GABA-A receptor activity in the noradrenergic locus coeruleus drives trigeminal neuropathic pain in the rat; contribution of NAα1 receptors in the medial prefrontal cortex

Trigeminal neuropathic pain is described as constant excruciating facial pain. The study goal was to investigate the role of nucleus locus coeruleus (LC) in a model of chronic orofacial neuropathic pain (CCI-ION). The study examines LC's relationship to both the medullary dorsal horn receiving trigeminal nerve sensory innervation and the medial prefrontal cortex (mPFC). LC is a major source of CNS noradrenaline (NA) and a primary nucleus involved in pain modulation. Although descending inhibition of acute pain by LC is well established, contribution of the LC to facilitation of chronic neuropathic pain is also reported. In the present study, a rat orofacial pain model of trigeminal neuropathy was induced by chronic constrictive injury of the infraorbital nerve (CCI-ION). Orofacial neuropathic pain was indicated by development of whisker pad mechanical hypersensitivity. Hypersensitivity was alleviated by selective elimination of NA neurons, including LC (A6 cell group), with the neurotoxin anti-dopamine-β-hydroxylase saporin (anti-DβH-saporin) microinjected either intracerebroventricularly (i.c.v.) or into trigeminal spinal nucleus caudalis (spVc). The GABA_A receptor antagonist, bicuculline, administered directly into LC (week 8) inhibited hypersensitivity. This indicates a valence shift in which increased GABA_A signaling ongoing in LC after trigeminal nerve injury paradoxically produces excitatory facilitation of the chronic pain state. Microinjection of NAα1 receptor antagonist, benoxathian, into mPFC attenuated whisker pad hypersensitivity, while NAα2 receptor antagonist, idazoxan, was ineffective. Thus, GABA_A-mediated activation of NA neurons during CCI-ION can facilitate hypersensitivity through NAα1 receptors in the mPFC. These data indicate LC is a chronic pain generator.

Regeneration complexities of Pinus gerardiana in dry temperate forests of Indian Himalaya

Pinus gerardiana is considered an important species in dry temperate forests of North-Western Indian Himalaya because of its influence on ecological processes and economic dependence of local people in the region. But, large numbers of biotic and abiotic factors have affected P. gerardiana in these forests; hence, there is a crucial need to understand the regeneration dynamics of this tree species. The present investigation was conducted in P. gerardiana forests to understand vegetation pattern and regeneration processes on different sites in the region. Statistical analysis was performed to know variability in growing stock and regeneration on sample plots, while correlation coefficients and regression models were developed to find the relationship between regeneration and site factors. The vegetation study showed dominance of P. gerardiana, which is followed by Cedrus deodara, Pinus wallichiana and Quercus ilex in the region. The growing stock of P. gerardiana showed steep increasing and then steadily declining trend from lower to higher diameter class. The distribution of seedling, sapling, pole and trees was not uniform at different sites and less number of plots in each site were observed to have effective conditions for continuous regeneration, but mostly showed extremely limited regeneration. Regeneration success ranging from 8.44 to 15.93 % was recorded in different sites of the region, which suggests that in different sites regeneration success is influenced by collection of cone for extracting seed, grazing/browsing and physico-chemical properties of soil. Regeneration success showed significant correlation and relationship with most of abiotic and biotic factors. The regeneration success is lower than the requirement of sustainable forest, but varies widely among sites in dry temperate forests of Himalaya. More forest surveys are required to understand the conditions necessary for greater success of P. gerardiana in the region.

Maintenance pemetrexed in nonsmall cell lung carcinoma: Outcome analysis from a tertiary care center

Background:

Maintenance pemetrexed is a standard treatment option for selected non squamous nonsmall cell lung carcinoma patients having a response to platin based doublet. We conducted a clinical audit of such selected patients and report the outcome among the Indian population.

Aim:

To evaluate the outcomes with maintenance pemetrexed in the patients with locally advanced and metastatic adenocarcinoma lung.

Objectives:

To calculate the progression free survival (PFS), overall survival (OS), and factors affecting the outcome.

Materials and Methods:

Data of patients with locally advanced and metastatic adenocarcinoma lung were retrieved from prospectively maintained lung cancer database registered between June 2011 and March 2014. The patients who achieved partial response (n = 87) or stable disease (n = 101) after 6 cycles of pemetrexed platin based doublet and received the maintenance pemetrexed were selected for final analysis (n = 188). Kaplan–Meir survival analysis was used for PFS and OS. Log rank test was used to evaluate the factors affecting the outcome.

