Diabetes, kidney disease and cardiovascular disease patients. Assessing care of complex patients using outpatient testing and visits: additional metrics by which to evaluate health care system functioning

Predictive analytics support for complex chronic medical conditions: An experience-based co-design study of physician managers' needs and preferences

PURPOSE

The literature suggests predictive technology applications in health care would benefit from physician and manager input during design and development. The aim was to explore the needs and preferences of physician managers regarding the role of predictive analytics in decision support for patients with the highly complex yet common combination of multiple chronic conditions of cardiovascular (Heart) and kidney (Nephrology) diseases and diabetes (HND).

METHODS

This qualitative study employed an experience-based co-design model comprised of three data gathering phases: 1. Patient mapping through non-participant observations informed by process mining of electronic health records data, 2. Semi-structured experience-based interviews, and 3. A co-design workshop. Data collection was conducted with physician managers working at or collaborating with the HND center, Danderyd University Hospital (DSAB), in Stockholm, Sweden. HND center is an integrated practice unit offering comprehensive person-centered multidisciplinary care to stabilize disease progression, reduce visits, and develop treatment strategies that enables a transition to primary care.

RESULTS

Interview and workshop data described a complex challenge due to the interaction of underlying pathophysiologies and the subsequent need for multiple care givers that hindered care continuity. The HND center partly met this challenge by coordinating care through multiple interprofessional and interdisciplinary shared decision-making interfaces. The large patient datasets were difficult to operationalize in daily practice due to data entry and retrieval issues. Predictive analytics was seen as a potentially effective approach to support decision-making, calculate risks, and improve resource utilization, especially in the context of complex chronic care, and the HND center a good place for pilot testing and development. Simplicity of visual interfaces, a better understanding of the algorithms by the health care professionals, and the need to address professional concerns, were identified as key factors to increase adoption and facilitate implementation.

CONCLUSIONS

The HND center serves as a comprehensive integrated practice unit that integrates different medical disciplinary perspectives in a person-centered care process to address the needs of patients with multiple complex comorbidities. Therefore, piloting predictive technologies at the same time with a high potential for improving care represents an extreme, demanding, and complex case. The study findings show that health care professionals' involvement in the design of predictive technologies right from the outset can facilitate the implementation and adoption of such technologies, as well as enhance their predictive effectiveness and performance. Simplicity in the design of predictive technologies and better understanding of the concept and interpretation of the algorithms may result in implementation of predictive technologies in health care. Institutional efforts are needed to enhance collaboration among the health care professionals and IT professionals for effective development, implementation, and adoption of predictive analytics in health care.

Diabetic retinopathy screening integrated in a multidisciplinary diabetes care clinic: a pilot project

OBJECTIVE

To characterize patients referred for diabetic retinopathy (DR) screening in a unique multidisciplinary diabetes care clinic at a tertiary care centre.

METHODS

A retrospective study was conducted involving patients who were referred to the Cardiac and Renal Endocrine Clinic at a tertiary care centre (University Health Network) for DR screening between April 2019-March 2020 and November 2020-August 2021. Patients' demographics; micro- and macrovascular disease measurements; visual acuity, intraocular pressure, fundus imaging, and optical coherence tomography results were collected and analyzed.

RESULTS

Of the 64 patients who attended the clinic, 21 patients (33%) with type 2 diabetes had on-site DR screening. The remaining 43 patients had DR screening within 6 months of the appointment or were under ophthalmology care with annual screening visits elsewhere. Of the 21 patients who underwent retinopathy screening, 7 patients (33%) had DR: 4 had mild nonproliferative DR, 2 had moderate nonproliferative DR, 1 had proliferative DR, and 1 had macular edema. Patients with DR had a significantly longer diabetes duration than patients without DR (24.5 ± 10.2 years vs 12.5 ± 5.8 years; p = 0.0247). No significant differences were observed in glycemic control, blood pressure, lipid profiles, kidney function, visual acuity, or intraocular pressure.

CONCLUSIONS

Our analysis suggests a potential benefit of integrated DR screening in patients with long-standing diabetes as part of a multidisciplinary diabetes care clinic to diagnose and manage DR. Future work is needed to further develop such clinics and investigate their long-term effect on patient outcomes.

A Unique Multi- and Interdisciplinary Cardiology-Renal-Endocrine Clinic: A Description and Assessment of Outcomes

Background:

Patients with diabetes and co-existing chronic kidney disease and/or cardiovascular disease have complex medical needs with multiple indications for different guideline-directed medical therapies and require high health care resource utilization. The Cardiac and Renal Endocrine Clinic (C.a.R.E. Clinic) is a multi- and interdisciplinary clinic offering a unique care model to this population to overcome barriers to optimal care.

