2012 April 27

Antipsychotic drugs and risk of pulmonary embolism.

Pharmacoepidemiol Drug Saf Start a Discussion »

Apr 272012

Antipsychotic drugs and risk of pulmonary embolism.

Pharmacoepidemiol Drug Saf. 2012 Jan;21(1):42-8

Authors: Allenet B, Schmidlin S, Genty C, Bosson JL

Abstract
BACKGROUND: Antipsychotic drugs (APs) expose users to several adverse effects. Some reports describe an increased risk of venous thromboembolism for particular drugs in this family.
PURPOSE: To examine the association between the risks of pulmonary embolism (PE) and AP use and assess any dose-effect relationships.
METHODS: This is a retrospective analysis of data in 'Premier's Perspective' a large US hospital database for 2006. Adults in the AP group had at least one prescription of AP. Logistic regression analysis was performed to detect association between PE and AP use. The dose-effect relationship was assessed according to quantities and administration routes. Analyses were adjusted for potential confounders: age, sex, the components of the Charlson co-morbidity index, diagnoses of infection, sepsis, inflammatory bowel disease, psychotic disorders and hospital inpatient or outpatient status.
RESULTS: Among 28,723,771 adults included in 2006, 450,951 (1.6%) were prescribed AP. Haloperidol was most commonly prescribed (157,667 patients or 35.0%), but atypical APs represented over 78% of prescriptions. The risk of PE was higher in AP users than in the total population (OR?=?1.17 [95%CI 1.13-1.21]; p?<?0.001) and depended on the type of AP used: clozapine was associated with the highest risk. Risk seemed correlated to higher doses.
LIMITATIONS: Non-hospital prescription data were unavailable, potentially underestimating the number of patients exposed. The relative timing of AP prescription and PE was not available. Results did not include deep vein thrombosis.
CONCLUSION: This study suggests an increased risk of PE with AP treatment, varying with type of AP and dependent on dose.

PMID: 22052683 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Contemporary Performance of U.S. Teaching and Nonteaching Hospitals.

Acad Med Start a Discussion »

Apr 272012

Contemporary Performance of U.S. Teaching and Nonteaching Hospitals.

Acad Med. 2012 Apr 24;

Authors: Shahian DM, Nordberg P, Meyer GS, Blanchfield BB, Mort EA, Torchiana DF, Normand SL

Abstract
PURPOSE: To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics. METHOD: The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards). RESULTS: Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care). CONCLUSIONS: Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value-relatively higher quality and safety in many areas, with similar adjusted costs.

PMID: 22534588 [PubMed - as supplied by publisher]

Link to Article at PubMed

An Educational Intervention to Improve Cost-Effective Care Among Medicine Housestaff: A Randomized Controlled Trial.

Acad Med Start a Discussion »

Apr 272012

An Educational Intervention to Improve Cost-Effective Care Among Medicine Housestaff: A Randomized Controlled Trial.

Acad Med. 2012 Apr 24;

Authors: Sommers BD, Desai N, Fiskio J, Licurse A, Thorndike M, Katz JT, Bates DW

Abstract
PURPOSE: High medical costs create significant burdens. Research indicates that doctors have little awareness of costs. This study tested whether a brief educational intervention could increase residents' awareness of cost-effectiveness and reduce costs without negatively affecting patient outcomes. METHOD: The authors conducted a clustered randomized controlled trial of 33 teams (96 residents) at an internal medicine residency program (2009-2010). The intervention was a 45-minute teaching session; residents reviewed the hospital bill of a patient for whom they had cared and discussed reducing unnecessary costs. Primary outcomes were laboratory, pharmacy, radiology, and total hospital costs per admission. Secondary measures were length of stay (LOS), intensive care unit (ICU) admission, 30-day readmission, and 30-day mortality. Multivariate adjustment controlled for patient demographics and health. A follow-up survey assessed resident attitudes three months later. RESULTS: Among 1,194 patients, there were no significant cost differences between intervention and control groups. In the intervention group, 30-day readmission was higher (adjusted odds ratio 1.51, P = .010). There was no effect on LOS or the composite outcome of readmission, mortality, and ICU transfer. In a subgroup analysis of 835 patients newly admitted during the study, the intervention group incurred $163 lower adjusted lab costs per admission (P = .046). The follow-up survey indicated persistent differences in residents' exposure to concepts of cost-effectiveness (P = .041). CONCLUSIONS: A brief intervention featuring a discussion of hospital bills can fill a gap in resident education and reduce laboratory costs for a subset of patients, but may increase readmission risk.

PMID: 22534589 [PubMed - as supplied by publisher]

Link to Article at PubMed

Exploring Error in Team-Based Acute Care Scenarios: An Observational Study From the United Kingdom.

