Return on Investment for a Computerized Physician Order Entry System

ObjectiveAlthough computerized physician order entry (CPOE) may decrease errors and improve quality, hospital adoption has been slow. The high costs and limited data on financial benefits of CPOE systems are a major barrier to adoption. The authors assessed the costs and financial benefits of the CPOE system at Brigham and Women's Hospital over ten years.DesignCost and benefit estimates of a hospital CPOE system at Brigham and Women's Hospital (BWH), a 720-adult bed, tertiary care, academic hospital in Boston.MeasurementsInstitutional experts provided data about the costs of the CPOE system. Benefits were determined from published studies of the BWH CPOE system, interviews with hospital experts, and relevant internal documents. Net overall savings to the institution and operating budget savings were determined. All data are presented as value figures represented in 2002 dollars.ResultsBetween 1993 and 2002, the BWH spent $11.8 million to develop, implement, and operate CPOE. Over ten years, the system saved BWH $28.5 million for cumulative net savings of $16.7 million and net operating budget savings of $9.5 million given the institutional 80% prospective reimbursement rate. The CPOE system elements that resulted in the greatest cumulative savings were renal dosing guidance, nursing time utilization, specific drug guidance, and adverse drug event prevention. The CPOE system at BWH has resulted in substantial savings, including operating budget savings, to the institution over ten years.ConclusionOther hospitals may be able to save money and improve patient safety by investing in CPOE systems.     

The design and evaluation of a novel algorithm for automated preference card optimization

BackgroundInaccurate surgical preference cards (supply lists) are associated with higher direct costs, waste, and delays. Numerous preference card improvement projects have relied on institution-specific, manual approaches of limited reproducibility. We developed and tested an algorithm to facilitate the first automated, informatics-based, fully reproducible approach.MethodsThe algorithm cross-references the supplies used in each procedure and listed on each preference card and uses a time-series regression to estimate the likelihood that each quantity listed on the preference card is inaccurate. Algorithm performance was evaluated by measuring changes in direct costs between preference cards revised with the algorithm and preference cards that were not revised or revised without use of the algorithm. Results were evaluated with a difference-in-differences (DID) multivariate fixed-effects model of costs during an 8-month pre-intervention and a 15-month post-intervention period.ResultsThe accuracies of the quantities of 469 155 surgeon–procedure-specific items were estimated. Nurses used these estimates to revise 309 preference cards across eight surgical services corresponding to, respectively, 1777 and 3106 procedures in the pre- and post-intervention periods. The average direct cost of supplies per case decreased by 8.38% ($352, SD $6622) for the intervention group and increased by 13.21% ($405, SD $14 706) for the control group (P < .001). The DID analysis showed significant cost reductions only in the intervention group during the intervention period (P < .001).ConclusionThe optimization of preference cards with a variety of institution-specific, manually intensive approaches has led to cost savings. The automated algorithm presented here produced similar results that may be more readily reproducible.     

大学生自杀意念与社会支持和生命质量的相关性

目的 探讨大学生自杀意念与社会支持和生命质量之间的相关性。 方法 采用分层整群随机抽样方法对重庆市9 808名在校大学生进行问卷调查,了解重庆市在校大学生自杀意念的发生情况,并通过多元相关分析探讨大学生自杀意念与社会支持和生命质量之间的关系。 结果 重庆市大学生自杀意念的报告率为13.04%,女生、文科学生、有宗教信仰和有自杀未遂史的大学生自杀意念的发生率较高（分别为16.39%、15.09%、15.05%和68.64%）;有自杀意念的大学生在社会支持总分、客观支持、主观支持、对支持的利用度以及生命质量总分、躯体健康状况、心理健康状况、经济状况、工作状况、与家人关系、与他人关系方面均低于无自杀意念大学生（P<0.01）;大学生自杀意念与社会支持因子的主观支持（r=-0.100,P<0.01）、对支持的利用度呈负相关（r=-0.094,P<0.01）,与生命质量因子的躯体健康状况（r=-0.127,P<0.01）、心理健康状况（r=-0.067,P<0.01）和经济状况（r=-0.081,P<0.01）呈负相关。 结论 重庆市大学生自杀意念的发生率较高。社会、家庭、学校应重视大学生心理健康,完善大学生的社会支持系统,并采取综合干预措施,预防大学生自杀意念和自杀行为的发生。     

Medicare payments,healthcare service use,and telemedicine implementation costs in a randomized trial comparing telemedicine case management with usual care in medically underserved participants with diabetes mellitus (IDEATel)

Objective

To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention.

