[Show abstract][Hide abstract] ABSTRACT: Drug-drug interactions (DDIs) are an important type of adverse drug events. Yet overall incidence and pattern of DDIs in Iran has not been well documented and little information is available about the strategies that have been used for their prevention. The purpose of this study was to systematically review the literature on the incidence and pattern of DDIs in Iran as well as the used strategies for their prevention. PubMed, Scopus, electronic Persian databases, and Google Scholar were searched to identify published studies on DDIs in Iran. Additionally, the reference lists of all retrieved articles were reviewed to identify additional relevant articles. Eligible studies were those that analyzed original data on the incidence of DDIs in inpatient or outpatient settings in Iran. Articles about one specific DDI and drug interactions with herbs, diseases, and nutrients were excluded. The quality of included studies was assessed using quality assessment criteria. Database searches yielded 1053 potentially eligible citations. After removing duplicates, screening titles and abstracts, and reading full texts, 34 articles were found to be relevant. The quality assessment of the included studies showed a relatively poor quality. In terms of study setting, 18 and 16 studies have been conducted in inpatient and outpatient settings, respectively. All studies focused on potential DDIs while no study assessed actual DDIs. The median incidence of potential DDIs in outpatient settings was 8.5% per prescription while it was 19.2% in inpatient settings. The most indicated factor influencing DDIs incidence was patient age. The most involved drug classes in DDIs were beta blockers, angiotensin-converting-enzyme inhibitors (ACEIs), diuretic agents, and non-steroidal anti-inflammatory drugs (NSAIDs). Thirty-one studies were observational and three were experimental in which the strategies to reduce DDIs were applied. Although almost all studies concluded that the incidence of potential DDIs in Iran in both inpatient and outpatient settings was relatively high, there is still no evidence of the incidence of actual DDIs. More extensive research is needed to identify and minimize factors associated with incidence of DDIs, and to evaluate the effects of preventive interventions especially those that utilize information technology.
Daru : journal of Faculty of Pharmacy, Tehran University of Medical Sciences. 06/2014; 22(1):52.
[Show abstract][Hide abstract] ABSTRACT: There is little evidence that electronic medical record (EMR) use is associated with better compliance with clinical guidelines on initiation of antiretroviral therapy (ART) among ART-eligible HIV patients. We assessed the effect of transitioning from paper-based to an EMR-based system on appropriate placement on ART among eligible patients.
Journal of the American Medical Informatics Association : JAMIA. 06/2014;
[Show abstract][Hide abstract] ABSTRACT: Abstract Objective: The objective of the present study is to investigate trends in birth asphyxia and perinatal mortality in the Netherlands over the last decade. Methods: A nationwide cohort study among women with a term singleton pregnancy. We assessed trends in birth asphyxia in relation to obstetric interventions for fetal distress. Birth asphyxia was defined as a 5 minute Apgar score < 7 (any asphyxia) or 5 minute Apgar score < 4 (severe asphyxia). Perinatal mortality was defined as mortality during delivery or within seven days after birth. Multivariable analyses were used to adjust for confounding factors. Results: The prevalence of birth asphyxia was 0.85% and severe asphyxia 0.16%. Between 1999 and 2010 birth asphyxia decreased significantly with approximately 6% (p = 0.03) and severe asphyxia with 11% (p = 0.03). There was no significant change in perinatal mortality rate (0.98 per 1000 live births). Simultaneously the referral rate from primary to secondary care during labor increased from 20% to 24% (p< 0.0001) and the intervention rate for fetal distress from 5.9% to 7.7% (P<0.0001). Conclusion: In the Netherlands, the risk of birth asphyxia among term singletons has slightly decreased over the last decade; without a significant change in perinatal mortality.
Journal of Maternal-Fetal and Neonatal Medicine. 05/2014;
[Show abstract][Hide abstract] ABSTRACT: Surviving Sepsis Campaign bundles have been associated with reduced mortality in severe sepsis and septic shock patients. Case-mix adjusted mortality evaluations have not been performed to compare hospitals participating in sepsis bundle programs with those not participating. We aimed to achieve an individual bundle target adherence more than 80% and a relative mortality reduction of at least 15% (absolute mortality reduction 5.2%) at the end of 2012.
Prospective multicenter cohort study in participating and nonparticipating centers.
Eighty-two ICUs in The Netherlands.
In total, 213,677 adult ICU patients admitted to all ICUs among which 8,387 severe sepsis patients at 52 participating ICUs and 8,031 severe sepsis patients at 30 nonparticipating ICUs.
A national program to screen patients for severe sepsis and septic shock and implement Surviving Sepsis Campaign bundles to complete within 6 and 24 hours after ICU admission.
