Clinical Utility of a Biomarker to Detect Contrast-Induced Acute Kidney Injury during Percutaneous Cardiovascular Procedures

INTRODUCTION

Contrast-induced acute kidney injury (CI-AKI) is a major clinical complication of percutaneous cardiovascular procedures requiring iodinated contrast. Despite its relative frequency, practicing physicians are unlikely to identify or treat this condition.

METHODS

In a 2-round clinical trial of simulated patients, we examined the clinical utility of a urine-based assay that measures liver-type fatty acid-binding protein (L-FABP), a novel marker of CI-AKI. We sought to determine if interventional cardiologists' ability to diagnose and treat potential CI-AKI improved using the biomarker assay for 3 different patient types: pre-procedure, peri-procedure, and post-procedure patients.

RESULTS

154 participating cardiologists were randomly divided into either control or intervention. At baseline, we found no difference in the demographics or how they identified and treated potential complications of AKI, with both groups providing less than half the necessary care to their patients (46.4% for control vs. 47.6% for intervention, p = 0.250). The introduction of L-FABP into patient care resulted in a statistically significant improvement of 4.6% (p = 0.001). Compared to controls, physicians receiving L-FABP results were 2.9 times more likely to correctly identify their patients' risk for AKI (95% CI 2.1-4.0) and were more than twice as likely to treat for AKI by providing volume expansion and withholding nephrotoxic medications. We found the greatest clinical utility in the pre-procedure and peri-procedure settings but limited value in the post-procedure setting.

CONCLUSION

This study suggests L-FABP as a clinical marker for assessing the risk of potential CI-AKI, has clinical utility, and can lead to more accurate diagnosis and treatment.

Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial

BACKGROUND

Unwarranted variability in clinical practice is a challenging problem in practice today, leading to poor outcomes for patients and low-value care for providers, payers, and patients.

OBJECTIVE

In this study, we introduced a novel tool, QualityIQ, and determined the extent to which it helps primary care physicians to align care decisions with the latest best practices included in the Merit-Based Incentive Payment System (MIPS).

METHODS

We developed the fully automated QualityIQ patient simulation platform with real-time evidence-based feedback and gamified peer benchmarking. Each case included workup, diagnosis, and management questions with explicit evidence-based scoring criteria. We recruited practicing primary care physicians across the United States into the study via the web and conducted a cross-sectional study of clinical decisions among a national sample of primary care physicians, randomized to continuing medical education (CME) and non-CME study arms. Physicians "cared" for 8 weekly cases that covered typical primary care scenarios. We measured participation rates, changes in quality scores (including MIPS scores), self-reported practice change, and physician satisfaction with the tool. The primary outcomes for this study were evidence-based care scores within each case, adherence to MIPS measures, and variation in clinical decision-making among the primary care providers caring for the same patient.

RESULTS

We found strong, scalable engagement with the tool, with 75% of participants (61 non-CME and 59 CME) completing at least 6 of 8 total cases. We saw significant improvement in evidence-based clinical decisions across multiple conditions, such as diabetes (+8.3%, P<.001) and osteoarthritis (+7.6%, P=.003) and with MIPS-related quality measures, such as diabetes eye examinations (+22%, P<.001), depression screening (+11%, P<.001), and asthma medications (+33%, P<.001). Although the CME availability did not increase enrollment in the study, participants who were offered CME credits were more likely to complete at least 6 of the 8 cases.

CONCLUSIONS

Although CME availability did not prove to be important, the short, clinically detailed case simulations with real-time feedback and gamified peer benchmarking did lead to significant improvements in evidence-based care decisions among all practicing physicians.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03800901; https://clinicaltrials.gov/ct2/show/NCT03800901.

Initiative to Improve Evidence-Based Chronic Obstructive Pulmonary Disease Hospitalist Care Using a Novel On-Line Gamification Patient Simulation Tool: A Prospective Study

Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality. Much of the disease burden comes from exacerbations requiring hospitalization. Unwarranted care variation and divergence from evidence-based COPD management guidelines among hospitalists is a leading driver of the poor outcomes and excess costs associated with COPD-related hospitalizations. We engaged with Novant Health hospitalists to determine if measurement and feedback using fixed-choice simulated patients improves evidence-based care delivery and reduces costs. We created a series of gamified acute-care COPD case simulations with real-time feedback over 16 weeks then performed a year-over-year analytic comparison of the cost, length of stay (LOS), and revisits over the six months prior to the introduction of the simulated patients, the four months while caring for the simulated patients, and the six months after. In total, 245 hospitalists from 15 facilities at Novant Health participated. At baseline, the overall quality-of-care was measured as 58.4% + 12.3%, with providers correctly identifying COPD exacerbation in 92.4% of cases but only identifying the grade and group in 61.9% and 49.5% of cases, respectively. By the study end, the quality-of-care had improved 10.5% (p < 0.001), including improvements in identifying the grade (+9.7%, p = 0.044) and group (+8.4%, p = 0.098). These improvements correlated with changes in real-world performance data, including a 19% reduction in COPD-related pharmacy costs. Overall, the annualized impact of COPD improvements led to 233 fewer inpatient days, 371 fewer revisit days, and inpatient savings totaling nearly $1 million. Engaging practicing providers with patient simulation-based serial measurements and gamified evidence-based feedback potentially reduces inpatient costs while simultaneously reducing patient LOS and revisit rates.

