Is detection of adverse events affected by record review methodology? an evaluation of the "Harvard Medical Practice Study" method and the "Global Trigger Tool"

BACKGROUND

There has been a theoretical debate as to which retrospective record review method is the most valid, reliable, cost efficient and feasible for detecting adverse events. The aim of the present study was to evaluate the feasibility and capability of two common retrospective record review methods, the "Harvard Medical Practice Study" method and the "Global Trigger Tool" in detecting adverse events in adult orthopaedic inpatients.

METHODS

We performed a three-stage structured retrospective record review process in a random sample of 350 orthopaedic admissions during 2009 at a Swedish university hospital. Two teams comprised each of a registered nurse and two physicians were assigned, one to each method. All records were primarily reviewed by registered nurses. Records containing a potential adverse event were forwarded to physicians for review in stage 2. Physicians made an independent review regarding, for example, healthcare causation, preventability and severity. In the third review stage all adverse events that were found with the two methods together were compared and all discrepancies after review stage 2 were analysed. Events that had not been identified by one of the methods in the first two review stages were reviewed by the respective physicians.

RESULTS

Altogether, 160 different adverse events were identified in 105 (30.0%) of the 350 records with both methods combined. The "Harvard Medical Practice Study" method identified 155 of the 160 (96.9%, 95% CI: 92.9-99.0) adverse events in 104 (29.7%) records compared with 137 (85.6%, 95% CI: 79.2-90.7) adverse events in 98 (28.0%) records using the "Global Trigger Tool". Adverse events "causing harm without permanent disability" accounted for most of the observed difference. The overall positive predictive value for criteria and triggers using the "Harvard Medical Practice Study" method and the "Global Trigger Tool" was 40.3% and 30.4%, respectively.

CONCLUSIONS

More adverse events were identified using the "Harvard Medical Practice Study" method than using the "Global Trigger Tool". Differences in review methodology, perception of less severe adverse events and context knowledge may explain the observed difference between two expert review teams in the detection of adverse events.

Quality of medical certificates issued in long-term sick leave or disability in relation to patient characteristics and delivery of health care

AIM

To assess the quality of medical certificates issued during long-term sick leave or disability.

METHODS

We collected a stratified randomised sample of 250 medical certificates issued for assessment of work capacity: Certificates issued in primary health care (PHC) with a locomotor, psychiatric or other main diagnosis, in psychiatric care, and in other secondary care. Four experts performed a quality assessment per section of the certificate and globally.

RESULTS

The certificates varied from short notes to extensive documents. Those issued in PHC included more diagnoses per certificate (p < 0.0001) than in secondary care. PHC physicians had a longer professional relationship to their patients (p = 0.009). Information on work capacity was entirely adequate and relevant in only 10% of the certificates. Disturbed mental function was indicated in 60% of the certificates without psychiatric main diagnosis. Whether indicated medical state influenced functional state was not assessable in 46 (19 %) of the certificates due to lack of information. Similarly, if reduced function influenced working capacity was not assessable in 66 (27 %) of the certificates. The global quality differed (p < 0.0001) between certificates issued in primary care 5.7 (CI 5.5-5.9) and secondary care 6.9 (CI 6.5-7.3).

CONCLUSIONS

There is a need for improvement of the quality of medical certificates issued in cases of long-term sick leave or disability. The quality of medical certificates was low and lacked necessary information requested by the Social Insurance Agency. The quality was lower in certificates issued in primary care, which might be explained by a different case-mix.

Incidence of pulmonary and venous thromboembolism in pregnancies after in vitro fertilisation: cross sectional study

OBJECTIVE

To estimate the risk of pulmonary embolism and venous thromboembolism in pregnant women after in vitro fertilisation.

DESIGN

Cross sectional study.

SETTING

Sweden.

PARTICIPANTS

23,498 women who had given birth after in vitro fertilisation between 1990 and 2008 and 116,960 individually matched women with natural pregnancies.

