Diana Mahoney

ORLANDO, FLA. — Continuity of care is not a protective factor—and may be a significant predictive factor—for medical errors, despite being linked to many positive outcomes in health care delivery, Eric Wong, M.D., said at the annual meeting of the North American Primary Care Research Group.

In an effort to assess the connection between continuity of care and occurrences of medical errors in family practice, Dr. Wong and colleagues at the University of Western Ontario undertook a cross-sectional chart review using a stratified randomized sample of eligible electronic medical records from patients at an academic family medical center in southwestern Ontario.

The study enrolled 202 patients aged 18 years or older who had visited the family medical center two or more times between July 2002 and June 2003, excluding pregnant patients and residents of a nearby drug rehabilitation center.

The investigators identified 37 “preventable” medical errors that occurred in 1,376 visits, and classified the errors as being related to diagnosis, investigation, or treatment.

The diagnostic errors included misdiagnoses and delayed diagnoses. The investigation errors included incorrect or omitted tests.

And the treatment errors included incorrect drug and nondrug treatment based on the indication, incorrect drug dosage, delayed drug and nondrug treatment, and omitted drug and nondrug treatment. Seven of the errors (in five patients) resulted in nonfatal but physically or emotionally harmful consequences, according to Dr. Wong.

Three multivariate analyses—each using a different continuity of care index, with continuity of care defined as frequency of provider/patient interaction—showed a positive correlation between medical errors and continuity of care, and no correlation between disease complexity or severity and the occurrence of medical errors. All three analyses also showed alcohol abuse to be a significant independent risk factor for medical errors, Dr. Wong noted.

“The results did not support our hypothesis that good continuity of care on its own decreases the risk of medical errors,” he said.

“It's possible that our assumptions about continuity of care—particularly the idea that seeing patients more often will lead to a better relationship and better care—are wrong,” Dr. Wong added.

There are a number of possible explanations for the possible link between increased contact with the same provider and the increased risk of medical error, Dr. Wong explained.

“It might be that what we define as continuity of care is really a proxy measure for problem patient/doctor relationships, or that some of the patients are being seen so much because they have multiple, difficult complaints, which could increase the likelihood of error,” he said.

Additionally, physicians may be more likely to book frequent return visits for patients whose symptoms are vague, not as a way to optimize care but as a way to “keep the patient happy” without really having a solid care plan, Dr. Wong said.

Another possibility is that familiarity breeds complacency. When physicians see the same patient frequently, they are likely to engage in more social conversation than they would with a new patient or a patient who hasn't been seen recently, with less attention paid to the medical problems or routine care.

“Nearly 57% of the noted errors involved the omission of necessary investigations. This could be a function of the clinician just not paying close enough attention to what has and has not been done recently, or simply assuming that the necessary tests must have been taken care of at the previous visits,” he said.

Finally, the findings could be indicative of an overall system failure, in which the sometimes stilted nature of patient/physician communication precludes an easy assessment of a problem.

“The occurrence of medical errors and higher levels of continuity may represent parallel effects of the interaction of patient, physician, and system factors,” Dr. Wong said. As a result, “some patients may be seen a lot, without really being seen at all.”

With respect to the alcohol abuse finding, “the diagnosis of alcohol abuse could also be a proxy measure of a problem with the doctor/patient relationship, thus leading to less attentive care and an increase in medical errors,” Dr. Wong hypothesized. “Or it may be that these patients are more difficult to diagnose and treat, or that physicians' attitudes toward them [are] negative.”

Although the study findings are provocative, they are limited by a number of factors, Dr. Wong stressed, including the small number of errors overall, the chart review and audit process, and the classification system.

Additionally, “the provider continuity indices might not capture some aspects of continuous care that could decrease risk of error,” he said.

Despite the study limitations, Dr. Wong said, “the findings do suggest that clinicians should pay closer attention to patients they see frequently and to those with a diagnosis of alcohol abuse, to avoid preventable medical errors.”

ORLANDO, FLA. — Continuity of care is not a protective factor—and may be a significant predictive factor—for medical errors, despite being linked to many positive outcomes in health care delivery, Eric Wong, M.D., said at the annual meeting of the North American Primary Care Research Group.

In an effort to assess the connection between continuity of care and occurrences of medical errors in family practice, Dr. Wong and colleagues at the University of Western Ontario undertook a cross-sectional chart review using a stratified randomized sample of eligible electronic medical records from patients at an academic family medical center in southwestern Ontario.

