Layla Parast

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system.

BACKGROUND: Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates. OBJECTIVE: The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic childrens hospital. PATIENTS AND METHODS: We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic childrens hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80 063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17 432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation. RESULTS: After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008–0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%–40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame. CONCLUSION: Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic childrens hospital.

Prevalence of adverse events in pediatric intensive care units in the United States.

Objectives: Selection of relevant patient safety interventions for the pediatric intensive care (PICU) requires identification of the types and severity of adverse events (AEs) and adverse drug events (ADEs) that occur in this setting. The studys objectives were to: 1) determine the rates of AEs/ADEs, including types, severity, and preventability, in PICU patients; 2) identify population characteristics associated with increased risk of AEs/ADEs; 3) develop and test a PICU specific trigger tool to facilitate identification of AEs/ADEs. Design, Setting, Patients: Retrospective, cross-sectional, randomized review of 734 patient records who were discharged from 15 U.S. PICUs between September and December 2005. Intervention: A novel PICU-focused trigger tool for AE/ADE detection. Measurements and Results: Sixty-two percent of PICU patients had at least one AE. A total of 1488 AEs, including 256 ADEs, were identified. This translates to a rate of 28.6 AEs and 4.9 ADEs per 100 patient-days. The most common types of AEs were catheter complications, uncontrolled pain, and endotracheal tube malposition. Ten percent of AEs were classified as life-threatening or permanent; 45% were deemed preventable. Higher adjusted rates of AEs were found in surgical patients (p = .02), patients intubated at some point during their PICU stay (p = .002), and patients who died (p < .001). Surgical patients had higher preventable adjusted AE (p = .01) and ADE rates (p = .02). The adjusted cumulative risk of an AE per PICU day was 5.3% and 1.6% for an ADE alone. There was a 4% increase in adjusted ADEs rates for every year increase in age. Conclusions: AEs and ADEs occur frequently in the PICU setting. These data provide areas of focus for evidence-based prevention strategies to decrease the substantial risk to this vulnerable pediatric population.

Axial and Reformatted Four-Chamber Right Ventricle–to–Left Ventricle Diameter Ratios on Pulmonary CT Angiography as Predictors of Death After Acute Pulmonary Embolism

OBJECTIVE The purpose of this article is to retrospectively compare right ventricular-to-left ventricular (RV/LV) diameter ratios measured on the standard axial view versus the reformatted four-chamber view as predictors of mortality after acute pulmonary embolism (PE). MATERIALS AND METHODS Six hundred seventy-four consecutive patients (mean age, 58 years; 372 women) with a diagnosis of acute PE on pulmonary CT angiography were considered. The axial and reformatted four-chamber RV/LV diameter ratios were compared as predictors of 30-day all-cause and PE-related mortality. RESULTS Ninety-seven patients (14%) died within 30 days; 39 deaths were PE related. There was no significant difference in the univariate hazard ratios (HRs) of axial and four-chamber RV/LV diameter ratios greater than 0.9 for both all-cause (HR, 2.13 [95% CI, 1.29-3.51] vs HR, 1.95 [95% CI, 1.22-3.14]; p = 0.74) and PE-related (HR, 19.6 [95% CI, 2.70-143] vs HR, 21.8 [95% CI, 2.99-158]; p = 1.0) mortality. Axial and four-chamber multivariate HRs accounting for potential confounders such as age and cancer were also similar for all-cause (HR, 1.79 [95% CI, 1.07-2.99] vs HR, 1.54 [95% CI, 0.95-2.49]; p = 0.62) and PE-related (HR, 16.3 [95% CI, 2.22-119] vs HR, 17.7 [95% CI, 2.43-130]; p = 1.0) mortality. There was no significant difference in sensitivity, specificity, negative predictive value, or positive predictive value. Axial and four-chamber measurements were well correlated (correlation coefficient, 0.857), and there was no significant difference in overall accuracy for predicting all-cause (area under the curve [AUC], 0.582 vs 0.577; p = 0.72) and PE-related (AUC, 0.743 vs 0.744; p = 1.0) mortality. CONCLUSION The axial RV/LV diameter ratio is no less accurate than the reformatted four-chamber RV/LV diameter ratio for predicting 30-day mortality after PE.

