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Purpose: In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices.Methods: We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports.Results: A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting.Conclusions: It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted. [ABSTRACT FROM AUTHOR]

Providing quality health care requires access to continuous patient data that developing countries often lack. A panel of medical informatics specialists, clinical human immunodeficiency virus (HIV) specialists, and program managers suggests a minimum data set for supporting the management and monitoring of patients with HIV and their care programs in developing countries. The proposed minimum data set consists of data for registration and scheduling, monitoring and improving practice management, and describing clinical encounters and clinical care. Data should be numeric or coded using standard definitions and minimal free text. To enhance accuracy, efficiency, and availability, data should be recorded electronically by those generating them. Data elements must be sufficiently detailed to support clinical algorithms/guidelines and aggregation into broader categories for consumption by higher level users (e.g., national and international health care agencies). The proposed minimum data set will evolve over time as funding increases, care protocols change, and additional tests and treatments become available for HIV-infected patients in developing countries. [ABSTRACT FROM AUTHOR]

Objective: Authors evaluated whether displaying context sensitive links to infrequently accessed educational materials and patient information via the user interface of an inpatient computerized care provider order entry (CPOE) system would affect access rates to the materials.Design: The CPOE of Vanderbilt University Hospital (VUH) included "baseline" clinical decision support advice for safety and quality. Authors augmented this with seven new primarily educational decision support features. A prospective, randomized, controlled trial compared clinicians' utilization rates for the new materials via two interfaces. Control subjects could access study-related decision support from a menu in the standard CPOE interface. Intervention subjects received active notification when study-related decision support was available through context sensitive, visibly highlighted, selectable hyperlinks.Measurements: Rates of opportunities to access and utilization of study-related decision support materials from April 1999 through March 2000 on seven VUH Internal Medicine wards.Results: During 4,466 intervention subject-days, there were 240,504 (53.9/subject-day) opportunities for study-related decision support, while during 3,397 control subject-days, there were 178,235 (52.5/subject-day) opportunities for such decision support, respectively (p = 0.11). Individual intervention subjects accessed the decision support features at least once on 3.8% of subject-days logged on (278 responses); controls accessed it at least once on 0.6% of subject-days (18 responses), with a response rate ratio adjusted for decision support frequency of 9.17 (95% confidence interval 4.6-18, p < 0.0005). On average, intervention subjects accessed study-related decision support materials once every 16 days individually and once every 1.26 days in aggregate.Conclusion: Highlighting availability of context-sensitive educational materials and patient information through visible hyperlinks significantly increased utilization rates for study-related decision support when compared to "standard" VUH CPOE methods, although absolute response rates were low. [ABSTRACT FROM AUTHOR]

The high burden of illness and frailty common among our growing population of older adults often results in fragmentation of care across providers and health care systems, increasing the complexity and costs of caring for these patients. Information technology offers one way to meet this challenge. Scientists at the Regenstrief Institute have more than a quarter-century of experience in using medical informatics to support clinicians in the day-to-day care of older adults. Their research has progressed through several evolutionary cycles, beginning with the acquisition of relevant data and moving to studies of the most efficient and effective mechanisms that bring information to bear at the time of clinical decision making. Information technology designed with the input of the end user has the greatest promise of changing provider behavior because it balances technological challenges with the cultural context of the practice environment. One topic of active research is information technology to support transitions of care among sites and providers. These transitions place older adults at increased risk for avoidable illness, death, and health care costs. Information systems that improve communication among providers during these transitions have the potential to improve safety and reduce costs. [ABSTRACT FROM AUTHOR]

