1
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Rigdon J, Ostasiewski B, Woelfel K, Wiseman KD, Hetherington T, Downs S, Kowalkowski M. Automated generation of comparator patients in the electronic medical record. Learn Health Syst 2024; 8:e10362. [PMID: 38249842 PMCID: PMC10797581 DOI: 10.1002/lrh2.10362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/17/2023] [Accepted: 02/18/2023] [Indexed: 03/30/2023] Open
Abstract
Background Well-designed randomized trials provide high-quality clinical evidence but are not always feasible or ethical. In their absence, the electronic medical record (EMR) presents a platform to conduct comparative effectiveness research, central to the emerging academic learning health system (aLHS) model. A barrier to realizing this vision is the lack of a process to efficiently generate a reference comparison group for each patient. Objective To test a multi-step process for the selection of comparators in the EMR. Materials and Methods We conducted a mixed-methods study within a large aLHS in North Carolina. We (1) created a list of 35 candidate variables; (2) surveyed 270 researchers to assess the importance of candidate variables; and (3) built consensus rankings around survey-identified variables (ie, importance scores >7) across two panels of 7-8 clinical research experts. Prioritized algorithm inputs were collected from the EMR and applied using a greedy matching technique. Feasibility was measured as the percentage of patients with 100 matched comparators and performance was measured via computational time and Euclidean distance. Results Nine variables were selected: age, sex, race, ethnicity, body mass index, insurance status, smoking status, Charlson Comorbidity Index, and neighborhood percentage in poverty. The final process successfully generated 100 matched comparators for each of 1.8 million candidate patients, executed in less than 100 min for the majority of strata, and had average Euclidean distance 0.043. Conclusion EMR-derived matching is feasible to implement across a diverse patient population and can provide a reproducible, efficient source of comparator data for observational studies, with additional testing in clinical research applications needed.
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Affiliation(s)
- Joseph Rigdon
- Department of Biostatistics and Data ScienceWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
- Center for Biomedical InformaticsWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
- Clinical and Translational Science InstituteWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Brian Ostasiewski
- Center for Biomedical InformaticsWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
- Clinical and Translational Science InstituteWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Kamah Woelfel
- Clinical and Translational Science InstituteWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Kimberly D. Wiseman
- Department of Social Sciences and Health PolicyWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Tim Hetherington
- Clinical and Translational Science InstituteWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Stephen Downs
- Center for Biomedical InformaticsWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Marc Kowalkowski
- Clinical and Translational Science InstituteWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
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2
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Woodward JM, Liu T, Kowalkowski M, Taylor YJ, Gutnik B, Mangieri DA. Assessing post-COVID symptomatology among persons with dementia and other older adults who were hospitalized due to COVID-19: An observational study. Health Sci Rep 2023; 6:e1345. [PMID: 37434750 PMCID: PMC10331926 DOI: 10.1002/hsr2.1345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/18/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023] Open
Affiliation(s)
| | - Tsai‐Ling Liu
- Center for Health System Sciences, Atrium HealthCharlotteNorth CarolinaUSA
| | - Marc Kowalkowski
- Center for Health System Sciences, Atrium HealthCharlotteNorth CarolinaUSA
| | - Yhenneko J. Taylor
- Center for Health System Sciences, Atrium HealthCharlotteNorth CarolinaUSA
| | - Bella Gutnik
- Center for Health System Sciences, Atrium HealthCharlotteNorth CarolinaUSA
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3
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Liu TL, Chou SH, Murphy S, Kowalkowski M, Taylor YJ, Hole C, Sitammagari K, Priem JS, McWilliams A. Evaluating Racial/Ethnic Differences in Care Escalation Among COVID-19 Patients in a Home-Based Hospital. J Racial Ethn Health Disparities 2023; 10:817-825. [PMID: 35257312 PMCID: PMC8900643 DOI: 10.1007/s40615-022-01270-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 11/25/2022]