Objective:

To describe the patient characteristics and clinical data of consecutive patients seen in the C.a.R.E. Clinic between 2014 and 2020, with a focus on the feasibility, strengths, and challenges of this outpatient care model.

Design:

Single-center retrospective cohort study.

Setting:

The C.a.R.E. Clinic is a multi- and interdisciplinary clinic at Toronto General Hospital in Toronto, Canada.

Patients:

We reviewed the charts of all 118 patients who had been referred to the C.a.R.E. Clinic with type 2 diabetes mellitus, co-existing renal disease, and/or cardiovascular disease.

Measurements:

Demographic data, medication data, clinic blood pressure measurements, and laboratory data were assessed at the first and last available clinic visit.

Methods:

Data were extracted via manual chart review of paper and electronic medical records.

Results:

First and last attended clinic visit data were available for descriptive analysis in 74 patients. There was a significant improvement in low-density lipoprotein (LDL) cholesterol (1.9 mmol/L vs 1.5 mmol/L, P < .01), hemoglobin A1C (7.5% vs 7.1%, P = .02), and the proportion of patients with blood pressure at target (52.7% vs 36.5%, P = .04), but not body mass index (29.7 kg/m² vs 29.6 kg/m², P = .15) between the last and first available clinic visits. There was higher uptake in evidence-based medication use including statins (93.2% vs 81.1%, P = .01), SGLT-2i (35.1% vs 4.1%, P < .01), and GLP-1 receptor agonists (13.5% vs 4.1%, P = .02), while RAAS inhibitor use was already high at baseline (81.8% vs 78.4%, P = .56). There remains a significant opportunity for therapy with sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists.

Limitations:

This is a retrospective chart review lacking a control group, therefore clinical improvements cannot be causally attributed to the clinic alone. New evidence and changes to guideline-recommended therapies also contributed to practice changes during this time period.

Conclusions:

A multi- and interdisciplinary clinic is a feasible and potentially effective way to improve evidence-based and patient-centered care for patients with diabetes, kidney, and cardiovascular disease.

Definition of patient complexity in adults: A narrative review

Background

Better identification of complex patients could help to improve their care. However, the definition of patient complexity itself is far from obvious. We conducted a narrative review to identify, describe, and synthesize the definitions of patient complexity used in the last 25 years.

Methods

We searched PubMed for articles published in English between January 1995 and September 2020, defining patient complexity. We extended the search to the references of the included articles. We assessed the domains presented in the definitions, and classified the definitions as based on (1) medical aspects (e.g., number of conditions) or (2) medical and/or non-medical aspects (e.g., socio-economic status). We assessed whether the definition was based on a tool (e.g., index) or conceptual model.

Results

Among 83 articles, there was marked heterogeneity in the patient complexity definitions. Domains contributing to complexity included health, demographics, behavior, socio-economic factors, healthcare system, medical decision-making, and environment. Patient complexity was defined according to medical aspects in 30 (36.1%) articles, and to medical and/or non-medical aspects in 53 (63.9%) articles. A tool was used in 36 (43.4%) articles, and a conceptual model in seven (8.4%) articles.

Conclusion

A consensus concerning the definition of patient complexity was lacking. Most definitions incorporated non-medical factors in the definition, underlining the importance of accounting not only for medical but also for non-medical aspects, as well as for their interrelationship.

Assessment of an Interactive Digital Health-Based Self-management Program to Reduce Hospitalizations Among Patients With Multiple Chronic Diseases: A Randomized Clinical Trial

IMPORTANCE

Digital health programs may have the potential to prevent hospitalizations among patients with chronic diseases by supporting patient self-management, symptom monitoring, and coordinated care.

OBJECTIVE

To compare the effect of an internet-based self-management and symptom monitoring program targeted to patients with 2 or more chronic diseases (internet chronic disease management [CDM]) with usual care on hospitalizations over a 2-year period.

DESIGN, SETTING, AND PARTICIPANTS

This single-blinded randomized clinical trial included patients with multiple chronic diseases from 71 primary care clinics in small urban and rural areas throughout British Columbia, Canada. Recruitment occurred between October 1, 2011, and March 23, 2015. A volunteer sample of 456 patients was screened for eligibility. Inclusion criteria included daily internet access, age older than 19 years, fluency in English, and the presence of 2 or more of the following 5 conditions: diabetes, heart failure, ischemic heart disease, chronic kidney disease, or chronic obstructive pulmonary disease. A total of 230 patients consented to participate and were randomized to receive either the internet CDM intervention (n = 117) or usual care (n = 113). One participant in the internet CDM group withdrew from the study after randomization, resulting in 229 participants for whom data on the primary outcome were available.

