CiteULike: Group: mgh-lcs - library [745 articles]

Facing the diabetes epidemic--mandatory reporting of glycosylated hemoglobin values in New York City.

R Steinbrook — 2007-11-23T08:31:52-00:00

N Engl J Med, Vol. 354, No. 6. (9 February 2006), pp. 545-548.

Standards for detailed clinical models as the basis for medical data exchange and decision support.

JF Coyle — 2007-10-12T13:51:08-00:00

Int J Med Inform, Vol. 69, No. 2-3. (March 2003), pp. 157-174.

INTRODUCTION: Detailed clinical models are necessary to exchange medical data between heterogeneous computer systems and to maintain consistency in a longitudinal electronic medical record system. At Intermountain Health Care (IHC), we have a history of designing detailed clinical models. The purpose of this paper is to share our experience and the lessons we have learned over the last 5 years. DESIGN: IHC's newest model is implemented using eXtensible Markup Language (XML) Schema as the formalism, and conforms to the Health Level Seven (HL7) version 3 data types. The centerpiece of the new strategy is the Clinical Event Model, which is a flexible name-value pair data structure that is tightly linked to a coded terminology. DISCUSSION: We describe IHC's third-generation strategy for representing and implementing detailed clinical models, and discuss the reasons for this design.

A grammar of integrity constraints in medical documentation systems.

R Goertzen — 2007-10-12T13:49:16-00:00

Comput Methods Programs Biomed, Vol. 86, No. 1. (April 2007), pp. 93-102.

An essential aspect for the utilization of medical data is their quality, thus a main feature of computer-based medical documentation systems should be to assist the user in complete and plausible data acquisition and maintenance. In this paper we define a grammar for modeling medical documentation systems to increase integrity and completeness of collected data, focusing attention on integrity constraints. An integrity constraint defines requirements that involved entities had to comply with. Furthermore it defines possibly implications in case of failure. The constraints presented in this paper are type constraint, length constraint, domain constraint, key constraint, quantity constraint, reference constraint, search constraint, result constraint, hierarchy constraint, and semantic constraint. Their grammar is declared using a schema in extensible markup language-format (XML-schema). The model introduced here can be used in computer-aided design and implementation of clinical documentation both minimizing effort and ensuring data quality, which was tested by an evaluation based on a specification of a registry for HIV-infected patients.

Survey Markup Language - SUML

University — 2007-10-12T13:47:05-00:00

A proposed ontology for online healthcare surveys.

SZ Huq — 2007-10-12T13:36:31-00:00

AMIA Annu Symp Proc (2003), pp. 304-309.

This paper results from the research efforts of the Clinical Informatics Research Group in building a generalized system for online survey implementation. Key to the success of any generalized survey system is a standard ontology for the differing components of any survey, particularly those sought to be implemented online, over the World Wide Web. In this paper, we introduce the need for generalized survey authoring tools, discuss our methods for elucidating the different components present in many healthcare instruments and classifying them as per existing standards, and later present our proposed ontology for online surveys in the healthcare domain. This is followed by a more detailed description of the different question types mentioned in this ontology. Finally, we compare some general purpose authoring systems currently available to determine their flexibility in representing these disparate question types (www.cirg.washington.edu/SuML).

Clinical decision support software for chronic heart failure.

SJ Leslie — 2007-09-15T09:47:49-00:00

Crit Pathw Cardiol, Vol. 6, No. 3. (September 2007), pp. 121-126.

Critical care pathways, protocols, and guidelines have become an everyday feature of clinical practice and represent a distillation of the best available evidence. Chronic heart failure guidelines can be complex, and it is acknowledged that a combination of knowledge and expert advice, in addition to guidelines, is required to optimally treat these patients. This current article describes the potential value of clinical decision support software (CDSS) in the treatment of patients with chronic heart failure and practical aspects of using such a tool. Barriers to implementation of our tool included relatively low computer skills among family physicians and a lack of complexity within CDSS in addressing the wider nonmedical needs of patients. Improving computer skills, integrating CDSS into referral pathways, and requests for investigation may be ways of enhancing the use of this technology.

Do multidisciplinary care plans result in better care for patients with type 2 diabetes?

NA Zwar — 2007-09-12T16:02:05-00:00

Aust Fam Physician, Vol. 36, No. 1-2. (b 2007), pp. 85-89.

BACKGROUND: Since the introduction of the Enhanced Primary Care package, care plans have become part of Australian general practice. Previous research has focused on barriers to the uptake of care plans. This study examined the effect of multidisciplinary care plans on provision and outcome of care for patients with type 2 diabetes. METHODS: A retrospective before/after medical record audit design was chosen. Subjects of the study were general practitioners practising in Southwest Sydney (New South Wales) and their diabetic patients who had written care plans. Outcome measures were frequency and results of glycosylated haemoglobin, blood pressure, foot, serum lipids, weight, and microalbumin checks. RESULTS: The medical records of 230 patients were audited. Following the care plan, adherence to diabetes guidelines increased. Metabolic control and cardiovascular risk factors improved for patients who had multidisciplinary care implemented. DISCUSSION: Whether the improved diabetes care shown here is attributed to improved teamwork and/or coordination of care needs further research.

The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: a 2-year follow-up.

TE Barnett — 2007-09-12T15:50:28-00:00

Am J Manag Care, Vol. 12, No. 8. (August 2006), pp. 467-474.

