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Ge J, Buenaventura A, Berrean B, Purvis J, Fontil V, Lai JC, Pletcher MJ. Applying human-centered design to the construction of a cirrhosis management clinical decision support system. Hepatol Commun 2024; 8:e0394. [PMID: 38407255 PMCID: PMC10898661 DOI: 10.1097/hc9.0000000000000394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/13/2023] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Electronic health record (EHR)-based clinical decision support is a scalable way to help standardize clinical care. Clinical decision support systems have not been extensively investigated in cirrhosis management. Human-centered design (HCD) is an approach that engages with potential users in intervention development. In this study, we applied HCD to design the features and interface for a clinical decision support system for cirrhosis management, called CirrhosisRx. METHODS We conducted technical feasibility assessments to construct a visual blueprint that outlines the basic features of the interface. We then convened collaborative-design workshops with generalist and specialist clinicians. We elicited current workflows for cirrhosis management, assessed gaps in existing EHR systems, evaluated potential features, and refined the design prototype for CirrhosisRx. At the conclusion of each workshop, we analyzed recordings and transcripts. RESULTS Workshop feedback showed that the aggregation of relevant clinical data into 6 cirrhosis decompensation domains (defined as common inpatient clinical scenarios) was the most important feature. Automatic inference of clinical events from EHR data, such as gastrointestinal bleeding from hemoglobin changes, was not accepted due to accuracy concerns. Visualizations for risk stratification scores were deemed not necessary. Lastly, the HCD co-design workshops allowed us to identify the target user population (generalists). CONCLUSIONS This is one of the first applications of HCD to design the features and interface for an electronic intervention for cirrhosis management. The HCD process altered features, modified the design interface, and likely improved CirrhosisRx's overall usability. The finalized design for CirrhosisRx proceeded to development and production and will be tested for effectiveness in a pragmatic randomized controlled trial. This work provides a model for the creation of other EHR-based interventions in hepatology care.
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Affiliation(s)
- Jin Ge
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California—San Francisco, San Francisco, California, USA
| | - Ana Buenaventura
- School of Medicine Technology Services, University of California—San Francisco, San Francisco, California, USA
| | - Beth Berrean
- School of Medicine Technology Services, University of California—San Francisco, San Francisco, California, USA
| | - Jory Purvis
- School of Medicine Technology Services, University of California—San Francisco, San Francisco, California, USA
| | - Valy Fontil
- Family Health Centers, NYU-Langone Medical Center, Brooklyn, New York, USA
| | - Jennifer C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California—San Francisco, San Francisco, California, USA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California—San Francisco, San Francisco, California, USA
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Bongiovanni T, Lancaster E, Behrends M, Zhang L, Wick E, Auerbach A, Pletcher MJ. Optimizing Uptake of Multimodal Pain Management After Surgery Using the Electronic Health Record. JAMA Surg 2023; 158:1108-1111. [PMID: 37610736 PMCID: PMC10448375 DOI: 10.1001/jamasurg.2023.3654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/08/2023] [Indexed: 08/24/2023]
Abstract
This quality improvement study evaluates the effect of an electronic health record intervention on multimodal pain management following surgery in 2 randomized clinical trials.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, San Francisco School of Medicine, University of California San Francisco
| | - Elizabeth Lancaster
- Department of Surgery, San Francisco School of Medicine, University of California San Francisco
| | - Matthias Behrends
- Department of Anesthesia, San Francisco School of Medicine, University of California San Francisco
| | - Li Zhang
- Department of Epidemiology and Biostatistics, San Francisco School of Medicine, University of California San Francisco
| | - Elizabeth Wick
- Department of Surgery, San Francisco School of Medicine, University of California San Francisco
| | - Andrew Auerbach
- Division of Hospital Medicine, San Francisco School of Medicine, University of California San Francisco
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, San Francisco School of Medicine, University of California San Francisco
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Ge J, Fontil V, Ackerman S, Pletcher MJ, Lai JC. Clinical decision support and electronic interventions to improve care quality in chronic liver diseases and cirrhosis. Hepatology 2023:01515467-990000000-00546. [PMID: 37611253 PMCID: PMC10998693 DOI: 10.1097/hep.0000000000000583] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/17/2023] [Indexed: 08/25/2023]
Abstract
Significant quality gaps exist in the management of chronic liver diseases and cirrhosis. Clinical decision support systems-information-driven tools based in and launched from the electronic health record-are attractive and potentially scalable prospective interventions that could help standardize clinical care in hepatology. Yet, clinical decision support systems have had a mixed record in clinical medicine due to issues with interoperability and compatibility with clinical workflows. In this review, we discuss the conceptual origins of clinical decision support systems, existing applications in liver diseases, issues and challenges with implementation, and emerging strategies to improve their integration in hepatology care.
