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DeClercq MG, Eberhardt L, Zakko P, Keeley J, Audet M, Park D. Equivalence in osteoporosis workup and management after femoral neck fracture fixation and vertebral compression fracture cement augmentation: A single-center retrospective study highlighting persistent Underdiagnosis and Undertreatment. J Orthop 2024; 56:133-140. [PMID: 38854776 PMCID: PMC11153879 DOI: 10.1016/j.jor.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/02/2024] [Accepted: 05/07/2024] [Indexed: 06/11/2024] Open
Abstract
Background The purpose of this study was to evaluate pre- and post-fracture medical management of osteoporosis among patients who underwent surgical fixation of femoral neck fractures (FNF) and vertebral compression fractures (VCF), and to investigate if there is a difference in treatment, management, and subsequent fractures between FNF and VCF patients. Methods Patients who underwent surgical fixation of FNF or VCF were retrospectively reviewed at a minimum 1 year follow up. Patients were excluded if their fracture was caused by high energy trauma or malignancy, <50 years-old, deceased, or lost to follow up. Patient demographics such as age, sex, BMI, American Society of Anesthesiology Physical Status Classification System and Charleston Comorbidity index were recorded. Management of osteoporosis, including medication regimen and dual-energy X-ray absorptiometry (DEXA) scans were assessed preoperatively and at minimum one year follow up. Subsequent fractures were also recorded. Results In the analysis of 370 patients (74.7% FNF, 25.2% VCF), demographics showed a predominantly female population (mean age 78.1). Preoperatively, 21.6% were diagnosed with osteoporosis, consistent between FNF and VCF. Postoperatively, there were no significant differences in new osteoporosis diagnoses, bisphosphonate use, or subsequent fractures. VCF patients, however, were more likely to receive denosumab and post-operative DEXA scans (p < 0.05). Within a year, 6.2% experienced subsequent fractures, with no significant FNF-VCF difference. Only 12.7% received appropriate post-operative osteoporosis treatment, 27.1% had DEXA scans, and 25% had a recorded osteoporosis diagnosis. Multivariable analysis highlighted pre-fracture osteoporosis diagnosis as the sole predictor for post-operative DEXA scans and anti-osteoporotic medication (p < 0.001). Conclusions This study suggests that factors beyond the type of fragility fracture may influence subsequent fracture risk and anti-osteoporotic medication administration in elderly patients. These findings underscore the importance of a comprehensive approach to fracture risk assessment and treatment decisions in this population. Level of evidence III.
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Affiliation(s)
- Madeleine Grace DeClercq
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Lauren Eberhardt
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Philip Zakko
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
| | - Jacob Keeley
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Megan Audet
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
| | - Daniel Park
- Corewell Health, William Beaumont University Hospital, Department of Orthopedic Surgery, Royal Oak, MI, USA
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Parker M, Kazemi F, Ahmed AK, Kuo CC, Nair SK, Rincon-Torroella J, Jackson C, Gallia G, Bettegowda C, Weingart J, Brem H, Mukherjee D. Exploring the impact of primary care utilization and health information exchange upon treatment patterns and clinical outcomes of glioblastoma patients. J Neurooncol 2024; 168:345-353. [PMID: 38662150 DOI: 10.1007/s11060-024-04677-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE There is limited literature describing care coordination for patients with glioblastoma (GBM). We aimed to investigate the impact of primary care