Unwarranted variability in antibiotic prophylaxis for cesarean section delivery: a national survey of anesthesiologists.

BACKGROUND: Current guidelines from the American College of Obstetricians and Gynecologists recommend antibiotic prophylaxis for cesarean delivery immediately before incision. The purpose of this study was to measure and describe correlates of adherence to these guidelines in a sample of United States anesthesiologists. METHODS: We invited a random sample of the membership of the American Society of Anesthesiologists (n = 10,000) to complete an online survey. RESULTS: Of 1052 respondents (10.5%) with complete information for analysis, 63.5% (95% confidence interval 60.6%, 66.3%, n = 668) reported preincision prophylaxis as the standard of care for scheduled cesarean delivery. Twenty-eight percent (n = 299) agreed that the anesthesiologist should take primary responsibility for prophylaxis timing. In a multivariable model, significant variability in preincision prophylaxis was noted for hospital type (community versus teaching, 62% vs 70%, P = 0.004), region (West versus Southeast, 70% vs 59%, P = 0.01; West versus Southwest, 70% vs 58%, P = 0.02), and respondents' belief in appropriate preincision timing (those endorsing routine preincision administration [80%], routine after cord clamp administration [17%], at the discretion of the obstetrician [47%], and the belief that more information was needed [43%]) (P < 0.001 all comparisons). Respondents' belief about appropriate preincision timing was the strongest discriminator in the model (change in area under the receiver operating characteristic curve = 0.13 vs ≤0.02 for all others). CONCLUSION: Adherence with current prophylactic antibiotic administration guidelines for cesarean delivery is not uniform. Education initiatives, regulatory maneuvers, and process improvement should be targeted at sites where anesthesiologists do not comply with current guidelines.

Patients' knowledge of risk and protective factors for cardiovascular disease.

Coronary heart disease is the leading cause of death in the United States. The American Heart Association has proposed improving overall cardiovascular health by promoting 7 components of ideal cardiovascular health, including health behaviors (not smoking, regular exercise, and healthy diet) and health factors (ideal body mass index, cholesterol, blood pressure, and blood glucose). The patients' knowledge of these 7 components is unknown. We performed a cross-sectional survey of patients at 4 primary care and 1 cardiology clinic. The survey measured demographic data, personal behaviors/health factors, cardiovascular disease history, and knowledge about these 7 components. A multivariate model was developed to assess patient characteristics associated with high knowledge scores. Of the 2,200 surveys distributed, 1,702 (77%) were returned with sufficient responses for analysis. Of these, 49% correctly identified heart disease as the leading cause of death, and 37% (95% confidence interval [CI] 35% to 39%) correctly identified all 7 components. The average respondent identified 4.9 components (95% CI 4.7 to 5.0). The lowest recognition rates were for exercise (57%), fruit/vegetable consumption (58%), and diabetes (63%). In a multivariate model, knowledge of all 7 components was positively associated with high school education or greater (odds ratio 2.43, 95% CI 1.68 to 3.52) and white ethnicity (odds ratio 1.78, 95% CI 1.27 to 2.50), and negatively associated with attending an urban neighborhood clinic (odds ratio 0.60, 95% CI 0.44 to 0.82). In conclusion, just >1/3 of patients could identify all 7 components of ideal cardiovascular health. Educational efforts should target patients in low socioeconomic strata and focus on improving knowledge about healthy diet and regular exercise. Although patients with diabetes were more likely than those without diabetes to recognize their risk, 1 in 5 were not aware that diabetes is a risk factor for cardiovascular disease.

Physician characteristics, attitudes, and use of computerized order entry.

