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Many physicians may not be able to interpret a CT scan well enough to tell if a stroke patient has intracranial bleeding. Drugs that break up blood clots have been approved for patients who are admitted to an emergency room with a stroke. However, these thrombolytic drugs can increase the risk of intracranial bleeding. Researchers tested 38 emergency physicians, 29 neurologists and 36 radiologists to see whether they could correctly identify intracranial bleeding on a CT scan. Only half the radiologists, 40% of the neurologists and 17% of the emergency physicians could consistently do so., Context.--Intracranial hemorrhage must be excluded prior to administration of thrombolytic agents in acute stroke. Objective.--To evaluate physician accuracy in cranial computed tomography scan interpretation for determining eligibility for thrombolytic therapy in acute stroke. Design.--Administration of randomly selected, randomly ordered series of 15 computed tomography scans from a pool of 54 scans that demonstrated intracerebral hemorrhage, acute infarction, intracerebral calcifications (impostor for hemorrhage), old cerebral infarction (impostor for acute infarction), and normal findings. Participants.--A convenience sample of 38 emergency physicians, 29 neurologists, and 36 general radiologists. Main Outcome Measures.--Physician determination of eligibility for thrombolytic therapy based on computed tomography scan interpretation. Results.--Average correct score by all physicians on all computed tomography scans was 77% (95% confidence interval, 74%-80%). Of 569 computed tomography readings by emergency physicians, 67% were correct; of 435 readings by neurologists, 83% were correct; and of 540 readings by radiologists, 83% were correct. Overall sensitivity for detecting hemorrhage was 82% (95% confidence interval, 78%-85%); 17% of emergency physicians, 40% of neurologists, and 52% of radiologists achieved 100% sensitivity for identification of hemorrhage. Conclusion.--Physicians in this study did not uniformly achieve a level of sensitivity for identification of intracerebral hemorrhage sufficient to permit safe selection of candidates for thrombolytic therapy. JAMA. 1998;279:1293-1297

Embedding clinical guidelines in the computerized medical record can enhance the implementation of the guidelines. These guidelines are developed to improve the quality of health care and hopefully save money in the process. Researchers at one hospital emergency department programmed the clinical guidelines for managing 280 health care workers exposed to body fluids into the medical records system. The system prompts the physician at each step, ensuring that the guidelines are followed. This successfully improved implementation of the guidelines and reduced the costs associated with the care of these workers., Context.--While clinical guidelines are considered an important mechanism to improve the quality of medical care, problems with implementation may limit their effectiveness. Few empirical data exist about the effect of computer-based systems for application of clinical guidelines on quality of care. Objective.--To determine whether real-time presentation of clinical guidelines using an electronic medical record can increase compliance with guidelines. Design.--Prospective off-on-off, interrupted time series with intent-to-treat analysis. Setting.--University hospital emergency department. Subjects.--Patients were 280 health care workers (50 in the baseline control phase, 156 in the intervention phase, and 74 in the postintervention control phase) who presented for initial treatment of occupational body fluid exposures, including 89% (248/280) who sustained punctures and 81% (208/257) who were exposed to blood. Physicians included resident physicians and attending physicians working in the emergency department during the study. Interventions.--Implementation of a computer charting system that provides real-time information regarding history and recommendations for laboratory testing, treatment, and disposition based on rules derived from clinical guidelines. Main Outcome Measures.--Quality of care as determined by essential items documented in the medical record and in aftercare instructions, compliance with testing and treatment guidelines, and total charges and percentage of charges attributable to guideline-endorsed activities. Results.--Mean percent documentation of 7 essential items regarding patient history in the medical record increased from 57% during the baseline period to 98% in the intervention phase (42% increase; 95% confidence interval [Cl], 34%-49%) and 11 items in aftercare instruction increased from 31 % at baseline to 93% during the intervention phase (62% increase; 95% Cl, 51%-74%), but both decreased to baseline when the computer system was removed. Percent compliance with 4 laboratory testing guidelines increased from 63% at baseline to 83% during the intervention phase (20% increase; 95% Cl,9%-31 %) but decreased to 52% when the computer system was removed. Compliance with 5 treatment guidelines increased from 83% at baseline to 96% during the intervention phase (13% increase; 95% Cl, 9%-17%) and decreased to 84% following the intervention. Percentage of charges incurred for indicated laboratory tests and treatment increased from 44% at baseline to 81% during the intervention phase (37% increase; 95% Cl, 22%-52%) and decreased to 36% following the intervention. Average total per-patient charges were $460, $384, and $373 in each phase, respectively. Conclusions.--Use of a computer-based system for clinical guidelines for management of patients with occupational exposure to body fluids improved documentation, compliance with guidelines, and percentage of charges spent on indicated activities, while decreasing overall charges. The parameters returned to baseline when the computer system was removed.

