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Biomedical subjects

Kaveh G Shojania

Publications and source records attributed to Kaveh G Shojania.

At least 19 recordsLinked to original sources
PubMed2006

Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.

A patient admitted to a teaching hospital with a mild episode of acute pancreatitis initially improved, but then her condition deteriorated and she subsequently died. The initial deterioration probably reflected bowel obstruction, as shown on an abdominal radiograph that an on-call intern forgot to review. This diagnostic delay was compounded by poor communication that resulted in a medical student inserting a feeding tube--rather than a nasogastric tube--to decompress the bowel, followed by failure to recognize how ill the patient had become. The case highlights the hazards of patient handoffs as well as the importance of clear communication techniques and knowing when to ask for help. The discussion also shows the vicious circle that results when attending physicians fail to provide effective supervision: Not only is safety compromised but trainees lose the experience of being supervised. Consequently, trainees have no models of effective supervision on which to draw when they become supervisors. They then fall into the same trap as those who taught them, busying themselves with direct patient care and providing supervision only as time allows.

Aged, 80 and over↗
PubMed2006

Do opiates affect the clinical evaluation of patients with acute abdominal pain?

CONTEXT: Clinicians have traditionally withheld opiate analgesia from patients with acute abdominal pain until after evaluation by a surgeon, out of concern that analgesia may alter the physical findings and interfere with diagnosis. OBJECTIVE: To determine the impact of opiate analgesics on the rational clinical examination and operative decision for patients with acute abdominal pain. DATA SOURCES AND STUDY SELECTION: MEDLINE (through May 2006), EMBASE, and hand searches of article bibliographies to identify placebo-controlled randomized trials of opiate analgesia reporting changes in the history, physical examination findings, or diagnostic errors (those resulting in "management errors," defined as the performance of unnecessary surgery or failure to perform necessary surgery in a timely fashion). DATA EXTRACTION: Two authors independently reviewed each study, abstracted data, and classified study quality. A third reviewer independently resolved discrepancies. DATA SYNTHESIS: Studies both in adults (9 trials) and in children (3 trials) showed trends toward increased risks of altered findings on the abdominal examination due to opiate administration, with risk ratios for changes in the examination of 1.51 (95% confidence interval [CI], 0.85 to 2.69) and 2.11 (95% CI, 0.60 to 7.35), respectively. When the analysis was restricted to the 8 adult and pediatric trials that reported significantly greater analgesia for patients who received opiates compared with those who received placebo, the risk of physical examination changes became significant (risk ratio, 2.13; 95% CI, 1.14 to 3.98). These trials exhibited significant heterogeneity (I2 = 68.6%; P = .002), and only 2 trials distinguished clinically significant changes such as loss of peritoneal signs from all other changes; consequently, we analyzed risk of management errors as a marker for important changes in the physical examination. Opiate administration had no significant association with management errors (+0.3% absolute increase; 95% CI, -4.1% to +4.7%). The 3 pediatric trials showed a nonsignificant absolute decrease in management errors (-0.8%; 95% CI, -8.6% to +6.9%). Across adult and pediatric trials with adequate analgesia, opiate administration was associated with a nonsignificant absolute decrease in the risk of management errors (-0.2%; 95% CI, -4.0% to +3.6%). CONCLUSIONS: Opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors. The existing literature does not rule out a small increase in errors, but this error rate reflects a conservative definition in which surgeries labeled as either delayed or unnecessary may have met appropriate standards of care. In published research reports, no patient experienced major morbidity or mortality attributable to opiate administration.

Abdomen, Acute↗
PubMed2006

Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.

