David A. Dorr

Venous thromboembolism and mortality associated with recombinant erythropoietin and darbepoetin administration for the treatment of cancer-associated anemia

CONTEXT The erythropoiesis-stimulating agents (ESAs) erythropoietin and darbepoetin are licensed to treat chemotherapy-associated anemia in patients with nonmyeloid malignancies. Although systematic overviews of trials have identified venous thromboembolism (VTE) risks, none have identified mortality risks with ESAs. OBJECTIVE To evaluate VTE and mortality rates associated with ESA administration for the treatment of anemia among patients with cancer. DATA SOURCES A published overview from the Cochrane Collaboration (search dates: January 1, 1985-April 1, 2005) and MEDLINE and EMBASE databases (key words: clinical trial, erythropoietin, darbepoetin, and oncology), the public Web site of the US Food and Drug Administration and ESA manufacturers, and safety advisories (search dates: April 1, 2005-January 17, 2008). STUDY SELECTION Phase 3 trials comparing ESAs with placebo or standard of care for the treatment of anemia among patients with cancer. DATA EXTRACTION Mortality rates, VTE rates, and 95% confidence intervals (CIs) were extracted by 3 reviewers from 51 clinical trials with 13 611 patients that included survival information and 38 clinical trials with 8172 patients that included information on VTE. DATA SYNTHESIS Patients with cancer who received ESAs had increased VTE risks (334 VTE events among 4610 patients treated with ESA vs 173 VTE events among 3562 control patients; 7.5% vs 4.9%; relative risk, 1.57; 95% CI, 1.31-1.87) and increased mortality risks (hazard ratio, 1.10; 95% CI, 1.01-1.20). CONCLUSIONS Erythropoiesis-stimulating agent administration to patients with cancer is associated with increased risks of VTE and mortality. Our findings, in conjunction with basic science studies on erythropoietin and erythropoietin receptors in solid cancers, raise concern about the safety of ESA administration to patients with cancer.

Informatics Systems to Promote Improved Care for Chronic Illness: A Literature Review

OBJECTIVE To understand information systems components important in supporting team-based care of chronic illness through a literature search. DESIGN Systematic search of literature from 1996-2005 for evaluations of information systems used in the care of chronic illness. MEASUREMENTS The relationship of design, quality, information systems components, setting, and other factors with process, quality outcomes, and health care costs was evaluated. RESULTS In all, 109 articles were reviewed involving 112 information system descriptions. Chronic diseases targeted included diabetes (42.9% of reviewed articles), heart disease (36.6%), and mental illness (23.2%), among others. System users were primarily physicians, nurses, and patients. Sixty-seven percent of reviewed experiments had positive outcomes; 94% of uncontrolled, observational studies claimed positive results. Components closely correlated with positive experimental results were connection to an electronic medical record, computerized prompts, population management (including reports and feedback), specialized decision support, electronic scheduling, and personal health records. Barriers identified included costs, data privacy and security concerns, and failure to consider workflow. CONCLUSION The majority of published studies revealed a positive impact of specific health information technology components on chronic illness care. Implications for future research and system designs are discussed.

The Effect of Technology-Supported, Multidisease Care Management on the Mortality and Hospitalization of Seniors

OBJECTIVES: To explore changes in mortality and hospital usage for chronically ill seniors enrolled in a multidisease care management program, Care Management Plus (CMP).

Use of health-related, quality-of-life metrics to predict mortality and hospitalizations in community-dwelling seniors

OBJECTIVES: To investigate whether health‐related quality‐of‐life (HRQoL) scores in a primary care population can be used as a predictor of future hospital utilization and mortality.

Information Technology to Support Improved Care For Chronic Illness

BackgroundIn populations with chronic illness, outcomes improve with the use of care models that integrate clinical information, evidence-based treatments, and proactive management of care. Health information technology is believed to be critical for efficient implementation of these chronic care models. Health care organizations have implemented information technologies, such as electronic medical records, to varying degrees. However, considerable uncertainty remains regarding the relative impact of specific informatics technologies on chronic illness care.ObjectiveTo summarize knowledge and increase expert consensus regarding informatics components that support improvement in chronic illness care. Design: A systematic review of the literature was performed. “Use case” models were then developed, based on the literature review, and guidance from clinicians and national quality improvement projects. A national expert panel process was conducted to increase consensus regarding information system components that can be used to improve chronic illness care.ResultsThe expert panel agreed that informatics should be patient-centered, focused on improving outcomes, and provide support for illness self-management. They concurred that outcomes should be routinely assessed, provided to clinicians during the clinical encounter, and used for population-based care management. It was recommended that interactive, sequential, disorder-specific treatment pathways be implemented to quickly provide clinicians with patient clinical status, treatment history, and decision support.ConclusionsSpecific informatics strategies have the potential to improve care for chronic illness. Software to implement these strategies should be developed, and rigorously evaluated within the context of organizational efforts to improve care.