MAIN OUTCOME MEASURES

Risk of pulmonary embolism and venous thromboembolism (identified by linkage to the Swedish national patient register) during the whole pregnancy and by trimester.

RESULTS

Venous thromboembolism occurred in 4.2/1000 women (n=99) after in vitro fertilisation compared with 2.5/1000 (n=291) in women with natural pregnancies (hazard ratio 1.77, 95% confidence interval 1.41 to 2.23). The risk of venous thromboembolism was increased during the whole pregnancy (P<0.001) and differed between the trimesters (P=0.002). The risk was particularly increased during the first trimester, at 1.5/1000 after in vitro fertilisation versus 0.3/1000 (hazard ratio 4.22, 2.46 to 7.26). The proportion of women experiencing pulmonary embolism during the first trimester was 3.0/10,000 after in vitro fertilisation versus 0.4/10,000 (hazard ratio 6.97, 2.21 to 21.96).

CONCLUSIONS

In vitro fertilisation is associated with an increased risk of pulmonary embolism and venous thromboembolism during the first trimester. The risk of pulmonary embolism is low in absolute terms but because the condition is a leading cause of maternal mortality and clinical suspicion is critical for diagnosis, an awareness of this risk is important.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01524393.

Integrating virtual patients into courses: follow-up seminars and perceived benefit

CONTEXT

  The use of virtual patients (VPs) suggests promising effects on student learning. However, currently empirical data on how best to use VPs in practice are scarce. More knowledge is needed regarding aspects of integrating VPs into a course, of which student acceptance is one key issue. Several authors call for looking beyond technology to see VPs in relation to the course context. The follow-up seminar is proposed as an important aspect of integration that warrants investigation.

METHODS

  A cross-sectional explanatory study was performed in a clinical clerkship introduction course at four teaching hospitals affiliated to the same medical faculty. The VP-related activities were planned collaboratively by teachers from all four settings. However, each setting employed a different strategy to follow up the activity in the course. Sixteen questionnaire items were grouped into three scales pertaining to: perceived benefit of VPs; wish for more guidance on using VPs, and wish for assessment and feedback on VPs. Scale scores were compared across the four settings, which were ranked according to the level of intensity of students' processing of cases during VP follow-up activities.

RESULTS

  The perceived benefit of VPs and their usage were higher in the two intense-use settings compared with the moderate- and low-intensity settings. The wish for more guidance was high in the low- and one of the high-intensity settings. Students in all settings displayed little interest in more assessment and feedback regarding VPs.

CONCLUSIONS

  High case processing intensity was related to positive perceptions of the benefit of VPs. However, the low interest in more assessment and feedback on the use of VPs indicates the need to clearly communicate the added value of the follow-up seminar. The findings suggest that a more intense follow-up pays off in terms of the benefit perceived by students. This study illustrates the need to consider VPs from the perspective of a holistic course design and not as isolated add-ons.

Endogenous estrogens lower plasma PCSK9 and LDL cholesterol but not Lp(a) or bile acid synthesis in women

OBJECTIVE

Cholesterol and lipoprotein metabolism display pronounced gender differences. Premenopausal women have lower LDL and higher HDL cholesterol, whereas men display higher synthetic rates of bile acids and cholesterol. The effects of the administration of exogenous hormones to humans and animals indicate that these gender differences can often be explained by estrogens. We evaluated how increased levels of endogenous estrogens modulate cholesterol and lipoprotein metabolism in women.

METHODS AND RESULTS

We studied healthy women during initiation of in vitro fertilization using blood samples obtained when endogenous estrogens were low and high. Cholesterol in VLDL and LDL, but not in HDL, was reduced 20% when estrogens were high. Apolipoprotein B levels decreased 13%. Apolipoprotein A-I and triglyceride levels increased 8% and 37%, respectively, whereas lipoprotein(a) levels were unchanged. Circulating PCSK9, a suppressor of LDL receptors, was reduced 14% when estrogens were high. Serum markers of bile acid and cholesterol synthesis were unaltered. Growth hormone levels increased 3-fold when estrogens were high, whereas insulin-like growth factor-1 and fibroblast growth factor-21 concentrations were unaltered.