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Affiliation(s)
- Jin Ge
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California – San Francisco, San Francisco, California, USA
| | - Valy Fontil
- Department of Medicine, NYU Grossman School of Medicine and Family Health Centers at NYU-Langone Medical Center, Brooklyn, New York, USA
| | - Sara Ackerman
- Department of Social and Behavioral Sciences, University of California – San Francisco, San Francisco, California, USA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California – San Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California – San Francisco, San Francisco, California, USA
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Bongiovanni T, Pletcher MJ, Lau C, Robinson A, Lancaster E, Zhang L, Behrends M, Wick E, Auerbach A. A behavioral intervention to promote use of multimodal pain medication for hospitalized patients: A randomized controlled trial. J Hosp Med 2023; 18:685-692. [PMID: 37357367 PMCID: PMC10578203 DOI: 10.1002/jhm.13153] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The use of nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce pain and has become a core strategy to decrease opioid use, but there is a lack of data to describe encouraging use when admitting patients using electronic health record systems. OBJECTIVE Assess an electronic health record system to increase ordering of NSAIDs for hospitalized adults. DESIGNS, SETTINGS AND PARTICIPANTS We performed a cluster randomized controlled trial of clinicians admitting adult patients to a health system over a 9-month period. Clinicians were randomized to use a standard admission order set. INTERVENTION Clinicians in the intervention arm were required to actively order or decline NSAIDs; the control arm was shown the same order but without a required response. MAIN OUTCOME AND MEASURES The primary outcome was NSAIDs ordered and administered by the first full hospital day. Secondary outcomes included pain scores and opioid prescribing. RESULTS A total of 20,085 hospitalizations were included. Among these hospitalizations, patients had a mean age of 58 years, and a Charlson comorbidity score of 2.97, while 50% and 56% were female and White, respectively. Overall, 52% were admitted by a clinician randomized to the intervention arm. NSAIDs were ordered in 2267 (22%) interventions and 2093 (22%) control admissions (p = .10). Similarly, there were no statistical differences in NSAID administration, pain scores, or opioid prescribing. Average pain scores (0-5 scale) were 3.36 in the control group and 3.39 in the intervention group (p = .46). There were no differences in clinical harms. CONCLUSIONS AND RELEVANCE Requiring an active decision to order an NSAID at admission had no demonstrable impact on NSAID ordering. Multicomponent interventions, perhaps with stronger decision support, may be necessary to encourage NSAID ordering.
