A new study of Veterans Health Administration (VA) hospitals shows excess deaths, longer hospital stays, and higher costs in all groups of patients who experienced potentially preventable safety problems indicated by patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality (AHRQ).
Patient Safety Indicators may be useful for comparing Quality of care Across Delivery Systems
PSIs indicate preventable care-related problems such as hospital-acquired infections or postoperative respiratory failure. The study's findings were similar to a previous study of nonfederal community hospitals. Thus, AHRQ's PSIs may be useful for comparing care quality across delivery systems. AHRQ researcher, Anne Elixhauser, Ph.D., and colleagues applied 9 PSIs to all 439,537 acute inpatient hospitalizations at 125 VA hospitals. They then compared these findings with those based on similar data on PSIs and adverse events at U.S. community hospitals from AHRQ's Healthcare Cost and Utilization Project Nationwide Inpatient Sample. They controlled for patient and facility characteristics while predicting the effect of the PSI on mortality, length of stay (LOS), and cost. All nine PSIs were significantly associated with increased LOS, cost, and mortality in similar patterns among both VA and non-VA hospitals.
The three PSIs that occurred most often--decubitus ulcer, postoperative pulmonary embolism/deep vein thrombosis, and accidental puncture/laceration--were associated with relatively smaller excess mortality, LOS, and cost. The three PSIs that occurred least often--postoperative sepsis (blood infection), respiratory failure, and dehiscence (disruption of the wound) were associated with the greatest excess mortality, LOS, and cost.
See "Using patient safety indicators to estimate the impact of potential adverse events on outcomes," by Peter E. Rivard, Ph.D., Stephen L. Luther, Ph.D., Cindy L. Christiansen, Ph.D., and others, in the February 2008 Medical Care Research and Review 65(1), pp. 67-87.
Study shows value and limitations of voluntary error reporting systems
The Institute of Medicine, in its 1999 To Err is Human report, recommended that health care organizations establish medical error reporting systems. A team of researchers, led by Chunliu Zhan, M.D., Ph.D., of the Agency for Healthcare Research and Quality, conducted a study to explore the value and limitations of voluntary medical error reports, using common errors in warfarin use as a case study.
The researchers analyzed warfarin medication errors reported by hospitals and clinics participating in the MEDMARX voluntary medication errors reporting system. A total of 8,837 inpatient warfarin errors were reported by 445 hospitals from 2002 to 2004, ranging from 1 to 289 errors per hospital; 820 outpatient warfarin errors were reported by 192 outpatient facilities during that same period. The most common types of warfarin errors were related to dosing.
The most commonly reported cause of errors in hospitals were prescription transcribing/ documenting (35 percent) and drug administering (30 percent) and in outpatient settings, drug prescribing (31 percent) and dispensing (39 percent). The causes of errors were often multiple. The most frequent cause was the failure to do what is known to be right, which is often related to a distracting work environment, heavy work load, and understaffing. Corrective interventions, therefore, need to be multidimensional, suggest the researchers.
They pointed out that voluntary reporting systems are limited by lack of details, incomplete reporting, underreporting, and various reporting biases; also, they cannot yield a true error rate. However, such systems nevertheless provide useful information to guide patient safety improvements. For example, in this study, 17 percent of inpatient and 13 percent of outpatient warfarin errors resulted in changes in patient care.
See "How useful are voluntary medication error reports? The case of warfarin-related medication errors" by Dr. Zhan, Scott R. Smith, Ph.D., Margaret A. Keyes, M.A., and others in the January 2008 Joint Commission Journal on Quality and Patient Safety 34(1), pp. 36-45.
Smoking in the home leads to more emergency visits and hospitalizations for lung problems among young children
Smoking inside the home may more than double the risk of a young child having an emergency department (ED) visit and more than triple their risk of hospitalization for respiratory conditions, finds a new study. Agency for Healthcare Research and Quality investigators Lan Liang, Ph.D., and Stephen C. Hill, Ph.D., examined health care use, expenditures, and bed days among 2,759 children up to age 4 from the 1999 and 2001 Medical Expenditure Panel Surveys. They then linked these data to reports of smoking inside the home from the National Health Interview Survey.
