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Reducing Adverse Drug Events: The Need to Rethink Outpatient Prescribing.
Kessler C, Ward MJ, McNaughton CD
(2016) JAMA 316: 2092-2093
MeSH Terms: Drug-Related Side Effects and Adverse Reactions, Humans, Medication Errors, Outpatients
Added April 6, 2017
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4 MeSH Terms
Growth of Secure Messaging Through a Patient Portal as a Form of Outpatient Interaction across Clinical Specialties.
Cronin RM, Davis SE, Shenson JA, Chen Q, Rosenbloom ST, Jackson GP
(2015) Appl Clin Inform 6: 288-304
MeSH Terms: Adult, Child, Cohort Studies, Computer Security, Delivery of Health Care, Electronic Health Records, Electronic Mail, Female, Humans, Male, Medicine, Middle Aged, Outpatients, Retrospective Studies
Show Abstract · Added August 25, 2015
OBJECTIVE - Patient portals are online applications that allow patients to interact with healthcare organizations. Portal adoption is increasing, and secure messaging between patients and healthcare providers is an emerging form of outpatient interaction. Research about portals and messaging has focused on medical specialties. We characterized adoption of secure messaging and the contribution of messaging to outpatient interactions across diverse clinical specialties after broad portal deployment.
METHODS - This retrospective cohort study at Vanderbilt University Medical Center examined use of patient-initiated secure messages and clinic visits in the three years following full deployment of a patient portal across adult and pediatric specialties. We measured the proportion of outpatient interactions (i.e., messages plus clinic visits) conducted through secure messaging by specialty over time. Generalized estimating equations measured the likelihood of message-based versus clinic outpatient interaction across clinical specialties.
RESULTS - Over the study period, 2,422,114 clinic visits occurred, and 82,159 unique portal users initiated 948,428 messages to 1,924 recipients. Medicine participated in the most message exchanges (742,454 messages; 78.3% of all messages sent), followed by surgery (84,001; 8.9%) and obstetrics/gynecology (53,424; 5.6%). The proportion of outpatient interaction through messaging increased from 12.9% in 2008 to 33.0% in 2009 and 39.8% in 2010 (p<0.001). Medicine had the highest proportion of outpatient interaction conducted through messaging in 2008 (23.3% of outpatient interactions in medicine). By 2010, this proportion was highest for obstetrics/gynecology (83.4%), dermatology (71.6%), and medicine (56.7%). Growth in likelihood of message-based interaction was greater for anesthesiology, dermatology, obstetrics/gynecology, pediatrics, and psychiatry than for medicine (p<0.001).
CONCLUSIONS - This study demonstrates rapid adoption of secure messaging across diverse clinical specialties, with messaging interactions exceeding face-to-face clinic visits for some specialties. As patient portal and secure messaging adoption increase beyond medicine and primary care, research is needed to understand the implications for provider workload and patient care.
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14 MeSH Terms
Outpatient thoracoscopy: safety and practical considerations.
Kern RM, DePew ZS, Maldonado F
(2015) Curr Opin Pulm Med 21: 357-62
MeSH Terms: Humans, Image-Guided Biopsy, Outpatients, Pleural Diseases, Talc, Thoracoscopy
Show Abstract · Added July 28, 2015
PURPOSE OF REVIEW - Medical thoracoscopy, also known as pleuroscopy, has been utilized by chest physicians for more than a century. Despite this, it has only recently re-emerged as an important tool for interventional pulmonologists to diagnose and treat pleural diseases. The purpose of this review is to critically assess the recent literature related to medical thoracoscopy, specifically as it pertains to its safety and feasibility as an outpatient procedure.
RECENT FINDINGS - Recent data have reaffirmed the clinical utility of medical thoracoscopy and suggest that it can be safely performed in an outpatient setting. A single-center study of 51 patients published in the past year described both the feasibility and safety of outpatient medical thoracoscopy. This study highlights the notion that the majority of patients do not require hospital admission after a routine diagnostic thoracoscopy in the absence of talc poudrage. Another study this year described the successful use of chest physician-directed ultrasound-guided cutting needle biopsy when medical thoracoscopy was not technically possible.
