Do practicing clinicians agree with expert ratings of neonatal intensive care unit quality measures?

OBJECTIVE: To assess the level of agreement when selecting quality measures for inclusion in a composite index of neonatal intensive care quality (Baby-MONITOR) between two panels: one comprised of academic researchers (Delphi) and another comprised of academic and clinical neonatologists (clinician). STUDY DESIGN: In a modified Delphi process, a panel rated 28 quality measures. We assessed clinician agreement with the Delphi panel by surveying a sample of 48 neonatal intensive care practitioners. We asked the clinician group to indicate their level of agreement with the Delphi panel for each measure using a five-point scale (much too high, slightly too high, reasonable, slightly too low and much too low). In addition, we asked clinicians to select measures for inclusion in the Baby-MONITOR based on a yes or no vote and a pre-specified two-thirds majority for inclusion. RESULT: In all, 23 (47.9%) of the clinicians responded to the survey. We found high levels of agreement between the Delphi and clinician panels, particularly across measures selected for the Baby-MONITOR. Clinicians selected the same nine measures for inclusion in the composite as the Delphi panel. For these nine measures, 74% of clinicians indicated that the Delphi panel rating was 'reasonable'. CONCLUSION: Practicing clinicians agree with an expert panel on the measures that should be included in the Baby-MONITOR, enhancing face validity.

Formal selection of measures for a composite index of NICU quality of care: Baby-MONITOR.

OBJECTIVE: To systematically rate measures of care quality for very low birth weight infants for inclusion into Baby-MONITOR, a composite indicator of quality. STUDY DESIGN: Modified Delphi expert panelist process including electronic surveys and telephone conferences. Panelists considered 28 standard neonatal intensive care unit (NICU) quality measures and rated each on a 9-point scale taking into account pre-defined measure characteristics. In addition, panelists grouped measures into six domains of quality. We selected measures by testing for rater agreement using an accepted method. RESULT: Of 28 measures considered, 13 had median ratings in the high range (7 to 9). Of these, 9 met the criteria for inclusion in the composite: antenatal steroids (median (interquartile range)) 9(0), timely retinopathy of prematurity exam 9(0), late onset sepsis 9(1), hypothermia on admission 8(1), pneumothorax 8(2), growth velocity 8(2), oxygen at 36 weeks postmenstrual age 7(2), any human milk feeding at discharge 7(2) and in-hospital mortality 7(2). Among the measures selected for the composite, the domains of quality most frequently represented included effectiveness (40%) and safety (30%). CONCLUSION: A panel of experts selected 9 of 28 routinely reported quality measures for inclusion in a composite indicator. Panelists also set an agenda for future research to close knowledge gaps for quality measures not selected for the Baby-MONITOR.

Understanding diagnostic errors in medicine: a lesson from aviation.

The impact of diagnostic errors on patient safety in medicine is increasingly being recognized. Despite the current progress in patient safety research, the understanding of such errors and how to prevent them is inadequate. Preliminary research suggests that diagnostic errors have both cognitive and systems origins. Situational awareness is a model that is primarily used in aviation human factors research that can encompass both the cognitive and the systems roots of such errors. This conceptual model offers a unique perspective in the study of diagnostic errors. The applicability of this model is illustrated by the analysis of a patient whose diagnosis of spinal cord compression was substantially delayed. We suggest how the application of this framework could lead to potential areas of intervention and outline some areas of future research. It is possible that the use of such a model in medicine could help reduce errors in diagnosis and lead to significant improvements in patient care. Further research is needed, including the measurement of situational awareness and correlation with health outcomes.

Comparison of use of medications after acute myocardial infarction in the Veterans Health Administration and Medicare.

BACKGROUND: There is concern that care provided in the Veterans Health Administration (VA) may be of poorer quality than non-VA health care. We compared use of medications after acute myocardial infarction in the VA with that in non-VA healthcare settings under fee-for-service (FFS) Medicare financing. METHODS AND RESULTS: We used clinical data from 2486 VA and 29 249 FFS men >65 years old discharged with a confirmed diagnosis of acute myocardial infarction from 81 VA hospitals and 1530 non-VA hospitals. We reported odds ratios (ORs) for use of thrombolytics, beta-blockers, ACE inhibitors, or aspirin among ideal candidates adjusted for age, sample design (hospital academic affiliation, availability of cardiac procedures, and volume), and within-hospital clustering. Ideal VA candidates were more likely to undergo thrombolytic therapy at arrival (OR [VA relative to Medicare] 1.40 [1.05, 1.74]) or to receive ACE inhibitors (OR 1.67 [1.12, 2.45]) or aspirin (OR 2.32 [1.81, 3.01]) at discharge and equally likely to receive beta-blockers (OR 1.09 [1.03, 1.40]) at discharge. CONCLUSIONS: Ideal candidates in VA were at least as likely as those in FFS to receive medical therapies of known benefit for acute myocardial infarction.