Bundle target adherence and case-mix adjusted in-hospital mortality were evaluated through odds ratios of time since program initiation by logistic generalized estimating equation analyses (July 2009 through January 2013). Outcomes were adjusted for age, gender, admission type, severity of illness, and sepsis diagnosis location. Participation duration was associated with improved bundle target adherence (adjusted odds ratio per month = 1.024 [1.016-1.031]) and decreased in-hospital mortality (adjusted odds ratio per month = 0.992 [0.986-0.997]) equivalent to 5.8% adjusted absolute mortality reduction over 3.5 years. Mortality reduced in screened patients with other diagnoses (1.9% over 3.5 yr, adjusted odds ratio per month = 0.995 [0.9906-0.9996]) and did not change in nonscreened patients in participating ICUs, nor in patients with sepsis or other diagnoses in nonparticipating ICUs.
Implementation of a national sepsis program resulted in improved adherence to sepsis bundles in severe sepsis and septic shock patients and was associated with reduced adjusted in-hospital mortality only in participating ICUs, suggesting direct impact of sepsis screening and bundle application on in-hospital mortality.
Critical care medicine 03/2014; · 6.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Previous efforts such as Assessing Care of Vulnerable Elders (ACOVE) provide quality indicators for assessing the care of elderly patients, but thus far little has been done to leverage this knowledge to improve care for these patients. We describe a clinical decision support system to improve general practitioner (GP) adherence to ACOVE quality indicators and a protocol for investigating impact on GPs' adherence to the rules.
We propose two randomized controlled trials among a group of Dutch GP teams on adherence to ACOVE quality indicators. In both trials a clinical decision support system provides un-intrusive feedback appearing as a color-coded, dynamically updated, list of items needing attention. The first trial pertains to real-time automatically verifiable rules. The second trial concerns non-automatically verifiable rules (adherence cannot be established by the clinical decision support system itself, but the GPs report whether they will adhere to the rules). In both trials we will randomize teams of GPs caring for the same patients into two groups, A and B. For the automatically verifiable rules, group A GPs receive support only for a specific inter-related subset of rules, and group B GPs receive support only for the remainder of the rules. For non-automatically verifiable rules, group A GPs receive feedback framed as actions with positive consequences, and group B GPs receive feedback framed as inaction with negative consequences. GPs indicate whether they adhere to non-automatically verifiable rules. In both trials, the main outcome measure is mean adherence, automatically derived or self-reported, to the rules.
We relied on active end-user involvement in selecting the rules to support, and on a model for providing feedback displayed as color-coded real-time messages concerning the patient visiting the GP at that time, without interrupting the GP's workflow with pop-ups. While these aspects are believed to increase clinical decision support system acceptance and its impact on adherence to the selected clinical rules, systems with these properties have not yet been evaluated.Trial registration: Controlled Trials NTR3566.
[Show abstract][Hide abstract] ABSTRACT: Objective
To develop a prognostic model for antenatal prediction of neonatal mortality in infants threatening to be born very preterm (< 32 weeks).
Nationwide cohort study in The Netherlands between 1999 and 2007. We studied 8,500 singletons born between 25+0 and 31+6 weeks of gestation where fetus was alive at birth without congenital anomalies. We developed a multiple logistic regression model to estimate the risk of neonatal mortality within 28 days after birth, based on characteristics that are known before birth. We used bootstrapping techniques for internal validation. Discrimination (AUC), accuracy (Brier score) and calibration (graph, c-statistics) were used to assess the model's predictive performance.
Neonatal mortality occurred in 766 (90 per 1000) live births. The final model consisted of seven variables. Predictors were low gestational age, no antental corticosteroids, male gender, maternal age ≥ 35 years, Caucasian ethnicity, non-cephalic presentation and non-3rd level of hospital. The predicted probabilities ranged from 0.003 to 0.697 (IQR 0.02-0.11). The model had an AUC of 0.83, the Brier score was 0.065. The calibration graph showed good calibration, and the test for the Hosmer Lemeshow c-statistic showed no lack of fit (p = 0.43).
Neonatal mortality can be predicted for very preterm births based on the antenatal factors gestational age, antental corticosteroids, fetal gender, maternal age, ethnicity, presentation and level of hospital. This model can be helpful in antenatal counselling.
