1
|
McIsaac WJ, Kukan S. Assessing the Validity of Electronic Medical Records for Identifying High Antibiotic Prescribers in Primary Care. J Prim Care Community Health 2023; 14:21501319231210616. [PMID: 37978835 PMCID: PMC10657523 DOI: 10.1177/21501319231210616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES Electronic medical record (EMR) prescription data may identify high antibiotic prescribers in primary care. However, practitioners doubt that population differences between providers and delayed antibiotic prescriptions are adequately accounted for in EMR-derived prescription rates. This study assessed the validity of using EMR prescription data to produce antibiotic prescription rates, accounting for these factors. METHODS The study was a secondary analysis of antimicrobial prescriptions collected from 4 primary care clinics from 2015 to 2017. For adults with selected respiratory and urinary infections, EMR diagnostic codes, prescription data, clinical diagnoses and demographics were abstracted. Overall and delayed prescription rates were produced for EMR diagnostic codes, clinical diagnoses, by clinic, and types of infection. Direct standardization was used to adjust for case mix differences by clinic. High antibiotic prescribers, above the 75th percentile for prescriptions, were compared with low antibiotic prescribers. RESULTS Of 3108 EMR visits, there were 2577 (85.4%) eligible visits with a clinical diagnosis and prescription information. Overall antibiotic prescription rates were similar utilizing EMR records (31.6%) or clinical diagnoses (32.6%, P = .40). When delayed prescriptions were removed, prescribing rates were lower (22.4%, P < .01). EMR data overestimated prescribing rates for conditions where antibiotics are usually not indicated (17.7% EMR vs 7.6% clinical diagnoses, P < .001). High antibiotic prescribers saw more cases where antibiotics are usually indicated (23.4%) compared to low prescribers (16.8%; P = .001). CONCLUSIONS Electronic medical record prescribing rates are similar to those using clinical diagnoses overall, but overestimate prescribing by clinicians for conditions usually not needing antibiotics. EMR prescription rates do not account for delayed antibiotic prescriptions or differences in infection case-mix.
Collapse
Affiliation(s)
- Warren J. McIsaac
- Sinai Health, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | | |
Collapse
|
2
|
Larsen L, Wensaas KA, Emberland KE, Rortveit G. Respiratory tract infections in Norwegian primary care 2006-2015: a registry-based study. Scand J Prim Health Care 2022; 40:173-180. [PMID: 35485789 PMCID: PMC9397465 DOI: 10.1080/02813432.2022.2069711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 02/22/2022] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Examine characteristics and time trends of respiratory tract infection (RTI) consultations in Norwegian primary care and compare consultations in daytime general practice and out-of-hours (OOH) services. DESIGN Registry-based study using reimbursement claims data. SETTING All in-person primary care consultations during 2006-2015. PATIENTS All patients visiting primary care during the study period. MAIN OUTCOME MEASURES The main outcome variable was RTI consultations. Differences regarding service type (general practice or OOH services) and changes over time were investigated. We report associations with patient age and sex, season, point-of-care C-reactive protein (CRP) test use, and sickness certificate issuing. RESULTS RTI consultations (n = 16 304 777) represented 11.6% of all consultations (N = 140 199 637) in primary care over the ten-year period. The annual number of RTI consultations per 1000 inhabitants decreased from 335 to 314, while the number of consultations for any reason increased. Of RTI consultations, 83.2% occurred in general practice. OOH services had a higher proportion of RTI consultations (21.4%) compared with general practice (10.6%). Young children (0-4 years) represented 18.9% of all patients in RTI consultations. CRP testing was used in 56.2% of RTI consultations, and use increased over time. Sickness certificates were issued in 31.9% of RTI consultations with patients of working age (20-67 years). CONCLUSION Most RTI consultations occurred in general practice, although the proportion was higher in OOH services. Laboratory testing and/or issuing of sickness certificates were part of most consultations. This could be an important reason for seeking health care. Key PointsPatients with a respiratory tract infection (RTI) are mostly managed in primary care, where they represent much of the workload.Most consultations for RTIs took place in daytime general practice, but out-of-hours services had a higher proportion of RTI consultations.RTIs were the dominating reason for encounter among young children both in out-of-hours services and daytime general practice.CRP tests were used in over half of RTI consultations, and their use expanded over time.
Collapse
Affiliation(s)
- Leo Larsen
- Department of Global Public Health and Primary Care, Section for General Practice, University of Bergen, Bergen, Norway
| | - Knut-Arne Wensaas
- Department of Health, Research Unit for General Practice, NORCE Norwegian Research Centre AS, Bergen, Norway
| | - Knut Erik Emberland
- Department of Global Public Health and Primary Care, Section for General Practice, University of Bergen, Bergen, Norway
- Department of Health, Research Unit for General Practice, NORCE Norwegian Research Centre AS, Bergen, Norway
| | - Guri Rortveit
- Department of Global Public Health and Primary Care, Section for General Practice, University of Bergen, Bergen, Norway
- Department of Health, Research Unit for General Practice, NORCE Norwegian Research Centre AS, Bergen, Norway
| |
Collapse
|
3
|
Abstract
Ethical issues related to electronic health records (EHRs) confront health personnel. Electronic health records create conflict among several ethical principals. Electronic health records may represent beneficence because they are alleged to increase access to health care, improve the quality of care and health, and decrease costs. Research, however, has not consistently demonstrated access for disadvantaged persons, the accuracy of EHRs, their positive effects on productivity, nor decreased costs. Should beneficence be universally acknowledged, conflicts exist with other ethical principles. Autonomy is jeopardized when patients' health data are shared or linked without the patients' knowledge. Fidelity is breached by the exposure of thousands of patients' health data through mistakes or theft. Lack of confidence in the security of health data may induce patients to conceal sensitive information. As a consequence, their treatment may be compromised. Justice is breached when persons, because of their socioeconomic class or age, do not have equal access to health information resources and public health services. Health personnel, leaders, and policy makers should discuss the ethical implications of EHRs before the occurrence of conflicts among the ethical principles. Recommendations to guide health personnel, leaders, and policy makers are provided.
Collapse
|
4
|
Komagamine J, Kobayashi M, Mori T. Prevalence of and rationale for antimicrobial prescription during ambulatory care visits in Japan: a prospective, multicentre, cross-sectional study. BMJ Open 2020; 10:e039329. [PMID: 32843518 PMCID: PMC7449277 DOI: 10.1136/bmjopen-2020-039329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To determine the rate of outpatient antimicrobial use and the rationale for antimicrobial prescription. DESIGN A prospective, multicentre, cross-sectional study. SETTING Ambulatory care settings at community general hospitals. PARTICIPANTS A total of 1972 consecutive ambulatory visits by 1952 patients were included from 2 February 2020 to 13 February 2020. Visits resulting in hospital admission and regularly scheduled visits were excluded. MAIN OUTCOME MEASURES The primary outcome was the proportion of ambulatory visits resulting in antimicrobial drug prescriptions. The secondary outcomes were the reasons for antimicrobial drug prescription and the proportion of unnecessary antimicrobial prescriptions among all antimicrobial drugs used for treatment. RESULTS The mean patient age was 53.8 (SD 25.8) years old, and the proportion of women was 52.6%. A total of 162 antimicrobial drugs were prescribed in 153 (7.8%) visits. The most common antimicrobial drugs were penicillins (n=48, 29.6%), followed by third-generation cephalosporins (n=35, 21.6%) and quinolones (n=20, 12.4%). Among all the antimicrobial drugs prescribed, 125 (77.2%), 18 (11.1%) and 11 (6.8%) were used for infection treatment, wound prophylaxis and surgical prophylaxis, respectively. Of the 125 antimicrobial drugs used for infection treatment, 60 (48.0%) were judged to be unnecessary. CONCLUSIONS One in every 13 ambulatory visits resulted in antimicrobial use in Japan. Three-fourths of the prescribed antimicrobial drugs were used for infection treatment, but approximately half of those drugs may have been unnecessary. Further efforts to reduce unnecessary antimicrobial drug use are needed. TRIAL REGISTRATION NUMBER UMIN000039360.
