Date Of Request Research Articles

Profile of patients submitted from primary health care in the municipality of Rio de Janeiro to the ambulatory of benigal pathology of mastology of the hospital universitário gaffrée e guinle (hugg) – a cross-sectional study

Introduction: In the Brazilian Unified Health System (Sistema Único de Saúde – SUS), since 2012, referrals to the municipal outpatient network are carried out through the National Regulation System (Sistema Nacional de Regulação – SISREG). The system works online and, daily, doctors in the family health strategy of Primary Care request consultations and tests that, after being approved, are scheduled by the units that provide the service. The objective of SISREG is to optimize resources and to improve the flow of calls. Calls are classified according to priority criteria containing an appointment period of 30 to 180 days. The Mastology outpatient clinic at HUGG offers SISREG 4 vacancies per week for consultation on benign breast pathology. Objective: To evaluate the profile of patients referred to the Mastology Service at HUGG and their role in the context of SUS. Method: The medical records of patients referred through SISREG to the Mastology outpatient clinic of HUGG were carried out from January to December 2019. Results: 97 patients were referred, but only 90 of them attended the consultation. 7% of the patients had no indication for specialized monitoring, 48% of the patients already had a previous biopsy, 15% had a biopsy, 30% had surgery indication, and 19% had a suspected or confirmed lesion for breast cancer. Of the patients with a family history record, 20% had an indication for genetic study for research of hereditary breast cancer. Of those with registered BMI, more than 60% were overweight or obese. The minority regularly drank alcoholic beverages (2%) or had a history of smoking (30%). A quarter of the patients did regular physical activity. The average time between the request date and the day of the consultation was 67 days, the majority of which was spent between the date of approval in the request unit until the appointment at HUGG. Priority time was respected 75% of the time. 40% of the vacancies offered were not filled. Conclusion: A good part of the population served is overweight, sedentary, and a significant portion has a positive family history for breast cancer. In addition, the offer in consultation for benign breast pathology seems excessive, and for this reason, in 2020, we decided to open vacancies for breast biopsy, aiming at better matching supply and demand, thus seeking the best assistance to the population of Rio de Janeiro.

Evaluation of the Patient Request Process for Radiology Imaging in U.S. Hospitals.

Background In the United States, patients have the right to access their protected health information. However, to the knowledge of the authors, no study has evaluated the patient request process and the barriers to patient access of their radiology images. Purpose To assess U.S. hospital compliance with federal regulations and patient ease of access to imaging studies. Materials and Methods In this cross-sectional study conducted from June 6 to December 3, 2018, 80 U.S. hospitals were contacted by telephone to determine their patient request process for imaging studies. A scripted interview was used to simulate the patient experience in requesting imaging studies. Hospitals were compared in terms of formats of release (compact disc [CD] via pick up, CD via mail, e-mail, online patient portal, or other online access), departments from which cine files can be requested, fees, and processing times. Results All 80 hospitals stated that they could provide imaging studies on CDs. Only six (8%) hospitals provided imaging studies via e-mail and three (4%) via an online patient portal. Requests for cine files were fulfilled by a department separate from diagnostic radiology in 47 of 80 (59%) hospitals. Patient charges ranged from $0 to $75 for a single CD, no charge to $6 via e-mail, and no charge via an online patient portal. Fifty-nine (74%) hospitals stated that they could release copies within 24 hours, 10 (13%) within 2-5 days, eight (10%) within 5-10 days, and three (4%) within 10-30 days from request date. Imaging studies from outside of the diagnostic radiology department may need to be requested through the departments that performed the study. Conclusion This study demonstrated that although fees and processing times are compliant with federal regulations, patient access to imaging studies is limited primarily to compact disc format. The request process is also complicated for patients because of dispersion of imaging studies across departments. © RSNA, 2019 Online supplemental material is available for this article.