CONCLUSION

In women, Apolipoprotein B-containing particles and circulating PCSK9 are reduced when endogenous estrogens are high, indicating that endogenous estrogens induce hepatic LDL receptors partly through a posttranscriptional mechanism. However, estrogens do not stimulate bile acid or cholesterol synthesis.

Pre-implant right ventricular function might be an important predictor of the response to cardiac resynchronization therapy

OBJECTIVE

Cardiac resynchronization therapy is proven efficacious in patients with heart failure (HF). Presence of biventricular HF is associated with a worse prognosis than having only left ventricular (LV) HF and pacing might deteriorate heart function. The aim of the study was to assess a possible significance of right ventricular (RV) pre-implant systolic function to predict response to CRT.

DESIGN

We studied 22 HF-patients aged 72 ± 11 years, QRS-duration 155 ± 20 ms and with an LV ejection fraction (EF) of 26 ± 6% before and four weeks after receiving a CRT-device.

RESULTS

There were no changes in LV diameters or end systolic volume (ESV) during the study. However, end diastolic volume (EDV) decreased from 226 ± 71 to 211 ± 64 ml (p = 0.02) and systolic maximal velocities (SMV) increased from 2.2 ± 0.4 to 2.6 ± 0.9 cm/s (p = 0.04). Pre-implant RV-SMV (6.2 ± 2.6 cm/s) predicted postoperative increase in LV contractility, p = 0.032.

CONCLUSIONS

Pre-implant decreased RV systolic function might be an important way to predict a poor response to CRT implicating that other treatments should be considered. Furthermore we found that 3D- echocardiography and Tissue Doppler Imaging were feasible to detect short-term changes in LV function.

Significance of pretreatment cardiovascular morbidity as a risk factor during treatment with parenteral oestrogen or combined androgen deprivation of 915 patients with metastasized prostate cancer: evaluation of cardiovascular events in a randomized trial

OBJECTIVE

This study aimed to evaluate prognostic risk factors for cardiovascular events during treatment of metastatic prostate cancer patients with high-dose parenteral polyoestradiol phosphate (PEP, Estradurin®) or combined androgen deprivation (CAD) with special emphasis on pretreatment cardiovascular disease.

MATERIAL AND METHODS

Nine-hundred and fifteen patients with T0-4, Nx, M1, G1-3, hormone- naïve prostate cancer were randomized to treatment with PEP 240 mg i.m. twice a month for 2 months and thereafter monthly, or to flutamide (Eulexin®) 250 mg per os three times daily in combination with either triptorelin (Decapeptyl®) 3.75 mg i.m. per month or on an optional basis with bilateral orchidectomy. Pretreatment cardiovascular morbidity was recorded and cardiovascular events during treatment were assessed by an experienced cardiologist. A multivariate analysis was done using logistic regression.

RESULTS

There was a significant increase in cardiovascular events during treatment with PEP in patients with previous ischaemic heart disease (p = 0.008), ischaemic cerebral disease (p = 0.002), intermittent claudication (p = 0.031) and especially when the whole group of patients with pretreatment cardiovascular diseases was analysed together (p < 0.001). In this group 33% of the patients had a cardiovascular event during PEP treatment. In the multivariate analysis PEP stood out as the most important risk factor for cardiac complications (p = 0.029). Even in the CAD group there was a significant increase in cardiovascular events in the group with all previous cardiovascular diseases taken together (p = 0.036).

CONCLUSIONS

Patients with previous cardiovascular disease are at considerable risk of cardiovascular events during treatment with high-dose PEP and even during CAD therapy. Patients without pretreatment cardiovascular morbidity have a moderate cardiovascular risk during PEP treatment and could be considered for this treatment if the advantages of this therapy, e.g. avoidance of osteopenia and hot flushes and the low price, are given priority.