Collapse
Affiliation(s)
- Junpei Komagamine
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Tochigi, Japan
| | - Masaki Kobayashi
- Geriatrics and Gerontology, National Hospital Organization Tokyo Medical Center, Meguro-ku, Tokyo, Japan
| | - Takahiro Mori
- Internal Medicine, National Hospital Organization Nagasaki Medical Center, Omura, Nagasaki, Japan
| |
Collapse
|
5
|
Carvalho É, Estrela M, Zapata-Cachafeiro M, Figueiras A, Roque F, Herdeiro MT. E-Health Tools to Improve Antibiotic Use and Resistances: A Systematic Review. Antibiotics (Basel) 2020; 9:antibiotics9080505. [PMID: 32806583 PMCID: PMC7460242 DOI: 10.3390/antibiotics9080505] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/04/2022] Open
Abstract
(1) Background: e-Health tools, especially in the form of clinical decision support systems (CDSSs), have been emerging more quickly than ever before. The main objective of this systematic review is to assess the influence of these tools on antibiotic use for respiratory tract infections. (2) Methods: The scientific databases, MEDLINE-PubMed and EMBASE, were searched. The search was conducted by two independent researchers. The search strategy was mainly designed to identify relevant studies on the effectiveness of CDSSs in improving antibiotic use, as a primary outcome, and on the acceptability and usability of CDSSs, as a secondary outcome. (3) Results: After the selection, 22 articles were included. The outcomes were grouped either into antibiotics prescription practices or adherence to guidelines concerning antibiotics prescription. Overall, 15 out of the 22 studies had statistically significant outcomes related to the interventions. (4) Conclusions: Overall, the results show a positive impact on the prescription and conscientious use of antibiotics for respiratory tract infections, both with respect to patients and prescribing healthcare professionals. CDSSs have been shown to have great potential as powerful tools for improving both clinical care and patient outcomes.
Collapse
Affiliation(s)
- Érico Carvalho
- iBiMED–Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, 3800 Aveiro, Portugal; (É.C.); (M.E.)
| | - Marta Estrela
- iBiMED–Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, 3800 Aveiro, Portugal; (É.C.); (M.E.)
| | - Maruxa Zapata-Cachafeiro
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain; (M.Z.-C.); (A.F.)
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health-CIBERESP), 28001 Madrid, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain; (M.Z.-C.); (A.F.)
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health-CIBERESP), 28001 Madrid, Spain
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Fátima Roque
- Research Unit for Inland Development-Polytechnic of Guarda (UDI-IPG), 6300 Guarda, Portugal;
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200 Covilhã, Portugal
| | - Maria Teresa Herdeiro
- iBiMED–Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, 3800 Aveiro, Portugal; (É.C.); (M.E.)
- Correspondence:
| |
Collapse
|
6
|
Koyama T, Hagiya H, Teratani Y, Tatebe Y, Ohshima A, Adachi M, Funahashi T, Zamami Y, Tanaka HY, Tasaka K, Shinomiya K, Kitamura Y, Sendo T, Hinotsu S, Kano MR. Antibiotic prescriptions for Japanese outpatients with acute respiratory tract infections (2013–2015): A retrospective Observational Study. J Infect Chemother 2020; 26:660-666. [DOI: 10.1016/j.jiac.2020.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 01/16/2020] [Accepted: 02/03/2020] [Indexed: 10/24/2022]
|
7
|
Teratani Y, Hagiya H, Koyama T, Adachi M, Ohshima A, Zamami Y, Tanaka HY, Tatebe Y, Tasaka K, Mikami N, Shinomiya K, Kitamura Y, Kano MR, Hinotsu S, Sendo T. Pattern of antibiotic prescriptions for outpatients with acute respiratory tract infections in Japan, 2013-15: a retrospective observational study. Fam Pract 2019; 36:402-409. [PMID: 30272148 DOI: 10.1093/fampra/cmy094] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In this age of antimicrobial resistance, unnecessary use of antibiotics to treat non-bacterial acute respiratory tract infections (ARTIs) and inappropriate use of antibiotics in treating bacterial ARTIs are public health concerns. PURPOSE Our aim is to identify the pattern of oral antibiotic prescriptions for outpatients with ARTIs in Japan. METHODS We analysed health insurance claims data of patients (aged ≤74 years) from 2013 to 2015, to determine the pattern of antibiotic prescriptions for outpatient ARTIs and calculated the proportion of each antibiotic. RESULTS Data on 4.6 million antibiotic prescriptions among 1559394 outpatients with ARTIs were analysed. The most commonly prescribed classes of antibiotics included cephalosporins (41.9%), macrolides (32.8%) and fluoroquinolones (14.7%). The proportion of first-, second- and third-generation cephalosporins was 1.0%, 1.7% and 97.3%, respectively. Fluoroquinolones accounted for a quarter of the prescriptions for ARTIs in patients aged >20 years. In contrast, penicillins accounted for just 8.0% of the total number of antibiotic prescriptions for ARTIs. CONCLUSIONS According to clinical guidelines, penicillins are first-line antibiotics against ARTIs. However, third-generation cephalosporins, macrolides and fluoroquinolones are more frequently prescribed in Japan. Although we could not assess the extent to which appropriate antibiotics are selected, our results support the necessity of improving antibiotic choices in the treatment of ARTIs.
Collapse
Affiliation(s)
- Yusuke Teratani
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hideharu Hagiya
- Department of Infection Control and Prevention, Osaka University Hospital, Osaka, Japan
| | - Toshihiro Koyama
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,Education and Research Center for Clinical Pharmacy, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Mayu Adachi
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Ayako Ohshima
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yoshito Zamami
- Department of Clinical Pharmacology and Therapeutics, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Hiroyoshi Y Tanaka
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yasuhisa Tatebe
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Ken Tasaka
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Naoko Mikami
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Kazuaki Shinomiya
- Education and Research Center for Clinical Pharmacy, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.,Department of Toji Pharmacy, Smile Co., Ltd, Hiroshima, Japan
| | | | - Mitsunobu R Kano
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,Department of Pharmaceutical Biomedicine, Graduate School of Interdisciplinary Science and Engineering in Health Systems, Okayama University, Okayama, Japan
| | - Shiro Hinotsu
- Department of Biostatistics and Clinical Epidemiology, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Toshiaki Sendo
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| |
Collapse
|
8
|
Teratani Y, Hagiya H, Koyama T, Ohshima A, Zamami Y, Tatebe Y, Tasaka K, Shinomiya K, Kitamura Y, Sendo T, Hinotsu S, Kano MR. Association between rapid antigen detection tests and antibiotics for acute pharyngitis in Japan: A retrospective observational study. J Infect Chemother 2019; 25:267-272. [PMID: 30642770 DOI: 10.1016/j.jiac.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/11/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
The application and clinical impact of rapid antigen detection test (RADT) in the treatment of acute pharyngitis is unknown in Japan. We aimed to examine the proportions of RADT usage to identify Group A β-hemolytic Streptococcus (GAS) in outpatients with acute pharyngitis and evaluate the association between RADT and antibiotic treatment. We analyzed health insurance claims data from 2013 to 2015. Logistic regression models were used to analyze associated factors with RADT, overall antibiotic prescription, or penicillin use. We analyzed 1.27 million outpatient visits with acute pharyngitis, in which antibiotics were prescribed in 59.3% of visits. Of the total visits, 5.6% of patients received RADT, and 10.8% of the antibiotics were penicillin. Penicillin selection rates were higher in cases with RADT (25.4%) than those without RADT (9.7%). Compared to large-scale facilities, antibiotic prescription rates were higher in physicians' offices. For factor analysis, age (3-15 years), diagnosis code (streptococcal pharyngitis), size of the medical facility (large-scale hospitals), and physician's specialty (pediatrics) were associated with RADT use. Penicillin selection rate increased with RADT implementation (25.4% vs. 9.7%: adjusted odds ratio 1.55; 95% CI, 1.50-1.60). At 63% of the facilities, the RADT implementation rate was <5% of acute pharyngitis visits prescribed antibiotics. In conclusion, the proportion of RADT usage for outpatients with acute pharyngitis was low in Japan. With appropriate indication and evaluation, we expect that more utilization of RADT can help promote antimicrobial stewardship for outpatients with acute pharyngitis by prompting penicillin therapy. Further investigation with detailed clinical data are warranted.