INTERVENTIONS

Internet-based self-management program using telephone nursing supports and integration within primary care compared with usual care over a 2-year period.

MAIN OUTCOMES AND MEASURES

The primary outcome was all-cause hospitalizations at 2 years. Secondary outcomes included hospital length of stay, quality of life, self-management, and social support. Additional outcomes included the number of participants with at least 1 hospitalization, the number of participants who experienced a composite outcome of all-cause hospitalization or death, the time to first hospitalization, and the number of in-hospital days.

RESULTS

Among 229 participants included in the analysis, the mean (SD) age was 70.5 (9.1) years, and 141 participants (61.6%) were male; data on race and ethnicity were not collected because there was no planned analysis of these variables. The internet CDM group had 25 fewer hospitalizations compared with the usual care group (56 hospitalizations vs 81 hospitalizations, respectively [30.9% reduction]; relative risk [RR], 0.68; 95% CI, 0.43-1.10; P = .12). The intervention group also had 229 fewer in-hospital days compared with the usual care group (282 days vs 511 days, respectively; RR, 0.52; 95% CI, 0.24-1.10; P = .09). Components of self-management and social support improved in the intervention group. Fewer participants in the internet CDM vs usual care group had at least 1 hospitalization (32 of 116 individuals [27.6%] vs 46 of 113 individuals [40.7%]; odds ratio [OR], 0.55; 95% CI, 0.31-0.96; P = .03) or experienced the composite outcome of all-cause hospitalization or death (37 of 116 individuals [31.9%] vs 51 of 113 individuals [45.1%]; OR, 0.57; 95% CI, 0.33-0.98; P = .04). Participants in the internet CDM group had a lower risk of time to first hospitalization (hazard ratio, 0.62; 95% CI, 0.39-0.97; P = .04) than those in the usual care group.

CONCLUSIONS AND RELEVANCE

In this study, an internet-based self-management program did not result in a significant reduction in hospitalization. However, fewer participants in the intervention group were admitted to the hospital or experienced the composite outcome of all-cause hospitalization or death. These findings suggest the internet CDM program has the potential to augment primary care among patients with multiple chronic diseases.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01342263.

Cultivating Innovative Pragmatic Cluster-Randomized Registry Trials Embedded in Hemodialysis Care: Workshop Proceedings From 2018

Hemodialysis is a life-sustaining treatment for persons with kidney failure. However, those on hemodialysis still face a poor quality of life and a short life expectancy. High-quality research evidence from large randomized controlled trials is needed to identify interventions that improve the experiences, outcomes, and health care of persons receiving hemodialysis. With the support of the Canadian Institutes of Health Research and its Strategy for Patient-Oriented Research, the Innovative Clinical Trials in Hemodialysis Centers initiative brought together Canadian and international kidney researchers, patients, health care providers, and health administrators to participate in a workshop held in Toronto, Canada, on June 2 and 3, 2018. The workshop served to increase knowledge and awareness about the conduct of innovative, pragmatic, cluster-randomized registry trials embedded into routine hemodialysis care and provided an opportunity to discuss and build support for new trial ideas. The workshop content included structured presentations, facilitated group discussions, and expert panel feedback. Partnerships and promising trial ideas borne out of the workshop will continue to be developed to support the implementation of future large-scale trials.

Extreme Consumers of Health Care: Patterns of Care Utilization in Patients with Multiple Chronic Conditions Admitted to a Novel Integrated Clinic

PURPOSE

Patients with multiple chronic conditions (MCC) of diabetes, cardiovascular and kidney diseases; hereafter referred to as HND (heart/cardiac-, nephrology-, diabetes mellitus-) patients, are high utilizers of health care. However, the care received is often insufficiently coordinated between different specialties and health-care providers. This study aims to describe the characteristics of HND patients and to explore the initial effects of a multidisciplinary and person-centered care on total care utilization.

PATIENTS AND METHODS

We conducted a sub-study of HND patients recruited in an ongoing randomized trial CareHND (NCT03362983). Descriptive statistics of patient characteristics, including diagnostic data and Charlson Comorbidity Index scores, informed a comparison of care utilization patterns between HND patient care and traditional care. Diagnostic and care utilization data were collected from a regional database. Wilcoxon signed ranked sum tests were performed to compare care utilization frequencies between the two groups.