and electronic health information exchange (HIE) between neurosurgeons, oncologists, and primary care providers (PCP) on GBM treatment patterns, postoperative outcomes, and survival. METHODS We identified adult GBM patients undergoing primary resection at our institution (2007-2020). HIE was defined as shared electronic medical information between PCPs, oncologists, and neurosurgeons. Multivariate logistic regression analyses were used to determine the effect of PCPs and HIE upon initiation and completion of adjuvant therapy. Kaplan-Meier and multivariate Cox regression models were used to evaluate overall survival (OS). RESULTS Among 374 patients (mean age ± SD: 57.7 ± 13.5, 39.0% female), 81.0% had a PCP and 62.4% had electronic HIE. In multivariate analyses, having a PCP was associated with initiation (OR: 7.9, P < 0.001) and completion (OR: 4.4, P < 0.001) of 6 weeks of concomitant chemoradiation, as well as initiation (OR: 4.0, P < 0.001) and completion (OR: 3.0, P = 0.007) of 6 cycles of maintenance temozolomide thereafter. Having a PCP (median OS [95%CI]: 14.6[13.1-16.1] vs. 10.8[8.2-13.3] months, P = 0.005) and HIE (15.40[12.82-17.98] vs. 13.80[12.51-15.09] months, P = 0.029) were associated with improved OS relative to counterparts in Kaplan-Meier analysis and in multivariate Cox regression analysis (hazard ratio [HR] = 0.7, [95% CI] 0.5-1.0, P = 0.048). In multivariate analyses, chemoradiation (HR = 0.34, [95% CI] 0.2-0.7, P = 0.002) and maintenance temozolomide (HR = 0.5, 95%CI 0.3-0.8, P = 0.002) were associated with improved OS relative to counterparts. CONCLUSION Effective care coordination between neurosurgeons, oncologists, and PCPs may offer a modifiable avenue to improve GBM outcomes.
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Affiliation(s)
- Megan Parker
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Foad Kazemi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Cathleen C Kuo
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Christopher Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Gary Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, 21287, Baltimore, MD, USA.
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An algorithm to predict data completeness in oncology electronic medical records for comparative effectiveness research. Ann Epidemiol 2022; 76:143-149. [PMID: 35878784 PMCID: PMC9741728 DOI: 10.1016/j.annepidem.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/01/2022] [Accepted: 07/14/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Electronic health record (EHR) discontinuity (missing out-of-network encounters) can lead to information bias. We sought to construct an algorithm that identifies high EHR-continuity among oncology patients. METHODS Using a linked Medicare-EHR database and regression, we sought to 1) measure how often Medicare claims for outpatient encounters were substantiated by visits recorded in the EHR, and 2) predict continuity ratio, defined as the yearly proportion of outpatient encounters reported to Medicare that were captured by EHR data. The prediction model...s performance was evaluated with the coefficient of determination and Spearman...s correlation. We quantified variable misclassification by decile of continuity ratio using standardized difference and sensitivity. RESULTS A total of 79,678 subjects met all eligibility criteria. Predicted and observed continuity was highly correlated (σSpearman=0.86). On average across all variables measured, MSD was reduced by a factor of 1/7th and sensitivity was improved 35-fold comparing subjects in the highest vs. lowest decile of CR. CONCLUSION In the oncology population, restricting EHR-based study cohorts to subjects with high continuity may reduce misclassification without greatly impacting representativeness. Further work is needed to elucidate the best manner of implementing continuity prediction rules in cohort studies.