Measuring the Variation in the Prevention and Treatment of CI-AKI Among Interventional Cardiologists

Contrast-induced acute kidney injury (CI-AKI) occurs in up to 10% of cardiac catheterizations and coronary interventions, resulting in increased morbidity, mortality, and cost. One main reason for these complications and costs is under-recognition of CI-AKI risk and under-treatment of patients with impaired renal status. 157 interventional cardiologists each cared for three simulated patients with common conditions requiring intravascular contrast media in three typical settings: pre-procedurally, during the procedure, and post-procedure. We evaluated their ability to assess the risk of developing CI-AKI, make the diagnosis, and treat CI-AKI, including proper volume expansion and withholding nephrotoxic medications. Overall, the quality-of-care scores averaged 46.0% ± 10.5, varying between 18% to 78%. The diagnostic scores for accurately assessing risk of CI-AKI were low at 57.1% ± 21.2% and the accuracy of diagnosis pre-existing chronic kidney disease was 50.2%. Poor diagnostic accuracy led to poor treatment: proper volume expansion done in only 30.7% of cases, in-hospital repeat creatinine evaluation performed in 32.1%, and avoiding nephrotoxic medications occurred in 14.2%. While volume expansion was relatively similar across the three settings (P = 0.287), the cardiologists were less likely to discontinue nephrotoxic medications in pre-procedurally (9.7%) compared to the other settings (27.0%), and to order in-hospital creatinine testing in peri-procedurally (18.8%) compared to post-procedure (57.8%) (P < 0.05 for both). The overall care of patients at risk for contrast-induced acute kidney injury varied widely and showed room for improvement. Improving care for this condition will require greater awareness by cardiologists and better diagnostic tools to guide them.

Finding the clinical utility of 1,5-anhydroglucitol among primary care practitioners

Background

HbA1c is widely used as the standard measure to track glycemic control in patients with diabetes and pre-diabetes but measures average levels of glycated hemoglobin over two to three months, with limited utility in the presence of recent and/or short-term fluctuations in glycemic control, which are correlated with worse patient outcomes.

Methods

We examined the clinical utility of 1-5-anhydroglucitol (1,5-AG) in six different, but common, case types of diabetes patients with short-term glycemic variability. We conducted a randomized controlled trial of simulated patients to examine the clinical practice patterns of primary care physicians before and after introducing 1,5-AG. The 145 participants were randomly assigned into standard care or standard care + 1,5-AG arms. Provider care was reviewed against explicit evidence-based care standards.

Results

At baseline, we saw no difference between the two study arms in clinical quality of care provided (p = 0.997). After introduction of 1,5-AG, standard care + 1,5-AG providers performed 3.2% better than controls (p = 0.025. In diagnosis and treatment, there was a slight, but nonsignificant trend toward better care (+1.1%, p = 0.507) for intervention providers. Upon disaggregation by case, almost all the improvement occurred in the medication-induced hyperglycemia patients (+8.1%, p = 0.047).

Conclusions

A nationally representative sample of primary care physicians demonstrated that of six different cases used in this study, 1,5-AG was found to be most effective increasing awareness of poor glucose control in medication-induced hyperglycemia. If 1,5-AG is used in this particular circumstance, the overall savings to the healthcare system is estimated to be $28 million.

A Direct Comparison of the Clinical Practice Patterns of Advanced Practice Providers and Doctors

BACKGROUND

Rising health care costs, physician shortages, and an aging patient population have increased the demand and utilization of advanced practice providers (APPs). Despite their expanding role in care delivery, little research has evaluated the care delivered by APPs compared with physicians.

METHODS

We used clinical patient simulations to measure and compare the clinical care offered by APPs and physicians, collecting data from 4 distinct health care systems/hospitals in the United States between 2013 and 2017. Specialties ranged from primary care to hospital medicine and oncology. Primary study outcomes were to 1) measure any differences in practice patterns between APPs and physicians, and 2) determine whether the use of serial measurement and feedback could mitigate any such differences.

RESULTS

At baseline, we found no major differences in overall performance of APPs compared with physicians (P = .337). APPs performed 3.2% better in history taking (P = .013) and made 10.5% fewer unnecessary referrals (P = .025), whereas physicians ordered 17.6% fewer low-value tests per case (P = .042). Regardless of specialty or site, after 4 rounds of serial measurement and provider-specific feedback, APPs and physicians had similar increases in average overall scores-7.4% and 7.6%, respectively (P < .001 for both). Not only did both groups improve, but practice differences between the groups disappeared, leading to a 9.1% decrease in overall practice variation.

CONCLUSIONS

We found only modest differences in quality of care provided by APPs and physicians. Importantly, both groups improved their performance with serial measurement and feedback so that after 4 rounds, the original differences were mitigated entirely and overall variation significantly reduced. Our data suggest that APPs can provide high quality care in multiple clinical settings.

Establishing Clinical Utility for Diagnostic Tests Using a Randomized Controlled, Virtual Patient Trial Design

Demonstrating clinical utility for diagnostic tests and securing coverage and reimbursement requires high quality and, ideally, randomized controlled trial (RCT) data. Traditional RCTs are often too costly, slow, and cumbersome for diagnostic firms. Alternative data options are needed. We evaluated four RCTs using virtual patients to demonstrate clinical utility. Each study used a similar pre-post intervention, two round design to facilitate comparison. Representative samples of physicians were recruited and randomized into control and intervention arms. All physicians were asked to care for their virtual patients during two assessment rounds, separated by a multi-week time interval. Between rounds, intervention physicians reviewed educational materials on the diagnostic test. All physician responses were scored against evidence-based care criteria. RCTs using virtual patients can demonstrate clinical utility for a variety of diagnostic test types, including: (1) an advanced multi-biomarker blood test, (2) a chromosomal microarray, (3) a proteomic assay analysis, and (4) a multiplex immunofluorescence imaging platform. In two studies, utility was demonstrated for all targeted patient populations, while in the other two studies, utility was only demonstrated for a select sub-segment of the intended patient population. Of these four tests, two received positive coverage decisions from Palmetto, one utilized the study results to support commercial payer adjudications, and the fourth company went out of business. RCTs using virtual patients are a cost-effective approach to demonstrate the presence or absence of clinical utility.

Variation in Assessing Renal Allograft Rejection: A National Assessment of Nephrology Practice

BACKGROUND

The clinical utility of early detection and treatment of allograft rejection is well-established. Despite frequent testing called for by standard of care protocols, the five-year kidney allograft survival rate is estimated to be as low as 71%. Herein, we report on posttransplant care provided to kidney allograft recipients by board-certified nephrologists in the United States.

