Biomedical subjects

J Fiskio

Publications and source records attributed to J Fiskio.

8 recordsLinked to original sources

PubMed2001

Use and monitoring of "statin" lipid-lowering drugs compared with guidelines.

BACKGROUND: In patients with high cholesterol, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (or "statins") have been shown to reduce overall mortality in primary and secondary prevention. The National Cholesterol Education Program expert panel's guidelines (Adult Treatment Panel II) recommend evaluation and treatment of high cholesterol based on stratification of patients according to cardiovascular risk. While evidence suggests that many patients are undertreated, comparatively few data are available regarding overtreatment. OBJECTIVES: To assess the appropriateness of statin therapy compared with national guidelines and to examine the appropriateness of monitoring for adverse effects. METHODS: For all patients at a tertiary medical center, electronic medical records were evaluated for presence or absence of statin use and for presence of established coronary heart disease or cardiac risk factors. Therapy was compared with the recommendations of the National Cholesterol Education Program guidelines. Our primary outcome measures included, for all patients taking statins, prevalence of appropriateness vs overuse, and for all patients with coronary heart disease, prevalence of appropriateness vs underuse. RESULTS: Overuse of statin therapy was found among 69% of patients undergoing primary prevention, and among 47% of patients undergoing secondary prevention. In addition, among patients with coronary heart disease who were not taking statins, 88% were undertreated. Monitoring of liver function varied widely, and did not correlate with the risk of adverse events secondary to statin use. CONCLUSIONS: Overtreatment and undertreatment for hyperlipidemia were frequent. Decision support may help physicians improve their performance compared with guidelines.

Adult↗

PubMed2001

Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines.

OBJECTIVE: To use an electronic medical record to measure rates of compliance with the National Cholesterol Education Program (NCEP) cholesterol guidelines for secondary prevention, to characterize the patterns of noncompliance, and to identify patient and physician-specific correlates of noncompliance. DESIGN: Cross-sectional descriptive analysis of data extracted from an electronic medical record. SETTING: Nineteen primary care clinics affiliated with a tertiary academic medical center. PATIENTS: All patients who visited their primary care physician in the preceding year who met criteria for secondary prevention of hypercholesterolemia. INTERVENTIONS: None. The main outcome was rate of compliance with NCEP cholesterol guidelines. MAIN RESULTS: Of 2,019 patients who qualified for secondary prevention, only 31% were in compliance with NCEP recommendations, although 44% were on lipid-lowering therapy. There was no low-density lipoprotein cholesterol (LDL-C) on record within the last three years for 771 (38%), and another 809 (40%) had a recent LDL-C that was above the recommended target of 100 mg/dL. Of the latter group, 374 (46%) were not on a statin, including 188 patients with an LDL-C >130 mg/dL. Compliance among secondary prevention patients with cerebrovascular or peripheral vascular disease, but not coronary disease, was even lower: 19% versus 36%, P <.0001. Most of the additional noncompliant patients never had an LDL-C checked. Patient-specific factors associated with compliance included having seen a cardiologist (45% vs 21%); having had a recent admission for myocardial infarction, unstable angina, or angina (41% vs 26%); being male (37% vs 24%); and being white (34% vs 26%). Patients over 79 and under 50 years old also were less likely to be compliant (22% vs 34% for 50-79 year olds). There were no significant differences in compliance rates based on physician-specific factors, such as level of training, gender, or panel size. CONCLUSION: We found poor compliance with nationally published and well-accepted guidelines on diagnosing and treating hypercholesterolemia in secondary prevention patients. Compliance was unrelated to physician or physician-specific characteristics, but it was especially low for women, African Americans, patients without a cardiologist, and patients with cerebrovascular and peripheral vascular disease.

Aged↗

PubMed1999

A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests.

PURPOSE: To determine the impact of giving physicians computerized reminders about apparently redundant clinical laboratory tests. SUBJECTS AND METHODS: We performed a prospective randomized controlled trial that included all inpatients at a large teaching hospital during a 15-week period. The intervention consisted of computerized reminders at the time a test was ordered that appeared to be redundant. Main outcome measures were the proportions of clinical laboratory orders that were canceled and the proportion of the tests that were actually performed. RESULTS: During the study period, there were 939 apparently redundant laboratory tests among the 77,609 study tests that were ordered among the intervention (n = 5,700 patients) and control (n = 5,886 patients) groups. In the intervention group, 69% (300 of 437) of tests were canceled in response to reminders. Of 137 overrides, 41% appeared to be justified based on chart review. In the control group, 51% of ordered redundant tests were performed, whereas in the intervention group only 27% of ordered redundant tests were performed (P <0.001). However, the estimated annual savings in laboratory charges was only $35,000. This occurred because only 44% of redundant tests performed had computer orders, because only half the computer orders were screened for redundancy, and because almost one-third of the reminders were overridden. CONCLUSIONS: Reminders about orders for apparently redundant laboratory tests were effective when delivered. However, the overall effect was limited because many tests were performed without corresponding computer orders, and many orders were not screened for redundancy.

