Biomedical subjects

Steven R Simon

Publications and source records attributed to Steven R Simon.

At least 19 recordsLinked to original sources

PubMed2007

Implementation and use of an electronic health record within the Indian Health Service.

OBJECTIVES: There are limited data regarding implementing electronic health records (EHR) in underserved settings. We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans. DESIGN: We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005. METHODS: The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings. We fit a multivariable logistic regression model to identify correlates of increased utilization of the EHR. RESULTS: The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient-doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05-8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records. CONCLUSIONS: Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.

Attitude of Health Personnel↗

PubMed2007

Laboratory monitoring of potassium and creatinine in ambulatory patients receiving angiotensin converting enzyme inhibitors and angiotensin receptor blockers.

PURPOSE: Serum potassium and creatinine monitoring is recommended for patients prescribed angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB). Much has been written about hyperkalemia associated with these drugs; little is known about laboratory monitoring patterns. The purpose of this retrospective cohort study was to assess creatinine and potassium monitoring and characteristics associated with monitoring among patients dispensed ACEi or ARB. METHODS: This study was conducted in 10 United States health maintenance organizations. Study patients (n = 52 906) were aged 18 or older with dispensings of ACEi or ARB for at least 1 year. Serum potassium and creatinine monitoring were assessed from administrative data and medical records. RESULTS: More than two-thirds (68.4%) of patients received laboratory monitoring. Likelihood of monitoring increased with age (adjusted odds ratio [OR] 2.10; 95% confidence interval [95%CI] 1.93, 2.28 [individuals >or= 80 compared to <50 years]), >9 outpatient visits (OR 1.46; 95%CI 1.39, 1.54), hospitalization (OR 1.15; 95%CI 1.06, 1.25), concomitant medications (potassium [OR 2.01; 95%CI 1.84, 2.20], diuretics [OR 1.54; 95%CI 1.47, 1.61], digoxin [OR 1.15; 95%CI 1.01, 1.30]), and comorbidities (diabetes [OR 1.68; 95%CI 1.61, 1.75], heart failure [OR 1.73; 95%CI 1.57, 1.90], chronic kidney disease [OR 2.95; 95%CI 2.48. 3.51]). CONCLUSIONS: Nearly one-third of patients dispensed ACEi or ARB did not undergo laboratory monitoring at least yearly. Though patients at increased risk of hyperkalemia were more likely to be monitored, many remained unmonitored.

Adult↗

PubMed2007

Economic analysis of a randomized trial of academic detailing interventions to improve use of antihypertensive medications.

The authors estimated the costs and cost savings of implementing a program of mailed practice guidelines and single-visit individual and group academic detailing interventions in a randomized controlled trial to improve the use of antihypertensive medications. Analyses took the perspective of the payer. The total costs of the mailed guideline, group detailing, and individual detailing interventions were estimated at 1000 dollars, 5500 dollars, and 7200 dollars, respectively, corresponding to changes in the average daily per person drug costs of -0.0558 dollars (95% confidence interval, -0.1365 dollars to 0.0250 dollars) in the individual detailing intervention and -0.0001 dollars (95% confidence interval, -0.0803 dollars to 0.0801 dollars) in the group detailing intervention, compared with the mailed intervention. For all patients with incident hypertension in the individual detailing arm, the annual total drug cost savings were estimated at 21,711 dollars (95% confidence interval, 53,131 dollars savings to 9709 dollars cost increase). Information on costs of academic detailing could assist with health plan decision making in developing interventions to improve prescribing.

Antihypertensive Agents↗

PubMed2006

Correlates of electronic health record adoption in office practices: a statewide survey.

OBJECTIVE: Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption. DESIGN: Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey. MEASUREMENTS: EHR adoption rates. RESULTS: The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28-5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53-3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60-3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%). CONCLUSIONS: While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.

Attitude to Computers↗

PubMed2006

Improved therapeutic monitoring with several interventions: a randomized trial.