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Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Catherine Lau
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew Robinson
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Lancaster
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Matthias Behrends
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
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Seki T, Aki M, Furukawa TA, Kawashima H, Miki T, Sawaki Y, Ando T, Katsuragi K, Kawashima T, Ueno S, Miyagi T, Noma S, Tanaka S, Kawakami K. Electronic Health Record-Nested Reminders for Serum Lithium Level Monitoring in Patients With Mood Disorder: Randomized Controlled Trial. J Med Internet Res 2023; 25:e40595. [PMID: 36947138 PMCID: PMC10139684 DOI: 10.2196/40595] [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: 06/28/2022] [Revised: 01/12/2023] [Accepted: 02/21/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Clinical guidelines recommend regular serum lithium monitoring every 3 to 6 months. However, in the real world, only a minority of patients receive adequate monitoring. OBJECTIVE This study aims to examine whether the use of the electronic health record (EHR)-nested reminder system for serum lithium monitoring can help achieve serum lithium concentrations within the therapeutic range for patients on lithium maintenance therapy. METHODS We conducted an unblinded, single-center, EHR-nested, parallel-group, superiority randomized controlled trial comparing EHR-nested reminders with usual care in adult patients receiving lithium maintenance therapy for mood disorders. The primary outcome was the achievement of therapeutically appropriate serum lithium levels between 0.4 and 1.0 mEq/L at 18 months after enrollment. The key secondary outcomes are included as follows: the number of serum lithium level monitoring except for the first and final monitoring; exacerbation of the mood disorder during the study period, defined by hospitalization, increase in lithium dose, addition of antipsychotic drugs or mood stabilizers, or addition or increase of antidepressants; adherence defined by the proportion of days covered by lithium carbonate prescription during the study period. RESULTS A total of 111 patients were enrolled in this study. A total of 56 patients were assigned to the reminder group, and 55 patients were assigned to the usual care group. At the follow-up, 38 (69.1%) patients in the reminder group and 33 (60.0%) patients in the usual care group achieved the primary outcome (odds ratio 2.14, 95% CI 0.82-5.58, P=.12). The median number of serum lithium monitoring was 2 in the reminder group and 0 in the usual care group (rate ratio 3.62; 95% CI 2.47-5.29, P<.001). The exacerbation of mood disorders occurred in 17 (31.5%) patients in the reminder group and in 16 (34.8%) patients in the usual care group (odds ratio 0.97, 95% CI 0.42-2.28, P=.95). CONCLUSIONS We found insufficient evidence for an EHR-nested reminder to increase the achievement of therapeutic serum lithium concentrations. However, the number of monitoring increased with relatively simple and inexpensive intervention. The EHR-based reminders may be useful to improve quality of care for patients on lithium maintenance therapy, and they have potentials to be applied to other problems. TRIAL REGISTRATION University Hospital Medical Information Network Clinical Trials Registry UMIN000033633; https://tinyurl.com/5n7wtyav.
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Affiliation(s)
- Tomotsugu Seki
- Department of Pharmacoepidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Morio Aki
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hirotsugu Kawashima
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Tomotaka Miki
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Yujin Sawaki
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
- National Epilepsy Center, National Hospital Organization Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Takaaki Ando
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Kentaro Katsuragi
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Takahiko Kawashima
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Senkei Ueno
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Takashi Miyagi
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
- Department of Psychiatry, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Shun'ichi Noma
- Department of Psychiatry, Toyooka Hospital, Toyooka, Japan
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
- Noma-Kokoro Clinic, Kyoto, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Collard HR, Grumbach K. A Call to Improve Health by Achieving the Learning Health Care System. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:29-35. [PMID: 36006840 DOI: 10.1097/acm.0000000000004949] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The learning health care system is an aspirational operational model for improving health care by learning from the care being delivered. The model, which has been endorsed by the National Academy of Medicine, aligns naturally with academic health systems, which have a mission to improve care for their communities through research and education. In this scholarly perspective, the authors define the learning health care system concept and its historical relationship to academic health systems; explore opportunities for and barriers to realizing the learning health care system; and propose actions to achieve the learning health care system at the local, regional, and national levels. The authors argue that the learning health care system model is essential to academic medicine's evolution and to achieving the foundational societal mission of academic health systems to advance health through research and education.