Case-based training of evidence-based clinical practice in primary care and decreased mortality in patients with coronary heart disease

PURPOSE

We investigated the 10-year mortality rates in a trial that tested a case-based intervention in primary care aimed at reducing the gap between evidence-based goals and clinical practice in patients with coronary heart disease (CHD).

METHODS

A prospective randomized controlled pragmatic trial was undertaken in a primary care setting. New evidence-based guidelines, with intensified lipid-lowering recommendations in CHD, were mailed to all general practitioners in the region and presented at a lecture in 1995. General practitioners (n = 54) and patients with CHD (n = 88) were assigned according to their primary health care center to 2 balanced groups and randomly allocated to usual care as a control or to an active intervention. General practitioners in the intervention group participated in repeated case-based training during a 2-year period. Patients whose CHD was treated by specialists (n = 167) served as an internal specialist comparison group. Altogether, 255 consecutive patients were included. Cox regression analysis was used to detect any survival benefit of the intervention.

RESULTS

At 10 years, 22% of the patients in the intervention group had died as compared with 44% in the control group (P = .02), with a hazard ratio of 0.45 (95% confidence interval, 0.20-0.95). This difference was mainly due to reduced cardiovascular mortality in the intervention group (P = .01). In addition, the mortality rate of 22% in the intervention group was comparable to the rate of 23% seen in patients treated by a specialist.

CONCLUSIONS

Use of case-based training to implement evidence-based practice in primary care was associated with decreased mortality at 10 years in patients with CHD.

Effects of interprofessional education on patient perceived quality of care

BACKGROUND

Active patient-based learning by working together at an interprofessional clinical education ward (CEW) increases collaborative and professional competence among students.

AIM

To assess the patients' perceptions of collaborative and communicative aspects of care when treated by interprofessional student teams as compared to usual care.

METHOD

Patients treated by student teams (medical, nurse, physiotherapy and occupational therapy students) at a CEW comprised the intervention group. Patients treated at a regular ward were taken as controls. The patients answered a questionnaire representing collaborative and communicative aspects of care. Questionnaires from CEW (n = 84) and control (n = 62) patients were obtained (82% vs 73% response rates).

RESULTS

CEW patients rated a significantly higher grade of own participation in decisions regarding treatment as compared to controls (p = 0.006). They did further rate a higher grade of satisfaction with information regarding need of help at home (p = 0.003) and perceived that the CEW staff had taken their home situation into account at a higher grade in the preparation of discharge (p = 0.0002). Finally, CEW patients felt better informed (p = 0.02).

CONCLUSION

Patients perceived a higher grade of quality of care as compared to controls with no signs of disadvantages when treated and informed by supervised interprofessional student teams.

Long-term effects of an expanded cardiac rehabilitation programme after myocardial infarction or coronary artery bypass surgery: a five-year follow-up of a randomized controlled study

Objective: To investigate the long-term effect of expanded cardiac rehabilitation on a composite end-point, consisting of cardiovascular death, myocardial infarction or readmission for cardiovascular disease, in patients with coronary artery disease.

Design: Single-centre prospective randomized controlled trial.

Setting: University hospital.

Subjects: Two hundred and twenty-four patients with acute myocardial infarction or undergoing coronary artery by-pass grafting.

Intervention: Patients were randomized to expanded cardiac rehabilitation (a one-year stress management programme, increased physical training, staying at a ‘patient hotel’ for five days after the event, and cooking sessions), or to standard cardiac rehabilitation.

Main measures: Data on cardiovascular death, myocardial infarction, readmission for cardiovascular disease and days at hospital for cardiovascular reasons were obtained from national registries of the Swedish National Board of Health and Welfare.

Results: The primary end-point occurred in 121 patients altogether (54%). The number of cardiovascular events were reduced in the expanded rehabilitation group compared with the standard cardiac rehabilitation (53 patients (47.7%) versus 68 patients (60.2%); hazard ratio 0.69; P =  0.049). This was mainly because of a reduction of myocardial infarctions in the expanded rehabilitation group. During the five years 12 patients (10.8%) versus 23 patients (20.3%); hazard ratio 0.47; P =  0.047 had a myocardial infarction. Days at hospital for cardiovascular reasons were significantly reduced in patients who received expanded cardiac rehabilitation (median 6 days) compared with standard cardiac rehabilitation (median 10 days; P =  0.02).