SUMMARY - The contribution of medical thoracoscopy in the diagnosis and management of pleural diseases is increasingly recognized. Evidence supports the routine practice of medical thoracoscopy on an outpatient basis in experienced centers.
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6 MeSH Terms
Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative.
DePew ZS, Wigle D, Mullon JJ, Nichols FC, Deschamps C, Maldonado F
(2014) Chest 146: 398-405
MeSH Terms: Aged, Clinical Competence, Cooperative Behavior, Diagnosis, Differential, Feasibility Studies, Female, Follow-Up Studies, Humans, Male, Minnesota, Outpatients, Pleural Effusion, Reproducibility of Results, Retrospective Studies, Tertiary Care Centers, Thoracoscopy
Show Abstract · Added February 1, 2016
BACKGROUND - Medical thoracoscopy (MT) is performed by relatively few pulmonologists in the United States. Recognizing that an outpatient minimally invasive procedure such as MT could provide a suitable alternative to hospitalization and surgery in patients with undiagnosed exudative pleural effusions, we initiated the Mayo Clinic outpatient MT program and herein report preliminary data on safety, feasibility, and outcomes.
METHODS - All consecutive patients referred for outpatient MT from October 2011 to August 2013 were included in this study. Demographic, radiographic, procedural, and histologic data were recorded prospectively and subsequently analyzed.
RESULTS - Outpatient MT was performed on 51 patients, with the most common indication being an undiagnosed lymphocytic exudative effusion in 86.3% of the cohort. Endoscopic findings included diffuse parietal pleural inflammation in 26 patients (51%), parietal pleural studding in 19 patients (37.3%), a normal examination in three patients (5.9%), diffuse parietal pleural thickening in two patients (3.9%), and a diaphragmatic defect in one patient (2%). Pleural malignancy was the most common histologic diagnosis in 24 patients (47.1%) and composed predominantly of mesothelioma in 14 (27.5%). Nonspecific pleuritis was the second most frequent diagnosis in 23 patients (45.1%). There were very few complications, with no significant cases of hemodynamic or respiratory compromise and no deaths.
CONCLUSIONS - Outpatient MT can be integrated successfully into a busy tertiary referral medical center through the combined efforts of interventional pulmonologists and thoracic surgeons. Outpatient MT may provide patients with a more convenient alternative to an inpatient surgical approach in the diagnosis of undiagnosed exudative pleural effusions while maintaining a high diagnostic yield and excellent safety.
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16 MeSH Terms
Immediate effects of the initial FDA notification on the use of surgical mesh for pelvic organ prolapse surgery in medicare beneficiaries.
Reynolds WS, Gold KP, Ni S, Kaufman MR, Dmochowski RR, Penson DF
(2013) Neurourol Urodyn 32: 330-5
MeSH Terms: Age Factors, Aged, Aged, 80 and over, Biological Dressings, Cohort Studies, Female, Humans, Hysterectomy, Inpatients, International Classification of Diseases, Medicare, Middle Aged, Outpatients, Pelvic Organ Prolapse, Suburethral Slings, Surgical Mesh, United States, United States Food and Drug Administration, Urologic Surgical Procedures
Show Abstract · Added March 5, 2014
AIMS - Prompted by increased reports of complications with the use of mesh for pelvic organ prolapse (POP) surgery, the FDA issued an initial public health notification (PHN) in 2008. We proposed to determine if the numbers of POP cases augmented with surgical mesh performed in U.S. Medicare beneficiaries changed relative to this PHN.
METHODS - Using administrative healthcare claims for beneficiaries enrolled in the U.S. Medicare program from 2008 to 2009, we identified women who underwent POP surgery with and without surgical mesh by procedural and diagnosis coding. In addition to comparing cases with and without mesh, we also calculated rates (number of cases per 100,000 female beneficiaries) and compared these relative to the timing of the PHN.
RESULTS - We identified 104,185 POP procedures, of which 27,839 (26.7%) included mesh material and 76,346 (73.3%) did not. Between the last three quarters of 2008 and the first three of 2009, the rates of mesh cases increased (40.3-42.1, P < 0.001) and those without mesh decreased (115.5-111.4, P < 0.001). Inpatient procedures decreased and outpatient procedures increased for both those with and without mesh augmentation. For inpatient procedures, the relative use of biologic graft and synthetic mesh material did not vary over the study period.