METHODS

We measured clinical practice in a representative sample of 175 practicing nephrologists. All providers cared for simulated patients' status after renal transplant ranging from 30-75 years in age and 3-24 months after transplant. Our sample of nephrologists cared for a total of 525 allograft cases. Provider responses to the cases were reviewed by trained clinicians, and care was compared to evidence-based care standards and accepted standard of care protocols.

RESULTS

Among nephrologists, practicing in settings ranging from transplant centers to community practice, we found that the clinical workup of kidney injury in posttransplant patients is highly variable and frequently deviates from evidence-based care. In cases with pathologic evidence of rejection, only 29.1% (102/350) received an appropriate, evidence-based biopsy, whereas, in cases with no pathological evidence of rejection, 41.3% (45/109) received low-value, unnecessary biopsies.

CONCLUSION

Clinical care in the posttransplant setting is highly variable. Biopsies are often ordered in cases where their results do not alter treatment. Additionally, we found that misdiagnosis was common as were opportunities for earlier biopsy and detection of rejection. This evidence suggests that better diagnostic tools may be helpful to determine which transplant patients should be biopsied and which should not. This study suggests that nephrologists and transplant patients need better tests than creatinine and proteinuria and less invasive approaches than routine biopsies to determine when transplant patients should be investigated for rejection and additional treatment.

Standardising practice in cardiology: reducing clinical variation and cost at Ochsner Health System

Objective

Low quality and unwarranted clinical variation harm patients and increase unnecessary costs. Effective approaches to improve clinical and economic value have been difficult. The Ochsner Health System looked to improve clinical care quality and reduce unnecessary costs in cardiology using active measurement and customised feedback.

Methods

We serially measured care decisions using online, simulated cases to capture clinical details of cardiology practice and provide individual feedback. Fifty cardiologists cared for two simulated patients in each of six assessment rounds occurring 4 months apart. Simulated patients presented with heart failure (HF), coronary artery disease (CAD), supraventricular tachyarrhythmia (SVT) or valvular heart disease. Using Ochsner’s patient-level data, we performed real-world pre–post analyses of physician practice changes, patient outcomes and costs.

Results

Between baseline and final rounds, overall simulated quality-of-care scores improved 14.1% (p<0.001). In the same period, we found cost-of-care variation decreased in patient-level data, with larger decreases for more severely ill patients. The total per-patient direct costs decreased $493 in SVT, $305 in HF and $55 in CAD (p<0.05 for SVT and HF). Readmission rates fell significantly for HF (from 20.0% to 11.9%) and SVT (from 14.5% to 7.8%) (both p<0.001) and non-significantly for CAD (from 13.7% to 11.3%, p=0.112). The cost avoidance/revenue generation opportunity from reduced readmissions and direct costs amounted to annual savings of $4.34 million, with no significant changes to in-hospital mortality rates (p>0.05).

Conclusions

Using simulated patients to serially measure and provide individual feedback on clinical practice significantly raises quality and reduces practice variation and costs without negatively impacting outcomes.

Standardising hospitalist practice in sepsis and COPD care

Background

Hospitalist medicine was predicated on the belief that providers dedicated to inpatient care would deliver higher quality and more cost-effective care to acutely hospitalised patients. The literature shows mixed results and has identified care variation as a culprit for suboptimal quality and cost outcomes. Using a scientifically validated engagement and measurement approach such as Clinical Performance and Value (CPV), simulated patient vignettes may provide the impetus to change provider behaviour, improve system cohesion, and improve quality and cost efficiency for hospitalists.

Methods

We engaged 33 hospitalists from four disparate hospitalist groups practising at Penn Medicine Princeton Health. Over 16 months and four engagement rounds, participants cared for two patients per round (with a diagnosis of chronic obstructive pulmonary disease [COPD] and sepsis), then received feedback, followed by a group discussion. At project end, we evaluated both simulated and real-world data to measure changes in clinical practice and patient outcomes.

Results

Participants significantly improved their evidence-based practice (+13.7% points, p<0.001) while simultaneously reducing their variation (−1.4% points, p=0.018), as measured by the overall CPV score. Correct primary diagnosis increased significantly for both sepsis (+19.1% points, p=0.004) and COPD (+22.7% points, p=0.001), as did adherence to the sepsis 3-hour bundle (+33.7% points, p=0.010) and correct admission levels for COPD (+26.0% points, p=0.042). These CPV changes coincided with real-world improvements in length of stay and mortality, along with a calculated $5 million in system-wide savings for both disease conditions.

Conclusion

This study shows that an engagement system—using simulated patients, benchmarking and feedback to drive provider behavioural change and group cohesion, using parallel tracking of hospital data—can lead to significant improvements in patient outcomes and health system savings for hospitalists.

Methods to improve quality performance at scale in lower- and middle-income countries

Universal Health Coverage is one of the Sustainable Development Goal targets. But coverage without quality health services limits benefits to populations. Performance-based financing programs (PBF) use strategic purchasing of services to expand coverage and promote quality by measuring quality and rewarding good performance. The widespread presence of PBF programs in lower and middle-income countries provide an opportunity to introduce and test new approaches for measuring and improving quality at scale. This article describes four approaches to improve quality of health services at scale in PBF programs. These approaches looked at structural and process measures of quality as well as outcome measures like patient satisfaction. Three types of tools were used in these approaches: clinical vignettes, competency tests and patient satisfaction surveys. Specific tools within each of the approaches are used in Kyrgyzstan, Cambodia, Democratic Republic of Congo and the Republic of Congo.

