CERTs.About.Annual Reports.Year 4.CERTs Progress.Improving.System

The CERTs' broadest and potentially most beneficial efforts are those that improve aspects of the health care system. Our studies work to improve the efficiency of health care, make therapies safer, and give health care providers better access to current treatment information.

Pharmacists play a critical role in health care, especially when monitoring potentially harmful interactions between medications prescribed for the same patient. Examining the daily habits of community pharmacists for a set amount of time, the CERTs studied their responses to drug-drug interaction alerts (DDIAs). The study found that alert systems produce many DDIAs that pharmacists frequently override. In many cases, the override occurs because the pharmacist can see that the alert involves a drug the patient is no longer taking or that the medication is a refill and the alert was examined previously. However, the study suggests that reducing the abundance of DDIAs in order to concentrate on more serious interactions could reduce the risk that important DDIAs are overridden and overlooked by pharmacists.

Voluntary error reporting programs help practitioners, patients, and organizations learn from mistakes, either through single case reports or from larger, systematic analyses. A case report developed by CERTs researchers on the U.S. Pharmacopeia Error Reporting System MedMARX SM showed that even a very minor change in operating procedure can cause harm by creating errors in dosages when system checks and safeguards are not in place. This serves as an example of when a subtle change in well-established routines opens the same possibility for harm that arises when practitioners are learning to use new tools. Therefore, measures should be taken to check and recheck materials and procedures to prevent errors.

It is also important to develop standard definitions for reporting errors to help correctly identify adverse events when they occur. For example, CERTs researchers are using a database containing all South Carolina emergency room discharges over a 3-year period to develop and validate a standard definition of anaphylaxis, which is a severe, life-threatening reaction to drugs.

There are significant gaps in health care that directly affect arthritis and gout treatment, and change is necessary to improve the quality of care for these painful diseases that significantly hamper the daily activities of millions of Americans. The problem is that there is little consensus about the way in which to treat either condition.

Gout is a form of arthritis in which a buildup of uric acid causes sudden, severe inflammation, swelling, and pain in one or more joints, often the big toe. It affects more than 2 million Americans, mostly men over 40.

Gout is an understudied disease, and there is little consensus on the best ways to manage it, leaving patients vulnerable to medication-related errors and less than optimal care. Further, there are no systematic guidelines for informing patients about the risks of common medications used to relieve arthritis pain.

Recognizing the severity of the problem, the CERTs designed a study to develop quality-of-care indicators for gout management. Using a combination of evidence reported from previous gout research and the opinions of two panels of experts, the study produced 10 quality indicators for minimal standards of care. These guidelines touched on the use of anti- inflammatory medications, behavioral modifications, and ways to lower levels of uric acid.

Having these standards in place will result in many benefits for gout patients, such as helping their providers avoid medication errors. The standards also provide a basis for future research of an understudied but painful disease.

Arthritis is the country's leading cause of disability, affecting as many as 70 million people. As part of the Arthritis foundation Quality Indicator Project, the CERTs conducted a study to assess the safe use of prescription and over-the-counter analgesics, including NSAIDs, aspirin, and acetaminophen. These medications are commonly used to relieve arthritis pain, but they can produce harmful side effects, particularly to the gastrointestinal tract and kidneys.

CERTs researchers synthesized previous guidelines and updated quality-of-care indicators with current knowledge. The 10 indicators developed in the study can help providers and patients balance the painrelieving benefits of analgesics with the risks of harmful side effects.

The economic implication of quality health care is of vital concern to consumers, health care providers, and policymakers. Many CERTs projects focus on the economic issues that will help inform better decision making on the part of policymakers.

In one study, the CERTs examined the effects of increased cost-sharing of prescription drugs for patients with a chronic illness requiring medication. The study selected 13,407 adults with diabetes mellitus who faced an increase in the copay for medications. The researchers compared their use of oral hypoglycemic (OH) medications over a 12-month period with use by patients whose copay was not increased.