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Affiliation(s)
- Harold R Collard
- H.R. Collard is professor of medicine and health policy, Department of Medicine, director, Clinical and Translational Science Institute, and associate vice chancellor, Clinical Research, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0002-8384-9506
| | - Kevin Grumbach
- K. Grumbach is professor and chair, Department of Family and Community Medicine, director, Community Engagement Program, Clinical and Translational Science Institute, and senior medical director, Office of Population Health, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0002-7809-214X
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7
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Molina MF, Hall SM, Stitzer M, Kushel M, Chakravarty D, Vijayaraghavan M. Contingency management to promote smoking cessation in people experiencing homelessness: Leveraging the electronic health record in a pilot, pragmatic randomized controlled trial. PLoS One 2022; 17:e0278870. [PMID: 36525405 PMCID: PMC9757562 DOI: 10.1371/journal.pone.0278870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Cigarette smoking is disproportionately high among people experiencing homelessness (PEH). Contingency management (CM) is a strategy that has shown considerable efficacy for smoking cessation and has been used in short-term studies of smoking abstinence in PEH. We describe a pilot, pragmatic randomized controlled trial protocol, which leverages an electronic health record (EHR) infrastructure to assess the feasibility and acceptability of an extended CM intervention to improve long-term abstinence in PEH. METHODS We will conduct the study at three safety-net clinics in San Francisco among 90 adults experiencing homelessness who smoke cigarettes currently and have a desire to quit. We will encourage all participants to receive smoking cessation services that include behavioral counseling and pharmacotherapy through their clinics. We will randomly assign participants to an extended CM intervention group with escalating incentives contingent on abstinence or to a control group with fixed incentives for attending study visits. We will use the EHR to recruit participants, track receipt of counseling and pharmacotherapy during clinical care, and communicate with providers on participants' progress. CM participants will get escalating incentives for demonstration of carbon monoxide-verified abstinence over 6 months, with a total possible earnings of $475. Control participants will receive a fixed incentive of $5 for attending study visits, totaling $125. We will conduct the carbon-monoxide verified abstinence assessments-which will determine CM incentive amounts-daily during week 1, bi-weekly through week 4, weekly through week 13, and monthly through week 24. Measures of feasibility and acceptability, both quantitative and qualitative, will include assessments of screening and recruitment, adherence to study visits, engagement in smoking cessation clinical care, retention, and participant satisfaction. One of the primary clinical outcomes will be biochemically verified 7-day point prevalence abstinence at 6 months. We will measure secondary outcomes, which will include 7-day point prevalence abstinence at 2 weeks, 3 and 12 months. DISCUSSION This trial will allow us to assess the feasibility and acceptability of a CM cessation intervention among PEH. The protocol's clinical setting and use of EHRs gives it significant potential for scalability. If found to be feasible, acceptable, and subsequently efficacious in a larger trial, the intervention could reduce tobacco-related health disparities by increasing long-term smoking abstinence among this vulnerable population. TRIAL REGISTRATION ClinicalTrials.gov NCT04982952. Registered on July 29, 2021.
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Affiliation(s)
- Melanie F. Molina
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Sharon M. Hall
- Department of Psychiatry and Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, CA, United States of America
| | - Maxine Stitzer
- Friends Research Institute, Baltimore, MD, United States of America
| | - Margot Kushel
- Division of Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States of America
| | - Deepalika Chakravarty
- Center for Aids Prevention Studies, University of California, San Francisco, San Francisco, CA, United States of America
| | - Maya Vijayaraghavan
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States of America
- * E-mail:
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Hou J, Zhao R, Cai T, Beaulieu-Jones B, Seyok T, Dahal K, Yuan Q, Xiong X, Bonzel CL, Fox C, Christiani DC, Jemielita T, Liao KP, Liaw KL, Cai T. Temporal Trends in Clinical Evidence of 5-Year Survival Within Electronic Health Records Among Patients With Early-Stage Colon Cancer Managed With Laparoscopy-Assisted Colectomy vs Open Colectomy. JAMA Netw Open 2022; 5:e2218371. [PMID: 35737384 PMCID: PMC9227003 DOI: 10.1001/jamanetworkopen.2022.18371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/26/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Temporal shifts in clinical knowledge and practice need to be adjusted for in treatment outcome assessment in clinical evidence. Objective To use electronic health record (EHR) data to (1) assess the temporal trends in treatment decisions and patient outcomes and (2) emulate a randomized clinical trial (RCT) using EHR data with proper adjustment for temporal trends. Design, Setting, and Participants The Clinical Outcomes of Surgical Therapy (COST) Study Group Trial assessing overall survival of patients with stages I to III early-stage colon cancer was chosen as the target trial. The RCT was emulated using EHR data of patients from a single health care system cohort who underwent colectomy for early-stage colon cancer from January 1, 2006, to December 31, 2017, and were followed up to January 1, 2020, from Mass General Brigham. Analyses were conducted from December 2, 2019, to January 24, 