Biomedical subjects

Penelope Pekow

Publications and source records attributed to Penelope Pekow.

10 recordsLinked to original sources

PubMed2006

Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Acute exacerbation of chronic obstructive pulmonary disease (COPD) is 1 of the 10 leading causes of hospitalization among adults in the United States. OBJECTIVE: To evaluate the quality of care provided to patients hospitalized for acute exacerbations of COPD and to determine whether hospital or patient characteristics influence treatment. DESIGN: Retrospective cohort study. SETTING: 360 hospitals throughout the United States. PATIENTS: 69,820 patients hospitalized for acute exacerbations of COPD. MEASUREMENTS: Adherence to diagnosis and treatment recommendations contained in guidelines produced by the American College of Physicians and the American College of Chest Physicians; analyses of associations between hospital and patient characteristics and composite measures of performance. RESULTS: Of the 69,820 patients, 66,276 (95%) underwent chest radiography, 63,715 (91%) received supplemental oxygen, 67 515 (97%) received bronchodilators, 59,240 (85%) received systemic steroids, and 59,053 (85%) were given antibiotics. In total, 45,800 (66%) received this entire set of recommended care processes. Numerous participants received tests or treatments that were not beneficial: 16,607 (24%) were treated with methylxanthine bronchodilators, 10,051 (14%) had sputum testing, 8354 (12%) underwent acute spirometry, 4299 (6%) had chest physiotherapy, and 1409 (2%) were treated with mucolytic medications. Overall, 31,519 patients (45%) received at least 1 of these nonrecommended care elements, and 22,929 (33%) received ideal care, defined as all of the recommended care processes and none of the nonrecommended ones. Individual hospital performance varied widely; whereas older patients and women were more likely to receive ideal care than their counterparts, a higher annual volume of admissions for COPD was not associated with improved hospital performance. LIMITATIONS: The study used administrative data, not chart review, and was limited to the inpatient management of COPD. CONCLUSIONS: The quality of care for patients hospitalized for acute exacerbations of COPD may be improved by increasing the use of systemic corticosteroid and antibiotic therapy, decreasing the use of unnecessary and potentially harmful treatments, and reducing variation in practice across hospitals.

Adult↗

PubMed2006

Physical activity patterns during pregnancy in a diverse population of women.

BACKGROUND: Participation in physical activity during pregnancy may reduce the risk of gestational diabetes mellitus and preeclampsia and help prevent excess maternal weight gain. However, studies describing patterns and correlates of activity during pregnancy are sparse. The purpose of this cross-sectional study was to describe total physical activity (household/caregiving, occupational, leisure, sports/exercise, and transportation) and correlates of total physical activity in a racially and economically diverse sample of 233 prenatal care patients. METHODS: Bilingual interviewers administered three 24-hour physical activity recalls among women in the first trimester (11%), second trimester (36%), and third trimester (53%) of pregnancy. RESULTS: Median total energy expenditure (MET-hours/day) was similar among women in the first and second trimesters (33.4 and 33.8 MET-hours/day, respectively) and was slightly, but not statistically significantly, lower among women in the third trimester (32.6 MET-hours/day). Moderate intensity activity followed a similar pattern, being statistically significantly lower among women in the third trimester; vigorous intensity activity was low among women in each trimester of pregnancy. In terms of activity type, household/ caregiving activity was the largest contributor to both total and combined moderate and vigorous intensity energy expenditure among women in each trimester, constituting 24%-40% of total energy expenditure. Overall, total energy expenditure was highest in white non-Hispanic women and positively associated with increasing education and a history of previous live births (p < 0.01). CONCLUSIONS: Results from this study highlight the importance of including household/caregiving and occupational activities in addition to sports/exercise activities in the assessment of total energy expenditure during pregnancy.

Adult↗

PubMed2006

Validation of the Kaiser Physical Activity Survey in pregnant women.

