Evidence map›Paper›PMID 25882785›Full record

ArticleBMJ quality & safety2015

Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications.

Todd H Wagner, Thomas Taylor, Elizabeth Cowgill, Steven M Asch, Pon Su, Barbara Bokhour, Janet Durfee, Richard A Martinello, Elizabeth Maguire, A Rani Elwy

Abstract readMulticenter Study
PubMed Full text at PMC Publisher
In one paragraph

Article in BMJ quality & safety, 2015. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 4 papers.

0numbers the graph read from it
0cells of the map it votes in
4citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

4 citing papers in PubMed.

  1. Article
  2. Observational
  3. Article
  4. Article
4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

10 authors.

Todd H WagnerCenter for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA Department of Health Research and Policy, Stanford University, Stanford, California, USA.
Thomas TaylorDepartment of Health Research and Policy, Stanford University, Stanford, California, USA.
Elizabeth CowgillDepartment of Health Research and Policy, Stanford University, Stanford, California, USA.
Steven M AschDepartment of Health Research and Policy, Stanford University, Stanford, California, USA Division of General Internal Medicine, Stanford University, Stanford California, USA.
Pon SuDepartment of Health Research and Policy, Stanford University, Stanford, California, USA.
Barbara BokhourCenter for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.
Janet DurfeeVeterans Health Administration, Office of Public Health, Washington DC, USA.
Richard A MartinelloVeterans Health Administration, Office of Public Health, Washington DC, USA Yale School of Medicine, Departments of Internal Medicine and Pediatrics, New Haven, Conneticut, USA.
Elizabeth MaguireCenter for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA.
A Rani ElwyCenter for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.

Funding

HSRD VA I01 HX000866
6 · The paper itself

Abstract

BACKGROUND AND

objectiveHow patients respond to being notified of a large-scale adverse event (LSAE), such as improper sterilisation of medical equipment that exposes them to bloodborne pathogens, is not well known. The objective of this study was to determine, using administrative data, the intended and unintended consequences of patient notification following a LSAE.

methodsWe examined five LSAEs where patients may have been inadvertently exposed to hepatitis C virus (HCV), HIV, and hepatitis B virus (HBV). A total of 9638 cases were identified at five Department of Veteran Affairs (VA) medical facilities between 2009 and 2012. We identified controls at the same facility prior to the exposure period and at neighbouring facilities (n=45,274). Difference-in-differences models were used with Veterans Health Administration (VHA) and Medicare data to examine infectious disease testing rates and subsequent utilisation patterns.

resultsReceipt of a LSAE notification was associated with a 73.2, 76.8 and 77.1 adjusted percentage point increase for HCV, HIV and HBV testing, respectively (all p<0.001). Compared with white patients, African-American patients were significantly less likely to return to VHA for follow-up testing. Patients exposed to a dental LSAE reduced their use of preventive and restorative dental care over the subsequent year, but they eventually came back to VHA for dental services 18-months post exposure.

conclusionsThe majority of patients notified of a LSAE responded by getting tested for HCV, HIV and HBV, although there remains room for improvement. Potential exposure to a LSAE was associated with increased odds of subsequently using non-VA facilities, but the size and timing of the shift depended on the type of care.

Indexed as

AdultAgedBlack or African AmericanContact TracingDisclosureFemaleHepatitis BHepatitis CHIV InfectionsHumansMaleMiddle AgedUnited StatesUnited States Department of Veterans AffairsVirus DiseasesWhite PeopleCommunicationDecision makingHealthcare quality improvementHealth services researchPatient safety

Identifiers

PMID25882785
PMCPMC4413746

What OpenQuestion holds

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.