OBJECTIVES: To assess healthcare use among veterans with diabetes mellitus (DM) enrolled in a Department of Veterans Affairs (VA) Care Coordination Home Telehealth (CCHT) program during 24 months and to contrast this utilization with the service use of a comparison group of veterans with DM not enrolled in the program. STUDY DESIGN: Two-year, retrospective, concurrent matched cohort study design. METHODS: The VA CCHT program included older veterans with type 2 DM at high risk for multiple VA inpatient and outpatient visits. Healthcare utilization (hospitalizations, length of stay, and outpatient visits by type) was assessed at baseline and at 24 months after intervention for the treatment (n = 400) and comparison (n = 400) groups. Propensity scores were used to improve the balance between the treatment and comparison groups. A difference-in-differences approach was used to control for selection bias and for intervening time factors. RESULTS: Two years after enrollment, the treatment group exhibited a statistically significant reduction in the likelihood of all-cause and DM-related hospitalizations. In a subgroup analysis in which we controlled for patients' baseline glycosylated hemoglobin levels, the treatment group had a lower likelihood of having any care coordinator-initiated primary care clinic visits (in which the care coordinator initiated referral to primary care based on health information received from patients' CCHT technology). CONCLUSION: After controlling for selection bias and for intervening time factors, the VA CCHT program reduced avoidable healthcare services for DM (such as hospitalizations) and reduced care coordinator-initiated primary care clinic visits.

Nurse care coordination for diabetes: a literature review and synthesis.

S Ingersoll — 2007-09-12T15:43:08-00:00

J Nurs Care Qual, Vol. 20, No. 3. (p 2005), pp. 208-214.

Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors

Joan Ash — 2007-09-06T14:32:46-00:00

Journal of the American Medical Informatics Association, Vol. 11, No. 2. (2003), pp. 104-112.

Untitled

2007-08-31T14:43:01-00:00

Tolerogenic dendritic cells and the quest for transplant tolerance

Adrian Morelli — 2007-07-26T11:31:52-00:00

Nature Reviews Immunology, Vol. 7, No. 8. (13 July 2007), pp. 610-621.

New mechanism of tolerance induction in cancer

Olive Leavy — 2007-07-26T11:31:52-00:00

Nature Reviews Immunology, Vol. 7, No. 8., pp. 580-580.

Getting to the site of inflammation: the leukocyte adhesion cascade updated

Klaus Ley — 2007-08-24T11:06:16-00:00

Nature Reviews Immunology, Vol. 7, No. 9., pp. 678-689.

Promiscuity and the single receptor: NKG2D

Robert Eagle — 2007-08-24T11:06:17-00:00

Nature Reviews Immunology, Vol. 7, No. 9. (03 August 2007), pp. 737-744.

Developmental pathways that generate natural-killer-cell diversity in mice and humans

Nicholas Huntington — 2007-08-24T11:06:16-00:00

Nature Reviews Immunology, Vol. 7, No. 9., pp. 703-714.

Holding antigen where B cells can find it

Ian Maclennan — 2007-08-22T13:55:16-00:00

Nature Immunology, Vol. 8, No. 9., pp. 909-910.

TH-17 differentiation: of mice and men

Arian Laurence — 2007-08-22T13:55:16-00:00

Nature Immunology, Vol. 8, No. 9., pp. 903-905.

Molecular Basis for Target RNA Recognition and Cleavage by Human RISC.

SL Ameres — 2007-07-18T21:33:51-00:00

Cell, Vol. 130, No. 1. (13 July 2007), pp. 101-112.

The RNA-Induced Silencing Complex (RISC) is a ribonucleoprotein particle composed of a single-stranded short interfering RNA (siRNA) and an endonucleolytically active Argonaute protein, capable of cleaving mRNAs complementary to the siRNA. The mechanism by which RISC cleaves a target RNA is well understood, however it remains enigmatic how RISC finds its target RNA. Here, we show, both in vitro and in vivo, that the accessibility of the target site correlates directly with the efficiency of cleavage, demonstrating that RISC is unable to unfold structured RNA. In the course of target recognition, RISC transiently contacts single-stranded RNA nonspecifically and promotes siRNA-target RNA annealing. Furthermore, the 5' part of the siRNA within RISC creates a thermodynamic threshold that determines the stable association of RISC and the target RNA. We therefore provide mechanistic insights by revealing features of RISC and target RNAs that are crucial to achieve efficiency and specificity in RNA interference.

NK cell subsets and CD107a mobilization assay

J Zimmer — 2005-08-04T10:51:17-00:00

Leukemia, Vol. aop, No. current.

NKG2D in NK and T Cell-Mediated Immunity

Kouetsu Ogasawara — 2005-12-31T15:05:45-00:00

Journal of Clinical Immunology, Vol. 25, No. 6. (November 2005), pp. 534-540.

One of the best characterized NK cell receptors is NKG2D, a highly conserved C-type lectin-like membrane glycoprotein expressed on essentially all NK cells, as well as on γδ-TcR+ T cells and αβ-TcR+ CD8+ T cells, in humans and mice. Here we review recent studies implicating NKG2D in T cell and NK cell-mediated immunity to viruses and tumors, and its potential role in autoimmune diseases and allogeneic bone marrow transplantation.