Abstract
The novel coronavirus disease 2019 (COVID-19) has infected over 414 million people worldwide with 5.8 million deaths, as of February 2022. Telemedicine-based interventions to expand healthcare systems' capacity and reduce infection risk have rapidly increased during the pandemic, despite concerns regarding equitable access. Atrium Health Hospital at Home (AH-HaH) is a home-based program that provides advanced, hospital-level medical care and monitoring for patients who would otherwise be hospitalized in a traditional setting. Our retrospective cohort study of positive COVID-19 patients who were admitted to AH-HaH aims to investigate whether the rate of care escalation from AH-HaH to traditional hospitalization differed based on patients' racial/ethnic backgrounds. Logistic regression was used to examine the association between care escalation within 14 days from index AH-HaH admission and race/ethnicity. We found approximately one in five patients receiving care for COVID-19 in AH-HaH required care escalation within 14 days. Odds of care escalation were not significantly different for Hispanic or non-Hispanic Blacks compared to non-Hispanic Whites. However, secondary analyses showed that both Hispanic and non-Hispanic Black patients were younger and with fewer comorbidities than non-Hispanic Whites. The study highlights the need for new care models to vigilantly monitor for disparities, so that timely and tailored adaptations can be implemented for vulnerable populations.
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Affiliation(s)
- Tsai-Ling Liu
- Center for Outcomes Research and Evaluation (CORE), Atrium Health, 1300 Scott Ave, Charlotte, NC, 28204, USA.
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation (CORE), Atrium Health, 1300 Scott Ave, Charlotte, NC, 28204, USA
| | - Stephanie Murphy
- Division of Hospital Medicine, Department of Internal Medicine, Atrium Health, Charlotte, NC, USA
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation (CORE), Atrium Health, 1300 Scott Ave, Charlotte, NC, 28204, USA
| | - Yhenneko J Taylor
- Center for Outcomes Research and Evaluation (CORE), Atrium Health, 1300 Scott Ave, Charlotte, NC, 28204, USA
| | - Colleen Hole
- Population Health, Atrium Health, Charlotte, NC, USA
| | - Kranthi Sitammagari
- Division of Hospital Medicine, Department of Internal Medicine, Atrium Health, Charlotte, NC, USA
| | - Jennifer S Priem
- Center for Outcomes Research and Evaluation (CORE), Atrium Health, 1300 Scott Ave, Charlotte, NC, 28204, USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation (CORE), Atrium Health, 1300 Scott Ave, Charlotte, NC, 28204, USA.,Division of Hospital Medicine, Department of Internal Medicine, Atrium Health, Charlotte, NC, USA
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4
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Liu TL, Woodward JM, Kowalkowski M, Taylor YJ, Gutnik B, Mangieri DA. Assessing healthcare outcomes among patients with dementia requiring hospitalization for COVID-19: An observational study. J Am Geriatr Soc 2023; 71:970-973. [PMID: 36268968 PMCID: PMC9874898 DOI: 10.1111/jgs.18093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 01/29/2023]
Affiliation(s)
- Tsai-Ling Liu
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | | | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Yhenneko J Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Bella Gutnik
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Deanna A Mangieri
- Atrium Health Senior Care, Atrium Health, Charlotte, North Carolina, USA
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5
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Taylor SP, Weissman GE, Kowalkowski M, Admon AJ, Skewes S, Xia Y, Chou SH. A Quantitative Study of Decision Thresholds for Initiation of Antibiotics in Suspected Sepsis. Med Decis Making 2023; 43:175-182. [PMID: 36062810 DOI: 10.1177/0272989x221121279] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Clinicians' decision thresholds for initiating antibiotics in patients with suspected sepsis have not been quantified. We aimed to define an average threshold of infection likelihood at which clinicians initiate antibiotics when treating a patient with suspected infection and to evaluate the influence of severity of illness and clinician-related factors on the threshold. DESIGN This was a prospective survey of 153 clinicians responding to 8 clinical vignettes constructed from real-world data from 3 health care systems in the United States. We treated each hour in the vignette as a decision to treat or not treat with antibiotics and assigned an