Using intranet-based order sets to standardize clinical care and prepare for computerized physician order entry.

Background: The high cost of computerized physician order entry (CPOE) and physician resistance to standardized care have delayed implementation. An intranet-based order set system can provide some of CPOE's benefits and offer opportunities to acculturate physicians toward standardized care. INTRANET CLINICIAN ORDER FORMS (COF): The COF system at the Medical University of South Carolina (MUSC) allows caregivers to enter and print orders through the intranet at points of care and to access decision support resources.

Patterns and trends in opioid use among individuals with back pain in the United States.

Study Design: Secondary analysis of Medical Expenditure Panel Survey from 1996 to 1999.

Objective: To examine patterns in opioid use in 1996, 1997, 1998, and 1999 among individuals with back pain in the United States and to investigate trends in the use of overall and individual opioid category.

Summary Of Background Data: To the authors' best knowledge, no study has examined at a national level the patterns and trends in opioid use among individuals with back pain in the United States.

Unnecessary cesarean delivery in Louisiana: an analysis of birth certificate data.

Objective: The purpose of this study was to explore the temporal trends and factors that are associated with cesarean deliveries and potentially unnecessary cesarean deliveries.

Study Design: The Louisiana birth certificate database was evaluated to identify a total of 57 potential indications/risk factors and maternal demographic factors that are associated with methods of delivery over the period from January 1993 to December 2000. A cesarean delivery without any potential indications/risk factors in the birth certificate was classified as unnecessary.

Estimates and patterns of direct health care expenditures among individuals with back pain in the United States.

Study Design: Secondary analysis of the 1998 Medical Expenditure Panel Survey.

Objective: To estimate total health care expenditures incurred by individuals with back pain in the United States, calculate the incremental expenditures attributable to back pain among these individuals, and describe health care expenditure patterns of individuals with back pain.

Summary Of Background Data: There is a lack of updated information on health care expenditures and expenditure patterns for individuals with back pain in the United States.

The guideline approach to chronic obstructive pulmonary disease: how effective?

Clinical practice guidelines are systematically developed to assist health care decisions in specific clinical circumstances. They first arose to improve quality of care by decreasing unexplained practice variation, controlling health care costs, fostering evidence-based decision-making, and accelerating the application of new advances in medical science to everyday practice. Unfortunately, multiple studies demonstrate incomplete and varied effectiveness of clinical practice guidelines in altering clinician behavior and improving patient outcomes.

Unanticipated harm to patients: deciding when to disclose outcomes.

Background: Patient safety standards of the Joint Commission on Accreditation of Healthcare Organizations require that "patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes."

What Outcomes Should Trigger Disclosure: Given that all medical treatments have an array of possible outcomes, how do we confidently say that an outcome is unanticipated? It is proposed that an adverse outcome meet one of two criteria to be considered unanticipated: (1) It would not be included in a reasonable informed consent process for treatment of the patient's condition(s) and/or would not be expected during the usual course of treatment; and (2) it may have been caused by human or systemic error--that is, it is not immediately possible to clearly and decisively rule out error. This definition requires less judgment because it represents an extension of the existing norms of communication that are expressed through the process of informed consent.

Reliability, validity, and responsiveness of the short form 12-item survey (SF-12) in patients with back pain.

Study Design: Secondary analysis of data collected from spine patients' normal clinic visits from 1998 to 2001.

Objective: To evaluate the reliability, validity, and responsiveness of the short form 12-item survey in patients with back pain.

Summary Of Background Data: The reliability, validity, and responsiveness of the short form 12-item survey in patients with back pain has not been previously evaluated.

Children's health insurance status and emergency department utilization in the United States.

Objectives: Emergency department (ED) overcrowding has become a national problem. Children account for nearly 25% of overall ED visits. It has been reported that uninsured and publicly insured children are likely to visit the ED for urgent and nonurgent problems, yet it remains unclear to what extent health insurance status would influence children's overall ED utilization or ED utilization for nonurgent problems at the national level after controlling for other confounding factors.

Can patients be anticoagulated after intracerebral hemorrhage? A decision analysis.

Background And Purpose: Warfarin increases both the likelihood and the mortality of intracerebral hemorrhage (ICH), particularly in patients with a history of prior ICH. In light of this consideration, should a patient with both a history of ICH and a clear indication for anticoagulation such as nonvalvular atrial fibrillation be anticoagulated? In the absence of data from a clinical trial, we used a decision-analysis model to compare the expected values of 2 treatment strategies-warfarin and no anticoagulation-for such patients.

Methods: We used a Markov state transition decision model stratified by location of hemorrhage (lobar or deep hemispheric).

Testing for factor V Leiden in patients with pulmonary or venous thromboembolism: a cost-effectiveness analysis.

Background: Survivors of venous thromboembolism who have the factor V Leiden mutation have an increased risk of recurrent venous thromboembolism (VTE), but the cost-effectiveness of testing for factor VLeiden has not been assessed.