The comparison showed that increases of more than $10 for a 30-day supply were associated with signifi- cantly reduced OH use, while more modest increases ($1-$10) were not. The decrease in OH use was independent of age, gender, concurrent insulin use, or income.

Researchers noted that over several years, underuse of OH medications can lead to a significant increase in complications. Further study could help determine whether the effects of higher cost-sharing will be significant in the long run.

Drugs known as beta-blockers have been shown to improve outcomes for patients with heart failure, but many patients with heart failure are still not treated with this therapy. In one study, the CERTs researchers looked specifically at the economic effects of betablocker therapy from the perspectives of society, Medicare, hospitals, physicians, and patients.

They found that beta-blocker therapy for heart failure increased survival by 0.3 years per patient and reduced societal costs by $3,959 per patient over 5 years. Medicare costs declined $6,064 per patient, primarily due to fewer hospitalizations. From the perspectives of the hospital and physician, however, revenue decreased. With no clear financial incentives for hospitals and physicians to support increased betablocker use, systems need to be created to encourage optimal use of beta-blockers that take into account these economic issues.

The CERTs also examined a similar cost-related issue involving the introduction of a drug-eluting coronary stent. The new drug-coated stent is more effective at preventing a coronary artery from narrowing again and decreases the need for further procedures. However, it is more expensive than uncoated stents, and it has been unclear whether a proposed increase in Medicare hospital reimbursements would cover the increased costs for the new stent.

The study reviewed the estimated costs and reimbursements and found that the proposed increase would not completely cover the hospital costs. It also acknowledged the ethical dilemmas posed by expensive new technologies. For example, these technologies can shift cost burdens so rapidly that it is difficult for those setting reimbursement policy to respond in a timely manner. The study suggests the need for carefully constructed, evidence-based simulation models to help physicians, patients, hospitals, policymakers, and manufacturers work through the dilemmas posed by new technological devices.

PROTECTING THE PUBLIC AGAINST BIOTERRORISM AND EMERGING INFECTIOUS DISEASES 25, 26

As concerns increase about bioterrorism, it is important to assess the capacity of the U.S. health system to handle such events. Effective communication between providers and public health officials is essential in recognizing and responding effectively to emerging infections or to deliberate attacks with biologic agents. However, little is known about which sources providers rely on for this kind of information. The CERTs examined sources of information about bioterrorism that are available to front-line health care providers, particularly emergency physicians.

In the 3 months following the 2001 anthrax attacks, most emergency physicians had access to specific protocols for management of anthrax, but only a quarter of them had access to protocols for treating smallpox. The researchers conducted a telephone survey of randomly selected emergency physicians in Pennsylvania; 97 physicians participated in the 10-minute interviews. The survey found that most respondents had read official public health updates on bioterrorism, including the new Health Alert Network developed by the Centers for Disease Control and Prevention (CDC) that distributes public health emergency notifications among government entities and health care organizations. This suggests that electronic alert networks, including broadcast faxes, e-mails, and the Web, are useful means for distributing official public health guidelines.

A majority of the respondents who used the Web accessed information from the CDC Web site, while 27 respondents contacted public health agencies by telephone, usually calling local or State health departments. The study concluded that Health Alerts are perceived as highly credible and that this system is useful in conveying important information. However, it is important that the alerts be presented in a concise, user-friendly format.

Researchers also detected a need for regional public health plans to address the large influx of patients that could be triggered by an attack using biological agents. In an effort to help assess preparedness for an attack involving the smallpox virus, the CERTs surveyed pediatric emergency health care workers to determine their willingness to receive a smallpox vaccination. The anonymous survey found that almost three-quarters of the respondents were willing to be vaccinated, although many of the respondents reported ambivalent or contradictory attitudes toward the vaccine. These inconsistent attitudes might explain poor participation in a subsequent smallpox vaccination program organized by the CDC for emergency health care workers.

This kind of survey is extremely useful in enhancing the success of future efforts to prepare health care workers for possible bioterrorism or emerging infectious diseases.

About CERTs

Annual Report Year 5

CERTs Progress

Improving the System