Indoor smoking increased by 5 percent the probability of ED visits for respiratory conditions and the probability of hospitalization for these conditions by 3 percent. Indoor smoking was also associated with an 8 percent increase in the probability that a child would be laid up in bed because of respiratory illness. Similarly, among children visiting the ED for respiratory problems, roughly 18 percent may have had at least one visit related to smoking inside the home. Also, among children with at least one hospital stay for respiratory problems, roughly 36 percent may have had at least one stay related to smoking inside the home.
Indoor smoking was also costly. It was associated with $117 in additional health care expenditures for each child exposed to indoor smoking. Extrapolating this figure to the U.S. population, smoking inside the home adds roughly $415 million to annual health care expenditures for young children. There were no significant effects of living with adult smokers who smoked outside the home.
More details are in "Smoking in the home and children's health," by Drs. Hill and Liang, in the February 2008 Tobacco Control 17, pp. 32-37.
Several factors can quickly identify mortality risk among frail elderly persons living in the community
Community-based long-term care programs such as PACE (Program of All-Inclusive Care for the Elderly) can help frail, chronically ill elderly people who would ordinarily enter nursing homes stay in the community. Asking about certain risk factors during routine clinical care can identify which of these frail community-dwelling elderly are at risk of dying, according to a new study.
Kenneth E. Covinsky, M.D., M.P.H., of the University of California at San Francisco, and colleagues developed an index to identify mortality risk among this fragile group. The researchers studied a total of 3,899 enrollees at 11 PACE sites; they studied 2,232 participants to develop the index and 1,667 participants to validate it.
The researchers predicted time to death using data on risk factors (demographic characteristics, coexisting medical conditions, and functional status), which they obtained from a geriatric assessment performed at the time of study enrollment. The risk scoring system scored male sex as 2 points; age 75-84, 2 points; 85 and older, 3 points; dependence for help with toileting, 1 point; dependence for partial or full help with dressing, 1 and 3 points, respectively; cancer, 2 points; congestive heart failure, 3 points; chronic obstructive pulmonary disease, 1 point; and renal insufficiency, 3 points.
In the validation group, respective 1 and 3-year mortality rates were 7 and 18 percent in the lowest risk group (0-3 points), 11 and 36 percent in the middle-risk group (4-5 points), and 22 and 55 percent in the highest-risk group (more than 5 points). The eight-variable index is easy to use and includes variables that can be obtained in the course of a routine clinical exam.
The ability of the index to predict mortality risk among the frail elderly reinforces the importance of considering multiple domains in assessing the prognosis of older patients. The study was supported in part by the Agency for Healthcare Research and Quality (HS00006).
More details are in "Prediction of mortality in community living frail elderly people with long-term care needs," by Elise C. Carey, M.D., Dr. Covinsky, Li-Yung Lui, M.A., M.S., and others, in the January 2008 Journal of the American Geriatric Society 56(1), pp. 68-75.
Telepsychiatrists and in-person therapists deliver similar therapy to veterans suffering from posttraumatic stress disorder
Therapists can conduct cognitive behavioral therapy (CBT) with veterans suffering from posttraumatic stress disorder (PTSD) equally well via videoconferencing (telepsychiatry) or in person, concludes a new study. This finding can help address the shortage of access to mental health care by veterans in rural and other underserved areas, notes B. Christopher Frueh, Ph.D., of the University of Hawaii at Hilo.
Dr. Frueh and colleagues compared the quality of CBT for combat-related PTSD by a therapist in the same room as affected male veterans with the quality of CBT by the same therapist via telepsychiatry. Overall, 21 of 38 male veterans seeking treatment for PTSD at a Veterans Affairs medical center were randomized to in-room treatment and 17 were randomized to telepsychiatry.
The researchers used independent raters to assess therapist competence and adherence to CBT best practices. For example, they looked at the therapist's ability to structure the therapeutic sessions; implement session activities such as social skills training, role playing, or anxiety management training; provide feedback to the patient; deal with difficulties that emerge during therapy; develop rapport with the patient; and convey empathy. CBT treatment for combat-related PTSD targets interpersonal difficulties commonly associated with combat-related PTSD, such as social anxiety, social alienation, and withdrawal, excessive anger and hostility, explosive episodes, and marital and family conflict.
The active treatment phase consisted of weekly, 90-minute group treatment sessions over the course of 14 weeks, with three followup sessions over the 3 months after the active treatment phase. There was no significant difference in therapist adherence to the CBT treatment manual for both groups. Also, the teletherapist and in-person therapist were rated good to excellent for rapport and empathy, which are considered critical components of successful psychotherapy.