infection probability to each hour using a previously developed infection prediction model. We then estimated decision thresholds using regression models based on the timing of antibiotic initiation. We compared thresholds across categories of severity of illness and clinician-related factors. RESULTS Overall, the treatment threshold occurred at a 69% probability of infection, but the threshold varied significantly across severity of illness categories-when patients had high severity of illness, the treatment threshold occurred at a 55% probability of infection; when patients had intermediate severity, the threshold for antibiotic initiation occurred at an infection probability of 69%, and the threshold was 84% when patients had low severity of illness (P < 0.001 for group differences). Thresholds differed significantly across specialty, highest among infectious disease and lowest among emergency medicine clinicians and across years of experience, decreasing with increasing years of experience. CONCLUSIONS The threshold infection probability above which physicians choose to initiate antibiotics in suspected sepsis depends on illness severity as well as clinician factors. IMPLICATIONS Incorporating these context-dependent thresholds into discriminating and well-calibrated models will inform the development of future sepsis clinical decision support systems. Clinician-related differences in treatment thresholds suggests potential unwarranted variation and opportunities for performance improvement. HIGHLIGHTS Decision making about antibiotic initiation in suspected sepsis occurs under uncertainty, and little is known about clinicians' thresholds for treatment.In this prospective study, 153 clinicians from 3 health care systems reviewed 8 real-world clinical vignettes representing patients with sepsis and indicated the time that they would initiate antibiotics.Using a model-based approach, we estimated decision thresholds and found that thresholds differed significantly across illness severity categories and by clinician specialty and years of experience.
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Affiliation(s)
- Stephanie Parks Taylor
- Department of Internal Medicine, Wake Forest University School of Medicine, Atrium Health, Charlotte NC, USA.,Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Charlotte NC, USA.,Center for Outcomes Research and Evaluation, Atrium Health, Charlotte NC, USA
| | - Gary E Weissman
- Palliative and Advanced Illness Research (PAIR) Center University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Pulmonary, Allergy, and Critical Care Division University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, And Institute for Biomedical Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte NC, USA
| | - Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Pulmonary Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sable Skewes
- Department of Internal Medicine, Wake Forest University School of Medicine, Atrium Health, Charlotte NC, USA
| | - Yunfei Xia
- Department of Mathematics and Statistics, University of North Carolina, Charlotte, NC, USA
| | - Shih-Hsuing Chou
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte NC, USA
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6
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Bullard JT, Kowalkowski M, Sparling A, Roberge J, Barkley JE. A Retrospective Evaluation of the Impacts of a Multidisciplinary Care Model for Managing Patients with Advanced Illness on Acute Care Utilization and Quality of Care at End of Life. J Palliat Med 2022; 25:1835-1843. [PMID: 36137010 DOI: 10.1089/jpm.2022.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: A home-based goal-concordant care model targeting patients with advanced illnesses may reduce acute care utilization and improve quality outcomes at end of life. Aim: Study aim was to determine impact of the Advanced Illness Management (AIM) program on end-of-life utilization and quality of care. Design: A retrospective observational study design using propensity score fine stratum weighting methodologies was applied to decedent patients identified for AIM enrollment/eligibility in 2018 to 2019. Setting/Participants: A total of 3859 decedents, 216 of whom were AIM enrollees, were identified from a metropolitan health system's electronic medical records (EMR) and met study eligibility criteria. Results: Compared with usual care, AIM enrollees spent more days away from acute care in the last 30, 90, and 180 days of life. Furthermore, AIM enrollees were less likely to expire in an acute care hospital. Conclusions: Enrollment in programs such as AIM should be considered for patients with advanced illnesses approaching end of life.
