Articles in  Major Medical Publications Find that Many Physicians Fail to Follow Established
          Treatment Guidelines:   Hypertension.Cholesterol.Diabetes.Asthma.Myocardial Infarction.CHF.Inadequate Staffing .
        BACK to  Medical Errors .

    The full text of these articles is generally available theough the publisher.  Fees may apply.

Inadequate management of blood pressure in a hypertensive population.
Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B, Moskowitz MA.
Center for Health Quality, Outcomes, and Economic Research, Bedford Veterans Affairs Hospital, MA 01730, USA.
N Engl J Med 1998 Dec 31;339(27):1957-63
BACKGROUND: Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care.
METHODS: We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure.
RESULTS: Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment. CONCLUSIONS: In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.  PMID: 9869666

 Failure of evidence-based medicine in the treatment of hypertension in older patients.  Journal of General Internal Medicine    2000 Oct;15(10):702-9
 Knight EL, Glynn RJ, Levin R, Ganz DA, Avorn J.  Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass. 02115, USA.
OBJECTIVE: Throughout the 1990s, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommended initial antihypertensive therapy with a thiazide diuretic or a beta-blocker based on evidence from randomized, controlled trials, unless an indication existed for another drug class. The committee also recommended beta-blockers in hypertensive patients with a history of myocardial infarction (MI), and angiotensin-converting enzyme (ACE) inhibitors in patients with congestive heart failure (CHF). Our objective was to determine whether prescribing practices for older hypertensive patients are consistent with evidence-based guidelines.
METHODS: We examined prescription patterns from January 1, 1991 through December 31, 1995 for 23,748 patients 65 years or older with a new diagnosis of hypertension from the New Jersey Medicaid program and that state's Pharmacy Assistance for the Aged and Disabled program (PAAD). We linked drug use data with information on demographic variables and comorbid medical conditions.
RESULTS: During the study period, calcium channel blockers were the most commonly prescribed initial therapy for hypertension  (41%), followed by ACE inhibitors (24%), thiazide diuretics (17%), and beta-blockers (10%). Eliminating patients with diabetes mellitus, CHF, angina, or history of MI did not substantially affect these results. Overall, initial use of a thiazide declined from 22% in 1991 to 10% in 1995, while initial use of a calcium channel blocker increased from 28% to 43%, despite publication during these years of studies demonstrating a benefit of thiazides in older patients. Only 15% of older hypertensive patients with a history of MI received beta-blockers.
CONCLUSIONS: Prescribing practices for older hypertensive patients are not consistent with evidence-based guidelines. Interventions are needed to encourage evidence-driven prescribing practices for the treatment of hypertension.  PMID: 11089713

Adherence to 1997 diabetes screening guidelines in a large ambulatory clinic. Koll E, Hewitt JB.
Diabetes Management Center, All Saints Healthcare System, Racine, Wisconsin, USA.    Diabetes Educ 2001 May-Jun;27(3):387-92
PURPOSE: The purpose of this study was to evaluate whether the 1997 American Diabetes Association screening guidelines were being implemented by primary care providers.
METHODS: A retrospective health record review was undertaken in a large midwestern ambulatory care clinic. A master list was developed of clients aged 45 to 54 years who had been given a physical examination between January 1, 1998, and June 30, 1998. A total of 310 records were systematically selected and abstracted. Data were analyzed using descriptive statistics.
RESULTS: Although all subjects met the age criterion by design, and a high percent were high risk, only 57.7% were screened for diabetes.
CONCLUSIONS: Adherence to the 1997 screening guidelines was inadequate in this practice setting; therefore the authors suggest replicating this study in other practice settings. Diabetes educators should continue to promote the practice of screening high-risk individuals of all ages.  PMID: 11912799

Inadequate therapy for asthma among children in the United States.
Halterman JS, Aligne CA, Auinger P, McBride JT, Szilagyi PG.    Pediatrics 2000 Jan;105(1 Pt 3):272-6