2022. Exposures Laparoscopy-assisted colectomy (LAC) vs open colectomy (OC). Main Outcomes and Measures The primary outcome was 5-year overall survival. To address confounding in the emulation, pretreatment variables were selected and adjusted. The temporal trends were adjusted by stratification of the calendar year when the colectomies were performed with cotraining across strata. Results A total of 943 patients met key RCT eligibility criteria in the EHR emulation cohort, including 518 undergoing LAC (median age, 63 [range, 20-95] years; 268 [52%] women; 121 [23%] with stage I, 165 [32%] with stage II, and 232 [45%] with stage III cancer; 32 [6%] with colon adhesion; 278 [54%] with right-sided colon cancer; 18 [3%] with left-sided colon cancer; and 222 [43%] with sigmoid colon cancer) and 425 undergoing OC (median age, 65 [range, 28-99] years; 223 [52%] women; 61 [14%] with stage I, 153 [36%] with stage II, and 211 [50%] with stage III cancer; 39 [9%] with colon adhesion; 202 [47%] with right-sided colon cancer; 39 [9%] with left-sided colon cancer; and 201 [47%] with sigmoid colon cancer). Tests for temporal trends in treatment assignment (χ2 = 60.3; P < .001) and overall survival (χ2 = 137.2; P < .001) were significant. The adjusted EHR emulation reached the same conclusion as the RCT: LAC is not inferior to OC in overall survival rate with risk difference at 5 years of -0.007 (95% CI, -0.070 to 0.057). The results were consistent for stratified analysis within each temporal period. Conclusions and Relevance These findings suggest that confounding bias from temporal trends should be considered when conducting clinical evidence studies with long time spans. Stratification of calendar time and cotraining of models is one solution. With proper adjustment, clinical evidence may supplement RCTs in the assessment of treatment outcome over time.
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Affiliation(s)
- Jue Hou
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Rachel Zhao
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tianrun Cai
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Brett Beaulieu-Jones
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Thany Seyok
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Kumar Dahal
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
| | - Qianyu Yuan
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Xin Xiong
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Clara-Lea Bonzel
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - David C. Christiani
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - Katherine P. Liao
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | | | - Tianxi Cai
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
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Ge J, Kim WR, Lai JC, Kwong AJ. "Beyond MELD" - Emerging strategies and technologies for improving mortality prediction, organ allocation and outcomes in liver transplantation. J Hepatol 2022; 76:1318-1329. [PMID: 35589253 DOI: 10.1016/j.jhep.2022.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/24/2022] [Accepted: 03/04/2022] [Indexed: 02/06/2023]
Abstract
In this review article, we discuss the model for end-stage liver disease (MELD) score and its dual purpose in general and transplant hepatology. As the landscape of liver disease and transplantation has evolved considerably since the advent of the MELD score, we summarise emerging concepts, methodologies, and technologies that may improve mortality prognostication in the future. Finally, we explore how these novel concepts and technologies may be incorporated into clinical practice.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California - San Francisco, San Francisco, CA, USA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California - San Francisco, San Francisco, CA, USA
| | - Allison J Kwong
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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10
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Flaherman VJ, Robinson A, Creasman J, McCulloch CE, Paul IM, Pletcher MJ. Clinical Decision Support for Newborn Weight Loss: A Randomized Controlled Trial. Hosp Pediatr 2022; 12:e180-e184. [PMID: 35611641 DOI: 10.1542/hpeds.2021-006470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The Newborn Weight Tool (NEWT) can inform newborn feeding decisions and might reduce health care utilization by preventing excess weight loss. Clinical decision support (CDS) displaying NEWT might facilitate its use. Our study's objective is to determine the effect of CDS displaying NEWT on feeding and health care utilization. METHODS At an hospital involved in NEWT development, we randomly assigned 2682 healthy infants born ≥36 weeks gestation in 2018-2019 either to CDS displaying NEWT with an electronic flag if most recent weight was ≥75th weight loss centile or to a control of usual care with NEWT accessed at clinician discretion. Our primary outcome was feeding type concordant with weight loss, defined as exclusive breastfeeding for those not flagged, exclusive breastfeeding or supplementation for those flagged once, and supplementation for those flagged more than once. Secondary outcomes included inpatient and outpatient utilization in the first 30 days. We used χ2 and Student's t tests to compare intervention infants with control and to compare trial infants with those born in 2017. RESULTS Feeding was concordant with for 1854 (74.5%) trial infants and did not differ between randomized groups (P = .65); concordant feeding was higher for all trial infants than for infants born in 2017 (64.4%; P < .0005). Readmission occurred for 51 (3.8%) CDS infants and 45 (3.4%) control infants (P = .56). Among the 60% of trial infants with outpatient records available, there were 3.5 ± 1.7 visits with no differences between randomized groups (P = .10). CONCLUSIONS At an hospital involved in NEWT development, CDS displaying NEWT did not alter either feeding or health care utilization compared with discretionary NEWT access.