Boston↗

PubMed1999

Evaluating physician satisfaction regarding user interactions with an electronic medical record system.

A limiting factor in realizing the full potential of electronic medical records (EMR) is physician reluctance to use these applications. There have been very few formal usability studies of experienced physician users of EMRs in routine clinical use. We distributed the Questionnaire for User Interaction Satisfaction (QUIS) to 75 primary care physicians who routinely use the Brigham and Women's Integrated Computing System (BICS). BICS scored highest in the area of screen design and lowest in the area of system capability. Overall user satisfaction was most highly correlated with screen design and layout, and surprisingly not with system response time. Human-computer interaction studies can help focus our design efforts as we strive to increase clinician usage of information technology.

Attitude of Health Personnel↗

PubMed1999

A computer based intervention to reduce unnecessary serologic testing.

OBJECTIVE: Laboratory testing is important in the evaluation of patients with possible systemic rheumatic disease, but uncritical use of any test may result in misleading information and unnecessary costs. We attempted to reduce the number of unnecessary antinuclear antibody, rheumatoid factor, and complement level tests ordered by house officers at a large teaching hospital, where inpatient orders are written through a computer based order entry system. METHODS: We conducted a prospective cohort study of an interactive test ordering program. The intervention consisted of displaying post-test probability estimates during the usual physician order entry session. These estimates were based on pretest probabilities entered by the ordering physician and sensitivities and specificities derived from a literature review. Another group of test orders did not prompt the intervention and were considered controls. The outcome of interest was the percentage of tests canceled in the intervention group versus the control group. RESULTS: Eleven percent (11/99) of intervention orders were canceled, versus only one order among 236 controls (p = 0.001). However, there was no association between the physicians' pretest probability estimates and whether test orders were canceled (p = 0.59). Additionally, 43 of the 335 orders (13%) yielded positive tests, but only 4 patients (1%) were given new diagnoses of rheumatic disease. CONCLUSION: The computer based intervention significantly reduced orders for antinuclear antibody and rheumatoid factor levels by 10%. Further reductions without clinical harm are probably possible, since the yield of testing for new rheumatic diseases was low.

Adult↗

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

Reducing vancomycin use utilizing a computer guideline: results of a randomized controlled trial.

BACKGROUND: Vancomycin-resistant enterococci represent an increasingly important cause of nosocomial infections. Minimizing vancomycin use represents a key strategy in preventing the spread of these infections. OBJECTIVE: To determine whether a structured ordering intervention using computerized physician order entry that requires use of a guideline could reduce intravenous vancomycin use. DESIGN: Randomized controlled trial assessing frequency and duration of vancomycin therapy by physicians. PARTICIPANTS AND SETTING: Three hundred ninety-six physicians and 1,798 patients in a tertiary-care teaching hospital. INTERVENTION: Computer screen displaying, at the time of physician order entry, an adaptation of the Centers for Disease Control and Prevention guidelines for appropriate vancomycin use. MAIN OUTCOME MEASURES: The frequency of initiation and renewal of vancomycin therapy as well the duration of therapy prescribed on a per prescriber basis. RESULTS: Compared with the control group, intervention physicians wrote 32 percent fewer orders (11.3 versus 16.7 orders per physician; P = 0.04) and had 28 percent fewer patients for whom they either initiated or renewed an order for vancomycin (7.4 versus 10.3 orders per physician; P = 0.02). In addition, the duration of vancomycin therapy attributable to physicians in the intervention group was 36 percent lower than the duration of therapy prescribed by control physicians (26.5 versus 41.2 days; P = 0.05). Analysis of pharmacy data confirmed a decrease in the overall hospital use of intravenous vancomycin during the study period. CONCLUSION: Implementation of a computerized guideline using physician order entry decreased vancomycin use. Computerized guidelines represent a promising tool for changing prescribing practices.

Drug Prescriptions↗

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↗