OBJECTIVE. Childhood asthma morbidity and mortality are increasing despite improvements in asthma therapy. We hypothesized that a substantial number of children with moderate to severe asthma are not taking the maintenance medications recommended by national guidelines. The objective of this study was to describe medication use among US children with asthma and determine risk factors for inadequate therapy.
METHODS. The National Health and Nutrition Examination Survey (NHANES) III 1988-1994 provided cross-sectional, parent-reported data for children 2 months to 16 years of age. Analysis focused on children with moderate to severe asthma (defined as having any hospitalization for wheezing, >/=2 acute visits for wheezing, or >/=3 episodes of wheezing over the past year). We defined these children as adequately treated if they had taken a maintenance medication (inhaled corticosteroid, cromolyn, or theophylline) during the past month. Demographic variables were analyzed for independent associations with inadequacy of therapy. The statistical analysis used SUDAAN software to account for the complex sampling design.
RESULTS. A total of 1025 children (9.4%) had physician-diagnosed asthma. Of those with moderate to severe asthma (n = 524), only 26% had taken a maintenance medication during the past month. Even among children with 2 or more hospitalizations over the previous year, only 32% had taken maintenance medications. In a logistic regression analysis, factors significantly associated with inadequate therapy included: age </=5 years, Medicaid insurance, and Spanish language. Children surveyed after 1991, when national guidelines for asthma management became available, were no more likely to have taken maintenance medications than children surveyed before 1991.
CONCLUSION. Most children with moderate to severe asthma in this nationally representative sample, including those with multiple hospitalizations, did not receive adequate asthma therapy. These children may incur avoidable morbidity. Young children, poor children, and children from Spanish-speaking families appear to be at particularly high risk for inadequate therapy.  PMID: 10617735

Acute asthma: observations regarding the management of a pediatric emergency room.  Pediatrics 1989 Apr;83(4):507-12
Canny GJ, Reisman J, Healy R, Schwartz C, Petrou C, Rebuck AS, Levison H. Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
Because inadequate assessment and inappropriate treatment of acute asthma have been implicated as contributing factors in morbidity and even deaths, the management of acute asthma, as practiced in an emergency room, were reviewed. The study population comprised 1,864 children (mean age 5.6 years; 65% boys) who attended the emergency room with acute asthma on 3,358 occasions during a 16-month period. Visits occurred more commonly in winter and usually in the evenings; 93% were self-referred and the mean duration of symptoms was 41 hours. Most acute episodes were associated with infection. Although chest auscultation, heart rate, and respiratory rate were recorded during the majority of visits, evidence that pulsus paradoxus had been measured could be found for only 1% of visits. Results of lung function and blood gas values were rarely recorded, but chest radiographs were obtained in 18% of visits. Drugs used in the emergency room included beta 2-agonists (93% of visits), theophylline (16%), and systemic steroids (4%), but no child received anticholinergic therapy. In 26% of patient visits, admission to hospital occurred; one patient died. The erratic fashion in which asthma severity appears to have been assessed and the failure to document whether lung function had been measured are causes for concern. The surprisingly high hospitalization rate may have been avoided if bronchodilators and corticosteroids had not been underused in the emergency room.
PMID: 2927989

Treatment of myocardial infarction in the United States (1990 to 1993).  Observations from the National Registry of Myocardial Infarction.  Rogers WJ, Bowlby LJ, Chandra NC, French WJ, Gore JM, Lambrew CT, Rubison  RM, Tiefenbrunn AJ, Weaver WD.
           University of Alabama Medical Center, Birmingham 35223.   Circulation 1994 Oct;90(4):2103-14
BACKGROUND: Multiple clinical trials have provided guidelines for the treatment of myocardial  infarction, but there is little documentation as to how consistently their recommendations are being  implemented in clinical practice.
METHODS AND RESULTS: Demographic, procedural, and  outcome data from patients with acute myocardial infarction were collected at 1073 US hospitals  collaborating in the National Registry of Myocardial Infarction during 1990 through 1993.  Registry hospitals composed 14.4% of all US hospitals and were more likely to have a coronary  care unit and invasive cardiac facilities than nonregistry US hospitals. Among 240,989 patients  with myocardial infarction enrolled, 84,477 (35.1%) received thrombolytic therapy. Thrombolytic  recipients were younger, more likely to be male, presented sooner after onset of symptoms, and  were more likely to have localizing ECG changes. Among the 60,430 patients treated with  recombinant tissue-type plasminogen activator (rTPA), 23.2% received it in the coronary care  unit rather than in the emergency department. Elapsed time from hospital presentation to starting  rTPA averaged 99 minutes (median, 57 minutes). Among patients receiving thrombolytic therapy,  concomitant pharmacotherapy included intravenous heparin (96.9%), aspirin (84.0%),  intravenous nitroglycerin (76.0%), oral beta-blockers (36.3%), calcium channel blockers  (29.5%), and intravenous beta-blockers (17.4%). Invasive procedures in thrombolytic recipients  included coronary arteriography (70.7%), angioplasty (30.3%), and bypass surgery (13.3%).  Trend analyses from 1990 to 1993 suggest that the time from hospital evaluation to initiating  thrombolytic therapy is shortening, usage of aspirin and beta-blockers is increasing, and usage of  calcium channel blockers is decreasing.
 CONCLUSIONS: This large registry experience  suggests that management of myocardial infarction in the United States does not yet conform to  many of the recent clinical trial recommendations. Thrombolytic therapy is underused, particularly  in the elderly and late presenters. Although emerging trends toward more appropriate treatment  are evident, hospital delay time in initiating thrombolytic therapy remains long, aspirin and  beta-blockers appear to be underused, and calcium channel blockers and invasive procedures  appear to be overused.

