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      Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus

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          Abstract

          Introduction

          Detection and response to medically urgent situations in patients with diabetes mellitus can improve the process and outcomes of care and potentially decrease morbidity and mortality. We examined the detection and remediation of medically urgent situations among older patients receiving telemedicine case management for diabetes.

          Methods

          In the setting of a randomized trial, 338 patients in the intervention group and living in upstate New York received a home telemedicine unit to transmit blood glucose and blood pressure values to a nurse case manager, videoconference with a nurse or dietitian every 4–6 weeks and access educational websites. The educators met with a supervising endocrinologist 4–5 times weekly and clinical recommendations were proposed to the primary care providers via mail, fax, or phone.

          Results

          Over a 36 month period, 67 medically urgent situations were identified and addressed (1.9 events/month). Some of these situations were potentially life-threatening, including major drug contraindications (N = 24), other medically urgent situations (N = 19), and medical urgent conditions (ie, unstable angina) (N = 24).

          Conclusion

          The interaction via telemedicine in rural upstate New York between patients with diabetes mellitus, a diabetes care team, and primary care providers can successfully identify and remediate medically urgent situations.

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          Most cited references 13

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          Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

           Jerry Gurwitz (2003)
          Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting. To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting. Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors. Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable. There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events. Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.
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            Crossing the Quality Chasm: A New Health System for the 21st Century

             B. Bloom (2002)
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              Adverse events among medical patients after discharge from hospital.

              Adverse events (AEs) are adverse outcomes caused by medical care. Several studies have indicated that a substantial number of patients experience AEs before or during hospitalization. However, few data describe AEs after hospital discharge. We determined the incidence, severity, preventability and ameliorability of AEs in patients discharged from the general internal medicine service of a Canadian hospital. At a multisite Canadian teaching hospital, we prospectively studied patients who were consecutively discharged home or to a seniors' residence from the general internal medicine service during a 14-week interval in 2002. We used telephone interview and chart review to identify outcomes after discharge. Two physicians independently reviewed each outcome to determine if the patient experienced an AE. The severity, preventability and ameliorability of all AEs were classified. During the study period, outcomes were determined for 328 of the 361 eligible patients, who averaged 71 years of age (interquartile range 54-81 years). After discharge, 76 of the 328 patients experienced at least 1 AE (overall incidence 23%, 95% confidence interval [CI] 19%-28%). The AE severity ranged from symptoms only (68% of the AEs) or symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%). The most common AEs were adverse drug events (72%), therapeutic errors (16%) and nosocomial infections (11%). Of the 76 patients, 38 had an AE that was either preventable or ameliorable (overall incidence 12%, 95% CI 9%-16%). Approximately one-quarter of patients in our study had an AE after hospital discharge, and half of the AEs were preventable or ameliorable.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                June 2007
                June 2007
                : 3
                : 3
                : 485-489
                Affiliations
                [1 ]Department of Medicine and Pediatrics, SUNY Upstate Medical University Syracuse, NY, USA
                [2 ]Veteran Affairs Medical Center Syracuse, NY, USA
                [3 ]Department of Biomedical Informatics, Columbia University New York, NY, USA
                [4 ]Naomi Berrie Diabetes Center and Department of Medicine, Columbia University New York, NY, USA
                [5 ]Hebrew Home for the Aged at Riverdale Bronx, NY, USA
                [6 ]Departments of Medicine, Epidemiology, and Biomedical Informatics, Columbia University New York, NY, USA
                Author notes
                Correspondence: Roberto Izquierdo Department of Medicine and Pediatrics, SUNY Upstate Medical University, 750 East Adam Street, Syracuse, NY 13210, USA Tel +1 315 464 5726 Fax +1 315 464 2510 Email izquierr@ 123456upstate.edu
                Article
                2386361
                18488079
                © 2007 Dove Medical Press Limited. All rights reserved
                Categories
                Original Research

                Medicine

                telemedicine, medically urgent situations, diabetes mellitus

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