Completeness and adequacy of clinical and demographic information in non- gynaecologic surgical pathology requisition forms: An analysis of 1046 cases

Background: An important cornerstone in health care delivery is the field of surgical pathology and one of its major aims is to provide a complete, precise and comprehensive diagnosis within a short period of time. In achieving this, the clinician needs to properly fill a surgical pathology requisition form.Method: All the consecutive requisition forms from January 1, 2018 to April 30, 2018, totaling 1046 were evaluated for completeness of the information. The requesting clinicians were unaware and cytologic smears were excluded. Patient confidentiality was maintained as no names were recorded. All the Information on the forms was recorded as being present or absent. Analysis was done using the Statistical Package for Social Science version 20.Results: Altogether 1046 forms were evaluated and (100%) of the sample population bore the surnames and first names. Ages were recorded in 93.7%. Similarly, 68.2% of the forms did not bear the hospital number. Clinical summary and date of request were absent in 42.9% and 35.4% of the forms respectively. Clinicians name/ signature and investigation required were absent in 25.1% and 21.1% of the forms respectively. Overall, 77.6% of information was provided while 22.4% not provided.Conclusion: The names were completely filled in all the requisition forms. Others were incompletely filled. These findings should be communicated to Clinicians and the recurring attitude of allowing House Officers to fill the requisition forms should be discouraged. Efforts should also be made to let Clinicians appreciate the importance of good clinical information since this determines to a large extent the output of laboratory results.Keywords: Surgical pathology, requisite form, laboratory result

Analysis requests for sonography examination made by emergency residents in Algamhuria Modern General Hospital- Aden -Yemen

There is an evidence that inadequate clinical information is associated with an increased level of inaccurate reports. In our practice, we have noticed that sonography requests sometimes do not contain enough information to aid to better sonography report. The aim of this study is to analyze the requests for sonography examination in the Emergency Department of Algamhuria Modern General Hospital –Aden- Republic of Yemen, and to determine if requests provide adequate information for sonographers. We have retrospectively reviewed 250 randomly selected request forms received by the ultrasound unit of Radiology Department, at the Emergency Department. The ultrasound most frequently requested by area is the abdominal and pelvic ultrasound, being 80.8% of the analyzed requests while one (0.4%) did not have the specific part of the body area to be investigated written on the request form. Four requests (1.6%) with no patient's name (s) and seven (2.8%) with no father name (s). Eighty eight requests (35.2%) did not have date of request on it. One hundred and twenty seven (50.8%) of the request form did not have the age of the patient. Patient status wasn't mentioned in almost all except 9 /250 (3.6%). Clinical and laboratory information were absent in 128(51.2%) of the requests forms. Only 10 (4%) had information of previous radiographic investigations, while 240 (96%) did not have any previous radiographic information.. Two hundred and nine (83.6%) of the request forms had the doctors names and signatures on the request. Our audit’s data analysis revealed that only two of the 250 requests reviewed were completed in full. We found that requests for sonography examination in the Emergency Department of our hospital haven't provided adequate information for sonographers.

Incomplete patient data on chemical pathology laboratory forms in a Tertiary Hospital in Nigeria

Background: Correct and complete filling of information on the laboratory request forms is necessary if preanalytical errors are to be minimized. It also gives the laboratory opportunity to compare results with the clinical details of the patient, which can point out the possibility of errors in either laboratory test or clinical diagnosis. Appropriately, filled laboratory forms allow for timely communication of critical results to physicians providing early intervention and improved patient care. We, therefore, evaluated the extent of incomplete laboratory forms in our center. Methodology: The study was a cross-sectional where assessment of forms received over 3 months from February 17, 2014, to May 28, 2014, in the Chemical Pathology Department of Federal Teaching Hospital, Gombe, during working hours were analyzed for the frequency of incomplete data. The forms were scrutinized for the presence of name, gender, age, clinical details, ward/clinic, consultant, hospital number, and doctor's signature. Results: Only 8% of a total of 4638 forms provided all the required data. Only patient's name appeared in all the forms. Time of sample collection (58%) was the most omitted parameter. Age and gender did not appear in 39% and 38%, respectively. No clinical details or location of the patient was provided in 25% and 24% of the cases. Consultant in charge was missing in 38% of forms. Date of request, doctor's signature, and hospital number were missing on 18%, 18%, and 13%, respectively. Conclusion: The study has demonstrated high frequency of incomplete information needed on the laboratory request forms. This may be responsible for many preanalytical errors. Increased interaction between clinicians and pathologist with a view to reducing the frequency of preanalytical errors should be encouraged.