Clinical Utility of Definitive Drug⁻Drug Interaction Testing in Primary Care

Drug–drug interactions (DDIs) are a leading cause of morbidity and mortality. New tools are needed to improve identification and treatment of DDIs. We conducted a randomized controlled trial to assess the clinical utility of a new test to identify DDIs and improve their management. Primary care physicians (PCPs) cared for simulated patients presenting with DDI symptoms from commonly prescribed medications and other ingestants. All physicians, in either control or one of two intervention groups, cared for six patients over two rounds of assessment. Intervention physicians were educated on the DDI test and given access to these test reports when caring for their patients in the second round. At baseline, we saw no significant differences in making the DDI diagnosis (p = 0.071) or DDI-related treatment (p = 0.640) between control and intervention arms. By round two, providers who accessed the DDI test performed significantly better in making the DDI diagnosis (+41.6%) and performing DDI-specific treatment (+12.2%) than in the previous round, and were 9.8 and 20.4 times more likely to diagnose and identify the DDI (p < 0.001 for all). The introduction of a definitive DDI test significantly increased identification, appropriate management, and counseling of DDIs among PCPs, which has the potential to improve clinical care.

Drug-Drug Interaction Assessment and Identification in the Primary Care Setting

Background

Drug-drug interactions (DDIs) are ubiquitous, harmful and a leading cause of morbidity and mortality. With an aging population, growth in polypharmacy, widespread use of supplements, and the rising opioid abuse epidemic, primary care physicians (PCPs) are increasingly challenged with identifying and preventing DDIs. We set out to evaluate current clinical practices related to identifying and treating DDIs and to determine if opportunities to increase prevention of DDIs and their adverse events could be identified.

Methods

In a nationally representative sample of 330 board-certified family and internal medicine practitioners, we evaluated whether PCPs assessed DDIs in the care they provided for three simulated patients. The patients were taking common prescription medications (e.g. opioids and psychiatric medications) along with other common ingestants (e.g. supplements and food) and presented with symptoms of DDIs. Physicians were scored on their ability to inquire about the patient's medications, investigate possible DDIs, evaluate the patient, and provide treatment recommendations. We scored the physicians' care recommendations against evidence-based criteria, including overall care quality and treatment for DDIs.

Results

Average overall quality of care score was 50.5% ± 12.0%. Despite >99% self-reported use of medication reconciliation practices and tools, physicians identified DDIs in only 15.3% of patients, with 15.5% ± 20.3% of DDI-specific treatment by the physicians.

Conclusions

PCPs in this study did not recognize or adequately treat DDIs. Better methods are needed to screen for DDIs in the primary care setting.

Primary care variability in patients at higher risk for colorectal cancer: evaluation of screening and preventive care practices

OBJECTIVE

Sub-optimal colorectal cancer (CRC) evaluations have been attributed to both physician and patient factors. The primary objective of this study was to evaluate physician practice variation in patients with a higher risk of CRC. We wanted to identify the physician characteristics and the types of patients that were associated with missed screening opportunities; we also explored whether screening for CRC served as a proxy for better preventive care practices.

METHODS

A total of 213 board-certified family and internal medicine physicians participated in the study, conducted between September and December 2016. We used Clinical Performance and Value (CPV^®) vignettes, simulated patients, to collect data on CRC screening. The CPV patients presented with a typical range of signs and symptoms of potential CRC. The care provided to the simulated patients was scored against explicit evidence-based criteria. The main outcome measure was rate a diagnostic CRC workup was ordered. This data quantified the clinical practice variability for CRC screening in high risk patients and other preventive and screening practices.

RESULTS

A total of 81% of participants ordered appropriate CRC workup in patients at risk for CRC, with a majority (71%) selecting diagnostic colonoscopy over FIT/FOBT. Only 6% of physicians ordering CRC workup, however, counseled patients on their higher risk for CRC. The most commonly recognized symptoms prompting testing were unexplained weight loss or inadequate screening history, while the least recognized symptoms of CRC risk were abdominal discomfort found on review of systems.

CONCLUSION

This study shows that primary care physician screening of CRC varies widely. Those physicians who successfully screened for CRC were more likely to complete other prevention and screening practices.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

Does health insurance coverage or improved quality protect better against out-of-pocket payments? Experimental evidence from the Philippines

This paper explores whether health insurance coverage or improved quality at the hospital level protect better against out-of-pocket payments. Using data from a randomized policy experiment in the Philippines, we found that interventions to expand insurance coverage and improve provider quality both had an impact on out-of-pocket payments. The sample consists of 3121 child-patient patient observations across 30 hospitals either at baseline in 2003/04 or at the follow-up in 2007/08. Compared to controls, interventions that expanded insurance and provided performance-based provider payments to improve quality both resulted in a decline in out-of-pocket spending (21% decline, p-value = 0.061; and 24% decline, p-value = 0.017, respectively). With lower out-of-pocket payments for hospital care, monthly household spending on personal hygiene rose by 0.9 (p-value = 0.026) and 0.6 US$ (p-value = 0.098) under the expanded insurance and provider payment interventions, respectively, amounting to roughly a 40-60% increase relative to the controls. With the current surge for health insurance expansion in developing countries, our study suggests paying increased and possibly, equal attention to supply-side interventions will have similar impacts with operational simplicity and greater provider accountability.

Clinical Utility of a Comprehensive, Whole Genome CMA Testing Platform in Pediatrics: A Prospective Randomized Controlled Trial of Simulated Patients in Physician Practices

BACKGROUND

Developmental disorders (DD), including autism spectrum disorder (ASD) and intellectual disability (ID), are a common group of clinical manifestations caused by a variety of genetic abnormalities. Genetic testing, including chromosomal microarray (CMA), plays an important role in diagnosing these conditions, but CMA can be limited by incomplete coverage of genetic abnormalities and lack of guidance for conditions rarely seen by treating physicians.

METHODS

We conducted a longitudinal, randomized controlled trial investigating the impact of a higher resolution 2.8 million (MM) probe-CMA test on the quality of care delivered by practicing general pediatricians and specialists. To overcome the twin problems of finding an adequate sample size of multiple rare conditions and under/incorrect diagnoses, we used standardized simulated patients known as CPVs. Physicians, randomized into control and intervention groups, cared for the CPV pediatric patients with DD/ASD/ID. Care responses were scored against evidence-based criteria. In round one, participants could order diagnostic tests including existing CMA tests. In round two, intervention physicians could order the 2.8MM probe-CMA test. Outcome measures included overall quality of care and quality of the diagnosis and treatment plan.