The study enrolled 202 patients aged 18 years or older who had visited the family medical center two or more times between July 2002 and June 2003, excluding pregnant patients and residents of a nearby drug rehabilitation center.

The investigators identified 37 “preventable” medical errors that occurred in 1,376 visits, and classified the errors as being related to diagnosis, investigation, or treatment.

The diagnostic errors included misdiagnoses and delayed diagnoses. The investigation errors included incorrect or omitted tests.

And the treatment errors included incorrect drug and nondrug treatment based on the indication, incorrect drug dosage, delayed drug and nondrug treatment, and omitted drug and nondrug treatment. Seven of the errors (in five patients) resulted in nonfatal but physically or emotionally harmful consequences, according to Dr. Wong.

Three multivariate analyses—each using a different continuity of care index, with continuity of care defined as frequency of provider/patient interaction—showed a positive correlation between medical errors and continuity of care, and no correlation between disease complexity or severity and the occurrence of medical errors. All three analyses also showed alcohol abuse to be a significant independent risk factor for medical errors, Dr. Wong noted.

“The results did not support our hypothesis that good continuity of care on its own decreases the risk of medical errors,” he said.

“It's possible that our assumptions about continuity of care—particularly the idea that seeing patients more often will lead to a better relationship and better care—are wrong,” Dr. Wong added.

There are a number of possible explanations for the possible link between increased contact with the same provider and the increased risk of medical error, Dr. Wong explained.

“It might be that what we define as continuity of care is really a proxy measure for problem patient/doctor relationships, or that some of the patients are being seen so much because they have multiple, difficult complaints, which could increase the likelihood of error,” he said.

Additionally, physicians may be more likely to book frequent return visits for patients whose symptoms are vague, not as a way to optimize care but as a way to “keep the patient happy” without really having a solid care plan, Dr. Wong said.

Another possibility is that familiarity breeds complacency. When physicians see the same patient frequently, they are likely to engage in more social conversation than they would with a new patient or a patient who hasn't been seen recently, with less attention paid to the medical problems or routine care.

“Nearly 57% of the noted errors involved the omission of necessary investigations. This could be a function of the clinician just not paying close enough attention to what has and has not been done recently, or simply assuming that the necessary tests must have been taken care of at the previous visits,” he said.

Finally, the findings could be indicative of an overall system failure, in which the sometimes stilted nature of patient/physician communication precludes an easy assessment of a problem.

“The occurrence of medical errors and higher levels of continuity may represent parallel effects of the interaction of patient, physician, and system factors,” Dr. Wong said. As a result, “some patients may be seen a lot, without really being seen at all.”

With respect to the alcohol abuse finding, “the diagnosis of alcohol abuse could also be a proxy measure of a problem with the doctor/patient relationship, thus leading to less attentive care and an increase in medical errors,” Dr. Wong hypothesized. “Or it may be that these patients are more difficult to diagnose and treat, or that physicians' attitudes toward them [are] negative.”

Although the study findings are provocative, they are limited by a number of factors, Dr. Wong stressed, including the small number of errors overall, the chart review and audit process, and the classification system.

Additionally, “the provider continuity indices might not capture some aspects of continuous care that could decrease risk of error,” he said.

Despite the study limitations, Dr. Wong said, “the findings do suggest that clinicians should pay closer attention to patients they see frequently and to those with a diagnosis of alcohol abuse, to avoid preventable medical errors.”

ORLANDO, FLA. — Continuity of care is not a protective factor—and may be a significant predictive factor—for medical errors, despite being linked to many positive outcomes in health care delivery, Eric Wong, M.D., said at the annual meeting of the North American Primary Care Research Group.

In an effort to assess the connection between continuity of care and occurrences of medical errors in family practice, Dr. Wong and colleagues at the University of Western Ontario undertook a cross-sectional chart review using a stratified randomized sample of eligible electronic medical records from patients at an academic family medical center in southwestern Ontario.

The study enrolled 202 patients aged 18 years or older who had visited the family medical center two or more times between July 2002 and June 2003, excluding pregnant patients and residents of a nearby drug rehabilitation center.

The investigators identified 37 “preventable” medical errors that occurred in 1,376 visits, and classified the errors as being related to diagnosis, investigation, or treatment.