Reservation policies of advance orders in the presence of multiple demand classes

We consider an inventory system where customers provide advance order information. Specifically each customer order contains two attributes: a request date when the order is received and a due date specifying when the customer wants the order delivered. We assume M different customer classes whose demands are generated by independent Poisson processes. All customers in the same class have the same constant demand lead-time (the difference between the due date and the request date), and all demand lead-times are less than the replenishment lead-time of the inventory system. The inventory system is operated as a base-stock system where a replenishment order is issued instantaneously upon the receipt of a customer order. A key characteristic is that customers with a long demand lead-time can be overtaken by customers with a shorter demand lead-time. Therefore, a potentially important issue is: should items in stock be reserved for specific order requests, and if so, when? Here it is understood that after the reservation, the item cannot be used to fill other customer requests. We describe a general reservation policy, meaning that to each customer class a given reservation delay arises between receipt of an order and the reservation. Assuming that the revenue of an order depends on the demand lead-time, we propose a profit optimization model where the expected profit is the difference between the expected revenue and the expected inventory holding costs. We derive the profit function for the general reservation policy and find the optimal base stock level and the reservation policy by exhaustive search. In our numerical results we find cases where, by using the general reservation policy, there are improvements by more than 5% compared to either making no reservations at all, or making a complete reservation (that is, reservation immediately upon receipt) of items to incoming orders. Our numerical results also show that instead of using a general reservation policy, one can, without much loss of optimality, resort to a simpler reservation policy, denoted Backward Delay, BD.

TARIFA SOCIAL DO ESTADO DO PARANÁ: UM ESTUDO DE CASO NO BAIRRO MONTE CRISTO NA CIDADE DE LONDRINA-PR

The objective of this paper is to describe the experience of the use of the social tariff carried through by the Company of Sanitation of the Parana State (SANEPAR). To get the social tariff for residential constructions, the income of the resident family in the property will be of until ½ minimum wage for person or of or up to two minimum wages (federal) for property with up to 4 occupants, effective in the date of request of the benefit. The Jardim Monte Cristo (neighborhood), area of study, presents 450 water linkings and the monthly average of consumption is of 10,48m3/unid, exists 170 families who are benefited by the social tariff. One concludes that some points exist to be argued and that they could be implanted, so that the number of benefited families increases, as of exploitation of the rain water for not potable ends, adoption a box for pressure in addition in cases of houses that also do not possess water tank and the revision on the necessity of exclusion of the houses with more than 70m2.

An audit of request forms submitted in a multidisciplinary diagnostic center in Lagos.

IntroductionRequest forms are important means of communication between physicians and diagnostic service providers. Pre-analytical errors account for over two thirds of errors encountered in diagnostic service provision. The importance of adequate completion of request forms is usually underestimated by physicians which may result in medical errors or delay in instituting appropriate treatment. The aim of this study was to audit the level of completion of request forms presented at a multidisciplinary diagnostic center.MethodsA review of all requests forms for investigations which included radiologic, laboratory and cardiac investigations received between July and December 2011 was performed to assess their level of completeness. The data was entered into a spreadsheet and analyzed.ResultsOnly 1.3% of the 7,841 request forms reviewed were fully completed. Patient's names, the referring physician's name and gender were the most completed information on the forms evaluated with 99.0%, 99.0% and 90.3% completion respectively. Patient's age was provided in 68.0%, request date in 88.2%, and clinical notes/ diagnosis in 65.9% of the requests. Patient's full address was provided in only 5.6% of requests evaluated.ConclusionThis study shows that investigation request forms are inadequately filled by physicians in our environment. Continuous medical education of physicians on the need for adequate completion of request forms is needed.

