Biomedical subjects

G J Kuperman

Publications and source records attributed to G J Kuperman.

42 records · Page 3Linked to original sources

PubMedDate not supplied

Automated evidence-based critiquing of orders for abdominal radiographs: impact on utilization and appropriateness.

OBJECTIVE: Inappropriate utilization of diagnostic testing has been well documented. The purpose of this study was to measure the impact of presenting real time, evidence-based critiques about the appropriateness of abdominal radiograph (KUB) orders on physician decision making. DESIGN: Prospective trial where evidence-based critiques were presented to ordering clinicians in two kinds of situations: (1) a KUB was likely to have a low probability of providing useful information, or (2) an alternative view(s) was more appropriate given the clinical circumstance. There were two phases of the trial: Phase 1 was a 9-week period where evidence-based critiques were presented at the time of ordering a KUB, followed by Phase 2, a 19-week period in which orderers were randomized to receive critiques either amended to include both institutional data regarding the utility of the critiques and stronger messages about the lack of utility of the study, or the same critiques as presented in Phase 1, depending upon indication. Based upon the radiologist's report of their interpretation of the exams, the results of the examinations were scored as positive, equivocal, or negative using structured criteria. RESULTS: 299 KUBs in Phase 1 and 385 KUBs in Phase 2 received at least one critique. Cancellation rates of low yield films were low, and were similar in Phase 1 and 2, 8/258 (3%) vs. 10/283 (4%). Compliance with the recommendation for alternative view(s) was higher: 19/104 (38%) in Phase 1 vs. 96/176 (55%) in Phase 2 (p = 0.006). The results differentiated low-yield from non-low-yield films: 5% of low-yield films vs. 20% of non-low-yield films were positive in Phase 2 (p < 0.0001). Surgical physicians were less likely to cancel (p = 0.07) or to change to the suggested view(s) (p < 0.0001) than medical physicians or nurses. CONCLUSIONS: The intervention identified clinical situations in which KUBs appeared to have a low clinical yield. In response to evidence-based critiques, providers were reluctant to cancel their order, but were more willing to change to different views. To reduce the number of inappropriate radiographic films, stronger incentives or interventions may be required.

Computer Systems↗

PubMedDate not supplied

How promptly are inpatients treated for critical laboratory results?

OBJECTIVE: The purpose of the study is to determine how frequently critical laboratory results (CLRs) occur and how rapidly they are acted upon. A CLR was defined as a result that met either the critical reporting criteria used by the laboratory at Brigham and Women's Hospital or other, more complex criteria. DESIGN: This is a retrospective cohort study in a large academic tertiary-care hospital. MEASUREMENTS: The proportion of chemistry and hematology results obtained in a 13-day period that met the hospital laboratory's critical reporting criteria were calculated. The charts of a stratified random sample of patients with CLRs due to sodium, potassium, and glucose were reviewed to determine the time interval until an appropriate treatment was ordered and the time interval until the critical condition was resolved. RESULTS: In 13 days, 1938 of 201,037 laboratory results (0.96%, or 0.44 per patient-day) met the hospital's critical reporting criteria. In the chart review, 222 CLRs were included in the stratified random sample, and 99 of these met the inclusion criteria. Among these 99 CLRs, the median time interval until an appropriate treatment was ordered was 2.5 hours. This interval was 1.8 hours when the CLR met the laboratory's criteria and a phone call was made, and 2.8 hours when the CLR met more complex criteria not requiring a phone call (p = 0.07). For 27 (27%) of the CLRs, an appropriate treatment was ordered only after five or more hours. The median time until the condition resolved was 14.3 hours: 12.0 hours for CLRs that met the hospital's criteria and 20.9 hours for the CLRs that met the more complex criteria (p = 0.006). CONCLUSION: Although CLRs meeting the hospital's criteria were reported promptly by the laboratory, treatment delays were still common. Results that did not meet the hospital's critical criteria but still represented serious clinical situations were more often associated with treatment delays. Difficulty communicating critical results directly to the responsible caregiver is the likely cause of some delays in treatment. New communications methods, including computer-based technologies, should be explored and tested for their potential to reduce treatment delays and improve clinical care.

Academic Medical Centers↗

PubMedDate not supplied

Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report.

