Robert J. Panzer

Test-retest performance of a mailed version of the Medical Outcomes Study 36-Item Short-Form Health Survey among older adults.

OBJECTIVES This study reports the reliability, internal consistency, and response patterns for a mailed version of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) among older adults. METHODS The SF-36 surveys were mailed to patients living in the community aged 65 years and older who were enrolled in two primary care practice clinics. Comorbidity scores also were assigned to patients based on their diagnoses from computerized clinic encounter forms using Deyo et als modification of the Charlson Index. Subjects repeated the SF-36 by mail after 1 months. RESULTS Four-hundred twenty-two subjects were mailed surveys and 253 returned them (60.0%). Missing items further reduced the number of subjects with scores on all SF-36 scales. A total of 186 subjects completed both base-line and retest SF-36 surveys. Intraclass correlation coefficients generally were high and ranged from 0.648 to 0.868. Internal consistency of scales also was high (0.802 to 0.924). Mean SF-36 scale scores decreased significantly with increasing comorbidity levels. CONCLUSIONS The SF-36 demonstrated good retest reliability and internal consistency among these older adults and also showed a strong relationship to an external measure of comorbidity/health status. Mailed surveys pose a problem of response among older adults, a problem not unique to the SF-36, and methods for increasing response are needed when personal interviews are not feasible.

Programmable Infusion Pumps in ICUs: An Analysis of Corresponding Adverse Drug Events

BackgroundPatients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable.ObjectivesTo determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software (“smart pump”) and to suggest potential improvements in smart-pump design.DesignUsing retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges.Participants4,604 critically ill adults at 1 academic and 1 nonacademic hospital.MeasurementsPreventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs.ResultsOf 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps’ capabilities might enable them to prevent more IV-ADEs.ConclusionThe smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.

Selecting a generic measure of health-related quality of life for use among older adults. A comparison of candidate instruments.

Selecting an outcomes assessment instrument requires knowledge of their relative merits, especially head-to-head comparisons. The authors compare health-related quality-of-life (HRQOL) instruments among older adults for theirpsychometric properties and subject burden, specifically the Sickness Impact Profile (SIP) and Medical Outcomes Study Short- Form 36 (SF-36). Subjects were 282 of 373 eligible older adults (75.6% response) ranging in age from 65 to 96. SIP scores demonstrated a strong skew toward low (good health) scores with a mean of 11.1% (SD 11.5) on the Total SIP index score. Similar components of the SIP and SF-36 were moderately to strongly correlated. The SIP suffered from a ceiling (good health) scaling effect, and the SF-36 scales also demonstrated some scaling extremes. These results demonstrate the relative scaling limits, especially the ceiling effect, of the SIP compared to the SF- 36, and in general, the SF-36 is preferredfor use among community-living older adults.

Costs of Intravenous Adverse Drug Events in Academic and Nonacademic Intensive Care Units

Background:Adverse drug events (ADEs), particularly those involving intravenous medications (IV-ADEs), are common among intensive care unit (ICU) patients and may increase hospitalization costs. Precise cost estimates have not been reported for academic ICUs, and no studies have included nonacademic ICUs. Objectives:To estimate increases in costs and length of stay after IV-ADEs at an academic and a nonacademic hospital. Research Design:This study reviewed medical records to identify IV-ADEs, and then, using a nested case-control design with propensity-score matching, assessed differences in costs and length of stay between cases and controls. Subjects:A total of 4604 adult ICU patients in 3 ICUs at an academic hospital and 2 ICUs at a nonacademic hospital in 2003 and 2004. Measures:Increased cost and length of stay associated with IV-ADEs. Results:Three hundred ninety-seven IV-ADEs were identified: 79% temporary physical injuries, 0% permanent physical injuries, 20% interventions to sustain life, and 2% in-hospital deaths. In the academic ICUs, patients with IV-ADEs had

Echocardiography, Endocarditis, and Clinical Information Bias

6647 greater costs (P < 0.0001) and 4.8-day longer stays (P = 0.0003) compared with controls. In the nonacademic ICUs, IV-ADEs were not associated with greater costs (

Quality of care during a community-wide experiment in prospective payment to hospitals.

188, P = 0.4236) or lengths of stay (−0.3 days, P = 0.8016). Cost and length-of-stay differences between the hospitals were statistically significant (P = 0.0012). However, there were no differences in IV-ADE severity or preventability, and the characteristics of patients experiencing IV-ADEs differed only modestly. Conclusions:IV-ADEs substantially increased hospitalization costs and length of stay in ICUs at an academic hospital but not at a nonacademic hospital, likely because of differences in practices after IV-ADEs occurred.

A computerized prompt for thromboprophylaxis in hospitalized cancer patients.

Although clinical information provided to the interpreter of imaging tests may improve disease detection, it may also bias the interpreter towards certain diagnoses, increasing the chance of false positives. To determine the possibility of this bias, the authors studied patients who were referred for echocardiography with a clinical suspicion of endocarditis. Hospital charts from a two-year period were reviewed to determine clinical data available to the echocardiographer, echocardiogram results, and the final diagnosis. Four clinical features, when present at the time of echocardiography, were associated with increased numbers of false-positive results. Test specificity was 97% (34/35) for patients without any of these features, but dropped to 80% (16/20) when two or more features were present. The authors conclude that clinical information may bias echocardiogram interpretations such that both test specificity and the posttest probability of disease may be overestimated when tests are used in clinical practice.

Chronic Bronchitis, Tetracycline, and Type II Error

To determine whether a community-wide experiment in hospital prospective payment adversely affected quality of care, availability and outcomes of care were studied in Rochester, NY from 1980 to 1984. During this 5-year period, prospective payment contained hospital expenditures in a community that was already below the national average in health-care costs. Access to necessary care was maintained, and there were increased admissions for management of maternal illness and acute myocardial infarction. Rates of inpatient elective surgery declined. Outcomes of care remained stable, including neonatal deaths, ischemic heart disease deaths, deaths from five selected surgical conditions, and rates of adverse outcomes from sentinel medical and surgical conditions. These results indicated that prospective payment programs in which incentives to decrease marginal or unneeded care are linked with a community-wide effort to plan for the delivery of services can be financially and clinically successful.

Library of Medical Computer Programs

Article history: Received 29 July 2009 Received in revised form 24 September 2009 Accepted 24 September 2009 Available online 30 October 2009 were less likely to receive prophylaxis than other medical patients [17]. In order to reduce the burdenofVTE in cancer and improveoutcomes for patients, it is important to close the gap between evidence-based guidelines and their implementation. Various interventions have been studied in order to enhance provider compliance with guidelines [18]. The increasing use of computerized order entry systems is an opportunity for point-of-care prompts that may increase adherence to clinical guidelines. In a prospective study, the use of a computer-alert

Epidemiology of Sepsis Syndrome in 8 Academic Medical Centers

Excerpt To the editor: The randomized controlled trial of the effectiveness of tetracycline in the treatment of acute exacerbations of chronic bronchitis reported by Nicotra and associates(l) faile...