Low-Risk Births Don't Need Hospital

Healthy pregnant women should be able to choose where to give birth, say British researchers who compared the safety of home births with deliveries at clinics and hospitals.


The risks were higher for first-time mothers who gave birth at home, but the overall risk was low regardless of where the delivery happened, investigators said in this week’s issue of the British Medical Journal.


For the study, researchers reviewed data for nearly 65,000 mothers and babies between 2008 and 2010 in England. Of those, the births included:


19,706 in hospital obstetric wards.
16,840 at home.
11,282 in "freestanding" midwifery units — independent facilities where there are no doctors or access to anesthetics.
16,710 in "alongside" midwifery units, often housed within hospitals.
All of the pregnancies were low risk in terms of the health of the women whose babies were carried to full term.


Among the first-time moms with planned home births, there were 9.3 adverse events per 1,000 births, such as babies born with encephalopathy, a type of brain injury, due to labour problems and stillbirth. In comparison, there were 5.3 adverse events per 1,000 births for those planning a hospital birth.


For women who had given birth before, there were no major differences.


"These results will enable women and their partners to have informed discussions with health professionals in relation to clinical outcomes and planned place of birth," Prof. Peter Brocklehurst from the University of Oxford for the Birthplace in England and his co-authors said.


If the pregnancy and labour are not complicated, a high level of specific expertise isn't needed, Brocklehurst said.


More than 90 per cent of pregnant women in England give birth in a hospital, with midwives delivering more than 60 per cent of babies.


Birth isn't an abnormal process, it's a physiological process," he said. "And if your pregnancy and labor is not complicated, then you don't need a high level of specific expertise."
Brocklehurst added that about 50 percent of pregnant women in England — those who are low-risk — should be able to choose where to have their baby.
More than 90 percent of pregnant women in England now give birth in a hospital. Some officials say the new study should prompt women to consider alternatives.
"This is about giving women a choice," said Mary Newburn of NCT, a U.K. charity for parents, one of the study's authors. She said midwife-run birth centers in England have a more homelike environment, with privacy, sofas and birthing pools.
In Britain, midwives deliver more than 60 percent of babies already. Similar care is provided in the Netherlands, where about a quarter of all births happen at home. Elsewhere in Europe, most births are led by doctors, although midwives may also be involved.
In the United States, however, less than one percent of births happen at home. The American College of Obstetricians and Gynecologists does not support planned home births and warns evidence shows they have a higher risk of newborn death compared to planned hospital births.
The training of midwives in the U.S. varies by state — and some have no regulations.
Brocklehurst and colleagues collected data for nearly 65,000 mothers and babies between 2008 and 2010 in England. Of those, there were 19,706 births in hospital obstetric wards, 16,840 births at home, 11,282 births in "freestanding" midwifery units — independent clinics where there are no doctors or access to anesthetics — and 16,710 births in "alongside" midwifery units, often housed within hospitals.
All the pregnancies were low-risk, meaning the mothers were healthy and carried their baby to term. Women planning C-sections or expecting twins or multiple births were excluded from the study.
In the U.K.'s hospital obstetric wards, most low-risk women don't see a doctor during labor and are only treated by midwives.
There didn't appear to be a difference for the infants' health based on where the mothers planned to give birth.
But researchers found a higher risk for first-time mothers planning a home birth. Among those women, there were 9.3 adverse events per 1,000 births, including babies with brain damage due to labor problems and stillbirth. That compared to 5.3 adverse events per 1,000 births for those planning a hospital birth.
The study was published Friday in the medical journal, BMJ. It was paid for by Britain's department of health and another government health research body.
Dr. Tony Falconer, president of the Royal College of Obstetricians & Gynecologists, said his group supports "appropriately selected home birth." He noted the higher risk of problems among first-time mothers choosing a home birth and said that raised questions about where they should deliver.
For Emily Shaw of London, giving birth in a hospital wasn't appealing. She wanted home births for both her sons but because her first baby was induced into labor, she had to deliver him in a hospital in October 2008.
Shaw delivered her second son at home in April. "I felt much more comfortable there," she said. "Instead of getting into a car to go to the hospital, the midwives came to me."
"It was nice to have the home comforts during labor," she added, saying she could eat in her own kitchen and use her own bathroom. "And unlike the hospital, they didn't kick out my partner in the middle of the night.

Families report adverse events in hospitalized children not tracked

Perhaps no one is more worried than a parent with a sick child in the hospital.


But families are doing more than just venting their fears and frustrations when they complain about the care their child is receiving, a new Canadian study suggests.