BACKGROUND: Adverse drug events (ADEs) are both common and costly. Most hospitals identify ADEs using spontaneous reporting, but this approach lacks sensitivity; chart review identifies more events but is expensive. Computer-based approaches to ADE identification appear promising, but they have not been directly compared with chart review and they are not widely used. OBJECTIVES: To develop a computer-based ADE monitor, and to compare the rate and type of ADEs found with the monitor with those discovered by chart review and by stimulated voluntary report. DESIGN: Prospective cohort study in one tertiary-care hospital. PARTICIPANTS: All patients admitted to nine medical and surgical units in a tertiary-care hospital over an eight-month period. MAIN OUTCOME MEASURE: Adverse drug events identified by the computer-based monitor, by chart review, and by stimulated voluntary report. METHODS: A computer-based monitoring program identified alerts, which were situations suggesting that an ADE might be present (e.g., an order for an antidote such as naloxone). A trained reviewer then examined patients' hospital records to determine whether an ADE had occurred. The results of the computer-based monitoring strategy were compared with two other ADE detection strategies: intensive chart review and stimulated voluntary report by nurses and pharmacists. The monitor and the chart review strategies were independent, and the reviewers were blinded. RESULTS: The computer monitoring strategy identified 2,620 alerts, of which 275 were determined to be ADEs. The chart review found 398 ADEs, whereas voluntary report detected 23. Of the 617 ADEs detected by at least one method, 76 ADEs were detected by both computer monitor and chart review. The computer monitor identified 45 percent; chart review, 65 percent; and voluntary report, 4 percent. The ADEs identified by computer monitor were more likely to be classified as "severe" than were those identified by chart review (51 versus 42 percent, p = .04). The positive predictive value of computer-generated alerts was 16 percent during the first eight weeks of the study; rule modifications increased this to 23 percent in the final eight weeks. The computer strategy required 11 person-hours per week to execute, whereas chart review required 55 person-hours per week and voluntary report strategy required 5. CONCLUSIONS: The computer-based monitor identified fewer ADEs than did chart review but many more ADEs than did stimulated voluntary report. The overlap among the ADEs identified using different methods was small, suggesting that the incidence of ADEs may be higher than previously reported and that different detection methods capture different events. The computer-based monitoring system represents an efficient approach for measuring ADE frequency and gauging the effectiveness of ADE prevention programs.

Adverse Drug Reaction Reporting Systems↗

PubMedDate not supplied

A reliability study for evaluating information extraction from radiology reports.

GOAL: To assess the reliability of a reference standard for an information extraction task. SETTING: Twenty-four physician raters from two sites and two specialties judged whether clinical conditions were present based on reading chest radiograph reports. METHODS: Variance components, generalizability (reliability) coefficients, and the number of expert raters needed to generate a reliable reference standard were estimated. RESULTS: Per-rater reliability averaged across conditions was 0.80 (95% CI, 0.79-0.81). Reliability for the nine individual conditions varied from 0.67 to 0.97, with central line presence and pneumothorax the most reliable, and pleural effusion (excluding CHF) and pneumonia the least reliable. One to two raters were needed to achieve a reliability of 0.70, and six raters, on average, were required to achieve a reliability of 0.95. This was far more reliable than a previously published per-rater reliability of 0.19 for a more complex task. Differences between sites were attributable to changes to the condition definitions. CONCLUSION: In these evaluations, physician raters were able to judge very reliably the presence of clinical conditions based on text reports. Once the reliability of a specific rater is confirmed, it would be possible for that rater to create a reference standard reliable enough to assess aggregate measures on a system. Six raters would be needed to create a reference standard sufficient to assess a system on a case-by-case basis. These results should help evaluators design future information extraction studies for natural language processors and other knowledge-based systems.

Evaluation Studies as Topic↗

PubMedDate not supplied

Improving response to critical laboratory results with automation: results of a randomized controlled trial.

OBJECTIVE: To evaluate the effect of an automatic alerting system on the time until treatment is ordered for patients with critical laboratory results. DESIGN: Prospective randomized controlled trial. INTERVENTION: A computer system to detect critical conditions and automatically notify the responsible physician via the hospital's paging system. PATIENTS: Medical and surgical inpatients at a large academic medical center. One two-month study period for each service. MAIN OUTCOMES: Interval from when a critical result was available for review until an appropriate treatment was ordered. Secondary outcomes were the time until the critical condition resolved and the frequency of adverse events. METHODS: The alerting system looked for 12 conditions involving laboratory results and medications. For intervention patients, the covering physician was automatically notified about the presence of the results. For control patients, no automatic notification was made. Chart review was performed to determine the outcomes. RESULTS: After exclusions, 192 alerting situations (94 interventions, 98 controls) were analyzed. The intervention group had a 38 percent shorter median time interval (1.0 hours vs. 1.6 hours, P = 0.003; mean, 4.1 vs. 4.6 hours, P = 0.003) until an appropriate treatment was ordered. The time until the alerting condition resolved was less in the intervention group (median, 8.4 hours vs. 8.9 hours, P = 0.11; mean, 14.4 hours vs. 20.2 hours, P = 0.11), although these results did not achieve statistical significance. The impact of the intervention was more pronounced for alerts that did not meet the laboratory's critical reporting criteria. There was no significant difference between the two groups in the number of adverse events. CONCLUSION: An automatic alerting system reduced the time until an appropriate treatment was ordered for patients who had critical laboratory results. Information technologies that facilitate the transmission of important patient data can potentially improve the quality of care.

Academic Medical Centers↗

PubMedDate not supplied

The impact of computerized physician order entry on medication error prevention.

BACKGROUND: Medication errors are common, and while most such errors have little potential for harm they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events. OBJECTIVE: To evaluate the impact of computerized physician order entry (POE) with decision support in reducing the number of medication errors. DESIGN: Prospective time series analysis, with four periods. SETTING AND PARTICIPANTS: All patients admitted to three medical units were studied for seven to ten-week periods in four different years. The baseline period was before implementation of POE, and the remaining three were after. Sophistication of POE increased with each successive period. INTERVENTION: Physician order entry with decision support features such as drug allergy and drug-drug interaction warnings. MAIN OUTCOME MEASURE: Medication errors, excluding missed dose errors. RESULTS: During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001). CONCLUSIONS: Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.

Clinical Pharmacy Information Systems↗