Behavioral changes induced by Toxoplasma infection of rodents are highly specific to aversion of cat odors.

A Vyas — 2007-08-12T01:53:36-00:00

Proc Natl Acad Sci U S A, Vol. 104, No. 15. (10 April 2007), pp. 6442-6447.

The protozoan parasite Toxoplasma gondii blocks the innate aversion of rats for cat urine, instead producing an attraction to the pheromone; this may increase the likelihood of a cat predating a rat. This is thought to reflect adaptive, behavioral manipulation by Toxoplasma in that the parasite, although capable of infecting rats, reproduces sexually only in the gut of the cat. The "behavioral manipulation" hypothesis postulates that a parasite will specifically manipulate host behaviors essential for enhancing its own transmission. However, the neural circuits implicated in innate fear, anxiety, and learned fear all overlap considerably, raising the possibility that Toxoplasma may disrupt all of these nonspecifically. We investigated these conflicting predictions. In mice and rats, latent Toxoplasma infection converted the aversion to feline odors into attraction. Such loss of fear is remarkably specific, because infection did not diminish learned fear, anxiety-like behavior, olfaction, or nonaversive learning. These effects are associated with a tendency for parasite cysts to be more abundant in amygdalar structures than those found in other regions of the brain. By closely examining other types of behavioral patterns that were predicted to be altered we show that the behavioral effect of chronic Toxoplasma infection is highly specific. Overall, this study provides a strong argument in support of the behavioral manipulation hypothesis. Proximate mechanisms of such behavioral manipulations remain unknown, although a subtle tropism on part of the parasite remains a potent possibility.

The cost of information technology-enabled diabetes management.

J Adler-Milstein — 2007-08-09T18:57:44-00:00

Dis Manag, Vol. 10, No. 3. (June 2007), pp. 115-128.

As a result of the high cost of diabetes, an array of interventions for managing this disease has been developed. Estimating the cost of various approaches to diabetes disease management is critical to inform purchasing decisions. This review focuses on 5 provider- and payer-sponsored diabetes management approaches that use information technology (IT) and provides cost estimates for each approach based on a literature review and interviews with 38 provider practices, hospitals, payers, and vendors. Cost estimates are reported for "typical" small, medium, and large provider practices and payers. Provider-sponsored diabetes registries are estimated to be the least expensive approach for small and medium sized practices. For large practices with electronic health record systems, modifying such systems with diabetes-specific clinical decision support capabilities is projected to be the most economical approach. While limited data prevented the inclusion of all implementation costs, these projections serve as a starting point to inform the purchasing decisions of organizations planning to introduce IT-enabled diabetes management.

Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea

Kenshi Yamasaki — 2007-08-07T12:38:20-00:00

Nature Medicine, Vol. 13, No. 8. (05 August 2007), pp. 975-980.

Computerized provider order entry: strategies for successful implementation.

S Jones — 2007-08-05T20:19:22-00:00

J Nurs Adm, Vol. 36, No. 3. (March 2006), pp. 136-139.

An estimated 522,000 serious medication errors can be eliminated in the United States each year through the use of computerized provider order entry. However, the implementation of computerized provider order entry is being slowed down by resistance from clinicians, particularly physicians. Nurses understand the work of physicians and are in a unique position to help overcome their resistance and smoothen the transition to computerized provider order entry. The authors outline the strategies for nurses to increase organizational acceptance during the process of computerized provider order entry implementation.

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry

Joan Ash — 2007-08-05T20:12:19-00:00

J Am Med Inform Assoc, Vol. 14, No. 4. (1 July 2007), pp. 415-423.

BackgroundComputerized provider order entry (CPOE) systems can help hospitals improve health care quality, but they can also introduce new problems. The extent to which hospitals experience unintended consequences of CPOE, which include more than errors, has not been quantified in prior research. ObjectiveTo discover the extent and importance of unintended adverse consequences related to CPOE implementation in U.S. hospitals. Design, Setting, and ParticipantsBuilding on a prior qualitative study involving fieldwork at five hospitals, we developed and then administered a telephone survey concerning the extent and importance of CPOE-related unintended adverse consequences to representatives from 176 hospitals in the U.S. that have CPOE. MeasurementsSelf report by key informants of the extent and level of importance to the overall function of the hospital of eight types of unintended adverse consequences experienced by sites with inpatient CPOE. ResultsWe found that hospitals experienced all eight types of unintended adverse consequences, although respondents identified several they considered more important than others. Those related to new work/more work, workflow, system demands, communication, emotions, and dependence on the technology were ranked as most severe, with at least 72% of respondents ranking them as moderately to very important. Hospital representatives are less sure about shifts in the power structure and CPOE as a new source of errors. There is no relation between kinds of unintended consequences and number of years CPOE has been used. Despite the relatively short length of time most hospitals have had CPOE (median five years), it is highly infused, or embedded, within work practice at most of these sites. ConclusionsThe unintended consequences of CPOE are widespread and important to those knowledgeable about CPOE in hospitals. They can be positive, negative, or both, depending on one's perspective, and they continue to exist over the duration of use. Aggressive detection and management of adverse unintended consequences is vital for CPOE success. 10.1197/jamia.M2373

A pilot study to document the return on investment for implementing an ambulatory electronic health record at an academic medical center.

DL Grieger — 2007-08-02T01:43:31-00:00

J Am Coll Surg, Vol. 205, No. 1. (July 2007), pp. 89-96.

