1
|
Kim TV, Pham TND, Phan P, Le MHN, Le Q, Nguyen PT, Nguyen HT, Nguyen DX, Trang B, Cao C, Gurakar A, Hoffmann CJ, Dao DY. Effectiveness and implementation of decentralized, community- and primary care-based strategies in promoting hepatitis B testing uptake: a systematic review and meta-analysis. EClinicalMedicine 2024; 76:102818. [PMID: 39309722 PMCID: PMC11416547 DOI: 10.1016/j.eclinm.2024.102818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
Background Expanding chronic hepatitis B (CHB) testing through effective implementation strategies in primary- and community-care setting is crucial for elimination. Our study aimed to determine the effectiveness of all available strategies in the literature and evaluate their specifications and implementation outcomes, thereby informing future programming and policymaking. Methods We conducted a systematic review and meta-analysis (PROSPERO CRD42023455781), searching Scopus, Embase, PubMed, and CINAHL databases up to June 05, 2024, for randomized controlled trials investigating primary- and community-care-based implementation strategies to promote CHB testing. Studies were screened against a priori eligibility criteria, and their data were extracted using a standardized protocol if included. ROB-2 was used to assess the risk of bias. Implementation strategies' components were characterized using the Behavior Change Wheel (BCW) framework. Random-effect models were applied to pool the effectiveness estimate by strategy. Mixed-effect meta-regression was employed to investigate if effectiveness varied by the number of strategy's BCW components. Findings 7146 unique records were identified. 25 studies were eligible for the review, contributing 130,598 participants. 19 studies were included in the meta-analysis. No studies were conducted in low-and-middle-income countries. Implementation outcomes were reported in only ten studies (40%). Community-based strategies included lay health workers-led education (Pooled Risk Difference = 27.9% [95% Confidence Interval = 3.4-52.4], I2 = 99.3%) or crowdsourced education on social media (3.1% [-2.2 to 8.4], 0.0%). Primary care-based strategies consisted of electronic alert system (8.4% [3.7-13.1], 95.0%) and healthcare providers-led education (HCPs, 62.5% [53.1-71.9], 27.5%). The number of BCW-framework-driven strategy components showed a significant dose-response relationship with effectiveness. Interpretation HCPs-led education stands out, and more enriched multicomponent strategies had better effectiveness. Future implementation strategies should consider critical contextual factors and policies to achieve a sustainable impact towards hepatitis B elimination targets. Funding Tran Dolch Post-Doctoral Fellowship in Hepatology, Johns Hopkins University School of Medicine, Baltimore MD, USA.
Collapse
Affiliation(s)
- Thanh Van Kim
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Pham Ngoc Thach University of Medicine, Viet Nam
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Trang Ngoc Doan Pham
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Paul Phan
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Minh Huu Nhat Le
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei, Taiwan
| | - Quan Le
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Phuong Thi Nguyen
- University of Health Sciences, Vietnam National University Ho Chi Minh City (VNUHCM-UHS), Binh Duong, Viet Nam
| | - Ha Thi Nguyen
- University of Health Sciences, Vietnam National University Ho Chi Minh City (VNUHCM-UHS), Binh Duong, Viet Nam
| | - Dan Xuan Nguyen
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Binh Trang
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Chelsea Cao
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christopher J. Hoffmann
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Doan Y Dao
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
2
|
Nguyen OT, Kunta AR, Katoju S, Gheytasvand S, Masoumi N, Tavasolian R, Alishahi Tabriz A, Hong YR, Hanna K, Perkins R, Parekh A, Turner K. Electronic Health Record Nudges and Health Care Quality and Outcomes in Primary Care: A Systematic Review. JAMA Netw Open 2024; 7:e2432760. [PMID: 39287947 PMCID: PMC11409160 DOI: 10.1001/jamanetworkopen.2024.32760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2024] Open
Abstract