Frequency of Inappropriate Metformin  Prescriptions Horlen, Malone, Brant, Dennis, Carey, Pignone, Rothman,  School of Pharmacy  Campbell University  Buies Creek, NC, Department of Medicine  University of North Carolina  Chapel Hill    JAMA Vol. 287 No. 19,  May 15, 2002
BACKGROUND: Metformin is the most commonly used medication in the management of  type 2 diabetes with more than 25 million prescriptions written in the United States in 2000. Metformin has been  associated with the development of lactic acidosis. Labeled  contraindications include renal dysfunction and congestive heart  failure (CHF) requiring pharmacologic treatment.
METHODS: Retrospective chart review. 100 patients randomly selected from all  patients with 2 or more prescriptions for metformin processed  between January 1, 2000, and September 30, 2000. The prevalence of inappropriate prescriptions for metformin was  defined as the percent of patients receiving metformin who had  documented CHF or renal dysfunction. Patients were considered to  have CHF if the diagnosis was included in the medical problem list or  clinic notes, and if they were taking medications for CHF. Renal dysfunction  was defined as a serum creatinine greater than 1.5 mg/dL (132.6  ?mol/L) for men and greater than 1.4 mg/dL (123.8 ?mol/L) for  women.
RESULTS: Twenty-two patients (22%; 95% confidence interval, 14%-30%) were  found to have either CHF requiring medications or renal insufficiency.  Of these 22 patients, 14 had CHF only, 5 had renal insufficiency only,  and 3 had both. Only 2 patients had  documentation in the medical record that providers considered  metformin contraindications.
COMMENT: Results suggest that metformin  frequently may be inappropriately prescribed despite black-box  contraindications. Documentation of this potential risk in the medical  record is limited and health care providers should consider improving  the documentation of the risk of lactic acidosis and provide  appropriate counseling for patients who receive the drug.

Underutilization and clinical benefits of angiotensin-converting enzyme inhibitors in patients with asymptomatic left ventricular dysfunction.:  Kermani M, Dua A, Gradman AH. -  Department of Medicine, Western Pennsylvania Hospital, Pittsburgh, USA. Am J Cardiol 2000 Sep 15;86(6):644-8
 Despite evidence of therapeutic benefit of angiotensin-converting enzyme (ACE) inhibitors for congestive heart failure and asymptomatic left ventricular (LV) dysfunction, recent studies suggest that in heart failure patients, rates of ACE inhibitor usage in clinical practice remain low.
In this study, the medical records of 107 patients with documented LV dysfunction were investigated for patterns of ACE inhibitor usage; 6-month and 1-year outcomes and event rates were evaluated. At index admission, 48% patients did not receive ACE inhibitor treatment, 32% were initiated on treatment, 19% continued on a prior regimen, and 1% were discontinued. Patients seen by a cardiologist were more likely to receive ACE inhibitor treatment (53% vs 35%, p = 0. 172), as were patients with histories of hypertension (60% vs 40%, p = 0.044) or myocardial infarction (56% vs 44%, p = 0.221).
 Significantly shorter hospitalizations (5.9 vs 9.5 days, p = 0.001) were noted for patients with on-going ACE inhibitor treatment compared with those receiving newly initiated treatment or no treatment. At time of hospital discharge, 102 patients were alive. Of 54 patients who received ACE inhibitors, 67% received an insufficient dose. At a 6-month follow-up, of 51 patients on ACE inhibitors, 23% died or were readmitted to hospital compared with 55% of nonusers (p = 0.001).
At 1 year, this event rate was 31% among ACE inhibitor users versus 71% among nonusers (p < 0.0001). Bivariate and multivariate analysis revealed absence of ACE inhibitor use as the only significant variable associated with the event rate (p < 0.0011).
Thus, about half of patients with asymptomatic LV dysfunction received ACE inhibitors; 2/3 of these did not receive a sufficient dose. ACE inhibitor usage increased with involvement of a cardiologist, presence of coexistent hypertension, or prior myocardial infarction. Ongoing ACE inhibitor therapy was associated with shorter hospitalizations and fewer hospital readmissions or deaths.

