Computerization is often alleged to improve patient care, but these
claims require rigorous evaluation. Two articles in this issue of JAMA report results of such evaluations. First, Koppel and colleaguesArticle tested the role of a widely used computerized physician order
entry (CPOE) system in facilitating medication errors at a hospital. In their
survey and observation of clinicians using the system, they found the CPOE
increased the probability of 22 potential sources of prescribing error. In
the second article, Garg and colleaguesArticle report results
of a review of controlled trials assessing the effects of computerized clinical
decision support systems (CDSSs), such as reminders, disease management, and
drug-dosing or prescribing systems, on practitioner performance or patient
outcomes. In about two thirds of the 100 studies reviewed, CDSSs were reported
to improve practitioner performance. However, few trials found improvements
in patient outcomes. In an editorial, Wears and BergArticle discuss the challenges of developing computer systems that capture the complexities of medicine.
Childhood vaccinations can protect children from vaccine-preventable
diseases, but only 18% of US children receive all vaccinations at the recommended
ages or within minimum age allowances. Luman and colleagues used data from
the 2003 National Immunization Survey to determine the extent of delay of
vaccination for children not meeting the recommendations. They found that
more than 1 in 3 children were undervaccinated for at least 6 months during
their first 2 years of life and 25% of children were delayed for at least
4 of the 6 recommended vaccines. The authors identified sociodemographic factors
associated with vaccine delay.
Chromosomal aberrations have been identified in lymphocytes of adult
smokers, but direct evidence that maternal smoking is genotoxic to the fetus
has been lacking. de la Chica and colleaguesArticle report
results of their investigation of the relationship between maternal smoking
and fetal chromosomal instability in amniocytes obtained at routine amniocentesis.
They found significantly more chromosomal abnormalities in cells obtained
from women who were current smokers of more than 10 cigarettes per day and
had a smoking history of more than 10 years compared with women who did not
smoke. In an editorial, DeMarini and PrestonArticle discuss
indirect data suggesting that tobacco smoke is a transplacental fetal mutagen
and suggest analytic issues to consider in future investigations.
Public reporting of information about the quality of physician, hospital,
and health care plan has been advanced as one way to improve health care,
but few studies have examined how public reports may affect health care delivery
or improvement or potential negative consequences of public reports. Werner
and Asch discuss the rationale and evidence favoring public reports of health
care quality and the shortcomings and risks of this presumed quality improvement
The US government has approved the use of antiretroviral medications
to prevent HIV infection after nonoccupational exposure to the virus.
The effectiveness of breast cancer screening in community-based practice,
including the value of new screening modalities.
Proponents of widespread screening of military personnel for psychological
illness must consider issues of confidentiality, the validity of the screening
instruments, the lack of evidence that interventions are effective, and the
possibility of causing harm.
For your patients: Information about smoking and pregnancy.
This Week in JAMA . JAMA. 2005;293(10):1165. doi:10.1001/jama.293.10.1165