RESULTS

Physicians ordering CMA testing had 5.43% (p<0.001) higher overall quality scores than those who did not. Intervention physicians ordering the 2.8MM probe-CMA test had 7.20% (p<0.001) higher overall quality scores. Use of the 2.8MM probe-CMA test led to a 10.9% (p<0.001) improvement in the diagnosis and treatment score. Introduction of the 2.8MM probe-CMA test led to significant improvements in condition-specific interventions including an 8.3% (p = 0.04) improvement in evaluation and therapy for gross motor delays caused by Hunter syndrome, a 27.5% (p = 0.03) increase in early cognitive intervention for FOXG1-related disorder, and an 18.2% (p<0.001) improvement in referrals to child neurology for Dravet syndrome.

CONCLUSION

Physician use of the 2.8MM probe-CMA test significantly improves overall quality as well as diagnosis and treatment quality for simulated cases of pediatric DD/ASD/ID patients, and delivers additional clinical utility over existing CMA tests.

A psychosocial resilience curriculum provides the "missing piece" to boost adolescent physical health: A randomized controlled trial of Girls First in India

RATIONALE AND OBJECTIVES

Despite a recent proliferation of interventions to improve health, education, and livelihoods for girls in low and middle income countries, psychosocial wellbeing has been neglected. This oversight is particularly problematic as attending to psychosocial development may be important not only for psychosocial but also physical wellbeing. This study examines the physical health effects of Girls First, a combined psychosocial (Girls First Resilience Curriculum [RC]) and adolescent physical health (Girls First Health Curriculum [HC]) intervention (RC + HC) versus its individual components (i.e., RC, HC) and a control group. We expected Girls First to improve physical health versus HC and controls.

METHODS

Over 3000 girls in 76 government middle schools in rural Bihar, India participated. Interventions were delivered through in-school peer-support groups, facilitated by pairs of local women. Girls were assessed before and after program participation on two primary outcomes (health knowledge and gender equality attitudes) and nine secondary outcomes (clean water behaviors, hand washing, menstrual hygiene, health communication, ability to get to a doctor when needed, substance use, nutrition, safety, vitality and functioning). Analyses included Difference-in-Difference Ordinary Least-Squares Regressions and F-tests for equality among conditions.

RESULTS

Girls First significantly improved both primary and eight secondary outcomes (all except nutrition) versus controls. Additionally, Girls First demonstrated significantly greater effects, improving both primary and six secondary outcomes (clean water behaviors, hand washing, health communication, ability to get to a doctor, nutrition, safety) versus HC.

CONCLUSIONS

This study is among the first to assess the impact of a combined psychosocial and adolescent health program on physical health. We found that combining these curricula amplified effects achieved by either curriculum alone. These findings suggest that psychosocial wellbeing should receive much broader attention, not only from those interested in improving psychosocial outcomes but also from those interested in improving physical health outcomes.

Do Health Reforms to Improve Quality Have Long-Term Effects? Results of a Follow-Up on a Randomized Policy Experiment in the Philippines

We tracked doctors who had previously participated in a randomized policy experiment in the Philippines. The original experiment involved 30 district hospitals divided equally into one control site and two intervention sites that increased insurance payments (full insurance support for children under 5 years old) or made bonus payments to hospital staff. During the 3 years of the intervention, quality-as measured by clinical performance and value vignettes-improved and was sustained in both intervention sites compared with controls. Five years after the interventions were discontinued, we remeasured the quality of care of the doctors. We found that the intervention sites continued to have significantly higher quality compared with the control sites. The previously documented quality improvement in intervention sites appears to be sustained; moreover, it was subject to a very low (less than 1% per year) rate of decay in quality scores.

Low Rates of Genetic Testing in Children With Developmental Delays, Intellectual Disability, and Autism Spectrum Disorders

To explore the routine and effective use of genetic testing for patients with intellectual disability and developmental delay (ID/DD), we conducted a prospective, randomized observational study of 231 general pediatricians (40%) and specialists (60%), using simulated patients with 9 rare pediatric genetic illnesses. Participants cared for 3 randomly assigned simulated patients, and care responses were scored against explicit evidence-based criteria. Scores were calculated as a percentage of criteria completed. Care varied widely, with a median overall score of 44.7% and interquartile range of 36.6% to 53.7%. Diagnostic accuracy was low: 27.4% of physicians identified the correct primary diagnosis. Physicians ordered chromosomal microarray analysis in 55.7% of cases. Specific gene sequence testing was used in 1.4% to 30.3% of cases. This study demonstrates that genetic testing is underutilized, even for widely available tests. Further efforts to educate physicians on the clinical utility of genetic testing may improve diagnosis and care in these patients.

Building psychosocial assets and wellbeing among adolescent girls: A randomized controlled trial

We conducted a randomized controlled trial of a 5-month resilience-based program (Girls First Resilience Curriculum or RC) among 2308 rural adolescent girls at 57 government schools in Bihar, India. Local women with at least a 10th grade education served as group facilitators. Girls receiving RC improved more (vs. controls) on emotional resilience, self-efficacy, social-emotional assets, psychological wellbeing, and social wellbeing. Effects were not detected on depression. There was a small, statistically significant negative effect on anxiety (though not likely clinically significant). Results suggest psychosocial assets and wellbeing can be improved for girls in high-poverty, rural schools through a brief school-day program. To our knowledge, this is one of the largest developing country trials of a resilience-based school-day curriculum for adolescents.

The impact of screening tools on diagnosis of chronic obstructive pulmonary disease in primary care

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is frequently misdiagnosed or undiagnosed, which can delay disease management interventions.

