Patients' Perspectives on Plans Generated During Primary Care Visits and Self-Reported Adherence at 3 Months: Data From a Randomized Trial

BACKGROUND

Effective primary care necessitates follow-up actions by the patient beyond the visit. Prior research suggests room for improvement in patient adherence.

OBJECTIVE

This study sought to understand patients' views on their primary care visits, the plans generated therein, and their self-reported adherence after 3 months.

METHODS

As part of a large multisite cluster randomized pragmatic trial in 3 health care organizations, patients completed 2 surveys-the first within 7 days after the index primary care visit and another 3 months later. For this analysis of secondary outcomes, we combined the results across all study participants to understand patient adherence to care plans. We recorded patient characteristics and survey responses. Cross-tabulation and chi-square statistics were used to examine bivariate associations, adjusting for multiple comparisons when appropriate. We used multivariable logistic regression to assess how patients' intention to follow, agreement, and understanding of their plans impacted their plan adherence, allowing for differences in individual characteristics. Qualitative content analysis was conducted to characterize the patient's self-reported plans and reasons for adhering (or not) to the plan 3 months later.

RESULTS

Of 2555 patients, most selected the top box option (9=definitely agree) that they felt they had a clear plan (n=2011, 78%), agreed with the plan (n=2049, 80%), and intended to follow the plan (n=2108, 83%) discussed with their provider at the primary care visit. The most common elements of the plans reported included reference to exercise (n=359, 14.1%), testing (laboratory, imaging, etc; n=328, 12.8%), diet (n=296, 11.6%), and initiation or adjustment of medications; (n=284, 11.1%). Patients who strongly agreed that they had a clear plan, agreed with the plan, and intended to follow the plan were all more likely to report plan completion 3 months later (P<.001) than those providing less positive ratings. Patients who reported plans related to following up with the primary care provider (P=.008) to initiate or adjust medications (P≤.001) and to have a specialist visit were more likely to report that they had completely followed the plan (P=.003). Adjusting for demographic variables, patients who indicated intent to follow their plan were more likely to follow-through 3 months later (P<.001). Patients' reasons for completely following the plan were mainly that the plan was clear (n=1114, 69.5%), consistent with what mattered (n=1060, 66.1%), and they were determined to carry through with the plan (n=887, 53.3%). The most common reasons for not following the plan were lack of time (n=217, 22.8%), having decided to try a different approach (n=105, 11%), and the COVID-19 pandemic impacted the plan (n=105, 11%).

CONCLUSIONS

Patients' initial assessment of their plan as clear, their agreement with the plan, and their initial willingness to follow the plan were all strongly related to their self-reported completion of the plan 3 months later. Patients whose plans involved lifestyle changes were less likely to report that they had "completely" followed their plan.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/study/NCT03385512.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/30431.

Targeting patients for early COVID-19 therapy; Pre-infection metabolic dysfunction, polycystic ovary syndrome and risk of severe disease in patients under 65: A Massachusetts community-based observational study

INTRODUCTION

The demographics of those developing severe coronavirus disease (COVID-19) outcomes are shifting to younger patients. In an observational study utilizing electronic health records from a Massachusetts group medical practice, we identified 5025 patients with confirmed COVID-19 from March 1 to December 18, 2020. Of these, 3870 were under 65 years of age. We investigated the hypothesis that pre-infection metabolic or immunologic dysregulation including polycystic ovary syndrome (PCOS) increased risk of serious COVID-19 outcomes in patients under 65 years of age.

MATERIALS AND METHODS

We compared those with COVID-19 related hospitalization or mortality to all other COVID-19 patients, using a case control approach. Using logistic regression and propensity score modeling, we evaluated risk of developing severe COVID-19 outcomes (hospitalization or death) in those with pre-infection comorbidities, metabolic risk factors, or PCOS.

RESULTS

Overall, propensity score matched analyses demonstrated pre-infection elevated liver enzymes alanine aminotransferase (ALT) >40, aspartate aminotransferase (AST) >40 and blood glucose ≥215 mg/dL were associated with more severe COVID-19 outcomes, OR = 1.74 (95% CI 1.31, 2.31); OR = 1.98 (95% CI 1.52, 2.57), and OR = 1.55 (95% CI 1.08, 2.23) respectively. Elevated hemoglobin A1C or blood glucose levels were even stronger risk factors for severe COVID-19 outcomes among those aged < 65, OR = 2.31 (95% CI 1.14, 4.66) and OR = 2.42 (95% CI 1.29, 4.56), respectively. In logistic regression models, women aged < 65 with PCOS demonstrated more than a four-fold increased risk of severe COVID-19, OR 4.64 (95% CI 1.98, 10.88).

CONCLUSION

Increased risk of severe COVID-19 outcomes in those < age 65 with pre-infection indicators of metabolic dysfunction heightens the importance of monitoring pre-infection indicators in younger patients for prevention and early treatment. The PCOS finding deserves further investigation. Meanwhile women who suffer from PCOS should be carefully evaluated and prioritized for earlier COVID-19 treatment and vaccination.

Effect of Technology-Assisted Brief Abstinence Game on Long-term Smoking Cessation in Individuals Not Yet Ready to Quit: A Randomized Clinical Trial

IMPORTANCE

Most trials of behavioral or pharmaceutical interventions for people who smoke are limited to individuals reporting they are ready to quit smoking. Engaging individuals who initially report they are not yet ready to quit in brief, precessation, skills-building interventions (eg, practice quit attempts or nicotine replacement therapy [NRT] sampling) is challenging.

OBJECTIVE

To test an integrated behavioral plus NRT-sampling intervention using a gamification approach supported by mobile health.

DESIGN, SETTING, AND PARTICIPANTS

A multisite randomized clinical trial with site-level 1-to-1 allocation into 2 conditions was conducted in 4 US health care systems. A total of 433 individuals who were currently smoking and reported at enrollment that they were not ready to quit smoking were enrolled. The study was conducted from November 7, 2016, to July 31, 2020.