Design

We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State.

Measurements

We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000– February 27, 2006).

Results

Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups, $9040 ($386) and $9669 ($443) per participant, respectively (p>0.05). Sensitivity analyses, including stratification by censored status, adjustment by enrollment site, and semi-parametric weighting by probability of dropping-out, rendered similar results. Over six budget years 28 821 participant/months of telemedicine intervention were delivered, at an estimated cost of $622 per participant/month.

Conclusion

Telemedicine case management was not associated with a reduction in Medicare claims in this medically underserved population. The cost of implementing the telemedicine intervention was high, largely representing special purpose hardware and software costs required at the time. Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used.     

Prescribers’ Responses to Alerts During Medication Ordering in the Long Term Care Setting

ObjectiveComputerized physician order entry with clinical decision support has been shown to improve medication safety in adult inpatients, but few data are available regarding its usefulness in the long-term care setting. The objective of this study was to examine opportunities for improving medication safety in that clinical setting by determining the proportion of medication orders that would generate a warning message to the prescriber via a computerized clinical decision support system and assessing the extent to which these alerts would affect prescribers’ actions.DesignThe study was set within a randomized controlled trial of computerized clinical decision support conducted in the long-stay units of a large, academically-affiliated long-term care facility. In March 2002, a computer-based clinical decision support system (CDSS) was added to an existing computerized physician order entry (CPOE) system. Over a subsequent one-year study period, prescribers ordering drugs for residents on three resident-care units of the facility were presented with alerts; these alerts were not displayed to prescribers in the four control units.MeasurementsWe assessed the frequency of drug orders associated with various categories of alerts across all participating units of the facility. To assess the impact of actually receiving an alert on prescriber behavior during drug ordering, we calculated separately for the intervention and control units the proportion of the alerts, within each category, that were followed by an appropriate action and estimated the relative risk of an appropriate action in the intervention units compared to the control units.ResultsDuring the 12 months of the study, there were 445 residents on the participating units of the facility, contributing 3,726 resident-months of observation time. During this period, 47,997 medication orders were entered through the CPOE system—approximately 9 medication orders per resident per month. 9,414 alerts were triggered (2.5 alerts per resident-month). The alert categories most often triggered were related to risks of central nervous system side-effects such as over-sedation (20%). Alerts for risk of drug-associated constipation (13%) or renal insufficiency/electrolyte imbalance (12%) were also common. Twelve percent of the alerts were related to orders for warfarin. Overall, prescribers who received alerts were only slightly more likely to take an appropriate action (relative risk 1.11, 95% confidence interval 1.00, 1.22). Alerts related to orders for warfarin or central nervous system side effects were most likely to engender an appropriate action, such as ordering a recommended laboratory test or canceling an ordered drug.ConclusionLong-term care facilities must implement new system-level approaches with the potential to improve medication safety for their residents. The number of medication orders that triggered a warning message in this study suggests that CPOE with a clinical decision support system may represent one such tool. However, the relatively low rate of response to these alerts suggests that further refinements to such systems are required, and that their impact on medication errors and adverse drug events must be carefully assessed.     

