Making health care safer II: an updated critical analysis of the evidence for patient safety practices

OBJECTIVES

To review important patient safety practices for evidence of effectiveness, implementation, and adoption.

DATA SOURCES

Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders.

REVIEW METHODS

The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption.

RESULTS

From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption.

CONCLUSIONS

The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.

Health profile preferences of hepatitis C patients

The side effects of interferon-alpha for chronic hepatitis C are well-known. Patients may differ with respect to their tolerance of these side effects and also with respect to their individual preferences. We administered a brief questionnaire to 67 outpatients with hepatitis C virus infection. Patients were asked to make hypothetical choices between six-month profiles of health. The results were as follows: (1) patients preferred to expedite rather than postpone intervals of poor health; (2) preferences of patients with low quality-of-life were quite similar to preferences of healthier patients; (3) patients' choices satisfied transitivity; (4) patients' choices satisfied preferential independence; and (5) patients gave a variety of reasons for their choices. These results corroborate other investigations of health preferences, and serve to introduce the field of preference elicitation to gastroenterologists.

Feasibility of quality-of-life research on the Internet: a follow-up study

OBJECTIVE

Assessment of the feasibility of conducting clinical research with patients using electronic mail and the World Wide Web.

DESIGN

We re-contacted 463 patients with ulcerative colitis (UC) and 154 benign prostatic hyperplasia (BPH) patients who had provided us with e-mail addresses as part of a Web-based study. In an electronic mail message, we informed patients of a web site with a new study and invited them to participate. We then examined the factors associated with patients' participation in the new study.

RESULTS

Completion rates were 28% for UC patients (single mailing) and 48% for BPH patients (up to four mailings in a two-month period). Some patients could not be contacted due to invalid e-mail addresses (23%). Those who completed the new study tended to be older, and less time had elapsed since their participation in the previous study. Furthermore, their health-related quality-of-life had significantly improved since the previous study.

CONCLUSION

It is possible to use direct electronic mail contact to conduct follow-up research with patients. Response rates appear to be related to the number of messages sent, age of the recipients, and time since the initial contact.

Effects on preferences of violations of procedural invariance

BACKGROUND

In studies of health preferences, utilities for hypothetical health states cannot always be successfully measured. One marker for unsuccessful measurement is violation of "procedural invariance": when the ranking of two health states varies across assessment procedures. Using preference values based on unsuccessful measurement may result in misinterpretation of patients' attitudes about health.

OBJECTIVE

The authors sought to determine whether people who violated procedural invariance had different preferences than people who satisfied it.

METHODS

They performed secondary analyses of three completed studies that used the same two assessment procedures, identifying participants who violated procedural invariance and comparing the mean standard gamble (SG) and visual analog scale (VAS) scores of violators and satisfiers.

PARTICIPANTS

Experiment 1, 30 healthy volunteers and 30 patients with cardiac arrhythmias; experiment 2, 139 patients with depressive illness; experiment 3, 98 family members of patients with schizophrenia.

RESULTS

Rates of violation of procedural invariance ranged from 16% to 32%. Violation of procedural invariance was not associated with age, education level, race, or gender. Subjects with violations of procedural invariance had, in general, less ability to discriminate among states and less reliable VAS and SG measurements, and sometimes had different mean SG and VAS values.

CONCLUSIONS

Violation of procedural invariance of preferences across scaling methods may be a signal for failure of the measurement process. Researchers should test for procedural invariance and consider reporting data separately for satisfiers and violators.

Health values and prospect theory

Health values are important components of medical decisions. Experimental data suggest that people value health in complex and dynamic ways. Prospect theory is a descriptive theory of choice that may accurately characterize how people assign values to health states. The authors first provide background on prospect theory and how it can be applied to health values. Next, they review the relevant health research and find mixed support for prospect theory. Last, they discuss implications of prospect theory for cost-effectiveness analysis. The application of prospect theory to health deserves further research because it may help clarify the link between health and values.

Associations between health status and utilities implications for policy

BACKGROUND

If shape of a person's utility function is associated with his health status, as is predicted by Prospect Theory, the use of utilities from the healthy could result in 'de facto' discrimination against the sick.

OBJECTIVES

To determine if patients' utilities for hypothetical states and for their current health were associated with their health status.

DESIGN

A cross-sectional study of the health and values of patients with depressive illnesses.

SETTING

Patients from three large primary care practices with various medical illnesses complicated by symptoms of depression.

MEASURES

Short-Form 12 health status measurements, standard gamble, and visual analog scale preference measurements for patients' current health and for three hypothetical states.

RESULTS

One hundred and forty nine patients enrolled in the study and 139 patients completed the survey. Utilities for the best and worst states were similar across different levels of health status; however, standard gamble utilities for intermediate health states were higher for patients in poorer health than patients in better health (P = 0.019,) suggesting utility functions with radically different shapes. Utilities for patients' current health were also associated with their health status. Patients in poor health tended to overvalue their current health relative to the most similar hypothetical state; whereas, patients in good health tended undervalue their current health state (P = 0.036).