BACKGROUND: Medication errors are frequently related to failure to appropriately select medications or adjust for laboratory parameters. Differences between guideline recommendations and actual frequency of therapeutic laboratory monitoring are substantial. This study evaluated interventions to improve laboratory monitoring at initiation of medication therapy. METHODS: This cluster-randomized trial compared 3 interventions to usual care for 10 medications in 15 primary care clinics in a health maintenance organization with an electronic medical record system. Eligible patients, identified from electronic databases, had not received recommended laboratory monitoring within 5 days after new dispensing of a study medication. Interventions were an electronic medical record reminder to the prescribing health care professional, an automated voice message to the patient, and a pharmacy team outreach to the patient. Primary outcome was completion of all recommended baseline laboratory monitoring. RESULTS: A total of 961 patients participated in the study. At 25 days, 95 (48.5%) of 196 patients in the electronic medical record reminder group, 177 (66.3%) of 267 in the automated voice message group, 214 (82.0%) of 261 in the pharmacy team outreach group, and 53 (22.4%) of 237 in the usual care group had completed all recommended baseline laboratory monitoring (P<.001). After adjustments, the hazard ratios for completing laboratory monitoring compared with usual care were 2.5 (95% confidence interval, 1.8-3.5) for electronic medical record reminder, 4.1 (95% confidence interval, 3.0-5.6) for automated voice message, and 6.7 (95% confidence interval, 4.9-9.0) for pharmacy team outreach. CONCLUSIONS: All 3 interventions were effective in increasing laboratory monitoring when initiating new medications in primary care. Further work is necessary to determine if these interventions improve patient outcomes.

Adult↗

PubMed2006

The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation.

BACKGROUND: Considerable effort and attention have focused on medication safety in elderly persons; one approach that has been understudied in the outpatient environment is the use of computerized provider order entry with clinical decision support. The objective of this study was to examine the effects of computerized provider order entry with clinical decision support in reducing the use of potentially contraindicated agents in elderly persons. METHODS: With data from a 39-month period of a natural experiment, we evaluated changes in medication dispensing using interrupted time series analysis to estimate changes, controlling for prealert prescribing trends. The setting was a large health maintenance organization in the Pacific Northwest. All adult enrollees of the health plan participated. The intervention was computerized alerts cautioning against using certain medications in elderly persons. The main outcome measure was dispensing per 10,000 members per month. RESULTS: Following the implementation of the drug-specific alerts, a large and persistent reduction (5.1 prescriptions per 10,000, P=.004), a 22% relative decrease from the month before alert implementation, in the exposure of elderly patients to nonpreferred medications was observed. We found no evidence of a decrease in use of nonpreferred agents for nonelderly patients. The reduction seen in use of nonpreferred agents for elderly persons was driven primarily by decreases in dispensing for tertiary tricyclic agents. CONCLUSIONS: We found that alerts in an outpatient electronic medical record aimed at decreasing prescribing of medication use in elderly persons may be an effective method of reducing prescribing of contraindicated medications. The effect of the alerts on patient outcomes is less certain and deserves further investigation.

Adult↗

PubMed2006

Reducing warfarin medication interactions: an interrupted time series evaluation.

BACKGROUND: Computerized decision support reduces medication errors in inpatients, but limited evidence supports its effectiveness in reducing the coprescribing of interacting medications, especially in the outpatient setting. The usefulness of academic detailing to enhance the effectiveness of medication interaction alerts also is uncertain. METHODS: This study used an interrupted time series design. In a health maintenance organization with an electronic medical record, we evaluated the effectiveness of electronic medical record alerts and group academic detailing to reduce the coprescribing of warfarin and interacting medications. Participants were 239 primary care providers at 15 primary care clinics and 9910 patients taking warfarin. All 15 clinics received electronic medical record alerts for the coprescription of warfarin and 5 interacting medications: acetaminophen, nonsteroidal anti-inflammatory medications, fluconazole, metronidazole, and sulfamethoxazole. Seven clinics were randomly assigned to receive group academic detailing. The primary outcome, the interacting prescription rate (ie, the number of coprescriptions of warfarin-interacting medications per 10 000 warfarin users per month), was analyzed with segmented regression models, controlling for preintervention trends. RESULTS: At baseline, nearly a third of patients had an interacting prescription. Coinciding with the alerts, there was an immediate and continued reduction in the warfarin-interacting medication prescription rate (from 3294.0 to 2804.2), resulting in a 14.9% relative reduction (95% confidence interval, -19.5 to -10.2) at 12 months. Group academic detailing did not enhance alert effectiveness. CONCLUSIONS: This study, using a strong and quasi-experimental design in ambulatory care, found that medication interaction alerts modestly reduced the frequency of coprescribing of interacting medications. Additional efforts will be required to further reduce rates of inappropriate prescribing of warfarin with interacting drugs.