Underutilisation of ACE inhibitors in patients with congestive heart failure. Drugs 2001;61(14):2021-33
 Bungard TJ, McAlister FA, Johnson JA, Tsuyuki RT.  Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.

 Congestive heart failure (CHF) is associated with substantial morbidity and mortality, and is the only major cardiovascular disease increasing in prevalence. Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF. This paper reviews the evidence for the sub-optimal use of ACE inhibitors in patients with CHF, the factors contributing to this, and its implications for health systems. A systematic review of all articles assessing practice patterns (specifically the use of ACE inhibitors in CHF) identified by MEDLINE, search of bibliographies, and contact with content experts was undertaken. 37 studies have documented the use of ACE inhibitors in patients with CHF. Studies assessing use among all patients with CHF document 33% to 67%
 (median 51%) of all patients discharged from hospital and 10% to 36% (median 26%) of community dwelling patients were prescribed ACE inhibitors. Rates of ACE inhibitor use range from 43% to 90% (median of 71%) amongst those discharged from hospital having known systolic dysfunction, and from 67% to 95% (median of 86%) for those monitored in specialty clinics. Moreover, the dosages used in the 'real world' are substantially lower than those proven efficacious in randomised, controlled trials, with evaluations reporting only a minority of patients achieving target doses and/or an overall mean dose achieved to be less than one-half of the target dose. Factors predicting the use and optimal dose administration of ACE inhibitors are identified, and include variables relating to the setting (previous hospitalisation, specialty clinic follow-up), the physician (cardiology specialty versus family practitioner or general internist, board certification), the patient (increased severity of symptoms, male, younger), and the drug (lower frequency of administration). In light of the substantial evidence for reductions in morbidity and mortality, clearly, the prescription of ACE inhibitors is sub-optimal. Wide variability in ACE inhibitor use is noted, with higher rates consistently reported among patients having systolic dysfunction confirmed by an objective assessment--an apparent minority of the those having CHF. Optimisation of the prescription of proven efficacious therapies has the potential to confer a substantial reduction in the total cost of care for patients with CHF by reducing hospitalisations and lengths of hospital stays. It is likely that only multifaceted programs targeted toward the population at large will yield benefits to the healthcare system, given the widespread nature of the sub-optimal prescription of therapies proven effective in the management of patients with CHF.             PMID: 11735631