BACKGROUND: Adoption rates for electronic health records (EHRs) have been slow, despite growing enthusiasm. Cost is a frequently cited obstacle to implementing an EHR. The body of literature citing a positive return on investment is largely anecdotal and infrequently published in peer-reviewed journals. STUDY DESIGN: Five ambulatory offices, with a total of 28 providers, within the University of Rochester Medical Center, participated in a pilot project using an EHR to document the return on investment. A staged implementation of the Touchworks EHR (Allscripts) was undertaken from November 2003 to March 2004. Measurements of key financial indicators were made in the third calendar quarters of 2003 and 2005. These indicators included chart pulls, new chart creation, filing time, support staff salary, and transcription costs. In addition, patient cycle time, evaluation and management codes billed, and days in accounts receivable were evaluated to assess impact on office efficiency and billing. The savings realized were compared with the costs of the first 2 years of EHR use to determine return on investment. RESULTS: Total annual savings were $393,662 ($14,055 per provider). Total capital cost was $484,577. First-year operating expenses were $24,539. Total expenses for the first year were $509,539 ($18,182 per provider). Ongoing annual cost for subsequent years is $114,016 ($4,072 per provider). So, initial costs were recaptured within 16 months, with ongoing annual savings of $9,983 per provider. CONCLUSIONS: An EHR can rapidly demonstrate a positive return on investment when implemented in ambulatory offices associated with a university medical center, with a neutral impact on efficiency and billing.

Improving the quality of health care for chronic conditions.

JE Epping-Jordan — 2006-08-21T20:04:42-00:00

Qual Saf Health Care, Vol. 13, No. 4. (August 2004), pp. 299-305.

Chronic conditions are increasingly the primary concern of health care systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (health care organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.

Deconstructing heart failure disease management.

EH Wagner — 2007-07-21T21:11:52-00:00

Ann Intern Med, Vol. 141, No. 8. (19 October 2004), pp. 644-646.

High quality care for people with chronic diseases.

T Groves — 2006-08-21T18:53:48-00:00

BMJ, Vol. 330, No. 7492. (19 March 2005), pp. 609-610.

Improving outcomes for patients with diabetes using Joslin Diabetes Center's Registry and Risk Stratification system.

KG Russell — 2007-07-21T20:52:45-00:00

J Healthc Inf Manag, Vol. 21, No. 2. (2007), pp. 26-33.

Joslin Diabetes Center's Registry and Risk Stratification System collects data on key measures of diabetes care and provides diabetes decision support to primary care providers. Specifically, this system identifies high-risk patients in a population, recommends patient-specific interventions based on Joslin's clinical guidelines, and reports a clinic's process and quality metrics for benchmarking and regional comparisons. This article describes Joslin's system and its impact on the quality of diabetes care in the primary care setting.

Epidemiology of type 1 and type 2 diabetes. The added value of diabetes registries for conducting clinical studies: the Belgian paradigm.

FK Gorus — 2007-07-21T20:37:45-00:00

Acta Clin Belg, Vol. 59, No. 1. (b 2004), pp. 1-13.

Diabetes registries have documented that the lifetime risk of diabetes amounts to at least 10% in the western world. Moreover the prevalence of type 2 diabetes is increasing worldwide especially in developing countries. Furthermore there is a secular trend toward earlier clinical manifestation of both type 1 and type 2 diabetes. In the absence of a permanent cure for primary diabetes the present estimated number of at least 150 million diabetic patients worldwide is expected to double within the next 20 years. Consequently a sharp increase in the global burden of chronic diabetes complications is to be feared in the coming decades. Therefore it is absolutely mandatory to intensify research efforts aiming at identifying the etiological factors involved and designing effective strategies for prediction and prevention of the disease and its devastating complications. Diabetes registries constitute instruments of choice to conduct such studies because they are able to collect standardised clinical, demographic and biological information from sufficiently large representative groups of patients and risk groups such as first degree relatives. Since 1989, the Belgian Diabetes Registry is studying all types of diabetes presenting before age 40 in Belgium and provides a paradigm of how diabetes registries may also contribute to the advancement of knowledge on disease heterogeneity, etiology, prediction and prevention.

Using a simple patient registry to improve your chronic disease care.

DD Ortiz — 2007-07-21T04:04:10-00:00

Fam Pract Manag, Vol. 13, No. 4. (April 2006)

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

S Kripalani — 2007-07-14T03:58:57-00:00

JAMA, Vol. 297, No. 8. (28 February 2007), pp. 831-841.

CONTEXT: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. OBJECTIVES: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. DATA SOURCES: MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. STUDY SELECTION: Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18). DATA EXTRACTION: Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. DATA SYNTHESIS: Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents. CONCLUSIONS: Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.

Electronic Health Records in Specialty Care: A Time-Motion Study.

