Gary E. Rosenthal

Polypharmacy and Prescribing Quality in Older People

OBJECTIVES: To evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients.

Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees

BACKGROUNDDisclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood.OBJECTIVETo survey physicians and trainees about their practices and attitudes regarding error disclosure to patients.DESIGN AND PARTICIPANTSSurvey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States.MEASUREMENTSActual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors.RESULTSResponses were received from 538 participants (response rateu2009=u200977%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost.CONCLUSIONSThere appears to be a gap between physicians’ attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation.

Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals.

BACKGROUND: It has been suggested that inexperience of new housestaff early in an academic year may worsen patient outcomes. Yet, few studies have evaluated the “July Phenomenon,” and no studies have investigated its effect in intensive care patients, a group that may be particularly susceptible to deficiencies in management stemming from housestaff inexperience.OBJECTIVE: Compare hospital mortality and length of stay (LOS) in intensive care unit (ICU) admissions from July to September to admissions during other months, and compare that relationship in teaching and nonteaching hospitals, and in surgical and nonsurgical patients.DESIGN, SETTING, AND PATIENTS: Retrospective cohort analysis of 156,136 consecutive eligible patients admitted to 38 ICUs in 28 hospitals in Northeast Ohio from 1991 to 1997.RESULTS: Adjusting for admission severity of illness using the APACHE III methodology, the odds of death was similar for admissions from July through September, relative to the mean for all months, in major (odds ratio [OR], 0.96; 95% confidence interval [95% CI], 0.91 to 1.02; P=.18), minor (OR, 1.02; 95% CI, 0.93 to 1.10; P=.66), and nonteaching hospitals (OR, 0.96; 95% CI, 0.91 to 1.01; P=.09). The adjusted difference in ICU LOS was similar for admissions from July through September in major (0.3%; 95% CI, −0.7% to 1.2%; P=.61) and minor (0.2%; 95% CI, −0.9% to 1.4%; P=.69) teaching hospitals, but was somewhat shorter in nonteaching hospitals (−0.8%; 95% CI, −1.4 to −0.1; P=.03). Results were similar when individual months and academic years were examined separately, and in stratified analyses of surgical and nonsurgical patients.CONCLUSIONS: We found no evidence to support the existence of a July phenomenon in ICU patients. Future studies should examine organizational factors that allow hospitals and residency programs to compensate for inexperience of new house-staff early in the academic year.

An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors

AbstractBACKGROUND: Physician disclosure of medical errors to institutions, patients, and colleagues is important for patient safety, patient care, and professional education. However, the variables that may facilitate or impede disclosure are diverse and lack conceptual organization.n OBJECTIVE: To develop an empirically derived, comprehensive taxonomy of factors that affects voluntary disclosure of errors by physicians.n DESIGN: A mixed-methods study using qualitative data collection (structured literature search and exploratory focus groups), quantitative data transformation (sorting and hierarchical cluster analysis), and validation procedures (confirmatory focus groups and expert review).n RESULTS: Full-text review of 316 articles identified 91 impeding or facilitating factors affecting physicians’ willingness to disclose errors. Exploratory focus groups identified an additional 27 factors. Sorting and hierarchical cluster analysis organized factors into 8 domains. Confirmatory focus groups and expert review relocated 6 factors, removed 2 factors, and modified 4 domain names. The final taxonomy contained 4 domains of facilitating factors (responsibility to patient, responsibility to self, responsibility to profession, responsibility to community), and 4 domains of impeding factors (attitudinal barriers, uncertainties, helplessness, fears and anxieties).n CONCLUSIONS: A taxonomy of facilitating and impeding factors provides a conceptual framework for a complex field of variables that affects physicians’ willingness to disclose errors to institutions, patients, and colleagues. This taxonomy can be used to guide the design of studies to measure the impact of different factors on disclosure, to assist in the design of error-reporting systems, and to inform educational interventions to promote the disclosure of errors to patients.

Patient and Hospital Differences Underlying Racial Variation in Outcomes After Coronary Artery Bypass Graft Surgery

Background—Few studies have examined the association of race and outcomes after coronary artery bypass graft (CABG) surgery while controlling for both patient and hospital effects. Methods and Results—We retrospectively analyzed data on a cohort of 566 785 white and 24 354 black Medicare beneficiaries 65 years old and older undergoing CABG in 1091 US hospitals from 1997 to 2000. Mortality and repeat revascularization rates were examined after sequential adjustment for patient and hospital differences by use of generalized estimating equations. Unadjusted mortality was higher (P<0.001) in black than in white patients at 30 (6.4% versus 5.2%), 90 (8.3% versus 6.6%), and 365 days (13.5% versus 9.8%) after surgery. Black patients were more likely (P<0.001) to undergo CABG at hospitals with the highest mortality (56% versus 47%) and at hospitals in the lowest volume quintile (24% versus 20%). Adjusted only for patient characteristics, mortality was 8%, 11%, and 25% higher in black patients at 30, 90, and 365 days. After adjustment for hospital effects, 30 and 90 day mortality was similar but 17% higher in black patients at 365 days. Racial differences in mortality were greater in men than in women. On adjustment for patient and hospital effects, repeat revascularization rates were similar in black and white patients. Conclusions—Racial disparities in CABG outcomes are sensitive to the effects of sex and duration of postsurgical follow-up. The increasing disparity in outcomes as follow-up increased is consistent with the hypothesis that black patients have less access to secondary prevention and rehabilitation services after surgery.