P155 Compliance With Guidelines For The Management Of Theophylline In Patients With Acute Exacerbations Of Copd

Introduction Theophylline therapy has a role in COPD patients who fail to respond adequately to inhaled bronchodilators and show symptomatic benefit from a trial of the drug. Treatment is complicated by drug interactions and its narrow therapeutic range (10–20 mg/L). High serum levels increase the risk of toxicity, demonstrating numerous symptoms such as nausea, vomiting, headaches, dyspepsia, insomnia and behavioural disturbances. Serious adverse effects such as cardiac arrhythmias and epileptic seizures tend to occur at serum levels above this reference range. NICE guidelines for COPD state that a theophylline level should be measured on admission in patients admitted for acute exacerbation of COPD (AE-COPD). 1 The aim of this study was to audit compliance with these guidelines. Methods Patients with a diagnosis of AE-COPD were retrospectively analysed over a 6-month period (June–December 2013) at a university hospital. Those who were prescribed theophylline within 24 h of admission were included in the study. Further information was gathered including theophylline level, date of request, and subsequent dose adjustment. Paper and computerised medical and prescribing records were reviewed using a set pro-forma. Results Of a total of 54 patients in the study, 23 patients (43%) had theophylline levels checked during their hospital admission. Only 5 (9%) patients had theophylline levels within 24 h of admission, with the mean number of days from admission to assessment being 4.69 (SD+ 5.29). Of those patients, 13 patients (56.5%) had a level within subtherapeutic range ( 20 mg/l). Conclusion Improvement is needed in compliance with guidelines for the theophylline monitoring in patients with AE-COPD, as more than half of patients did not have levels checked during their hospital admission. Furthermore, dose adjustments were made in only 2 of 3 patients. Changes can be implemented through education to junior doctors, implementation of electronic prescribing alerts, and adding this to our MDT COPD bundle checklist. Further prospective audit cycle will be performed to assess improvements. Reference NICE Guidelines [CG101]2010

Are immunohistochemical (IHC)/microsatellite instability (MSI) testing necessary as part of Lynch syndrome work-up in the era of multiplex genetic testing?

425 Background: IHC for mismatch repair proteins and MSI are commonly used to direct genetic testing for Lynch Syndrome. Abnormal results in the setting of a positive family history often lead to genetic testing for Lynch syndrome. The often cumbersome process of completing IHC/MSI requires obtaining stored tissue +/- blood from a family member affected with cancer. Upfront genetic testing is not favoured due to concerns about identifying variants of uncertain significance. We performed a review of Lynch syndrome work-up in Ireland, and propose a model that is the reverse of the current international standard, and may expedite and simplify work up of these families. Methods: Data was ascertained from three cancer genetics services in Dublin and included the following variables: date of birth, date of request and reporting results for IHC, MSI and genetic tests. Time intervals were determined for LS work-up for all patients who had the process initiated in these 3 centres. Results: Probands from 50 families referred for LS work-up were included.The median time from date of IHC request to date of IHC report (total of 50 patients) was 4 weeks (range: 4 days to 36 weeks). The median time between date of IHC request to date of MSI report (n = 32 patients) was 20 weeks (range: 4 to 56 weeks). The median time from date of genetic test request to date of result (n = 9 patients) was 9 weeks (range: 2 to 26 weeks). The median time for completion of all 3 tests in one individual (n=3 patients) was 14 weeks (range: 10 to 60 weeks). Conclusions: The diagnostic pathway for Lynch syndrome is cumbersome and often lengthy. Appropriate upfront multiplex genetic testing would expedite the identification of mismatch repair gene mutation carriers. IHC/MSI testing could be used to characterise variants of uncertain significance.

Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study

UK primary care physicians receive their laboratory test results electronically. This study reports a computerised physician order entry (CPOE) system error in the pathology test request date that went unnoticed in family practices. We conducted a case study using a causation of risk theoretical framework; comprising interviews with clinicians and the manufacturer to explore the identification of and reaction to the error. The primary outcome was the evolution and recognition of and response to the problem. The secondary outcome was to identify other issues with this system noted by users. The problem was defined as the incorrect logging of test dates ordered through a CPOE system. The system assigned the test request date to the results, hence a blood test taken after a therapeutic intervention (e.g. an increase in cholesterol-lowering therapy) would appear in the computerised medical record as though it had been tested prior to the increase in treatment. This case demonstrates that: the manufacturers failed to understand family physician workflow; regulation of medical software did not prevent the error; and inherent user trust in technology exacerbated this problem. It took three months before users in two practices independently noted the date errors. This case illustrates how users take software on trust and suppliers fail to make provision for risks associated with new software. Resulting errors led to inappropriate prescribing, follow-up, costs and risk. The evaluation of such devices should include utilising risk management processes (RMP) to minimise and manage potential risk.