RESULTS

Patients included in the study were care-intensive with several diagnoses and experienced a high level of variation in care utilization and diagnoses profiles. HND patients were sicker than their counterparts in the control group. Utilization indicators were similar between the two arms. There was some indication that the HND center is beginning to perform as expected, but no results were statistically significant.

CONCLUSION

This study sits among many studies reporting difficulties obtaining statistically significant findings for MCC patients. However, previous research has shown that the key components of this intervention, such as integrated, multidisciplinary, inter-professional collaboration within patient-centered care have had a positive effect on health-care outcomes. More innovative methods beyond the RCT, such as machine learning should be explored to evaluate the impact of integrated care interventions on care utilization.

The BC Glomerulonephritis Network: Improving Access and Reducing the Cost of Immunosuppressive Treatments for Glomerular Diseases

Glomerulonephritis (GN) is a common cause of end-stage renal disease in Canada and worldwide, and results in significant health care resource utilization and patient morbidity. However, GN has not been a traditional priority of provincial renal health care organizations, despite the known benefits to health services delivery and patient outcomes from integrated provincial care in other types of chronic kidney disease. To address this deficiency, the British Columbia (BC) Provincial Renal Agency created the BC GN Network in 2013 to coordinate provincial GN health services delivery informed by robust population-level data capture on all GN patients in the province via the BC GN Registry. This report describes the use of the BC GN Network infrastructure to systematically develop and evaluate a provincial GN drug formulary to improve patient and physician access to evidence-based immunosuppressive treatments for GN in a cost-efficient manner that successfully halted historical trends of increasing medication costs. An example is provided of using the provincial infrastructure to implement and subsequently evaluate an evidence-informed health policy of converting brand to generic tacrolimus for the treatment of GN. The BC GN Network, including the provincial drug formulary and data infrastructure, is an example of the benefits of expanding the mandate of provincial renal health administrative organizations to include the care of patients with GN, and constitutes a viable health delivery model that can be implemented in other Canadian provinces to achieve similar goals.

Novel combined management approaches to patients with diabetes, chronic kidney disease and cardiovascular disease

Most patients we care for today suffer from more than one chronic disease, and multimorbidity is a rapidly growing challenge. Concomitant cardiovascular disease, renal dysfunction and diabetes represent a large proportion of all patients in cardiology, nephrology and diabetology. These entities commonly overlap due to their negative effects on vascular function and an accelerated atherosclerosis progression. At the same time, a progressive subspecialisation has caused the cardiologist to treat 'only' the heart, nephrologists 'only' the kidneys and endocrinologists' 'only' diabetes. Studies and guidelines follow the same pattern. This often requires patients to visit specialists for each field, with a risk of both under-diagnosis and under-treatment. From the patient's perspective, there is a great need for coordination and facilitation of the care, not only to reduce disease progression but also to improve quality of life. Person-centred integrated clinics for patients with cardiovascular disease, renal dysfunction and diabetes are a promising approach for complex chronic disease management.

Multimorbidity in Older Patients with Cardiovascular Disease

Multimorbidity affects more than two thirds of older individuals and the vast majority of patients with chronic cardiovascular disease. Patients with multimorbidity have high resource utilization, poor mobility, and poor health status and are at an increased risk for death. The presence of multimorbidity imposes numerous management challenges in caring for patients with chronic cardiovascular disease. It complicates decision-making, promotes fragmented care, and imposes an immense burden on the patient and their social support system. Novel models of care, such as the cardiovascular patient-centered medical home, are needed to provide high-quality, efficient, effective care to this growing population.

Perceptions of prognostic risks in chronic kidney disease: a national survey

Background

Predicting the clinical trajectories of chronic kidney disease (CKD) to discern personalized care remains a complex challenge in nephrology. Understanding the appropriate risk thresholds and time frame associated with predicting risks of key outcomes (kidney failure, cardiovascular (CV) events, and death) is critical in facilitating decision-making. As part of an exploratory research and practice support needs assessment, we aimed to determine the importance of the time frames for predicting key outcomes, and to assess the perceived demand for risk prediction tools among Canadian nephrologists.

Methods

A web-based survey was developed by a pan-Canadian expert panel of practitioners. Upon pre-test for clarity and ease of completion, the final survey was nationally deployed to Canadian nephrologists. Anonymous responses were gathered over a 4-month period. The results were analyzed using descriptive statistics.