PURPOSE

The Screening, Evaluating and Assessing Rate CHanges of diagnosing respiratory conditions in primary care 1 (SEARCH1) study assessed whether screening using the COPD Population Screener (COPD-PS) questionnaire to detect COPD risk factors and symptoms, with or without a handheld spirometer (copd-6) to detect airflow limitation, can increase yields of COPD diagnosis and respiratory-related clinician actions in primary care.

DESIGN

A prospective, multi-center, pragmatic, comparative-effectiveness, cluster-randomized study conducted from September 2010 to October 2011 (data analyzed from December 2011 to January 2013).

PARTICIPANTS

Men and women aged ≥40 years visiting their participating primary care practice for any reason.

INTERVENTION

Practices were randomized to three study arms: COPD-PS + copd-6, COPD-PS alone, and usual care (no interventions). No practices received any specific education about COPD or its diagnosis.

MAIN OUTCOME MEASURES

The primary endpoint was yield of new clinical COPD diagnosis; the secondary endpoint was yield of respiratory-related clinician actions.

RESULTS

Of 9,704 patients enrolled, 8,770 had no prior COPD diagnosis and were included in endpoint analyses. Both interventions significantly increased COPD diagnostic yield over 8 weeks. Compared with a mean yield of 0.49% (0.13%) (controls), yields were 1.07% (0.20%) (OR=2.20, 95% CI=1.26, 3.84, p=0.006) and 1.16% (0.22%) (OR=2.38, 95% CI=1.38, 4.13, p=0.002) for COPD-PS and COPD-PS+copd-6 study arms, respectively. Respiratory-related clinician actions were not significantly different across study arms.

CONCLUSIONS

Office-based assessment can significantly increase COPD diagnosis by primary care physicians. Future trials must evaluate whether screening can improve outcomes for patients with COPD.

Public Hospital Care

In low- and middle-income countries, government budgets are rarely sufficient to cover a public hospital’s operating costs. Shortfalls are typically financed through a combination of health insurance contributions and user charges. The mixed nature of this financing arrangement potentially creates financial incentives to treat patients with equal health need unequally. Using data from the Philippines, the authors analyzed whether doctors respond to such incentives. After controlling for a patient’s condition, they found that patients using insurance, paying more for hospital accommodation, and being treated in externally monitored hospitals were likely to receive more care. This highlights the worrying possibility that public hospital patients with equal health needs are not always equally treated.

Demonstrating bias and improved inference for stoves' health benefits

BACKGROUND

Many studies associate health risks with household air pollution from biomass fuels and stoves. Evaluations of stove improvements can suffer from bias because they rarely address health-relevant differences between the households who get improvements and those who do not.

METHODS

We demonstrate both the potential for bias and an option for improved stove inference by applying to household air pollution a technique used elsewhere in epidemiology, propensity-score matching (PSM), based on a stoves-and-health survey for China (15 counties, 3500 households).

RESULTS

Health-relevant factors (age, wealth, kitchen ventilation) do in fact differ considerably between the households with stove improvements and those without. We study the resulting bias in estimates of cleaner-stove impacts using a self-reported Physical Component Summary (PCS). Typical stoves-literature regressions with little control for non-stove factors suggest no benefits from a cleaner-fuel stove relative to a traditional biomass stove. Yet increasing controls raises the impact estimates. Our PSM estimates address the differences in health-relevant factors using 'apples to apples' comparisons between those with improved stoves and 'similar' households. This generates higher estimates of clean-stove benefits, which are on the order of one half the standard deviation of the PCS outcome.

CONCLUSIONS

Our data demonstrate the potential importance of bias in household air pollution studies. This results from failure to address the possibility that those receiving improved stoves are themselves prone to better or worse health outcomes. It suggests the value of data collection and of study design for cookstove interventions and, more generally, for policy interventions within many health outcomes.

Do doctors under-provide, over-provide or do both? Exploring the quality of medical treatment in the Philippines

OBJECTIVE

To assess the quality of medical treatment by disaggregating quality into components that distinguish between insufficient and unnecessary care.

DESIGN

Randomly selected doctors were asked how they would treat a sick child. Their responses were disaggregated into how much of an evidence-based essential treatment plan was completed and the number of additional non-essential treatments that were given. Key variables included the expected cost, the health consequences of insufficient and unnecessary care and comparisons between public and private physicians. Responses to 160 clinical performance vignettes (CPVs) were analysed.

SETTING

Philippines.

PARTICIPANTS

One hundred and forty-three public and private physicians in the Philippines, collected in November 2003-December 2004 and September 2006-June 2007.

INTERVENTIONS

CPVs administered to physicians.

MAIN OUTCOME MEASURES

Process quality measures (accounting for the possibility of both over-treatment and under-treatment).

RESULTS

Based on CPVs, doctors gave both insufficient and unnecessary treatment to under-five children in 69% of cases. Doctors who provided the least sufficient care were also the most likely to give costly or harmful unnecessary care. Insufficient care typically had potentially worse health consequences for the patient than unnecessary care, though unnecessary care remains a concern because of overuse of antibiotics (47%) and unnecessary hospitalization (34%).

CONCLUSIONS

Quality of care is complex, but over- and under-treatment coexist and, in our analysis physicians that were more likely to under-treat a sick child were also those more likely to over-treat.

An unhealthy public-private tension: pharmacy ownership, prescribing, and spending in the Philippines

Physicians' links with pharmacies may create perverse financial incentives to overprescribe, prescribe products with higher profit margins, and direct patients to their pharmacy. Interviews with pharmacy customers in the Philippines show that those who use pharmacies linked to public-sector physicians had 5.4 greater odds of having a prescription from such physicians and spent 49.3 percent more than customers using other pharmacies. For customers purchasing brand-name medicines, switching to generics would reduce drug spending by 58 percent. Controlling out-of-pocket spending on drugs requires policies to control financial links between doctors and pharmacies, as well as tighter regulation of nongeneric prescribing.