The study was funded in part by the Agency for Healthcare Research and Quality (HS11642).
See "Therapist adherence and competence with manualized cognitive-behavioral therapy for PTSD delivered via videoconferencing technology," by Dr. Frueh, Jeannine Monnier, Ph.D., Anouk L. Grubaugh, Ph.D., and others, in the November 2007 Behavior Modification 34(6), pp. 856-866.
Living wills should be updated, since preferences for life-prolonging treatments change when health status changes
Life-prolonging treatment preferences change as an individual's health deteriorates, according to a new study. To be useful, living wills should be updated with changes in health status, suggest Laraine Winter, Ph.D., and Barbara Parker, B.A., of Thomas Jefferson University. They asked 304 community-dwelling people aged 60 and older about their preferences for life-prolonging treatments for 4 life-threatening conditions: gall bladder surgery for an inflamed or infected gall bladder, antibiotics for pneumonia, cardiopulmonary resuscitation (CPR) for cardiac or respiratory arrest, and tube feeding for inability to eat or drink. For each treatment, individuals were asked their preference given eight health scenarios that varied in severity, prognosis, and level of pain, and one scenario that involved a return to current health.
Individuals' current health status was measured by number of deficits in physical functioning. Life-prolonging treatments were more strongly preferred by lower-functioning people, compared with high functioning, with the preference strengthening as health prospects worsened. The highest functioning individuals tended to reject life-prolonging treatments in the worse-health scenarios. It is likely that, to healthy individuals, the prospect of life in poor health is remote and therefore indistinguishable from death. For less healthy individuals, by contrast, the difference between these two states seems larger, and life-prolonging treatment more acceptable, explain the researchers. Stronger preferences for life-prolonging treatment in most health scenarios were also associated with higher religiosity. Depressed mood did not seem to influence advanced care decisions.
The study was supported by the Agency for Healthcare Research and Quality (HS13785). More details are in "Current health and preferences for life-prolonging treatments: An application of prospect theory to end-of-life decisionmaking," by Dr. Winter and Ms. Parker, in Social Science & Medicine 65, pp. 1695-1707, 2007
New pill card helps patients take medications on time
Free, online instructions for creating a pill card--an illustrated medication schedule--using only a personal or lap top computer and printer are now available from the Agency for Healthcare Research and Quality.
One in four Americans do not take prescription medicines as prescribed. Adherence to medication instructions is particularly important when people have chronic illnesses such as diabetes or heart failure. Many people who fail to adhere to medication instructions do so because they do not understand how to take their medicines. Medication non-adherence costs an estimated $100 billion annually in hospital admissions, doctor visits, lab tests, and nursing home admissions.
Research has shown that using a pill card with pictures and simple phrases to show each medicine, its purpose, how much to take, and when to take it reduces misunderstandings. A pill card can serve as a visual aid for confirming that patients understand how to take the medicines properly and as a reminder to take medicines.
AHRQ's How to Create a Pill Card provides step-by-step instructions for making a pill card. A person needs a computer with word processing software, a printer, and information on all of their medicines.
How to Create a Pill Card is intended for anyone who takes medicines regularly or who cares for someone who does. More information can be found at www.ahrq.gov/qual/pillcard/pillcard.htm.
Researchers examine the relationship of workarounds to technology implementation and medication safety in nursing homes
As many as 42 percent of adverse drug events in nursing homes are preventable. One way to reduce these errors is through the implementation of technology in the systems of medication administration. This technology, however, sometimes causes blocks in the work flow (e.g., through safety alerts and requests for more documentation). When nursing home staff work around these blocks, new types of medical errors and unintended consequences are introduced. A new study provides practical examples of workarounds in the nursing home and examines the risks to medication safety.
Researchers observed five Midwestern nursing homes that had implemented a fully integrated electronic health record (EHR) and an electronic medication record (eMAR). The medication administration system was mapped before the technology was implemented and then six months after implementation.
The authors identified two distinct root causes for workarounds. First were those introduced by the technology itself. For example, intentional blocks were designed in the system to prevent the ordering of excessive medication, but staff often worked around this block by entering several smaller doses of the same medication to obtain the full order.
Unintentional blocks were also evident; for instance, slow wireless connections when viewing multiple screens of a patient's health record led frustrated staff to consult written notes instead. A second root cause of workarounds was the failure to reengineer related processes for technology. For example, staff bypassed safety features that they perceived to be time consuming, such as a double documentation check at the time when medication was prepared and again when administered.