BACKGROUND: Computerized physician order entry (CPOE) is a widely advocated patient safety intervention, yet little is known about its adoption by attending physicians or community hospitals. METHODS: We calculated the order entry rates of attending physicians at 2 hospitals by measuring the number of orders entered directly and dividing this by the sum of orders entered directly and those written by hand. These findings were paired with the results of a survey that assessed attitudes concerning the impact of CPOE on personal efficiency, quality of care, and patient safety. RESULTS: Three hundred and fifty-six (71%) of the 502 surveys were returned by physicians, whose median order entry rate was 66%. Forty-two percent of respondents placed at least 80% of their orders electronically (high use), 26% placed 21%-79% of their orders electronically (intermediate use), and 32% placed 20% or less of their orders electronically (low use). Sex, years since medical school graduation, years in practice at the study institution, and use of computers in the outpatient arena were not meaningfully different among the 3 groups. However, use of the system to place orders varied by specialty, and those with intermediate or high use of the system were more likely than low users to have used CPOE during training and to be regular users of computers for personal activities. These physicians were more likely to believe that CPOE enabled orders to be placed efficiently, that directly entered orders were carried out more rapidly, and that such orders were associated with fewer errors. CONCLUSIONS: The adoption of CPOE by attending physicians at community hospitals varies widely. In addition to purchasing systems that support physician work flow, hospitals intent on successfully implementing CPOE should emphasize the benefits in safety and quality of this new technology.

Open-label, sequential comparison of eptifibatide with abciximab for patients undergoing percutaneous coronary intervention.

BACKGROUND: Platelet glycoprotein IIb/IIIa antagonists reduce complications following percutaneous coronary intervention (PCI). There are limited data comparing different agents. OBJECTIVE: The purpose of this study was to compare in-hospital and 30-day outcomes in 2 sequential cohorts of consecutive patients undergoing PCI at our institution who received abciximab or eptifibatide. METHODS: The first cohort included patients who received abciximab between September 1, 1998, and January 9, 1999, and the second included patients who were treated with eptifibatide between January 11 and April 27, 1999. Per formulary decision, during the latter period, patients with renal insufficiency continued to be treated with abciximab and were ineligible for therapy with eptifibatide. Major adverse cardiac events (MACEs) were evaluated by one or more of the authors and compared. RESULTS: A total of 319 patients were treated with abciximab and 301 with eptifibatide. There were no differences in baseline characteristics between the 2 groups, with the exception of a significantly higher proportion of patients with chronic renal insufficiency in the abciximab-treated group (4% vs 0% with eptifibatide; P = 0.03) The majority of interventions were performed for an acute coronary syndrome. Procedural success was 97% in both groups. Eptifibatide patients were treated for a mean 20.4 (5.2) hours, with 10.1% receiving the drug before the procedure. There were no differences in overall or individual MACEs in hospital or at 30 days. CONCLUSION: Our data suggest similar in-hospital and 30-day outcomes for abciximab- and eptifibatide-treated patients undergoing PCI.

The role of the institutional review board in quality improvement: a survey of quality officers, institutional review board chairs, and journal editors.

PURPOSE: There has been growing concern about whether and when quality improvement activities require Institutional Review Board (IRB) review and informed consent. We sought to determine whether quality officers, IRB chairs, and journal editors share similar views about the role of IRB review and informed consent in quality improvement. METHODS: A survey consisting of six quality improvement scenarios detailing the development, implementation, and evaluation of a clinical practice guideline for the management of patients with acute myocardial infarction was mailed to all medical directors of quality and IRB chairpersons at hospitals with at least 400 beds that are members of the Council of Teaching Hospitals of the Association of American Medical Colleges. The same survey was mailed to the editors of all U.S. medical journals that appear in Abridged Index Medicus. RESULTS: Quality officers were less likely than IRB chairs to believe that IRB review was required for all but one of the scenarios. When a clinical practice guideline developed by a national specialty society was implemented locally and its effects evaluated by chart review and telephone calls to patients, 47% (44/94) of IRB chairs, 66% (25/38) of journal editors, but only 20% (20/100) of quality officers believed the activity should be subjected to IRB review. Among those who thought that IRB review was required, there were similar but less striking differences in the perceived need for informed consent. Agreement between quality officers and IRB chairs within the same institution was poor, ranging from 44% to 52% for three of the six scenarios. CONCLUSION: In light of the pressing need to improve quality while protecting the rights of patients, efforts should be supported to clarify the role of the IRB in quality improvement activities.