INTERVENTIONS

Take a Break (TAB) was a 3-week game experience and included 5 behavioral components (motivational messaging, challenge quizzes, brief abstinence goal setting, mobile health apps for cravings management, and reward points for participation) integrated with NRT sampling. TAB draws on social cognitive theory and game mechanics concepts to engage participants in health behavior change. The comparison included NRT sampling only.

MAIN OUTCOMES AND MEASURES

Time to first quit attempt (duration from TAB experience to primary outcome) and carbon monoxide level-verified smoking cessation at 6-month follow-up. All analyses used an intention-to-treat approach.

RESULTS

Of the 433 individuals included in the trial, 223 were women (52%); mean (SD) age was 54 (13) years. More than half (53% [112 of 213]) of the TAB participants completed 100% of the daily challenge quizzes in the first week, 73% (145 of 199) of participants who completed the goal-setting call set a brief abstinence goal (most frequently 1-2 days of abstinence from cigarettes), and 75% (159 of 213) of participants used the mobile health apps to manage nicotine cravings. Time to the first quit attempt was lower for the TAB vs comparison group (hazard ratio, 1.68; 95% CI, 1.09-2.60; P = .02). At the 6-month follow-up, 18% (28 of 160) of TAB participants and 10% (17 of 171) of the comparison (χ2 test, P = .045) participants obtained carbon monoxide level-verified smoking cessation (accounting for clustering of outcomes by site; odds ratio, 1.92; 95% CI, 1.01-3.68; P = .048).

CONCLUSIONS AND RELEVANCE

The findings of this randomized clinical trial demonstrate that individuals not yet ready to quit smoking could be engaged in a brief abstinence game. Six months later, the TAB group had nearly double the rate of smoking cessation vs the NRT sampling comparison group. Integrating a skills-building game experience with brief NRT sampling can enhance long-term cessation among those not yet ready to quit smoking.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02973425.

Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results

Background

Patient–physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient–physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters.

Objective

In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient–physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters.

Methods

We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit “patient important issue” questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient–staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes.

Results

The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient–clinician communication, particularly during the COVID-19 pandemic.

Conclusions

EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians’ work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians.

Trial Registration

ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512

International Registered Report Identifier (IRRID)

DERR1-10.2196/30431

Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications: A Randomized Clinical Trial

IMPORTANCE

The National Action Plan for Adverse Drug Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids.

OBJECTIVE

To determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older who were discharged from the hospital and prescribed at least 1 high-risk medication. Participants were enrolled into the trial from June 2016 through September 2018.

INTERVENTIONS

The pharmacist-directed intervention included an in-home assessment by a clinical pharmacist, evidence-based educational resources, communication with the primary care team, and telephone follow-up. Participants in the control group were provided educational materials via mail.

MAIN OUTCOMES AND MEASURES

The study assessed 2 outcomes over a 45-day posthospital discharge period: (1) adverse drug-related incidents and (2) a subset defined as clinically important medication errors, which included preventable or ameliorable ADEs and potential ADEs (ie, medication-related errors that may not yet have caused injury to a patient, but have the potential to cause future harm if not addressed). Clinically important medication errors were the primary study outcome.

RESULTS

There were 361 participants (mean [SD] age, 68.7 [9.3] years; 177 women [49.0%]; 319 White [88.4%] and 8 Black individuals [2.2%]). Of these, 180 (49.9%) were randomly assigned to the intervention group and 181 (50.1%) to the control group. Among all participants, 100 (27.7%) experienced 1 or more adverse drug-related incidents, and 65 (18%) experienced 1 or more clinically important medication errors. There were 81 adverse drug-related incidents identified in the intervention group and 72 in the control group. There were 44 clinically important medication errors in the intervention group and 45 in the control group. The intervention did not significantly alter the per-patient rate of adverse drug-related incidents (unadjusted incidence rate ratio, 1.13; 95% CI, 0.83-1.56) or clinically important medication errors (unadjusted incidence rate ratio, 0.99; 95% CI, 0.65-1.49).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention. However, there were study recruitment challenges and lower than expected numbers of events among the study population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02781662.

Hypertension, medications, and risk of severe COVID-19: A Massachusetts community-based observational study

It remains uncertain whether the hypertension (HT) medications angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) mitigate or exacerbate SARS-CoV-2 infection. We evaluated the association of ACEi and ARB with severe coronavirus disease 19 (COVID-19) as defined by hospitalization or mortality among individuals diagnosed with COVID-19. We investigated whether these associations were modified by age, the simultaneous use of the diuretic thiazide, and the health conditions associated with medication use. In an observational study utilizing data from a Massachusetts group medical practice, we identified 1449 patients with a COVID-19 diagnosis. In our study, pre-infection comorbidities including HT, cardiovascular disease, and diabetes were associated with increased risk of severe COVID-19. Risk was further elevated in patients under age 65 with these comorbidities or cancer. Twenty percent of those with severe COVID-19 compared to 9% with less severe COVID-19 used ACEi, 8% and 4%, respectively, used ARB. In propensity score-matched analyses, use of neither ACEi (OR = 1.30, 95% CI 0.93 to 1.81) nor ARB (OR = 0.94, 95% CI 0.57 to 1.55) was associated with increased risk of severe COVID-19. Thiazide use did not modify this relationship. Beta blockers, calcium channel blockers, and anticoagulant medications were not associated with COVID-19 severity. In conclusion, cardiovascular-related comorbidities were associated with severe COVID-19 outcomes, especially among patients under age 65. We found no substantial increased risk of severe COVID-19 among patients taking antihypertensive medications. Our findings support recommendations against discontinuing use of renin-angiotensin system (RAS) inhibitors to prevent severe COVID-19.

Hyperoxia is associated with adverse outcomes in the cardiac intensive care unit: insights from the Medical Information Mart for Intensive Care (MIMI-III) database

Background

Hyperoxia produces reactive oxygen species, apoptosis, and vasoconstriction, and is associated with adverse outcomes in patients with heart failure and cardiac arrest. Our aim was to evaluate the association between hyperoxia and mortality in patients (pts) receiving positive pressure ventilation (PPV) in the cardiac intensive care unit (CICU).