European journal of obstetrics, gynecology, and reproductive biology 01/2014; · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Storage and transportation of red blood cells (RBCs) outside the standard temperature range as defined by guidelines can lead to hemolysis. One of the main factors believed to cause hemolysis is temperature.Infusion of the corrupted RBCs leads to haemolytic reactions which are severe and life-threatening. We developed a temperature monitoring system to monitor temperature changes of each blood bag during storage and transportation. The main objective of the present study was evaluating the accuracy of the temperature monitoring system and studying its feasibility. Validating the system relied on accurate digital thermometers that latch on a blood bag. To evaluate the feasibility, a case study was performed on 20 RBC bags transported from hospital blood bank to the cardiac surgery intensive care unit and the heart operating room. The results indicated that 12% of 25605 recorded temperatures (per minute) were outside the standard range. Minimum and maximum temperatures were 0.5°C and 16°C that were below and above the standard, respectively. The system was shown to be easily handled by users. The system is capable to alarm when a blood bag's temperature is outside the standard temperature and prevents blood corruption. This system can be used as a decision support system in blood transfusion services to improve storage and transportation conditions of the blood bags.
Studies in health technology and informatics 01/2014; 205:730-734.
[Show abstract][Hide abstract] ABSTRACT: Falls form a major health problem for older persons, and increasingly strain the healthcare system. The Internet is a potentially useful platform for empowering seniors. The aim of this study was therefore to investigate the information-seeking behavior about falls among elderly Internet users. A web-based survey was distributed among all members of an association of elderly people (> 60 years old). Fallers and non-fallers, seniors with and without experience with information seeking and the willingness of elderly for undertaking self-assessment tests on the Internet versus solely receiving information about falls were compared. In general, there was much stated interest in receiving information about conditions and medications that increase the risk of falls and information on safety in the house. Around half of the 62 respondents did not feel that they are well-informed about falls. Searching for fall-related information was not significantly associated with having falls in the previous 12 months (OR 2.11, CI: 0.55-8.16). The majority expressed higher interest in receiving fall-related information than undertaking a self-assessment test. However, only a small proportion had searched for this information already.
Studies in health technology and informatics 01/2014; 205:647-651.
[Show abstract][Hide abstract] ABSTRACT: In critically ill patients, glucose control with insulin mandates time- and blood-consuming glucose monitoring. Blood glucose level fluctuations are accompanied by metabolomic changes that alter the composition of volatile organic compounds (VOC), which are detectable in exhaled breath. This review systematically summarizes the available data on the ability of changes in VOC composition to predict blood glucose levels and changes in blood glucose levels.
[Show abstract][Hide abstract] ABSTRACT: Background and Objective: Internet forms an opportunity to inform, teach, and connect professionals and patients. However, much information on Internet is incomplete, inaccurate, or misleading, and not only in the medical domain. Because of the potential for damage from misleading and inaccurate health information, many organizations and individuals have published or implemented scoring tools for evaluating the appropriateness or quality of these resources. The objective of this study is to identify and summarize scoring tools that have evaluated web-sites providing reproductive health information in order to compare them and recommend an overarching evaluation tool. Methods: We searched Ovid MEDLINE(R) (1946 to July 2013) and OVID Embase (1980 to July 2013); and included English language studies that have evaluated the quality of websites providing reproductive health information. Studies only assessing the content of websites were excluded. Results: We identified 5 scoring tools: 1-The HON (health on the net) Code of Conduct for medical and health Web sites, 2-Silberg scores, 3-Hogne Sandvik scale, 4-Jim Kapoun's Criteria for Evaluating Web Pages, and 5-The Health Information Technology Institute (HITI) criteria. We have compared these scales and identified 14 criteria: authorship, ownership, currency, objectivity/content, transparency/source, interactivity, privacy/ethics, financial disclosure, navigability/links, complementarity, advertising policy, design, quantity, and accessibility. We integrated these criteria and introduced a new tool with 10 criteria. Conclusion: Website evaluation tools differ in their evaluation criteria and there is a lack of consensus about which to use; therefore, an integrated easy to use set of criteria is needed.
Studies in health technology and informatics 01/2014; 205:895-899.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to assess the classification accuracy of an e-Nose in detecting acute liver failure (ALF) in rats. Exhaled breath from 14 rats was repeatedly sampled by e-Nose (8 sensors) and an additional external CO2 sensor at three stages: healthy period; portacaval shunt; and during the development of ALF due to surgically induced complete liver ischemia. We performed principal component analysis (PCA) on the (grouped) sensor data in each stage and the classification accuracy of the first two principal components was assessed by the leave-one-out approach. In addition we performed gas chromatography-mass spectrometry (GC-MS) analysis of the exhaled breath from three rats. The first and second principal components from the PCA analysis of e-Nose data accounted for more than 95% variance in the data. Measurements in the ALF stage were contrasted with the measurements in the control stage. Leave-one-out validation showed classification accuracy of 96%. This accuracy was reached after 3h of ALF development, and was reached already after 2h when data of an external CO2 sensor were also included. GC-MS identified 2-butanol, 2-butanone, 2-pentanone and 1-propanol to be possibly elevated in the ALF stage. This is the first study to demonstrate that ALF in rats can be detected by e-Nose data analysis of the exhaled breath. Confirmation of these results in humans will be an important step forward in the non-invasive diagnosis of ALF.