Results

One hundred eleven nephrologists responded to our survey. The majority of the respondents described prediction of events over time frames of 1–5 years as being “extremely important” or “very important” to decision-making on a 5-point Likert scale. To plan for arteriovenous fistula referral, the respondents deemed thresholds which would predict probability of kidney failure between >30 and >50 % at 1 year, as useful, while many commented that the rate of progression should be included for decision-making. Over 80 % of the respondents were not satisfied with their current ability to predict the progression to kidney failure, CV events, and death. Most of them indicated that they would value and use validated risk scores for decision-making.

Conclusions

Our national survey of nephrologists shows that the risk prediction for major adverse clinical outcomes is valuable in CKD at multiple time frames and risk thresholds. Further research is required in developing relevant and meaningful risk prediction models for clinical decision-making in patient-centered CKD care.

Electronic supplementary material

The online version of this article (doi:10.1186/s40697-015-0088-z) contains supplementary material, which is available to authorized users.

Evaluation of a Remote Monitoring System for Diabetes Control

PURPOSE

The use of technology to implement cost-effective health care management on a large scale may be an alternative for diabetes management but needs to be evaluated in controlled trials. This study assessed the utility and cost-effectiveness of an automated Diabetes Remote Monitoring and Management System (DRMS) in glycemic control versus usual care.

METHODS

In this randomized, controlled study, patients with uncontrolled diabetes on insulin were randomized to use of the DRMS or usual care. Participants in both groups were followed up for 6 months and had 3 clinic visits at 0, 3, and 6 months. The DRMS used text messages or phone calls to remind patients to test their blood glucose and to report results via an automated system, with no human interaction unless a patient had severely high or low blood glucose. The DRMS made adjustments to insulin dose(s) based on validated algorithms. Participants reported medication adherence through the Morisky Medication Adherence Scale-8, and diabetes-specific quality of life through the diabetes Daily Quality of Life questionnaire. A cost-effectiveness analysis was conducted based on the estimated overall costs of DRMS and usual care.

FINDINGS

A total of 98 patients were enrolled (59 [60%] female; mean age, 59 years); 87 participants (89%) completed follow-up. HbA1c was similar between the DRMS and control groups at 3 months (7.60% vs 8.10%) and at 6 months (8.10% vs 7.90%). Changes from baseline to 6 months were not statistically significant for self-reported medication adherence and diabetes-specific quality of life, with the exception of the Daily Quality of Life-Social/Vocational Concerns subscale score (P = 0.04).

IMPLICATIONS

An automated system like the DRMS may improve glycemic control to the same degree as usual clinic care and may significantly improve the social/vocational aspects of quality of life. Cost-effectiveness analysis found DRMS to be cost-effective when compared to usual care and suggests DRMS has a good scale of economy for program scale up. Further research is needed to determine how to sustain the benefits seen with the automated system over longer periods.

Remembering the forgotten non-communicable diseases

The forthcoming post-Millennium Development Goals era will bring about new challenges in global health. Low- and middle-income countries will have to contend with a dual burden of infectious and non-communicable diseases (NCDs). Some of these NCDs, such as neoplasms, COPD, cardiovascular diseases and diabetes, cause much health loss worldwide and are already widely recognised as doing so. However, 55% of the global NCD burden arises from other NCDs, which tend to be ignored in terms of premature mortality and quality of life reduction. Here, experts in some of these 'forgotten NCDs' review the clinical impact of these diseases along with the consequences of their ignoring their medical importance, and discuss ways in which they can be given higher global health priority in order to decrease the growing burden of disease and disability.

Are doctors the structural weakness in the e-health building?

Progressive evaluations by the Organization for Economic Co-operation and Development (OECD) demonstrate that health care is now or becoming unaffordable. This means nations must change the way they manage health care. The costly nature of health care in most nations, as a percentage of Gross Domestic Product (GDP) seems independent of the national funding models. Increasing evidence is demonstrating that the lack of involvement by clinicians (doctors, nurses, pharmacists, ancillary care and patients) in e-health projects is a major factor for the costly failures of many of these projects. The essential change in focus required to improve healthcare delivery using e-health technologies has to be on clinical care. To achieve this change clinicians must be involved at all stages of e-health implementations. From a clinicians perspective medicine is not a business. Our business is clinical medicine and e-health must be focussed on clinical decision making. This paper views the roles of physicians in e-health structural reforms.