A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older,Ethnically Diverse,Medically Underserved Patients with Diabetes Mellitus

BackgroundTelemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness.MethodsThe authors conducted a randomized, controlled trial comparing telemedicine case management to usual care, with blinding of those obtaining outcome data, in 1,665 Medicare recipients with diabetes, aged 55 years or greater, and living in federally designated medically underserved areas of New York State. The primary endpoints were HgbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels.ResultsIn the intervention group (n = 844), mean HgbA1c improved over one year from 7.35% to 6.97% and from 8.35% to 7.42% in the subgroup with baseline HgbA1c ≥7% (n = 353). In the usual care group (n = 821) mean HgbA1c improved over one year from 7.42% to 7.17%. Adjusted net reductions (one-year minus baseline mean values in each group, compared between groups) favoring the intervention were as follows: HgbA1c, 0.18% (p = 0.006), systolic and diastolic blood pressure, 3.4 (p = 0.001) and 1.9 mm Hg (p < 0.001), and LDL cholesterol, 9.5 mg/dL (p < 0.001). In the subgroup with baseline HgbA1c ≥7%, net adjusted reduction in HgbA1c favoring the intervention group was 0.32% (p = 0.002). Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York.ConclusionTelemedicine case management improved glycemic control, blood pressure levels, and total and LDL cholesterol levels at one year of follow-up.     

Celecoxib as an adjuvant to chemotherapy for patients with metastatic colorectal cancer: A randomized controlled clinical study

Objectives:To investigate the anti-tumor activity and tolerability of celecoxib as an adjuvant therapy for patients with metastatic colorectal cancer (CRC).Methods:In this randomized controlled study, 54 patients with metastatic CRC were randomized into 2 groups; the control group (n=28) which received 6 cycles of folinic acid, fluorouracil and irinotecan (FOLFIRI) regimen (5-flourouracil, leucovorin, irinotecan), and the celecoxib group (n=26) which received 6 cycles of FOLFIRI regimen plus celecoxib 200 mg twice daily. The study duration was 3 months. Patients were assessed at baseline and at the end of intervention through the Response Evaluation Criteria in Solid Tumors objective response rate (ORR) and through evaluating the serum concentrations of vascular endothelial growth factor (VEGF), soluble factor-related apoptosis (sFAS), sFAS ligand (sFASL), and epithelial neutrophil-activating peptide -78 (ENA-78/CXCL5). Common Terminology Criteria for Adverse Events version 6.0 was used for evaluating drug-related toxicity.Results:After intervention, celecoxib/FOLFIRI arm showed significant elevation in ORR as compared to FOLFIRI arm (p=0.001). As compared to FOLFIRI arm, celecoxib/FOLFIRI arm showed significantly lower VEGF (p<0.001), CXCL5 (p<0.001), and sFASL (p<0.001) serum levels and significantly higher sFAS serum level and sFAS/FASL ratio (p<0.001). Furthermore, celecoxib/FOLFIRI arm showed significantly higher progression-free survival and one-year overall survival when compared to FOLFIRI arm.Conclusion:Celecoxib plus chemotherapy may represent an effective and safe synergetic protocol for patients with metastatic CRC. Clinicaltrial.gov ID:{"type":"clinical-trial","attrs":{"text":"NCT03645187","term_id":"NCT03645187"}}NCT03645187     

Effect of a self-care education program on medical visits

A prospective, randomized, controlled trial of self-care educational interventions was conducted in a health maintenance organization to determine their effect on ambulatory care utilization. Statistically significant decreases in total medical visits and minor illness visits were found in each of three experimental groups as compared with a control group. These decreases averaged 17% and 35%, respectively. These results were most clearly linked to a system of written communications emphasizing personal decision making about the use of medical care. The addition of a nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent ona nurse counseling session to the written materials may increase cost savings and appears to be attractive to "high utilizers." A telephone information service was offered but not used. It is estimated that the decreases in utilization could result in a savings of approximately $ 2.50 to $ 3.50 for each dollar spent on the educational interventions. Self-care education systems may have important effects on medical care costs, physician satisfaction, and patient confidence.     