Cost Analysis of Nursing Home Registered Nurse Staffing Times

Objectives: To examine potential cost savings from decreased adverse resident outcomes versus additional wages of nurses when nursing homes have adequate staffing.

Design and Implementation of a Medication Reconciliation Kiosk: the Automated Patient History Intake Device (APHID)

Errors associated with medication documentation account for a substantial fraction of preventable medical errors. Hence, the Joint Commission has called for the adoption of reconciliation strategies at all United States healthcare institutions. Although studies suggest that reconciliation tools can reduce errors, it remains unclear how best to implement systems and processes that are reliable and sensitive to clinical workflow. The authors designed a primary care process that supported reconciliation without compromising clinic efficiency. This manuscript describes the design and implementation of Automated Patient History Intake Device (APHID): ambulatory check-in kiosks that allow patients to review the names, dosage, frequency, and pictures of their medications before their appointment. Medication lists are retrieved from the electronic health record and patient updates are captured and reviewed by providers during the clinic session. Results from the roll-in phase indicate the device is easy for patients to use and integrates well with clinic workflow.

A framework for information system usage in collaborative care

UNLABELLED Clinical information systems (CIS) can affect the quality of patient care. In this paper, we focus on CIS use in the collaborative treatment of chronic diseases. We have developed a framework to determine which CIS functions have general usefulness for improving patient outcomes. METHODS We reviewed the use of clinical information systems within a collaborative care environment, identifying CIS functions important in chronic disease care. We grouped the functions into categories of access, best practices, and communication (ABC). Three independent raters selected the most important collaborative care related functions from the HL7 Electronic Health Record Systems functional model, and mapped the HL7 functions against the ABC categories. We then built a model of CIS use and tested it on data from a cohort of patients with chronic illnesses. RESULTS Of the 133 HL7 elements in the ABC model, 60 (45%) were ranked as important for collaborative care by two reviewers. Agreement was moderate for importance (kappa=.20) but high for ABC categorization (kappa=.67). In our data tests, for the 1105 patients, access 4.4+/-6.5, best practices 0.8+/-1.6, and communication 2.9+/-4.5. CIS functions were used per episode of care. We were able to identify several key functions that may affect patient care. For example, certain CIS functions related to best practices were associated with higher clinician adherence to testing guidelines. DISCUSSION This framework may be useful to assess and compare CIS systems for collaborative care. Future refinements of the model are discussed.

Interdisciplinary collaboration in geriatrics: Advancing health for older adults

The call for interdisciplinary research, education, and practice is heightened by the recognition of the potential it holds in generating creative solutions to complex problems in health care and to improving quality and effectiveness of care. With the aging of the population and the complex issues in caring for older adults, interdisciplinary collaboration is particularly salient to the field of geriatrics. However, despite interest in this approach for several decades, adoption has been slow and dissemination is not widespread. This article provides examples of recent initiatives and presents driving and restraining forces involved in adoption of interdisciplinary approaches.

Using Consumer-Based Kiosk Technology to Improve and Standardize Medication Reconciliation in a Specialty Care Setting

BACKGROUND Discrepancies in medication documentation most often occur at handoffs or transition points in care. A process improvement team at the Portland Department of Veterans Affairs developed a standardized medication reconciliation process for the Portland chemotherapy administration unit, a physically self-contained clinic with a standard intake process and a uniform patient traffic pattern. METHODS The team developed the automated patient history intake device (APHID), a reconciliation software program accessed by the patient using a computer terminal kiosk in the clinic lobby. The program simultaneously checks in patients for an appointment and gathers a medication-adherence history by retrieving medication lists from all Veterans Affairs facilities and pairing each medication with a pill picture. Installation of the APHID kiosk included an initial two-week roll-in period beginning in February 2008. RESULTS During the roll-in period, 91 (82.0%) of 111 patients completed check-in and performed medication reconciliation using the kiosk. Medication lists gathered at the kiosk were compared with existing health record documentation and clinician interviews. For each patient encounter, the process demonstrated an average of 4.59 discrepancies and an average of 1.61 clinically significant or potentially lethal discrepancies. The new process saved approximately 0.24 full-time equivalents of nursing time in the chemotherapy clinic-a nearly 50% reduction in nursing time dedicated to reconciliation activities without an apparent loss in data accuracy. DISCUSSION A patient-centered reconciliation model using consumer-based kiosk technology helped providers efficiently retrieve a comprehensive list of medications across a geographically diverse area and improve patient medication recall using visual cues including medication pictures.