Clinical Communication in Diagnostic Imaging Studies

To examine how and why the quality of clinical communication between radiologists and referring physicians was changed in the inpatient imaging process after implementation of a hospital information system (HIS). A mixed-method study of the chest X-ray (CXR) requests and reports, and their involved processes within a pre- and post-HIS implementation setting. Documentation of patient age, patient ward, and name and signature of requesting physician decreased significantly in post-HIS CXR requests (P<0.05). However, documentation of requested position and technique increased significantly (P<0.05). In post-HIS CXR reports, documentation of patient age, patient chart number, urgent/normal status of requisition, position and technique of CXR, name of referring physician, and date of request were increased significantly (P<0.05). However, documentation of discussion for important findings was decreased significantly (P<0.05). The mean number of words in the body text of post-HIS reports was increased significantly (18.65 vs. 16.3, P = 0.00).Our qualitative findings highlighted that involving nursing and radiology staff in the communication loop between physicians and radiologists after the implementation resulted in extra steps in the workflow and more workload for them. To cope with the new workload, they adopted different workarounds that could explain the results seen in the quantitative study. The HIS improved communication of administrative and identification information but did not improve communication of clinically relevant information. The reason was traced to the complications that the inappropriate implementation of the system brought to clinical workflow and communication loop.

Utility of Routine Bone Marrow Fluorescent in Situ Hybridization (FISH) Panel Testing in Patients Suspected of Myelodysplastic Syndrome (MDS): An Analysis of 3,418 Patients and Comparison of Academic Versus Community Practices

AbstractAbstract 3855 Background:Metaphase cytogenetics and FISH panel testing are commonly performed on bone marrow aspirate samples from patients suspected of having MDS. We performed this study to determine the frequency of simultaneous testing in academic versus community practices and whether routine FISH panel provides additional information to metaphase cytogenetics. Methods:After approval from our institutional review boards, a list of patients who had bone marrow aspirate samples submitted to the Wisconsin State Laboratory of Hygiene between January 2000 to June 2011, with a diagnosis of anemia, thrombocytopenia, neutropenia, or pancytopenia, and suspected MDS was obtained from Wisconsin State Laboratory of Hygiene. If multiple samples were submitted for the same patient, we included only the first sample. We collected data pertaining to demographics, indication/diagnosis, requesting institution, date of request, and cytogenetics/FISH results. The FISH panel included probes for chromosomes 5q31, 7q31, 8, and 20q (Abbott Molecular, Abbott Park, IL). Results:We included 3,418 patients who met our study criteria. The median age was 57.5 years (18–97 years) and 55.2% were males. The samples came from 1 academic center (36.9%), 4 community practices (44.7%), and 3 referral laboratories (18.4%). The top clinical indications for bone marrow aspiration were anemia (48.5%), pancytopenia (26.8%), thrombocytopenia (15.2%), neutropenia (5.2%) and possible MDS (2.3%). Karyotype was normal in 2,527 (73.9%), abnormal in 617 (18.1%), and could not be determined in 274 (8.0%) due to culture failure or inadequate karyotypes.Simultaneous testing for cytogenetics and FISH was performed in 379 patients (11.1%). In this subgroup, abnormal karyotypes were identified in 64 (16.8%) and abnormal FISH results in 55 (14.5%). Among the 299 samples which had adequate metaphases for cytogenetic analysis, FISH panel detected additional cytogenetic abnormalities in 11 (3.6%) patients. The cytogenetic abnormalities detected by FISH but not by karyotyping were −20q (5 patients), −7q (4 patients), −5q (1 patient), and −5q/-20q (1 patient). However, this would have changed the MDS International Prognostic Scoring System karyotype score in only 5 of these patients (1.7%) patients. In cases with inadequate karyotypes or no growth (n = 80), abnormal FISH result was found in 13 (16.2%). The cytogenetic abnormalities detected were −20q (4 patients), −7q (4 patients), −5q (3 patients), −5q/-7q/-20q (1 patient) and −5q/-7q (1 patient).The karyotype inadequacy/failure rates were similar regardless of whether samples came from academic center or the community (8.7% vs 7.6%; P = 0.277). However, community physicians were more likely to perform simultaneous cytogenetic and FISH testing compared to academic physicians (14.0% vs 6.2%; P < 0.0001). FISH testing detected additional abnormalities at a similar rate among samples coming from the academic and community practices (2.6% vs 7.3%; P = 0.190). There was a significant variability in the rates of simultaneous cytogenetic and FISH testing among community practices ranging from 0% to 23.4% (P < 0.0001). Conclusions:In our study of a large sample of patients being evaluated for cytopenias and suspected of MDS, routine bone marrow FISH panel testing added little to cytogenetic study except when karyotype failed or was inadequate. Community physicians requested simultaneous testing for cytogenetics and FISH significantly more often than their academic counterparts even though karyotype inadequacy or failure rate was similar. There was a large variation in simultaneous testing rates among community practices. Disclosures:No relevant conflicts of interest to declare.