Methods

Patients admitted to our medical center CICU who received any PPV (invasive or non-invasive) from 2001 through 2012 were included. Hyperoxia was defined as time-weighted mean of PaO2 &gt;120mmHg and non-hyperoxia as PaO2 ≤120mmHg during CICU admission. Primary outcome was in-hospital mortality. Multivariable logistic regression was used to assess the association between hyperoxia and in-hospital mortality adjusted for age, female sex, Oxford Acute Severity of Illness Score, creatinine, lactate, pH, PaO2/FiO2 ratio, PCO2, PEEP, and estimated time spent on PEEP.

Results

Among 1493 patients, hyperoxia (median PaO2 147mmHg) during the CICU admission was observed in 702 (47.0%) pts. In-hospital mortality was 29.7% in the non-hyperoxia group and 33.9% in the hyperoxia group ((log rank test, p=0.0282, see figure). Using multivariable logistic regression, hyperoxia was independently associated with in-hospital mortality (OR 1.507, 95% CI 1.311–2.001, p=0.00508). Post-hoc analysis with PaO2 as a continuous variable was consistent with the primary analysis (OR 1.053 per 10mmHg increase in PaO2, 95% CI 1.024–1.082, p=0.0002).

Conclusions

In a large CICU cohort, hyperoxia was associated with increased mortality. Trials of titration of supplemental oxygen across the full spectrum of critically ill cardiac patients are warranted.

Funding Acknowledgement

Type of funding source: None

Electronic Health Record Portal Messages and Interactive Voice Response Calls to Improve Rates of Early Season Influenza Vaccination: Randomized Controlled Trial

Background

Patient reminders for influenza vaccination, delivered via an electronic health record patient portal and interactive voice response calls, offer an innovative approach to engaging patients and improving patient care.

Objective

The goal of this study was to test the effectiveness of portal and interactive voice response outreach in improving rates of influenza vaccination by targeting patients in early September, shortly after vaccinations became available.

Methods

Using electronic health record portal messages and interactive voice response calls promoting influenza vaccination, outreach was conducted in September 2015. Participants included adult patients within a large multispecialty group practice in central Massachusetts. Our main outcome was electronic health record–documented early influenza vaccination during the 2015-2016 influenza season, measured in November 2015. We randomly assigned all active portal users to 1 of 2 groups: (1) receiving a portal message promoting influenza vaccinations, listing upcoming clinics, and offering online scheduling of vaccination appointments (n=19,506) or (2) receiving usual care (n=19,505). We randomly assigned all portal nonusers to 1 of 2 groups: (1) receiving interactive voice response call (n=15,000) or (2) receiving usual care (n=43,596). The intervention also solicited patient self-reports on influenza vaccinations completed outside the clinic. Self-reported influenza vaccination data were uploaded into the electronic health records to increase the accuracy of existing provider-directed electronic health record clinical decision support (vaccination alerts) but were excluded from main analyses.

Results

Among portal users, 28.4% (5549/19,506) of those randomized to receive messages and 27.1% (5294/19,505) of the usual care group had influenza vaccinations documented by November 2015 (P=.004). In multivariate analysis of portal users, message recipients were slightly more likely to have documented vaccinations when compared to the usual care group (OR 1.07, 95% CI 1.02-1.12). Among portal nonusers, 8.4% (1262/15,000) of those randomized to receive calls and 8.2% (3586/43,596) of usual care had documented vaccinations (P=.47), and multivariate analysis showed nonsignificant differences. Over half of portal messages sent were opened (10,112/19,479; 51.9%), and over half of interactive voice response calls placed (7599/14,984; 50.7%) reached their intended target, thus we attained similar levels of exposure to the messaging for both interventions. Among portal message recipients, 25.4% of message openers (2570/10,112) responded to a subsequent question on receipt of influenza vaccination; among interactive voice response recipients, 72.5% of those reached (5513/7599) responded to a similar question.

Conclusions

Portal message outreach to a general primary care population achieved a small but statistically significant improvement in rates of influenza vaccination (OR 1.07, 95% CI 1.02-1.12). Interactive voice response calls did not significantly improve vaccination rates among portal nonusers (OR 1.03, 95% CI 0.96-1.10). Rates of patient engagement with both modalities were favorable.

Trial Registration

ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277

The 'Take a Break' game: Randomized trial protocol for a technology-assisted brief abstinence experience designed to engage lower-motivated smokers

BACKGROUND

While smoking continues to be the most preventable cause of mortality in the United States, most current smokers remain not ready to quit at any given time. Engaging these 'motivation phase' smokers with brief experiences to build confidence and practice skills related to cessation could lead to sooner and more successful quit attempts. Increasingly available mobile technology and gamification can be used to provide smokers with accessible and engaging support.

METHODS

We describe our protocol for conducting a randomized controlled trial evaluating Take a Break, an mHealth-based smoking pre-cessation challenge designed for smokers not ready to quit. Participants in the intervention receive 1) Motivational Messages, 2) text message Challenge Quizzes, 3) Goal-setting with tobacco treatment specialist, 4) Coping Mini-Games apps, and 5) Recognition and Rewards for participation during a 3-week challenge. Access to coping mini-games and motivational messaging continues for 6-months. Both intervention and comparison group participants receive brief Nicotine Replacement Therapy (NRT) sampling and daily smoking assessment text messages for three weeks. Primary outcomes include number of days abstinent during the challenge, change in patient-reported self-efficacy after the challenge, time to first quit attempt following the challenge, and 7-day point prevalent smoking cessation at six months.

CONCLUSION

Take a Break is an innovative approach to engage those not prepared for a quit attempt. Take a Break provides motivation phase smokers with tools and a brief experience to prepare them for a quit attempt, filling a gap in tobacco cessation support and current research.

