The image of Marcus Welby, MD, would lead one to believe that experience promotes higher quality care. But don’t ask a hospitalist: Many aren’t old enough to remember seeing him on television.
3. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352:969-77.
March was DVT (deep vein thrombosis) Awareness Month. Despite the availability of numerous guidelines, providers fail to consistently prescribe prophylactic measures against venous thromboembolism (VTE) for their hospitalized patients who meet criteria for prophylaxis.
Kucher and colleagues tested an innovative approach to remind providers to undertake such measures for their patients. They designed a computer program to identify hospitalized patients at increased risk for VTE who were not presently receiving VTE prophylaxis. The program reviewed the records of inpatients on the medical and surgical services and assigned a VTE risk score for each patient based on their history (i.e., history of cancer, hypercoagulability, etc.) and their present medical treatment (i.e., hormone therapy, prescribed bed rest, etc.). For patients considered “high risk” for VTE, the computer reviewed orders to identify ongoing use of VTE prophylactic measures. High-risk patients not receiving prophylactic therapies were randomized into 2 groups. The responsible physician in the intervention group received an electronic alert about the risk of VTE in their patient. No alerts were sent to the physicians in the control group. Physicians who received the alerts were forced to acknowledge the alert by either actively withholding prophylaxis or ordering prophylaxis (mechanical or pharmacologic measures). Patients were followed for 90 days with a primary endpoint of clinically diagnosed, objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE). The primary endpoint occurred in 8.2% of the control group versus 4.9% in the invention group (p<.001). The alert reduced the risk of DVT or PE at 90 days by 41% (p=.001).
The results of the study are interesting. The authors acknowledged that many physicians had patients in both groups. So receiving 1 alert may have affected their use of prophylaxis in both groups. They also could not eliminate the possibility of diagnostic bias. Prophylaxis was not blinded and VTE testing was not routinely performed. Would physicians be more likely to order an imaging study for symptomatic patients on no prophylaxis than patients on prophylaxis? Nevertheless, for hospitals that have sufficient computer resources, implementation of such alerts can elevate physician awareness about VTE and other clinical conditions.
4. Lau DT, Kasper JD, Pofer DE, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165: 68-74.
Lau and colleagues studied the impact of potentially inappropriate medications among residents of longtermcare facilities. They used information from a 1996 national survey of home residents. The sample included 3372 residents, 65 years and older, who lived in a nursing home for 3 months or longer. Over half of the residents were older than 85 years old and 75% were female. Only 10% were black. Nearly two thirds had dementia or other mental disorders. The study used the Beers Criteria to define potentially inappropriate medications. The potential errors in medications were categorized as 1 of 3 types:
- inappropriate choice of medication
- excessive medication dosage
- drug–disease interactions
Residents were considered to have a potentially inappropriate medication if their medication administration records revealed any of the above findings.
A univariate analysis showed that the risk of hospitalization was almost 30% higher among residents who received potentially inappropriate medications in the preceding month and 33% higher among residents who received potentially inappropriate medications for 2 consecutive months, compared with residents with no inappropriate medication exposure. The odds of death in any month were 21% higher among residents who had inappropriate medication exposure during the month of death or the preceeding month, compared with those with no inappropriate medication exposure.