Importance Nudges have been increasingly studied as a tool for facilitating behavior change and may represent a novel way to modify the electronic health record (EHR) to encourage evidence-based care. Objective To evaluate the association between EHR nudges and health care outcomes in primary care settings and describe implementation facilitators and barriers. Evidence Review On June 9, 2023, an electronic search was performed in PubMed, Embase, PsycINFO, CINAHL, and Web of Science for all articles about clinician-facing EHR nudges. After reviewing titles, abstracts, and full texts, the present review was restricted to articles that used a randomized clinical trial (RCT) design, focused on primary care settings, and evaluated the association between EHR nudges and health care quality and patient outcome measures. Two reviewers abstracted the following elements: country, targeted clinician types, medical conditions studied, length of evaluation period, study design, sample size, intervention conditions, nudge mechanisms, implementation facilitators and barriers encountered, and major findings. The findings were qualitatively reported by type of health care quality and patient outcome and type of primary care condition targeted. The Risk of Bias 2.0 tool was adapted to evaluate the studies based on RCT design (cluster, parallel, crossover). Studies were scored from 0 to 5 points, with higher scores indicating lower risk of bias. Findings Fifty-four studies met the inclusion criteria. Overall, most studies (79.6%) were assessed to have a moderate risk of bias. Most or all descriptive (eg, documentation patterns) (30 of 38) or patient-centeredness measures (4 of 4) had positive associations with EHR nudges. As for other measures of health care quality and patient outcomes, few had positive associations between EHR nudges and patient safety (4 of 12), effectiveness (19 of 48), efficiency (0 of 4), patient-reported outcomes (0 of 3), patient adherence (1 of 2), or clinical outcome measures (1 of 7). Conclusions and Relevance This systematic review found low- and moderate-quality evidence that suggested that EHR nudges were associated with improved descriptive measures (eg, documentation patterns). Meanwhile, it was unclear whether EHR nudges were associated with improvements in other areas of health care quality, such as effectiveness and patient safety outcomes. Future research is needed using longer evaluation periods, a broader range of primary care conditions, and in deimplementation contexts.
Collapse
Affiliation(s)
- Oliver T Nguyen
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Industrial and Systems Engineering, University of Wisconsin at Madison, Madison
| | | | - SriVarsha Katoju
- Department of Community Health and Family Medicine, University of Florida, Gainesville
| | | | - Niloofar Masoumi
- College of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Ronia Tavasolian
- Department of Clinical Science and Nutrition, University of Chester, England
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Oncologic Science, University of South Florida, Tampa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, University of Florida, Gainesville
| | - Karim Hanna
- Department of Family Medicine, University of South Florida, Tampa
| | - Randa Perkins
- Department of Internal Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Arpan Parekh
- College of Medicine, University of Miami, Miami, Florida
| | - Kea Turner
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Oncologic Science, University of South Florida, Tampa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| |
Collapse
|
3
|
Marty C, Adam JP, Martel-Laferrière V, Doucet S, Martel D. Impact of universal hepatitis B virus (HBV) screening using chemotherapy orders on the HBV reactivation in cancer patients. Support Care Cancer 2024; 32:541. [PMID: 39046551 DOI: 10.1007/s00520-024-08750-6] [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: 01/29/2024] [Accepted: 07/18/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Hepatitis B virus (HBV) reactivation (HBVr) induced by chemotherapy in patients with resolved or chronic infection can lead to severe consequences. Despite recommendations, rates of HBV screening before chemotherapy are low due to poor recognition of risk factors by clinicians. The aim of the study is to assess whether routine HBV screening using universal HBV screening on chemotherapy orders (CO) could reduce HBVr incidence. METHODS This is a 1-year retrospective single-center observational study of patients who received intravenous chemotherapy post implementation of CO. We compared the incidence of HBVr in three groups of patients: those screened through CO (group 1), those screened by the medical team (group 2), and those not screened (group 3). RESULTS On a total of 1374 patients, 179 of 206 patients were screened as requested on CO (group 1) and 421 by the medical team (group 2), whereas 747 patients were not screened (group 3). Only one HBVr occurred, and no difference was seen on the incidence of HBVr between group 1 and group 3 (0% vs 0.1%; p = 1.00), probably because of a lack of follow-up after chemotherapy. Follow-up for HBVr was imperfect in group 1 and group 2 (16.7% vs 5.6%; p = 0.32). Screening was done for 92% of patients on anti-CD20 therapy. In group 3, 89 patients had ALT elevation during chemotherapy but only 17 (19%) were tested for HBVr. CONCLUSION Systematic HBV detection requested on CO is an effective way to obtain a high percentage of patients with adequate screening, particularly when chemotherapy is at high risk of HBVr. Nevertheless, this screening method do not guarantee optimal follow-up and requires improvements.