Racial differences in the use of invasive cardiovascular procedures: review of the literature and prescription for future research.

PURPOSE: The cause of racial disparities in the use of invasive cardiac procedures remains unclear. To summarize, evaluate, and clarify gaps in the literature, studies examining racial differences in cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG) were reviewed. DATA SOURCES: MEDLINE search for English-language articles published from 1966 to May 2000. STUDY SELECTION: Empirical studies of adults. DATA EXTRACTION: The odds ratios for procedure use by race were examined for each study; cohorts and covariates were also documented. DATA SYNTHESIS: Literature was classified as one of three groups on the basis of study design. For the first group, which used administrative data, odds ratios (ORs) for African-American patients compared with white patients ranged from 0.41 to 0.94 for cardiac catheterization, from 0.32 to 0.80 for PTCA, and from 0.23 to 0.68 for CABG. Procedure rates were also lower for Hispanic and Asian patients. In the second group, which used detailed clinical data, African-American patients remained disproportionately less likely to receive cardiac catheterization (OR, 0.03 to 0.85), PTCA (OR, 0.20 to 0.87), and CABG (OR, 0.22 to 0.68). A few studies noted that Hispanic and Asian patients were also disproportionately less likely to receive such procedures. The third group used survey methods but found conflicting results regarding patient refusals as a source of racial variation. Less-educated patients and patients who were not as experienced with the procedure were more likely to decline PTCA. Physician bias was also associated with racial variation in recommendations for treatment. CONCLUSIONS: Racial differences in invasive cardiac procedure use were found even after adjustment for disease severity. Future studies should comprehensively and simultaneously examine the full range of patient, physician, and health care system variables related to racial differences in the provision of invasive cardiac procedures.

Effects of amino acid and trace element supplementation on pneumocandin production by Glarea lozoyensis: impact on titer, analogue levels, and the identification of new analogues of pneumocandin B(0).

Addition of the amino acids threonine, serine, proline, and arginine to fermentations of the fungus Glarea lozoyensis influenced both the pneumocandin titer and the spectrum of analogues produced. Addition of threonine or serine altered the levels of the "serine analogues" of pneumocandins B(0) and B(5) and allowed for their isolation and identification. Proline supplementation resulted in a dose-dependent increase in the levels of pneumocandins B(0) and E(0), whereas pneumocandins C(0) and D(0) decreased as a function of proline level. Moreover, proline supplementation resulted in an overall increase in the synthesis of both trans-3- and trans-4-hydroxyproline while maintaining a low trans-4-hydroxyproline to trans-3-hydroxyproline ratio compared to the unsupplemented culture. Pneumocandin production and the synthesis of hydroxyprolines was also affected by addition of the proline-related amino acid arginine but not by the addition of glutamine or ornithine. Zinc, cobalt, copper, and nickel, trace elements that are known to inhibit alpha-ketoglutarate-dependent dioxygenases, affected the pneumocandin B(0) titer and altered the levels of pneumocandins B(1), B(2), B(5), B(6), and E(0), analogues that possess altered proline, ornithine, and tyrosine hydroxylation patterns.

[Evidence-based grounds of physical therapy. Focus on training/exercise therapy of musculoskeletal problems]. / Det evidensbaserede grundlag for fysioterapi. Med fokus på traening/øvelsesterapi ved bevaegeapparatsproblemer.

Evidence of the benefit of exercise for patients with musculoskeletal problems was examined by analysing meta-analyses and systematic reviews. The literature search was confined to studies where pain and/or function was used as the outcome measure. Twenty-three meta-analyses/systematic reviews were covered, and the methodical quality was assessed. Nine out of twelve meta-analyses showed that exercise had a positive effect on groups groups diagnosed with intermittent claudication, fibromyalgia, incontinence, low back pain, and stroke, whereas one meta-analysis (exercise to prevent falls in the elderly) showed no effect. Of the systematic reviews, six out of 12 showed a positive effect and five were inconclusive, owing to the lack of clinical trials. We conclude that much more research in the field of exercise and physiotherapy is needed.