A retrospective case-control analysis of the outpatient expenditures for western medicine and dental treatment modalities in CKD patients in Taiwan

BACKGROUND

To determine if expenditures for dentistry (DENT) correlate with severity of chronic kidney disease (CKD).

METHODS

A total of 10,457 subjects were enrolled from January 2008 to December 2010, divided into three groups: healthy control (HC) group (n = 1,438), high risk (HR) group (n = 3,392), and CKD group (n = 5,627). Five stages were further categorized for the CKD group. OPD utilization and expenditures for western medicine (WM), DENT, and TCM (traditional Chinese medicine) were analyzed retrospectively (2000-2008) using Taiwan's National Health Insurance Research Database. Three major areas were analyzed among groups CKD, HR and HC in this study: 1) demographic data and medical history; 2) utilization (visits/person/year) and expenditures (9-year cumulative expenditure, expenditure/person/year) for OPD services in WM, DENT, and TCM; and 3) utilization and expenditures for dental OPD services, particularly in dental filling, root canal and periodontal therapy.

RESULTS

OPD utilization and expenditures of WM increased significantly for the CKD group compared with the HR and HC groups, and increased steadily along with the severity of CKD stages. However, overall DENT and TCM utilization and expenditures did not increase for the CKD group. In comparison among different CKD stages, the average expenditures and utilization for DENT including restorative filling and periodontal therapy, but not root canal therapy, showed significant decreases according to severity of CKD stage, indicating less DENT OPD utilization with progression of CKD.

CONCLUSIONS

Patients with advanced CKD used DENT OPD service less frequently. However, the connection between CKD and DENT service utilization requires further study.

Impact of a prototype visualization tool for new information in EHR clinical documents

BACKGROUND

EHR clinical document synthesis by clinicians may be time-consuming and error-prone due to the complex organization of narratives, excessive redundancy within documents, and, at times, inadvertent proliferation of data inconsistencies. Development of EHR systems that are easily adaptable to the user's work processes requires research into visualization techniques that can optimize information synthesis at the point of care.

OBJECTIVE

To evaluate the effect of a prototype visualization tool for clinically relevant new information on clinicians' synthesis of EHR clinical documents and to understand how the tool may support future designs of clinical document user interfaces.

METHODS

A mixed methods approach to analyze the impact of the visualization tool was used with a sample of eight medical interns as they synthesized EHR clinical documents to accomplish a set of four pre-formed clinical scenarios using a think-aloud protocol.

RESULTS

Differences in the missing (unretrieved) patient information (2.3±1.2 [with the visualization tool] vs. 6.8±1.2 [without the visualization tool], p = 0.08) and accurate inferences (1.3±0.3 vs 2.3±0.3, p = 0.09) were not statistically significant but suggest some improvement with the new information visualization tool. Despite the non-significant difference in total times to task completion (43±4 mins vs 36±4 mins, p = 0.35) we observed shorter times for two scenarios with the visualization tool, suggesting that the time-saving benefits may be more evident with certain clinical processes. Other observed effects of the tool include more intuitive navigation between patient details and increased efforts towards methodical synthesis of clinical documents.

CONCLUSION

Our study provides some evidence that new information visualization in clinical notes may positively influence synthesis of patient information from EHR clinical documents. Our findings provide groundwork towards a more effective display of EHR clinical documents using advanced visualization applications.

Surveillance of chronic kidney disease around the world: tracking and reining in a global problem

In recent years, there has been a general recognition of the importance of tackling noncommunicable chronic diseases throughout the world and not just in developed nations. Chronic kidney disease (CKD) is increasingly recognized as a public health threat, based on its high prevalence, rising incidence, associated complications, and cost. It is imperative that nations develop screening and surveillance programs related to CKD. This article provides a global perspective on existing and emerging CKD surveillance efforts. A variety of programs are described, ranging from cross-sectional screening studies to determine CKD prevalence; targeted screening of high-risk populations presenting for voluntary testing; to more systematic surveillance within the scope of integrated health care systems in many developed nations. The choice of surveillance programs for many countries will depend on available resources and competing health care priorities. Integration with surveillance programs for other major chronic diseases such as diabetes, hypertension, and obesity is highly desirable and could be a key to the prevention of CKD. Finally, we propose the model of integrated health systems as one that is perhaps best suited to systematic, longitudinal surveillance of many chronic diseases, a model based on a national electronic health care record with linkage across primary care and hospital-based programs. Robust health education efforts and timely dissemination strategies will remain the key to the success of disease surveillance. It is gratifying to note that more and more countries are developing and adopting CKD surveillance programs as part of national disease prevention strategies.