In This Issue of Archives of Internal Medicine FREE

Collecting data on medical errors is essential for improving patient safety, but factors affecting error reporting by physicians are poorly understood. Kaldjian et al surveyed 338 faculty and resident physicians in different regions of the United States and found that most respondents would likely report a hypothetical error resulting in minor (73%) or major (92%) harm to a patient. However, few of these physicians had ever reported an actual minor (18%) or major (4%) error, and only 55% knew how to report errors. Physicians were more likely to report hypothetical errors if they believed reporting improves the quality of care, knew how to report errors, believed in forgiveness, or were faculty physicians (compared with residents).

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While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood. Leslie et al used data from Medicare administrative files, hospital billing records, and the Connecticut Long-term Care Registry to compute 1-year health care costs for a cohort of 841 hospitalized older persons, 107 (13%) of whom developed delirium. Patients with delirium had significantly higher health care costs and survived fewer days than patients without delirium. Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion per year.

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In a retrospective cohort study of 39 031 Veterans Healthcare Administration clinic users with diabetes and stage 3 or 4 chronic kidney disease during 1997 to 2000, consistency of outpatient nephrologic care was found to be independently associated in a graded fashion with lower dialysis-free mortality. Degree of consistency of visits to a nephrologist was defined as the number of calendar quarters (3 months) in which at least 1 visit occurred during a 12-month baseline period, ranging from 0 to 4. Adjusted hazard ratios (95% confidence intervals) were 0.80 (0.67-0.97), 0.68 (0.55-0.86), and 0.45 (0.32-0.63), when the groups of 2, 3, and 4 visits, respectively, were compared with those who had no visits. One visit only was not associated with a mortality difference when compared with no visits (adjusted hazard ratio, 1.02; 95% confidence interval, 0.89-1.16). Only a minority of patients visited a nephrologist in the baseline year: 3.1%, 9.5%, and 28.2% of patients in early stage 3, late stage 3, and stage 4 chronic kidney disease, respectively, visited a nephrologist.

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Meier et al prospectively examined the association between serum levels of testosterone and estradiol on the one side and fracture risk on the other side in 609 community-dwelling men 60 years or older, whose bone health had been assessed between 1989 and 2005. After adjustment for sex hormone–binding globulin and risk factors such as age, bone mineral density, and lifestyle factors, reduced serum testosterone levels were significantly associated with the risk of fracture (hazard ratio, 1.3). In contrast, serum estradiol levels were unrelated to fracture risk (hazard ratio, 1.2). The authors suggest that testosterone affects fracture risk in men via both skeletal and nonskeletal mechanisms and that measurement of serum testosterone provides additional clinical information for the assessment of fracture risk in elderly men.

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Vitamin D supplementation plays a role in the prevention of falling, but the effect in patients living in the community in sunny climates remains uncertain. In women aged 70 to 90 years living in Perth, Australia, at latitude 32°S, equivalent to San Diego, California, with a history of falling in the previous year and vitamin D insufficiency, Prince et al evaluated the effect of 1000-IU/d ergocalciferol and 1000-mg/d calcium citrate compared with calcium alone on the risks of falling. After 1 year, 53% of the patients in the ergocalciferol group had fallen, whereas in the calcium group, 63% had fallen. The biggest effect of ergocalciferol use on preventing falling was in the winter.

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