Results:

Median follow-up is 14 months. The median number of maintenance pemetrexed cycles received is 6 (1–38). Common reason for the discontinuation are disease progression (n = 127), renal toxicity (n = 4), and social/financial (n = 7). Median PFS and OS are 8 months and 20 months, respectively. The patients with baseline pleural effusion had better PFS (9 months vs. 7 months, P = 0.02) and OS (26 months vs. 18 months, P = 0.05). The patients receiving more than 6 cycles of maintenance had improved PFS (12 vs. 7 months, P = 0.002) and OS (26 vs. 16 months, P = 0.05).

Conclusion:

Maintenance pemetrexed is feasible and well tolerated by the majority of Indian patients who achieved the response after platin based doublet. The patients with baseline pleural effusion benefit more with maintenance pemetrexed.

Association between electronic health records and health care utilization

BACKGROUND

The federal government is investing approximately $20 billion in electronic health records (EHRs), in part to address escalating health care costs. However, empirical evidence that provider use of EHRs decreases health care costs is limited.

OBJECTIVE

To determine any association between EHRs and health care utilization.

METHODS

We conducted a cohort study (2008-2009) in the Hudson Valley, a multi-payer, multiprovider community in New York State. We included 328 primary care physicians in predominantly small practices (median practice size four primary care physicians), who were caring for 223,772 patients. Data from an independent practice association was used to determine adoption of EHRs. Claims data aggregated across five commercial health plans was used to characterize seven types of health care utilization: primary care visits, specialist visits, radiology tests, laboratory tests, emergency department visits, hospital admissions, and readmissions. We used negative binomial regression to determine associations between EHR adoption and each utilization outcome, adjusting for ten physician characteristics.

RESULTS

Approximately half (48%) of the physicians were using paper records and half (52%) were using EHRs. For every 100 patients seen by physicians using EHRs, there were 14 fewer specialist visits (adjusted p < 0.01) and 9 fewer radiology tests (adjusted p = 0.01). There were no significant differences in rates of primary care visits, laboratory tests, emergency department visits, hospitalizations or readmissions.

CONCLUSIONS

Patients of primary care providers who used EHRs were less likely to have specialist visits and radiology tests than patients of primary care providers who did not use EHRs.

How could health information exchange better meet the needs of care practitioners?

BACKGROUND

Health information exchange (HIE) has the potential to improve the quality of healthcare by enabling providers with better access to patient information from multiple sources at the point of care. However, HIE efforts have historically been difficult to establish in the US and the failure rates of organizations created to foster HIE have been high.

OBJECTIVES

We sought to better understand how RHIO-based HIE systems were used in practice and the challenges care practitioners face using them. The objective of our study were to so investigate how HIE can better meet the needs of care practitioners.

METHODS

We performed a multiple-case study using qualitative methods in three communities in New York State. We conducted interviews onsite and by telephone with HIE users and non-users and observed the workflows of healthcare professionals at multiple healthcare organizations participating in a local HIE effort in New York State.

RESULTS

The empirical data analysis suggests that challenges still remain in increasing provider usage, optimizing HIE implementations and connecting HIE systems across geographic regions. Important determinants of system usage and perceived value includes users experienced level of available information and the fit of use for physician workflows.

CONCLUSIONS

Challenges still remain in increasing provider adoption, optimizing HIE implementations, and demonstrating value. The inability to find information reduced usage of HIE. Healthcare organizations, HIE facilitating organizations, and states can help support HIE adoption by ensuring patient information is accessible to providers through increasing patient consents, fostering broader participation, and by ensuring systems are usable.

A case report in health information exchange for inter-organizational patient transfers

OBJECTIVE

To provide a case report of barriers and promoters to implementing a health information exchange (HIE) tool that supports patient transfers between hospitals and skilled nursing facilities.

METHODS

A multi-disciplinary team conducted semi-structured telephone and in-person interviews in a purposive sample of HIE organizational informants and providers in New York City who implemented HIE to share patient transfer information. The researchers conducted grounded theory analysis to identify themes of barriers and promoters and took steps to improve the trustworthiness of the results including vetting from a knowledgeable study participant.

RESULTS

Between May and October 2011, researchers recruited 18 participants: informaticians, healthcare administrators, software engineers, and providers from a skilled nursing facility. Subjects perceived the HIE tool's development a success in that it brought together stakeholders who had traditionally not partnered for informatics work, and that they could successfully share patient transfer information between a hospital and a skilled nursing facility. Perceived barriers included lack of hospital stakeholder buy-in and misalignment with clinical workflows that inhibited use of HIE-based patient transfer data. Participants described barriers and promoters in themes related to organizational, technical, and user-oriented issues. The investigation revealed that stakeholders could develop and implement health information technology that technically enables clinicians in both hospitals and skilled nursing facilities to exchange real-time information in support of patient transfers. User level barriers, particularly in the emergency department, should give pause to developers and implementers who plan to use HIE in support of patient transfers.