Household CO and PM measured as part of a review of China's National Improved Stove Program

In 2001-2003, a team of researchers from the United States and China performed an independent, multidisciplinary review of China's National Improved Stove Program carried out since the 1980s. As part of a 3500-household survey, a subsample of 396 rural households were monitored for particulate matter less than 4 microm (PM(4)) in kitchens and living rooms over 24 h, of which 159 were measured in both summer and winter. Carbon monoxide was measured in a 40% subsample. The results of this indoor air quality (IAQ) component indicate that for nearly all household stove or fuel groupings, PM(4) levels were higher than - and sometimes more than twice as high as - the national PM(10) standard for indoor air (150 microg PM(10)/m(3)). If these results are typical, then a large fraction of China's rural population is now chronically exposed to levels of pollution far higher than those determined by the Chinese government to harm human health. Further, we observed highly diverse fuel usage patterns in these regions in China, supporting the observations in the household survey of multiple stoves being present in many kitchens. Improved stoves resulted in reduced PM(4) from biomass fuel combinations, but still not at levels that meet standards, and little improvement was observed in indoor pollution levels when other unimproved stoves were present in the same kitchen. As many households change fuels according to daily and seasonal factors, resulting in different seasonal concentrations in living rooms and kitchens, assessing health implications from fuel use requires longitudinal evaluation of fuel use and IAQ levels, combined with accurate time-activity information.

PRACTICAL IMPLICATIONS

Leaving aside the difficult issue of enforcement, it is uncertain whether Chinese household IAQ standards represent realistic objectives for current attainment given current patterns of energy consumption in rural China, which rely so heavily on unprocessed solid fuels. Even when used with chimneys, these fuels emit substantial pollution into the household environment. It is probable that low-emission technologies involving gaseous/liquid fuels or high combustion - efficiency biomass stoves need to be promoted in order to achieve these standards for the greater part of the population.

Why we love quality but hate to measure it

As a group, physicians strive for quality but often resist quality measurement. Cost, inconvenience, lack of time, mistrust of quality measures, and a fear of what assessment may find are all factors contributing to this resistance. However, quality, in both rich and poor counties, continues to be poor at worse and varied at best. If we are to improve the quality of our care, we need quality measurement to show us our weaknesses. A variety of tools are available to assess quality, which, when followed by the right policy interventions, can lead to improved care. Quality measurements are most effective when they are comparative, reflect the complexity of clinical practice, are not expected to be a panacea for spiraling costs, and are made available to our colleagues and our patients.

Assessing Measurement Properties of Two Single-item General Health Measures

BACKGROUND

Multi-item health status measures can be lengthy, expensive, and burdensome to collect. Single-item measures may be an alternative. We compared measurement properties of two single-item, general self-rated health (GSRH) questions to assess how well they captured information in a validated, multi-item instrument.

METHODS

We administered a general health survey (SF-12V) that included "standard" and "comparative" forms of a GSRH. We repeated the survey two weeks later to the same 75 medically stable outpatients to test for GSRH reproducibility, reliability, and validity using SF-12V Physical Functioning and Emotional Health subscales as a reference.

RESULTS

At each survey administration, the two GSRH questions demonstrated good alternate forms reliability (first administration: r = 0.74, p < 0.001; second administration: r = 0.74, p < 0.001) and good reproducibility ("standard": ICC 0.69; "comparative": ICC 0.85). Both GSRH items correlated with physical functioning ("standard": r = 0.66; "comparative": r = 0.56) and emotional health measures ("standard": r = 0.65; "comparative": r = 0.59). Mean subscale measures associated with responses in each GSRH category were significantly different (ANOVA, p < 0.001), indicating strong discriminant scale performance.

CONCLUSIONS

Our single-item, GSRH questions demonstrated good reproducibility, reliability, and strong concurrent and discriminant scale performance with an established health status measure.

Cardiac risk underestimation in urban, black women

BACKGROUND

Black women have a disproportionately higher incidence of cardiovascular disease mortality than other groups and the reason for this health disparity is incompletely understood. Underestimation of personal cardiac risk may play a role.

OBJECTIVE

We investigated the personal characteristics associated with underestimating cardiovascular disease in black women.

DESIGN, SETTING, PARTICIPANTS

Trained surveyors interviewed 128 black women during the baseline evaluation for a randomized controlled trial in an urban, academic continuity clinic affiliated with a public hospital system. They provided information on the presence of cardiac risk factors and demographic and psychosocial characteristics. These self-report data were supplemented with medical record abstraction for weight.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was the accurate perception of cardiac risk. Objective risk was determined by a simple count of major cardiac risk factors and perceived risk by respondent's answer to a survey question about personal cardiac risk. The burden of cardiac risk factors was high in this population: 77% were obese; 72% had hypertension; 48% had high cholesterol; 49% had a family history of heart disease; 31% had diabetes, and 22% currently used tobacco. Seventy-nine percent had 3 or more cardiac risk factors. Among those with 3 or more risk factors ("high risk"), 63% did not perceive themselves to be at risk for heart disease. Among all patients, objective and perceived cardiac risk was poorly correlated (kappa=0.026). In a multivariable model, increased perceived personal stress and lower income were significant correlates of underestimating cardiac risk.

CONCLUSIONS

Urban, disadvantaged black women in this study had many cardiac risk factors, yet routinely underestimated their risk of heart disease. We found that the strongest correlates of underestimation were perceived stress and lower personal income.

pT1 SUBSTAGING IN RENAL CELL CARCINOMA: VALIDATION OF THE 2002 TNM STAGING MODIFICATION OF MALIGNANT RENAL EPITHELIAL TUMORS

PURPOSE

Tumor size has been used as one of the criteria to stratify renal cell carcinoma (RCC) into different pathological stages (pT). The recent 2002 UICC/TNM classification of malignant epithelial renal tumors is modified to substratify pT1 RCC into pT1a (less than 4.0 cm) and pT1b (greater than 4.0 but less than 7.0 cm). In this study we ascertained if this stage modification has prognostic relevance.