CONTEXT: There have been numerous reports of interventions designed to improve the care of patients with diabetes, but the effectiveness of such interventions is unclear. OBJECTIVE: To assess the impact on glycemic control of 11 distinct strategies for quality improvement (QI) in adults with type 2 diabetes. DATA SOURCES AND STUDY SELECTION: MEDLINE (1966-April 2006) and the Cochrane Collaboration's Effective Practice and Organisation of Care Group database, which covers multiple bibliographic databases. Eligible studies included randomized or quasi-randomized controlled trials and controlled before-after studies that evaluated a QI intervention targeting some aspect of clinician behavior or organizational change and reported changes in glycosylated hemoglobin (HbA1c) values. DATA EXTRACTION: Postintervention difference in HbA1c values were estimated using a meta-regression model that included baseline glycemic control and other key intervention and study features as predictors. DATA SYNTHESIS: Fifty randomized controlled trials, 3 quasi-randomized trials, and 13 controlled before-after trials met all inclusion criteria. Across these 66 trials, interventions reduced HbA(1c) values by a mean of 0.42% (95% confidence interval [CI], 0.29%-0.54%) over a median of 13 months of follow-up. Trials with fewer patients than the median for all included trials reported significantly greater effects than did larger trials (0.61% vs 0.27%, P = .004), strongly suggesting publication bias. Trials with mean baseline HbA1c values of 8.0% or greater also reported significantly larger effects (0.54% vs 0.20%, P = .005). Adjusting for these effects, 2 of the 11 categories of QI strategies were associated with reductions in HbA(1c) values of at least 0.50%: team changes (0.67%; 95% CI, 0.43%-0.91%; n = 26 trials) and case management (0.52%; 95% CI, 0.31%-0.73%; n = 26 trials); these also represented the only 2 strategies conferring significant incremental reductions in HbA1c values. Interventions involving team changes reduced values by 0.33% more (95% CI, 0.12%-0.54%; P = .004) than those without this strategy, and those involving case management reduced values by 0.22% more (95% CI, 0.00%-0.44%; P = .04) than those without case management. Interventions in which nurse or pharmacist case managers could make medication adjustments without awaiting physician authorization reduced values by 0.80% (95% CI, 0.51%-1.10%), vs only 0.32% (95% CI, 0.14%-0.49%) for all other interventions (P = .002). CONCLUSIONS: Most QI strategies produced small to modest improvements in glycemic control. Team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval. Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias.

Blood Glucose↗
PubMed2006

Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: a Bayesian analysis.

BACKGROUND: Spiral computed tomographic pulmonary angiography (CTPA) has become the primary test used to investigate suspected pulmonary embolism (PE) at many institutions, despite uncertainty regarding its sensitivity and specificity. Although CTPA-based diagnostic algorithms focus on minimizing the false-negative rate, we hypothesized that increasing use of CTPA also might lead to false-positive diagnoses. OBJECTIVE: Determine the frequency of possible false-positive diagnoses of PE when CTPA is the primary diagnostic test. DESIGN: Retrospective cohort study. SETTING: Two academic teaching hospitals. PARTICIPANTS: 322 patients with suspected PE evaluated with CTPA. MEASUREMENTS: We used a validated prediction rule to determine the pretest probability of PE in each patient. We combined these pretest probabilities with published estimates of CTPA test characteristics to generate expected posttest probabilities of PE. We compared these posttest probabilities to actual treatment decisions to determine the rate of false-positive diagnoses of PE. RESULTS: Among 322 patients investigated for PE, 37 (12%) had high pretest probability, 101 (32%) moderate, and 184 (57%) low. CT scans were interpreted as positive for PE in 57 patients (17.8%). Regardless of the pretest probability of PE, 96.5% of patients with a positive CTPA were treated with anticoagulants. Even under an optimistic assumption of CTPA test characteristics, as many as 25.4% of these patients may have been treated unnecessarily as a result of a false-positive diagnosis. Most of these patients had a low pretest probability of PE. CONCLUSIONS: Failure to utilize Bayesian reasoning when interpreting CTPA may lead to false-positive diagnoses of pulmonary embolism in a substantial proportion of patients.