Use of carbetocin in elective caesarean sections

BackgroundThe Pharmacy and Therapeutics Committee (PTC) decided to evaluate the use of carbetocin following a request by the Obstetrics and Gynaecology department.PurposeTo evaluate the use of carbetocin in elective Caesareans.Materials...

Pre-Processing of Query Logs in Web Usage Mining

In For the past few years, query log data has been collected to find user's behavior in using the site. Many researches have studied on the usage of query logs to extract user's preference, recommend personalization, improve caching and pre-fetching of Web objects, build better adaptive user interfaces, and also to improve Web search for a search engine application. A query log contain data such as the client's IP address, time and date of request, the resources or page requested, status of request HTTP method used and the type of browser and operating system. A query log can offer valuable insight into web site usage. A proper compilation and interpretation of query log can provide a baseline of statistics that indicate the usage levels of website and can be used as tool to assist decision making in management activities. In this paper we want to discuss on the tasks performed of query logs in pre-processing of web usage mining. We will use query logs from an online newspaper company. The query logs will undergo pre-processing stage, in which the clickstream data is cleaned and partitioned into a set of user interactions which will represent the activities of each user during their visits to the site. The query logs will undergo essential task in pre-processing which are data cleaning and user identification.

Evaluation of a wireless handheld medication management device in the prevention of drug-drug interactions in a Medicaid population.

With the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, widespread adoption of certain health information technologies, such as electronic health records (EHRs) and electronic prescribing (e-prescribing), is imminent. Drug-drug interaction (DDI) screening and medication history information are commonly incorporated into health information exchange systems to improve medical decision making, safety, and quality of care, but the value of these features is unclear. To evaluate the effect of providing access to an early generation electronic medication management program with medication history accessible to prescribers via a wireless handheld personal digital assistant (PDA) device on the incidence of potential DDIs (i.e., DDIs that may or may not cause patient harm). This study employed a retrospective pre-intervention/post-intervention study design with a comparison group to evaluate the effectiveness of a wireless handheld medication management program in preventing serious potential DDIs. Licensed prescribers in a state Medicaid program who wrote prescriptions during the period from August 2003 through June 2006 were included in this study. The intervention (PDA) group consisted of clinicians who requested and were granted access to the wireless handheld device containing prescription drug history between August 1, 2004, and June 30, 2005. Initially the device contained 100-day patient-specific medication history, but other functionalities were added during the study period including the ability to check for drug-drug interactions and e-prescribing. The comparison group consisted of prescribers who sent a request to obtain, but did not receive, the wireless handheld device during the same time period. Baseline prescribing patterns of 25 previously identified clinically important potential DDIs were assessed over two 12-month periods, one period prior to (baseline) and one period after (follow-up) an index date (date of device deployment for PDA group; date of request for comparison group). A random-effects negative binomial model was used to analyze the primary outcome, the number of potential DDIs per prescriber per 12-month time period. A secondary outcome of interest, the likelihood that a prescriber would prescribe at least 1 potentially interacting medication pair during the baseline and follow-up periods, was analyzed using a random-effects logistic model. A total of 1,615 prescribers constituted the PDA group, and 600 prescribers made up the comparison group. Prescribers in the 2 groups were significantly different in their specialty practice areas (P less than 0.001), number of pharmacy claims at baseline (P less than 0.001), and the likelihood of prescribing at least 1 potential DDI combination during the 1-year baseline period (P=0.003). However, the prescriber groups were similar in their average age (P=0.241) and geographic location (P=0.181). The most widely prescribed potential DDIs included those involving warfarin with nonsteroidal anti-inflammatory drugs (NSAIDs) and thyroid hormones. The median number of patient medication history updates requested per PDA group prescriber during follow-up was 24 (range 0 to 1,073). At baseline, 1,104 (68.4%) of the PDA group and 449 (74.8%) of the comparison group had no potential DDIs. During the next year, 1,131 (70.0%) and 462 (77.0%) of the PDA group and comparison group, respectively, had no DDIs. The incidence rate ratio was 1.01 (95% CI=0.87-1.17) for the PDA group relative to the comparison group for change in number of potential DDIs. In the logistic regression model, the odds of prescribing at least 1 potential DDI did not significantly differ by group (odds ratio=1.26, 95% CI=0.96-1.66). These results indicate that there was no significant difference between the intervention and comparison group with regard to the change in the rate of potential DDIs between the baseline and follow-up periods. A stand-alone medication management program in a wireless PDA device was not frequently used by most prescribers to update patient medication histories and was not associated with a reduction in the rate of prescribing potentially clinically important DDIs.