Outcome of myocardial infarction in Veterans Health Administration patients as compared with medicare patients.

BACKGROUND: Some have the opinion that patients cared for in Veterans Health Administration (VHA) hospitals receive care of poorer quality than those cared for in non-VHA institutions. To assess the quality of care in VHA hospitals, we compared the outcome of acute myocardial infarction among patients in VHA and non-VHA institutions while controlling for potential confounders, including coexisting conditions and severity of illness. METHODS: We studied 2486 veterans discharged from 81 VHA hospitals and 29,249 Medicare patients discharged from 1530 non-VHA hospitals, restricting our samples to men at least 65 years of age who were discharged with confirmed acute myocardial infarction. We compared coexisting conditions, severity of illness, and 30-day and 1-year mortality in the two samples. RESULTS: VHA patients were significantly more likely than Medicare patients to have a recorded history of hypertension (64.3 percent vs. 57.3 percent), chronic obstructive pulmonary disease or asthma (30.9 percent vs. 23.5 percent), diabetes (34.8 percent vs. 29.0 percent), stroke (20.4 percent vs. 14.2 percent), or dementia (7.2 percent vs. 4.8 percent) (P<0.001 for all comparisons). According to both multivariate logistic regression and an analysis using 2265 matched pairs of VHA and Medicare patients, there were no significant differences in 30-day or 1-year mortality. The matched-pairs analysis found that the difference in mortality at 30 days (the mortality rate among Medicare patients minus the mortality rate among VHA patients), averaged over the 5-year age groups, was -0.8 percent (95 percent confidence interval, -2.8 percent to 1.3 percent), and the difference in mortality at 1 year was -1.3 percent (95 percent confidence interval, -3.9 percent to 1.3 percent). CONCLUSIONS: VHA patients had more coexisting conditions than Medicare patients. Nevertheless, we found no significant difference in mortality between VHA and Medicare patients, a result that suggests a similar quality of care for acute myocardial infarction.

Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group.

BACKGROUND: Adverse drug events (ADEs) are common in hospitalized patients, but few empirical data are available regarding the strength of patient risk factors for ADEs. METHODS: We performed a nested case-control study within a cohort that included 4108 admissions to a stratified random sample of 11 medical and surgical units in 2 tertiary care hospitals during a 6-month period. Analyses were conducted on 2 levels: (1) using a limited set of variables available for all patients using computerized data available from 1 hospital and (2) using a larger set of variables for the case patients and matched controls from both hospitals. Case patients were patients with an ADE, and the matched control for each case patient was the patient on the same unit as the case patient with the most similar prevent length of stay. Main outcome measures were presence of an ADE, preventable ADE, or severe ADE. RESULTS: In the cohort analysis, electrolyte concentrates (odds ratio [OR], 1.7), diuretics (OR, 1.7), and medical admission (OR, 1.6) were independent correlates of ADEs. Independent correlates of preventable ADEs in the cohort analysis were low platelet count (OR, 4.5), antidepressants (OR, 3.3), antihypertensive agents (OR, 2.9), medical admission (OR, 2.2), and electrolyte concentrates (OR, 2.1). In the case-control analysis, exposure to psychoactive drugs (OR, 2.1) was an independent correlate of an ADE, and use of cardiovascular drugs (OR, 2.4) was independently correlated with severe ADEs. For preventable ADEs, no independent predictors were retained after multivariate analysis. CONCLUSIONS: Adverse drug events occurred more frequently in sicker patients who stayed in the hospital longer. However, after controlling for level of care and preevent length of stay, few risk factors emerged. These results suggest that, rather than targeting ADE-prone individuals, prevention strategies should focus on improving medication systems.

Positive predictive value of the diagnosis of acute myocardial infarction in an administrative database.

OBJECTIVE: To determine the positive predictive value of ICD-9-CM coding of acute myocardial infarction and cardiac procedures. METHODS: Using chart-abstracted data as the standard, we examined administrative data from the Veterans Health Administration for a national random sample of 5,151 discharges. MAIN RESULTS: The positive predictive value of acute myocardial infarction coding in the primary position was 96.9%. The sensitivity and specificity of coding were, respectively, 96% and 99% for catheterization, 95.7% and 100% for coronary artery bypass graft surgery, and 90.3% and 99. 7% for percutaneous transluminal coronary angioplasty. CONCLUSIONS: The positive predictive value of acute myocardial infarction and related procedure coding is comparable to or better than previously reported observations of administrative databases.