Meta-analysis for rare events

Meta-analysis provides a useful framework for combining information across related studies and has been widely utilized to combine data from clinical studies in order to evaluate treatment efficacy. More recently, meta-analysis has also been used to assess drug safety. However, because adverse events are typically rare, standard methods may not work well in this setting. Most popular methods use fixed or random effects models to combine effect estimates obtained separately for each individual study. In the context of very rare outcomes, effect estimates from individual studies may be unstable or even undefined. We propose alternative approaches based on Poisson random effects models to make inference about the relative risk between two treatment groups. Simulation studies show that the proposed methods perform well when the underlying event rates are low. The methods are illustrated using data from a recent meta-analysis (N. Engl. J. Med. 2007; 356(24):2457-2471) of 48 comparative trials involving rosiglitazone, a type 2 diabetes drug, with respect to its possible cardiovascular toxicity.

The Value of Surgery for Retroperitoneal Sarcoma

Introduction. Retroperitoneal sarcomas are uncommon large malignant tumors. Methods. Forty-one consecutive patients with localized retroperitoneal sarcoma were retrospectively studied. Results. Median age was 58 years (range 20–91 years). Median tumor size was 17.5 cm (range 4–41 cm). Only 2 tumors were <5 cm. Most were liposarcoma (44%) and high-grade (59%). 59% were stage 3 and the rest was stage 1. Median followup was 10 months (range 1–106 months). Thirty-eight patients had an initial complete resection; 15 (37%) developed recurrent sarcoma and 12 (80%) had a second complete resection. Patients with an initial complete resection had a 5-year survival of 46%. For all patients, tumor grade affected overall survival (P = .006). Complete surgical resection improved overall survival for high-grade tumors (P = .03). Conclusions. Tumor grade/stage and complete surgical resection for high-grade tumors are important prognostic variables. Radiation therapy or chemotherapy had no significant impact on overall or recurrence-free survival. Complete surgical resection is the treatment of choice for patients with initial and locally recurrent retroperitoneal sarcoma.

Landmark Prediction of Long-Term Survival Incorporating Short-Term Event Time Information

In recent years, a wide range of markers have become available as potential tools to predict risk or progression of disease. In addition to such biological and genetic markers, short-term outcome information may be useful in predicting long-term disease outcomes. When such information is available, it would be desirable to combine this along with predictive markers to improve the prediction of long-term survival. Most existing methods for incorporating censored short-term event information in predicting long-term survival focus on modeling the disease process and are derived under restrictive parametric models in a multistate survival setting. When such model assumptions fail to hold, the resulting prediction of long-term outcomes may be invalid or inaccurate. When there is only a single discrete baseline covariate, a fully nonparametric estimation procedure to incorporate short-term event time information has been previously proposed. However, such an approach is not feasible for settings with one or more continuous covariates due to the curse of dimensionality. In this article, we propose to incorporate short-term event time information along with multiple covariates collected up to a landmark point via a flexible varying-coefficient model. To evaluate and compare the prediction performance of the resulting landmark prediction rule, we use robust nonparametric procedures that do not require the correct specification of the proposed varying-coefficient model. Simulation studies suggest that the proposed procedures perform well in finite samples. We illustrate them here using a dataset of postdialysis patients with end-stage renal disease.

Incorporating short-term outcome information to predict long-term survival with discrete markers.

In disease screening and prognosis studies, an important task is to determine useful markers for identifying high-risk subgroups. Once such markers are established, they can be incorporated into public health practice to provide appropriate strategies for treatment or disease monitoring based on each individuals predicted risk. In the recent years, genetic and biological markers have been examined extensively for their potential to signal progression or risk of disease. In addition to these markers, it has often been argued that short-term outcomes may be helpful in making a better prediction of disease outcomes in clinical practice. In this paper we propose model-free non-parametric procedures to incorporate short-term event information to improve the prediction of a long-term terminal event. We include the optional availability of a single discrete marker measurement and assess the additional information gained by including the short-term outcome. We focus on the semi-competing risk setting where the short-term event is an intermediate event that may be censored by the terminal event while the terminal event is only subject to administrative censoring. Simulation studies suggest that the proposed procedures perform well in finite samples. Our procedures are illustrated using a data set of post-dialysis patients with end-stage renal disease.