A TRIAL TO IMPROVE MEDICATION SAFETY IN OLDER ADULTS: RECRUITMENT CHALLENGES HAVE GENERALIZABILITY IMPLICATIONS

For older adults, the transition from hospital to home is a high-risk period for adverse drug events, functional decline, and hospital readmission. Randomized trials of interventions to improve this transition must recruit potential subjects immediately after hospital discharge, when people are recovering and tired. Within a randomized trial assessing the impact of a pharmacist home visit to provide medication assistance immediately post-discharge, we determined whether individuals who enrolled were comparable to those who were invited but did not enroll, and described reasons for not enrolling. Individuals ≥50 years of age discharged from the hospital and prescribed a high-risk medication were eligible. We attempted to recruit individuals by phone within 3 days of discharge, and recorded reasons for not enrolling. Of 3,606 eligible individuals reached, 3,147 (87%) declined, 361 (10%) were enrolled, and 98 (3%) were initially recruited but did not complete a consent form. Individuals ≥80 years of age (odds ratio 0.45, CI 0.25, 0.78) and those with an assigned visiting nurse (odds ratio 0.64, CI 0.48, 0.85) were least likely to enroll. Among those who provided a reason for declining (2,473) the most common reason given was the belief they did not need medication assistance (22%). An additional 332 (13%) declined because they were receiving visiting nurse services. Recruiting older adults recently discharged from the hospital is difficult and may under-enroll the oldest individuals, limiting the ability to generalize findings across older patient populations. Researchers planning RCTs among newly discharged older adults may need creative approaches to overcome resistance.

Use of Electronic Health Record Access and Audit Logs to Identify Physician Actions Following Noninterruptive Alert Opening: Descriptive Study

Background

Electronic health record (EHR) access and audit logs record behaviors of providers as they navigate the EHR. These data can be used to better understand provider responses to EHR–based clinical decision support (CDS), shedding light on whether and why CDS is effective.

Objective

This study aimed to determine the feasibility of using EHR access and audit logs to track primary care physicians’ (PCPs’) opening of and response to noninterruptive alerts delivered to EHR InBaskets.

Methods

We conducted a descriptive study to assess the use of EHR log data to track provider behavior. We analyzed data recorded following opening of 799 noninterruptive alerts sent to 75 PCPs’ InBaskets through a prior randomized controlled trial. Three types of alerts highlighted new medication concerns for older patients’ posthospital discharge: information only (n=593), medication recommendations (n=37), and test recommendations (n=169). We sought log data to identify the person opening the alert and the timing and type of PCPs’ follow-up EHR actions (immediate vs by the end of the following day). We performed multivariate analyses examining associations between alert type, patient characteristics, provider characteristics, and contextual factors and likelihood of immediate or subsequent PCP action (general, medication-specific, or laboratory-specific actions). We describe challenges and strategies for log data use.

Results

We successfully identified the required data in EHR access and audit logs. More than three-quarters of alerts (78.5%, 627/799) were opened by the PCP to whom they were directed, allowing us to assess immediate PCP action; of these, 208 alerts were followed by immediate action. Expanding on our analyses to include alerts opened by staff or covering physicians, we found that an additional 330 of the 799 alerts demonstrated PCP action by the end of the following day. The remaining 261 alerts showed no PCP action. Compared to information-only alerts, the odds ratio (OR) of immediate action was 4.03 (95% CI 1.67-9.72) for medication-recommendation and 2.14 (95% CI 1.38-3.32) for test-recommendation alerts. Compared to information-only alerts, ORs of medication-specific action by end of the following day were significantly greater for medication recommendations (5.59; 95% CI 2.42-12.94) and test recommendations (1.71; 95% CI 1.09-2.68). We found a similar pattern for OR of laboratory-specific action. We encountered 2 main challenges: (1) Capturing a historical snapshot of EHR status (number of InBasket messages at time of alert delivery) required incorporation of data generated many months prior with longitudinal follow-up. (2) Accurately interpreting data elements required iterative work by a physician/data manager team taking action within the EHR and then examining audit logs to identify corresponding documentation.

Conclusions

EHR log data could inform future efforts and provide valuable information during development and refinement of CDS interventions. To address challenges, use of these data should be planned before implementing an EHR–based study.

Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE): A Cluster-Randomized Pragmatic Trial of a Multifactorial Fall Injury Prevention Strategy: Design and Methods

Background

Fall injuries are a major cause of morbidity and mortality among older adults. We describe the design of a pragmatic trial to compare the effectiveness of an evidence-based, patient-centered multifactorial fall injury prevention strategy to an enhanced usual care.

Methods

Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) is a 40-month cluster-randomized, parallel-group, superiority, pragmatic trial being conducted at 86 primary care practices in 10 health care systems across United States. The 86 practices were randomized to intervention or control group using covariate-based constrained randomization, stratified by health care system. Participants are community-living persons, ≥70 years, at increased risk for serious fall injuries. The intervention is a comanagement model in which a nurse Falls Care Manager performs multifactorial risk assessments, develops individualized care plans, which include surveillance, follow-up evaluation, and intervention strategies. Control group receives enhanced usual care, with clinicians and patients receiving evidence-based information on falls prevention. Primary outcome is serious fall injuries, operationalized as those leading to medical attention (nonvertebral fractures, joint dislocation, head injury, lacerations, and other major sequelae). Secondary outcomes include all fall injuries, all falls, and well-being (concern for falling; anxiety and depressive symptoms; physical function and disability). Target sample size was 5,322 participants to provide 90% power to detect 20% reduction in primary outcome rate relative to control.

Results

Trial enrolled 5,451 subjects in 20 months. Intervention and follow-up are ongoing.

Conclusions

The findings of the STRIDE study will have important clinical and policy implications for the prevention of fall injuries in older adults.

Consensus Statement: Feature and Function Recommendations to Optimize Clinician Usability of Direct Interoperability to Enhance Patient Care

Background  Secure clinical messaging and document exchange utilizing the Direct Protocol (Direct interoperability) has been widely implemented in health information technology (HIT) applications including electronic health records (EHRs) and by health care providers and organizations in the United States. While Direct interoperability has allowed clinicians and institutions to satisfy regulatory requirements and has facilitated communication and electronic data exchange as patients transition across care environments, feature and function enhancements to HIT implementations of the Direct Protocol are required to optimize the use of this technology.