Helen G Lo — 2007-07-12T17:20:32-00:00

J Am Med Inform Assoc (28 June 2007)

Background Electronic health records (EHRs) have great potential to improve safety, quality, and efficiency in medicine. However, adoption has been slow, and a key concern has been that clinicians will require more time to complete their work using EHRs. Most previous studies addressing this issue have been done in primary care. OBJECTIVE To assess the impact of using an EHR on specialists' time. DESIGN Prospective, before-after trial of the impact of an EHR on attending physician time in four specialty clinics at an integrated delivery system: cardiology, dermatology, endocrine, and pain. Measuerments We used a time-motion method to measure physician time spent in one of 85 designated activities. RESULTS Attending physicians were monitored before and after the switch from paper records to a web-based ambulatory EHR. Across all specialties, 15 physicians were observed treating 157 patients while still using paper-based records, and 15 physicians were observed treating 146 patients after adoption. Following EHR implementation, the average adjusted total time spent per patient across all specialties increased slightly but not significantly (Delta=0.94 min., p=0.83) from 28.8 (SE=3.6) to 29.8 (SE=3.6) min. CONCLUSION These data suggest that implementation of an EHR had little effect on overall visit time in specialty clinics.

Update on the clinical management of childhood lead poisoning.

AD Woolf — 2007-07-10T14:27:53-00:00

Pediatr Clin North Am, Vol. 54, No. 2. (April 2007)

Childhood lead poisoning is still an enormous public health issue in the United States, affecting thousands of children and their families. New evidence suggests that even very low blood lead levels, less than 10 microg/dL, can be associated with neurologic injury. This article discusses characteristics of children at high risk for lead poisoning, unusual sources of lead contamination, and new aspects of lead's pathophysiology. It includes current thinking on the clinical management and prevention of childhood lead poisoning.

Medication errors related to computerized order entry for children.

KE Walsh — 2007-07-09T20:49:45-00:00

Pediatrics, Vol. 118, No. 5. (November 2006), pp. 1872-1879.

OBJECTIVE: The objective of this study was to determine the frequency and types of pediatric medication errors attributable to design features of a computerized order entry system. METHODS: A total of 352 randomly selected, inpatient, pediatric admissions were reviewed retrospectively for identification of medication errors, 3 to 12 months after implementation of computerized order entry. Errors were identified and classified by using an established, comprehensive, active surveillance method. Errors attributable to the computer system were classified according to type. RESULTS: Among 6916 medication orders in 1930 patient-days, there were 104 pediatric medication errors, of which 71 were serious (37 serious medication errors per 1000 patient-days). Of all pediatric medication errors detected, 19% (7 serious and 13 with little potential for harm) were computer related. The rate of computer-related pediatric errors was 10 errors per 1000 patient-days, and the rate of serious computer-related pediatric errors was 3.6 errors per 1000 patient-days. The following 4 types of computer-related errors were identified: duplicate medication orders (same medication ordered twice in different concentrations of syrup, to work around computer constraints; 2 errors), drop-down menu selection errors (wrong selection from a drop-down box; 9 errors), keypad entry error (5 typed instead of 50; 1 error), and order set errors (orders selected from a pediatric order set that were not appropriate for the patient; 8 errors). In addition, 4 preventable adverse drug events in drug ordering occurred that were not considered computer-related but were not prevented by the computerized physician order entry system. CONCLUSIONS: Serious pediatric computer-related errors are uncommon (3.6 errors per 1000 patient-days), but computer systems can introduce some new pediatric medication errors that are not typically seen in a paper ordering system.

Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.

MA Del Beccaro — 2007-07-09T19:14:22-00:00

Pediatrics, Vol. 118, No. 1. (July 2006), pp. 290-295.

OBJECTIVE: Our goal was to determine if there were any changes in risk-adjusted mortality after the implementation of a computerized provider order entry system in our PICU. METHODS: Study was undertaken in a tertiary care PICU with 20 beds and 1100 annual admissions. Demographic, admission source, primary diagnosis, crude mortality, and Pediatric Risk of Mortality III risk-adjusted mortality were abstracted retrospectively on all admissions from the PICUEs database for the period October 1, 2002, to December 31, 2004. This time period reflects the 13 months before and 13 months after computerized provider order entry implementation. Pediatric Risk of Mortality III mortality risk adjustment was used to determine standardized mortality ratios. RESULTS: During the study period, 2533 patients were admitted to the PICU, of which 284 were transported from another facility. The 13-month preimplementation mortality rate was 4.22%, and the 13-month postimplementation mortality rate was 3.46%, representing a nonsignificant reduction in the risk of mortality in the postimplementation period. The standardized mortality ratio was 0.98 vs 0.77, respectively, and the mortality rate for the transported patients was 9.6% vs 6.29%. This yields a nonsignificant mortality risk reduction in the postimplementation period. The standardized mortality ratio was 1.10 preimplementation versus 0.70 postimplementation. Analysis of the 13-month preimplementation versus 5-month postimplementation periods showed a non-statistically significant trend in reduction of mortality for all PICU patients and for transported patients. CONCLUSIONS: Implementation of a computerized provider order entry system, even in the early months after implementation, was not associated with an increase in mortality. Our experience suggests that careful design, build, implementation, and support can mitigate the risk of implementing new technology even in an ICU setting.

Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.

YY Han — 2006-02-15T04:26:18-00:00

Pediatrics, Vol. 116, No. 6. (December 2005), pp. 1506-1512.