CONCLUSIONS - A substantial number of Medicare beneficiaries underwent mesh POP procedures in 2008-2009. However, despite the PHN cautioning about potential mesh complications, the numbers of mesh cases continued to rise in the immediate period after the PHN.
Copyright © 2012 Wiley Periodicals, Inc.
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19 MeSH Terms
Prevalence and outcomes of antimicrobial treatment for Staphylococcus aureus bacteremia in outpatients with ESRD.
Chan KE, Warren HS, Thadhani RI, Steele DJ, Hymes JL, Maddux FW, Hakim RM
(2012) J Am Soc Nephrol 23: 1551-9
MeSH Terms: Anti-Bacterial Agents, Bacteremia, Cefazolin, Comorbidity, Female, Humans, Kidney Failure, Chronic, Longitudinal Studies, Male, Methicillin-Resistant Staphylococcus aureus, Middle Aged, Outpatients, Prevalence, Renal Dialysis, Retrospective Studies, Risk Factors, Staphylococcal Infections, Staphylococcus aureus, Treatment Outcome, United States, Vancomycin
Show Abstract · Added May 20, 2014
Staphylococcus bacteremia is a common and life-threatening medical emergency, but it is treatable with appropriate antibiotic therapy. To identify opportunities that may reduce morbidity and mortality associated with S. aureus, we analyzed data from 293,094 chronic hemodialysis outpatients to characterize practices of antibiotic selection. In the study population, the overall rate of bacteremia was 15.4 per 100 outpatient-years; the incidence rate for methicillin-sensitive (MSSA) was 2.1 per 100 outpatient-years, and the incidence rate for methicillin-resistant (MRSA) S. aureus was 1.9 per 100 outpatient-years. One week after the collection of the index blood culture, 56.1% of outpatients with MSSA bacteremia were receiving vancomycin, and 16.7% of outpatients with MSSA were receiving cefazolin. Among MSSA-bacteremic patients who did not die or get hospitalized 1 week after blood culture collection, use of cefazolin was associated with a 38% lower risk for hospitalization or death compared with vancomycin (adjusted HR=0.62, 95% CI=0.46-0.84). In conclusion, vancomycin is commonly used to treat MSSA bacteremia in outpatients receiving chronic dialysis, but there may be more risk of treatment failure than observed among those individuals who receive a β-lactam antibiotic such as cefazolin.
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21 MeSH Terms
Outpatient nephrology referral rates after acute kidney injury.
Siew ED, Peterson JF, Eden SK, Hung AM, Speroff T, Ikizler TA, Matheny ME
(2012) J Am Soc Nephrol 23: 305-12
MeSH Terms: Acute Kidney Injury, Aged, Female, Glomerular Filtration Rate, Humans, Male, Middle Aged, Nephrology, Outpatients, Referral and Consultation, Renal Dialysis
Show Abstract · Added August 21, 2013
AKI associates with an increased risk for the development and progression of CKD and mortality. Processes of care after an episode of AKI are not well described. Here, we examined the likelihood of nephrology referral among survivors of AKI at risk for subsequent decline in kidney function in a US Department of Veterans Affairs database. We identified 3929 survivors of AKI hospitalized between January 2003 and December 2008 who had an estimated GFR (eGFR) <60 ml/min per 1.73 m(2) 30 days after peak injury. We analyzed time to referral considering improvement in kidney function (eGFR ≥60 ml/min per 1.73 m(2)), dialysis initiation, and death as competing risks over a 12-month surveillance period. Median age was 73 years (interquartile range, 62-79 years) and the prevalence of preadmission kidney dysfunction (baseline eGFR <60 ml/min per 1.73 m(2)) was 60%. Overall mortality during the surveillance period was 22%. The cumulative incidence of nephrology referral before dying, initiating dialysis, or experiencing an improvement in kidney function was 8.5% (95% confidence interval, 7.6-9.4). Severity of AKI did not affect referral rates. These data demonstrate that a minority of at-risk survivors are referred for nephrology care after an episode of AKI. Determining how to best identify survivors of AKI who are at highest risk for complications and progression of CKD could facilitate early nephrology-based interventions.