Economic burden of routine hematologic tests and intensive care unit observation for elective anterior cervical discectomy and fusion

BackgroundAnterior cervical discectomy and fusion is one of the most common surgical interventions performed by spine surgeons. As efforts are made to control healthcare spending because of the limited or capped resources offered by the National Health Insurance, surgeons are faced with the challenge of offering high-level patient care while minimizing associated healthcare expenditures. Routine ordering of postoperative hematologic tests and observational intensive care unit (ICU) stay might be areas of potential cost containment. This study was designed to determine the necessity of routine postoperative hematologic tests and ICU stay for patients undergoing elective anterior cervical discectomy and fusion and to investigate whether the elimination of unnecessary postoperative laboratory blood studies and ICU stay inhibits patient care.MethodsThe necessity for postoperative blood tests was determined if there were needs for a postoperative blood transfusion and hospital readmission within 1 month after surgery. The necessity for postoperative ICU observation was decided if immediate surgical intervention was required when any kind of complications occurred during the ICU stay.ResultsThere were 168 patients collected in the study. Among them, all had routine preoperative and postoperative blood tests and were transferred to ICU for observation. No need for blood transfusion was observed, and no patient required immediate surgical intervention when the complications occurred during the ICU stay.ConclusionCost savings per admission amounted to approximately 10% of the hospitalization cost by the elimination of unnecessary postoperative routine laboratory blood studies and observational ICU stay without waiving patient care in the current volatile, cost-conscious healthcare environment in Taiwan.     

Isolation of antileishmanial,antimalarial and antimicrobial metabolites from Jatropha multifida

ObjectiveTo investigate the antileishmanial, antimicrobial and antimalarial activities of the pure metabolites from Jatropha multifida used in African ethnomedicine.MethodsThe methanolic stem bark extract of Jatropha multifida used in Nigerian folk medicine as remedy against bacterial infections was subjected to column chromatography and HPLC analyses to obtain three known metabolites, microcyclic lathyrane diterpenoids (1-3). Structures were confirmed by comparison of 1D and 2D spectral data with literature.ResultsThe three compounds exhibited inhibition of antileishmanial, antimalarial and antimicrobial actions against the tested organisms with compouds 2 and 3 active against Cryptococcus neoformans at IC₅₀ of 8.2 and 8.7 μg/mL, respectively.ConclusionsThe research lends support to the ethnomedicinal use of the plant in combating microbial infections, leishmaniasis and malarial infections.     

Efficacy of group intervention on tobacco cessation among male employees in health-care setting: A randomized controlled trial

BackgroundThe tobacco epidemic is one of the biggest public health threats the world has ever faced. World Health Organization has estimated that tobacco use (smoking and smokeless) is currently responsible for the death of about 7 million people across the world each year. The objective of the study was not only to find the effect of group intervention on tobacco cessation but also to describe certain epidemiological factors associated with tobacco cessation and make suitable recommendations to tackle this epidemic.MethodsA randomized controlled trial was carried out among male employees who were tobacco users in health-care setting in Western Maharashtra. In the study, 60 subjects each in intervention and control arm were taken. Pretested validated questionnaires were used for the study. The intervention comprised of two sessions delivered 5 weeks apart. Control arm received self-help material (Booklet) immediately after baseline data collection. The outcomes were measured using structured interview schedule. The data were analyzed using SPSS, version 20.ResultsOverall, 13.3% of the study subjects had quit tobacco use post intervention. In the intervention group 21.7% of the participants had quit tobacco since past one month and 5% in the control group (relative risk (RR) = 4.33). Low to moderate nicotine dependence (p = 0.023, RR = 6.46) and stage of contemplation (p = 0.018) were found to be important predictors of abstinence.ConclusionCommunity-based group intervention for tobacco cessation is the way forward to tackle the tobacco epidemic.     