Collapse
Affiliation(s)
- Céline Marty
- Faculty of Pharmacy, Aix-Marseille Université, Marseille, France
| | - Jean-Philippe Adam
- Department of Pharmacy, Centre Hospitalier de L'Université de Montréal (CHUM), 1050 Sanguinet St, Montréal, QC, Canada.
- Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CRCHUM), Montréal, QC, H2X 0C1, Canada.
| | - Valérie Martel-Laferrière
- Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CRCHUM), Montréal, QC, H2X 0C1, Canada
- Division of Microbiology and Infectious Diseases, Centre Hospitalier de L'Université de Montréal, Montréal, QC, Canada
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montréal, QC, Canada
| | - Stéphane Doucet
- Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CRCHUM), Montréal, QC, H2X 0C1, Canada
- Division of Medicine-Medical Oncology/Hematology, Centre Hospitalier de L'Université de Montréal, Montréal, QC, Canada
| | - Dominic Martel
- Department of Pharmacy, Centre Hospitalier de L'Université de Montréal (CHUM), 1050 Sanguinet St, Montréal, QC, Canada
- Centre de Recherche du Centre Hospitalier de L'Université de Montréal (CRCHUM), Montréal, QC, H2X 0C1, Canada
| |
Collapse
|
4
|
Anyiwe K, Erman A, Hassan M, Feld JJ, Pullenayegum E, Wong WWL, Sander B. Characterising the effectiveness of social determinants of health-focused hepatitis B interventions: a systematic review. THE LANCET. INFECTIOUS DISEASES 2024; 24:e366-e385. [PMID: 38184004 DOI: 10.1016/s1473-3099(23)00590-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/31/2023] [Accepted: 09/14/2023] [Indexed: 01/08/2024]
Abstract
Social determinants of health are important in designing effective interventions for hepatitis B virus (HBV) infection. This systematic review characterises equity-oriented, social determinants of health-focused HBV interventions, and describes their effectiveness in terms of the prevention, care, or treatment of HBV in high-income countries. We searched electronic databases for central concepts of 'HBV', 'equity', 'social determinants of health', 'intervention', and 'Organization for Economic Co-operation and Development (OECD) countries'. Screening and data abstraction were conducted independently by two reviewers. Data were abstracted from 66 studies; articles with a comparative study design (n=36) were included in the narrative synthesis, highlighting social determinants of health domains of interventions, HBV-relevant health outcomes, and extra-health social determinants of health effects (ie, those effects that extend beyond health outcomes). Synthesis aligned with six emergent themes corresponding to HBV prevention and care: knowledge and education, diagnosis and screening, immunisation, care initiation, engagement with clinical care and treatment, and upstream prevention. Studies presented a heterogeneous array of HBV-relevant health outcomes. Most interventions were tailored for social determinants of health domains of race, ethnicity, culture, and language; drug use; and socioeconomic status. Across the themes, at least two-thirds of interventions showed comparative effectiveness for addressing HBV. Extra-health social determinants of health outcomes were observed for two studies. Considerable diversity in population-level approaches was observed regarding intervention goals and effectiveness; most interventions were effective at enhancing the prevention, care, or treatment of HBV.
Collapse
Affiliation(s)
- Kikanwa Anyiwe
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, University Health Network, Toronto, ON, Canada.