Acetaminophen↗

PubMed2006

Frequency of serum creatinine monitoring during allopurinol therapy in ambulatory patients.

BACKGROUND: Allopurinol dosage reduction is recommended in patients with renal dysfunction because drug toxicity risk is increased. Little information is available about serum creatinine (SCr) monitoring in ambulatory patients taking allopurinol. OBJECTIVE: To evaluate SCr monitoring among patients prescribed allopurinol, identify associated factors, and evaluate administrative data in assessing monitoring. METHODS: Information for this retrospective cohort study was drawn from a dataset of 2 020 037 individuals; approximately 200 000 members from each of 10 organizations. Study patients had received at least one year of ongoing allopurinol prescription dispensings. Patient variables analyzed included age, gender, chronic diseases, outpatient visits, hospitalizations, gout diagnosis, and SCr monitoring. A random sample of medical records was reviewed to assess the accuracy of the automated data. Statistical analysis included descriptive and logistic regression techniques. RESULTS: Overall, 1139 (26%) of 4357 patients did not have SCr monitoring. For individuals without recent hospitalization, factors protective against lack of monitoring were increasing age (OR 0.77 per 10 y; 95% CI 0.74 to 0.79), more chronic diseases (OR 0.81; 95% CI 0.78 to 0.83), more outpatient visits (OR 0.87 per 5 visits; 95% CI 0.83 to 0.91), and gout diagnosis (OR 0.74; 95% CI 0.65 to 0.85). The sensitivity and specificity of administrative data compared with medical records for SCr monitoring were 92% and 65%, respectively. CONCLUSIONS: More than one-fourth of patients dispensed allopurinol did not have SCr monitoring during one year of therapy. Lack of monitoring and lack of subsequent possible dosage adjustment put patients at increased risk of allopurinol toxicity.

Adolescent↗

PubMed2006

Universal health care and reform of the health care system: views of medical students in the United States.

PURPOSE: Nearly 46 million Americans did not have health insurance in 2004. Recent studies have documented physicians' support for various remedies, including universal health care. The authors undertook this study to assess medical students' views on these topics. METHOD: In 2002, the authors surveyed a national random sample of first-year and fourth-year medical students (from the American Medical Association Masterfile) to determine their views about health care reform options, including universal health care. Response data were weighted and compared using chi-squared tests; statistical significance was set at p < or = .05. RESULTS: Of 1,363 medical students, 770 completed the questionnaire (response rate = 56.5%). In rating the importance of several health care issues, more than 80% of both first-year and fourth-year students rated the expansion of health care coverage as important. Nearly all first-year (90%) and fourth-year (88%) students agreed with the statement, "Everyone is entitled to adequate medical care regardless of ability to pay." Most students favored health care reform that would achieve universal health care, with first-year students (70%) somewhat more likely than fourth-year students (61%) to support universal health care (p = .012). Students were less likely to believe that physicians support universal health care, and more likely to believe that the public does. CONCLUSIONS: Both groups of students generally support the expansion of health coverage to the uninsured and some form of universal health care. This may be relevant both to policymakers in their considerations of health care reform and to medical educators concerned with teaching students about health policy issues.

Attitude of Health Personnel↗

PubMed2006

Clinical and nonclinical correlates of adherence to prescribing guidelines for hypertension in a large managed care organization.

To examine correlates of guideline adherence in a population with access to health care and prescription drug benefits, the authors conducted a cross-sectional analysis among 5789 patients undergoing hypertension treatment with a single medication in a large New England managed care organization. Logistic regression was used to determine correlates of adherence, defined as use of diuretics or beta blocker as antihypertensive monotherapy during the 1-year study period. Women were more likely than men to receive guideline-adherent therapy (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.45-1.85). Compared with patients covered by health maintenance organization plans, Medicare coverage was positively associated with guideline adherence (OR, 1.38; 95% CI, 1.13-1.69), but fee-for-service coverage was negatively associated (OR, 0.66; 95% CI, 0.48-0.91). Patient age was not a significant correlate of adherence to guidelines (OR, 1.01; 95% CI, 0.94-1.09). Understanding these observations may lead to strategies to improve guideline adherence and reduce health care disparities.