Collapse
Affiliation(s)
- Yusuke Teratani
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan
| | - Hideharu Hagiya
- Division of Infection Control and Prevention, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka 5650871, Japan
| | - Toshihiro Koyama
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan; Education and Research Center for Clinical Pharmacy, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan.
| | - Ayako Ohshima
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan
| | - Yoshito Zamami
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Biomedical Sciences, Tokushima University, 3-18-15 Kuramoto, Tokushima, 7708503, Japan
| | - Yasuhisa Tatebe
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 7008558, Japan
| | - Ken Tasaka
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 7008558, Japan
| | - Kazuaki Shinomiya
- Education and Research Center for Clinical Pharmacy, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan; Department of Toji Pharmacy, SSmile Co., Ltd., 6-1-11 Syoko-center, Nishi-ku, Hiroshima, 7330833, Japan
| | - Yoshihisa Kitamura
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 7008558, Japan
| | - Toshiaki Sendo
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 7008558, Japan
| | - Shiro Hinotsu
- Department of Biostatistics and Clinical Epidemiology, Sapporo Medical University, South 1, West 17, Chuo-Ku, Sapporo, Hokkaido 0608556, Japan
| | - Mitsunobu R Kano
- Department of Pharmaceutical Biomedicine, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushima-naka, Kita-ku, Okayama 7008530, Japan; Department of Pharmaceutical Biomedicine, Graduate School of Interdisciplinary Science and Engineering in Health Systems, Okayama University, 1-1-1 Tsushima-Naka, Kita-ku, Okayama, 7008530, Japan
| |
Collapse
|
9
|
Hardenbol AX, Knols B, Louws M, Meulendijk M, Askari M. Usability aspects of medication-related decision support systems in the outpatient setting: A systematic literature review. Health Informatics J 2018; 26:72-87. [DOI: 10.1177/1460458218813732] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this study, we evaluated the usability aspects of medication-related clinical decision support systems in the outpatient setting. Articles published between 2000 and 2016 in Scopus, PubMed and EMBASE were searched and classified into three usability aspects: Effectiveness, Efficiency and Satisfaction. Using Van Welie et al.’s usability model, we categorized usability aspects in terms of usage indicators and means. Out of the 1999 articles, 24 articles met the selection criteria of which the main focus was on reducing inappropriate medication, prescription rate and prescription errors. Evidence could mainly be found for Effectiveness and showed high rates of positive results in reducing medication errors. To date, the effects of Efficiency and Satisfaction of clinical decision support systems regarding medication prescription remain understudied. Usability aspects such as memorability, learnability, adaptability, shortcuts and consistency require more attention. Studies are needed for better insight into the user model and to design a knowledge/task model for clinical decision support systems regarding medication prescription.
Collapse
|
10
|
Fathima S, Simmonds KA, Drews SJ, Svenson LW, Kwong JC, Mahmud SM, Quach S, Johnson C, Schwartz KL, Crowcroft NS, Russell ML. How well do ICD-9 physician claim diagnostic codes identify confirmed pertussis cases in Alberta, Canada? A Canadian Immunization Research Network (CIRN) Study. BMC Health Serv Res 2017; 17:479. [PMID: 28701222 PMCID: PMC5508611 DOI: 10.1186/s12913-017-2321-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/19/2017] [Indexed: 12/16/2022] Open
Abstract
Background Rates of Bordetella pertussis have been increasing in Alberta, Canada despite vaccination programs. Waning immunity from existing acellular component vaccines may be contributing to this. Vaccine effectiveness can be estimated using a variety of data sources including diagnostic codes from physician billing claims, public health records, reportable disease and laboratory databases. We sought to determine if diagnostic codes from billing claims (administrative data) are adequately sensitive and specific to identify pertussis cases among patients who had undergone disease-specific laboratory testing. Methods Data were extracted for 2004–2014 from a public health communicable disease database that contained data on patients under investigation for B. pertussis (both those who had laboratory tests and those who were epidemiologically linked to laboratory-confirmed cases) in Alberta, Canada. These were deterministically linked using a unique lifetime person identifier to the provincial billing claims database, which contains International Classification of Disease version 9 (ICD-9) diagnostic codes for physician visits. We examined visits within 90 days of laboratory testing. ICD-9 codes 033 (whooping cough), 033.0 (Bordetella pertussis), 033.1 (B. parapertussis), 033.8 (whooping cough, other specified organism), and 033.9 (whooping cough, other unspecified organism) in any of the three diagnostic fields for a claim were classified as being pertussis-specific codes. We calculated sensitivity, specificity, positive (PPV) and negative (NPV) predictive values. Results We identified 22,883 unique patients under investigation for B. pertussis. Of these, 22,095 underwent laboratory testing. Among those who had a laboratory test, 2360 tested positive for pertussis. The sensitivity of a pertussis-specific ICD-9 code for identifying a laboratory-confirmed case was 38.6%, specificity was 76.9%, PPV was 16.0%, and NPV was 91.6%. Conclusion ICD-9 codes from physician billing claims data have low sensitivity and moderate specificity to identify laboratory-confirmed pertussis among persons tested for pertussis. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2321-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sumana Fathima
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kimberley A Simmonds
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Ministry of Health, Edmonton, Alberta, Canada
| | - Steven J Drews
- Provincial Laboratory (ProvLab) for Public Health, Edmonton, Alberta, Canada.,University of Alberta, Edmonton, Alberta, Canada
| | - Lawrence W Svenson
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Ministry of Health, Edmonton, Alberta, Canada.,University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey C Kwong
- University of Toronto, Toronto, Canada.,Public Health Ontario, Toronto, Canada.,The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Salaheddin M Mahmud
- Vaccine and Drug Evaluation Centre, University of Manitoba, Winnipeg, MB, Canada
| | | | | | - Kevin L Schwartz
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Natasha S Crowcroft
- University of Toronto, Toronto, Canada.,Public Health Ontario, Toronto, Canada
| | - Margaret L Russell
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Department of Community Health Sciences, University of Calgary, 3rd Floor TRW, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | | |
Collapse
|
11
|
Rawson TM, Moore LSP, Hernandez B, Charani E, Castro-Sanchez E, Herrero P, Hayhoe B, Hope W, Georgiou P, Holmes AH. A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately? Clin Microbiol Infect 2017; 23:524-532. [PMID: 28268133 DOI: 10.1016/j.cmi.2017.02.028] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/23/2017] [Accepted: 02/25/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. METHOD PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation. RESULTS Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38;76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor. CONCLUSION Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence.
Collapse
Affiliation(s)
- T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK.
| | - L S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - B Hernandez
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - E Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - E Castro-Sanchez
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - P Herrero
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - B Hayhoe
- School of Public Health, Imperial College, London, UK
| | - W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| |
Collapse
|
12
|
Abstract
BACKGROUND Acute respiratory infections (ARIs) are the most common symptomatic reason to seek ambulatory care, but many ARI visits may not be necessary. OBJECTIVE To measure the proportion of primary care ARI visits that may not require an office visit. METHODS We identified 58398 ARI visits to 14 primary care practices between May 2011 and May 2012 and randomly selected 500 visits, 439 of which were new ARI visits. We separated non-visit-required information [e.g. history of present illness (HPI), past medical history, etc.] from information that required an office visit (e.g. physical exam, testing, etc.). Reviewing non-visit-required information, we identified the diagnosis (HPI diagnosis) and whether office visit appeared necessary. Independently, we reviewed the visit-required information and determined if the visit changed antibiotic management. RESULTS Based on non-visit-required information, 72% (316/439) of visits did not appear to require an office visit. The most common diagnoses were non-specific upper respiratory infection (39%), sinusitis (24%) and acute bronchitis (22%). The HPI diagnosis was an exact match for clinicians' diagnosis in 67% (213/316) of visits. After reviewing the visit-required information, antibiotic management did not change for 87% (276/316) of visits. For the remaining 13% (40/316) for which the visit changed management, the clinician prescribed an antibiotic for an antibiotic-appropriate diagnosis (65%; 26/40); prescribed an antibiotic for a non-antibiotic-appropriate diagnosis (25%; 10/40); or avoided an antibiotic prescription for patients with an HPI diagnosis of sinusitis (10%; 4/40). CONCLUSION About two-thirds of primary care ARI visits may not be necessary for appropriate antibiotic management.