| | - Aysegul Erman
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Marian Hassan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, University Health Network, Toronto, ON, Canada; London School of Hygiene & Tropical Medicine, London, UK
| | - Jordan J Feld
- Sandra Rotman Centre for Global Health, University of Toronto, Toronto, ON, Canada; Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Eleanor Pullenayegum
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - William W L Wong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, University Health Network, Toronto, ON, Canada; School of Pharmacy, University of Waterloo, Kitchener, ON, Canada; ICES, Toronto, ON, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, University Health Network, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada
| |
Collapse
|
5
|
Funes Hernandez M, Bhalla V. Underdiagnosis of Primary Aldosteronism: A Review of Screening and Detection. Am J Kidney Dis 2023; 82:333-346. [PMID: 36965825 DOI: 10.1053/j.ajkd.2023.01.447] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/08/2023] [Indexed: 03/27/2023]
Abstract
A clinical condition may be missed due to its higher-than-recognized prevalence or inadequate diagnostic screening. Both factors apply to primary aldosteronism, which is woefully underdiagnosed as a cause of hypertension and end-organ damage. Screening tests should be strongly considered for diseases that pose significant morbidity or mortality if left untreated, that have a high prevalence, and that have treatments that lead to improvement or cure. In this review we present the evidence for each of these points. We outline studies that estimate the prevalence of primary aldosteronism in different at-risk populations and how its recognition has changed over time. We also evaluate myriad studies of screening rates for primary aldosteronism and what factors do and do not influence current screening practices. We discuss the ideal conditions for screening, measuring the aldosterone to renin ratio in different populations that use plasma renin activity or direct renin concentration, and the steps for diagnostic workup of primary aldosteronism. Finally, we conclude with potential strategies to implement higher rates of screening and diagnosis of this common, consequential, and treatable disease.
Collapse
Affiliation(s)
- Mario Funes Hernandez
- Stanford Hypertension Center and Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Vivek Bhalla
- Stanford Hypertension Center and Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California.
| |
Collapse
|
6
|
Chak EW, Luna R, MacDonald S, Stewart SL, Chen MS, Bowlus C. Automated electronic health registry-based hepatitis B screening. J Viral Hepat 2023; 30:228-231. [PMID: 36514989 PMCID: PMC10803191 DOI: 10.1111/jvh.13784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Eric W. Chak
- Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento, California, USA
| | - Randy Luna
- Division of Clinical Informatics, UC Davis Medical Center, Sacramento, California, USA
| | - Scott MacDonald
- Division of Clinical Informatics, UC Davis Medical Center, Sacramento, California, USA
| | - Susan L. Stewart
- Division of Biostatistics, UC Davis Department of Public Health Sciences, Sacramento, California, USA
| | - Moon S. Chen
- Division of Hematology and Oncology, UC Davis School of Medicine, Sacramento, California, USA
| | - Christopher Bowlus
- Division of Gastroenterology and Hepatology, UC Davis School of Medicine, Sacramento, California, USA
| |
Collapse
|
7
|
Xiao Y, van Gemert C, Howell J, Wallace J, Richmond J, Adamson E, Thompson A, Hellard M. A survey of knowledge, attitudes, barriers and support needs in providing hepatitis B care among GPs practising in Australia. BMC PRIMARY CARE 2022; 23:137. [PMID: 35655159 PMCID: PMC9161590 DOI: 10.1186/s12875-022-01754-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 05/25/2022] [Indexed: 11/10/2022]
Abstract
Background In Australia, only 22% of people with chronic hepatitis B (CHB) are clinically managed; and a national effort is engaging primary care workforce in providing CHB-related care. This study explored CHB-related knowledge, attitudes, barriers and support needs of general practitioners (GPs). Methods A survey was sent to a random sample of 1,000 Australian GPs in April- October 2018; 134 of 978 eligible GPs completed the questionnaire (14%). Results Respondents had high knowledge of at-risk populations (> 79%) and hepatitis B serology (82%), and most saw hepatitis B testing and monitoring as part of their work (95% and 86%, respectively). However, the survey revealed low knowledge, awareness and intention with respect to hepatitis B treatment: 23% correctly understood treatment initiation; 40% were aware that treatment for CHB could be dispensed in the community; 23% agreed that prescribing was part of their work. Lack of time was considered the greatest barrier (38%) and clear guidelines was the most important facilitator to providing care (72%). Conclusion Interventions are needed to generate interest and skills to provide CHB-related care by GPs. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01754-3.