Quality measures to assess care transitions for hospitalized children

BACKGROUND: Transitions between sites of care are inherent to all hospitalizations, yet we lack pediatric-specific transitions-of-care quality measures. We describe the development and validation of new transitions-of-care quality measures obtained from medical record data. METHODS: After an evidence review, a multistakeholder panel prioritized quality measures by using the RAND/University of California, Los Angeles modified Delphi method. Three measures were endorsed, operationalized, and field-tested at 3 children’s hospitals and 2 community hospitals: quality of hospital-to-home transition record content, timeliness of discharge communication between inpatient and outpatient providers, and ICU-to-floor transition note quality. Summary scores were calculated on a scale from 0 to 100; higher scores indicated better quality. We examined between-hospital variation in scores, associations of hospital-to-home transition quality scores with readmission and emergency department return visit rates, and associations of ICU-to-floor transition quality scores with ICU readmission and length of stay. RESULTS: A total of 927 charts from 5 hospitals were reviewed. Mean quality scores were 65.5 (SD 18.1) for the hospital-to-home transition record measure, 33.3 (SD 47.1) for the discharge communication measure, and 64.9 (SD 47.1) for the ICU-to-floor transition measure. The mean adjusted hospital-to-home transition summary score was 61.2 (SD 17.1), with significant variation in scores between hospitals (P < .001). Hospital-to-home transition quality scores were not associated with readmissions or emergency department return visits. ICU-to-floor transition note quality scores were not associated with ICU readmissions or hospital length of stay. CONCLUSIONS: These quality measures were feasible to implement in diverse settings and varied across hospitals. The development of these measures is an important step toward standardized evaluation of the quality of pediatric transitional care.

Screening in Primary Care: What Is the Best Way to Identify At-Risk Youth for Substance Use?

BACKGROUND: It is important to improve primary care providers’ capability to identify youth at risk for alcohol and other drug use. To our knowledge, this is the first study to use Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria to compare screeners for youth for both alcohol and marijuana, given that these are the most frequently used substances by this age group. METHODS: We compared the psychometric performance of 4 screeners: the National Institute on Alcohol Abuse and Alcoholism Screening Guide (NIAAA SG), the Alcohol Use Disorders Identification Test, the Car–Relax–Alone–Forget–Family and Friends–Trouble (CRAFFT) screener, and the Personal Experience Screening Questionnaire Problem Severity Scale (PESQ-PS) in identifying alcohol and marijuana use outcomes. Youth age 12 through 18 (N = 1573; 27% black, 51% Hispanic) were screened with the NIAAA SG, followed by a Web survey that included the other screeners and outcomes. RESULTS: Sensitivity for alcohol outcomes indicated that the NIAAA SG (0.87) did not perform as well as the CRAFFT (0.97) or PESQ-PS (0.97) screeners but performed better than the Alcohol Use Disorders Identification Test (0.70). The pattern for sensitivity across screeners for marijuana outcomes was similar. CONCLUSIONS: An important tradeoff in primary care settings is precision versus practicality. Because of brevity and focus on frequency of drinking, the NIAAA SG offers ease of administration and is good at identifying youth with probably problematic drinking levels. The PESQ-PS and the CRAFFT correctly identify more at-risk youth for alcohol and marijuana than the NIAAA SG. Future work is needed to elucidate how to efficiently and accurately identify at-risk youth in the primary care setting, including determining the best cutoff points to use to increase sensitivity.

A randomized controlled trial of a web-based, personalized normative feedback alcohol intervention for young-adult veterans.

Objective: Young-adult American veterans are at risk for problematic alcohol use. However, they are unlikely to seek care and may drop out from lengthy, multicomponent treatments when they do get care. This randomized controlled trial tested a very brief alcohol intervention delivered over the Internet to reach the population of young-adult veterans to help reduce their drinking. Method: Veterans (N = 784) were recruited from Facebook and randomized to either a control condition or a personalized normative feedback (PNF) intervention seeking to correct drinking perceptions of gender-specific veteran peers. Results: At immediate postintervention, PNF participants reported greater reductions in their perceptions of peer drinking and intentions to drink over the next month, compared with control participants. At 1-month follow-up, PNF participants reduced their drinking behavior and related consequences to a significantly greater extent than controls. Specifically, PNF participants drank 3.4 fewer drinks per week, consumed 0.4 fewer drinks per occasion, binge drank on 1.0 fewer days, and experienced about 1.0 fewer consequences than control participants in the month after the intervention. Intervention effects for drinks per occasion were most pronounced among more problematic drinkers. Changes in perceived norms from baseline to 1-month follow-up mediated intervention efficacy. Conclusion: Though effects were assessed after only 1 month, findings have potential to inform broader, population-level programs designed for young veterans to prevent escalation of drinking and development of long-term alcohol problems. Given the simplicity of the PNF approach and ease of administration, this intervention has the potential for a substantial impact on public health.