Collapse
Affiliation(s)
- Sruthi Renati
- Transitional Year Program, Beaumont Hospital, Dearborn, MI
| | - Jeffrey A Linder
- Harvard Medical School and Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
| |
Collapse
|
13
|
Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, Knight TK, Hay JW, Doctor JN. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA 2016; 315:562-70. [PMID: 26864410 PMCID: PMC6689234 DOI: 10.1001/jama.2016.0275] [Citation(s) in RCA: 563] [Impact Index Per Article: 70.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Interventions based on behavioral science might reduce inappropriate antibiotic prescribing. OBJECTIVE To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded. INTERVENTIONS Three behavioral interventions, implemented alone or in combination: suggested alternatives presented electronic order sets suggesting nonantibiotic treatments; accountable justification prompted clinicians to enter free-text justifications for prescribing antibiotics into patients' electronic health records; peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of "top performers" (those with the lowest inappropriate prescribing rates). MAIN OUTCOMES AND MEASURES Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention's effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians. RESULTS There were 14,753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16,959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, -11.0%) for control practices; from 22.1% to 6.1% (absolute difference, -16.0%) for suggested alternatives (difference in differences, -5.0% [95% CI, -7.8% to 0.1%]; P = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, -18.1%) for accountable justification (difference in differences, -7.0% [95% CI, -9.1% to -2.9%]; P < .001); and from 19.9% to 3.7% (absolute difference, -16.3%) for peer comparison (difference in differences, -5.2% [95% CI, -6.9% to -1.6%]; P < .001). There were no statistically significant interactions (neither synergy nor interference) between interventions. CONCLUSIONS AND RELEVANCE Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01454947.
Collapse
Affiliation(s)
- Daniella Meeker
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles2RAND Corporation, Santa Monica, California
| | - Jeffrey A Linder
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts4Harvard Medical School, Boston, Massachusetts
| | - Craig R Fox
- Anderson School of Management, University of California, Los Angeles6Department of Psychology, David Geffen School of Medicine at UCLA, Los Angeles
| | - Mark W Friedberg
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts4Harvard Medical School, Boston, Massachusetts7RAND Corporation, Boston, Massachusetts
| | | | - Noah J Goldstein
- Anderson School of Management, University of California, Los Angeles6Department of Psychology, David Geffen School of Medicine at UCLA, Los Angeles
| | - Tara K Knight
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Joel W Hay
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Jason N Doctor
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| |
Collapse
|
14
|
Abstract
The goal of the present study was to determine whether pre-hospital 25-hydroxyvitamin D (25(OH)D) levels are associated with the risk of hospital-acquired new-onset delirium (HANOD). We performed a retrospective cohort study of 4508 adult inpatients at two teaching hospitals in Boston from 1993 to 2006. All patients had 25(OH)D levels measured before hospital admission. The main outcome measure was HANOD, defined as the onset of delirium during an acute care hospitalisation. Patients with a history of delirium or dementia, or those with a diagnosis of delirium or dementia upon acute care hospitalisation were excluded from the analysis. To test the association of pre-hospital 25(OH)D levels with HANOD, we constructed a multivariable logistic regression model to adjust for clinically relevant covariates. Among our patient cohort, the mean 25(OH)D level was 22 (sd 13) ng/ml and approximately 4% of patients met the criteria for HANOD. Following adjustment for age, sex, race (non-white v. white), patient type (medical v. surgical) and Deyo-Charlson Index, patients with 25(OH)D levels < 10, 10-19·9 and 20-29·9 ng/ml had higher odds of HANOD than patients with 25(OH)D levels ≥ 30 ng/ml: OR 2·15 (95% CI 1·32, 3·50), OR 1·54 (95% CI 0·98, 2·43) and OR 1·23 (95% CI, 0·76, 1·99), respectively. These data support the rationale for randomised, controlled trials to test the role of vitamin D supplementation in the prevention of HANOD.
Collapse
|
15
|
Hsu J, Pacheco JA, Stevens WW, Smith ME, Avila PC. Accuracy of phenotyping chronic rhinosinusitis in the electronic health record. Am J Rhinol Allergy 2015; 28:140-4. [PMID: 24717952 DOI: 10.2500/ajra.2014.28.4012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is prevalent, morbid, and poorly understood. Extraction of electronic health record (EHR) data of patients with CRS may facilitate research on CRS. However, the accuracy of using structured billing codes for EHR-driven phenotyping of CRS is unknown. We sought to accurately identify CRS cases and controls using EHR data and to determine the accuracy of structured billing codes for identifying patients with CRS. METHODS We developed and validated distinct algorithms to identify patients with CRS and controls using International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology codes. We used blinded clinician chart review as the reference standard to evaluate algorithm and billing code accuracy. RESULTS Our initial control algorithm achieved a control positive predictive value (PPV) of 100% (i.e., negative predictive value of 100% for CRS). Our initial algorithm for CRS cases relied exclusively on billing codes and had a low case PPV (54%). Notably, ICD-9 code 471.x was associated with a case PPV of 85%, whereas the case PPV of ICD-9 code 473.x was only 34%. After multiple algorithm iterations, we increased the case PPV of our final algorithm to 91% by adding several requirements, e.g., that ICD-9 codes occur with 1 or more evaluations by a CRS specialist to enhance availability of objective clinical data for accurately phenotyping CRS. CONCLUSION These algorithms are an important first step to identify patients with CRS, and may facilitate EHR-based research on CRS pathogenesis, morbidity, and management. Exclusive use of coded data for phenotyping CRS has limited accuracy, especially because CRS symptomatology overlaps with that of other illnesses. Incorporating natural language processing (e.g., to evaluate results of nasal endoscopy or sinus computed tomography) into future work may increase algorithm accuracy and identify patients whose disease status may not be ascertained by only using billing codes.
Collapse
Affiliation(s)
- Joy Hsu
- Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | | | | |
Collapse
|
16
|
Fu AZ, Iglay K, Qiu Y, Engel S, Shankar R, Brodovicz K. Risk characterization for urinary tract infections in subjects with newly diagnosed type 2 diabetes. J Diabetes Complications 2014; 28:805-10. [PMID: 25161100 DOI: 10.1016/j.jdiacomp.2014.06.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 05/21/2014] [Accepted: 06/10/2014] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the risk of urinary tract infections (UTI) in subjects with newly diagnosed type 2 diabetes mellitus (T2DM). METHODS Subjects aged ≥18years and diagnosed with T2DM between 1/1/10 and 12/31/10 were identified using the MarketScan® databases, which are representative of the commercially insured US population and those with both Medicare and supplemental coverage. The index date was the first T2DM diagnosis date in 2010 (date randomly selected for those without T2DM). Subjects without T2DM were matched (1:1) by index date, age, gender, urban/rural location, and region. All subjects had continuous enrollment for 12 months before (baseline) and after (follow-up) the index date. UTI diagnosis was defined using ICD-9-CM codes. Measurements of glycemic control and body weight were not available. An adjusted logistic regression model assessed the likelihood of UTI. RESULTS A total of 89,790 matched pairs were selected. During follow-up, a UTI diagnosis was more common in subjects with T2DM than without T2DM (9.4% vs. 5.7%; p<0.0001). Recurrence of UTI was also more likely with T2DM (1.6% vs. 0.6%; p<0.0001). In a logistic regression, subjects with T2DM had a greater likelihood of UTI during follow up (adjusted odds ratio [OR]=1.54 [95% CI: 1.47-1.60]). This relationship remained after stratifying by gender. CONCLUSION Subjects with T2DM were more likely to experience a UTI and recurrent UTIs than subjects without T2DM during follow-up.
Collapse
Affiliation(s)
- Alex Z Fu
- Georgetown University Medical Center, Washington, DC
| | | | - Ying Qiu
- Merck & Co., Inc., Whitehouse Station, NJ
| | | | | | | |
Collapse
|
17
|
Corsonello A, Abbatecola AM, Fusco S, Luciani F, Marino A, Catalano S, Maggio MG, Lattanzio F. The impact of drug interactions and polypharmacy on antimicrobial therapy in the elderly. Clin Microbiol Infect 2014; 21:20-6. [PMID: 25636922 DOI: 10.1016/j.cmi.2014.09.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/29/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
Infectious diseases are more prevalent in older people than in younger adults, and represent a major healthcare issue in older populations. Indeed, infections in the elderly are often associated with higher morbidity and mortality, and may present atypically. Additionally, older patients are generally treated with polypharmacy regimens, which increase the likelihood of drug-drug interactions when the prescription of an antimicrobial agent is needed. A progressive impairment in the functional reserve of multiple organs may affect either pharmacokinetics or pharmacodynamics during aging. Changes in body composition occurring with advancing age, reduced liver mass and perfusion, and reduced renal excretion may affect either pharmacokinetics or pharmacodynamics. These issues need to be taken into account when prescribing antimicrobial agents to older complex patients taking multiple drugs. Interventions aimed at improving the appropriateness and safety of antimicrobial prescriptions have been proposed. Educational interventions targeting physicians may improve antimicrobial prescriptions. Antimicrobial stewardship programmes have been found to reduce the length of hospital stay and improve safety in hospitalized patients, and their use in long-term care facilities is worth testing. Computerized prescription and decision support systems, as well as interventions aimed at improving antimicrobial agents dosage in relation to kidney function, may also help to reduce the burden of interactions and inherent costs.