Adrenergic alpha-Antagonists↗

PubMed2006

Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people.

OBJECTIVES: To examine the effect of replacing drug-specific computerized prescribing alerts with age-specific alerts on rates of dispensing potentially inappropriate medications in older people and to determine whether group academic detailing enhances the effectiveness of these alerts. DESIGN: Cluster-randomized trial of group academic detailing and interrupted time-series analysis. SETTING: Fifteen clinics of a staff-model health maintenance organization. PARTICIPANTS: Seven practices (113 clinicians, 24,119 patients) were randomly assigned to receive age-specific prescribing alerts plus the academic detailing intervention; eight practices (126 clinicians, 26,805 patients) received alerts alone. Prior implementation of drug-specific alerts established a downward trend in use of target medications that served as the baseline trend for the present study. INTERVENTION: The computerized age-specific alerts occurred at the time of prescribing a targeted potentially inappropriate medication (e.g., tertiary tricyclic amine antidepressants, long-acting benzodiazepines, propoxyphene) and suggested an alternative medication. Clinicians at seven sites were randomized to group academic detailing, an interactive educational program delivering evidence-based information. MEASUREMENTS: Number of target medications dispensed per 10,000 patients per quarter, 2 years before and 1.5 years after the replacement of drug-specific with age-specific alerts. RESULTS: Age-specific alerts resulted in a continuation of the effects of the drug-specific alerts without measurable additional effect (P=.75 for level change), but the age-specific alerts led to fewer false-positive alerts for clinicians. Group academic detailing did not enhance the effect of the alerts. CONCLUSION: Age-specific alerts sustained the effectiveness of drug-specific alerts to reduce potentially inappropriate prescribing in older people and resulted in a considerably decreased burden of the alerts.

Aged↗

PubMed2006

Web-based learning versus standardized patients for teaching clinical diagnosis: a randomized, controlled, crossover trial.

BACKGROUND: Little evidence exists to guide the selection of methods for teaching clinical diagnosis. PURPOSE: To compare the efficacy, student preference, and cost of a Web-based (WB) program versus a standardized patient (SP) encounter for teaching clinical diagnosis skills to 2nd-year medical students. METHODS: Randomized, controlled, crossover study comparing WB versus SP-based teaching for the clinical diagnosis of abdominal pain and headache. Outcome measures were performance on a 2-case SP examination (scored on the basis of a checklist completed by a faculty observer and an objective score on a postencounter subjective-objective assessment plan [SOAP] note), format preferences as assessed by end-of-course evaluations, and cost. RESULTS: Thirty students consented to participate. WB and SP training produced similar scores on both the Abdominal Pain checklist (66% vs. 62%; p = .17) and Headache checklist (56% vs. 63%; p = .07). WB training produced a higher score on the Abdominal Pain SOAP note (69% vs. 47%; p = .006), but not the Headache SOAP note (69% vs. 67%; p = .85). Students rated the SP format higher than the WB format on all 7 preference measures. Start-up costs were estimated at 2,190 dollars for the SP format and 2,250 dollars for the WB format. Ongoing costs per case per student were estimated to be 45 dollars for the SP format and 30 dollars for the WB format. CONCLUSIONS: WB and SP learning outcomes were comparable, but students preferred the SP format. Start-up costs were comparable, but the ongoing costs of the WB format were less expensive, suggesting that WB teaching may be a viable strategy.

Algorithms↗

PubMed2006

Monitoring of drugs with a narrow therapeutic range in ambulatory care.