Objective: Direct physician order entry (POE) offers many potential benefits, but evidence suggests that POE requires substantially more time than traditional paper-based ordering methods. The Medical Gopher is a well-accepted system for direct POE that has been in use for more than 15 years. The authors hypothesized that physicians using the Gopher would not spend any more time writing orders than physicians using paper-based methods.Design: A randomized controlled trial of POE using the Medical Gopher system in 11 primary care internal medicine practices.Measurements: The authors collected detailed time use data using time motion studies of the physicians and surveyed their opinions about the POE system.Results: The authors found that physicians using the Gopher spent 2.2 min more per patient overall, but when duplicative and administrative tasks were taken into account, physicians were found to have spent only 0.43 min more per patient. With experience, the order entry time fell by 3.73 min per patient. The survey revealed that the physicians believed that the system improved their patient care and wanted the Gopher to continue to be available in their practices.Conclusions: Little extra time, if any, was required for physicians to use the POE system. With experience in its use, physicians may even save time while enjoying the many benefits of POE. [ABSTRACT FROM AUTHOR]

Increasing amounts of medical knowledge, clinical data, and patient expectations have created a fertile environment for developing and using clinical practice guidelines. Electronic medical records have provided an opportunity to invoke guidelines during the everyday practice of clinical medicine to improve health care quality and control costs. In this paper, efforts to incorporate complex guidelines [those for heart failure from the Agency for Health Care Policy and Research (AHCPR)] into a network of physicians' interactive microcomputer workstations are reported. The task proved difficult because the guidelines often lack explicit definitions (e.g., for symptom severity and adverse events) that are necessary to navigate the AHCPR algorithm. They also focus more on errors of omission (not doing the right thing) than on errors of commission (doing the wrong thing) and do not account for comorbid conditions, concurrent drug therapy, or the timing of most interventions and follow-up. As they stand, the heart failure guidelines give good general guidance to individual practitioners, but cannot be used to assess quality or care without extensive "translation" into the local environment. Specific recommendations are made so that future guidelines will prove useful to a wide range of prospective users. [ABSTRACT FROM AUTHOR]

The objectives of this study were to evaluate and compare the psychometric properties of a generic health status measure, the Medical Outcomes Study SF-36, and a disease-specific health status measure, a modified version of the Chronic Heart Failure Questionnaire (CHQ), among outpatients known to have coronary artery disease (CAD) and/or congestive heart failure (CHF). A cross-sectional analysis of baseline data obtained from 670 outpatients participating in a randomized controlled clinical trial in the general medicine clinics of a major academic medical center was performed. The SF-36 was more comprehensive in its coverage of different health status domains. In contrast, the CHQ had fewer problems with floor and ceiling effects, was more internally consistent, had better dimensional reproducibility, and exhibited less factorial complexity. Although both instruments are appropriate for use among outpatients known to have CAD and/or CHF, the CHQ has significantly better psychometric properties than does the SF-36. [ABSTRACT FROM AUTHOR]

Presents a question regarding asthma, and suggests an answer by way of a medical synopsis. Relationship between the measuring of peak expiratory flow rate and asthmatic exacerbations; Details of the study conducted to research the answer to the question of the relationship; Findings of the study.

OBJECTIVES:The purpose of this study was to first estimate the crude cross-sectional and longitudinal associations between age and the sense of control, and then to partition any joint variance attributable to a theoretically specified set of potential confounders. METHODS:Sense of control was measured at baseline and at each of six bimonthly follow-up interviews among 1,662 patients at two medical centers. Potential confounders were measured at baseline. Analyses include descriptive assessments of level and normative stability, repeated measures analysis of covariance, and hierarchical multiple linear and change score regressions. RESULTS:Although the sense of control is relatively stable between any two successive waves of data collection, significant gradual changes are observed over a 1-year period. Compelling evidence is found for statistically and substantively significant associations between age and the sense of control at baseline, and between age and changes in the sense of control over time. The only other major predictor of the sense of control is mental well-being. DISCUSSION:Longitudinal studies with repeated assessments over prolonged observation periods are now needed to elucidate age-related trajectories in the sense of control. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We assessed whether the events of 9-11 affected the personal stress, mental health, or sense of control of older adults participating in an ongoing longitudinal study, and whether baseline characteristics were associated with the magnitude of any such changes. METHODS: Personal stress, mental health, and sense of control were measured at baseline and at six bimonthly follow-up interviews among 1662 patients. Of these, 437 had the opportunity to complete three interviews before and after 9-11, with 291 (67%) completing all six. We performed graphic comparisons, paired t tests, classification based on standard errors of measurement (SEMs), and multiple linear regressions for patients who completed all six interviews. RESULTS: No noticeable changes in aggregate trends for personal stress or mental health were associated with 9-11. However, 9-11 was associated with an aggregate decline in sense of control. This decline in sense of control was greater among those who were working for pay, had more comfortable incomes, and reported greater religiosity. DISCUSSION: Older adults more closely resembling those who died during 9-11 and those with greater levels of religiosity were most likely to have their sense of control affected by this catastrophic event. [ABSTRACT FROM AUTHOR]