Collapse
Affiliation(s)
- A Corsonello
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), Cosenza, Italy.
| | - A M Abbatecola
- Scientific Direction, Italian National Research Centre on Aging (INRCA), Ancona, Italy
| | - S Fusco
- Department of Internal Medicine, University of Messina, Messina, Italy
| | - F Luciani
- Infectious Diseases Unit, "Annunziata" Hospital, Cosenza, Italy
| | - A Marino
- Department of Pharmacy, Health and Nutritional Sciences, Italy
| | - S Catalano
- Department of Pharmacy, Health and Nutritional Sciences, Italy
| | - M G Maggio
- Department of Clinical and Experimental Medicine, Section of Geriatrics, University of Parma, Parma, Italy
| | - F Lattanzio
- Scientific Direction, Italian National Research Centre on Aging (INRCA), Ancona, Italy
| |
Collapse
|
18
|
The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness*. Crit Care Med 2014; 42:918-29. [PMID: 24448196 DOI: 10.1097/ccm.0000000000000118] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Red cell distribution width is associated with mortality and bloodstream infection risk in the critically ill. In hospitalized patients with critical illness, it is not known if red cell distribution width can predict subsequent risk of all-cause mortality following hospital discharge. We hypothesized that an increase in red cell distribution width at hospital discharge in patients who survived to discharge following critical care would be associated with increased postdischarge mortality. DESIGN Two-center observational cohort study SETTING : All medical and surgical ICUs at the Brigham and Women's Hospital and Massachusetts General Hospital. PATIENTS We studied 43,212 patients, who were 18 years old or older and received critical care between 1997 and 2007 and survived hospitalization. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The exposure of interest was red cell distribution width within 24 hours of hospital discharge and categorized a priori in quintiles as less than or equal to 13.3%, 13.3-14.0%, 14.0-14.7%, 14.7-15.8%, and more than 15.8%. The primary outcome was all-cause mortality in the 30 days following hospital discharge. Secondary outcomes included 90-day and 365-day mortality following hospital discharge. Mortality was determined using the U.S. Social Security Administration Death Master File, and 365-day follow-up was present in all cohort patients. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both red cell distribution width and mortality. Adjustment included age, race, gender, Deyo-Charlson Index, patient type (medical vs surgical), sepsis, and number of organs with acute failure. In patients who received critical care and survived hospitalization, the discharge red cell distribution width was a robust predictor of all-cause mortality and remained so following multivariable adjustment. Patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 2.86 (95% CI, 2.25-3.62), 4.57 (95% CI, 3.66-5.72), and 8.80 (95% CI, 7.15-10.83), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Following multivariable adjustment, patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 1.63 (95% CI, 1.27-2.07), 2.36 (95% CI, 1.87-2.97), and 4.18 (95% CI, 3.36-5.20), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Similar significant robust associations post multivariable adjustments are seen with death by days 90 and 365 postdischarge. Estimating the receiver-operating characteristic area under the curve shows that discharge red cell distribution width has moderate discriminative power for mortality 30 days following hospital discharge (area under the curve = 0.70; SE 0.006; 95% CI, 0.69-0.71; p < 0.0001). CONCLUSION In patients treated with critical care who survive hospitalization, an elevated red cell distribution width at the time of discharge is a robust predictor of subsequent all-cause patient mortality. Increased discharge red cell distribution width likely reflects the presence of proinflammatory state, oxidative stress, arterial underfilling, or a combination, thereof which may explain the observed impact on patient survival following discharge. Elevated red cell distribution width at hospital discharge may identify ICU survivors who are at risk for adverse outcomes following hospital discharge.
Collapse
|
19
|
Abstract
OBJECTIVE We hypothesized that deficiency in 25-hydroxyvitamin D prior to hospital admission would be associated with sepsis in the critically ill. DESIGN Two-center observational study of patients treated in medical and surgical ICUs. SETTING Two hundred nine medical and surgical intensive care beds in two teaching hospitals in Boston, MA. PATIENTS Three thousand three hundred eighty-six patients, 18 years old or older, in whom 25-hydroxyvitamin D was measured prior to hospitalization between 1998 and 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS : Preadmission 25-hydroxyvitamin D was categorized as deficiency in 25-hydroxyvitamin D (≤ 15 ng/mL), insufficiency (15-30 ng/mL), and sufficiency (≥ 30 ng/mL). The primary outcome was sepsis as defined by International Classification of Diseases, 9th Edition, Clinical Modification and validated by the 2001 Society of Critical Care Medicine/European Society of Intensive Care Medicine, American College of Chest Physicians, American Thoracic Society, and Surgical Infection Society international sepsis definitions conference guidelines. Logistic regression examined the presence of sepsis 3 days prior to critical care initiation to 7 days after critical care initiation. Adjusted odds ratios were estimated by multivariable logistic regression models. Preadmission 25-hydroxyvitamin D deficiency is predictive for the risk of sepsis. In the full cohort, 25-hydroxyvitamin D deficiency is a significant predictor for the risk of International Classification of Diseases, 9th Edition, Clinical Modification-defined sepsis following multivariable adjustment, including age, gender, race, type (surgical vs medical), and Deyo-Charlson index (adjusted odds ratio, 1.51 [95% CI, 1.17-1.94]; p = 0.001) relative to patients with 25-hydroxyvitamin D sufficiency. In a subset of cohort patients enriched for those with International Classification of Diseases, 9th Edition, Clinical Modification-diagnosed sepsis (n = 444), preadmission 25-hydroxyvitamin D deficiency is a significant predictor for the risk of conference guideline-defined sepsis following multivariable adjustment, including age, gender, race, type (surgical vs medical), and Acute Physiology and Chronic Health Evaluation II (adjusted odds ratio, 2.05 [95% CI, 1.19-3.52]; p = 0.009) relative to patients with 25-hydroxyvitamin D sufficiency. Furthermore, in cohort patients with International Classification of Diseases, 9th Edition, Clinical Modification-defined sepsis (n = 568), the multivariable adjusted risk of 90-day mortality was 1.6-fold higher in those with preadmission 25-hydroxyvitamin D values in the insufficient and deficient range, compared with those with preadmission vitamin D sufficiency (adjusted odds ratio, 1.63 [95% CI, 1.11-2.39]; p = 0.01). CONCLUSION 25-hydroxyvitamin D deficiency prior to hospital admission is a significant predictor of sepsis in the critically ill. Additionally, patients with sepsis who are not vitamin D sufficient have an increased risk of mortality following critical care initiation.
Collapse
|
20
|
Quraishi SA, Litonjua AA, Moromizato T, Gibbons FK, Camargo CA, Giovannucci E, Christopher KB. Association between prehospital vitamin D status and hospital-acquired Clostridium difficile infections. JPEN J Parenter Enteral Nutr 2014; 39:47-55. [PMID: 24492311 DOI: 10.1177/0148607113511991] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To investigate whether preadmission 25-hydroxyvitamin D (25(OH)D) levels are associated with the risk of hospital-acquired Clostridium difficile infection (HACDI). MATERIALS AND METHODS Our retrospective cohort study focused on 568 adult patients from 2 Boston teaching hospitals between August 1993 and November 2006. All patients had 25(OH)D levels measured before hospitalization and were at risk for HACDI (defined as the presence of C difficile toxin A or B in stool samples obtained >48 hours after hospitalization). We performed multivariable regression analyses to test the association of prehospital 25(OH)D levels with HACDI while adjusting for clinically relevant covariates. RESULTS In these 568 patients, mean (SD) 25(OH)D level was 19 (12) ng/mL, and 11% of patients met criteria for incident HACDI. Following adjustment for age, sex, race (nonwhite vs white), patient type (medical vs surgical), and Deyo-Charlson index, patients with 25(OH)D levels <10 ng/mL had higher odds of HACDI (odds ratio [OR], 2.90; 95% confidence interval [CI], 1.01-8.34) compared with patients with 25(OH)D levels ≥30 ng/mL. When patients with HACDI were analyzed relative to a larger patient cohort without HACDI (n = 5047), those with 25(OH)D levels <10 ng/mL (OR, 4.96; 95% CI, 1.84-13.38) and 10-19.9 ng/mL (OR, 3.36; 95% CI, 1.28-8.85) had higher adjusted odds of HACDI compared with patients with 25(OH)D levels ≥30 ng/mL. CONCLUSIONS In our cohort of adult patients, vitamin D status before hospital admission was inversely associated with the risk of developing HACDI. These data support the need for randomized, controlled trials to test the role of vitamin D supplementation to prevent HACDI.