OBJECTIVES: To describe the proportion of patients receiving drugs with a narrow therapeutic range who lacked serum drug concentration monitoring during a 1-year period of therapy and to identify patient characteristics associated with lack of monitoring. STUDY DESIGN: Retrospective cohort. METHODS: Ambulatory patients (n = 17,748) at 10 health maintenance organizations who were receiving ongoing continuous drug therapy with digoxin, carbamazepine, divalproex sodium, lithium carbonate, lithium citrate, phenobarbital sodium, phenytoin, phenytoin sodium, primidone, quinidine gluconate, quinidine sulfate, procainamide hydrochloride, theophylline, theophylline sodium glycinate, tacrolimus, or cyclosporine for at least 12 months between January 1, 1999, and June 30, 2001, were identified. Serum drug concentration monitoring was assessed from administrative data and from medical record data. RESULTS: Fifty percent or more of patients receiving digoxin, theophylline, procainamide, quinidine, or primidone were not monitored, and 25% to 50% of patients receiving divalproex, carbamazepine, phenobarbital, phenytoin, or tacrolimus were not monitored. Younger age was associated with lack of monitoring for patients prescribed digoxin (adjusted odds ratio, 1.86; 95% confidence interval, 1.39-2.48) and theophylline (adjusted odds ratio, 1.58; 95% confidence interval, 1.23-2.04), while older age was associated with lack of monitoring for patients prescribed carbamazepine (adjusted odds ratio, 0.59; 95% confidence interval, 0.44-0.80) and divalproex (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.66). Patients with fewer outpatient visits were also less likely to be monitored (P < .001). CONCLUSIONS: A substantial proportion of ambulatory patients receiving drugs with narrow intervals between doses resulting in beneficial and adverse effects did not have serum drug concentration monitoring during 1 year of use. Clinical implications of this finding need to be evaluated.

Ambulatory Care↗

PubMed2005

Failure of Internet-based audit and feedback to improve quality of care delivered by primary care residents.

OBJECTIVE: To determine the effectiveness of Internet-based audit and feedback to physicians to improve care for diabetes and hypertension. DESIGN: Time-series analysis of an intervention. METHODS: The study setting was Harvard Vanguard Medical Associates, a 14-site multispecialty group in greater Boston. The study period was July 1997-June 1999. PARTICIPANTS: were 12 primary care internal medicine residents who provided care to adult patients with diabetes (n = 76 pre-intervention and n = 88 post-intervention), hypertension (n = 329 pre-intervention and n = 338 post-intervention), or both (n = 62 pre-intervention and n = 71 post-intervention). We determined the proportion of each resident's patients whose care fulfilled national guidelines for quality (i.e. diabetes patients had hemoglobin testing in the previous 6 months or hypertension patients received a beta-blocker or diuretic in the same time period). After meeting individually with each resident to obtain informed consent and to encourage participation, we sent each resident information for accessing his or her practice profile on a secure website. The main outcome measures were (i) the proportion of resident physicians who accessed their profiles and (ii) change following the intervention in the proportion of patients whose care followed national guidelines. RESULTS: Over a 1-year period, only four of the 12 residents accessed their websites. One of the residents visited her site three times, while the other three residents visited their sites once each. In interrupted time-series analyses, the intervention had no discernible effect on adherence to practice guidelines for diabetes or hypertension. CONCLUSION: The lack of participation in this Internet-based intervention may have important implications for the development of future programs that require physicians to interact with technology to improve quality of care.

Attitude to Computers↗

PubMed2005

Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial.

PURPOSE: To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension. METHODS: We conducted a cluster-randomized controlled trial in a large health maintenance organization. Subjects (N=9820) were patients with newly treated hypertension in the year preceding the intervention (N=3692), the 9 months following the intervention (N=3556), and the second year following intervention (N=2572). We randomly allocated 3 practice sites to group detailing (N=227 prescribers), 3 to individual detailing (N=235 prescribers), and 3 to usual care (N=319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guideline-recommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians. RESULTS: In the first year following the intervention, the rates of diuretic or beta-blocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices, and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% confidence interval (CI), 1.11 - 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 - 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 - 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 - 1.39), as compared with usual care. CONCLUSION: Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements.

Adrenergic beta-Antagonists↗

PubMed2005

Medical students' knowledge of the U.S. health care system and their preferences for curricular change: a national survey.