Objective  To describe and address this gap, we developed a prioritized list of recommended features and functions desired by clinicians to utilize Direct interoperability for improved quality, safety, and efficiency of patient care. This consensus statement is intended to inform policy makers and HIT vendors to encourage further development and implementation of system capabilities to improve clinical care.

Methods  An ad hoc group of interested clinicians came together under the auspices of DirectTrust to address challenges of usability and create a consensus recommendation. This group drafted a list of desired features and functions that was published online. Comments were solicited from interested parties including clinicians, EHR and other HIT vendors, and trade organizations. Resultant comments were collected, reviewed by the authors, and incorporated into the final recommendations.

Results  This consensus statement contains a list of 57 clinically desirable features and functions categorized and prioritized for support by policy makers, development by HIT vendors, and implementation and use by clinicians.

Conclusion  Fully featured, standardized implementation of Direct interoperability will allow clinicians to utilize Direct messaging more effectively as a component of HIT and EHR interoperability to improve care transitions and coordination.

Patient Portals: An Underused Resource for Improving Patient Engagement

The potential of patient portals to improve patient engagement and health outcomes has been discussed for more than a decade. The slow growth in patient portal adoption rates among patients and providers in the United States, despite external incentives, indicates that this is a complex issue. We examined evidence of patient portal use and effects with a focus on the pulmonary domain. We found a paucity of studies of patient portal use in pulmonary practice, and highlight gaps for future research. We also report on the experience of a pulmonary department using a patient portal to highlight the potential of these systems.

A Pilot Health Information Technology-Based Effort to Increase the Quality of Transitions From Skilled Nursing Facility to Home: Compelling Evidence of High Rate of Adverse Outcomes

OBJECTIVES

Older adults are often transferred from hospitals to skilled nursing facilities (SNFs) for post-acute care. Patients may be at risk for adverse outcomes after SNF discharges, but little research has focused on this period.

DESIGN

Assessment of the feasibility of a transitional care intervention based on a combination of manual information transmission and health information technology to provide automated alert messages to primary care physicians and staff; pre-post analysis to assess potential impact.

SETTING

A multispecialty group practice.

PARTICIPANTS

Adults aged 65 and older, discharged from SNFs to home; comparison group drawn from SNF discharges during the previous 1.5 years, matched on facility, patient age, and sex.

MEASUREMENTS

For the pre-post analysis, we tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days.

RESULTS

The intervention was developed and implemented with manual transmission of information between 8 SNFs and the group practice followed by entry into the electronic health record. The process required a 5-day delay during which a large portion of the adverse events occurred. Over a 1-year period, automated alert messages were delivered to physicians and staff for the 313 eligible patients discharged from the 8 SNFs to home. We compared outcomes to those of individually matched discharges from the previous 1.5 years and found similar percentages with 30-day rehospitalizations (31% vs 30%, adjusted HR 1.06, 95% CI 0.80-1.4). Within the adverse drug event (ADE) study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days.

CONCLUSION

Older adults discharged from SNFs are at high risk of adverse outcomes immediately following discharge. Simply providing alerts to outpatient physicians, especially if delivered multiple days after discharge, is unlikely to have any impact on reducing these rates.

Economic simulation of canagliflozin and sitagliptin treatment outcomes in patients with type 2 diabetes mellitus with inadequate glycemic control

OBJECTIVES

This study examines the association between changes in diabetes-related quality measures (QMs) (HbA1c, systolic and diastolic blood pressure [BP], low-density lipoprotein cholesterol [LDL-C], and body weight) and healthcare costs in Type 2 diabetes mellitus (T2DM) patients. It also performs an economic simulation that evaluates the cost implications of the changes in QMs and of the incidence rates (IRs) of adverse events (AEs) associated with canagliflozin (CANA) and sitagliptin (SITA) treatments in a real-world setting.

METHODS

Health-insurance claims and electronic medical records from the Reliant Medical Group database (2007-2011) were used to identify adult patients with T2DM receiving metformin and sulfonylurea who did not achieve adequate glycemic control. The association between the changes in QMs and healthcare costs was evaluated using multivariate regression and non-parametric bootstrap methods. AE-related costs were taken from the literature. The cost impact of CANA and SITA outcomes was evaluated using the aforementioned costs and the changes in QMs and the IRs of AEs observed in a recent phase 3 trial comparing CANA and SITA as third oral agent (DIA3015).

RESULTS

Eight hundred and fifty-six T2DM patients were identified (mean age = 65.8; female 45.4%). The regression analysis found that increases of 1 percentage point in HbA1C and 1% in systolic and diastolic BP, LDL-C, or weight were associated with a per patient per year (PPPY) cost increase of $4476 (p = 0.028) and $566 (p = 0.006), a decrease of $362 (p = 0.070) and $7 (p = 0.817), and an increase of $241 (p = 0.481), respectively. The economic simulation showed that changes in QMs and IRs of AEs equivalent to those reported in DIA3015 would be associated with a reduction in PPPY healthcare costs of $6061 (p = 0.036) for CANA and $2190 (p = 0.098) for SITA.

CONCLUSIONS

This study suggests that integrated approaches that manage to control a combination of quality measures are most successful at reducing downstream healthcare costs.

An electronic health record-based intervention to increase follow-up office visits and decrease rehospitalization in older adults

OBJECTIVES

To assess the effect of an electronic health record-based transitional care intervention involving automated alerts to primary care providers and staff when older adults were discharged from the hospital.

DESIGN

Randomized controlled trial.

SETTING

Large multispecialty group practice.

PARTICIPANTS

Individuals aged 65 and older discharged from hospital to home.

INTERVENTION

In addition to notifying primary care providers about the individual's recent discharge, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and laboratory monitoring of high-risk medications, and alerts to the primary care provider's support staff to schedule a posthospitalization office visit.

MEASUREMENTS

An outpatient office visit with a primary care provider after discharge and rehospitalization within 30 days after discharge.