Conclusion: Expanded cardiac rehabilitation after acute myocardial infarction or coronary artery bypass grafting reduces cardiovascular morbidity and days at hospital for cardiovascular reasons.

Homozygous expression of haemophilia B in a heterozygote

A case of clinically severe haemophilia B in a woman is described. In 1977 she was delivered of a healthy male child, showing that she is heterozygous for the haemophilia gene. This seems to be the first report of a proven heterozygote with the homozygous expression of severe haemophilia.

Validity assessment of the detection method of maize event Bt10 through investigation of its molecular structure

In March 2005, U.S. authorities informed the European Commission of the inadvertent release of unauthorized maize GM event Bt10 in their market and subsequently the grain channel. In the United States measures were taken to eliminate Bt10 from seed and grain supplies; in the European Union an embargo for maize gluten and brewer's grain import was implemented unless certified of Bt10 absence with a Bt10-specific PCR detection method. With the aim of assessing the validity of the Bt10 detection method, an in-depth analysis of the molecular organization of the genetic modification of this event was carried out by both the company Syngenta, who produced the event, and the European Commission Joint Research Centre, who validated the detection method. Using a variety of molecular analytical tools, both organizations found the genetic modification of event Bt10 to be very complex in structure, with rearrangements, inversions, and multiple copies of the structural elements (cry1Ab, pat, and the amp gene), interspersed with small genomic maize fragments. Southern blot analyses demonstrated that all Bt10 elements were found tightly linked on one large fragment, including the region that would generate the event-specific PCR amplicon of the Bt10 detection method. This study proposes a hypothetical map of the insert of event Bt10 and concludes that the validated detection method for event Bt10 is fit for its purpose.

N-acetylcysteine improves microcirculatory flow during smoking: new effects of an old drug with possible benefits for smokers

BACKGROUND

Cigarette smoking provokes marked acute changes in the microcirculatory vasculature, including a reduced blood flow velocity. In accordance with the hypothesis that the reduced blood flow is due to an imbalance between pro-oxidants and oxidants, we recently showed that most of the reduction could be reversed by a high dose of vitamin C.

HYPOTHESIS

In the present work we tested the hypothesis that N-acetylcysteine, a mucolyticum and an antioxidant, may have an effect on the smoking-induced changes observed by vital capillary microscopy of the nailfold.

METHODS

In all, 37 healthy volunteers of both genders and with varied smoking habits were treated with N-acetylcysteine 200 mg t.i.d. for 2 weeks. In vivo investigation of the microcirculation by capillaroscopy was performed before and after treatment.

RESULTS

Treatment with N-acetylcysteine significantly reduced the smoking-induced relative decrease in capillary blood flow velocity in a group of volunteers with varied smoking habits (p = 0.0016). The preventive effect was clearly significant in smokers (p = 0.003).

CONCLUSION

Treatment with N-acetylcysteine has a positive impact on microcirculatory flow during smoking, particularly in habitual smokers.

Active interprofessional education in a patient based setting increases perceived collaborative and professional competence

BACKGROUND

Interprofessional competence can be defined as knowledge and understanding of their own and the other team members' professional roles, comprehension of communication and teamwork and collaboration in taking care of patients.

AIM

To evaluate whether students perceived that they had achieved interprofessional competence after participating in clinical teamwork training.

METHOD

Six hundred and sixteen students from four undergraduate educational programs-medicine, nursing, physiotherapy and occupational therapy-participated in an interprofessional course at a clinical education ward. The students filled out pre and post questionnaires (96% response rate).