Integrating “Best of Care” Protocols into Clinicians' Workflow via Care Provider Order Entry: Impact on Quality-of-Care Indicators for Acute Myocardial Infarction

ObjectiveIn the context of an inpatient care provider order entry (CPOE) system, to evaluate the impact of a decision support tool on integration of cardiology “best of care” order sets into clinicians' admission workflow, and on quality measures for the management of acute myocardial infarction (AMI) patients.DesignA before-and-after study of physician orders evaluated (1) per-patient use rates of standardized acute coronary syndrome (ACS) order set and (2) patient-level compliance with two individual recommendations: early aspirin ordering and beta-blocker ordering.MeasurementsThe effectiveness of the intervention was evaluated for (1) all patients with ACS (suspected for AMI at the time of admission) (N = 540) and (2) the subset of the ACS patients with confirmed discharge diagnosis of AMI (n = 180) who comprise the recommended target population who should receive aspirin and/or beta-blockers. Compliance rates for use of the ACS order set, aspirin ordering, and beta-blocker ordering were calculated as the percentages of patients who had each action performed within 24 hours of admission.ResultsFor all ACS admissions, the decision support tool significantly increased use of the ACS order set (p = 0.009). Use of the ACS order set led, within the first 24 hours of hospitalization, to a significant increase in the number of patients who received aspirin (p = 0.001) and a nonsignificant increase in the number of patients who received beta-blockers (p = 0.07). Results for confirmed AMI cases demonstrated similar increases, but did not reach statistical significance.ConclusionThe decision support tool increased optional use of the ACS order set, but room for additional improvement exists.     

Morbidity,mortality, and emerging drug resistance in Device-associated infections (DAIs) in intensive care patients at a 1000-bedded tertiary care teaching hospital

BackgroundDevice-associated infections (DAIs) such as ventilator associated pneumonia (VAP), central line–associated blood stream infection (CLABSI), and catheter-related urinary tract infection (CAUTI) are principal contributors to health hazard and a major preventable threat to patient safety. Robust surveillance of DAI delineates infections, pathogens, resistograms, and facilitates antimicrobial therapy, infection-control, antimicrobial stewardship, and improvement in quality of care.MethodsThis prospective outcome surveillance study was conducted amongst 2067 ICU patients in a 1000-bedded teaching hospital. Clinical, laboratory, and environmental surveillance, as well as screening of health care professionals (HCPs) were conducted using the modified US Centers for Disease Control and Prevention–National Healthcare Safety Network definitions and methods. Morbidity, mortality, and health-care indices were analyzed and two-tier infection prevention and control was promulgated.ResultsMean occupancy was 95.34% for 2061 patients of 7381 patients/bed/ICU days. One hundred seventeen episodes of DAI occurred in 1258 patients of 12,882 device-days with mean device utilization ratio of 1.79. Mean rate of DAI was 7.40 per 1000 device days. Multiresistant Pseudomonas aeruginosa was most commonly followed by Acinetobacter. Mean all-cause mortality in ICU was 24.85%, whereas all-cause mortality after DAI was 9.79%. Methicillin-resistant Staphylococcus aureus prevalence was 38.46% amongst health-care professionals.ConclusionMean rates of VAP, CLABSI, and CAUTI were 20.69, 2.53, and 2.23 per 1000 device days comparable with Indian and global ICUs. Resolute conviction and sustained momentum in infection prevention and control is an essential step toward patient safety.     

Use of a Personal Digital Assistant for Managing Antibiotic Prescribing for Outpatient Respiratory Tract Infections in Rural Communities

ObjectiveTo assess the acceptability and usage of a standalone personal digital assistant (PDA)-based clinical decision-support system (CDSS) for the diagnosis and management of acute respiratory tract infections (RTIs) in the outpatient setting.DesignObservational study performed as part of a larger randomized trial in six rural communities in Utah and Idaho from January 2002 to March 2004. Ninety-nine primary care providers received a PDA-based CDSS for use at the point-of-care, and were asked to use the tool with at least 200 patients with suspected RTIs.MeasurementsClinical data were collected electronically from the devices at periodic intervals. Providers also completed an exit questionnaire at the end of the study period.ResultsProviders logged 14,393 cases using the CDSS, the majority of which (n=7624; 53%) were from family practitioners. Overall adherence with CDSS recommendations for the five most common diagnoses (pharyngitis, otitis media, sinusitis, bronchitis, and upper respiratory tract infection) was 82%. When antibiotics were prescribed (53% of cases), adherence with the CDSS-recommended antibiotic was high (76%). By logistic regression analysis, the odds of adherence with CDSS recommendations increased significantly with each ten cases completed (P=0.001). Questionnaire respondents believed the CDSS was easy to use, and most (44/65; 68%) did not believe it increased their encounter time with patients, regardless of prior experience with PDAs.ConclusionA standalone PDA-based CDSS for acute RTIs used at the point-of-care can encourage better outpatient antimicrobial prescribing practices and easily gather a rich set of clinical data.     