RESULTS

Of the 1,870 discharges in the intervention group, 27.7% had an office visit with a primary care provider within 7 days of discharge. Of the 1,791 discharges in the control group, 28.3% had an office visit with a primary care provider within 7 days of discharge. In the intervention group, 18.8% experienced a rehospitalization within the 30-day period after discharge, compared with 19.9% in the control group. The hazard ratio for an office visit with a primary care physician did not significantly differ between the intervention and control groups. The hazard ratio for rehospitalization in the 30-day period after hospital discharge in the intervention versus the control group was 0.94 (95% confidence interval = 0.81-1.1).

CONCLUSION

This electronic health record-based intervention did not have a significant effect on the timeliness of office visits to primary care providers after hospitalization or risk of rehospitalization.

Quality measure attainment in patients with type 2 diabetes mellitus

OBJECTIVES

This study examined the demographics, comorbidities, clinical characteristics, and treatments of people with type 2 diabetes mellitus (T2DM) treated with metformin and sulfonylurea as well as an elderly subgroup. Achievement of predefined quality measure goals (glycated hemoglobin [A1C], blood pressure [BP], low-density lipoprotein cholesterol [LDL-C], body mass index [BMI]) and their association with diabetes-related healthcare costs were assessed.

STUDY DESIGN

The study applied a retrospective longitudinal cohort design.

METHODS

Health insurance claims and electronic medical records from 14,532 adults with T2DM (2007- 2011) were used to identify a sample receiving metformin and sulfonylurea (MET+SU) concomitantly. The index date was the first dispensing of MET+SU after 6 months of eligibility. Clinical characteristics were assessed during baseline. Quality measure attainment (A1C <8%, BP <140/90 mm Hg, LDL-C level <100 mg/dL, BMI <30 kg/m²), was evaluated during the 12 months following the index date. Association between attainment and diabetes-related costs was evaluated using non-parametric bootstrap methods adjusting for imbalance in baseline characteristics between cohorts.

RESULTS

Among 2044 patients, including 1283 patients 65 years and older, hyperlipidemia, hypertension, and cardiovascular disease were the most common baseline comorbidities. Quality measure goal attainment was 63.9% for A1C, 33.1% for BP, 68.2% for LDL-C level, and 34.4% for BMI, and was associated with significantly lower diabetes-related costs per patient per year compared with nonattainment (adjusted mean cost differences: -$1445 for A1C; -$1218 for BMI; -$2029 for A1C and BMI; -$2073 for A1C, BMI, and BP; all P <.05).

CONCLUSION

This study highlights the high incidence of comorbidities and potential financial implications of attaining T2DM quality outcomes.

Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers Criteria Medications

OBJECTIVES

To characterize adverse drug events (ADEs) occurring within the high-risk 45-day period after hospitalization in older adults.

DESIGN

Clinical pharmacists reviewed the ambulatory records of 1,000 consecutive discharges.

SETTING

A large multispecialty group practice closely aligned with a Massachusetts-based health plan.

PARTICIPANTS

Hospitalized individuals aged 65 and older discharged home.

MEASUREMENTS

Possible drug-related incidents occurring during the 45-day period after hospitalization were identified and presented to a pair of physician-reviewers who classified incidents as to whether an ADE was present, whether the event was preventable, and the severity of the event. Medications implicated in ADEs were further characterized according to their inclusion in the 2012 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

RESULTS

At least one ADE was identified during the 45-day period in 18.7% (n = 187) of the 1,000 discharges. Of the 242 ADEs identified, 35% (n = 84) were deemed preventable, of which 32% (n = 27) were characterized as serious, and 5% (n = 4) as life threatening. More than half of all ADEs occurred within the first 14 days after hospitalization. The percentage of ADEs in which Beers Criteria medications were implicated was 16.5% (n = 40). Beers criteria medications with both a high quality of evidence and strong strength of recommendation were implicated in 6.6% (n = 16) of the ADEs.

CONCLUSION

ADEs are common and often preventable in older adults after hospital discharge, underscoring the need to address medication safety during this high-risk period in this vulnerable population. Beers criteria medications played a small role in these events, suggesting that efforts to improve the quality and safety of medication use during this critical transition period must extend beyond a singular focus on Beers criteria medications.

Association of self-monitoring of blood glucose use on glycated hemoglobin and weight in newly diagnosed, insulin-naïve adult patients with type 2 diabetes

BACKGROUND

Clinical trials have shown that self-monitoring of blood glucose (SMBG) combined with patient education and medication titration can lead to improved glycated hemoglobin (HbA1c) and reduced weight in recently diagnosed non-insulin-treated type 2 diabetes mellitus (T2DM) patients. This retrospective matched cohort study assessed the association of SMBG with achieving long-term clinical outcomes in these patients in a real-world clinical setting.

METHODS

Using electronic medical records (2008-2011), we selected a population of adult patients recently diagnosed with T2DM not receiving insulin who were SMBG users and a population of non-SMBG controls with similar demographic and clinical characteristics using propensity score matching. The main study outcomes compared between the two groups were time to achieve (1) HbA1c <7% for patients with baseline HbA1c ≥ 7% and (2) a ≥ 5% reduction in weight from baseline.

RESULTS

Of the 589 patients identified in each group, 113 in each group had a baseline HbA1c ≥ 7% (mean, 8.2%). The SMBG users were more likely to achieve an HbA1c <7% (12 months: 58.4% versus 38.9%, p = .0037; 36 months: 84.0% versus 70.0%, p = .0013) and to do so faster (median, 6.5 versus 20.5 months; log-rank p = .0016). Self-monitoring of blood glucose was associated with faster weight reduction (median time to achieve a ≥ 5% reduction, 23.5 versus 35.9 months for SMBG and non-SMBG, respectively; log-rank p = .0005).

CONCLUSIONS

In newly diagnosed T2DM insulin-naïve patients, SMBG users had an improved rate of achieving long-term glycemic control and weight loss in a real-world clinical setting.