Collapse
Affiliation(s)
- Sadeq A Quraishi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston
| | - Augusto A Litonjua
- Channing Division of Network Medicine and Pulmonary and Critical Care Division Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Takuhiro Moromizato
- The Nathan E. Hellman Memorial Laboratory, Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Fiona K Gibbons
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Edward Giovannucci
- Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Kenneth B Christopher
- The Nathan E. Hellman Memorial Laboratory, Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
21
|
Webber E, Warhurst H, Smith S, Cox E, Crumby A, Nichols K. Conversion of a single-facility pediatric antimicrobial stewardship program to multi-facility application with computerized provider order entry and clinical decision support. Appl Clin Inform 2013; 4:556-68. [PMID: 24454582 PMCID: PMC3885915 DOI: 10.4338/aci-2013-07-ra-0054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 10/23/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Antimicrobial stewardship programs (ASPs) help meet quality and safety goals with regard to antimicrobial use. Prior to CPOE implementation, the ASP at our pediatric tertiary hospital developed a paper-based order set containing recommendations for optimization of dosing. In adapting our ASP for CPOE, we aimed to preserve consistency in our ASP recommendations and expand ASP expertise to other hospitals in our health system. METHODS Nine hospitals in our health system adopted pediatric CPOE and share a common domain (Cerner Millenium). ASP clinicians developed sixty individual electronic order sets (vendor reference PowerPlans) to be used independently or as part of larger electronic order sets. Analysis of incidents reported during CPOE implementation and medication variances reports was used to determine the effectiveness of the ASP adaptation. RESULTS 769 unique PowerPlans were used 15,889 times in the first 30 days after CPOE implementation. Of these, 43 were PowerPlans included in the ASP design and were used a total of 1149 times (7.2% of all orders). During CPOE implementation, 437 incidents were documented, 1.1% of which were associated with ASP content or workflow. Additionally, analysis of medication variance following CPOE implementation showed that ASP errors accounted for 2.9% of total medication variances. DISCUSSION ASP content and workflow accounted for proportionally fewer incidents than expected as compared to equally complex and frequently used CPOE content. CONCLUSION Well-defined ASP recommendations and modular design strengthened successful CPOE implementation, as well as the adoption of specialized pediatric ASP expertise with other facilities.
Collapse
Affiliation(s)
- E.C. Webber
- Indiana University School of Medicine, Pediatrics, Indianapolis, Indiana, United States
| | - H.M. Warhurst
- Riley Hospital for Children at IU Health, Clinical Pharmacy, Indianapolis, Indiana, United States
| | - S.S. Smith
- Indiana University Health, Pharmacy Clinical Informatics, Indianapolis, Indiana, United States
| | - E.G. Cox
- Indiana University School of Medicine, Pediatrics, Indianapolis, Indiana, United States
| | - A.S. Crumby
- Riley Hospital for Children at IU Health, Clinical Pharmacy, Indianapolis, Indiana, United States
| | - K.R. Nichols
- Riley Hospital for Children at IU Health, Clinical Pharmacy, Indianapolis, Indiana, United States
| |
Collapse
|
22
|
Quraishi SA, Litonjua AA, Moromizato T, Gibbons FK, Camargo CA, Giovannucci E, Christopher KB. Association between prehospital vitamin D status and hospital-acquired bloodstream infections. Am J Clin Nutr 2013; 98:952-9. [PMID: 23945717 PMCID: PMC3778865 DOI: 10.3945/ajcn.113.058909] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Alterations in immune function can predispose patients to nosocomial infections. Few studies have explored potentially modifiable host factors that may improve immune function and decrease risk of hospital-acquired bloodstream infection (HABSI). Vitamin D is a key regulator of innate and adaptive immune systems that may influence host susceptibility to infections. OBJECTIVE We investigated the association between prehospital serum 25-hydroxyvitamin D [25(OH)D] concentrations and risk of HABSI. DESIGN We performed a retrospective cohort study of 2135 adult patients from 2 Boston teaching hospitals. All patients had 25(OH)D concentrations measured before hospitalization between 1993 and 2010. The main outcome measure was HABSI, which was defined as positive blood cultures from samples drawn 48 h after hospital admission. Coagulase-negative Staphylococcus isolates were not considered to be bloodstream infections. Associations between 25(OH)D groups and HABSI were estimated by using bivariable and multivariable logistic regression models. Adjusted ORs were estimated with the inclusion of covariate terms thought to plausibly interact with both 25(OH)D concentration and HABSI. RESULTS Compared with patients with 25(OH)D concentrations ≥30 ng/mL, patients with concentrations <30 ng/mL had higher odds of HABSI. For 25(OH)D concentrations <10 ng/mL, the OR was 2.33 (95% CI: 1.45, 3.74); for 25(OH)D concentrations from 10 to 19.9 ng/mL, the OR was 1.60 (95% CI: 1.04, 2.46); and for 25(OH)D concentrations from 20 to 29.9 ng/mL, the OR was 1.13 (95% CI: 0.69, 1.84). After adjustment for age, sex, race (nonwhite compared with white), patient type (medical compared with surgical), and Deyo-Charlson index, the ORs of HABSI were 1.95 (95% CI: 1.22, 3.12), 1.36 (95% CI: 0.89, 2.07), and 0.98 (95% CI: 0.60, 1.62), respectively. CONCLUSIONS The analysis of 2135 adult patients showed that 25(OH)D concentrations <10 ng/mL before hospitalization were associated with significantly increased odds of developing HABSI. These data support the initiation of randomized trials to test the role of vitamin D supplementation in HABSI prevention.
Collapse
Affiliation(s)
- Sadeq A Quraishi
- Departments of Anesthesia, Critical Care and Pain Medicine and The Nathan E Hellman Memorial Laboratory, Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | | | | |
Collapse
|
23
|
Association of low serum 25-hydroxyvitamin D levels and acute kidney injury in the critically ill. Crit Care Med 2013; 40:3170-9. [PMID: 22975885 DOI: 10.1097/ccm.0b013e318260c928] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Given the importance of inflammation in acute kidney injury and the relationship between vitamin D and inflammation, we sought to elucidate the effect of vitamin D on acute kidney injury. We hypothesized that deficiency in 25-hydroxyvitamin D prior to hospital admission would be associated with acute kidney injury in the critically ill. DESIGN Two-center observational study of patients treated in medical and surgical intensive care units. SETTING Two hundred nine medical and surgical intensive care beds in two teaching hospitals in Boston, Massachusetts. PATIENTS Two thousand seventy-five patients, aged ≥ 18 yrs, in whom serum 25-hydroxyvitamin D was measured prior to hospitalization between 1998 and 2009. INTERVENTIONS : None. MEASUREMENTS AND MAIN RESULTS The exposure of interest was preadmission serum 25-hydroxyvitamin D and categorized a priori as deficiency (25-hydroxyvitamin D <15 ng/mL), insufficiency (25-hydroxyvitamin D 15-30 ng/mL), or sufficiency (25-hydroxyvitamin D ≥ 30 ng/mL). The primary outcome was acute kidney injury defined as meeting Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) Injury or Failure criteria. Logistic regression examined the RIFLE criteria outcome. Adjusted odds ratios were estimated by multivariate logistic regression models. Preadmission 25-hydroxyvitamin D deficiency is predictive of acute kidney injury. Patients with 25-hydroxyvitamin D deficiency have an odds ratio for acute kidney injury of 1.73 (95% confidence interval 1.30-2.30; p < .0001) relative to patients with 25-hydroxyvitamin D sufficiency. 25-Hydroxyvitamin D deficiency remains a significant predictor of acute kidney injury following multivariable adjustment (adjusted odds ratio 1.50; 95% confidence interval 1.42-2.24; p < .0001). Patients with 25-hydroxyvitamin D insufficiency have an odds ratio for acute kidney injury of 1.49 (95% confidence interval 1.15-1.94; p = .003) and an adjusted odds ratio of 1.23 (95% confidence interval 1.12-1.72; p = .003) relative to patients with 25-hydroxyvitamin D sufficiency. In addition, preadmission 25-hydroxyvitamin D deficiency is predictive of mortality. Patients with 25-hydroxyvitamin D insufficiency have an odds ratio for 30-day mortality of 1.60 (95% confidence interval 1.18-2.17; p = .003) and an adjusted odds ratio of 1.61 (95% confidence interval 1.06-1.57; p = .004) relative to patients with 25-hydroxyvitamin D sufficiency. CONCLUSION Deficiency of 25-hydroxyvitamin D prior to hospital admission is a significant predictor of acute kidney injury and mortality in a critically ill patient population.