The diagnostic errors included misdiagnoses and delayed diagnoses. The investigation errors included incorrect or omitted tests.

And the treatment errors included incorrect drug and nondrug treatment based on the indication, incorrect drug dosage, delayed drug and nondrug treatment, and omitted drug and nondrug treatment. Seven of the errors (in five patients) resulted in nonfatal but physically or emotionally harmful consequences, according to Dr. Wong.

Three multivariate analyses—each using a different continuity of care index, with continuity of care defined as frequency of provider/patient interaction—showed a positive correlation between medical errors and continuity of care, and no correlation between disease complexity or severity and the occurrence of medical errors. All three analyses also showed alcohol abuse to be a significant independent risk factor for medical errors, Dr. Wong noted.

“The results did not support our hypothesis that good continuity of care on its own decreases the risk of medical errors,” he said.

“It's possible that our assumptions about continuity of care—particularly the idea that seeing patients more often will lead to a better relationship and better care—are wrong,” Dr. Wong added.

There are a number of possible explanations for the possible link between increased contact with the same provider and the increased risk of medical error, Dr. Wong explained.

“It might be that what we define as continuity of care is really a proxy measure for problem patient/doctor relationships, or that some of the patients are being seen so much because they have multiple, difficult complaints, which could increase the likelihood of error,” he said.

Additionally, physicians may be more likely to book frequent return visits for patients whose symptoms are vague, not as a way to optimize care but as a way to “keep the patient happy” without really having a solid care plan, Dr. Wong said.

Another possibility is that familiarity breeds complacency. When physicians see the same patient frequently, they are likely to engage in more social conversation than they would with a new patient or a patient who hasn't been seen recently, with less attention paid to the medical problems or routine care.

“Nearly 57% of the noted errors involved the omission of necessary investigations. This could be a function of the clinician just not paying close enough attention to what has and has not been done recently, or simply assuming that the necessary tests must have been taken care of at the previous visits,” he said.

Finally, the findings could be indicative of an overall system failure, in which the sometimes stilted nature of patient/physician communication precludes an easy assessment of a problem.

“The occurrence of medical errors and higher levels of continuity may represent parallel effects of the interaction of patient, physician, and system factors,” Dr. Wong said. As a result, “some patients may be seen a lot, without really being seen at all.”

With respect to the alcohol abuse finding, “the diagnosis of alcohol abuse could also be a proxy measure of a problem with the doctor/patient relationship, thus leading to less attentive care and an increase in medical errors,” Dr. Wong hypothesized. “Or it may be that these patients are more difficult to diagnose and treat, or that physicians' attitudes toward them [are] negative.”

Although the study findings are provocative, they are limited by a number of factors, Dr. Wong stressed, including the small number of errors overall, the chart review and audit process, and the classification system.

Additionally, “the provider continuity indices might not capture some aspects of continuous care that could decrease risk of error,” he said.

Despite the study limitations, Dr. Wong said, “the findings do suggest that clinicians should pay closer attention to patients they see frequently and to those with a diagnosis of alcohol abuse, to avoid preventable medical errors.”

ORLANDO, FLA. — Low dietary magnesium may elevate serum levels of C-reactive protein, but high vitamin E intake does not reduce levels of the inflammatory marker among at-risk individuals, according to two separate studies.

Both studies were conducted by researchers at the Medical University of South Carolina in Charleston and were presented at the annual meeting of the North American Primary Care Research Group.

Recent clinical studies have uncovered structural changes in C-reactive protein (CRP) linked to dietary magnesium intake, said Dana King, M.D. To assess the validity of that association, she and her colleagues at the university studied 5,021 adults in the National Health and Nutrition Examination Survey (NHANES) database.

The current recommended dietary allowance (RDA) for magnesium is 400 mg/day. Of the study population, 75% consumed less than 309 mg of magnesium per day—the lower end of adequate, Dr. King said. Regression analysis showed these adults to be 55% more likely to have elevated CRP levels, compared with those adults who met the RDA for magnesium.

After the investigators controlled for the various factors associated with low magnesium intake in this population, including older age, female gender, nonwhite race, nondrinker status, and reduced exercise, low magnesium intake was still a significant predictor of elevated CRP.

The subgroups at highest risk for elevated CRP linked to low magnesium included adults over age 40, those with a body mass index over 25 kg/m2, and those who consumed less than 50% of the RDA for magnesium. “The inverse association was clearly linear. The lower the magnesium intake, the greater the risk for elevated CRP,” Dr. King noted.