Collapse
|
8
|
Aiding the prescriber: developing a machine learning approach to personalized risk modeling for chronic opioid therapy amongst US Army soldiers. Health Care Manag Sci 2022; 25:649-665. [PMID: 35895214 DOI: 10.1007/s10729-022-09605-4] [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: 01/28/2021] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
The opioid epidemic is a major policy concern. The widespread availability of opioids, which is fueled by physician prescribing patterns, medication diversion, and the interaction with potential illicit opioid use, has been implicated as proximal cause for subsequent opioid dependence and mortality. Risk indicators related to chronic opioid therapy (COT) at the point of care may influence physicians' prescribing decisions, potentially reducing rates of dependency and abuse. In this paper, we investigate the performance of machine learning algorithms for predicting the risk of COT. Using data on over 12 million observations of active duty US Army soldiers, we apply machine learning models to predict the risk of COT in the initial months of prescription. We use the area under the curve (AUC) as an overall measure of model performance, and we focus on the positive predictive value (PPV), which reflects the models' ability to accurately target military members for intervention. Of the many models tested, AUC ranges between 0.83 and 0.87. When we focus on the top 1% of members at highest risk, we observe a PPV value of 8.4% and 20.3% for months 1 and 3, respectively. We further investigate the performance of sparse models that can be implemented in sparse data environments. We find that when the goal is to identify patients at the highest risk of chronic use, these sparse linear models achieve a performance similar to models trained on hundreds of variables. Our predictive models exhibit high accuracy and can alert prescribers to the risk of COT for the highest risk patients. Optimized sparse models identify a parsimonious set of factors to predict COT: initial supply of opioids, the supply of opioids in the month being studied, and the number of prescriptions for psychotropic medications. Future research should investigate the possible effects of these tools on prescriber behavior (e.g., the benefit of clinician nudging at the point of care in outpatient settings).
Collapse
|
9
|
Bitter CC, Parmentier M, Subramaniam DS, Byrne L, Buchanan P. An electronic health record alert increases human immunodeficiency virus screening and case identification in a high-risk emergency department population. Int J STD AIDS 2022; 33:722-725. [PMID: 35531598 DOI: 10.1177/09564624221096001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increased screening for HIV is required to reduce mortality and transmission. Patients with risk factors for HIV may lack access to routine care and emergency departments are an important site for screening and linkage to care. We implemented an electronic health record algorithm to identify patients meeting criteria for HIV screening. Compared to unstructured clinical judgement, the EHR alert increased the number of patients screened and case identification.
Collapse
Affiliation(s)
- Cindy C Bitter
- Department of Surgery, Division of Emergency Medicine, 12274Saint Louis University School of Medicine, St Louis, MO, USA
| | | | - Divya S Subramaniam
- Department of Health and Clinical Outcomes Research, 12274Saint Louis University School of Medicine, St Louis, MO, USA.,Advanced HEAlth Data (AHEAD) Institute, 12274Saint Louis University School of Medicine, St Louis, MO, USA
| | - Laurie Byrne
- Department of Surgery, Division of Emergency Medicine, 12274Saint Louis University School of Medicine, St Louis, MO, USA
| | - Paula Buchanan
- Department of Health and Clinical Outcomes Research, 12274Saint Louis University School of Medicine, St Louis, MO, USA.,Advanced HEAlth Data (AHEAD) Institute, 12274Saint Louis University School of Medicine, St Louis, MO, USA
| |
Collapse
|
10
|
Clinical Decision Support Systems for Diagnosis in Primary Care: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168435. [PMID: 34444182 PMCID: PMC8391274 DOI: 10.3390/ijerph18168435] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/29/2021] [Accepted: 08/04/2021] [Indexed: 01/18/2023]
Abstract
Diagnosis is one of the crucial tasks performed by primary care physicians; however, primary care is at high risk of diagnostic errors due to the characteristics and uncertainties associated with the field. Prevention of diagnostic errors in primary care requires urgent action, and one of the possible methods is the use of health information technology. Its modes such as clinical decision support systems (CDSS) have been demonstrated to improve the quality of care in a variety of medical settings, including hospitals and primary care centers, though its usefulness in the diagnostic domain is still unknown. We conducted a scoping review to confirm the usefulness of the CDSS in the diagnostic domain in primary care and to identify areas that need to be explored. Search terms were chosen to cover the three dimensions of interest: decision support systems, diagnosis, and primary care. A total of 26 studies were included in the review. As a result, we found that the CDSS and reminder tools have significant effects on screening for common chronic diseases; however, the CDSS has not yet been fully validated for the diagnosis of acute and uncommon chronic diseases. Moreover, there were few studies involving non-physicians.