PURPOSE: Participation in physical activity during pregnancy may reduce the risk of maternal and fetal disorders. However, few studies have validated physical activity questionnaires for use during pregnancy, a time characterized by different patterns of activity than nonpregnancy. Therefore, the aim of this study was to assess the validity and reliability of the Kaiser Physical Activity Survey (KPAS) for use during pregnancy. METHODS: The KPAS, adapted from the Baecke physical activity survey, was designed specifically to assess physical activity in women. Unique features of the KPAS include the assessment of multiple domains of physical activity (household/caregiving, occupational, active living, and sports/exercise) as well as total activity. Summary KPAS indices were compared with objective (ActiGraph accelerometer by ActiGraph LLC) and subjective (Pregnancy Physical Activity Questionnaire (PPAQ)) measures of physical activity. Participants completed the self-administered PPAQ followed by the interviewer-administered KPAS and then wore the accelerometer for the following 7 d. At the end of the 7-d period, the questionnaires were repeated. RESULTS: Intraclass correlation coefficients used to measure reproducibility of the KPAS were r = 0.84 for total activity and ranged from r = 0.76 for active living activities to r = 0.86 for occupational activity. Spearman correlations between the KPAS and three published cut points used to classify accelerometer data ranged from r = 0.49-0.59 for total activity, r = 0.12-0.26 for household/caregiving, r = 0.26-0.33 for occupational activity, r = 0.31-0.36 for active living, and r = 0.34-0.51 for sports/exercise. Spearman correlations between the KPAS and the PPAQ ranged from r = 0.71 for household/caregiving to r = 0.84 for sports/exercise. CONCLUSIONS: The KPAS is a reliable and reasonably accurate instrument for estimating physical activity among pregnant women.

Adolescent↗

PubMed2005

Perioperative beta-blocker therapy and mortality after major noncardiac surgery.

BACKGROUND: Despite limited evidence from randomized trials, perioperative treatment with beta-blockers is now widely advocated. We assessed the use of perioperative beta-blockers and their association with in-hospital mortality in routine clinical practice. METHODS: We conducted a retrospective cohort study of patients 18 years of age or older who underwent major noncardiac surgery in 2000 and 2001 at 329 hospitals throughout the United States. We used propensity-score matching to adjust for differences between patients who received perioperative beta-blockers and those who did not receive such therapy and compared in-hospital mortality using multivariable logistic modeling. RESULTS: Of 782,969 patients, 663,635 (85 percent) had no recorded contraindications to beta-blockers, 122,338 of whom (18 percent) received such treatment during the first two hospital days, including 14 percent of patients with a Revised Cardiac Risk Index (RCRI) score of 0 and 44 percent with a score of 4 or higher. The relationship between perioperative beta-blocker treatment and the risk of death varied directly with cardiac risk; among the 580,665 patients with an RCRI score of 0 or 1, treatment was associated with no benefit and possible harm, whereas among the patients with an RCRI score of 2, 3, or 4 or more, the adjusted odds ratios for death in the hospital were 0.88 (95 percent confidence interval, 0.80 to 0.98), 0.71 (95 percent confidence interval, 0.63 to 0.80), and 0.58 (95 percent confidence interval, 0.50 to 0.67), respectively. CONCLUSIONS: Perioperative beta-blocker therapy is associated with a reduced risk of in-hospital death among high-risk, but not low-risk, patients undergoing major noncardiac surgery. Patient safety may be enhanced by increasing the use of beta-blockers in high-risk patients.

Adrenergic beta-Antagonists↗

PubMed2004

Follow-up treatment for osteoporosis after fracture.

Studies of the management of osteoporosis in older women who have had hip or wrist fractures have found underdiagnosis and undertreatment of the disease. Few such studies have been conducted in the United States, however, and most studies have been confined to a subset of the treatments currently available to treat osteoporosis. Mail surveys were sent to 381 women between 50 and 84 years of age who had been treated for a hip or wrist fracture at a large northeast US teaching hospital between October 1, 1998, and September 30, 2000. These surveys included questions about osteoporosis risk factors and physician treatment both before and after the index fracture. Of 381 surveys mailed, 70 were returned because of an invalid address or by a relative because a patient was deceased. Of the remaining 311 surveys, 147 completed responses were received. Fifty-two percent of respondents reported having received either a prescription or a recommendation for a nonprescription medication used to treat osteoporosis before the fracture. After fracture, 60% of subjects were advised to take any osteoporosis medication, and 42% of were advised to take a prescription medication. Of women reporting no treatment advice before fracture, 33% reported treatment after. Twenty-four percent of patients reported a change in treatment after fracture versus before. No significant differences in treatment were found according to fracture history, maternal history of fracture, or maternal history of osteoporosis. Both prescription and nonprescription treatment prevalence after fracture were lower than expected, and there was only a small change in reported treatment prevalence after fracture versus before. There was also little difference in treatment prevalence based on risk factors for osteoporosis or osteoporotic fractures. A sizeable opportunity exists for intervention to reduce the risk of osteoporotic fractures for patients who have a history of fracture.