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11 MeSH Terms
Relation of visceral adiposity to circulating natriuretic peptides in ambulatory individuals.
Cheng S, Fox CS, Larson MG, Massaro JM, McCabe EL, Khan AM, Levy D, Hoffmann U, O'Donnell CJ, Miller KK, Newton-Cheh C, Coviello AD, Bhasin S, Vasan RS, Wang TJ
(2011) Am J Cardiol 108: 979-84
MeSH Terms: Adiposity, Adult, Biomarkers, Female, Follow-Up Studies, Humans, Immunoassay, Incidence, Intra-Abdominal Fat, Male, Massachusetts, Middle Aged, Natriuretic Peptide, Brain, Natriuretic Peptides, Obesity, Abdominal, Outpatients, Peptide Fragments, Prognosis, ROC Curve, Retrospective Studies, Risk Factors, Tomography, X-Ray Computed
Show Abstract · Added April 15, 2014
Natriuretic peptides have important roles in the regulation of vasomotor tone, salt homeostasis, and ventricular remodeling. Lower natriuretic peptide levels observed in obese individuals may underlie the greater cardiovascular risk associated with obesity. Thus the aim of this study was to determine whether lower natriuretic peptide levels in obesity are attributable to differences in regional fat distribution. We investigated the relation of plasma N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) to regional adiposity in 1,873 community-based individuals (46% women, mean age 45 years). Subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) volumes were measured by multidetector computed tomography. In gender-specific multivariable analyses adjusting for age and blood pressure, log NT-pro-BNP was inversely associated with VAT in men (beta -0.11 per standard deviation increment, p <0.001) and women (beta -0.19, p <0.001). Log NT-pro-BNP was inversely associated with SAT in women only (beta -0.14, p <0.001). In models containing VAT and SAT, only VAT was significantly associated with log NT-pro-BNP (men, beta -0.137, p <0.001; women, beta -0.184, p <0.001). VAT remained associated with log NT-pro-BNP even after adjustment for body mass index and waist circumference (beta -0.119, p <0.001) and in analyses restricted to nonobese patients (beta -0.165, p <0.001). Adjustment for insulin resistance attenuated the associations of NT-pro-BNP with VAT and SAT. In conclusion, this study demonstrates that circulating NT-pro-BNP is related to variations in regional and particularly visceral adiposity. These findings suggest that excess visceral adiposity and concomitant hyperinsulinemia may contribute to the natriuretic peptide "deficiency" observed in obesity.
Copyright © 2011 Elsevier Inc. All rights reserved.
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22 MeSH Terms
Healthcare utilization and cost of pneumococcal disease in the United States.
Huang SS, Johnson KM, Ray GT, Wroe P, Lieu TA, Moore MR, Zell ER, Linder JA, Grijalva CG, Metlay JP, Finkelstein JA
(2011) Vaccine 29: 3398-412
MeSH Terms: Adolescent, Adult, Aged, Child, Child, Preschool, Delivery of Health Care, Health Care Costs, Humans, Infant, Inpatients, Middle Aged, Models, Economic, Otitis Media, Outpatients, Pneumococcal Infections, Sepsis, Sinusitis, United States, Young Adult
Show Abstract · Added July 27, 2018
BACKGROUND - Streptococcus pneumoniae continues to cause a variety of common clinical syndromes, despite vaccination programs for both adults and children. The total U.S. burden of pneumococcal disease is unknown.
METHODS - We constructed a decision tree-based model to estimate U.S. healthcare utilization and costs of pneumococcal disease in 2004. Data were obtained from the 2004-2005 National (Hospital) Ambulatory Medical Care Surveys (outpatient visits, antibiotics) and the National Hospital Discharge Survey (hospitalization rates), and CDC surveillance data. Other assumptions regarding the incidence of each syndrome due to pneumococcus, expected health outcomes, and healthcare utilization were derived from literature and expert opinion. Healthcare and time costs used 2007 dollars.