OBJECTIVE: In response to the landmark 1999 report by the Institute of Medicine and safety initiatives promoted by the Leapfrog Group, our institution implemented a commercially sold computerized physician order entry (CPOE) system in an effort to reduce medical errors and mortality. We sought to test the hypothesis that CPOE implementation results in reduced mortality among children who are transported for specialized care. METHODS: Demographic, clinical, and mortality data were collected of all children who were admitted via interfacility transport to our regional, academic, tertiary-care level children's hospital during an 18-month period. A commercially sold CPOE program that operated within the framework of a general, medical-surgical clinical application platform was rapidly implemented hospital-wide over 6 days during this period. Retrospective analyses of pre-CPOE and post-CPOE implementation time periods (13 months before and 5 months after CPOE implementation) were subsequently performed. RESULTS: Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94-5.55) after adjustment for other mortality covariables. CONCLUSIONS: We have observed an unexpected increase in mortality coincident with CPOE implementation. Although CPOE technology holds great promise as a tool to reduce human error during health care delivery, our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies.

A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.

EG Van Eaton — 2007-07-02T20:30:05-00:00

J Am Coll Surg, Vol. 200, No. 4. (April 2005), pp. 538-545.

BACKGROUND: Adoption of limits on resident work hours prompted us to develop a centralized, Web-based computerized rounding and sign-out system (UWCores) that securely stores sign-out information; automatically downloads patient data (vital signs, laboratories); and prints them to rounding, sign-out, and progress note templates. We tested the hypothesis that this tool would positively impact continuity of care and resident workflow by improving team communication involving patient handovers and streamlining inefficiencies, such as hand-copying patient data during work before rounds ("prerounds"). STUDY DESIGN: Fourteen inpatient resident teams (6 general surgery, 8 internal medicine) at two teaching hospitals participated in a 5-month, prospective, randomized, crossover study. Data collected included number of patients missed on resident rounds, subjective continuity of care quality and workflow efficiency with and without UWCores, and daily self-reported prerounding and rounding times and tasks. RESULTS: UWCores halved the number of patients missed on resident rounds (2.5 versus 5 patients/team/month, p = 0.0001); residents spent 40% more of their prerounds time seeing patients (p = 0.36); residents reported better sign-out quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree). UWCores halved the portion of prerounding time spent hand-copying basic data (p < 0.0001); it shortened team rounds by 1.5 minutes/patient (p = 0.0006); and residents reported finishing their work sooner using UWCores (82.1% agree or strongly agree). CONCLUSIONS: This system enhances patient care by decreasing patients missed on resident rounds and improving resident-reported quality of sign-out and continuity of care. It decreases by up to 3 hours per week (range 1.5 to 3) the time used by residents to complete rounds; it diverts prerounding time from recopying data to more productive tasks; and it facilitates meeting the 80-hour work week requirement by helping residents finish their work sooner.

Characteristics of Internet use in relation to game genre in Korean adolescents.

MS Lee — 2007-06-18T22:04:26-00:00

Cyberpsychol Behav, Vol. 10, No. 2. (April 2007), pp. 278-285.

As the number of internet users increases, a new game genre using the internet as a networking tool is emerging. Some game genres are regarded as having greater addiction potentials than others. Games and the internet are closely related. We investigated games frequently used by adolescents and classified each of them with the help of game professionals. We also examined internet use patterns to identify relationships between game genre and internet use patterns. 627 middle school and high school students (male 488, female 139) completed questionnaires concerning computer and game use patterns and Korean internet addiction scales. Game genres were divided into eight criteria (simulation, role playing game, web board, community, action, adventure, shooting, and sports). Using Korean internet addiction scales, 627 participants were divided into a normal group (474), a potential risk group (128), and a high-risk group (25). Each group showed significant differences in total internet addiction scores. We classified players into specific game users based upon the game types they most prefer. Role playing game users showed significantly higher internet addiction scores than web board and sports game users. Game and internet addictions are also connected with interpersonal relationship patterns. We suggest that users of some game genre have unique psychological addiction potentials that are different from others and that this influences both game selection and internet use.

Action-Video-Game Experience Alters the Spatial Resolution of Vision

Green — 2007-03-13T01:31:20-00:00

Psychological Science, Vol. 18, No. 1. (January 2007), pp. 88-94.

Overutilization of Central Venous Catheters in Incident Hemodialysis Patients: Reasons and Potential Resolution Strategies

Lenz — 2006-11-16T05:09:22-00:00

Seminars in Dialysis, Vol. 19, No. 6. (December 2006), pp. 543-550.

An analysis of research in computing disciplines

Robert Glass — 2007-05-29T08:23:37-00:00

Commun. ACM, Vol. 47, No. 6. (June 2004), pp. 89-94.

The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients.

JL Xue — 2007-05-25T20:36:26-00:00

Am J Kidney Dis, Vol. 42, No. 5. (November 2003), pp. 1013-1019.