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Affiliation(s)
| | | | | | | | - Ian M Paul
- Penn State College of Medicine, Hershey, Pennsylvania
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Najafi N, Robinson A, Pletcher MJ, Patel S. Effectiveness of an Analytics-Based Intervention for Reducing Sleep Interruption in Hospitalized Patients: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:172-177. [PMID: 34962506 PMCID: PMC8715385 DOI: 10.1001/jamainternmed.2021.7387] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Sleep has major consequences for physical and emotional well-being. Hospitalized patients experience frequent iatrogenic sleep interruptions and there is evidence that such interruptions can be safely reduced. OBJECTIVE To determine whether a clinical decision support tool, powered by real-time patient data and a trained prediction algorithm, can help physicians identify clinically stable patients and safely discontinue their overnight vital sign checks. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial, with inpatient encounters randomized 1:1 to intervention vs usual care, was conducted from March 11 to November 24, 2019. Participants included physicians serving on the primary team of 1699 patients on the general medical service (not in the intensive care unit) of a tertiary care academic medical center. INTERVENTIONS A clinical decision support notification informed the physician if the patient had a high likelihood of nighttime vital signs within the reference ranges based on a logistic regression model that used real-time patient data as input. The notification provided the physician an opportunity to discontinue measure of nighttime vital signs, dismiss the notification for 1 hour, or dismiss the notification for that day. MAIN OUTCOMES AND MEASURES The primary outcome was delirium, as determined by bedside nurse assessment of Nursing Delirium Screening Scale scores, a standardized delirium screening tool (delirium diagnosed with score ≥2). Secondary outcomes included mean nighttime vital sign checks. Potential harms included intensive care unit transfers and code blue alarms. All analyses were conducted on the basis of intention-to-treat. RESULTS A total of 1930 inpatient encounters in 1699 patients (intervention encounters: 566 of 966 [59%] men; mean [SD] age, 53 [15] years) were randomized. In the intervention vs control arm, there was a significant decrease in the mean (SD) number of nighttime vital sign checks (0.97 [0.95] vs 1.41 [0.86]; P < .001) with no increase in intensive care unit transfers (49 [5%] vs 47 [5%]; P = .92) or code blue alarms (2 [0.2%] vs 9 [0.9%]; P = .07). The incidence of delirium was not significantly reduced (108 [11%] vs 123 [13%]; P = .32). CONCLUSIONS AND RELEVANCE While this randomized clinical trial found no difference between groups in the primary outcome, delirium incidence, the secondary findings indicate that a real-time prediction algorithm embedded within a clinical decision support tool in the electronic health record can help physicians identify clinically stable patients who can forgo routine vital sign checks, safely giving them greater opportunity to sleep. Other aspects of hospital care that depend on clinical stability, such as level of care or cardiac monitoring, may be amenable to a similar intervention. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04046458.
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Affiliation(s)
- Nader Najafi
- Department of Medicine, University of California, San Francisco
| | - Andrew Robinson
- University of California, San Francisco Medical Center, San Francisco
| | - Mark J Pletcher
- Department of Medicine, University of California, San Francisco
| | - Sajan Patel
- Department of Medicine, University of California, San Francisco
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Auerbach A, Bates DW. Introduction: Improvement and Measurement in the Era of Electronic Health Records. Ann Intern Med 2020; 172:S69-S72. [PMID: 32479178 DOI: 10.7326/m19-0870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Andrew Auerbach
- University of California, San Francisco, San Francisco, California (A.A.)
| | - David W Bates
- Brigham and Women's Hospital, Boston, Massachusetts (D.W.B.)
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