Collapse
|
11
|
Haridy J, Iyngkaran G, Nicoll A, Hebbard G, Tse E, Fazio T. eHealth Technologies for Screening, Diagnosis, and Management of Viral Hepatitis: A Systematic Review. Clin Gastroenterol Hepatol 2021; 19:1139-1150.e30. [PMID: 32896632 DOI: 10.1016/j.cgh.2020.09.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND & AIMS Chronic viral hepatitis is a leading cause of worldwide liver-related morbidity and mortality, despite the availability of effective treatments that reduce or prevent complications in most patients. Electronic-health (eHealth) technologies have potential to intervene along the whole cascade of care. We aimed to summarize available literature on eHealth interventions with respect to conventional screening, diagnostic and treatment outcomes in chronic hepatitis B (HBV) and hepatitis C (HCV). METHODS We systematically reviewed MEDLINE, EMBASE, Cochrane Library and international conference abstracts, including studies published from 2009 - 2020. Overall 80 studies were included, covering electronic medical record (EMR) interventions (n=39), telemedicine (n=20), mHealth (n=5), devices (n=4), clinical decision support (n=3), web-based (n=5), social media (n=1) and electronic communication (n=3). RESULTS Compared to standard care, EMR alerts increase screening rates in eligible populations including birth cohort screening in HCV, universal HCV screening in Emergency Departments, ethnic groups with high HBV prevalence, and HBV screening prior to immunosuppression. Direct messaging alerts to providers and automated testing may have a greater effect. No significant difference was found in sustained virological response outcomes between telemedicine and face-to-face management for community, rural and prison cohorts in HCV in the direct acting antiviral era of treatment, with higher patient satisfaction in telemedicine groups. CONCLUSIONS EMR alerts significantly increase screening rates in eligible cohorts in both chronic HBV and HCV. Telemedicine is equally efficacious to face-to-face care in HCV treatment. Other eHealth technologies show promise; however rigorous studies are lacking.
Collapse
Affiliation(s)
- James Haridy
- University of Melbourne, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia.
| | - Guru Iyngkaran
- University of Melbourne, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Australia; Department of Gastroenterology, Royal Darwin Hospital, Darwin, Australia
| | - Amanda Nicoll
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Australia; Monash University, Eastern Health Clinical School, Melbourne, Australia
| | - Geoffrey Hebbard
- University of Melbourne, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Australia
| | - Edmund Tse
- Department of Gastroenterology, Royal Darwin Hospital, Darwin, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia; University of Adelaide, School of Medicine, Faculty of Health and Medical Sciences, Adelaide, Australia
| | - Timothy Fazio
- University of Melbourne, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Metabolic Diseases Unit, Royal Melbourne Hospital, Melbourne, Australia; Business Intelligence Unit, Royal Melbourne Hospital, Melbourne, Australia
| |
Collapse
|
12
|
Healthcare Disparities Identified Between Hmong and Other Asian Origin Groups Living with Chronic Hepatitis B Infection in Sacramento County 2014-2017. J Community Health 2021; 45:412-418. [PMID: 31612369 DOI: 10.1007/s10900-019-00763-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic hepatitis B (CHB) disproportionately affects non-US born Asians. The Hmong have been shown to have the highest rates of CHB and mortality from liver cancer compared to other Asian groups. From September 2014 to September 2017, testing for CHB within Sacramento County was conducted through community-based testing events and an electronic health record alert that identified Asian patients by surname. Demographic and laboratory data were collected for analysis and patients were followed through the study period to assess linkage to care and treatment to compare differences between Asian origin groups. Of 4350 patients tested for CHB, 318 (7.3%) were HBsAg positive, including 90 Chinese, 47 Hmong, and 101 Vietnamese. Hmong were more likely to have Medicaid insurance compared to other Asian origin groups (15%, p < 0.001). Hmong had significantly lower rates of hepatitis B DNA testing (p < 0.001), referral to hepatology (p < 0.001), attendance of first (p < 0.001) and second medical visit (p = 0.0003), and lower rates of antiviral treatment compared to other Asian origin groups. Hmong also had the highest proportion of non-English speakers (p < 0.001). Hmong patients in the Sacramento CHB testing and linkage to care program experience socioeconomic disadvantages compared to Vietnamese and Chinese patients. These factors may contribute to decreased linkage of care and decreased anti-viral treatment rates for CHB.