Collapse
|
24
|
McMahon GM, Mendu ML, Gibbons FK, Christopher KB. Association between hyperkalemia at critical care initiation and mortality. Intensive Care Med 2012; 38:1834-42. [PMID: 22806439 DOI: 10.1007/s00134-012-2636-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 06/02/2012] [Indexed: 12/15/2022]
Abstract
PURPOSE To investigate the association between potassium concentration at the initiation of critical care and all-cause mortality. METHODS We performed a retrospective observational study on 39,705 patients, age ≥18 years, who received critical care between 1997 and 2007 in two tertiary care hospitals in Boston, Massachusetts. The exposure of interest was the highest potassium concentration on the day of critical care initiation and categorized a priori as 4.0-4.5, 4.5-5.0, 5.0-5.5, 5.5-6.0, 6.0-6.5, or ≥6.5 mEq/l. Logistic regression examined death by days 30, 90, and 365 post-critical care initiation, and in-hospital mortality. Adjusted odds ratios were estimated by multivariable logistic regression models. RESULTS The potassium concentration was a strong predictor of all-cause mortality 30 days following critical care initiation with a significant risk gradient across potassium groups following multivariable adjustment: K = 4.5-5.0 mEq/l OR 1.25 (95 % CI, 1.16-1.35; P < 0.0001); K = 5.0-5.5 mEq/l OR 1.42 (95 % CI, 1.29-1.56; P < 0.0001); K = 5.5-6.0 mEq/l OR 1.67 (95 % CI, 1.47-1.89; P < 0.0001); K = 6.0-6.5 mEq/l OR 1.63 (95 % CI, 1.36-1.95; P < 0.0001); K > 6.5 mEq/l OR 1.72 (95 % CI, 1.49-1.99; P < 0.0001); all relative to patients with K = 4.0-4.5 mEq/l. Similar significant associations post multivariable adjustments are seen with in-hospital mortality and death by days 90 and 365 post-critical care initiation. In patients whose hyperkalemia decreases ≥1 mEq/l in 48 h post-critical care initiation, the association between high potassium levels and mortality is no longer significant. CONCLUSIONS Our study demonstrates that a patient's potassium level at critical care initiation is robustly associated with the risk of death even at moderate increases above normal.
Collapse
|
25
|
Kim HY, Park HA. Development and evaluation of data entry templates based on the entity-attribute-value model for clinical decision support of pressure ulcer wound management. Int J Med Inform 2012; 81:485-92. [DOI: 10.1016/j.ijmedinf.2011.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 10/17/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
|
26
|
Relationship between neighborhood poverty rate and bloodstream infections in the critically ill*. Crit Care Med 2012; 40:1427-36. [DOI: 10.1097/ccm.0b013e318241e51e] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
27
|
Hasley SK. Decision support and patient safety: the time has come. Am J Obstet Gynecol 2011; 204:461-5. [PMID: 21144494 DOI: 10.1016/j.ajog.2010.10.901] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 09/15/2010] [Accepted: 10/12/2010] [Indexed: 11/16/2022]
Abstract
Decision support (DS) may help to improve patient safety by helping clinicians improve the evaluation, assessment, and treatment of patients. By providing best practice guidelines at critical decision points, errors can be prevented. Location of these decision points varies in different care environments, therefore DS must be customizable. Being able to customize the design, functionality, and clinical context of how a DS rule behaves may help each unique clinical environment improve performance. The ability to review aggregate data on the behavior of both the DS system and the providers will be necessary to further adapt the DS rule to the setting. A robust tool set and ongoing institutional engagement are critical elements for a successful DS implementation.
Collapse
Affiliation(s)
- Steve K Hasley
- Department of Obstetrics, Gynecology, and Reproductive Services, Magee Womens Hospital of University of Pittsburgh Medical Center, PA, USA
| |
Collapse
|
28
|
Linder JA, Schnipper JL, Tsurikova R, Volk LA, Middleton B. Self-reported familiarity with acute respiratory infection guidelines and antibiotic prescribing in primary care. Int J Qual Health Care 2010; 22:469-75. [PMID: 20935008 PMCID: PMC3003551 DOI: 10.1093/intqhc/mzq052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2010] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Familiarity with guidelines is generally thought to be associated with guideline implementation, adherence and improved quality of care. We sought to determine if self-reported familiarity with acute respiratory infection (ARI) antibiotic treatment guidelines was associated with reduced or more appropriate antibiotic prescribing for ARIs in primary care. DESIGN SETTING PARTICIPANTS and MAIN OUTCOME MEASURES We surveyed primary care clinicians about their familiarity with ARI antibiotic treatment guidelines and linked responses to administrative diagnostic and prescribing data for non-pneumonia ARI visits. RESULTS Sixty-five percent of clinicians responded to the survey question about guideline familiarity. There were 208 survey respondents who had ARI patient visits during the study period. Respondents reported being 'not at all' (7%), 'somewhat' (30%), 'moderately' (45%) or 'extremely' (18%) familiar with the guidelines. After dichotomizing responses, compared with clinicians who reported being less familiar with the guidelines, clinicians who reported being more familiar with the guidelines had higher rates of antibiotic prescribing for all ARIs combined (46% versus 38%; n = 11 164; P < 0.0001), for antibiotic-appropriate diagnoses (69% versus 59%; n = 3213; P < 0.0001) and for non-antibiotic appropriate diagnoses (38% versus 28%; n = 7951; P < 0.0001). After adjusting for potential confounders, self-reported guideline familiarity was an independent predictor of increased antibiotic prescribing (odds ratio, 1.36; 95% confidence interval, 1.25-1.48). CONCLUSIONS Self-reported familiarity with an ARI antibiotic treatment guideline was, seemingly paradoxically, associated with increased antibiotic prescribing. Self-reported familiarity with guidelines should not be assumed to be associated with consistent guideline adherence or higher quality of care.
Collapse
Affiliation(s)
- Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA 02120, USA.
| | | | | | | | | |
Collapse
|
29
|
Linder JA, Nieva HR, Blumentals WA. Antiviral and antibiotic prescribing for influenza in primary care. J Gen Intern Med 2009; 24:504-10. [PMID: 19225847 PMCID: PMC2659164 DOI: 10.1007/s11606-009-0933-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 12/02/2008] [Accepted: 01/27/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Anti-influenza antiviral medications reduce influenza-related morbidity, but may often be used inappropriately. OBJECTIVE To measure the rate of antiviral and antibiotic prescribing, the appropriateness of antiviral prescribing, and evaluate independent predictors of antiviral and antibiotic prescribing for influenza in primary care. DESIGN AND PATIENTS Retrospective analysis of 958 visits of clinician-diagnosed influenza in 21 primary care clinics in eastern Massachusetts from 1999 to 2007. We considered antiviral prescribing appropriate if patients had symptoms for 2 or fewer days, had fever, and any 2 of headache, sore throat, cough, or myalgias. MEASUREMENTS AND MAIN RESULTS Clinicians prescribed antivirals in 557 (58%) visits and antibiotics in 104 visits (11%). Of antiviral prescriptions, 38% were not appropriate, most commonly because of symptoms for more than 2 days (24% of antiviral prescriptions). In multivariate modeling, selected independent predictors of antiviral prescribing were symptom duration of 2 or fewer days (odds ratio [OR], 12.4; 95% confidence interval [CI], 8.3 to 18.6), year (OR, 1.4 for each successive influenza season; 95% CI, 1.3 to 1.7), patient age (OR, 1.3 per decade; 95% CI, 1.2 to 1.5), and, compared to having no influenza testing, having a negative influenza test (OR, 5.5; 95% CI, 3.4 to 9.1) or a positive influenza test (OR, 11.4; 95% CI, 6.7 to 19.3). Independent predictors of antibiotic prescribing included otoscopic abnormalities (OR, 3.3; 95% CI, 1.8 to 6.0), abnormal lung examination (OR, 4.0; 95% CI, 2.1 to 6.2), and having a chest x-ray performed (OR, 2.2; 95% CI, 1.3 to 3.8). CONCLUSIONS Primary care clinicians are much more likely to prescribe antivirals to patients with symptoms for 2 or fewer days, but also commonly prescribe antivirals inappropriately.