[Show abstract][Hide abstract] ABSTRACT: Polypharmacy, and specifically the use of multiple fall-risk-increasing drugs (FRID), have been associated with increased risk of falling in older age. However, it is not yet clear whether the known set of FRIDs can be extrapolated to recurrent fallers, since they form a distinct group of more vulnerable older persons with different characteristics.
We aim to investigate which classes of medications are associated with recurrent falls in elderly patients visiting the Emergency Department (ED) after a fall.
This study had a cross-sectional design and was conducted in the ED of an academic medical center. Patients who sustained a fall, 65 years or older, and who visited the ED between 2004 and 2010 were invited to fill in a validated fall questionnaire designed to assess patient and fall characteristics (CAREFALL Triage Instrument [CTI]). We translated self-reported medications to anatomical therapeutic chemical (ATC) codes (at the second level). Univariate logistic regression analysis was performed to explore the association between medication classes and the outcome parameter (recurrent fall). Multivariate logistic regression was used to assess the associations after adjustment to potential confounders.
In total 2,258 patients participated in our study, of whom 39 % (873) had sustained two or more falls within the previous year. After adjustment for the potential confounders, drugs for acid-related disorders (adjusted odds ratio [aOR] 1.29; 95 % CI 1.03-1.60), analgesics (aOR 1.22; 95 % CI 1.06-1.41), anti-Parkinson drugs (aOR 1.59; 95 % CI 1.02-2.46), nasal preparations (aOR 1.49; 95 % CI 1.07-2.08), ophthalmologicals (aOR 1.51; 95 % CI 1.10-2.09); antipsychotics (aOR 2.21; 95 % CI 1.08-4.52), and antidepressants (aOR 1.64; 95 % CI 1.13-2.37) remained statistically significantly associated with an ED visit due to a recurrent fall.
Known FRIDs, such as psychotropic drugs, also increase the risk of recurrent falls. However, we found four relatively new classes that showed significant association with recurrent falls. In part, these classes may act as markers of frailty and comorbidity, or they may reflect differences in the risk factors affecting the older, frailer population that tends to sustain recurrent falls. Further investigation is needed to elucidate causes and ways to prevent recurrent falls.
[Show abstract][Hide abstract] ABSTRACT: To analyze the influence of using mortality 1, 3, and 6 months after intensive care unit (ICU) admission instead of in-hospital mortality on the quality indicator standardized mortality ratio (SMR).
A cohort study of 77,616 patients admitted to 44 Dutch mixed ICUs between 1 January 2008 and 1 July 2011. Four Acute Physiology and Chronic Health Evaluation (APACHE) IV models were customized to predict in-hospital mortality and mortality 1, 3, and 6 months after ICU admission. Models' performance, the SMR and associated SMR rank position of the ICUs were assessed by bootstrapping.
The customized APACHE IV models can be used for prediction of in-hospital mortality as well as for mortality 1, 3, and 6 months after ICU admission. When SMR based on mortality 1, 3 or 6 months after ICU admission was used instead of in-hospital SMR, 23, 36, and 30 % of the ICUs, respectively, received a significantly different SMR. The percentages of patients discharged from ICU to another medical facility outside the hospital or to home had a significant influence on the difference in SMR rank position if mortality 1 month after ICU admission was used instead of in-hospital mortality.
The SMR and SMR rank position of ICUs were significantly influenced by the chosen endpoint of follow-up. Case-mix-adjusted in-hospital mortality is still influenced by discharge policies, therefore SMR based on mortality at a fixed time point after ICU admission should preferably be used as a quality indicator for benchmarking purposes.
European Journal of Intensive Care Medicine 08/2013; · 5.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports.
The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011.
Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months.
We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded.
The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports.
The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD, 2.3; range, 0.6-8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0-12). ICU length of stay did not significantly reduce after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92-1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality).
In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.
Critical care medicine 08/2013; 41(8):1893-1904. · 6.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To propose a combined disease management and process modeling approach for evaluating and improving care processes, and demonstrate its usability and usefulness in a real-world fall management case study.