MATERIALS AND METHODS

A total of 259 consecutive radical nephrectomy specimens of organ confined RCC from 1970 to 1997 at 1 institution, including 153 of conventional RCC (CRCC), 71 of papillary RCC, 28 of chromophobe RCC, 1 of collecting duct carcinoma and 6 of RCC not otherwise specified, with a mean clinical followup of 7.5 years (median 6.4) were included in the study.

RESULTS

There were 115 pT1a (44.4%), 95 pT1b (36.7%) and 49 pT2 tumors (18.9%). Disease recurrences (DR) and disease specific death occurred in 2 (1.7%) and 0 cases (0%) of pT1a, 7 (7.3%) and 5 (5.3%) of pT1b, and 16 (32.6%) and 12 (24.5%) of pT2. DR for pT1b was higher compared with pT1a (all histological subtypes RR 3.68), although this difference was not statistically significant (p = 0.106). If only CRCCs were analyzed, DR in the pT1b group was statistically higher compared with pT1a (RR 8.54, p = 0.047). Disease specific survival in pT1a could not be evaluated because no deaths occurred in this subgroup. DR and disease specific survival were significantly different between pT1b and pT2 tumors for all histological subtypes (RR 5.51, p = 0.001 and 5.49, p = 0.001) and for the CRCC subtype (RR 5.50, p = 0.001 and 5.18, p = 0.005, respectively). Using size as a continuous variable the logarithmic change in tumor size was a significant predictor of DR (RR 8.82, p = 0.001). All statistical analyses were adjusted for age and sex.

CONCLUSIONS

Substaging RCC into pT1a and pT1b yields prognostically important information, validating the 2002 TNM modification for malignant renal epithelial malignancies. The substratification of pT1 is particularly useful in tumors with CRCC histology.

A review of the case for neonatal thyrotropin screening in developing countries: the example of India

BACKGROUND

Infantile hypothyroidism, either caused by iodine-deficiency disorder (IDD) or congenital hypothyroidism (CH), is the world's leading cause of preventable mental retardation. Such hypothyroidism has virtually been eliminated in the developed world by salt iodization and neonatal thyroid screening. However, most developing countries do not have neonatal thyroid screening programs. Using India as an example, we review the case for newborn screening in the developing world.

METHODS

A literature review on infantile hypothyroidism in India was conducted and three Indian thyroid experts were queried about their views on neonatal screening in India.

RESULTS

Iodine nutrition improved markedly in India during the 1990s; 49% of the households are now using adequately iodized salt. The control of IDD is still insufficient in India. Nationally representative data on neonatal screening in India are not available, but two regional studies have been published. One study (n = 12,407) measured cord blood thyrotropin and the other (n = 25,244) measured filter paper thyroxine. These studies reported difficult socioeconomic and organizational barriers to the implementation of neonatal screening in India.

DISCUSSION

It is time for India to make neonatal thyroid screening and mandatory iodization of salt a priority and develop a comprehensive infantile hypothyroidism policy. Prioritization of infantile hypothyroidism prevention is justified by its high frequency, sensitivity of screening in detecting both IDD and CH, adverse consequences of missing diagnosis at birth, high effectiveness of prevention, severity of disability from hypothyroidism, cost effectiveness of prevention, and lack of a clinical method of diagnosis near birth.

Predictive modeling techniques in prostate cancer

A number of new predictive modeling techniques have emerged in the past several years. These methods can be used independently or in combination with traditional modeling techniques to produce useful tools for the management of prostate cancer. Investigators should be aware of these techniques and avail themselves of their potentially useful properties. This review outlines selected predictive methods that can be used to develop models that may be useful to patients and clinicians for prostate cancer management.

Genetic adaptive neural network to predict biochemical failure after radical prostatectomy: a multi-institutional study

BACKGROUND AND PURPOSE

Despite many new procedures, radical prostatectomy remains one of the commonest methods of treating clinically localized prostate cancer. Both from the physician's and the patient's point of view, it is important to have objective estimation of the likelihood of recurrence, which forms the foundation for treatment selection for an individual patient. Currently, it is difficult to predict the probability of biochemical recurrence (rising serum prostate specific antigen [PSA] concentration) in an individual patient, and approximately 30% of the patients do experience recurrence. Tools predicting the recurrence will be of immense practical utility in the treatment selection and planning follow up. We have utilized preoperative parameters through a computer based genetic adaptive neural network model to predict recurrence in such patients, which can help primary care physicians and urologists in making management recommendations.

PATIENTS AND METHODS

Fourteen hundred patients who underwent radical prostatectomy at participating institutions form the subjects of this study. Demographic data such as age, race, preoperative PSA, systemic biopsy based staging and Gleason scores were used to construct a neural network model. This model simulated the functioning of a trained human mind and learned from the database. Once trained, it was used to predict the outcomes in new patients.

RESULTS

The patients in this comprehensive database were representative of the average prostate cancer patients as seen in USA. Their mean age was 68.4 years, the mean PSA concentration before surgery was 11.6 ng/mL, and 67% patients had a Gleason sum of 5 to 7. The mean length of follow-up was 41.5 months. Eighty percent of the cancers were clinical stage T2 and 5% T3. In our series, 64% of patients had pathologically organ-confined cancer, 33% positive margins, and 14% had seminal vesicle invasion. Lymph node positive patients were not included in this series. Progression as judged by serum PSA was noted in 30.6%. With entry of a few routinely used parameters, the model could correctly predict recurrence in 76% of the patients in the validation set. The area under the curve was 0.831. The sensitivity was 85%, the specificity 74%, the positive predictive value 77%, and the negative predictive value of 83%.

CONCLUSION

It was possible to predict PSA recurrence with a high accuracy (76%). Physicians desiring objective treatment counseling can use this model, and significant cost savings are anticipated because of appropriate treatment selection and patient-specific follow-up protocols. This technology can be extended to other treatments such as watchful waiting, external-beam radiation, and brachytherapy.