Technological resources and personnel costs required to implement an automated alert system for ambulatory physicians when patients are discharged from hospitals to home

BACKGROUND

With the adoption of electronic medical records by medical group practices, there are opportunities to improve the quality of care for patients discharged from hospitals. However, there is little guidance for medical groups outside integrated hospital systems to automate the flow of patient information during transitions in care.

OBJECTIVE

To describe the technological resources, expertise and time needed to develop an automated system providing information to ambulatory physicians when their patients are discharged from hospitals to home.

DEVELOPMENT

Within a medical group practice, we developed an automated alert system that provides notification of discharges, reminders of the need for follow-up visits, drugs added during inpatient stays, and recommendations for laboratory monitoring of high-risk drugs. We tracked components of the information system required and the time spent by team members. We used USA national averages of hourly wages to estimate personnel costs.

APPLICATION

Critical components of the information system are notifications of hospital discharges through an admission, discharge and transfer registration (ADT) interface, linkage to the group's scheduling system, access to information on pharmacy dispensing and lab tests, and an interface engine. Total personnel cost was $76,314. Nearly half (47%) was for 614 hours by physicians who developed content, provided overall project management, and reviewed alerts to ensure that only 'actionable' alerts would be sent.

CONCLUSION

Implementing a system to provide information about hospital discharges requires strong internal informatics expertise, cooperation between facilities and ambulatory providers, development of electronic linkages, and extensive commitment of physician time.

Overcoming challenges integrating patient-generated data into the clinical EHR: lessons from the CONtrolling Disease Using Inexpensive IT--Hypertension in Diabetes (CONDUIT-HID) Project

INTRODUCTION

The CONDUIT-HID intervention integrates patients' electronic blood pressure measurements directly into the clinical EHR using Microsoft HealthVault as an intermediary data store. The goal of this paper is to describe generalizable categories of patient and technical challenges encountered in the development and implementation of this inexpensive, commercial off-the-shelf consumer health informatics intervention, examples of challenges within each category, and how the example challenges were resolved prior to conducting an RCT of the intervention.

METHODS

The research team logged all challenges and mediation strategies during the technical development of the intervention, conducted home visits to observe patients using the intervention, and conducted telephone calls with patients to understand challenges they encountered. We then used these data to iteratively refine the intervention.

RESULTS

The research team identified a variety of generalizable categories of challenges associated with patients uploading data from their homes, patients uploading data from clinics because they did not have or were not comfortable using home computers, and patients establishing the connection between HealthVault and the clinical EHR. Specific challenges within these categories arose because: (1) the research team had little control over the device and application design, (2) multiple vendors needed to coordinate their actions and design changes, (3) the intervention use cases were not anticipated by the device and application designers, (4) PHI accessed on clinic computers needed to be kept secure, (5) the research team wanted the data in the clinical EHR to be valid and reliable, (6) patients needed the ability to share only the data they wanted, and (7) the development of some EHR functionalities were new to the organization. While these challenges were varied and complex, the research team was able to successfully resolve each one prior to the start of the RCT.

CONCLUSIONS

By identifying these generalizable categories of challenges, we aim to help others proactively search for and remedy potential challenges associated with their interventions, rather than reactively responding to problems as they arise. We posit that this approach will significantly increase the likelihood that these types of interventions will be successful.

Non-commercial poultry industries: Surveys of backyard and gamefowl breeder flocks in the United States

The National Animal Health Monitoring System (NAHMS) Poultry '04 study was conducted to better describe non-commercial United States poultry populations, in particular, backyard and gamefowl breeder flocks. To estimate the density of backyard flocks in close proximity to commercial operations, a sample of 350 commercial poultry operations in 18 top poultry producing states was selected from the National Agricultural Statistics Service (NASS) list of poultry operations. A 1 mile radius circle was drawn around each operation, and door-to-door canvassing was conducted within these circles to enumerate premises with all species of birds. Premises with backyard poultry flocks completed a questionnaire focusing on bird health, bird movement, and biosecurity practices. A similar questionnaire, provided in both English and Spanish, was mailed to all members of State affiliates of the United Gamefowl Breeders Association (UGBA) as well as to members of State associations not affiliated with UGBA. An average of 29.4 residences was found within a 1 mile radius of commercial operations, of which 1.9 residences per circle had backyard poultry flocks. Gamefowl breeder flocks were larger, used more health care and biosecurity practices, and moved birds more frequently compared to backyard flocks.

The concept of compartmentalisation

The rationale for establishing trade 'regions' and 'zones' is based on principles of epidemiological science and risk analysis that assess and manage animal disease risks so that the safety of trade can be ensured. However, the boundaries of geographical regions and zones may readily be breached through numerous epidemiological pathways. The concept of a 'compartment' extends the application of a 'risk boundary' beyond that of a geographical interface and considers all epidemiological factors that can contribute to the creation of an effective boundary. The fundamental requirement for application of either concept (regions/zones or compartments) is that the population considered for trade is maintained within management or geographical boundaries which allow clear epidemiological differentiation to be made between those animals and surrounding populations of higher risk. Seven factors are presented that an exporting country might use to guide the identification and documentation of a compartment. Additionally, the steps that would be undertaken to implement trade based on the compartmentalisation concept are discussed.

The Isolation of Exotic Newcastle Disease (END) Virus from Nonpoultry Avian Species Associated with the Epidemic of END in Chickens in Southern California: 2002–2003

During the first 11 months of the 2002-2003 exotic Newcastle disease (END) epidemic in chickens in southern California, a total of 27,688 cloacal and tracheal (oropharyngeal) swab pools and/or tissue pools from 86 different avian species other than chickens and turkeys were submitted for Newcastle disease virus (NDV) isolation and characterization. Fifty-seven specimens (0.23%), representing 12 species of birds and 13 unspecified species, from a total of 24,409 accessions or submissions were positive for NDV. The NDV isolate was characterized as ENDV by real-time reverse transcription-polymerase chain reaction (RT-PCR). Of the 11,486 premises with other avian species, 1599 also had chickens. There were 1900 positive chicken samples from 164 premises, and 56 positive other avian species from 51 premises. Twelve premises had both positive chickens and positive other avian species. All positive other avian species were located on premises either on or within a 1 km radius of known infected premises. In this epidemic, premises with positive other avian species were significantly more likely to have chickens, and were significantly more likely to have positive chickens (OR = 3.7, P < 0.0001).