Acad Med Start a Discussion »

Apr 272012

Exploring Error in Team-Based Acute Care Scenarios: An Observational Study From the United Kingdom.

Acad Med. 2012 Apr 24;

Authors: Tallentire VR, Smith SE, Skinner J, Cameron HS

Abstract
PURPOSE: To investigate the errors made by junior doctors (first year after primary medical qualification) in simulated acute care settings, using (and, for some purposes, amplifying) a previously published generic error-modeling system (GEMS). Possible error types were skill-based slips and lapses, rule-based mistakes, knowledge-based mistakes, and violations. METHOD: In August 2010, 38 junior doctors participated in high-fidelity simulated acute care scenarios in NHS Lothian, Scotland. Each video-recorded scenario was immediately followed by an audio-recorded debrief that encouraged articulation of underlying cognitive processes. Two researchers used evidence from the scenario, debrief, and field notes to determine which errors were attributable to a single underlying cause. In such cases, the errors were coded by template analysis into the GEMS framework. Errors for which a single cause could be identified but which did not fit the framework were coded inductively. RESULTS: A total of 243 errors were identified, with sufficient evidence available to identify a single cause in 190. Skill-based slips and lapses, rule-based mistakes, and knowledge-based mistakes were all clearly identified within the data. Two error types not originally included in the GEMS framework were identified: compound errors and submission errors. CONCLUSIONS: Amplification of GEMS provides a valid framework for categorization of the errors made by junior doctors in simulated acute care contexts. In addition, the amplified framework may be transferable to other, team-based contexts. An improved understanding of the knowledge and skills that are most vulnerable to each specific type of error will allow tailored educational strategies to be developed.

PMID: 22534595 [PubMed - as supplied by publisher]

Link to Article at PubMed

Risk of contrast induced nephropathy in the critically ill: a prospective, case matched study.

Crit Care Start a Discussion »

Apr 272012

Risk of contrast induced nephropathy in the critically ill: a prospective, case matched study.

Crit Care. 2012 Apr 25;16(2):R67

Authors: Cely CM, Schein RM, Quartin AA

Abstract
ABSTRACT: INTRODUCTION: Computerized tomography is frequently employed in the critically ill, often using intravenous radiocontrast material. Many of these patients have clinical features that are considered risk factors for contrast induced nephropathy, but are simultaneously at risk for renal injury from other factors related to their acute illnesses. The attributable risk for renal dysfunction from radiocontrast exposure has not been well quantified in this population. METHODS: Prospective matched cohort study of patients scanned with or without radiocontrast enhancement while receiving intensive care in a Veterans Affairs Medical Center. Patients were matched for pre-scan measured creatinine clearance, diabetes, mechanical ventilation, and vasopressor use. Measured clearance was followed for 3 days following scanning. Evolution of nephropathy, as determined by change in measured clearance, was compared within matched pairs. RESULTS: 53 pairs of patients satisfied matching criteria. Unmatched characteristics were similar among the pairs, including serum creatinine variability during the week preceding scanning (67+/-85% among contrast recipients, 63+/-62% among others) and clinical risk factors for renal failure. In 29 pairs, pre-scan measured clearances were less than 60 mL/min/1.73 m2. Following scanning measured clearance declined by at least 33% in 14 contrast and 19 non-contrast patients (95% confidence interval for contrast associated difference in nephropathy rates 27% to 9%), while a 50% reduction in clearance persisted 3 days after scanning in 3 contrast and 9 non-contrast patients (95% confidence interval for difference in rates 25% to 2%). CONCLUSIONS: Among established intensive care unit patients declines in glomerular filtration following contrast enhanced scanning are common, but these changes are far more likely to be attributable to factors other than the contrast exposure itself. The upper bound for the incidence of contrast induced renal injury lasting even 3 days was 2% in the population studied.

PMID: 22534554 [PubMed - as supplied by publisher]

Link to Article at PubMed

‘Shift work’: 24-hour workdays are out as residents, hospitals deal with changes, mixed feelings on restrictions.

Mod Healthc Start a Discussion »

Apr 272012

'Shift work': 24-hour workdays are out as residents, hospitals deal with changes, mixed feelings on restrictions.

Mod Healthc. 2011 Jul 25;41(30):6-7, 16, 1

Authors: Robeznieks A

Abstract
Shorter work hours for first-year residents are causing a big shift as hospitals adapt to the new limits. It has meant a hiring boom for hospitalists and a need to pack more tasks into shorter shifts. And physicians are now finding themselves performing more basic tasks that used to be handled by residents, causing something of a professional identity crisis, says Dr. Bradley Sharpe, of the University of California at San Francisco.

PMID: 22533264 [PubMed - in process]

Link to Article at PubMed

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