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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. eric.knight@hitchcock.org
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
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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
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Inadequate therapy for asthma among children in the United States.
Halterman JS, Aligne CA, Auinger P, McBride JT, Szilagyi PG. jill_halterman@urmc.rochester.edu
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
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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
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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.
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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.
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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
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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.
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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
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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.
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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. laiken@nursing.upenn.edu
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.
DESIGN, SETTING, AND PARTICIPANTS:
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.