1. Dexter PR, Perkins SM, Mahany KS, Jones K, McDonald CJ. Inpatient computer-based standing orders vs. physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA. 2004; 292: 2366-71.
Past studies have suggested that most patients admitted with severe pneumococcal infections have been hospitalized in the preceding 5 years, and simply being hospitalized is a potential risk factor for later pneumococcal infection. Likewise, hospitalization provides an opportunity to vaccinate high-risk patients against influenza, and raising pneumococcal and influenza immunization rates is a CMS quality improvement priority. Prior investigations have supported the use of labor-intensive manual standing orders as well as computerized reminders, but this prospective trial was conducted in 1998 and 1999 to assess the effectiveness of a computer-based system to screen for eligible patients and then generate orders to perform pneumonia and influenza vaccinations on inpatients at the time of discharge.
Over 13 months, a total of 3777 inpatients were entered into the study. The hospital computer identified patients eligible for vaccination based on common criteria and randomized them to one of two groups of physician teams. For one group of teams, the computer order-entry system would automatically generate vaccination orders at the time of discharge for vaccine-eligible patients; for the other group of teams, only computer reminders were provided to physicians. The outcome measure was administration of vaccine; long-term outcomes such as incidence of subsequent disease or mortality were not measured.
During the study period, 50% of all hospitalized patients were identified as eligible for influenza vaccination; 22% were eligible for pneumococcal vaccination. In each case, the “standing order” group received vaccine more often (influenza: 42% vs. 30%, p<.001; pneumococcal vaccine: 51% vs. 31%). The numbers were subsequently adjusted to allow for patients who had previously received vaccine, but the impressive differences persisted. Nurses reported reasons for non-administration in 98% of the eligible patients who were not vaccinated; the most common reason was patient refusal. It is not clear if the physicians knew that a study was being conducted. No adverse reactions were reported.
CMS has pushed for the development of institutional standing order sets as a tool to improve compliance with vaccination rate targets. Where the technology is available, computer systems that can screen eligible patients and generate automatic orders are an effective tool in implementing many quality-improvement initiatives, and hospitalists are in a crucial position to take an active role in their development and implementation.
2. Fang MC, Chang Y, Hylek EM, et al. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for a trial fibrillation. Ann Intern Med. 2004; 141: 745-52.
Warfarin has been shown to reduce risk of stroke in patients with chronic and paroxysmal atrial fibrillation. Intracranial hemorrhage remains one of the most feared complications of warfarin, especially among older patients, prompting suggestions to consider lower intensity anticoagulation among patients older than 75 years who have atrial fibrillation.
This study evaluated the relationship between the intensity of anticoagulation, risk of intracranial hemorrhage, and age of patients with atrial fibrillation.
This was a retrospective case control study conducted at a tertiary care medical center. One-hundred and seventy patients on warfarin and admitted with intracranial hemorrhage from 1993 to 2002 were matched with 1020 patients who were on warfarin but without intracranial bleed. After controlling for comorbid conditions and aspirin use, authors conducted multivariable logistic regression analysis to determine the odds of intracranial hemorrhage with regard to age and INR. The risk of intracranial hemorrhage increased at 85 years of age and at INR values of 3.5 or greater. The risk of intracranial hemorrhage at INR less than 2.0 did not differ statistically from the risk at INR of 2.0–3.0.