RESULTS - We estimate that, in 2004, pneumococcal disease caused 4.0 million illness episodes, 22,000 deaths, 445,000 hospitalizations, 774,000 emergency department visits, 5.0 million outpatient visits, and 4.1 million outpatient antibiotic prescriptions. Direct medical costs totaled $3.5 billion. Pneumonia (866,000 cases) accounted for 22% of all cases and 72% of pneumococcal costs. In contrast, acute otitis media and sinusitis (1.5 million cases each) comprised 75% of cases but only 16% of direct medical costs. Patients ≥ 65 years old, accounted for most serious cases and the majority of direct medical costs ($1.8 billion in healthcare costs annually). In this age group, pneumonia caused 242,000 hospitalizations, 1.4 million hospital days, 194,000 emergency department visits, 374,000 outpatient visits, and 16,000 deaths. However, if work loss and productivity are considered, the cost of pneumococcal disease among younger working adults (18-<50) nearly equaled those ≥ 65.
CONCLUSIONS - Pneumococcal disease remains a substantial cause of morbidity and mortality even in the era of routine pediatric and adult vaccination. Continued efforts are warranted to reduce serious pneumococcal disease, especially adult pneumonia.
Copyright © 2011 Elsevier Ltd. All rights reserved.
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MeSH Terms
Cardiovascular risks of nonsteroidal antiinflammatory drugs in patients after hospitalization for serious coronary heart disease.
Ray WA, Varas-Lorenzo C, Chung CP, Castellsague J, Murray KT, Stein CM, Daugherty JR, Arbogast PG, García-Rodríguez LA
(2009) Circ Cardiovasc Qual Outcomes 2: 155-63
MeSH Terms: Aged, Anti-Inflammatory Agents, Non-Steroidal, Cardiovascular Diseases, Celecoxib, Cohort Studies, Coronary Artery Disease, Cyclooxygenase 2 Inhibitors, Diclofenac, Female, Follow-Up Studies, Hospitalization, Humans, Ibuprofen, Incidence, Lactones, Male, Middle Aged, Myocardial Infarction, Naproxen, Outpatients, Pyrazoles, Retrospective Studies, Risk Factors, Stroke, Sulfonamides, Sulfones, Tennessee
Show Abstract · Added January 20, 2015
BACKGROUND - The cardiovascular safety of individual nonsteroidal antiinflammatory drugs (NSAIDs) is highly controversial, particularly in persons with serious coronary heart disease.
METHODS AND RESULTS - We conducted a multisite retrospective cohort study of commonly used individual NSAIDs in Tennessee Medicaid, Saskatchewan Health, and United Kingdom General Practice Research databases. The cohort included 48566 patients recently hospitalized for myocardial infarction, revascularization, or unstable angina pectoris with more than 111000 person-years of follow-up. Naproxen users had the lowest adjusted rates of serious coronary heart disease (myocardial infarction, coronary heart disease death) and serious cardiovascular disease (myocardial infarction, stroke)/death from any cause, with respective incidence rate ratios (relative to NSAID nonusers) of 0.88 (95% CI, 0.66 to 1.17) and 0.91 (0.78 to 1.06). Risk did not increase with doses >or=1000 mg. Relative to NSAID nonusers, serious coronary heart disease risk increased with short term (<90 days) use for ibuprofen (1.67 [1.09 to 2.57]), diclofenac (1.86 [1.18 to 2.92]), celecoxib (1.37 [0.96 to 1.94]), and rofecoxib (1.46 [1.03 to 2.07]), but not for naproxen (0.88 [0.50 to 1.55]). Relative to naproxen, current users of diclofenac had increased risk of serious coronary heart disease (1.44 [0.96 to 2.15], P=0.076) and serious cardiovascular disease/death (1.52 [1.22 to 1.89], P=0.0002), and those of ibuprofen had increased risk of the latter end point (1.25 [1.02 to 1.53], P=0.032). Compared to naproxen in doses >or=1000 mg, serious coronary heart disease incidence rate ratios were increased for rofecoxib >25 mg (2.29 [1.24 to 4.22], P=0.008) and celecoxib >200 mg (1.61 [1.01 to 2.57], P=0.046).
CONCLUSIONS - In patients recently hospitalized for serious coronary heart disease, naproxen had better cardiovascular safety than did diclofenac, ibuprofen, and higher doses of celecoxib and rofecoxib.
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27 MeSH Terms