Bayes Theorem↗
PubMed2006

Adverse events detected by clinical surveillance on an obstetric service.

OBJECTIVE: Adverse events are adverse patient outcomes resulting from medical care. We performed this study to estimate the rate of adverse events and potential adverse events-errors that have a high likelihood of causing patient harm-occurring during obstetric care. METHODS: This was a prospective cohort study of an obstetric unit in a teaching hospital. We included patients admitted consecutively to the hospital. A trained observer monitored patients for 72 triggers, which were predefined occurrences deemed likely to indicate an actual or potential adverse event. When a trigger occurred, the observer captured information describing it. A five-person multidisciplinary team, including the observer, three physicians, and a hospital risk manager, judged whether the trigger represented an adverse event or potential adverse event. Adverse events were further characterized as preventable. RESULTS: The cohort included 425 patients; 47% were in active labor. We identified 110 triggers. Nine were considered adverse events (risk 2%, 95% confidence interval [CI] 1-4%, rate 0.8 events per 100 patient days), and six were preventable (risk 1%, 95% CI 0-3%, rate 0.5 events per 100 patient days). The remaining triggers included 14 potential adverse events (risk 3%, 95% CI 2-5%, rate 1.3 events per 100 patient days). No adverse event resulted in permanent disability or death. Adverse events and potential adverse events were most commonly "system" problems, such as unavailable staff or operating rooms, or poor fetal outcomes, such as trauma to the newborn. CONCLUSION: Serious adverse events occur infrequently on an obstetric service. However, important quality problems are common and should be targeted for improvement. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2006

Improving antibiotic selection: a systematic review and quantitative analysis of quality improvement strategies.

OBJECTIVE: We sought to assess which interventions are most effective at improving the prescribing of recommended antibiotics for acute outpatient infections. DESIGN AND METHODS: We undertook a systematic review with quantitative analysis of the Cochrane Registry Effective Practice and Organization of Care (EPOC) database, supplemented by MEDLINE and hand-searches. Inclusion criteria included clinical trials with contemporaneous or strict historical controls that reported data on antibiotic selection in acute outpatient infections. The effect size of studies with different intervention types were compared using nonparametric statistics. To maximize comparability between studies, quantitative analysis was restricted to studies that reported absolute changes in the amount of or percent compliance with recommended antibiotic prescribing. RESULTS: Twenty-six studies reporting 33 trials met inclusion criteria. Most interventions used clinician education alone or in combination with audit and feedback. Among the 22 comparisons amenable to quantitative analysis, recommended antibiotic prescribing improved by a median of 10.6% (interquartile range [IQR] 3.4-18.2%). Trials evaluating clinician education alone reported larger effects than interventions combining clinician education with audit and feedback (median effect size 13.9% [IQR 8.6-21.6%] vs. 3.4% [IQR 1.8-9.7%], P = 0.03). This result was confounded by trial sample size, as trials having a smaller number of participating clinicians reported larger effects and were more likely to use clinician education alone. Active forms of education, sustained interventions, and other features traditionally associated with successful quality improvement interventions were not associated with effect size and showed no evidence of confounding the association between clinician education-only strategies and outcome. CONCLUSIONS: Multidimensional interventions using audit and feedback to improve antibiotic selection were less effective than interventions using clinician education alone. Although confounding may partially account for this finding, our results suggest that enhancing the intensity of a focused intervention may be preferable to a less intense, multidimensional approach.

Anti-Bacterial Agents↗
PubMed2006

Quality improvement strategies for hypertension management: a systematic review.