Collapse
|
13
|
Chak E, Li CS, Chen MS, MacDonald S, Bowlus C. Electronic health record alerts enhance mass screening for chronic hepatitis B. Sci Rep 2020; 10:19153. [PMID: 33154429 PMCID: PMC7644717 DOI: 10.1038/s41598-020-75842-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/16/2020] [Indexed: 12/23/2022] Open
Abstract
To measure the effect of an electronic health record (EHR) alert on chronic hepatitis B (CHB) screening among at-risk Asian and Pacific Islanders (API). API patients who had not yet completed hepatitis B surface antigen (HBsAg) testing were identified by a novel EHR-based population health tool. At-risk API patients in Cohort 1 (primarily privately insured) and Cohort 2 (includes Medicare and/or Medicaid) were randomized to alert activation in their electronic medical charts or not. In total, 8299 API were found to be deficient in HBsAg completion at baseline within our health system. In Cohort 1, 1542 patients and 1568 patients were randomized to the alert and control respectively. In Cohort 2, 2599 patients and 2590 patients were randomized to the alert and control respectively. For both cohorts combined, 389 HBsAg tests were completed in the alert group compared to 177 HBsAg tests in the control group (p < 0.0001; OR = 2.3; 95% CI 1.94-2.80), but there was no increased detection of HBsAg positivity from the alert (15 versus 13 respectively, p = 0.09; OR = 0.5; 95% CI 0.24-1.09). Our results demonstrate that personalized, automated electronic alerts increase screening for CHB, but more comprehensive measures are needed to detect HBsAg positive patients.NIH Trial Registry Number: NCT04240678.
Collapse
Affiliation(s)
- Eric Chak
- Division of Gastroenterology and Hepatology, UC Davis School of Medicine, 4150 V Street, PSSB 3500, Sacramento, CA, USA.
| | - Chin-Shang Li
- School of Nursing, The State University of New York, University at Buffalo, Buffalo, NY, USA
| | - Moon S Chen
- Division of Hematology and Oncology, UC Davis School of Medicine, Sacramento, CA, USA
| | - Scott MacDonald
- Division of Clinical Informatics, UC Davis Medical Center, Sacramento, CA, USA
| | - Christopher Bowlus
- Division of Gastroenterology and Hepatology, UC Davis School of Medicine, 4150 V Street, PSSB 3500, Sacramento, CA, USA
| |
Collapse
|
14
|
Hwang JP, Feld JJ, Hammond SP, Wang SH, Alston-Johnson DE, Cryer DR, Hershman DL, Loehrer AP, Sabichi AL, Symington BE, Terrault N, Wong ML, Somerfield MR, Artz AS. Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update. J Clin Oncol 2020; 38:3698-3715. [PMID: 32716741 DOI: 10.1200/jco.20.01757] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This Provisional Clinical Opinion update presents a clinically pragmatic approach to hepatitis B virus (HBV) screening and management. PROVISIONAL CLINICAL OPINION All patients anticipating systemic anticancer therapy should be tested for HBV by 3 tests-hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) total immunoglobulin (Ig) or IgG, and antibody to hepatitis B surface antigen-but anticancer therapy should not be delayed. Findings of chronic HBV (HBsAg-positive) or past HBV (HBsAg-negative and anti-HBc-positive) infection require HBV reactivation risk assessment.Patients with chronic HBV receiving any systemic anticancer therapy should receive antiviral prophylactic therapy through and for minimum 12 months following anticancer therapy. Hormonal therapy alone should not pose a substantial risk of HBV reactivation in patients with chronic HBV receiving hormonal therapy alone; these patients may follow noncancer HBV monitoring and treatment guidance. Coordination of care with a clinician experienced in HBV management is recommended for patients with chronic HBV to determine HBV monitoring and long-term antiviral therapy after completion of anticancer therapy.Patients with past HBV infection undergoing anticancer therapies associated with a high risk of HBV reactivation, such as anti-CD20 monoclonal antibodies or stem-cell transplantation, should receive antiviral prophylaxis during and for minimum 12 months after anticancer therapy completion, with individualized management thereafter. Careful monitoring may be an alternative if patients and providers can adhere to frequent, consistent follow-up so antiviral therapy may begin at the earliest sign of reactivation. Patients with past HBV undergoing other systemic anticancer therapies not clearly associated with a high risk of HBV reactivation should be monitored with HBsAg and alanine aminotransferase during cancer treatment; antiviral therapy should commence if HBV reactivation occurs.Additional information is available at www.asco.org/supportive-care-guidelines.