It found relatives were much more likely to officially report problems than hospital staff, and that their com-plaints often had merit. Almost half of parents' complaints were legitimate patient-safety concerns, "not merely reports of dissatisfaction," the study found.


The study was published Monday in the Canadian Medical Association Journal.


British Columbia researchers tested whether having a system for family members to report "adverse events" - incidents that negatively affected the recovery or health of their child - while in hospital would affect the rate at which health care providers reported the incidents.


The findings revealed just 2.5 per cent of the adverse events reported by families were also reported by health care providers.


"Parents are often much more aware of things that go wrong because they're there at the bedside with one patient all the time," said Dr. Mark Anser-mino, senior author of the study.


"Whereas the health care provider has multiple patients to look after and may not have the same vested interested in looking after that patient. Parents are much better observers of that individual subject than multiple health care providers will be."


Many hospitals in Canada have established systems for health care providers to report errors in a patient's care to help prevent similar mistakes from happening again.


Researchers from British Columbia conducted a study to determine whether an adverse event system involving families would result in a change in events reporting by health care providers. The researchers expected that reporting rates would increase and that families would provide useful information on patient safety.


The study included 544 families whose children were on an inpatient ward that provided general medical, general surgical, neurologic or neurosurgical care in British Columbia's Children's Hospital to babies, children and adolescents. Each family submitted a report and of these 544 participants, 201 (37%) noted at least one adverse event or near miss during hospitalization, for a total of 321 adverse events. Adverse events included medication problems such as a reaction or incorrect dosage, treatment complications, equipment problems and miscommunication. Most of these events — 313 out of 321 — were not reported by the hospital.


However, "the results of this study showed that the introduction of a family-initiated adverse event reporting system administered at the time of discharge from a pediatric inpatient surgical ward was not associated with a change in the rate of reporting of adverse events by health care providers," writes Dr. Jeremy Daniels, University of British Columbia, with coauthors.


Only 2.5% of the events noted by families were documented by health care providers, although "almost half of the adverse events reported by families represented valid safety concerns, not merely reports of dissatisfaction," states the authors. In 139 cases, families received apologies for these incidents.


"The initiation of [the] family-based patient safety reporting system provided new opportunities to learn and improve the safety of health care provision without an additional reporting burden for health care providers," write the authors. "Giving families the opportunity to report patient safety events did not remove the barriers to reporting by providers (time pressure, culture of blame, fear of reprisal and lack of belief in the value of reporting) but served to complement such reporting."


The authors conclude that "further research is needed to delineate how best to harness the potential of families to improve the safety of the health care system."

Adverse Events in Elderly Mostly From Common Drugs

An estimated 100,000 older Americans are hospitalized for adverse drug reactions yearly, and most of those emergencies stem from four common medications, a new study finds.


The four types of medication — two for diabetes and two blood-thinning agents — account for two-thirds of those drug-related emergency hospitalizations.


“Of the thousands of medications available to older patients, a small group of blood thinners and diabetes medications caused a high proportion of emergency hospitalizations for adverse drug events among elderly Americans,” said lead study author Dr. Daniel Budnitz, director of the U.S. Centers for Disease Control and Prevention’s medication safety program.


Medications previously designated “high-risk” were implicated in only 1.2 percent of hospitalizations, the study found.


Working with a nationally representative database, CDC researchers identified more than 5,000 cases of drug-related adverse events that occurred among people aged 65 and older from 2007 to 2009 and used that to make their estimates for the whole population.


Nearly half (48 percent) of the hospitalizations occurred among adults 80 and up, according to the study, published in the Nov. 24 issue of the New England Journal of Medicine. Nearly two-thirds (66 percent) were the result of unintentional overdoses.


The four medications, used alone or together, most often cited:


The blood thinning medication warfarin (Coumadin, Jantoven), which is used to treat blood clots, was involved in 33 percent of emergency hospitalizations.


Insulin, used to control blood sugar in diabetes patients, was involved in 14 percent of cases.


Antiplatelet drugs such as aspirin and clopidogrel (Plavix), which are used to prevent blood clots, were involved in 13 percent of cases.


The medications most often implicated were warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents, which either alone or in combination accounted for 33%, 14%, 13%, and 11% of the hospitalizations, respectively, the investigators reported (N. Engl. J. Med. 2011;365:2002-12).


Emergency department visits resulting in hospitalization were more likely than those not resulting in hospitalization to involve unintentional overdoses (66% vs. 46%) and to involve at least five medications (55% vs. 40%).