BACKGROUND: Care remains suboptimal for many patients with hypertension. PURPOSE: The purpose of this study was to assess the effectiveness of quality improvement (QI) strategies in lowering blood pressure. DATA SOURCES: MEDLINE, Cochrane databases, and article bibliographies were searched for this study. STUDY SELECTION: Trials, controlled before-after studies, and interrupted time series evaluating QI interventions targeting hypertension control and reporting blood pressure outcomes were studied. DATA EXTRACTION: Two reviewers abstracted data and classified QI strategies into categories: provider education, provider reminders, facilitated relay of clinical information, patient education, self-management, patient reminders, audit and feedback, team change, or financial incentives were extracted. DATA SYNTHESIS: Forty-four articles reporting 57 comparisons underwent quantitative analysis. Patients in the intervention groups experienced median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) that were 4.5 mm Hg (interquartile range [IQR]: 1.5 to 11.0) and 2.1 mm Hg (IQR: -0.2 to 5.0) greater than observed for control patients. Median increases in the percentage of individuals achieving target goals for SBP and DBP were 16.2% (IQR: 10.3 to 32.2) and 6.0% (IQR: 1.5 to 17.5). Interventions that included team change as a QI strategy were associated with the largest reductions in blood pressure outcomes. All team change studies included assignment of some responsibilities to a health professional other than the patient's physician. LIMITATIONS: Not all QI strategies have been assessed equally, which limits the power to compare differences in effects between strategies. CONCLUSION: QI strategies are associated with improved hypertension control. A focus on hypertension by someone in addition to the patient's physician was associated with substantial improvement. Future research should examine the contributions of individual QI strategies and their relative costs.

Blood Pressure Determination↗
PubMed2005

Challenges in systematic reviews: synthesis of topics related to the delivery, organization, and financing of health care.

Some important health policy topics, such as those related to the delivery, organization, and financing of health care, present substantial challenges to established methods for evidence synthesis. For example, such reviews may ask: What is the effect of for-profit versus not-for-profit delivery of care on patient outcomes? Or, which strategies are the most effective for promoting preventive care? This paper describes innovative methods for synthesizing evidence related to the delivery, organization, and financing of health care. We found 13 systematic reviews on these topics that described novel methodologic approaches. Several of these syntheses used 3 approaches: conceptual frameworks to inform problem formulation, systematic searches that included nontraditional literature sources, and hybrid synthesis methods that included simulations to address key gaps in the literature. As the primary literature on these topics expands, so will opportunities to develop additional novel methods for performing high-quality comprehensive syntheses.

Decision Support Techniques↗
PubMed2004

Is acetylcysteine effective in preventing contrast-related nephropathy? A meta-analysis.

PURPOSE: Clinical trials evaluating acetylcysteine for the prevention of contrast-related nephropathy have reported mixed results. Although previous meta-analyses have concluded that acetylcysteine is beneficial, the recent availability of additional trials calls for reassessment of current evidence. METHODS: We performed a computerized search to identify relevant published and unpublished randomized clinical trials that evaluated acetylcysteine for the prevention of contrast-related nephropathy. Abstracted data from each trial included assessments of clinical outcomes, trial quality, and additional characteristics. The primary outcome of interest was the incidence of nephropathy after contrast administration. Data were combined using random-effects models with the performance of standard tests to assess for heterogeneity and publication bias. Subgroup analyses were also performed. RESULTS: Twenty trials involving 2195 patients met our inclusion criteria. Trials varied in patient demographic characteristics, inclusion criteria, dosing regimens, and trial quality. The summary risk ratio for contrast-related nephropathy was 0.73 (95% confidence interval: 0.52 to 1.0; P = 0.08), a nonsignificant trend towards benefit in patients treated with acetylcysteine. This effect varied, however, across the 20 trials (test of heterogeneity, P = 0.04). Although higher-quality trials demonstrated a stronger benefit for acetylcysteine in general, few reported important elements of study design, such as concealment of allocation, placebo-controls, or double-blinding. Heterogeneity was unexplained by subgroup analyses. CONCLUSION: Acetylcysteine may reduce the incidence of contrast-related nephropathy, but this finding is reported inconsistently across currently available trials. High-quality, large clinical trials are needed before acetylcysteine use in this indication can be recommended universally.

Acetylcysteine↗