CONCLUSIONS

In patients with depressive illnesses, there were significant interactions between health and values, that were consistent with the predictions of Prospect Theory, and that could result in systematic under valuation of the health effects of treatments that primarily benefit more severely patients ill.

Tests of preferential independence in the QALY model

The author presents evidence for the descriptive adequacy of the quality-adjusted life years (QALY) model as applied to health profiles. One important assumption of the model is preferential independence: if two profiles have the same health state during year X, then preference between them does not switch if the level of health changes during year X. In experiment 1, 30-year health profiles were used to perform 27 empirical tests of independence with 98 subjects. Independence was reliably satisfied in all 27 tests. In experiment 2, 15 additional tests were conducted. These tests had been specifically designed to be more sensitive to independence violations, but independence was still mostly satisfied. In both experiments, the conclusions about independence hold regardless of what discount rate is used. These results act as a "lower bound" on the validity of the QALY model for health profiles.

Lisfranc arthrodesis for chronic pain: a cannulated screw technique

Nine patients with injury to the tarsometatarsal joint underwent fusion with cannulated screw fixation after conservative treatment had failed. Symptoms consisted of localized pain, forefoot abduction, and progressive collapse of the medical column. Early diagnosis and treatment were associated with a better functional outcome. The technique involved either a single or double incisional approach, resection of joints, reduction and fixation with cannulated cancellous screws. A total of 43 joints were fused: 37 tarsometatarsal joints and 6 tarsal joints. A partial Lisfranc joint complex fusion (medial three joints) was performed in four patients and a total joint complex fusion was performed in five patients. Intertarsal fusion was performed when pathologic change was evident. A cannulated screw was used to fixated 40 of the 43 joints fused. Reduction was performed prior to arthrodesis, when significant fracture-dislocation had occurred. The cannulated self-tapping cancellous screw technique provides a method of reduction that decreases technical difficulty while providing compression across the fusion site. After an average follow-up of 29 months (range 20 to 36 months), seven patients (78%) rated their outcome as good. One patient had a fair result (11%), and one patient had a poor result (11%).

Do physicians do as they say? The case of mammography

OBJECTIVE

To assess the utility of survey-based physician policy in predicting actual mammography ordering behavior, as measured by medical record abstraction.

DESIGN

Cross-sectional survey of practicing community physicians. Responses were correlated with data abstracted from the medical records of patients in the practices of the participating physicians.

PARTICIPANTS

Family and general practitioners in Washington State. Medical records of female patients aged 40 to 80 years provided data on actual mammography performance.

MAIN OUTCOME MEASURES

The proportions of female patients aged 40 to 49 and 50 to 80 years who had received a screening mammogram within the previous 2 years.

RESULTS

Of the more than 100 potential predictors available, only 4 were significantly associated with screening rates for women younger than 50 years and only 3 were associated with screening rates for older women. Regression models explained only 21% to 25% of the variance in screening rates. Physician estimates of screening rates were poorly correlated with actual screening rates.

CONCLUSIONS

Practicing physicians do not know how well they screen their patients using mammography. Extensive survey data, including direct estimates of behavior, demographics, policy measures, and case scenario responses, were of limited use in predicting actual screening rates. Our results underscore the importance of using data rather than proxy measures to study physician performance.

Posterior tibial tendon dysfunction: secondary MR signs

We evaluated four potential secondary magnetic resonance imaging signs to aid in clinical diagnosis of posterior tibial tendon (PTT) tears. Seventy-one ankles (25 PTT tears and 46 controls) were evaluated for the following secondary signs: (1) PTT sheath fluid, (2) a distal tibial spur located just anterior to the PTT, (3) unroofing of the talus, and (4) "bone bruise"--like medullary lesions. Two musculoskeletal radiologists rated their confidence using a scale and were compared for level of agreement. The presence of PTT sheath fluid had modest specificity and fair to moderate sensitivity. Tibial spurring and unroofing of the talus had excellent specificity and fair sensitivity. Bone bruise-like lesions were commonly seen in cases and controls. Examination of divergence of opinion between the two radiologists revealed pitfalls in interpretation of PTT sheath fluid and bone bruise-like lesions, which were commonly the result of adjacent vessels and inhomogeneous fat saturation, respectively. We conclude that secondary signs of PTT tears with high specificities include unroofing of the talus, tibial spurring, and PTT sheath fluid.

Dynamic unilateral distraction fixation: surgical management of tibial pilon fractures

The tibial pilon fracture is a severe injury that can result in disastrous complications. Articulated unilateral external fixation provides an alternate method for the surgical treatment of intra-articular fractures of the distal tibia. This technique provides early mobilization of the ankle joint, stabilizes the fracture site, and through distraction prevents collapse and displacement of the fracture fragments.

The antiglide plate for the Danis-Weber type-B fibular fracture: a review of 71 cases

The authors present a retrospective study of 71 fractures seen in 70 patients who had sustained the Danis-Weber type-B fibular fracture. All patients had the fractures fixated with the posterior antiglide plate. Of the 71 cases studied, 2 developed peroneal tendonitis. No other type of complication related specifically to the antiglide plate was noted. Because of the very low incidence of complications and good biomechanical strength, the authors recommend the antiglide plate for the fixation of type-B fibular fracture.