Methods: We used a Markov state transition decision model to evaluate the cost-effectiveness of factor V Leiden testing and treatment strategies in survivors of VTE using a societal perspective for costs, effectiveness-measured in quality-adjusted life years, and incremental cost-effectiveness. Data sources included the English language literature using MEDLINE searches and bibliographies from selected articles.

Cost-effectiveness of pravastatin therapy for survivors of myocardial infarction with average cholesterol levels.

Background: The objective of this study was to assess the cost-effectiveness of pravastatin therapy in survivors of myocardial infarction with average cholesterol levels.

Methods: We performed a cost-effectiveness analysis based on actual clinical, cost, and health-related quality-of-life data from the Cholesterol and Recurrent Events (CARE) trial. Survival and recurrent coronary heart disease events were modeled from trial data in Markov models, with the use of different assumptions regarding the long-term benefit of therapy.

Reducing unnecessary coagulation testing in hypertensive disorders of pregnancy.

Objective: To estimate the magnitude of laboratory testing for hypertension in pregnancy and determine whether abnormalities in prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen can be predicted by results of common, less expensive tests.

Materials And Methods: Laboratory records were searched and charts were reviewed to identify gravidas tested for hypertension and to exclude conditions producing coagulopathy. Contingency tables were constructed to assess the ability of the platelet count, lactate dehydrogenase, and transaminases to predict coagulation test results.

Race and differences in breast cancer survival in a managed care population.

Background: African-American women with breast cancer have poorer survival than European-American women. After adjustment for socioeconomic variables, survival differences diminish but do not disappear, possibly because of residual differences in health care access, biology, or behavior. This study compared breast cancer survival in African-American and European-American women with similar health care access.

Health service use by African Americans and Caucasians with asthma in a managed care setting.

Managed care plan members provide a population for analysis that minimizes the financial barriers to routine medical care that have been linked to high rates of asthma-related hospitalization, emergency care, and mortality among urban African Americans. We examined patterns of asthma care among 464 African American (AA) and 1,609 Caucasian (C) asthma patients, age 15 to 45 yr, in a southeast Michigan managed care system during 1993. Compared with C, AA had fewer visits to asthma specialists (0.

Influenza immunization in a managed care organization.

Objective: To compare the effects of different types of computer-generated, mailed reminders on the rate of influenza immunization and to analyze the relative cost-effectiveness of the reminders.

Design: Randomized controlled trial.

Setting: Multispecialty group practice.

Evaluation of narrative text for case finding: the need for accuracy measurement.

This article reviews the analysis of a narrative text electronic search technique being used in the insurance industry. We reviewed a previously published study of motor vehicle crashes in roadway construction workzones as well as additional data supplied by the authors with respect to the methods of keyword selection. The narrative text search technique was evaluated with decision statistics and was found to have a sensitivity of 92.

Patient-related risk factors that predict poor outcome after total hip replacement.

Objective: To identify factors associated with poor outcome after total hip replacement (THR) surgery.

Data Sources: This article is the first to present results from the American Medical Group Association (AMGA) THR consortium.

Study Design: The outcomes evaluated were pain and physical function.

Screening mammography use: the importance of a population perspective.

Mammography has been shown to be effective in decreasing breast cancer mortality. However, not all women receive recommended screening. The purpose of this study was to measure the effect of systemic health care delivery factors and patient demographic factors on the use of mammography among a population of women with insurance coverage for screening mammography.

Development and multi-institutional implementation of coding and transmission standards for health outcomes data.

Health care delivery institutions and providers, employers, and government agencies throughout the U.S. are sharing information and pooling resources in an attempt to produce reliable measurements of health outcomes.

Description and evaluation of a program for the early discharge of infants from a neonatal intensive care unit.

The effect of a cost-containment program focused on decreasing the lengths of hospital stay of high-risk neonates was assessed by comparison of discharge weights and lengths of stay for 257 study infants, discharged from a neonatal intensive care unit (NICU) after an early-discharge program began, with those of 477 control infants discharged during a prior 1-year period. Demographic data and costs, as well as data on emergency department use and hospital readmissions, were included in the comparisons. There was a significant decrease in mean discharge weight and length of stay for infants in the study group.

Economic outcomes of withdrawal of digoxin therapy in adult patients with stable congestive heart failure.

Objectives: This study sought to analyze the health and economic outcomes of withdrawal of digoxin therapy among U.S. adult patients with stable congestive heart failure.

Who should be screened for HIV infection? A cost-effectiveness analysis.

Background: The advent of effective prophylactic treatments for asymptomatic persons infected with human immunodeficiency virus has led to interest in widespread screening programs. However, the costs of screening programs and therapy are high, and the prevalence of infection above which screening becomes an appropriate use of scarce health care dollars remains undetermined.

Methods: To examine the cost-effectiveness of screening in populations with differing prevalences of infection, we developed a Markov model to compare costs and life expectancy for two strategies: (1) screening and prophylactic treatment for infected persons who have or who develop low CD4+ (T4) cell counts, and (2) no screening.