed). DISCUSSION: Most studies found no difference in the relationship between results of performance-based and self-reported measures and outcomes. However, we identified few studies using multiple instruments and/or objective outcomes.

Comparison of brief health literacy screens in the emergency department.

Measuring health literacy efficiently yet accurately is of interest both clinically and in research. The authors examined 6 brief health literacy measures and compared their categorization of patient health literacy levels and their comparative associations with patients' health status. The authors assessed 400 emergency department patients with the Short Test of Functional Health Literacy in Adults, the Newest Vital Sign, Single Item Literacy Screen, brief screening questions, Rapid Estimate of Adult Literacy in Medicine-Revised, and the Medical Term Recognition Test. The authors analyzed data using Spearman's correlation coefficients and ran separate logistic regressions for each instrument for patient self-reported health status. Tests differed in the proportion of patients' skills classified as adequate, but all instruments were significantly correlated; instruments targeting similar skills were more strongly correlated. Scoring poorly on any instrument was significantly associated with worse health status after adjusting for age, sex and race, with a score in the combined inadequate/marginal category on the Short Test of Functional Health Literacy in Adults carrying the largest risk (OR = 2.94, 95% CI [1.23, 7.05]). Future research will need to further elaborate instrument differences in predicting different outcomes.