BACKGROUND: Dialysis access is critical for therapy delivery. Few studies have linked type of dialysis access to patient survival in the elderly population. METHODS: We included 1995 to 1997 incidence Medicare hemodialysis patients (N = 66,595) who were 67 years and older at dialysis therapy initiation. Medicare Physician/Supplier claims were used to determine initial access type: simple fistula, autologous vein graft, synthetic graft, and hemodialysis catheter. We used International Classification of Diseases, Ninth Revision, Clinical Modification, codes to determine vascular access placement for renal failure. A Cox regression analysis assessed risk for death within 1 year, with explanatory variables of incidence year, age, sex, race, diabetes, initial access type, body mass index, days from first access placement date to initial dialysis date, and serum albumin, creatinine, and blood urea nitrogen levels. RESULTS: One-year crude death rates were 24.9%, 27.2%, 28.1%, and 41.5% for patients with simple fistulae, autologous vein grafts, synthetic grafts, and hemodialysis catheters, respectively. Patients with simple fistulae (the reference) had the lowest (P < 0.0001) likelihood of death compared with those with synthetic grafts (hazard ratio [HR], 1.160; 95% confidence interval [CI], 1.084 to 1.241) or catheters (HR, 1.696; 95% CI, 1.593 to 1.806). No difference (P > 0.09) in mortality risk was detected between simple fistulae and autologous vein grafts or between autologous vein grafts and synthetic grafts. CONCLUSION: In the US Medicare dialysis population, type of initial hemodialysis access was associated with 1-year mortality. Mortality risks were (in ascending order) fistulae, grafts, and catheters.

Vascular access for hemodialysis: the impact on morbidity and mortality.

BR Di Iorio — 2007-05-25T20:34:29-00:00

J Nephrol, Vol. 17, No. 1. (b 2004), pp. 19-25.

BACKGROUND: In chronic hemodialysis (HD), central venous catheter (CVC) use seems associated with an increased risk of death. This study, using registry data, evaluated the morbidity and mortality risk associated with the use of different permanent vascular access (VA) in a HD patient cohort. METHOD: We evaluated hospitalization and death rate in prevalent and incident HD patients recorded in the uremic registry of Campania (southern Italy) for 2001. Patients were divided into three groups: CVC, artero-venous graft (AVG) and artero-venous fistula (AVF). RESULTS: One hundred and eleven dialysis units in the Campania region (69%) provided data. A total of 2201 out of 3387 prevalent HD patients were included: 92 patients (4.2%) were on CVC, 24 patients (1.1%) were on AVG and 2085 patients (94.7%) were on AVF. In comparison with AVF, the CVC group had a greater prevalence of female gender, old age, diabetes, comorbidities, hypoalbuminemia, anemia, erythropoietin (EPO) resistance, and less frequent synthetic membrane use, but had a similar dialysis duration (hr/week). Similar data were collected in the 635 incident patients registered in 2001. During the study, in both prevalent and incident CVC patients, either hospitalization or death rates were enhanced; however, the difference in the relative risk (RR) of death disappeared after correction for age, gender, malnutrition, diabetes, hemoglobin, albumin and comorbidity. Among incident patients, survival analysis was performed in patients remaining on the same VA type throughout the follow-up period; while a similar survival between groups was demonstrated in the 1st year of follow-up, survival was worse in the CVC group during the 2nd year of follow-up; however, this difference also disappeared in the adjusted analysis. CONCLUSION: This cohort study demonstrates that in chronic dialysis patients CVC choice, with respect to AVF, is mainly associated with female gender, advanced age and worse clinical conditions at baseline, and a worst outcome in both prevalent and incident CVC patients compared to AVF patients. Hospitalization, mortality rate and RR of death increased significantly; however, differences disappeared after correction for comorbidity. Therefore, these data suggest that CVC use per se is not associated with increased mortality risks with respect to AVF.

Effect of change in vascular access on patient mortality in hemodialysis patients.

M Allon — 2007-05-25T20:29:20-00:00

Am J Kidney Dis, Vol. 47, No. 3. (March 2006), pp. 469-477.

BACKGROUND: Hemodialysis patients using a catheter have a greater mortality risk than those using an arteriovenous (AV) access (fistula or graft). However, catheter-dependent patients also differ from those with an AV access in several clinical features, and these differences may themselves contribute to their excess mortality. METHODS: The current study evaluates whether a change in vascular access affects risk for mortality in patients enrolled in the Hemodialysis Study. Time-dependent Cox regression was used to relate mortality risk to current type of access and change in access type during the preceding 1 year. RESULTS: Compared with patients who dialyzed using an AV access at both the beginning and end of the preceding 1-year interval, relative risks for mortality were 3.43 (95% confidence interval [CI], 2.42 to 4.86) in patients who dialyzed with a catheter at both times; 2.38 (95% CI, 1.76 to 3.23) in patients switching from an AV access to a catheter, and 1.37 (95% CI, 0.81 to 2.32) in patients switching from a catheter to an AV access. Change from AV access to a catheter was associated with an antecedent decrease in serum albumin level (odds ratio, 1.25; 95% CI, 1.09 to 1.45 per 0.5 g/dL; P = 0.002), weight loss (odds ratio, 1.14; 95% CI, 1.06 to 1.22 per 2 kg; P < 0.001), and decreases in equilibrated normalized protein catabolic rate (odds ratio, 2.22; 95% CI, 1.41 to 3.57 per 0.25 g/kg/d; P < 0.001) and non-access-related hospitalization (odds ratio, 1.19; 95% CI, 1.06 to 1.32 per 1 additional hospitalization over 4 months; P = 0.002). Change from a catheter to AV access was predicted by only the antecedent non-access-related hospitalization rate (odds ratio, 0.93; 95% CI, 0.87 to 0.97 per 1 additional hospitalization over 4 months; P < 0.001). CONCLUSION: Change from a catheter to AV access is associated with a substantial decrease in mortality risk.

Type of vascular access and mortality in U.S. hemodialysis patients.

RK Dhingra — 2006-10-19T21:20:21-00:00

Kidney Int, Vol. 60, No. 4. (October 2001), pp. 1443-1451.