Nursing home staff most often engaged in first-order problem solving when they bypassed blocks in their work flow. That is, they found the most immediate solution to getting past the block. But a more effective and sophisticated approach is second-order problem solving, which addresses the root causes of the blocks. This strategy can be enhanced by the presence of the medication safety team, as well as by encouraging open communication among the staff so that they can talk openly about the blocks they face. Workarounds, such as overriding alerts, are a particular concern for patient safety. This study was supported in part by the Agency for Healthcare Research and Quality (HS14281).
More details are in "Technology implementation and workarounds in the nursing home," by Amy A. Vogelsmeier, M.S.N., R.N., Jonathon R. B. Halbesleben, Ph.D., Jill R. Scott-Cawiezell, R.N., Ph.D., in the January/February 2008 Journal of the American Medical Informatics Association 15(1), pp. 114-119.
Limited health literacy is a barrier to patients taking the correct prescribed medications
Patients with low health literacy typically have difficulty understanding the names of prescription medications, their indications for use, and dosing instructions. This confusion can lead to missed doses or wrongly timed doses. Low literacy can also lead to a disconnect between what medications the patient and doctor think the patient is taking, suggests a new study. When doctors and patients agree on what medications the patient is taking (medication reconciliation), there is less likelihood of medication errors or adverse effects. However, the study found that low health literacy among adults with hypertension was linked to a greater number of unreconciled medications.
Northwestern University researchers, led by Stephen D. Persell, M.D., M.P.H., administered the short-form Test of Functional Health Literacy to 119 adults with hypertension from 3 community health centers. They also asked them about the medications they took for their high blood pressure. Nearly one-third (31 percent) of the adults had inadequate health literacy. After adjusting for age and income, less literate patients were nearly three times less able than their more literate counterparts to name any of their antihypertensive medications.
Agreement between patient-reported medications and those documented in their medical record was low: 64.9 percent of patients with inadequate and 37.8 percent with adequate literacy had no medications common to both lists. Being unable to state which medications they are using by name (and also by dose) could be important, particularly when patients interact with providers other than their usual source of outpatient care (for example, hospitals or emergency departments). The study was supported in part by the Agency for healthcare Research and Quality (HS15647).
See "Limited health literacy is a barrier to medication reconciliation in ambulatory care," by Dr. Persell, Chandra Y. Osborn, Ph.D., Robert Richard, M.D., and others, in the November 2007 Journal of General Internal Medicine 22(11), pp. 1523-1526.
Nurses can facilitate quality improvement in primary care practices with electronic medical records
Nurses can play an important role in facilitating quality improvement in primary care practices with electronic medical record (EMR) systems, concludes a new study. The Practice Partners Research Network (PPRNet), a primary care practice-based research network, disseminated a five-pronged improvement model to its practices through quarterly performance reports for each quality of care indicator, practice site visits, and annual network meetings. The goal of the Quality Indicator (QI) model was to prioritize performance, involve all staff, redesign delivery systems, activate the patient, and use EMR tools.
The PPRNet practices boosted the involvement of staff members to determine approaches to improvement and focused on specific quality indicators each quarter. They also made efforts to redesign the delivery system. For example, they reviewed office processes to streamline and reduce redundancy or inefficiency, established written protocols to guide chronic disease management, and formed care management teams of providers and nurses to help patients with chronic illness. They also made more use of EMR tools. For example, they used EMR ticklers and recall systems to remind patients of screening services needed. Except for one patient education tool, patient activation strategies were the least commonly adopted improvement strategies.
Practice nursing staff assumed many new roles to enhance communication between patients and providers. Using templates within the EMR system, they reviewed what health maintenance screening tests were due and reconciled medication lists with patients. They increased the accuracy of patients' medication lists. Nurses also alerted providers to elevated blood pressures and other clinical parameters not at goal, and prompted them to administer or schedule interventions.
The study was supported by the Agency for Healthcare Research and Quality (HS13716).
See "Strategies to accelerate translation of research into primary care within practices using electronic medical records," by Lynne S. Nemeth, Ph.D., R.N., Andrea M. Wessell, Pharm.D., Ruth G. Jenkins, Ph.D., and others, in the October-December 2007 Journal of Nursing Care Quality 22(4), pp. 343-349.