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991.
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Boustani MA Campbell NL Khan BA Abernathy G Zawahiri M Campbell T Tricker J Hui SL Buckley JD Perkins AJ Farber MO Callahan CM 《Journal of general internal medicine》2012,27(5):561-567
Background
Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system.Objective
Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI.Design
A randomized controlled clinical trial.Setting
A public hospital in Indianapolis.Population
A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female.Intervention
A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs.Measurements
Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs.Results
Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11).Conclusion
A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-1994-8) contains supplementary material, which is available to authorized users.KEY WORDS: cognitive impairment, clinical trial, decision support, hospitalized elders 相似文献994.
Cucciare MA Ketroser N Wilbourne P Midboe AM Cronkite R Berg-Smith SM Chardos J 《Journal of general internal medicine》2012,27(8):953-961
BACKGROUND
The Veterans Health Administration (VHA) is implementing the patient-centered medical home (PCMH) model of primary care which emphasizes patient-centered care and the promotion of healthy lifestyle changes. Motivational Interviewing (MI) is effective for promoting various health behaviors, thus a training protocol for primary care staff was implemented in a VHA health care setting.OBJECTIVES
We examined the effect of the training protocol on MI knowledge, confidence in ability to use MI-related skills and apply them to written vignettes, perceived comfort level and skill in lifestyle counseling, and job-related burnout.DESIGN
Training was provided by experts in MI. The training protocol consisted of three sessions??one half day in-person workshop followed by a 60-minute virtual training, followed by a second workshop. Each of the sessions were spaced two weeks apart and introduced trainees to the theory, principles, and skills of using MI in health care settings.PARTICIPANTS
All primary care staff at the Veterans Affairs Palo Alto Health Care System were invited to participate.MEASUREMENTS
Trainees completed a short set of questionnaires immediately before and immediately after the training.RESULTS
We found support for our primary hypotheses related to knowledge, confidence, and written responses to the vignettes. Changes in perceived comfort level and skill in lifestyle counseling, and job-related burnout were not observed.CONCLUSIONS
Training primary care staff in MI is likely to become increasingly common as health care systems transition to the PCMH model of care. Therefore, it is important for health care systems to have low-cost methods for evaluating the effectiveness of such trainings. This study is a first step in developing a brief written assessment with the potential of measuring change in a range of behaviors and skills consistent with MI. 相似文献995.
996.
997.
Leung AA Keohane C Amato M Simon SR Coffey M Kaufman N Cadet B Schiff G Zimlichman E Seger DL Yoon C Song P Bates DW 《Journal of general internal medicine》2012,27(7):801-807
BACKGROUND
It is uncertain if computerized physician order entry (CPOE) systems are effective at reducing adverse drug event (ADE) rates in community hospitals, where mainly vendor-developed applications are used.OBJECTIVE
To evaluate the impact of vendor CPOE systems on the frequency of ADEs.DESIGN AND PATIENTS
Prospective before-and-after study conducted from January 2005 to September 2010 at five Massachusetts community hospitals. Participants were adults admitted during the study period. A total of 2,000 charts were reviewed for orders, medication lists, laboratory reports, admission histories, notes, discharge summaries, and flow sheets.MAIN MEASURES
The primary outcome measure was the rate of preventable ADEs. Rates of potential ADEs and overall ADEs were secondary outcomes.KEY RESULTS
The rate of preventable ADEs decreased following implementation (10.6/100 vs. 7.0/100 admissions; p?=?0.007) with a similar effect observed at each site. However, the associated decrease in preventable ADEs was balanced against an increase in potential ADEs (44.4/100 vs. 57.5/100 admissions; p?0.001). We observed a reduction of 34.0% for preventable ADEs, but an increase of 29.5% in potential ADEs following implementation. The overall rate of ADEs increased (14.6/100 vs. 18.7/100 admissions; p?=?0.03), which was driven by non-preventable events (4.0/100 vs. 11.7/100 admissions; p?0.001).CONCLUSIONS
Adoption of vendor CPOE systems was associated with a decrease in the preventable ADE rate by a third, although the rates of potential ADEs and overall ADEs increased. Our findings support the use of vendor CPOE systems as a means to reduce drug-related injury and harm. The potential ADE rate could be reduced by making refinements to the vendor applications and their associated decision support. 相似文献998.
Kong MC Nahata MC Lacombe VA Seiber EE Balkrishnan R 《Journal of general internal medicine》2012,27(9):1159-1164
Background
Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist.Objective
To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients.Design
Retrospective cohort study.Setting
Multi-state Medicaid database (Thomson Reuters MarketScan®).Participants
Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed.Main Measures
Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables.Key Results
In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63–0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12–3.29).Conclusions
Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.KEY WORDS: HIV, adherence, depression, race, Medicaid 相似文献999.
Madaras-Kelly KJ Remington RE Sloan KL Fan VS 《Journal of general internal medicine》2012,27(7):845-852
Background
Guidelines recommend administration of antibiotics with activity against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa for treatment of healthcare-associated pneumonia (HCAP). It is unclear if this therapy improves outcomes for patients with HCAP.Objective
To determine if administration of guideline-similar therapy (GST) was associated with a reduction in 30-day mortality for HCAP.Design
Multi-center retrospective study.Participants
Thirteen hundred and eleven admissions for HCAP in six Veterans Affairs Medical Centers.Interventions
Each admission was classified as receiving GST, anti-MRSA or anti-pseudomonal components of GST, or other non-HCAP therapy initiated within 48 hours of hospitalization. Association between 30-day mortality and GST was estimated with a logistic regression model that included GST, propensity to receive GST, probability of recovering an organism from culture resistant to antibiotics traditionally used to treat community-acquired pneumonia (CAP-resistance), and a GST by CAP-resistance probability interaction.Main Measures
Odds ratios and 95% confidence intervals [OR (95% CI)] of 30-day mortality for patients treated with GST and predicted probability of recovering a CAP-resistant organism, and ratio of odds ratios [ROR (95% CI)] for treatment by CAP-resistance probability interaction.Key Results
Receipt of GST was associated with increased odds of 30-day mortality [OR?=?2.11 (1.11, 4.04), P?=?0.02)] as was the predicted probability of recovering a CAP-resistant organism [OR?=?1.67 (1.26, 2.20), P?0.001 for a 25% increase in probability]. An interaction between predicted probability of recovering a CAP-resistant organism and receipt of GST demonstrated lower mortality with GST at high probability of CAP resistance [ROR?=?0.71(??1.00) for a 25% increase in probability, P?=?0.05].Conclusions
For HCAP patients with high probability of CAP-resistant organisms, GST was associated with lower mortality. Consideration of the magnitude of patient-specific risk for CAP-resistant organisms should be considered when selecting HCAP therapy. 相似文献1000.
Schwarz EB Postlethwaite D Hung YY Lantzman E Armstrong MA Horberg MA 《Journal of general internal medicine》2012,27(2):196-201