Glycosylated hemoglobin levels appears to be a promising approach to diagnosing diabetes mellitus. Measuring glycosylated hemoglobin measurement offers several advantages over measuring fasting glucose and the oral glucose tolerance test. Glycosylated hemoglobin level is already used to determine whether to treat and the effectiveness of treatment. An analysis of the correlation in 8,984 persons of glycosylated hemoglobin level with fasting blood glucose and glucose level two hours after a glucose drink revealed that all persons likely to have diabetes could be identified by using a threshold of 7% for glycosylated hemoglobin., Objective--To determine whether a glycosylated hemoglobin level can be used in place of an oral glucose tolerance test (OGTT) to diagnose diabetes. Data Sources/Study Selection.--An augmented MEDLINE search was performed to identify all reports from 1966 through June 1994 in which glycosylated hemoglobin levels were measured concurrently with performance of OGTT's in the same study. The corresponding authors were contacted and asked to provide individual data for all subjects tested. A total of 31 investigators representing 34 possible studies responded, and 18 were able to provide us with the data requested. Overall fasting plasma glucose concentrations, 2-hour postdextrose glucose concentrations, and glycosylated hemoglobin levels were available from 11 276 individuals. Data Extraction--To define normal glucose tolerance, impaired glucose tolerance (IGT), and diabetes, modified World Health Organization criteria were used. Data Synthesis.--An analysis of the methods used for measurement of glycosylated hemoglobin levels revealed that the [HbA.sub.1c] assay showed the least variance in normal subjects. Therefore, only data from the 8984 subjects who had [HbA.sub.1c]. levels measured were used. When we used the mean [HbA.sub.1c] level plus 4 SDs as a cutpoint, the sensitivity was 36% and specificity was 100% compared with the results of the OGTT. Because of the lack of agreement between OGTT results and [HbA.sub.1c] levels, models were created to analyze the distribution of [HbA.sub.1c] levels in each study. Using these models, we identified 3 subpopulations. The third subpopulation was likely to represent subjects with diabetes. When we applied an [HbA.sub.1c] level of 7.0% as a cutpoint, the sensitivity was 99.6% for the third subpopulation. When this cutpoint was reapplied to the OGTT results, of those subjects with an [HbA.sub.1c] level of at least 7.0%, 89% had diabetes, 7% had IGT, and 4% were normal. Conclusions.--Although the OGTT is the "gold standard" for diagnosing diabetes, it is known to be poorly reproducible and is often not performed. Not only is use of an [HbA.sub.1c] level to diagnose diabetes more convenient, but therapeutic decisions are based on this value, regardless of the findings on the OGTT. An [HbA.sub.1c] level of 7.0% or higher often requires pharmacological intervention and is most often associated with the diagnosis of diabetes by World Health Organization standards. An [HbA.sub.1c] level below 7.0% would generally be treated with diet and exercise, regardless of the diagnosis of IGT or diabetes by OGTT. Thus, measurement of [HbA.sub.1c] levels may represent a reasonable approach to identifying treatment-requiring diabetes. JAMA 1996;276:1246-1252