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ABSTRACT: Follow-up of abnormal ambulatory laboratory results is often suboptimal. The impact of an ambulatory electronic health record (EHR) on follow-up of markedly elevated blood potassium (K( +)) results was investigated via a retrospective medical record review-before and after EHR implementation-of patients at an adult primary care practice who had a nonhemolyzed K(+) ≥ 6.0 mEq/L. In all, 188 patients in the pre-EHR group and 30 in the EHR group satisfied inclusion criteria. The mean K(+) for the 2 groups was 6.3 mEq/L. The EHR group had 4.5 times the odds (95% confidence interval = 1.3-15.8) of having their episodes of hyperkalemia followed up within 4 days. Patients in the EHR group were also more likely to have their blood K(+) rechecked within 4 days (63.3% vs 43.6%; P = .044). An ambulatory EHR with a results management system improves documentation and time to follow-up for patients with markedly abnormal lab results.
American Journal of Medical Quality 01/2011; 26(4):308-14. · 1.64 Impact Factor
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ABSTRACT: Purpose: To assess internal medicine physicians' perceptions regarding delays in the follow up of ambulatory test results and the clinical consequences of delays.
Methods: Anonymous survey of internal medicine physicians at 3 large academic medical centers. The survey asked about physician practices regarding follow up of commonly ordered ambulatory test results, major barriers to follow-up, and perception of harm due to delayed follow-up.
Results: One hundred ninety-five (66%) of 297 eligible physicians completed the survey. House staff physicians were more likely to take 1 or more weeks to review the results of tests sent on their ambulatory patients. Forty-six percent of house staff physicians took 1 or more weeks to review laboratory results compared with only 8% of attending physicians (P < 0.001), and 58.7% of house staff physicians took 1 or more weeks to review radiographic study results compared with 24.5% of attending physicians (P < 0.001). The most common barrier to timely follow up was the lack of a reminder system. Overall, at least a few times per year, 70.4% of respondents reported seeing patients with delays in diagnosis or treatment because of delays in test result follow-up, and 40.4% reported seeing patients with worsening medical conditions because of delays in follow-up.
Conclusions: Physicians perceive that the lack of timely follow up of abnormal test results is common in the ambulatory setting and that patients are harmed as a result. Interventions such as automatic reminders and changes in house staff workflow are needed to ensure that abnormal test results are followed up in a timely manner.
Journal of Patient Safety 11/2008; 4(4):241-244.
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ABSTRACT: Patients are increasingly being discharged from the hospital with unresolved medical problems requiring outpatient follow-up. This study evaluates the frequency with which hospital physicians recommend outpatient workups to address patients' unresolved medical problems and the impact that availability of discharge summaries has on workup completion.
We conducted a retrospective cohort study of patients discharged from the medicine or geriatrics service of a large teaching hospital between June 1, 2002, and December 31, 2003. Each subject's inpatient medical record was reviewed to determine if the hospital physician recommended an outpatient workup. Subjects' outpatient medical records were then reviewed to determine if the workups were completed.
Of 693 hospital discharges, 191 discharged patients (27.6%) had 240 outpatient workups recommended by their hospital physicians. The types of workups were diagnostic procedures (47.9%), subspecialty referrals (35.4%), and laboratory tests (16.7%). The most common diagnostic procedures were computed tomographic scans to follow up abnormalities seen on previous radiographic studies and endoscopic procedures to follow up gastrointestinal tract bleeding. Of recommended workups, 35.9% were not completed. Increasing time to the initial postdischarge primary care physician visit decreased the likelihood that a recommended workup was completed (odds ratio, 0.77; P=.002), and availability of a discharge summary documenting the recommended workup increased the likelihood of workup completion (odds ratio, 2.35; P=.007).
Noncompletion of recommended outpatient workups after hospital discharge is common. Primary care physicians' access to discharge summaries documenting the recommended workup is associated with better completion of recommendations. Future research should focus on interventions to improve the quality and dissemination of discharge information to primary care physicians.
Archives of Internal Medicine 07/2007; 167(12):1305-11. · 11.46 Impact Factor
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ABSTRACT: Pain is a major quality issue. The objective of this study was to evaluate the effectiveness of a series of interventions on pain management.
This controlled clinical trial (April 1, 2002, to February 28, 2003) involved the staggered implementation of 3 interventions into 2 blocks of matched hospital units. The setting was an 1171-bed hospital. A total of 3964 adults were studied. Interventions included education, standardized pain assessment using a 1- or 4-item (enhanced) pain scale, audit and feedback of pain scores to nursing staff, and a computerized decision support system. The main outcome measures were pain assessment and severity and analgesic prescribing.
Units using enhanced pain scales had significantly higher pain assessment rates than units using 1-item pain scales (64% vs 32%; P<.001), audit and feedback of pain results was associated with increases in pain assessment rates compared with units in which audit and feedback was not used (85% vs 64%; P<.001), and the addition of the computerized decision support system was associated with significant increases in pain assessment only when compared with units without audit and feedback (79% vs 64%; P<.001). The enhanced pain scale was associated with significant increases in prescribing of World Health Organization step 2 or 3 analgesic for patients with moderate or severe pain compared with the 1-item scale (83% vs 66%; P=.01). The interventions did not improve pain scores.