PURPOSE: To measure medical students' knowledge of central issues in the U.S. health care system and to understand their perception of the importance and quality of health policy curricula at their medical schools. METHOD: A questionnaire was developed using facts from recent national and international health reports to test students' knowledge of health policy. The instrument, containing 14 questions about health policy and four questions about school curriculum on health policy, was mailed to a national probability sample of 516 first-year and 847 fourth-year students in the United States. Chi-square and t tests were used to compare the responses of first- and fourth-year students. RESULTS: A total of 295 first-year (57%) and 475 fourth-year students (56%) responded. Nearly all respondents were aware of the adverse health consequences for the uninsured, but 40% of first- and fourth-year students underestimated the numbers of uninsured in the United States. Thirty-two percent of respondents incorrectly answered that the United States had the highest life expectancy of any nation, and 27% were not aware that the United States has the highest health cost per-person of any nation. First- and fourth-year students performed similarly on knowledge questions. Ninety-six percent of respondents felt that knowledge of health policy is important to their career, and 54% expressed dissatisfaction with the health policy curriculum in medical school. CONCLUSION: Medical students have significant gaps in knowledge concerning the U.S. health care system. Most students perceive that these deficiencies are not adequately addressed in the medical school curriculum.

Adult↗

PubMed2005

Laboratory monitoring of drugs at initiation of therapy in ambulatory care.

BACKGROUND AND OBJECTIVES: Product labeling and published guidelines reflect the importance of monitoring laboratory parameters for drugs with a risk of organ system toxicity or electrolyte imbalance. Limited information exists about adherence to laboratory monitoring recommendations. The objective of this study was to describe laboratory monitoring among ambulatory patients dispensed medications for which laboratory testing is recommended at therapy initiation. DESIGN AND SUBJECTS: We conducted a retrospective cross-sectional analysis of patients in 10 geographically distributed health maintenance organizations who were newly prescribed medications with recommended laboratory test monitoring. The main outcome measure was the proportion of initial drug dispensing without recommended baseline laboratory monitoring for 35 newly initiated drugs or drug classes. RESULTS: One hundred seven thousand, seven hundred sixty-three of 279,354 (39%) initial drug dispensings occurred without recommended laboratory monitoring. Patients without monitoring were younger than patients who had monitoring (median 57 vs 61 years, P<.001). Thirty-two percent of dispensings where a serum creatinine was indicated did not have it evaluated (range across drugs, 12% to 61%); 39% did not have liver function testing (range 10% to 75%); 32% did not have hematologic monitoring (range 9% to 51%); and 34% did not have electrolyte monitoring (range 20% to 62%) (P<.001). CONCLUSIONS: Substantial opportunity exists to improve laboratory monitoring of drugs for which such monitoring is recommended. This study emphasizes the need for research to identify the clinical implications of not conducting recommended laboratory monitoring, existing barriers to monitoring, and methods to improve practice.

Ambulatory Care↗

PubMed2005

Baseline laboratory monitoring of cardiovascular medications in elderly health maintenance organization enrollees.

OBJECTIVES: To identify correlates of laboratory monitoring errors in elderly health maintenance organization (HMO) members at the initiation of therapy with cardiovascular medications. DESIGN: Cross-sectional study in 10 HMOs. SETTING: United States. PARTICIPANTS: From a 2 million-member sample, individuals aged 65 and older who received one of seven cardiovascular medications (angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), amiodarone, digoxin, diuretics, potassium supplements, and statins) and did not have recommended baseline monitoring performed during the 180 days before or 14 days after the index dispensing. MEASUREMENTS: The proportion of members receiving each drug for whom recommended laboratory monitoring was not performed. Laboratory monitoring error rates stratified by sex, age group, chronic disease score, and HMO site were examined, and logistic regression was used to identify predictors of laboratory monitoring errors. RESULTS: Error rates varied by medication class, ranging from 23% of patients receiving potassium supplementation without serum potassium and serum creatinine monitoring to 58% of patients receiving amiodarone who did not have recommended monitoring for thyroid and liver function. Highest error rates occurred in the youngest elderly for ACE inhibitors, ARBs, digoxin, diuretics, and potassium supplements, although in patients receiving amiodarone and statins, errors were most frequent in the oldest elderly. Errors occurred more frequently in patients with less comorbidity. CONCLUSION: Laboratory monitoring errors occurred frequently in elderly HMO members at the initiation of therapy with cardiovascular medications. Further study must examine the association between these errors and adverse outcomes.

Aged↗