Background & Aims: Acute enteric infections are well known to result in long-term gastrointestinal (GI) disorders. Although COVID-19 is principally a respiratory illness, it demonstrates significant GI tropism, possibly predisposing to prolonged gut manifestations. We aimed to examine the long-term GI impact of hospitalization with COVID-19., Methods: Nested within a large-scale observational cohort study of patients hospitalized with COVID-19 across North America, we performed a follow-up survey of 530 survivors 12-18 months later to assess for persistent GI symptoms and their severity, and for the development of disorders of gut-brain interaction (DGBIs). Eligible patients were identified at the study site level and surveyed electronically. The survey instrument included the Rome IV Diagnostic Questionnaire for DGBI, a rating scale of 24 COVID-related symptoms, the Gastrointestinal Symptoms Rating Scale, and the Impact of Events-Revised trauma symptom questionnaire (a measure of posttraumatic stress associated with the illness experience). A regression analysis was performed to explore the factors associated with GI symptom severity at follow-up., Results: Of the 530 invited patients, 116 responded (52.6% females; mean age, 55.2 years), and 73 of those (60.3%) met criteria for 1 or more Rome IV DGBI at follow-up, higher than the prevalence in the US general population (P < .0001). Among patients who experienced COVID-related GI symptoms during the index hospitalization (abdominal pain, nausea, vomiting, or diarrhea), 42.1% retained at least 1 of these symptoms at follow-up; in comparison, 89.8% of respondents retained any (GI or non-GI) COVID-related symptom. The number of moderate or severe GI symptoms experienced during the initial COVID-19 illness by self-report correlated with the development of DGBI and severity of GI symptoms at follow-up. Posttraumatic stress disorder (Impact of Events-Revised score ≥33) related to the COVID-19 illness experience was identified in 41.4% of respondents and those individuals had higher DGBI prevalence and GI symptom severity. Regression analysis revealed that higher psychological trauma score (Impact of Events-Revised) was the strongest predictor of GI symptom severity at follow-up., Conclusions: In this follow-up survey of patients 12-18 months after hospitalization with COVID-19, there was a high prevalence of DGBIs and persistent GI symptoms. Prolonged GI manifestations were associated with the severity of GI symptoms during hospitalization and with the degree of psychological trauma related to the illness experience., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

