To address whether Factor V Leiden (FVL) testing alone, or in combination with prothrombin G20210A testing, leads to improved clinical outcomes in adults with a personal history of venous thromboembolism (VTE) or to improved clinical outcomes in adult family members of mutation-positive individuals.Searches of MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo through December 2008.We focused on the analytic validity, clinical validity, and clinical utility of these tests. Each included article underwent double review for data abstraction and assessment of study quality. We pooled the results of studies addressing the clinical validity of these tests when there were sufficient data. Other evidence was summarized in evidence tables. We graded the evidence by adapting a scheme recommended by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group by assessing the limitations affecting individual study quality, the certainty regarding the directness of the observed effects in the studies, the precision and strength of the findings, and the availability (or lack) of data to answer the relevant key question. Evidence for each sub-question was graded as high, moderate, or low.We reviewed 7,777 titles and included 124 articles. No direct evidence addressed the primary objective. However, high-grade evidence supported the conclusion that tests for the detection of FVL and prothrombin G20210A have excellent analytic validity. Most clinical laboratories test for these mutations accurately. Heterozygosity [odds ratio (OR) =1.56 (95 percent confidence interval (CI) 1.14 to 2.12)] and homozygosity [OR=2.65 (95 percent C.I. 1.2 to 6.0)] for FVL in probands are predictive of recurrent VTE. Heterozygosity for FVL predicts VTE in family members [OR=3.5 (95 percent C.I. 2.5 to 5.0)] as does homozygosity for FVL [OR=18 (95 percent C.I. 7.8 to 40)]. Heterozygosity for prothrombin G20210A is not predictive of recurrence in probands [OR=1.45 (95 percent C.I. 0.96-2.2)]. Evidence is insufficient about heterozygosity for prothrombin G20210A in family members and insufficient about homozygosity for prothrombin G20210A. A single study supported the hypothesis that clinicians might change management based on test results. There was high-grade evidence that anticoagulation reduces recurrent events in probands with FVL or prothrombin G20210A, however, there was low-grade evidence that the relative reduction with treatment is comparable to that seen in individuals without mutations. There was moderate evidence to support the conclusion that neither harms nor benefits of testing have been demonstrated conclusively. Decision-analysis models suggest that testing may be cost-effective in select individuals.There is no direct evidence that testing for these mutations leads to improved clinical outcomes in adults with a history of VTE or their adult family members. The literature supports the conclusion that while these assays have high analytic validity, the test results have variable clinical validity for predicting VTE in these populations and have only weak clinical utility.
The development and implementation of a postdischarge home-based, pharmacist-provided medication management service are described.A work group composed of pharmacy administrators, clinical specialists, physicians, and nursing leadership developed the structure and training requirements to implement the service. Eligible patients were identified during their hospital admission by acute care pharmacists and consented for study participation. Pharmacists and pharmacy residents visited the patient at home after discharge and conducted medication reconciliation, provided patient education, and completed a comprehensive medication review. Recommendations for medication optimization were communicated to the patient's primary care provider, and a reconciled medication list was faxed to the patient's community pharmacy. Demographic and medication-related data were collected to characterize patients receiving the home-based service. A total of 50 patients were seen by pharmacists in the home. Patient education provided by the home-based pharmacists included monitoring instructions, adherence reinforcement, therapeutic lifestyle changes, administration instructions, and medication disposal instructions. Pharmacists provided the following recommendations to providers to optimize medication regimens: adjust dosage, suggest laboratory tests, add medication, discontinue medication, need prescription for refills, and change product formulation. Pharmacists identified a median of two medication discrepancies per patient and made a median of two recommendations for medication optimization to patients' primary care providers.The implementation of a post-discharge, pharmacist-provided home-based medication management service enhanced the continuity of patient care during the transition from hospital to home. Pharmacists identified and resolved medication discrepancies, educated patients about their medications, and provided primary care providers and community pharmacies with a complete and reconciled medication list.
Abstract Significant variation in coding intensity among hospitals has been observed and can lead to reimbursement inequities and inadequate risk adjustment for quality measures. Reliable tools to quantify hospital coding intensity are needed. We hypothesized that coded sepsis rates among patients hospitalized with common infections may serve as a useful surrogate for coding intensity and derived a hospital‐level sepsis coding intensity measure using prevalence of “sepsis” primary diagnoses among patients hospitalized with urinary tract infection, cellulitis, and pneumonia. This novel measure was well correlated with the hospital mean number of discharge diagnoses, which has historically been used to quantify hospital‐level coding intensity. However, it has the advantage of inferring hospital coding intensity without the strong association with comorbidity that the mean number of discharge diagnoses has. Our measure may serve as a useful tool to compare coding intensity across institutions.
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