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Beckley M, Olson AK, Portman MA. Tolerability of COVID-19 Infection and Messenger RNA Vaccination Among Patients With a History of Kawasaki Disease. JAMA Netw Open 2022; 5:e2226236. [PMID: 35960521 PMCID: PMC9375169 DOI: 10.1001/jamanetworkopen.2022.26236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Kawasaki disease (KD) symptoms significantly overlap with multisystem inflammatory syndrome in children due to COVID-19. Patients with KD may be at risk for adverse outcomes from exposure to SARS-CoV-2 infection or vaccination. OBJECTIVE To describe the outcomes of patients with KD to SARS-CoV-2 infection or vaccination. DESIGN, SETTING, AND PARTICIPANTS This case series evaluated 2 cohorts using an existing KD database and reviewed individual electronic medical records for the period spanning January 1, 2020, through January 31, 2022, via electronic medical records that include Washington state immunization records. Vaccine cohort inclusion criteria consisted of being 21 years or younger at immunization and receiving 1 or more BNT162b2 (Pfizer-BioNTech) or messenger RNA (mRNA)-1273 (Moderna) vaccine doses. The COVID-19 cohort included patients 21 years or younger with positive polymerase chain reaction or nuclear capsid IgG findings for SARS-CoV-2. Participants included 826 patients from a preexisting KD database. One hundred fifty-three patients received at least 1 BNT162b2 or mRNA-1273 vaccine dose and were included in the mRNA vaccine cohort. Thirty-seven patients had positive test results for SARS-CoV-2 and were included in the COVID-19 cohort. EXPOSURES SARS-CoV-2 vaccination and/or infection. MAIN OUTCOMES AND MEASURES Adverse events after mRNA vaccination and/or COVID-19, including clinician visits, emergency department encounters, or hospitalizations. RESULTS Among the 153 patients included in the mRNA vaccination cohort (mean [SD] age, 13.0 [4.3] years; 94 male [61.4%]), the BNT162b2 vaccine was provided for 143 (93.5%), and the remaining 10 (6.5%) received mRNA-1273 or a combination of both. Among patients in the vaccine cohort, 129 (84.3%) were fully vaccinated or received a third-dose booster. No clinically severe adverse events occurred, and there were no reports of vaccine-related hospitalizations or outpatient visits. The COVID-19 cohort included 37 patients (mean [SD] age, 11.0 [5.5] years; 22 male [59.5%]). No patients required hospitalization due to COVID-19. The most common symptoms included low-grade fever, fatigue, cough, and myalgia with resolution within a few days. Two patients, aged 9 and 19 years, had extended cough and fatigue for 3 to 4 weeks. One patient developed COVID-19 within 6 weeks of receiving intravenous immunoglobulin for KD. CONCLUSIONS AND RELEVANCE These findings suggest that the mRNA vaccines may be safe and COVID-19 may not be severe for patients with a history of KD.
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Affiliation(s)
| | - Aaron K. Olson
- Seattle Children’s Research Institute, Seattle, Washington
- Division of Cardiology, Department of Pediatrics, University of Washington, Seattle
| | - Michael A. Portman
- Seattle Children’s Research Institute, Seattle, Washington
- Division of Cardiology, Department of Pediatrics, University of Washington, Seattle
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Fellows JL, Atchison KA, Chaffin J, Chávez EM, Tinanoff N. Oral Health in America. J Am Dent Assoc 2022; 153:601-609. [PMID: 35643534 PMCID: PMC9637008 DOI: 10.1016/j.adaj.2022.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 11/22/2022]
Abstract
Background Important, but insufficient, gains have been achieved in access to and delivery of oral health care since the 2000 US surgeon general’s report on oral health in America. Access to care has increased for children and young adults, but considerable work remains to meet the oral health care needs of all people equitably. The National Institutes of Health report, Oral Health in America: Advances and Challenges, reviews the state of the US oral health care system, achievements made since 2000, and remaining challenges. In this article, the authors highlight key advances and continuing challenges regarding oral health status, access to care and the delivery system, integration of oral and systemic health, financing of oral health care, and the oral health workforce. Results Public insurance coverage has increased since 2000 but remains limited for many low-income, minority, and older adult populations. The oral health care workforce has expanded to include new dental specialties and allied professional models, increasing access to health promotion and preventive services. Practice gains made by women and Asian Americans have not extended to other minority demographic groups. Oral health integration models are improving access to and delivery of patient-centered care for some vulnerable populations. Conclusions and Practical Implications Coordinated policies and additional resources are needed to further improve access to care, develop dental insurance programs that reduce out-of-pocket costs to lower-income adults, and improve the integration of oral and medical health care delivery targeting a common set of patient-centered outcomes. Dental care professionals need to fully participate in meaningful and system-wide change to meet the needs of the population equitably.