The findings are important given that most Americans consume magnesium at levels well below the RDA, and because CRP is a marker of risk for ischemic heart disease—the leading cause of death in developed countries, said Dr. King. “It is possible that increasing dietary magnesium to adequate levels can reduce heart disease risk substantially,” she added.

Because of the limitations of the cross-sectional study design, “the relationship between magnesium and CRP should be further evaluated in prospective studies,” Dr. King concluded.

The second study investigated the possible link between vitamin E intake and CRP concentrations. Because individuals with a combination of high ferritin and high LDL cholesterol levels tend to have elevated CRP levels due to increased oxidative stress, investigators at the Medical University of South Carolina hypothesized that higher intakes of vitamin E, because of its antioxidant properties, might help mitigate the CRP elevation in these people.

Using data from the 1999-2000 NHANES database, Brian Wells, M.D., now of the Cleveland Clinic, and colleagues, stratified a random cluster sampling of 4,204 adults aged 25 years and older by daily vitamin E intake. The researchers used logistic regression to determine predicted levels of CRP and divided the study population into quartiles by daily vitamin E intake.

As expected, those at-risk individuals with elevated levels of both ferritin and LDL cholesterol had significantly higher levels of CRP than did those individuals with normal iron and cholesterol measures. Within both the at-risk group and the general population, vitamin E intakes equal to or greater than the high end of intakes seen in the general population—about 50 IU—were not significantly associated with CRP levels, said Dr. Wells.

“Having high iron and LDL means having a lot of cholesterol available to be oxidized. Our hypothesis was that if oxidized LDL causes an inflammatory response leading to increased CRP, the antioxidant might mitigate that response,” he said. “What we saw was that vitamin E intake at the high end of normal levels in the diet was not linked with a reduction in CRP.”

It is possible that much higher levels of vitamin E, “or another antioxidant entirely,” could have an effect on CRP, said Dr. Wells, and these possibilities should be the focus of future research.

ORLANDO, FLA. — Low dietary magnesium may elevate serum levels of C-reactive protein, but high vitamin E intake does not reduce levels of the inflammatory marker among at-risk individuals, according to two separate studies.

Both studies were conducted by researchers at the Medical University of South Carolina in Charleston and were presented at the annual meeting of the North American Primary Care Research Group.

Recent clinical studies have uncovered structural changes in C-reactive protein (CRP) linked to dietary magnesium intake, said Dana King, M.D. To assess the validity of that association, she and her colleagues at the university studied 5,021 adults in the National Health and Nutrition Examination Survey (NHANES) database.

The current recommended dietary allowance (RDA) for magnesium is 400 mg/day. Of the study population, 75% consumed less than 309 mg of magnesium per day—the lower end of adequate, Dr. King said. Regression analysis showed these adults to be 55% more likely to have elevated CRP levels, compared with those adults who met the RDA for magnesium.

After the investigators controlled for the various factors associated with low magnesium intake in this population, including older age, female gender, nonwhite race, nondrinker status, and reduced exercise, low magnesium intake was still a significant predictor of elevated CRP.

The subgroups at highest risk for elevated CRP linked to low magnesium included adults over age 40, those with a body mass index over 25 kg/m2, and those who consumed less than 50% of the RDA for magnesium. “The inverse association was clearly linear. The lower the magnesium intake, the greater the risk for elevated CRP,” Dr. King noted.

The findings are important given that most Americans consume magnesium at levels well below the RDA, and because CRP is a marker of risk for ischemic heart disease—the leading cause of death in developed countries, said Dr. King. “It is possible that increasing dietary magnesium to adequate levels can reduce heart disease risk substantially,” she added.

Because of the limitations of the cross-sectional study design, “the relationship between magnesium and CRP should be further evaluated in prospective studies,” Dr. King concluded.

The second study investigated the possible link between vitamin E intake and CRP concentrations. Because individuals with a combination of high ferritin and high LDL cholesterol levels tend to have elevated CRP levels due to increased oxidative stress, investigators at the Medical University of South Carolina hypothesized that higher intakes of vitamin E, because of its antioxidant properties, might help mitigate the CRP elevation in these people.