Accidental Falls↗

PubMed2004

Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery.

CONTEXT: Cardiovascular complications following major noncardiac surgery are an important source of perioperative morbidity and mortality. Although lipid-lowering medications are considered a key component in the primary and secondary prevention of cardiovascular disease, their potential benefit during the perioperative period is uncertain. OBJECTIVE: To examine the association between treatment with lipid-lowering medications and in-hospital mortality following major noncardiac surgery. DESIGN, SETTING, AND PATIENTS: A retrospective cohort study based on hospital discharge and pharmacy records of 780,591 patients aged 18 years or older who underwent major noncardiac surgery from January 1, 2000, to December 31, 2001, at any 1 of 329 hospitals throughout the United States. Only patients who survived through at least the second hospital day were included. Lipid-lowering therapy was defined as use during the first 2 hospital days. Propensity matching was used to adjust for numerous baseline differences. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: Of the 780,591 patients, 77,082 patients (9.9%) received lipid-lowering therapy perioperatively and 23 100 (2.96%) died during the hospitalization. Treatment with lipid-lowering agents was associated with lower crude mortality (2.13% vs 3.05%, P<.001). In an analysis using matching by propensity score, 1595 patients (2.18%) treated with lipid-lowering medications died compared with 4158 patients (3.15%) who did not receive therapy or in whom treatment was initiated after the second day (P<.001). After adjusting for residual differences in the propensity matched groups using conditional logistic regression, risk of mortality remained lower among treated patients (adjusted odds ratio [OR], 0.62; 95% confidence interval [CI], 0.58-0.67). Based on this adjusted OR, the number needed to treat to prevent a postoperative death in the propensity matched cohort was 85 (95% CI, 77-98) and varied from 186 among patients at lowest risk to 30 among those with a revised cardiac risk index score of 4 or more. In a further analysis using the entire study cohort and adjusting for quintile of propensity, a significant effect of treatment persisted (adjusted OR, 0.71; 95% CI, 0.67-0.75). CONCLUSIONS: Treatment with lipid-lowering agents may reduce risk of death following major noncardiac surgery. Clinical trials are required to confirm this observation.

Aged↗

PubMed2003

Errors in a busy emergency department.

STUDY OBJECTIVE: We describe errors occurring in a busy ED. METHODS: This is a prospective, observational study of reported errors at an academic emergency department (ED) with 100000 annual visits. Trained personnel interviewed all ED staff with direct patient contact, during and at the end of every shift, by using standardized data sheets. RESULTS: One thousand nine hundred thirty-five ED patients registered during the 7-day study period in the summer of 2001. Four hundred error reports were generated, identifying 346 nonduplicative errors (18 per 100 registered patients; 95% confidence interval [CI] 15.9 to 20.0). Forty percent of errors were reported by nurses, 25% by providers, 19% by clerical staff, 13% by technicians and orderlies, and 3% multiple reporters. Errors reported for every 100 hours worked were similar for all groups (5.5; 95% CI 5.2 to 5.9). Errors were categorized as 22% diagnostic studies, 16% administrative procedures, 16% pharmacotherapy, 13% documentation, 12% communication, 11% environmental, and 9% other. Patients involved in errors were more likely to be older (P <.0001) and more likely to have higher visit level intensity (P <.0001) than registered ED patients. Ninety-eight percent of errors did not have a significant adverse outcome. Seven errors (0.36 per 100 registered patients; 95% CI 0.14 to 0.72) were associated with an adverse outcome. CONCLUSION: Reported errors occurred in almost every aspect of emergency care. Ninety-eight percent of errors in the ED do not result in adverse outcomes. System changes need to be implemented to reduce ED errors.

Academic Medical Centers↗

PubMed2002

Quality of care for patients hospitalized with heart failure: assessing the impact of hospitalists.