The researchers noted that medications typically deemed high risk or inappropriate for elderly patients resulted in relatively few emergency hospitalizations, accounting for only about 1% and 7% of the 65-and-over emergency admissions, respectively.


The findings have important implications for reducing harm and health care costs among older adults, said Dr. Budnitz and his colleagues. Such detailed and drug-specific data can help focus current patient-safety efforts, such as the Partnership for Patients, they said. That $1 billion federal initiative has the goal of decreasing preventable hospitalizations 20% by the end of 2013.


The investigators used adverse-event data for 2007 through 2009 from the National Electronic Injury Surveillance System – Cooperative Adverse Drug Event Surveillance Project. They based their national estimates on an analysis of 5,077 emergency hospitalizations in older adults at 58 nonpediatric hospitals that participate in the surveillance system.


The numbers probably represent underestimates of emergency hospitalizations, the investigators said. They explained that some patient groups – such as those admitted for diagnostic evaluation or transferred from other hospitals – were not represented in the analysis.


"Our findings suggest that efforts to improve medication safety for older adults should focus on areas in which improvements are most likely to have sizable, clinically significant, and measurable effects, such as improving the management of antithrombotic and antidiabetic drugs," the investigators concluded.


In a press statement, Dr. Budnitz acknowledged that blood thinners and diabetes medications are critical medicines for many older adults. "Doctors and patients should continue to use them but remember to work together to safely manage them," he said.


Neither Dr. Budnitz nor any of the other investigators disclosed any conflict of interest.

Four common meds send thousands of seniors to hospital

Four Drugs Cause Most Hospitalizations in Older Adults
All these drugs are commonly prescribed to older adults, and they can be hard to use correctly. ... Some require blood testing to adjust their doses, and a small dose can have a powerful effect. Blood sugar can be notoriously hard to control in people with diabetes, for example, and taking a slightly larger dose of insulin than needed can send a person into shock.


The most significant finding of this study was [that] of the thousands of medicines available to older adults, it's really a small group ... that causes two-thirds of the hospitalizations," he tells WebMD.


The blood thinner warfarin, insulin, oral anti-platelets such as aspirin, and oral diabetes drugs led the list.


"Both blood thinners and diabetes medicines are critical drugs that can be lifesaving," Budnitz says. However, he says that ''these are medications that you do need to pay attention to," being sure the dose and timing are correct, among other measures.


High-risk medications, such as narcotics, only accounted for about 1% of the hospitalizations, the researchers found.


The study is published in The New England Journal of Medicine.


Tracking Bad Events From Drugs


The researchers used data collected between 2007 and 2009 from 58 hospitals around the country. The facilities participate in the CDC's drug event surveillance project.


The researchers looked at how often an adult 65 or older was hospitalized after emergency department visits for adverse drug events.


The researchers estimated that 265,802 visits to emergency departments for adverse drug events occurred from 2007 to 2009 for adults 65 or older.


Over a third of these visits, or nearly 100,000, required hospitalization. About half of the patients hospitalized were age 80 or older.


Unintentional overdose of medication was the most common reason, accounting for nearly two-thirds of hospitalizations.


When Budnitz's team looked at the medicines most likely to cause problems, they found:


33%, or 33,171 hospitalizations, involved warfarin, a blood thinner used to prevent clots.
14%, or 13,854 hospitalizations, involved insulin.
13%, or 13,263 hospitalizations, involved oral anti-platelet drugs, such as aspirin.
11%, or 10,656 hospitalizations, involved oral diabetes drugs.


These are often critical medicines for patients' health," he said. "Patients who are on these medicines should tell all their doctors what they are taking and work together with their doctors and pharmacist to make sure that they are taking these medicines correctly."
Among U.S. adults aged 65 and up, 40 percent take five to nine medications and 18 percent take 10 or more, according to the study authors. Prior research has also found that older adults are nearly seven times more likely than younger people to have an adverse drug event that requires hospitalization. "As most people age, there often are changes in how their kidneys, liver, heart, and other organs work that can make them more susceptible to adverse drug events," Budnitz said.
And though taking lots of pills raises safety issues, in 82 percent of cases the treating physician attributed the overdose to a single drug, Budnitz added.
To reduce risks, Steinman said doctors and patients need to discuss whether the drug is truly necessary. For people with very high blood pressure or blood sugar, "the answer is almost always 'yes,' you should treat it," Steinman said. "But if you have only mildly elevated blood pressure or blood sugar, the benefits of treating it versus the harms start to shift. Do these drugs really provide enough benefit that it's worth taking them?"