Contrasting Views of Physicians and Nurses about an Inpatient Computer-based Provider Order-entry System

Objective: Many hospitals are investing in computer-based provider order-entry (POE) systems, and providers’ evaluations have proved important for the success of the systems. The authors assessed how physicians and nurses viewed the effects of one modified commercial POE system on time spent patients, resource utilization, errors with orders, and overall quality of care. Design: Survey. Measurements: Opinions of 271 POE users on medicine wards of an urban teaching hospital: 96 medical house officers, 49 attending physicians, 19 clinical fellows with heavy inpatient loads, and 107 nurses. Results: Responses were received from 85 percent of the sample. Most physicians and nurses agreed that orders were executed faster under POE. About 30 percent of house officers and attendings or fellows, compared with 56 percent of nurses, reported improvement in overall quality of care with POE. Forty-four percent of house officers and 34 percent of attendings/fellows reported that their time with patients decreased, whereas 56 percent of nurses indicated that their time with patients increased (P \u3c 0.001). Sixty percent of house officers and 41 percent of attendings/fellows indicated that order errors increased, whereas 69 percent of nurses indicated a decrease or no change in errors. Although most nurses reported no change in the frequency of ordering tests and medications with POE, 61 percent of house officers reported an increased frequency. Conclusion: Physicians and nurses had markedly different views about effects of a POE system on patient care, highlighting the need to consider both perspectives when assessing the impact of POE. With this POE system, most nurses saw beneficial effects, whereas many physicians saw negative effects

Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: A systematic review

To summarize the evidence on the predictive value of clinical prediction rules for the diagnosis of venous thromboembolism. We selected all studies in the English literature in which a clinical prediction rule was prospectively validated against a reference standard, and calculated likelihood ratios, predictive values, and the area under the receiver operating characteristic (ROC) curve for each prediction rule. Twenty-three studies met our eligibility criteria: 17 evaluated prediction rules for the diagnosis of deep venous thrombosis and six evaluated rules for pulmonary embolism. The most frequently evaluated prediction rule for deep vein thrombosis was the Wells rule, which had median positive likelihood ratios of 6.62 for patients with a high pretest probability, 1 for moderate pretest probability, and 0.22 for low pretest probability. The median area under the ROC curve was 0.82. Addition of the D-dimer test to the prediction rule increased the median area under the curve to 0.90. The Wells prediction rule was the most commonly studied for pulmonary embolus and had median positive likelihood ratios of 6.75 for those with high pretest probability, 1.82 for moderate pretest probability, and 0.13 for low pretest probability. The median area under the ROC curve was 0.82. The Wells prediction rule is useful in identifying patients at low risk of being diagnosed with venous thromboembolism. The addition of a rapid latex D-dimer assay improved the overall performance of the prediction rule

Outpatient therapy with low molecular weight heparin for the treatment of venous thromboembolism: a review of efficacy, safety, and costs

To summarize the evidence comparing the efficacy, safety, and costs of outpatient and inpatient treatment of venous thromboembolism. We searched the literature through March 2002 for studies comparing outpatient and inpatient treatment of venous thromboembolism with low molecular weight heparin or unfractionated heparin, and for studies addressing the costs of low molecular weight heparin use in any setting. We included studies with comparison groups or decision analyses. Eight studies (three randomized trials and five cohort studies) compared outpatient use of low molecular weight heparin with inpatient use of unfractionated heparin in 3762 patients. The incidence of recurrent deep venous thrombosis was similar in the two groups (median, 4% [range, 0% to 7%] vs. 6% [range, 0% to 9%]), as was major bleeding (median, 0.5% [range, 0% to 2%] vs. 1% [range, 0% to 2%]). Use of low molecular weight heparin was associated with shorter hospitalization (median, 2.7 days [range, 0.03 to 5.1 days] vs. 6.5 days [range, 4 to 9.6 days]) and lower costs (median difference, $1600). Comparisons of outpatient and in-hospital use of low molecular weight heparin reported no difference in outcomes, but there were savings in hospitalization costs. Low molecular weight heparin was also found to be more cost saving and cost-effective than unfractionated heparin, with savings of 0% to 64% (median, 57%). The evidence indicates that outpatient treatment of deep venous thrombosis with low molecular weight heparin is likely to be efficacious, safe, and cost-effective

Cultural competence: a systematic review of health care provider educational interventions

We sought to synthesize the findings of studies evaluating interventions to improve the cultural competence of health professionals. This was a systematic literature review and analysis. We performed electronic and hand searches from 1980 through June 2003 to identify studies that evaluated interventions designed to improve the cultural competence of health professionals. We abstracted and synthesized data from studies that had both a before- and an after-intervention evaluation or had a control group for comparison and graded the strength of the evidence as excellent, good, fair, or poor using predetermined criteria. We sought evidence of the effectiveness and costs of cultural competence training of health professionals. Thirty-four studies were included in our review. There is excellent evidence that cultural competence training improves the knowledge of health professionals (17 of 19 studies demonstrated a beneficial effect), and good evidence that cultural competence training improves the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial effect and 14 of 14 studies evaluating skills demonstrated a beneficial effect). There is good evidence that cultural competence training impacts patient satisfaction (3 of 3 studies demonstrated a beneficial effect), poor evidence that cultural competence training impacts patient adherence (although the one study designed to do this demonstrated a beneficial effect), and no studies that have evaluated patient health status outcomes. There is poor evidence to determine the costs of cultural competence training (5 studies included incomplete estimates of costs). Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. Future research should focus on these outcomes and should determine which teaching methods and content are most effective