Collapse
Affiliation(s)
- Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, BC-3-2X, Boston, MA 02120, USA.
| | | | | |
Collapse
|
30
|
Using Electronic Health Records to Measure Physician Performance for Acute Conditions in Primary Care. Med Care 2009; 47:208-16. [DOI: 10.1097/mlr.0b013e318189375f] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
31
|
Cadieux G, Tamblyn R. Accuracy of physician billing claims for identifying acute respiratory infections in primary care. Health Serv Res 2008; 43:2223-38. [PMID: 18665858 PMCID: PMC2614002 DOI: 10.1111/j.1475-6773.2008.00873.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To assess the accuracy of physician billing claims for identifying acute respiratory infections in primary care. STUDY SETTING. Nine primary care physician practices in Montreal, Canada (2002-2005). STUDY DESIGN A validation study was carried out to compare diagnoses in 3,526 physician billing claims with diagnoses documented in the corresponding patient medical records. DATA COLLECTION In-office medical record abstraction. PRINCIPAL FINDINGS Claims had a high positive predictive value (PPV), negative predictive value, and specificity for identifying respiratory infections; however, their sensitivity was below 50 percent. Large variation in sensitivity and PPV was observed among physicians. CONCLUSIONS Because claims data are now routinely used to monitor antibiotic prescribing in primary care, future research should determine if acute respiratory infection diagnoses are missing from claims at random, or if bias is present.
Collapse
Affiliation(s)
- Geneviève Cadieux
- Clinical and Health Informatics Research Group, McGill University, 1140 Pine Avenue West, Montreal, QC H3A1A3, Canada.
| | | |
Collapse
|
32
|
Golob JF, Fadlalla AM, Kan JA, Patel NP, Yowler CJ, Claridge JA. Validation of Surgical Intensive Care–Infection Registry: A Medical Informatics System for Intensive Care Unit Research, Quality of Care Improvement, and Daily Patient Care. J Am Coll Surg 2008; 207:164-73. [DOI: 10.1016/j.jamcollsurg.2008.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 04/08/2008] [Indexed: 10/21/2022]
|
33
|
Matheny ME, Sequist TD, Seger AC, Fiskio JM, Sperling M, Bugbee D, Bates DW, Gandhi TK. A randomized trial of electronic clinical reminders to improve medication laboratory monitoring. J Am Med Inform Assoc 2008; 15:424-9. [PMID: 18436905 PMCID: PMC2442256 DOI: 10.1197/jamia.m2602] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 03/11/2008] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Recommendations for routine laboratory monitoring to reduce the risk of adverse medication events are not consistently followed. We evaluated the impact of electronic reminders delivered to primary care physicians on rates of appropriate routine medication laboratory monitoring. DESIGN We enrolled 303 primary care physicians caring for 1,922 patients across 20 ambulatory clinics that had at least one overdue routine laboratory test for a given medication between January and June 2004. Clinics were randomized so that physicians received either usual care or electronic reminders at the time of office visits focused on potassium, creatinine, liver function, thyroid function, and therapeutic drug levels. MEASUREMENTS Primary outcomes were the receipt of recommended laboratory monitoring within 14 days following an outpatient clinic visit. The effect of the intervention was assessed for each reminder after adjusting for clustering within clinics, as well as patient and provider characteristics. RESULTS Medication-laboratory monitoring non-compliance ranged from 1.6% (potassium monitoring with potassium-supplement use) to 6.3% (liver function monitoring with HMG CoA Reductase Inhibitor use). Rates of appropriate laboratory monitoring following an outpatient visit ranged from 14% (therapeutic drug levels) to 64% (potassium monitoring with potassium-sparing diuretic use). Reminders for appropriate laboratory monitoring had no impact on rates of receiving appropriate testing for creatinine, potassium, liver function, renal function, or therapeutic drug level monitoring. CONCLUSION We identified high rates of appropriate laboratory monitoring, and electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.
Collapse
Affiliation(s)
- Michael E. Matheny
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Decision Systems Group, Department of Radiology, Brigham & Women's Hospital, Boston, MA
| | - Thomas D. Sequist
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Andrew C. Seger
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Massachusetts College of Pharmacy and Health Sciences, Cambridge, MA
| | - Julie M. Fiskio
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Partners HealthCare System, Boston, MA
| | | | | | - David W. Bates
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Tejal K. Gandhi
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
34
|
Abstract
Ethical issues related to electronic health records (EHRs) confront health personnel. Electronic health records create conflict among several ethical principals. Electronic health records may represent beneficence because they are alleged to increase access to health care, improve the quality of care and health, and decrease costs. Research, however, has not consistently demonstrated access for disadvantaged persons, the accuracy of EHRs, their positive effects on productivity, nor decreased costs. Should beneficence be universally acknowledged, conflicts exist with other ethical principles. Autonomy is jeopardized when patients' health data are shared or linked without the patients' knowledge. Fidelity is breached by the exposure of thousands of patients' health data through mistakes or theft. Lack of confidence in the security of health data may induce patients to conceal sensitive information. As a consequence, their treatment may be compromised. Justice is breached when persons, because of their socioeconomic class or age, do not have equal access to health information resources and public health services. Health personnel, leaders, and policy makers should discuss the ethical implications of EHRs before the occurrence of conflicts among the ethical principles. Recommendations to guide health personnel, leaders, and policy makers are provided.
Collapse
|
35
|
Schnipper JL, Linder JA, Palchuk MB, Einbinder JS, Li Q, Postilnik A, Middleton B. "Smart Forms" in an Electronic Medical Record: documentation-based clinical decision support to improve disease management. J Am Med Inform Assoc 2008; 15:513-23. [PMID: 18436911 DOI: 10.1197/jamia.m2501] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Clinical decision support systems (CDSS) integrated within Electronic Medical Records (EMR) hold the promise of improving healthcare quality. To date the effectiveness of CDSS has been less than expected, especially concerning the ambulatory management of chronic diseases. This is due, in part, to the fact that clinicians do not use CDSS fully. Barriers to clinicians' use of CDSS have included lack of integration into workflow, software usability issues, and relevance of the content to the patient at hand. At Partners HealthCare, we are developing "Smart Forms" to facilitate documentation-based clinical decision support. Rather than being interruptive in nature, the Smart Form enables writing a multi-problem visit note while capturing coded information and providing sophisticated decision support in the form of tailored recommendations for care. The current version of the Smart Form is designed around two chronic diseases: coronary artery disease and diabetes mellitus. The Smart Form has potential to improve the care of patients with both acute and chronic conditions.
Collapse
Affiliation(s)
- Jeffrey L Schnipper
- Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120-1613, USA.
| | | | | | | | | | | | | |
Collapse
|
36
|
Linder J, Schnipper JL, Volk LA, Tsurikova R, Palchuk M, Olsha-Yehiav M, Melnikas AJ, Middleton B. Clinical decision support to improve antibiotic prescribing for acute respiratory infections: results of a pilot study. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2007; 2007:468-472. [PMID: 18693880 PMCID: PMC2655801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 07/20/2007] [Accepted: 10/11/2007] [Indexed: 05/26/2023]
Abstract
Acute Respiratory Infections (ARIs) are the number one reason for antibiotic prescribing in the United States, and much antibiotic prescribing for ARIs is inappropriate. We designed an electronic health record-integrated, documentation-based clinical decision support system for the care of patients with ARIs, the ARI Smart Form. To evaluate the ARI Smart Form and assess the feasibility of performing a larger trial, we conducted a pilot study with 10 clinicians who used the ARI Smart Form with 26 patients. Clinicians prescribed antibiotics to 6 of 6 patients with antibiotic-appropriate diagnoses and to 3 of 20 (15%) patients with antibiotic-inappropriate diagnoses. The average duration of use of the ARI Smart Form was 7.5 (SD+/-4.5) minutes. Eight of 10 respondents reported that the ARI Smart Form was either time-neutral or timesaving. The ARI Smart Form requires further evaluation but has the potential to improve workflow and reduce inappropriate antibiotic prescribing.
Collapse
|