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Affiliation(s)
- Jarrod T Bullard
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Marc Kowalkowski
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Alica Sparling
- Health Economics, Novant Health, Charlotte, North Carolina, USA
| | - Jason Roberge
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - John E Barkley
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
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7
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Hilton RS, Hauschildt K, Shah M, Kowalkowski M, Taylor S. The Assessment of Social Determinants of Health in Postsepsis Mortality and Readmission: A Scoping Review. Crit Care Explor 2022; 4:e0722. [PMID: 35928537 PMCID: PMC9345631 DOI: 10.1097/cce.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To summarize knowledge and identify gaps in evidence about the relationship between social determinants of health (SDH) and postsepsis outcomes. DATA SOURCES We conducted a comprehensive search of PubMed/Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, and the Cochrane Library. STUDY SELECTION We identified articles that evaluated SDH as risk factors for mortality or readmission after sepsis hospitalization. Two authors independently screened and selected articles for inclusion. DATA EXTRACTION We dual-extracted study characteristics with specific focus on measurement, reporting, and interpretation of SDH variables. DATA SYNTHESIS Of 2,077 articles screened, 103 articles assessed risk factors for postsepsis mortality or readmission. Of these, 28 (27%) included at least one SDH variable. Inclusion of SDH in studies assessing postsepsis adverse outcomes increased over time. The most common SDH evaluated was race/ethnicity (n = 21, 75%), followed by payer type (n = 10, 36%), and income/wealth (n = 9, 32%). Of the studies including race/ethnicity, nine (32%) evaluated no other SDH. Only one study including race/ethnicity discussed the use of this variable as a surrogate for social disadvantage, and none specifically discussed structural racism. None of the studies specifically addressed methods to validate the accuracy of SDH or handling of missing data. Eight (29%) studies included a general statement that missing data were infrequent. Several studies reported independent associations between SDH and outcomes after sepsis discharge; however, these findings were mixed across studies. CONCLUSIONS Our review suggests that SDH data are underutilized and of uncertain quality in studies evaluating postsepsis adverse events. Transparent and explicit ontogenesis and data models for SDH data are urgently needed to support research and clinical applications with specific attention to advancing our understanding of the role racism and racial health inequities in postsepsis outcomes.
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Affiliation(s)
- Ryan S Hilton
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Katrina Hauschildt
- Center for Clinical Management and Research, VA Ann Arbor Health Care System, Ann Arbor, MI
| | - Milan Shah
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC
| | - Stephanie Taylor
- Department of Internal Medicine, Wake Forest University School of Medicine Atrium Health Enterprise, Charlotte, NC
- Critical Illness, Injury, and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, NC
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8
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Donohue SJ, Reinke CE, Evans SL, Jordan MM, Warren YE, Hetherington T, Kowalkowski M, May AK, Matthews BD, Ross SW. Laparoscopy is associated with decreased all-cause mortality in patients undergoing emergency general surgery procedures in a regional health system. Surg Endosc 2022; 36:3822-3832. [PMID: 34477959 DOI: 10.1007/s00464-021-08699-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/24/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the use of laparoscopic surgery for common emergency general surgery (EGS) procedures within an integrated Acute Care Surgery (ACS) network. We hypothesized that laparoscopy would be associated with improved outcomes. METHODS Our integrated health care system's EGS registry created from AAST EGS ICD-9 codes was queried from January 2013 to October 2015. Procedures were grouped as laparoscopic or open. Standard descriptive and univariate tests were performed, and a multivariable logistic regression controlling for open status, age, BMI, Charlson Comorbidity Index (CCI), trauma tier, and resuscitation diagnosis was performed. Laparoscopic procedures converted to open were identified and analyzed using concurrent procedure billing codes across episodes of care. RESULTS Of 60,604 EGS patients identified over the 33-month period, 7280 (12.0%) had an operation and 6914 (11.4%) included AAST-defined EGS procedures. There were 4813 (69.6%) surgeries performed laparoscopically. Patients undergoing a laparoscopic procedure tended to be younger (45.7 ± 18.0 years vs. 57.2 ± 17.6, p < 0.001) with similar BMI (29.7 ± 9.0 kg/m2 vs. 28.8 ± 8.3, p < 0.001). Patients in the laparoscopic group had lower mean CCI score (1.6 ± 2.3 vs. 3.4 ± 3.2, p ≤ 0.0001). On multivariable analysis, open surgery had the highest association with inpatient mortality (OR 8.67, 4.23-17.75, p < 0.0001) and at all time points (30-, 90-day, 1-, 3-year). At all time points, conversion to open was found to be a statistically significant protective factor. CONCLUSION Use of laparoscopy in EGS is common and associated with a decreased risk of all-cause mortality at all time points compared to open procedures. Conversion to open was protective at all time points compared to open procedures.
