The quality of care for Medicare patients with peptic ulcer disease

OBJECTIVE: The aim of this study was to examine quality of care for hospitalized Medicare beneficiaries with peptic ulcer disease. METHODS: Collaborating with five Peer Review Organizations, we used 1995 Medicare claim files to select samples of inpatients with a principal diagnosis of peptic ulcer disease. Quality of care indicators developed by content experts included percentages for ulcer patients tested for Helicobacter pylori (H. pylori); biopsied patients who received tissue tests; H. pylori-positive patients who received appropriate therapy; and ulcer patients screened for preadmission nonsteroidal anti-inflammatory drug (NSAID) use and counseled about risks. RESULTS: Of 2,644 patients eligible for medical record review, 56% were tested for H. pylori, and 73% of those testing positive were treated appropriately; 84% of patients with endoscopic biopsies received a tissue test for H. pylori; 74% of patients were screened for preadmission NSAID use, 24% had documented counseling of NSAID use, and only 2% had documented counseling on the ulcer risk of NSAID use. Statistically significant regional variation occurred in four of six quality indicators. Outpatient records were reviewed for 529 patients to document prior outpatient H. pylori in this population; only 2% (n = 12) were tested for H. pylori in the year before admission. CONCLUSIONS: Opportunities exist to improve quality of care by testing for and treating H. pylori in hospitalized Medicare beneficiaries with peptic ulcer disease and to improve screening for NSAIDs and counseling on ulcer risks.     

Coexisting nephrolithiasis and cholelithiasis in premature infants

Though the coexistence of nephrolithiasis and cholelithiasis in premature infants is extremely rare, we report four patients seen in a two year period. All patients weighed less than 1100 grams at birth, developed severe bronchopulmonary dysplasia, and all had Grade III or IV bilateral intraventricular hemorrhages. All four infants received prolonged furosemide therapy lasting at least 28 consecutive days. The renal stones disappeared in all four upon cessation of therapy, while in none have the gallstones disappeared after a mean follow-up period of 13 months. Ultrasound was superior in identifying and monitoring these stones. Their presence resulted in manipulating diuretic therapy which then was shown to limit renal and possibly biliary complications.     

Percutaneous ultrasonic lithotripsy of symptomatic renal calculi in children

Percutaneous ultrasonic lithotripsy of upper urinary tract lithiasis is a well-established procedure in adults. We successfully applied this technique to completely remove symptomatic renal calculi in two children with idiopathic hypercalciuria. The procedure was well tolerated and no complications occurred. Both patients were discharged within 4 days of the lithotripsy. This method is an alternative to surgery for the removal of large or impacted calculi from the upper urinary tracts of pediatric patients.     

The relation between methods and recommendations in clinical practice guidelines for hypertension and hyperlipidemia

OBJECTIVE: To assess the association between methods used to develop clinical practice guidelines and the recommendations that are made. STUDY DESIGN: Systematic review of clinical practice guidelines for hypertension or hyperlipidemia. OUTCOMES MEASURED: Two people independently appraised guideline methods by using 8 criteria and the aggressiveness of recommendations for treatment thresholds, initial drug selection, and screening. RESULTS: We identified 33 guidelines. Only 6 fulfilled 5 or more of the 8 criteria. For 5 of the criteria, fewer than 50% of the guidelines fulfilled those criteria. There was wide variation in recommendations for treatment thresholds, drug selection, and cholesterol screening. Guidelines that did not fulfill the criteria tended to suggest more aggressive recommendations than did guidelines that met the criteria. For 6 of the 8 criteria, guidelines published by specialty societies were less likely to fulfill them compared with guidelines not published by specialty societies. CONCLUSIONS: Guideline developers who did not use rigorous methods tended to promote intervening more aggressively for hypertension and hyperlipidemia.     

Comparison of directed and self-directed learning in evidence-based medicine: a randomised controlled trial

OBJECTIVES: To compare 2 educational programmes for teaching evidence-based medicine (EBM). DESIGN: Prospective randomised controlled trial accompanied by a qualitative evaluation. SETTING: University of Oslo, Norway, 2002-03. PARTICIPANTS: A total of 175 students entered the study. All tenth semester medical students from 3 semesters were eligible for inclusion if they completed baseline assessment and consent forms and either attended teaching on the first day of the semester or gave reasons for their absence on the first day in advance. Interventions One intervention was based on computer-assisted, self-directed learning (self-directed intervention), whilst the other was organised as workshops based on social learning theory (directed intervention). Both educational interventions consisted of 5 half-day sessions. MAIN OUTCOME MEASURES: The primary outcomes were knowledge about EBM and skills in critical appraisal. A secondary outcome measured attitudes to EBM. Outcomes were compared on an intention-to-treat basis using a stratified Wilcoxon rank-sum test. RESULTS: There were no differences in outcomes for the 2 study groups in terms of EBM knowledge (mean deviation 0.0 [95% confidence interval - 1.0, 1.0], P = 0.8), critical appraisal skills (MD 0.1 [95% CI - 0.9, 1.1], P = 0.5), or attitudes to EBM (MD - 0.3 [95% CI - 1.4, 0.8], P = 0.5). Follow-up rates were 96%, 97% and 63%, respectively. CONCLUSIONS: This trial and its accompanying qualitative evaluation suggest that self-directed, computer-assisted learning may be an alternative format for teaching EBM. However, further research is needed to confirm this and investigate alternative educational models.