Reducing referral delays in colorectal cancer diagnosis: is it about how you ask?

Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. The authors tested whether certain details of information transmitted through computerised provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed CRC. The authors studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees and other specialists. From the colonoscopy referral preceding CRC diagnosis, the authors determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. The authors compared distributions of proportions of diagnostic clues between patients with a lag of >60 and ≤60 day, and examined predictors of lag time. Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had a lag of >60 days. Referrals associated with longer lag times included those with 'positive faecal occult blood test' (92 days, p<0.0001), 'haematochesia' (75 days, p=0.02), 'history of polyps' (221 days, p=0.0006) and when 'screening' (vs specific symptoms) was given as the reason for diagnostic colonoscopy (203 days, p=0.002). Independent predictors of shorter wait times included three diagnostic clues, notation of urgency and documentation of verbal contact. Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.

Effect of the UK Postcode Lottery on Survival of Patients with Metastatic Renal Cancer: an Audit of Outcomes in Patients with Metastatic Renal Cancer Suitable for Treatment with Tyrosine Kinase Inhibitors

Aims To determine whether primary care trusts’ agreement or refusal to fund sorafenib or sunitinib affects outcomes for patients with metastatic renal cell carcinoma. Materials and methods This retrospective audit was conducted in a tertiary referral centre for urological cancer. Requests to prescribe drugs not approved by the National Institute for Health and Clinical Excellence are recorded on a trust database. We obtained details of all requests made for sunitinib and sorafenib for patients with renal cell carcinoma since licence in 2006. Outcome measures analysed were overall survival measured from the date of request for funding and hospital resource use as measured from Payment by Results data. Known prognostic factors and the patient's Index of Multiple Deprivation score were assessed at baseline as potential confounders of survival difference. Results Seventy-nine patients were identified. The groups were similar with respect to prognostic factors and Index of Multiple Deprivation scores. Thirty-seven and eight patients had funding approved for sunitinib and sorafenib, respectively; 21 and 13 were turned down. Seven patients who were denied funding received one or other of these drugs by self-funding treatment. Survival was longer for patients who received treatment with a drug for which they had applied for funding than for those who did not (hazards ratio 0.46; 95% confidence interval 0.21–1.01; χ 2 = 3.80; 1 d.f.; P = 0.05); the advantage was similar for patients receiving sunitinib (hazards ratio = 0.49; 95% confidence interval 0.18–1.36; χ 2 = 1.86; 1 d.f.; P = 0.17) and sorafenib (hazard ratio = 0.44; 95% confidence interval 0.11–1.69; χ 2 = 1.58; 1 d.f.; P = 0.21). Overall National Health Service resource use apart from funding for the renal cancer drugs was similar for both groups. Conclusions Compared with patients receiving treatment, patients denied access to sunitinib and sorafenib had substantially worse survival outcomes, despite receiving treatment from the same clinical team. Access to the new drugs did not have an effect on overall use of National Health Service resources by funded patients. Modern treatments for advanced renal cancer should be available to all National Health Service patients with the disease.