Increasing use of Medicare services by veterans with acute myocardial infarction.

OBJECTIVES: Some of the nation's 26 million veterans have two government-financed health care entitlements: Medicare and the Department of Veterans Affairs (VA). The aims of this investigation were to examine trends where Medicare-eligible VA users are initially hospitalized for acute myocardial infarction (AMI) and then to assess rates of cardiac procedure use and mortality for veterans initially admitted to each system of care. METHODS: We used VA and HCFA national databases to identify VA users (age range, > or = 65 years) who were initially admitted to a VAMC or Medicare financed hospital (Medicare hospital) with a primary diagnosis of AMI between January 1, 1992, and December 31, 1995, (n = 47,598). We examined the use of cardiac procedures (cardiac catheterization [CC], coronary artery bypass surgery [CABG], and coronary angioplasty [CA] and mortality (30-day and 1-year) by the type of initial admitting hospital within each system of care. RESULTS: Almost 70% of VA users hospitalized for AMI were initially admitted to Medicare hospitals versus VAMCs between 1992 (64%) and 1995 (72%). After adjusting for patient characteristics in logistic models, VA users initially hospitalized in Medicare hospitals were significantly more likely to undergo cardiac procedures than were VA users hospitalized in VAMCs. Differences in the odds of receiving a procedure were most significant when comparing Medicare hospitals with on-site cardiac technology to VA hospitals without on-site cardiac technology (CC: OR 4.34, 95% CI 3.98-4.73; CABG: OR 2.16, 95% CI 1.92-2.43; CA: OR 4.56, 95% CI 3.98-5.25). We found no significant differences in 30-day and 1-year adjusted mortality rates between VA users initially admitted to VAMCs or Medicare hospitals. CONCLUSIONS: Medicare-eligible VA users are increasingly hospitalized in Medicare hospitals for AMI. VA users cared for in Medicare hospitals receive more cardiac procedures but have the same survival as VA users cared for in VAMCs. These findings have policy implications for access, quality, and costs in both systems of care.

Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

CONTEXT: Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. OBJECTIVES: To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient. DESIGN: Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physician computer order entry (POE) and the combination of POE plus a team intervention. SETTING: Large tertiary care hospital. PARTICIPANTS: For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period. INTERVENTIONS: A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units. MAIN OUTCOME MEASURE: Nonintercepted serious medication errors. RESULTS: Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additional benefit over POE. CONCLUSIONS: Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.

Nonurgent emergency department visits: the effect of having a regular doctor.

OBJECTIVES: The authors assess the association between having a regular doctor and presentation for nonurgent versus urgent emergency department visits while controlling for potential confounders such as sociodemographics, health status, and comorbidity. METHODS: A cross-sectional study was conducted in emergency departments of five urban teaching hospitals in the northeast. Adult patients presenting with chest pain, abdominal pain, or asthma (n = 1696; 88% of eligible) were studied. Patients completed a survey on presentation, reporting sociodemographics, health status, comorbid diseases, and relationship with a regular doctor. Urgency on presentation was assessed by chart review using explicit criteria. RESULTS: Of the 1,696 study participants, 852 (50%) presented with nonurgent complaints. In logistic regression analyses, absence of a relationship with a regular physician was an independent correlate of presentation for a nonurgent emergency department visit (odds ratio 1.6; 95% confidence interval 1.2, 2.2) when controlling for age, gender, marital status, health status, and comorbid diseases. Race, lack of insurance, and education were not associated with nonurgent use. CONCLUSIONS: Absence of a relationship with a regular doctor was correlated with use of the emergency department for selected nonurgent conditions when controlling for important potential confounders. Our study suggests that maintaining a relationship with a regular physician may reduce nonurgent use of the emergency department regardless of insurance status or health status.

Availability of cardiac technology: trends in procedure use and outcomes for patients with acute myocardial infarction.

This study examines temporal trends in the use and outcomes of cardiac procedures for patients hospitalized with acute myocardial infarction in Department of Veterans Affairs (VA) hospitals with and without invasive cardiac services. Between 1988 and 1994, there was striking overall growth in the use of cardiac procedures in the VA. Over this time period, the authors found persistent variation in the use of cardiac procedures but diminished differences in patient survival among patients admitted to different types of hospitals. Growth of cardiac procedure use and improvements in patient survival were most significant in hospitals without on-site invasive cardiac services. We were unable to determine whether survival gains were associated with increased procedure use or unmeasured improvements in the process of care. These trends raise intriguing questions about access to and outcomes of cardiac procedures in health systems composed of hospitals with and without a full complement of on-site invasive cardiac services.