Strategies for detecting adverse drug events among older persons in the ambulatory setting

OBJECTIVE

To examine various strategies for the identification of adverse drug events (ADEs) among older persons in the ambulatory clinical setting.

DESIGN

A cohort study of Medicare enrollees (n = 31,757 per month) receiving medical care from a large multispecialty group practice during a 12-month observation period (July 1, 1999 through June 30, 2000).

MEASUREMENTS

Possible drug-related incidents occurring in the ambulatory clinical setting were detected using signals from multiple sources.

RESULTS

During the tracking period, there were 1,523 identified ADEs, of which 421 (28%) were considered preventable. Across all sources, 23,917 signals were found; 12,791 (53%) were potential incidents that led to review of a patient's medical record and 2,266 (9%) were presented to physician reviewers. Although the positive predictive value (PPV) for reports from providers was high compared with other sources (54%), only 11% of the ADEs and 6% of the preventable ADEs were identified through this source. PPVs for other sources ranged from a low of 4% for administrative incident reports to a high of 12% for free-text review of electronic notes. Computer-generated signals were the source for 31% of the ADEs and 37% of the preventable ADEs. Electronic notes were the source for 39% of the ADEs and 29% of the preventable ADEs. There was little overlap in the ADEs identified across all sources.

CONCLUSION

Our findings emphasize the limitations of voluntary reporting by health care providers as the principal means for detection of ADEs and suggest that multiple strategies are required to detect ADEs in geriatric ambulatory patients.

Epidemiologic and surveillance studies on avian influenza in live-bird markets in New York and New Jersey, 2001

In 2001, all 109 retail live-bird markets (LBMs) in New York and New Jersey were surveyed for the presence of avian influenza virus (AIV) by a real time reverse transcriptase/polymer chain reaction assay (RRT/PCR) and results compared to virus isolation (VI) in embryonating chicken eggs. The RRT/PCR had a 91.9% sensitivity and 97.9% specificity in detecting presence of AIV at the market level. However, the sensitivity at the sample level is 65.87%. The RRT/PCR is a reliable method to identify AIV at the market level. In addition, a cross-sectional epidemiologic study of the LBMs showed that, during the past 12 months, markets that were open 7 days per week and those that also sold rabbits had the highest risk for being positive for AIV. Markets that were closed one or more days per week and those that performed daily cleaning and disinfecting had the lowest risk for being AIV positive.

Descriptive and surveillance studies of suppliers to New York and New Jersey retail live-bird markets

Low pathogenicity avian influenza virus (AIV) H7N2 has been isolated since 1994 from retail live-bird markets (LBMs) in the northeastern United States. This study examines the suppliers to the LBMs in New York and New Jersey. In 2001, 185 supplier premises in nine states were surveyed for the presence of AIV by virus isolation (VI) in embryonating chicken eggs. No H7 or H5 virus was isolated. In addition, 104 producer premises in two states were serologically negative for H7 and H5 AIV. Information on management practices was obtained via questionnaire for 191 premises in 12 states. The survey results suggest that current biosecurity practices at supplier premises could be improved, especially regarding movement of birds. The study supports the hypothesis that H7N2 AIV is primarily maintained within the LBMs and, if reintroduction from suppliers is occurring, it is likely reintroduced at a very low level or from suppliers not included in this study.

Incidence and preventability of adverse drug events among older persons in the ambulatory setting

CONTEXT

Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting.

OBJECTIVE

To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting.

DESIGN, SETTING, AND PATIENTS

Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors.

MAIN OUTCOME MEASURES

Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable.

RESULTS

There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events.

CONCLUSIONS

Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.

Factors associated with fecal shedding of verotoxin-producing Escherichia coli O157 on dairy farms

Fecal samples were collected from 4,361 dairy cows on 91 dairy operations between 26 February and 8 July 1996. Fecal samples were cultured for Escherichia coli O157, and positive isolates were probed for verotoxin-producing genes. A total of 52 (1.2%) fecal samples on 22 (24.2%) operations were positive for verotoxin-producing E. coli O157. Herds in which samples were collected on or after 1 May 1996 were significantly more likely to test positive than herds sampled before that date (odds ratio = 7.7). Herds maintained on farms on which alleyways were flushed with water to remove manure were 8.0 times more likely to have samples test positive for verotoxin-producing E. coli O157 than were herds maintained on farms cleaned by use of other methods of manure removal.

Prevalence of enterohemorrhagic Escherichia coli O157:H7 in a survey of dairy herds

The prevalence of Escherichia coli O157:H7 in dairy herds is poorly understood, even though young dairy animals have been reported to be a host. From February to May 1993, 662 fecal samples from 50 control herds in 14 states, and from June to August 1993, 303 fecal samples from 14 case herds in 11 states were collected for isolation of E. coli O157:H7. Case herds were those in which E. coli O157:H7 was isolated from preweaned calves in a previous U.S. Department of Agriculture study, whereas control herds from which E. coli O157:H7 had not been isolated previously were randomly selected from the same states as case herds. Among the control herds, E. coli O157:H7 was isolated from 6 of 399 calves (1.5%) that were between 24 h old and the age of weaning and from 13 of 263 calves (4.9%) that were between the ages of weaning and 4 months. Eleven of 50 control herds (22%) were positive. Among the case herds, E. coli O157:H7 was isolated from 5 of 171 calves (2.9%) that were between 24 h old and the age of weaning and from 7 of 132 calves (5.3%) that were between the ages of weaning and 4 months. Seven of 14 case herds (50%) were positive. Sixteen of 31 isolates were obtained by direct plating, with populations ranging from 10(3) to 10(5) CFU/g. Fifteen of 31 isolates were isolated by enrichment only. Nineteen of the isolates produced both verocytotoxin 1 (VT-1) and VT-2, whereas 12 produced VT-2 only.