CONCLUSIONS

Participants' experiences demonstrate how stakeholders may succeed in developing and piloting an electronic transfer form that relies on HIE to aggregate, communicate, and display relevant patient transfer data across health care organizations. Their experiences also provide insights for others seeking to develop HIE applications to improve patient transfers between emergency departments and skilled nursing facilities.

State funding for health information technology and selected ambulatory healthcare quality measures

BACKGROUND

Previous studies on the effects of health information technology (health IT) on ambulatory quality have had mixed results. New York State has invested heavily in health IT throughout the State, creating a unique opportunity to assess effects on health care quality across multiple communities.

OBJECTIVE

To determine any association between primary care providers' receipt of funding from New York State's Healthcare Efficiency and Affordability Law for New Yorkers Program (HEAL NY) and ambulatory quality of care.

METHODS

A statewide, longitudinal cohort study of primary care physicians in New York State was conducted. Data regarding which primary care physicians received funding through the HEAL NY program (Phase 5 or Phase 10) in 2008 or 2009 were obtained from the New York State Department of Health. Health care quality in 2010 was measured using claims data that had been aggregated across 7 commercial health plans across the state. Physicians were divided into 2 groups, based on receipt of HEAL funding (yes/no). Any association was measured between study group and each of 7 quality measures, all of which appear in the Stage 1 federal Meaningful Use program. Negative binomial regression was used, adjusting for provider gender and specialty.

RESULTS

The study included 3,988 primary care providers, of whom 863 (22%) had received HEAL NY funding. The HEAL-funded physicians provided higher quality of care on 5 of the 7 measures: breast cancer screening, eye exams in patients with diabetes, nephropathy screening in patients with diabetes, influenza vaccination and pneumococcal vaccination (p<0.0001 for all adjusted comparisons). The HEAL-funded group provided higher quality of care by an absolute 2 to 6 percentage points per measure for those 5 measures.

CONCLUSION

Primary care physicians who received state funding for health IT provided higher quality of care than those who did not receive such funding.

Association between use of a health information exchange system and hospital admissions

OBJECTIVE

Relevant patient information is frequently difficult to obtain in emergency department (ED) visits. Improved provider access to previously inaccessible patient information may improve the quality of care and reduce hospital admissions. Health information exchange (HIE) systems enable access to longitudinal, community-wide patient information at the point of care. However, the ability of HIE to avert admissions is not well demonstrated. We sought to determine if HIE system usage is correlated with a reduction in admissions via the ED.

METHODS

We identified 15,645 adults from New York State with an ED visit during a 6-month period, all of whom consented to have their information accessible in the HIE system, and were continuously enrolled in two area health plans. Using claims we determined if the ED encounter resulted in an admission. We used the HIE's system log files to determine usage during the encounter. We determined the association between HIE system use and the likelihood of admission to the hospital from the ED and potential cost savings.

RESULTS

The HIE system was accessed during 2.4% of encounters. The odds of an admission were 30% lower when the system was accessed after controlling for confounding (odds ratio = 0.70; 95%C I= 0.52, 0.95). The annual savings in the sample was $357,000.

CONCLUSION

These findings suggest that the use of an HIE system may reduce hospitalizations from the ED with resultant cost savings. This is an important outcome given the substantial financial investment in interventions designed to improve provider access to patient information in the US.

Effects of automated immunization registry reporting via an electronic health record deployed in community practice settings

BACKGROUND

Among the expected benefits of electronic health records (EHRs) is increased reporting of public health information, such as immunization status. State and local immunization registries aid control of vaccine-preventable diseases and help offset fragmentation in healthcare, but reporting is often slow and incomplete. The Primary Care Information Project (PCIP), an initiative of the NYC Department of Health and Mental Hygiene, has implemented EHRs with immunization reporting capability in community settings.

OBJECTIVE AND METHODS

To evaluate the effect of automated reporting via an EHR on use and efficiency of reporting to the NY Citywide Immunization Registry, we conducted a secondary analysis of 1.7 million de-identified records submitted between January 2007 and June 2011 by 217 primary care practices enrolled in PCIP, pre and post launch of automated reporting via an EHR. We examined differences in records submitted per day, lag time, and documentation of eligibility for subsidized vaccines.

RESULTS

Mean submissions per day did not change. Automated submissions of new and historical records increased by 18% and 98% respectively. Submissions within 14 days increased from 84% to 87%, and within 2 days increased from 60% to 77%. Median lag time decreased from 13 to 10 days. Documentation of eligibility decreased. Results are significant at p<0.001.

