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In This Issue of Archives of Internal Medicine
July 09, 2007

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2007;167(13):1341. doi:10.1001/archinte.167.13.1341
Health Care–Associated Pneumonia Requiring Hospital Admission

Carratalà et al examined the epidemiology, empirical antibiotic therapy, and outcomes of healthcare-associated pneumonia (HCAP) among a prospective cohort of patients requiring hospitalization. Of 727 cases of pneumonia, 126 (17.3%) were health care associated and 601 (82.7%) were community acquired. There were significant differences in the spectrum of causative organisms and antibiotic susceptibilities between the 2 pneumonia groups. Patients with HCAP more frequently received an initial inappropriate empirical antibiotic therapy and had higher case-fatality rates. These results indicate that patients with HCAP require a targeted approach when selecting an empirical antibiotic therapy.

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Electronic Health Record Use and the Quality of Ambulatory Care in the United States

To determine if electronic health record (EHR) use was associated with better quality of care, Linder et al performed a retrospective, cross-sectional analysis of ambulatory visits made in 2003 and 2004. The authors examined 17 quality indicators and found no difference in quality between visits in which an EHR was and was not used for 14 of the indicators. For 2 quality indicators, visits to practices using EHRs had significantly better performance: avoiding benzodiazepine use for patients with depression (91% vs 84%; P = .01) and avoiding routine urinalysis during general medical examinations (94% vs 91%; P = .003). For 1 quality indicator, visits to practices using EHRs had significantly worse quality: statin prescribing to patients with hypercholesterolemia (33% vs 47%; P = .01). These results indicate that as EHR use expands in the United States, one should not assume an automatic diffusion of improved quality of care.

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“America's Best Hospitals” in the Treatment of Acute Myocardial Infarction

Wang et al investigated the treatment of acute myocardial infarction (AMI) in hospitals ranked by U.S. News & World Report (“America's Best Hospitals”) compared with a nationwide sample of nonranked institutions. According to a hierarchical regression model based on Medicare administrative data, risk-standardized 30-day mortality rates for patients with AMI in ranked hospitals were significantly lower than in nonranked hospitals (16.0% vs 17.9%). While most ranked hospitals were in the best performing quartile based on risk-standardized mortality, nearly one-third fell outside this group. When individual hospital performance was measured, ranked hospitals were much more likely to have significantly lower standardized mortality ratios compared with nonranked hospitals. However, when identifying hospitals with significantly lower standardized mortality ratios, nonranked hospitals outnumbered ranked hospitals 28 to 11. While the U.S. News & World Report rankings did identify some institutions with superior performance in treating AMI, many more nonranked hospitals achieved similar performance.

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Patient Factors That Physicians Use to Assign Asthma Treatment

Diette et al surveyed 236 pulmonary specialists and 225 family physicians in the United States using clinical vignettes and tested whether recent acute care (hospitalization 6 months ago), bother (patient bothered by asthma), control (symptom/reliever medication frequency), and direction (change in symptoms since last visit) influence asthma treatment decisions. Asthma control greatly influenced physician decisions about asthma treatments (P < .05). However, patient bother, recent acute care, and direction of illness also influenced decisions, particularly by increasing the amount of medication prescribed (all P < .05). This study provides strong support for the clinical importance of indicators of control, but it also points out that additional dimensions of the illness could strongly influence the physician's decision to change therapy.

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Practitioner-Level Determinants of Inappropriate Prostate-Specific Antigen Screening

None of the major clinical practice guidelines recommend that prostate-specific antigen (PSA) screening be routinely performed in asymptomatic men older than 75 years or younger than 40 years. Kerfoot et al investigated the practitioner-level determinants of inappropriate PSA screening in 7 Veterans Health Administration hospitals. The mean ± SD percentage of inappropriate tests by provider was 19.3% ± 15.0%. Several important provider-level determinants of PSA misuse were identified. The percentage of inappropriate PSA screening increased significantly with the age of male providers (P < .001) but decreased with the age of female providers (P = .048). Further work is needed to determine the degree to which “prostatempathy” contributes to PSA misuse by older male providers.

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