BACKGROUND: The quality of care provided to patients hospitalized for heart failure has been shown to vary by physician, hospital, and region. Hospitalists appear to reduce costs and length of stay, yet their impact on quality of care is less certain. OBJECTIVE: To compare quality of care and resource utilization among patients with heart failure treated by hospitalists and nonhospitalist general internists. METHODS: We reviewed the medical records of patients with a principal diagnosis of heart failure between April 1, 1999, and March 30, 2000, at a 550-bed community-based teaching hospital in Massachusetts. We evaluated quality of care by measuring adherence to a set of commonly used process measures and compared resource utilization using severity-adjusted length of stay and costs. RESULTS: The analysis included 280 patients, accounting for 326 heart failure admissions: 20 hospitalists cared for 137 (42%) cases, while 65 nonhospitalists cared for 189 (58%). Of 137 hospitalist cases, 129 (94%) had new or prior left ventricular ejection fraction testing results documented during the hospitalization compared with 165 (87%) of 189 nonhospitalist cases (P =.04). In cohorts of ideal candidates, performance rates for hospitalist and nonhospitalist cases were similar for prescriptions of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for patients with ejection fractions lower than 40% (97% vs 96%; P>.99) and warfarin for patients with atrial fibrillation (60% vs 55%; P =.64). Rates of comprehensive discharge counseling was similar in the 2 groups. Multivariable modeling did not substantially alter these findings. After adjusting for differences in severity, patients treated by hospitalists had a shorter length of stay but similar overall costs when compared with those treated by nonhospitalists. CONCLUSION: Compared with nonhospitalists, hospitalists were more likely to document assessment of left ventricular function and their patients had a shorter length of stay.

Aged↗

PubMed2002

The role of the institutional review board in quality improvement: a survey of quality officers, institutional review board chairs, and journal editors.

PURPOSE: There has been growing concern about whether and when quality improvement activities require Institutional Review Board (IRB) review and informed consent. We sought to determine whether quality officers, IRB chairs, and journal editors share similar views about the role of IRB review and informed consent in quality improvement. METHODS: A survey consisting of six quality improvement scenarios detailing the development, implementation, and evaluation of a clinical practice guideline for the management of patients with acute myocardial infarction was mailed to all medical directors of quality and IRB chairpersons at hospitals with at least 400 beds that are members of the Council of Teaching Hospitals of the Association of American Medical Colleges. The same survey was mailed to the editors of all U.S. medical journals that appear in Abridged Index Medicus. RESULTS: Quality officers were less likely than IRB chairs to believe that IRB review was required for all but one of the scenarios. When a clinical practice guideline developed by a national specialty society was implemented locally and its effects evaluated by chart review and telephone calls to patients, 47% (44/94) of IRB chairs, 66% (25/38) of journal editors, but only 20% (20/100) of quality officers believed the activity should be subjected to IRB review. Among those who thought that IRB review was required, there were similar but less striking differences in the perceived need for informed consent. Agreement between quality officers and IRB chairs within the same institution was poor, ranging from 44% to 52% for three of the six scenarios. CONCLUSION: In light of the pressing need to improve quality while protecting the rights of patients, efforts should be supported to clarify the role of the IRB in quality improvement activities.

Attitude of Health Personnel↗

PubMedDate not supplied

Maternal body mass index, delivery route, and induction of labor in a midwifery caseload.

The purpose of this study was to identify the association between prepregnancy body mass index (BMI), weight gain in pregnancy, and newborn birth weight on route of delivery and induction of labor in patients receiving nurse-midwifery care. This retrospective cohort study examined the outcomes of 1500 consecutively delivered women who were cared for by two midwifery practices and delivered between January 1, 1998, and December 31, 2000. Cesarean delivery was significantly associated with the obese BMI (P < .001), nulliparity (P < .02), and newborn birth weight (P =.006). Prenatal weight gain did not have a significant correlation with cesarean birth (P = .24). In multivariable modeling, obese BMI, high newborn birth weight, nulliparity, and induction of labor increased the risk of cesarean birth. There was also a significant association between higher BMI and risk of induction of labor (P < .001). In a secondary analysis, obese BMI was associated with increased risk of induction in cases with ruptured membranes (OR 2.2; 95% CI 1.4-3.4) and postdates pregnancy (OR 2.0; 95% CI 1.1-3.4).

Adult↗