CONCLUSIONS

Significant improvements in registry use and efficiency of reporting were found after launch of automated reporting via an EHR. A decrease in eligibility documentation was attributed to EHR workflow. The limitations to comprehensive evaluation found in these data, which were extracted from a registry initiated prior to widespread EHR implementation suggests that reliable evaluation of immunization reporting via the EHR may require modifications to legacy registry databases.

Physician specialty and variations in adoption of electronic health records

OBJECTIVE

Efforts to promote adoption of electronic health records (EHRs) have focused on primary care physicians, who are now expected to exchange data electronically with other providers, including specialists. However, the variation of EHR adoption among specialists is underexplored.

METHODS

We conducted a retrospective cross-sectional study to determine the association between physician specialty and the prevalence of EHR adoption, and a retrospective serial cross-sectional study to determine the association of physician specialty and the rate of EHR adoption over time. We used the 2005-2009 National Ambulatory Medical Care Survey. We considered fourteen specialties, and four definitions of EHR adoption (any EHR, basic EHR, full EHR, and a novel definition of EHR sophistication). We used multivariable logistic regression, and adjusted for several covariates (geography, practice characteristics, revenue characteristics, physician degree).

RESULTS

Physician specialty was significantly associated with EHR adoption, regardless of the EHR definition, after adjusting for covariates. Psychiatrists, dermatologists, pediatricians, ophthalmologists, and general surgeons were significantly less likely to adopt EHRs, compared to the reference group of family medicine/general practitioners. After adjustment for covariates, these specialties were 44-94% less likely to adopt EHRs than the reference group. EHR adoption increased in all specialties, by approximately 40% per year. The rate of EHR adoption over time did not significantly vary by specialty.

CONCLUSIONS

Although EHR adoption is increasing in all specialties, adoption varies widely by specialty. In order to insure each individual's network of providers can electronically share data, widespread adoption of EHRs is needed across all specialties.

Predictors of success for electronic health record implementation in small physician practices

BACKGROUND

The federal government is promoting adoption of electronic health records (EHRs) through financial incentives for EHR use and implementation support provided by regional extension centers. Small practices have been slow to adopt EHRs.

OBJECTIVES

Our objective was to measure time to EHR implementation and identify factors associated with successful implementation in small practices receiving financial incentives and implementation support. This study is unique in exploiting quantitative implementation time data collected prospectively as part of routine project management.

METHODS

This mixed-methods study includes interviews of key informants and a cohort study of 544 practices that had worked with the Primary Care Information Project (PCIP), a publicly funded organization that since 2007 has subsidized EHRs and provided implementation support similar to that supplied by the new regional extension centers. Data from a project management database were used for a cohort study to assess time to implementation and predictors of implementation success.

RESULTS

Four hundred and thirty practices (79%) implemented EHRs within the analysis period, with a median project time of 24.7 weeks (95% CI: 23.3 - 26.4). Factors associated with implementation success were: fewer providers, practice sites, and patients; fewer Medicaid and uninsured patients; having previous experience with scheduling software; enrolling in 2010 rather than earlier; and selecting an integrated EHR plus practice management product rather than two products. Interviews identified positive attitude toward EHRs, resources, and centralized leadership as additional practice-level predictors of success.

CONCLUSIONS

A local initiative similar to current federal programs successfully implemented EHRs in primary care practices by offsetting software costs and providing implementation assistance. Nevertheless, implementation success was affected by practice size and other characteristics, suggesting that the federal programs can reduce barriers to EHR implementation but may not eliminate them.

Health information exchange and ambulatory quality of care

BACKGROUND

Health information exchange is a national priority, but there is limited evidence of its effectiveness.

OBJECTIVE

We sought to determine the effect of health information exchange on ambulatory quality.

METHODS

We conducted a retrospective cohort study over two years of 138 primary care physicians in small group practices in the Hudson Valley region of New York State. All physicians had access to an electronic portal, through which they could view clinical data (such as laboratory and radiology test results) for their patients over time, regardless of the ordering physician. We considered 15 quality measures that were being used by the community for a pay-for-performance program, as well as the subset of 8 measures expected to be affected by the portal. We adjusted for 11 physician characteristics (including health care quality at baseline).

RESULTS

Nearly half (43%) of the physicians were portal users. Non-users performed at or above the regional benchmark on 48% of the measures at baseline and 49% of the measures at followup (p = 0.58). Users performed at or above the regional benchmark on 57% of the measures at baseline and 64% at follow-up (p<0.001). Use of the portal was independently associated with higher quality of care at follow-up for those measures expected to be affected by the portal (p = 0.01), but not for those not expected to be affected by the portal (p = 0.12).

CONCLUSIONS

Use of an electronic portal for viewing clinical data was associated with modest improvements in ambulatory quality.