Collapse
Affiliation(s)
- Jessica P Hwang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Su H Wang
- Saint Barnabas Medical Center, Florham Park, NJ
| | | | | | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center at Columbia University, New York, NY
| | | | | | | | - Norah Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Melisa L Wong
- University of California San Francisco, San Francisco, CA
| | | | - Andrew S Artz
- City of Hope Comprehensive Cancer Center, Duarte, CA
| |
Collapse
|
15
|
DeSilva MB, Kodet A, Walker PF. A Best Practice Alert for Identifying Hepatitis B-Infected Patients. Am J Trop Med Hyg 2020; 103:884-886. [PMID: 32431283 DOI: 10.4269/ajtmh.20-0041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We developed and evaluated the Global Health Wizard Hepatitis B Best Practice Alert (BPA) to increase primary care provider adherence to evidence-based guidelines for hepatitis B virus (HBV) infection screening in non-U.S.-born patients. We conducted a pilot study using nine clinics to test BPA effectiveness. Eligible patients were aged ≥ 12 years, from a country of origin with ≥ 2% HBV prevalence, had no electronic health record documentation of HBV screening, and were seen for primary care during July 2012-March 2013. The BPA triggered for > 4,500 patients and identified six previously unrecognized HBV-infected patients. The pilot project demonstrated BPA effectiveness and continued to be used at pilot clinics until 2018 and was expanded to additional clinics in 2019; 29 additional HBV-infected patients were identified. Although successful, BPA usage steadily decreased over time. Poor BPA usage limits the power to achieve the goal of improved population-based HBV screening.
Collapse
Affiliation(s)
- Malini B DeSilva
- HealthPartners Travel and Tropical Medicine Department St. Paul, Minnesota.,HealthPartners Institute, Minneapolis, Minnesota
| | - Amy Kodet
- HealthPartners Institute, Minneapolis, Minnesota
| | - Patricia F Walker
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota.,HealthPartners Travel and Tropical Medicine Department St. Paul, Minnesota.,HealthPartners Institute, Minneapolis, Minnesota
| |
Collapse
|
16
|
The Lived Experience of Chronic Hepatitis B: A Broader View of Its Impacts and Why We Need a Cure. Viruses 2020; 12:v12050515. [PMID: 32392763 PMCID: PMC7290920 DOI: 10.3390/v12050515] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/25/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic hepatitis B (CHB) is one of the most widespread liver diseases in the world. It is currently incurable and can lead to liver cirrhosis and cancer. The considerable impacts on society caused by CHB through patient mortality, morbidity, and economic loss are well-recognised in the field. This is, however, a narrow view of the harms, given that people living with CHB can be asymptomatic for the majority of their life-long infection. Of less-appreciated importance are the psychosocial harms, which can continue throughout an affected person's lifetime. Here we review the broad range of these impacts, which include fear and anxiety; financial loss and instability; stigma and discrimination; and rejection by society. Importantly, these directly affect patient diagnosis, management, and treatment. Further, we highlight the roles that the research community can play in taking these factors into account and mitigating them. In particular, the development of a cure for hepatitis B virus infection would alleviate many of the psychosocial impacts of CHB. We conclude that there should be a greater recognition of the full impacts associated with CHB to bring meaningful, effective, and deliverable results to the global community living with hepatitis B.
Collapse
|
17
|
Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev 2009; 2009:CD001096. [PMID: 19588323 PMCID: PMC4171964 DOI: 10.1002/14651858.cd001096.pub2] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'. OBJECTIVES To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. SEARCH STRATEGY We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. SELECTION CRITERIA Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. MAIN RESULTS Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). AUTHORS' CONCLUSIONS Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.
Collapse
Affiliation(s)
- Kaveh G Shojania
- Director, University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Room D474, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5
| | | | | | | | | | | |
Collapse
|