Evaluation of Home Telehealth Following Hospitalization for Heart Failure: A Randomized Trial

Previous studies have found that home-based intervention programs reduce readmission rates for patients with heart failure. Only one previous trial has compared telephone and videophone to traditional care to deliver a home-based heart failure intervention program. The objective of this study was to evaluate the efficacy of a telehealth-facilitated postdischarge support program in reducing resource use in patients with heart failure. Patients at a Midwestern Department of Veterans Affairs Medical Center were randomized to telephone, videophone, or usual care for follow-up care after hospitalization for heart failure exacerbation. Outcome measures included readmission rates; time to first readmission; urgent care clinic visits; survival; and quality of life. The intervention resulted in a significantly longer time to readmission but had no effect on readmission rates or mortality. There were no differences in hospital days or urgent care clinic use. All subjects reported higher disease-specific quality of life scores at 1 year. There was evidence of the value of telephone follow-up, but there was no evidence to support the benefit of videophone care over telephone care. Rigorous evaluation is needed to determine which patients may benefit most from specific telehealth applications and which technologies are most cost-effective.

Facilitating and Impeding Factors for Physicians’ Error Disclosure: A Structured Literature Review

BACKGROUNDnIt is important for physicians to disclose medical errors to institutions (for patient safety), to colleagues (for professional learning), and to patients (as part of direct patient care), but no comprehensive review of factors that may facilitate or impede disclosure has been undertaken.nnnMETHODSnA MEDLINE search was conducted of English-language articles published from 1975-2004, with review of bibliographies. A total of 5,509 articles were reviewed by title, 881 articles were retrieved for full text review, and 475 articles satisfied the inclusion criteria. Article content was assessed by identifying factors that facilitate or impede disclosure and classifying each articles primary goal of disclosure.nnnRESULTSnThirty-five factors believed to facilitate disclosure were identified (for example, accountability, honesty, restitution), as were 41 factors believed to impede it (for example, professional repercussions, legal liability, blame). The three most common goals of disclosure were to improve patient safety, enhance learning, and inform patients. Facilitating factors were more commonly cited when the goal of disclosure was to inform patients.nnnDISCUSSIONnA wide range of factors are capable of facilitating or impeding the disclosure of medical errors. Innovations to enhance error disclosure should address both sides of the equation: impeding factors should be removed and facilitating factors should be promoted.

Trends in the Use of Percutaneous Ventricular Assist Devices: Analysis of National Inpatient Sample Data, 2007 Through 2012

IMPORTANCEnPercutaneous ventricular assist devices (PVADs) provide robust hemodynamic support compared with intra-aortic balloon pumps (IABPs), but clinical use patterns are unknown.nnnOBJECTIVEnTo examine contemporary patterns in PVAD use in the United States and compare them with use of IABPs.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective study of adults older than 18 years who received a PVAD or IABP while hospitalized in the United States (2007-2012).nnnMAIN OUTCOMES AND MEASURESnTemporal trends in utilization, patient and hospital characteristics, in-hospital mortality, and cost of PVAD use compared with IABP.nnnRESULTSnDuring 2007 through 2012, utilization of PVADs increased 30-fold (4.6 per million discharges in 2007 to 138 per million discharges in 2012; P for trend <u2009.001) while utilization of IABPs decreased from 1738 per million discharges in 2008 to 1608 per million discharges in 2012 (P for trendu2009=u2009.02). In 2007, an estimated 72 hospitals used PVADs, increasing to 477 in 2011 (P for trend <u2009.001). The number of hospitals with an annual volume of 10 or more PVAD procedures per year increased from 0 in 2007 to 102 in 2011 (21.4% of PVAD-using hospitals; P for trend <u2009.001). Among PVAD recipients, 67.3% had a diagnosis of cardiogenic shock or acute myocardial infarction (AMI). There was a temporal increase in the use of PVADs in older patients and patients with AMI, hypertension, diabetes mellitus, and chronic kidney disease (P for trend <u2009.001 for all). Overall, mortality in PVAD recipients was 28.8%, and mean (SE) hospitalization cost was

Outcomes of a home telehealth intervention for patients with heart failure

85,580 (

Internists’ attitudes towards terminal sedation in end of life care

4165); both were significantly higher in PVAD recipients with cardiogenic shock (mortality, 47.5%; mean [SE] cost,