短疗程睑缘清洁联合抗生素滴眼液的使用对白内障术前眼表菌群抑制作用的临床研究（英文）

目的 探讨睑缘清洁与抗生素滴眼液的联合使用对白内障患者术前睑缘和结膜囊细菌抑制作用的临床效果。方法 收集于北京大学第三医院拟行超声乳化白内障吸除联合人工晶体植入术的年龄相关性白内障患者61例（97只眼）。试验组术前3 d滴用左氧氟沙星眼液并联合使用睑缘清洁棉片;对照组术前3 d滴用左氧氟沙星滴眼液。试验组和对照组均在采取抗菌措施前、采取抗菌措施3 d后2个时间点对术眼睑缘、结膜囊分别取材进行细菌培养及鉴定。结果 试验组在使用抗菌措施前睑缘和结膜囊细菌培养阳性率分别为100%(50/50)和40%(20/50);采用抗菌措施3d后分别为10%(5/50)和0%(0/50)。对照组在使用抗菌措施前睑缘和结膜囊细菌培养阳性率分别为97.9%(46/47)和29.8%(14/47);采用抗菌措施3d后分别为40.4%(19/47)和10.6%(5/47)。采用抗菌措施前试验组和对照组睑缘和结膜囊细菌培养阳性率差异无统计学意义（P值分别为0.485和0.395）,采用抗菌措施后差异有统计学意义（P值分别为0.001和0.024）。结论 白内障摘除术前,抗生素滴眼液联合睑缘清洁棉片对睑缘和结膜囊有...     

Efficacy and safety of obinutuzumab for the first-line treatment of follicular lymphoma: a subgroup analysis of Chinese patients enrolled in the phase III GALLIUM study

Backgrounds: GALLIUM is a global phase III study that demonstrated significant improvements in progression-free survival (PFS) for obinutuzumab plus chemotherapy (G-chemo)vs. rituximab plus chemotherapy (R-chemo) in previously untreated patients with follicular lymphoma (FL). This study aimed to report the results of a subgroup of patients in China.Methods: Patients were randomized to G-chemo or R-chemo. Responders received maintenance therapy for 2 years or until disease progression. The primar...     

Antioxidant and antimicrobial properties of Litsea elliptica Blume and Litsea resinosa Blume (Lauraceae)

ObjectiveTo investigate antioxidant and antimicrobial activities of two plant species, Litsea elliptica (L. elliptica) and Litsea resinosa (L. resinosa).MethodsIn vitro method -2,2-diphenyl-1-picrylhydrazyl radical scavenging assay was conducted for antioxidant activity determination while antimicrobial assay consisted of agar well diffusion assay and mycelial radial growth assay.ResultsMethanol extracts of root and stem of L. elliptica and L. resinosa exhibited the highest antioxidant activity with EC₅₀ of 23.99, 41.69, 11.22 and 35.48 mg/L respectively. All methanol extracts of L. resinosa as well as root extracts from L. elliptica showed significant scavenging activity. Hexane extract from stem of L. resinosa presented the largest inhibition zone in Gram-negative bacteria Pseudomonas aeruginosa and Escherichia coli while chloroform extract from inner bark of L. resinosa showed major inhibition towards Gram-positive bacteria Bacillus subtilis. Essential oils from the root of both species showed significant antifungal activities which are 80.11% and 66.85% respectively.ConclusionsOverall, methanol extracts from root and stem of both species showed antioxidant activity comparable to standard butylated hydroxytoluene. Extracts from L. resinosa demonstrated stronger antimicrobial properties compared to that from L. elliptica.