Obtaining Medical Records from Healthcare Facilities under the HIPAA Privacy Rule: The Experience of a National Longitudinal Cohort Study

The processes for acquiring medical records from healthcare facilities in longitudinal cohort studies have not been well examined post-HIPAA Privacy Rule. We examined the response rates, correlates of response rates, and response times for obtaining patient medical records from healthcare facilities under the HIPAA Privacy Rule. Medical records were requested from facilities across the country on adults 45 or older enrolled in the national longitudinal cohort study REGARDS (Reasons for Geographic and Racial Differences in Stroke) who reported physician encounters for potential stroke events. From October 2003 to October 2006, 1,439 medical records were received out of 1,518 reported eligible events (94.7%), with 39 (2.6%) requests pending at the time of the analysis. The refusal rate for record requests from healthcare facilities was only 0.4%. The median length of time to receipt of a record was 26 days (range 1–679 days). Hospitals had the fastest return time (22 days from date of request to date of receipt) compared with outpatient clinics (28 days), doctor’s offices (31 days), and long-term care facilities (55 days, p < 0.01). Healthcare facilities located in the Southern region had fastest return time compared with those in the Northwestern region (23 vs. 46 days, p = 0.048). Medical records retrieval in prospective research studies is still feasible under HIPAA regulation.

Implementing Screening Colonoscopy at a VAMC. A 1 Year Experience

Purpose: Implementing colonoscopy for CRC screening may be challenging when the demand exceeds the supply creating significant backlogs that may be perceived as detrimental. Aim: (1) To report the results of a rapid and progressive implementation of screening colonoscopy at a VAMC. (2) To determine whether a delay in performing the procedure, negatively influences the findings at colonoscopy Methods: Endoscopic, medical and pathology records of patients undergoing screening colonoscopy (1/04–12/04). Demographics, presence/absence of polyps, size and location were noted. Cecal intubation rate was calculated. Proximal location = proximal to splenic flexure. Advanced neoplasia = adenoma ≥ 10 mm, villous component, HGD, or invasive carcinoma. The delay between the date of performance and date of request was calculated. Results: Of 2617 colonoscopies, 915 were for CRC screening; mean age: 61 yrs. The screening colonoscopy: flexible sigmoidoscopy ratio was 74%: 26% during the 1st QTR and 98%: 2% during the 4th QTR. The overall waiting time for colonoscopy was 141 days. By the 4th QTR, the time delay (169.1 ± 7.3 days) was significantly longer than the 1st QTR (135.6 ± 3.6 days) (p < 0.05). The cecal intubation rate was 97.4%. The no show up rate for outpatiens colonoscopy was 8%. There was 1 post-polypectomy bleeding. 643 patients (71%) had no adenomas/advanced neoplasia; 9 had: leiomyomas (3), carcinoids (2), lipoma, lipogranuloma, ganglioneuroma and juvenile polyps, 1 each. 212 (23.2%) had adenomas < 10 mm and 51 (5.6%) advanced neoplasias Of the 6 advanced neoplasias found proximally only, 4 were adenomas ≥ 10 mm and 2 villous adenomas. During the 1st QTR, 29.9% of colonoscopies yielded adenomas and advanced neoplasia whereas in the 4th QTR, the yield was 20.7% (p = 0.03). For advanced neoplasia only however, the yield was 6.6% and 5.5%, respectively (NS) Conclusions: Implementation of a screening colonoscopy program at a VAMC is challenging and is associated with time delays due to a progressive backlog The prevalence of adenoma and advanced neoplasia was 28.7% Proximal adenomas and advanced neoplasia without any other adenoma(s) distally were found in 24.7% Proximal advanced neoplasia was found in 11.8% (0.7% of total number of screening colonoscopies) The time delay did not negatively affect the yield for advanced neoplasiaTable: Location Distribution of Adenomas < 10 mm and Advanced Neoplasias