BACKGROUND: Vascular access (VA) complications account for 16 to 25% of hospital admissions. This study tested the hypothesis that the type of VA in use is correlated with overall mortality and cause-specific mortality. METHODS: Data were analyzed from the U.S. Renal Data System Dialysis Morbidity and Mortality Study Wave 1, a random sample of 5507 patients, prevalent on hemodialysis as of December 31, 1993. The relative mortality risk during a two-year observation was analyzed by Cox-regression methods with adjustments for demographic and comorbid conditions. Using similar methods, cause-specific analyses also were performed for death caused by infection and cardiac causes. RESULTS: In diabetic mellitus (DM) patients with end-stage renal disease, the associated relative mortality risk was higher for those with arteriovenous graft (AVG; RR = 1.41, P < 0.003) and central venous catheter (CVC; RR = 1.54, P < 0.002) as compared with arteriovenous fistula (AVF). In non-DM patients, those with CVC had a higher associated mortality (RR = 1.70, P < 0.001), as did to a lesser degree those with AVG (RR = 1.08, P = 0.35) when compared with AVF. Cause-specific analyses found higher infection-related deaths for CVC (RR = 2.30, P < 0.06) and AVG (RR = 2.47, P < 0.02) compared with AVF in DM; in non-DM, risk was higher also for CVC (RR = 1.83, P < 0.04) and AVG (RR = 1.27, P < 0.33). In contrast to our hypothesis that AV shunting increases cardiac risk, deaths caused by cardiac causes were higher in CVC than AVF for both DM (RR = 1.47, P < 0.05) and non-DM (RR = 1.34, P < 0.05) patients. CONCLUSION: This case-mix adjusted analysis suggests that CVC and AVG are correlated with increased mortality risk when compared with AVF, both overall and by major causes of death.

Vascular access and increased risk of death among hemodialysis patients.

S Pastan — 2007-05-25T20:23:38-00:00

Kidney Int, Vol. 62, No. 2. (August 2002), pp. 620-626.

BACKGROUND: Hemodialysis with a venous catheter increases the risk of infection. The extent to which venous catheters are associated with an increased risk of death among hemodialysis patients has not been extensively studied. METHODS: We conducted a retrospective cohort study of 7497 prevalent hemodialysis patients to assess the association between dialysis with a venous catheter and risk of death due to all causes and to infection. RESULTS: A tunneled cuffed catheter was used for access in 12% of the patients and non-cuffed, not tunneled catheter in 2%. Younger age (P = 0.0005), black race (P = 0.0022), female gender (P = 0.0004), short duration since starting dialysis (P = 0.0003) and impaired functional status (P = 0.0001) were independently associated with increased use of catheter access. The proportion of patients who died was higher among those who were dialyzed with a non-cuffed (16.8%) or cuffed (15.2%) catheter compared to those dialyzed with either a graft (9.1%) or a fistula (7.3%; P < 0.001). The proportion of deaths due to infection was higher among patients dialyzed with a catheter (3.4%) compared to those dialyzed with either a graft (1.2%) or a fistula (0.8%; P < 0.001). The adjusted odds ratio (95% CI) for all-cause and infection-related death among patients dialyzed with a catheter was 1.4 (1.1, 1.9) and 3.0 (1.4, 6.6), respectively, compared to those with an arteriovenous (AV) fistula. CONCLUSION: Venous catheters are associated with an increased risk of all-cause and infection-related mortality among hemodialysis patients.

Septicemia in dialysis patients: incidence, risk factors, and prognosis.

NR Powe — 2007-05-25T19:48:41-00:00

Kidney Int, Vol. 55, No. 3. (March 1999), pp. 1081-1090.

BACKGROUND: Infection is second to cardiovascular disease as a cause of death in patients with end-stage renal disease (ESRD), and septicemia causes a majority of these infectious deaths. To identify patients at high risk and to characterize modifiable risk factors for septicemia, we examined the incidence, risk factors, and prognosis for septicemia in a large, representative group of U.S. dialysis patients. METHODS: We conducted a longitudinal cohort study of incident ESRD patients in the case-mix study of the U.S. Renal Data System with seven years of follow-up from hospitalization and death records. Poisson regression was used to examine independent risk factors for hospital-managed septicemia. Cox proportional hazards analysis was used to assess the independent effect of septicemia on all-cause mortality and on death from septicemia. Separate analyses were performed for patients on peritoneal dialysis (PD) and hemodialysis (HD). RESULTS: Over seven years of follow-up, 11.7% of 4005 HD patients and 9.4% of 913 PD patients had at least one episode of septicemia. Older age and diabetes were independent risk factors for septicemia in all patients. Among HD patients, low serum albumin, temporary vascular access, and dialyzer reuse were also associated with increased risk. Among PD patients, white race and having no health insurance at dialysis initiation were also risk factors. Patients with septicemia had twice the risk of death from any cause and a fivefold to ninefold increased risk of death from septicemia. CONCLUSIONS: Septicemia, which carries a marked increased risk of death, occurs frequently in patients on PD as well as HD. Early referral to a nephrologist, improving nutrition, and avoiding temporary vascular access may decrease the incidence of septicemia. Further study of how race, insurance status, and dialyzer reuse can contribute to the risk of septicemia among ESRD patients is indicated.