The human pathogen herpes simplex virus 1 (HSV-1) produces a lifelong infection in the majority of the world's population. While the generalities of alpha herpesvirus assembly and egress pathways are known, the precise molecular and spatiotemporal details remain unclear. In order to study this aspect of HSV-1 infection, we engineered a recombinant HSV-1 strain expressing a pH-sensitive reporter, gM-pHluorin. Using a variety of fluorescent microscopy modalities, we can detect individual virus particles undergoing intracellular transport and exocytosis at the plasma membrane. We show that particles exit from epithelial cells individually, not bulk release of many particles at once, as has been reported for other viruses. In multiple cell types, HSV-1 particles accumulate over time at the cell periphery and cell-cell contacts. We show that this accumulation effect is the result of individual particles undergoing exocytosis at preferential sites and that these egress sites can contribute to cell-cell spread. We also show that the viral membrane proteins gE, gI, and US9, which have important functions in intracellular transport in neurons, are not required for preferential egress and clustering in non-neuronal cells. Importantly, by comparing HSV-1 to a related alpha herpesvirus, pseudorabies virus, we show that this preferential exocytosis and clustering effect are cell type dependent, not virus dependent. This preferential egress and clustering appear to be the result of the arrangement of the microtubule cytoskeleton, as virus particles co-accumulate at the same cell protrusions as an exogenous plus end-directed kinesin motor.IMPORTANCEAlpha herpesviruses produce lifelong infections in their human and animal hosts. The majority of people in the world are infected with herpes simplex virus 1 (HSV-1), which typically causes recurrent oral or genital lesions. However, HSV-1 can also spread to the central nervous system, causing severe encephalitis, and might also contribute to the development of neurodegenerative diseases. Many of the steps of how these viruses infect and replicate inside host cells are known in depth, but the final step, exiting from the infected cell, is not fully understood. In this study, we engineered a novel variant of HSV-1 that allows us to visualize how individual virus particles exit from infected cells. With this imaging assay, we investigated preferential egress site formation in certain cell types and their contribution to the cell-cell spread of HSV-1., Competing Interests: The authors declare no conflict of interest.

Importance: The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy., Objective: To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors., Design, Setting, and Participants: This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022., Exposure: Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals., Main Outcomes and Measures: Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year., Results: A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25)., Conclusions and Relevance: In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.

Clinical decision support systems (CDSS) for the ongoing decision making required to support health behavior change for chronic disease management should incorporate behavioral science (e.g., a collaborative goal setting workflow) with more common CDSS components (i.e., an evidence-based knowledge base that processes patient data). Given known challenges with CDSS usability and adoption, engaging clinician end-users in designing new CDSS is vital. Therefore, we tested Nutri, a CDSS for collaborative diet goal setting, with 10 clinicians in a simulated primary care appointment with a patient actor. Simulation recordings, usability surveys, and debriefing interviews provided a multi-method view of clinicians' perceptions of Nutri's value and usability. 100% of participating clinicians achieved Nutri's main objective: selecting a high impact diet goal during a collaborative goal setting discussion with the patient; participants found Nutri usable, potentially timesaving, and increased their diet counseling self-efficacy. Insights will improve Nutri's usability and clinical workflow integration., (©2022 AMIA - All rights reserved.)

Background: Health information technology is a leading cause of clinician burnout and career dissatisfaction, often because it is poorly designed by nonclinicians who have limited knowledge of clinicians' information needs and health care workflow., Objective: Describe how we engaged primary care clinicians and their patients in an iterative design process for a software application to enhance clinician-patient diet discussions., Design: Descriptive study of the steps followed when involving clinicians and their at-risk patients in the design of the content, layout, and flow of an application for collaborative dietary goal setting. This began with individual clinician and patient interviews to detail the desired informational content of the screens displayed followed by iterative reviews of intermediate and final versions of the program and its outputs., Participants: Primary care clinicians practicing in an urban federally qualified health center and two academic primary care clinics, and their patients who were overweight or obese with diet-sensitive conditions., Main Measures: Descriptions of the content, format, and flow of information from pre-visit dietary history to the display of evidence-based, guideline-driven suggested goals to final display of dietary goals selected, with information on how the patient might reach them and patients' confidence in achieving them., Key Results: Through three iterations of design and review, there was substantial evolution of the program's content, format, and flow of information. This involved "tuning" of the information desired: from too little, to too much, to the right amount displayed that both clinicians and patients believed would facilitate shared dietary goal setting., Conclusions: Clinicians' well-founded criticisms of the design of health information technology can be mitigated by involving them and their patients in the design of such tools that clinicians may find useful, and use, in their everyday medical practice., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)