Serratia marcescens Bacteremia Traced to an Infused Narcotic Belinda E. Ostrowsky, M.D., M.P.H., Cynthia Whitener, M.D., Helen K. Bredenberg, M.D., Loretta A.  Carson, M.S., Stacey Holt, B.S., Lori Hutwagner, M.S., Matthew J. Arduino, Dr.P.H., and William R.  Jarvis, M.D. N Engl J Med 2002 May; 346(20)
BACKGROUND From June 30, 1998, through March 21, 1999, several patients in the surgical intensive care unit of a hospital acquired Serratia marcescens bacteremia. We investigated this outbreak.
METHODS A case was defined as the occurrence of S. marcescens bacteremia in any patient in the surgical intensive care unit during the period of the epidemic. To identify risk factors, we compared patients with S. marcescens bacteremia with randomly selected controls. Isolates from patients and from medications were evaluated by pulsed-field gel electrophoresis. The hair of one employee was tested for fentanyl.
RESULTS Twenty-six patients with S. marcescens bacteremia were identified; eight (31 percent) had polymicrobial bacteremia, and seven of these had Enterobacter cloacae and S. marcescens in the same culture. According to univariate analysis, patients with S. marcescens bacteremia stayed in the surgical intensive care unit longer than controls (13.5 vs. 4.0 days, P<0.001), were more likely to have received fentanyl in the surgical intensive care unit (odds ratio, 31; P<0.001), and were more likely to have been exposed to two particular respiratory therapists (odds ratios, 13.1 and 5.1; P<0.001 for both comparisons). In a multivariate analysis, receipt of fentanyl and exposure to the two respiratory therapists (adjusted odds ratio for one therapist, 6.7; P=0.002; adjusted odds ratio for the other therapist, 9.5; P=0.02) remained significant. One respiratory therapist had been reported for tampering with fentanyl; his hair sample tested positive for fentanyl. Cultures of fentanyl infusions from two case patients yielded S. marcescens and E. cloacae. The isolates from the case patients and from the fentanyl infusions had similar patterns on pulsed-field gel electrophoresis. After removal of the implicated respiratory therapist, no further cases occurred.
CONCLUSIONS An outbreak of S. marcescens and E. cloacae bacteremia in a surgical intensive care unit was traced to extrinsic contamination of the parenteral narcotic fentanyl by a health care worker. Our findings underscore the risk of complications in patients that is associated with illicit narcotic use by health care workers.

Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease. Sueta CA, Chowdhury M, Boccuzzi SJ, Smith SC Jr, Alexander CM, Londhe A, Lulla A, Simpson RJ Jr.      Am J Cardiol 1999 May 1;83(9):1303-7
There is a lack of data evaluating the implementation of guidelines in the management of coronary artery disease (CAD) or congestive heart failure (CHF) in the outpatient setting. We analyzed an administrative data set from the Merck & Co. sponsored national Quality Assurance Program, a retrospective outpatient chart audit of 58,890 adult outpatients from 140 medical practices (80% cardiology only) in the USA with diagnoses of CAD and/or CHF identified from medical claims data. We determined the (1) frequency of lipid documentation and prescription of lipid-lowering agents in patients with CAD, (2) frequency of assessment of left ventricular function and prescription of an angiotensin-converting enzyme inhibitor in patients with CHF, and (3) predictors of medication prescription. Of the 48,586 patients with CAD, 44% had annual diagnostic testing of low-density lipoprotein cholesterol. Only 25% of these patients reached the target low-density lipoprotein cholesterol of < or = 100 mg/dl, and only 39% were taking lipid-lowering therapy, which was less among the elderly than in the younger patients. Of the 16,603 patients with CHF, 64% had diagnostic testing of left ventricular function, and 50% of patients were taking an angiotensin-converting enzyme inhibitor; 67% of patients received medication if they had documented systolic dysfunction. Significant predictors of medication prescription included diagnostic testing, younger age, history of myocardial infarction or coronary artery bypass grafting, hypertension, cardiology specialty, and geographic region. Thus, current practice patterns in the management of CAD and CHF are inadequate. Patient age, diagnostic testing, and practice environment influence medication prescription. PMID: 10235085

 Do house officers learn from their  mistakes?
Wu AW, Folkman S, McPhee SJ, Lo B.             JAMA 265(16):2089-94 (1991 Apr 24)
Department of Veterans Affairs, University of California, San Francisco.
Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it.
Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases.
 Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.

Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.
  Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH.               JAMA 2002 Oct 23-30;288(16):1987-93
 Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 420 Guardian Dr, Philadelphia, PA 19104-6096, USA.
 CONTEXT: The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-to-nurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice.
 OBJECTIVE: To determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue (deaths following complications) among surgical patients, and factors related to nurse retention.
 Cross-sectional analyses of linked data from 10 184 staff nurses surveyed, 232 342 general, orthopedic, and vascular surgery patients discharged from the hospital between April 1, 1998, and November 30, 1999, and administrative data from 168 nonfederal adult general hospitals in Pennsylvania.
 MAIN OUTCOME MEASURES: Risk-adjusted patient mortality and failure-to-rescue within 30 days of admission, and nurse-reported job dissatisfaction and job-related burnout.
RESULTS: After adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in the odds of job dissatisfaction. CONCLUSIONS: In hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses are more likely to experience burnout and job dissatisfaction.