Fetal surveillance in multifetal pregnancy.

Multiple methods of tocolysis and fetal surveillance provide unprecedented ways to improve multifetal outcomes through meticulous antepartum care. Although few practitioners have much experience with these complicated pregnancies, knowledge is growing with the increasing incidence of multifetal pregnancy. A review of the current literature regarding antepartum surveillance provides the basis for a discussion of the techniques essential to quality nursing care during multifetal pregnancy. Guidelines are provided for nursing standards in documentation, terminology, and care during surveillance of multiple fetuses.

Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events.

BACKGROUND: Many medical injuries are preventable, but there are few reported successful strategies to prevent such injuries. Previous work identified coverage by house staff not primarily responsible for the patient (cross-coverage) as a significant correlate of risk for preventable adverse events. A four-month intervention--computerized sign-outs--was introduced in 1993 in an urban teaching hospital to improve continuity of care during cross-coverage and thereby reduce risk for preventable adverse events. MEASUREMENTS: A previously tested confidential self-report system was used to identify adverse events, which were defined as unexpected complications of medical therapy that resulted in increased length of stay or disability at discharge. A panel of three board-certified internists confirmed events and evaluated preventability based on case summaries. RESULTS: After the intervention, the rate of preventable adverse events among the 3,747 patients admitted to the medical service decreased from 1.7% to 1.2% (p < 0.10). Both univariate and multivariate analysis revealed no association between cross coverage and preventable adverse events after the intervention. In the baseline period, the odds ratio (OR) for a patient suffering a preventable adverse event during cross coverage was 5.2 (95% confidence interval [CI], 1.5-18.2; p = 0.01), but was no longer significant after the intervention (OR, 1.5; 95% CI, 0.2-9.0). CONCLUSION: House staff are willing participants in efforts to measure and improve the quality of health care systems. The intervention may have reduced the risk for medical injury associated with discontinuity of inpatients care. Four years after the end of the study, the computerized sign-out program remained an integral part of the computing support system for house staff and was widely used.

Identification and characterization of an operon in Salmonella typhimurium involved in thiamine biosynthesis.

Thiamine pyrophosphate (TPP) is synthesized de novo in Salmonella typhimurium and is a required cofactor for many enzymes in the cell. Five kinase activities have been implicated in TPP synthesis, which involves joining a 4-methyl-5-(beta-hydroxyethyl)thiazole (THZ) moiety and a 4-amino-5-hydroxymethyl-2-methylpyrimidine (HMP) moiety. We report here identification of a 2-gene operon involved in thiamine biosynthesis and present evidence that the genes in this operon, thiMD, encode two previously identified kinases, THZ kinase and HMP phosphate (HMP-P) kinase, respectively. We further show that this operon belongs to the growing class of genes involved in TPP synthesis that are transcriptionally regulated by TPP. Our data are consistent with ThiM being a salvage enzyme and ThiD being a biosynthetic enzyme involved in TPP synthesis, as previously suggested.

Variegate porphyria in South Africa, 1688-1996--new developments in an old disease.

Variegate porphyria, an autosomal dominant inherited trait resulting in decreased activity of protoporphyrinogen oxidase, the penultimate haem biosynthetic enzyme, is characterised clinically by photosensitive skin disease and a propensity to acute neurovisceral crises. The disease has an exceptionally high frequency in South Africa, owing to a founder effect. The specific mutation in the protoporphyrinogen oxidase gene sequence which represents this founder gene has been identified. Genetic diagnosis is therefore now possible in families in whom the gene defect is known. However, the exact nature and degree of activity of the porphyria can only be determined by detailed quantitative biochemical analysis of excreted porphyrins. The relative contributions of the acute attack and the skin disease to the total disease burden of patients with variegate porphyria is not static, and in South Africa there have been significant changes over the past 25 years, with fewer patients presenting with acute attacks, leaving a greater proportion to present with skin disease or to remain asymptomatic with the diagnosis being made in the laboratory. The most common precipitating cause of the acute attack of VP is administration of porphyrinogenic drugs. Specific suppression of haem synthesis with intravenous haem arginate is the most useful treatment of a moderate or severe acute attack. Although cutaneous lesions are limited to the sun-exposed areas, management of the skin disease of VP remains inadequate.