Using data from the 1999-2000 NHANES database, Brian Wells, M.D., now of the Cleveland Clinic, and colleagues, stratified a random cluster sampling of 4,204 adults aged 25 years and older by daily vitamin E intake. The researchers used logistic regression to determine predicted levels of CRP and divided the study population into quartiles by daily vitamin E intake.

As expected, those at-risk individuals with elevated levels of both ferritin and LDL cholesterol had significantly higher levels of CRP than did those individuals with normal iron and cholesterol measures. Within both the at-risk group and the general population, vitamin E intakes equal to or greater than the high end of intakes seen in the general population—about 50 IU—were not significantly associated with CRP levels, said Dr. Wells.

“Having high iron and LDL means having a lot of cholesterol available to be oxidized. Our hypothesis was that if oxidized LDL causes an inflammatory response leading to increased CRP, the antioxidant might mitigate that response,” he said. “What we saw was that vitamin E intake at the high end of normal levels in the diet was not linked with a reduction in CRP.”

It is possible that much higher levels of vitamin E, “or another antioxidant entirely,” could have an effect on CRP, said Dr. Wells, and these possibilities should be the focus of future research.

ORLANDO, FLA. — Low dietary magnesium may elevate serum levels of C-reactive protein, but high vitamin E intake does not reduce levels of the inflammatory marker among at-risk individuals, according to two separate studies.

Both studies were conducted by researchers at the Medical University of South Carolina in Charleston and were presented at the annual meeting of the North American Primary Care Research Group.

Recent clinical studies have uncovered structural changes in C-reactive protein (CRP) linked to dietary magnesium intake, said Dana King, M.D. To assess the validity of that association, she and her colleagues at the university studied 5,021 adults in the National Health and Nutrition Examination Survey (NHANES) database.

The current recommended dietary allowance (RDA) for magnesium is 400 mg/day. Of the study population, 75% consumed less than 309 mg of magnesium per day—the lower end of adequate, Dr. King said. Regression analysis showed these adults to be 55% more likely to have elevated CRP levels, compared with those adults who met the RDA for magnesium.

After the investigators controlled for the various factors associated with low magnesium intake in this population, including older age, female gender, nonwhite race, nondrinker status, and reduced exercise, low magnesium intake was still a significant predictor of elevated CRP.

The subgroups at highest risk for elevated CRP linked to low magnesium included adults over age 40, those with a body mass index over 25 kg/m2, and those who consumed less than 50% of the RDA for magnesium. “The inverse association was clearly linear. The lower the magnesium intake, the greater the risk for elevated CRP,” Dr. King noted.

The findings are important given that most Americans consume magnesium at levels well below the RDA, and because CRP is a marker of risk for ischemic heart disease—the leading cause of death in developed countries, said Dr. King. “It is possible that increasing dietary magnesium to adequate levels can reduce heart disease risk substantially,” she added.

Because of the limitations of the cross-sectional study design, “the relationship between magnesium and CRP should be further evaluated in prospective studies,” Dr. King concluded.

The second study investigated the possible link between vitamin E intake and CRP concentrations. Because individuals with a combination of high ferritin and high LDL cholesterol levels tend to have elevated CRP levels due to increased oxidative stress, investigators at the Medical University of South Carolina hypothesized that higher intakes of vitamin E, because of its antioxidant properties, might help mitigate the CRP elevation in these people.

Using data from the 1999-2000 NHANES database, Brian Wells, M.D., now of the Cleveland Clinic, and colleagues, stratified a random cluster sampling of 4,204 adults aged 25 years and older by daily vitamin E intake. The researchers used logistic regression to determine predicted levels of CRP and divided the study population into quartiles by daily vitamin E intake.

As expected, those at-risk individuals with elevated levels of both ferritin and LDL cholesterol had significantly higher levels of CRP than did those individuals with normal iron and cholesterol measures. Within both the at-risk group and the general population, vitamin E intakes equal to or greater than the high end of intakes seen in the general population—about 50 IU—were not significantly associated with CRP levels, said Dr. Wells.

“Having high iron and LDL means having a lot of cholesterol available to be oxidized. Our hypothesis was that if oxidized LDL causes an inflammatory response leading to increased CRP, the antioxidant might mitigate that response,” he said. “What we saw was that vitamin E intake at the high end of normal levels in the diet was not linked with a reduction in CRP.”

It is possible that much higher levels of vitamin E, “or another antioxidant entirely,” could have an effect on CRP, said Dr. Wells, and these possibilities should be the focus of future research.