A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions

Background  Requiring accountable justifications—visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert—has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts. Methods  We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications. Results  There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for “anxiety” or “acute pain”); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., “risks and benefits discussed”). Most accountable justifications (65%) were of uncertain clinical appropriateness. Conclusion  Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making.     

Prevalence of resistant hypertension in the United States, 2003-2008

The prevalence of resistant hypertension is unknown. Much previous knowledge comes from referral populations or clinical trial participants. Using data from the National Health and Nutrition Examination Survey from 2003 through 2008, nonpregnant adults with hypertension were classified as resistant if their blood pressure was ≥140/90 mm Hg and they reported using antihypertensive medications from 3 different drug classes or drugs from ≥4 antihypertensive drug classes regardless of blood pressure. Among US adults with hypertension, 8.9% (SE: 0.6%) met criteria for resistant hypertension. This represented 12.8% (SE: 0.9%) of the antihypertensive drug-treated population. Of all drug-treated adults whose hypertension was uncontrolled, 72.4% (SE: 1.6%) were taking drugs from <3 classes. Compared with those with controlled hypertension using 1 to 3 medication classes, adults with resistant hypertension were more likely to be older, to be non-Hispanic black, and to have higher body mass index (all P<0.001). They were more likely to have albuminuria, reduced renal function, and self-reported medical histories of coronary heart disease, heart failure, stroke, and diabetes mellitus (P<0.001). Most (85.6% [SE: 2.4%]) individuals with resistant hypertension used a diuretic. Of this group, 64.4% (SE: 3.2%) used the relatively weak thiazide diuretic hydrochlorothiazide. Although not rare, resistant hypertension is currently found in only a modest proportion of the hypertensive population. Among those classified here as resistant, inadequate diuretic therapy may be a modifiable therapeutic target. Cardiovascular diseases, diabetes mellitus, obesity, and renal dysfunction were all common in this population.     

Aspirin use among adults with diabetes: recent trends and emerging sex disparities

BACKGROUND: Despite high cardiovascular risk among adults with diabetes mellitus, aspirin use has been low. METHODS: To assess recent self-reported regular aspirin use among adults 35 years or older with diabetes, we used statewide telephone surveys conducted in 7 states in 1997 and 20 states in 1999 and 2001 including 875, 3205, and 4272 subjects in 1997, 1999, and 2001, respectively. RESULTS: Aspirin use increased from 37.5% in 1997 to 48.7% in 2001. In 2001, 74.2% (95% confidence interval [CI], 70.9%-77.5%) of diabetic adults with cardiovascular disease, but only 37.9% (95% CI, 35.1%-40.7%) of those without cardiovascular disease, used aspirin regularly, including less than 40% with diagnosed hypertension or hypercholesterolemia or who smoked. After adjusting for cardiac risk factors and socioeconomic characteristics, among those without cardiovascular disease, aspirin use was less common in women aged 35 to 49 years (adjusted rate ratio [RR], 0.35; 95% CI, 0.24-0.51) and 50 to 64 years (RR, 0.69; 95% CI, 0.53-0.88) and in men aged 35 to 49 years (RR, 0.62; 95% CI, 0.43-0.85) compared with men 65 years and older. For those with diagnosed cardiovascular disease, aspirin use was lower among women (RR, 0.81 compared with men; 95% CI, 0.70-0.90) and adults younger than 50 years (RR compared with those >/=65 years, 0.81; 95% CI, 0.61-0.98). The disparity in aspirin use between men and women appeared between 1997 and 2001. CONCLUSIONS: Aspirin use among adults with diabetes has increased. However, many high-risk individuals, especially women and those younger than 50 years, do not use this effective and inexpensive therapy.     

Detection and early identification in bioterrorism events

Syndromic surveillance, collecting and analyzing symptoms before diagnosis, has the potential to identify bioterrorist attacks in a timely, flexible, and specific manner. Nurses are important resources in collecting and interpreting surveillance data. Clinical skills in early diagnosis may identify a bioterrorist attack before surveillance systems and independently trigger investigations. Computerized syndromic surveillance systems are difficult to sustain and are not in use nationwide. Traditional public health surveillance is not replaced by syndromic surveillance. Weaknesses remain in surveillance related to bioterrorism preparedness. Bioterrorist events must be recognized in a timely manner, but this is dependent on sufficient funding for training, equipment, and personnel.     

Medication Reconciliation and Hypertension Control

Background

Discrepancies between the medical record and patient medication list are common. The relationship of discrepancies to chronic disease control has not been established.

Methods

To determine the frequency and type of antihypertensive medication discrepancies between patient-named antihypertensive medications and the medical record, we performed a cross-sectional study of 315 adults with medically treated hypertension from 6 safety-net clinics in 3 states. We determined the association between medication discrepancies and uncontrolled blood pressure (≥140/90 mm Hg or ≥130/80 mm Hg if diabetes) using multivariate logistic regression models.

Results

Discrepancies were present for 75.2% of patients; 25.7% of patients could not provide the name of any antihypertensive medication they took; 49.5% could name 1 or more antihypertensive medications but had discrepancies between patient-reported antihypertensive medications and those listed in the medical record. Both patients who were unable to name any of their antihypertensive medications and patients with discrepancies between patient-named medications and the medical record were significantly more likely to have uncontrolled blood pressure than patients who named the same medications as the medical record in adjusted analyses, adjusted risk ratios 1.66 (95% confidence interval, 1.31-2.10) and 1.51 (95% confidence interval, 1.11-2.07), respectively. Twelve percent of patients reporting medications took antihypertensive medication that altered potassium metabolism that was not in their medical record.

Conclusions

Among patients at safety-net clinics, inability to name one's antihypertensive medications and discrepancies between patient-reported medications and the medical record were very common. Both were strongly associated with inadequate hypertension control. Performing medication reconciliation at the point of care may be an important way to identify patients at high risk for inadequate disease control or safety problems.     

National Cholesterol Education Program risk assessment and potential for risk misclassification

BACKGROUND: The National Cholesterol Education Program Adult Treatment Panel report from 2001 (ATP III) recommends clinicians calculate 10-year coronary risk using multivariable methods only for adults with 2 or more risk factors. We aimed to determine who would be falsely classified as low risk using this approach. METHODS: We studied 4097 adults aged 20 to 79 years without diagnosed cardiovascular disease or diabetes from the National Health and Nutrition Examination Survey from 1999 to 2002. We determined the proportion with fewer than 2 risk factors who nonetheless had estimated 10-year risk of cardiac death or myocardial infarction > or =10% using multivariable methods. RESULTS: Among persons with fewer than 2 risk factors, 5.3% (95% confidence interval 4.7 to 6.1%), had a 10-year risk > or =10% using the Framingham Risk Score and would be misclassified using the risk factor counting method (this corresponds to approximately 5,640,000 U.S. adults). Compared to individuals whose classification was unchanged, those misclassified as low risk were older (P<0.001) and more likely male (85.5% vs. 41.2%, P<0.001). CONCLUSIONS: Relying on the ATP III risk factor counting method rather than determining risk using multivariable methods in all patients resulted in misclassifiying as low risk over 5 million adults with at least moderately high risk of coronary heart disease, most of whom are middle-aged and older men.