A clinically meaningful pain assessment instrument combined with either audit and feedback or a computerized decision support system improved pain documentation to more than 80%. The enhanced pain scale was associated with improved analgesic prescribing. Future interventions should be directed toward altering physician behavior related to titration of opioid analgesics.
Archives of Internal Medicine 06/2006; 166(9):1033-9. · 11.46 Impact Factor
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ABSTRACT: To describe the patterns of opioid prescribing and the factors associated with reductions in the potency of patients' analgesic medications at the time of hospital discharge.
Prospective cohort.
Two hundred forty-four patients (171 surgical and 73 nonsurgical) hospitalized in an urban academic medical center who have experienced moderate or severe pain and who are taking opioid analgesics prior to discharge.
Step-down (or reduction) in the potency of patients' analgesic medication at the time of discharge. A step-down is defined as the analgesic medication that a patient is prescribed for outpatient analgesia at the time of discharge being less potent then the last pain medication administered to that patient just prior to hospital discharge.
Thirty-three percent of all patients had reductions in the potency of their opioid pain medication at the time of discharge (36% for surgical and 26% for nonsurgical patients). For nonsurgical patients, we found a trend toward Hispanic ethnicity being an independent risk factor for having a step-down in analgesic potency at discharge (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 0.9-14.9).
Physicians frequently reduce the potency of hospitalized patients' pain medications at discharge and Hispanic patients may be at increased risk of this occurring. Further research is needed to determine if the reductions in analgesic potency we observed are associated with poor posthospital pain outcomes.
Journal of Palliative Medicine 03/2006; 9(1):41-9. · 1.85 Impact Factor
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ABSTRACT: Declining rates of tuberculosis (TB) in the United States has resulted in a low prevalence of the disease among patients placed on respiratory isolation. The purpose of this study is to systematically review decision rules to predict the patient's risk for active pulmonary TB at the time of admission to the hospital.
We searched MEDLINE (1975 to 2003) supplemented by reference tracking. We included studies that reported the sensitivity and specificity of clinical variables for predicting pulmonary TB, used Mycobacterium TB culture as the reference standard, and included at least 50 patients.
Two reviewers independently assessed study quality and abstracted data regarding the sensitivity and specificity of the prediction rules.
Nine studies met inclusion criteria. These studies included 2,194 participants. Most studies found that the presence of TB risk factors, chronic symptoms, positive tuberculin skin test (TST), fever, and upper lobe abnormalities on chest radiograph were associated with TB. Positive TST and a chest radiograph consistent with TB were the predictors showing the strongest association with TB (odds ratio: 5.7 to 13.2 and 2.9 to 31.7, respectively). The sensitivity of the prediction rules for identifying patients with active pulmonary TB varied from 81% to 100%; specificity ranged from 19% to 84%.
Our analysis suggests that clinicians can use prediction rules to identify patients with very low risk of infection among those suspected for TB on admission to the hospital, and thus reduce isolation of patients without TB.
Journal of General Internal Medicine 11/2005; 20(10):947-52. · 2.83 Impact Factor
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ABSTRACT: It is unclear why some hospitalized adults experiencing severe pain report that this degree of pain is acceptable to them.
A 25% random sample of cognitively intact patients admitted to nine medical/surgical units in a New York City hospital were enrolled. Patients were interviewed daily, Monday to Friday from April 1, 2001 through February 14, 2003, to collect information on the presence of pain, pain intensity, analgesic use, and acceptance of pain. Patients were asked to rate their current level of pain using a four-point scale.
Three hundred ninety-two of 1254 patients ( 31%) experiencing severe pain reported that their pain was acceptable to them. Variables significantly associated with an episode of acceptable severe pain in multivariate analyses included resolution of the painful episode (odds ratio = 4.7; 95% confidence interval [CI], 3.54-6.17), recent surgery (odds ratio = 1.5; 95% CI, 1.11-1.99), African American compared to white (odds ratio = 0.7; 95% CI, 0.48-0.955), age (odds ratio = 0.985; 95% CI, 0.977-0.993), and patients taking analgesics (odds ratio = 0.7; 95% CI, 0.46-0.964 for nonsteroidal anti-inflammatory drugs [NSAIDs]/acetaminophen and odds ratio = 0.6; 95% CI, 0.46-0.85 for opioids). Overall, 86 of 252 (34%) reported the pain was acceptable because it had resolved, 47 (19%) believed the pain would eventually go away, and 47 (19%) reported they were able to tolerate the pain.
A substantial percentage of patients reporting severe pain report this experience as acceptable. Given recent research linking high intensity pain to adverse outcomes, future studies directed at improving the management of pain need to target both pain intensity and patients' beliefs about the acceptability of severe pain.
Journal of Palliative Medicine 07/2004; 7(3):443-50. · 1.85 Impact Factor
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ABSTRACT: To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes.
Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge.
Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors.
Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit.
Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations.
We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.
Journal of General Internal Medicine 09/2003; 18(8):646-51. · 2.83 Impact Factor
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ABSTRACT: Failure to follow up outpatient test results is a potential patient safety concern; however, data about how house-staff physicians follow up on tests are sparse. The authors sought to assess internal medicine house-staff practices and perceptions regarding the follow-up of outpatient tests and identified barriers to timely follow-up. Seventy-five of 111 eligible house staff at a large urban teaching hospital (68%) completed the survey. Seventy-four percent reported they were sometimes unable to follow up on test results, 78% were at least somewhat worried about inadequate follow-up, and 46% stated that they have seen a patient's medical condition worsen due to a delay in test result follow-up at least a few times a year. Barriers to timely follow-up included lack of a reminder system (40%), difficulty accessing results (24%), too many competing demands on time (27%), and uncertainty about who should follow up on results (16%).
American Journal of Medical Quality 21(3):178-84. · 1.64 Impact Factor
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ABSTRACT: Physicians frequently express dissatisfaction about caring for patients with chronic pain and frequently report that inadequate training and concern about addiction are impediments to prescribing opioids. Elderly patients with chronic pain may be at increased risk of experiencing uncontrolled pain and this patient population is increasingly being cared for by geriatricians rather than internists. We sought to determine if there is a differential impact on internists and geriatricians of the factors that adversely affect attitudes toward opioid prescribing.
Anonymous survey of geriatric and internal medicine physicians at a large urban academic medical center about their beliefs and behaviors regarding opioid prescribing.
One hundred thirty-two of 187 physicians completed the survey for an overall response rate of 71%. Controlling for level of training, internists were more likely to be concerned about illegal diversion (adjusted odds ratio=10.0, P=0.004), were more concerned about causing addiction (38% vs. 0%, P<0.001), and were more likely to be concerned about their inability to prescribe the correct opioid dose (adjusted odds ratio=11.1, P=0.020).
Factors shown to have an adverse affect on opioid prescribing disproportionately impact on the attitudes of internists compared with geriatricians. Further research is needed to determine if there is also a differential impact on how internists care for their elderly patients with chronic pain.
Clinical Journal of Pain 23(9):799-803. · 2.81 Impact Factor
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ABSTRACT: Few studies have investigated the time it takes physicians to follow up abnormal outpatient laboratory results.
Medical record review of all adult patients seen at a primary care practice between January 2002 and December 2005 with serum potassium results > or = 6.0 mEq/L. We used a proportional hazards model to assess factors associated with time to follow-up for episodes of hyperkalemia.
259 of 48,333 serum potassium results met inclusion criteria. The median follow-up time was 3 days; after 30 days, 10% of cases had no follow-up. Residing in the same zip code as the clinic (HR = 1.39; P = .029), degree of hyperkalemia (HR = 2.97; P < .001), and renal insufficiency (HR = 1.41; P = .015) were associated with decreased time to repeat testing. Conversely, African Americans (HR = .51; P = .007) had increased time to repeat testing.
Follow-up of abnormal laboratory results in outpatients is suboptimal and research is needed to better understand factors that delay follow-up.
American Journal of Medical Quality 22(6):428-37. · 1.64 Impact Factor
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ABSTRACT: To better inform clinicians on the optimal management of patients on oral anticoagulation who need to undergo surgery or invasive procedures, the authors performed a decision analysis examining whether a perioperative aggressive or minimalist strategy results in greater quality-adjusted survival.
A decision analysis model was created comparing withholding warfarin (minimalist strategy) to withholding warfarin and administering treatment-dose subcutaneous low-molecular-weight heparin (LMWH) or intravenous heparin perioperatively (aggressive strategy). The base-case analysis examined a hypothetical 60-year-old hypertensive individual with mechanical aortic valve replacement undergoing major abdominal surgery. A probabilistic sensitivity analysis was performed using a Monte Carlo simulation with quality-adjusted life expectancy (QALE) as the outcome. Secondary analyses examined patients with a mechanical mitral valve and atrial fibrillation. Sensitivity analyses were performed for each variable.
Under the base-case scenario, the minimalist strategy was preferred for 78% of trials in the Monte Carlo simulation, with a mean benefit of 0.003 years (95% confidence interval, -0.005 years to 0.011 years). Sensitivity analyses based on point estimates indicate that the aggressive strategy is preferred when the annual stroke rate is >5.6% or the increase in postoperative major bleeding induced by heparin is <2.0%; however, the benefit is small over the range of plausible values.
For most patients with a mechanical aortic valve or atrial fibrillation undergoing major surgery, a minimalist strategy of simply withholding oral anticoagulation provides similar QALE as an aggressive strategy of administering perioperative subcutaneous LMWH or intravenous heparin. The aggressive therapy provides greater QALE for patients at higher risk of stroke (e.g., mechanical mitral valves), although the benefit is small.
Medical Decision Making 25(4):387-97. · 2.33 Impact Factor