We identified essential disease management related concepts and mapped them into explicit questions meant to expose areas for improvement in the respective care processes. We applied the disease management oriented questions to a process model of a comprehensive real world fall prevention and treatment program covering primary and secondary care. We relied on interviews and observations to complete the process models, which were captured in UML activity diagrams. A preliminary evaluation of the usability of our approach by gauging the experience of the modeler and an external validator was conducted, and the usefulness of the method was evaluated by gathering feedback from stakeholders at an invitational conference of 75 attendees.
The process model of the fall management program was organized around the clinical tasks of case finding, risk profiling, decision making, coordination and interventions. Applying the disease management questions to the process models exposed weaknesses in the process including: absence of program ownership, under-detection of falls in primary care, and lack of efficient communication among stakeholders due to missing awareness about other stakeholders' workflow. The modelers experienced the approach as usable and the attendees of the invitational conference found the analysis results to be valid.
The proposed disease management view of process modeling was usable and useful for systematically identifying areas of improvement in a fall management program. Although specifically applied to fall management, we believe our case study is characteristic of various disease management settings, suggesting the wider applicability of the approach.
International Journal of Medical Informatics 07/2013; · 2.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with atrial fibrillation (AF) are at increased risk for stroke. Antithrombotic treatment reduces this risk. Antithrombotic treatment consists of either administration of oral anticoagulants (OAC) or the provision of an antiplatelet drug. International guidelines provide advice on the preferred treatment, thereby balancing the risks and benefits of OAC. However, adherence to these guidelines is reported to be as low as 50%. There is paucity in research on why adherence rates are low. Recent studies have shown decision support systems can improve guideline adherence. We investigate the use of a clinical decision support system to improve guideline adherence among general practitioners (GPs) treating patients with AF and study reasons for guideline non-adherence.
The study is a randomized controlled trial, which is performed among Dutch general practitioners. Initially, GPs in the vicinity of the Academic Medical Center (AMC) in Amsterdam will be included, after which other practices will be recruited. We have developed a novel decision support system that displays a list with pending messages for the on-screen medical record in real time,. Messages are generated on a server that evaluates a decision rule based on the atrial fibrillation guideline of the Dutch College of General Practitioners. By interacting with the list, messages can be opened for a description and explanation, or be ignored. GPs are allocated into three groups: 1) control group; 2) intervention group A, in which messages can be ignored without justification; and 3) intervention group B, in which messages can only be ignored with justification.Our main outcome measure is the between-group difference in the proportion of patients receiving antithrombotic prescriptions in adherence to the Dutch GP guideline for atrial fibrillation. Secondary outcomes are reasons GPs state for deviating from the guideline and the effect on guideline adherence of requiring justification when ignoring a message.
This paper describes the protocol for a cluster randomized trial to study the effects of a clinical decision support system in patients with atrial fibrillation. The system is characterized by a non-interruptive presentation and real-time messages that are updated after each relevant action the GP performs.Trial registration: This trial is registered with the Dutch Trial Register under registration number 3570.
[Show abstract][Hide abstract] ABSTRACT: & Aims: Guidelines recommend prescribing gastroprotective agents (proton-pump inhibitors, misoprostol) to older patients (primarily ≥65 y old) taking non-steroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal ulcers. Older individuals are under-represented in clinical trials of these agents. We systematically reviewed evidence from observational studies on the use of gastroprotective agents in elderly patients and their ability to prevent NSAID-related ulcers in this population.
We performed a systematic search of Embase and MedLine, and identified 23 observational studies that focused on elderly patients and reported data on co-prescription of gastroprotective agents and NSAIDs and/or the effectiveness of the agents in preventing gastrointestinal events in NSAID users. We collected data on rates of co-prescription and NSAID-related gastrointestinal events in patients with and without gastroprotection.
A median of 24% (range 10%-69%) of elderly patients taking NSAIDs received a co-prescription for gastroprotective agents; this percentage was only slightly higher in the oldest age groups. All studies of efficacy showed a positive effect of gastroprotection. However, the adjusted results were not suitable for synthesis, and the 5 studies reporting unadjusted results were too heterogeneous for meta-analysis (I(2) =97%). The studies differed in outcomes, definitions of co-prescription, and differences in baseline risk factors between patients with and without gastroprotection. None of the studies assessed adverse effects of gastroprotective agents. The 2 cost-effectiveness studies reached opposing conclusions.
In a systematic review, the observational evidence for the efficacy of gastroprotective agents in preventing NSAID-associated gastrointestinal events was in agreement with results of randomized controlled trials. However, due to heterogeneity of included studies, it is not clear what the effect would be if more patients were treated, or at what age gastroprotection should be recommended. We offer suggestions to facilitate comparison with other work and address the questions of risk and benefit in relation to age.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 06/2013; · 5.64 Impact Factor