RESULTS

All student groups increased their perceived interprofessional competence. Occupational therapy and medical students had the greatest achievements. All student groups perceived improved knowledge of the other three professions' work (p = 0.000000) and assessed that the course had contributed to the understanding of the importance of communication and teamwork to patient care (effect size 1.0; p = 0.00002). The medical students had the greatest gain (p = 0.00093). All student groups perceived that the clarity of their own professional role had increased significantly (p = 0.00003). Occupational therapy students had the greatest gain (p = 0.000014).

CONCLUSIONS

Active patient based learning by working together in a real ward context seemed to be an effective means to increase collaborative and professional competence.

Parenteral estrogen versus combined androgen deprivation in the treatment of metastatic prostatic cancer: part 2. Final evaluation of the Scandinavian Prostatic Cancer Group (SPCG) Study No. 5

OBJECTIVE

To compare parenteral estrogen therapy in the form of high-dose polyestradiol phosphate (PEP; Estradurin) with combined androgen deprivation (CAD) in the treatment of prostate cancer patients with skeletal metastases. The aim of the study was to compare anticancer efficacy and adverse events, especially cardiovascular events.

MATERIAL AND METHODS

In total, 910 eligible patients with T0-4, NX, M1, G1-3 prostate cancer with an Eastern Cooperative Oncology Group performance status of 0-2 were randomized to treatment with either PEP 240 mg i.m. twice a month for 2 months and thereafter monthly, or flutamide (Eulexin) 250 mg t.i.d. per os in combination with either triptorelin (Decapeptyl) 3.75 mg i.m. per month or on an optional basis bilateral orchidectomy.

RESULTS

At this final evaluation of the trial 855 of the 910 patients were dead. There was no difference between the treatment groups in terms of biochemical or clinical progression-free survival or in overall or disease-specific survival. There was no difference in cardiovascular mortality, but a significant increase in non-fatal cardiovascular events in the PEP arm (p<0.05) predominantly caused by an increase in ischemic heart and heart decompensation events. There were 18 grave skeletal events in the CAD group but none in the PEP group (p=0.001).

CONCLUSIONS

PEP has an anticancer efficacy equal to CAD and does not increase cardiovascular mortality in metastasized patients, but carries a significant risk of non-fatal cardiovascular events, which should be balanced against the skeletal complications in the CAD group. It is feasible to use Estradurin in the primary or secondary endocrine treatment of metastasized patients without prominent cardiac risk factors and especially those with osteoporosis.

Short- and long-term decrease of blood pressure in women during breastfeeding

BACKGROUND AND AIMS

The benefits of breastfeeding for infants are well known. Recently data have started to emerge showing that breastfeeding may also induce positive effects in the mother. This study aimed to investigate the pattern of maternal blood pressure before, during, and after a breastfeed 2 days postpartum. Additionally, blood pressure during the following 25-week breastfeeding period was investigated.

METHODS

Sixty-six primiparae with normal deliveries were consecutively recruited. Blood pressure was measured at -5, 10, 30, and 60 minutes in connection with a morning breastfeed. Thirty-three women continued to measure blood pressure before and after breastfeeding for 25 weeks.

RESULTS

Blood pressure fell significantly in response to breastfeeding 2 days after birth. The fall in systolic and diastolic blood pressure amounted to 8.8 (SD = 11.00) and 7.7 (SD = 9.3) mm Hg, respectively. During the 25-week follow-up period a significant fall of basal blood pressure (systolic, df = 3, F = 7.843, p < 0.001; diastolic, df = 3, F = 5.453, p = 0.002) was observed. The total fall in systolic and diastolic blood pressure amounted to a mean of 15 (SD = 10.4) mm Hg and 10 (SD = 9.7) mm Hg, respectively. In addition, blood pressure fell significantly in response to individual breastfeeding sessions during the entire observation period.

CONCLUSIONS

In conclusion, both systolic and diastolic blood pressures fall during a breastfeeding session, and pre-breastfeeding blood pressure decreases during at least the first 6 months of a breastfeeding period in a homelike environment. This study lends further support to the health-promoting effects of breastfeeding.