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Ross MK, Sanz J, Tep B, Follett R, Soohoo SL, Bell DS. Accuracy of an Electronic Health Record Patient Linkage Module Evaluated between Neighboring Academic Health Care Centers. Appl Clin Inform 2020; 11:725-732. [PMID: 33147645 DOI: 10.1055/s-0040-1718374] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Patients often seek medical treatment among different health care organizations, which can lead to redundant tests and treatments. One electronic health record (EHR) platform, Epic Systems, uses a patient linkage tool called Care Everywhere (CE), to match patients across institutions. To the extent that such linkages accurately identify shared patients across organizations, they would hold potential for improving care. OBJECTIVE This study aimed to understand how accurate the CE tool with default settings is to identify identical patients between two neighboring academic health care systems in Southern California, The University of California Los Angeles (UCLA) and Cedars-Sinai Medical Center. METHODS We studied CE patient linkage queries received at UCLA from Cedars-Sinai between November 1, 2016, and April 30, 2017. We constructed datasets comprised of linkages ("successful" queries), as well as nonlinkages ("unsuccessful" queries) during this time period. To identify false positive linkages, we screened the "successful" linkages for potential errors and then manually reviewed all that screened positive. To identify false-negative linkages, we applied our own patient matching algorithm to the "unsuccessful" queries and then manually reviewed a sample to identify missed patient linkages. RESULTS During the 6-month study period, Cedars-Sinai attempted to link 181,567 unique patient identities to records at UCLA. CE made 22,923 "successful" linkages and returned 158,644 "unsuccessful" queries among these patients. Manual review of the screened "successful" linkages between the two institutions determined there were no false positives. Manual review of a sample of the "unsuccessful" queries (n = 623), demonstrated an extrapolated false-negative rate of 2.97% (95% confidence interval [CI]: 1.6-4.4%). CONCLUSION We found that CE provided very reliable patient matching across institutions. The system missed a few linkages, but the false-negative rate was low and there were no false-positive matches over 6 months of use between two nearby institutions.
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Affiliation(s)
- Mindy K Ross
- Department of Pediatrics, University of California Los Angeles, Los Angeles, United States
| | - Javier Sanz
- Department of Medicine, Clinical and Translational Science Institute, University of California Los Angeles, Los Angeles, United States
| | - Brian Tep
- Department of Enterprise Information Services, Advanced Analytic Services, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Rob Follett
- Department of Medicine, Clinical and Translational Science Institute, University of California Los Angeles, Los Angeles, United States
| | - Spencer L Soohoo
- Department of Biomedical Sciences, Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Douglas S Bell
- Department of Medicine, University of California Los Angeles, Los Angeles, United States
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Leviton A, Oppenheimer J, Chiujdea M, Antonetty A, Ojo OW, Garcia S, Weas S, Fleegler E, Chan E, Loddenkemper T. Characteristics of Future Models of Integrated Outpatient Care. Healthcare (Basel) 2019; 7:healthcare7020065. [PMID: 31035586 PMCID: PMC6627383 DOI: 10.3390/healthcare7020065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 01/01/2023] Open
Abstract
Replacement of fee-for-service with capitation arrangements, forces physicians and institutions to minimize health care costs, while maintaining high-quality care. In this report we described how patients and their families (or caregivers) can work with members of the medical care team to achieve these twin goals of maintaining-and perhaps improving-high-quality care and minimizing costs. We described how increased self-management enables patients and their families/caregivers to provide electronic patient-reported outcomes (i.e., symptoms, events) (ePROs), as frequently as the patient or the medical care team consider appropriate. These capabilities also allow ongoing assessments of physiological measurements/phenomena (mHealth). Remote surveillance of these communications allows longer intervals between (fewer) patient visits to the medical-care team, when this is appropriate, or earlier interventions, when it is appropriate. Systems are now available that alert medical care providers to situations when interventions might be needed.
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Affiliation(s)
- Alan Leviton
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Julia Oppenheimer
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Madeline Chiujdea
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Annalee Antonetty
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Oluwafemi William Ojo
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Stephanie Garcia
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Sarah Weas
- Division of Developmental Medicine, Department of Medicine, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Eric Fleegler
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Eugenia Chan
- Division of Developmental Medicine, Department of Medicine, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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