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Affiliation(s)
- Sean J Donohue
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Susan L Evans
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Mary M Jordan
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Yancey E Warren
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Timothy Hetherington
- Carolinas Medical Center, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Marc Kowalkowski
- Carolinas Medical Center, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Brent D Matthews
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
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9
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Chou SH, McWilliams A, Murphy S, Sitammagari K, Liu TL, Hole C, Kowalkowski M. Factors Associated With Risk for Care Escalation Among Patients With COVID-19 Receiving Home-Based Hospital Care. Ann Intern Med 2021; 174:1188-1191. [PMID: 33971099 PMCID: PMC8252136 DOI: 10.7326/m21-0409] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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10
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Taylor YJ, Kowalkowski M, Spencer MD, Evans SM, Hall MN, Rissmiller S, Shrestha R, McWilliams A. Realizing a learning health system through process, rigor and culture change. Healthc (Amst) 2021; 8 Suppl 1:100478. [PMID: 34175095 DOI: 10.1016/j.hjdsi.2020.100478] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 07/28/2020] [Accepted: 09/18/2020] [Indexed: 12/19/2022]
Abstract
While many healthcare organizations strive to achieve the patient care benefits of being a learning health system (LHS), myriad challenges stand in the way of successful implementation. The reality of creating a true LHS requires top-to-bottom commitment to culture change with the necessary vision, leadership, and investment. The Center for Outcomes Research and Evaluation (CORE) is a multidisciplinary research unit embedded within a large, vertically integrated healthcare system in the southeastern United States. We used a two-pronged approach to: a) methodically recruit a team of experts, while generating early wins that demonstrated real success; and b) build relationships and buy-in across organizational leadership. Building out a team with diverse expertise created the ability to deploy pragmatic, data-driven research designs that fit seamlessly into real-world care delivery, resulting in agile study execution that aligns with health system timelines. Case study examples from hospital readmissions and antibiotic stewardship illustrate how our LHS operationalizes practice-informed research and research-informed practice. Lessons from this experience can serve as a blueprint for other healthcare systems or networks seeking to expand the promise of the LHS framework to improve health for patients and communities.
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Affiliation(s)
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, USA.
| | | | - Susan M Evans
- Center for Outcomes Research and Evaluation, Atrium Health, USA.
| | - Mary N Hall
- Division of Medical Education and Research, Atrium Health, USA; Medical Group Division, Atrium Health, USA.
| | | | | | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, USA; Medical Group Division, Atrium Health, USA; Department of Internal Medicine, Hospital Medicine, Atrium Health, USA.
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11
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Kowalkowski M, Eaton T, McWilliams A, Tapp H, Rios A, Murphy S, Burns R, Gutnik B, O'Hare K, McCurdy L, Dulin M, Blanchette C, Chou SH, Halpern S, Angus DC, Taylor SP. Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS). BMC Health Serv Res 2021; 21:544. [PMID: 34078374 PMCID: PMC8170654 DOI: 10.1186/s12913-021-06521-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sepsis survivors experience high morbidity and mortality, and healthcare systems lack effective strategies to address patient needs after hospital discharge. The Sepsis Transition and Recovery (STAR) program is a navigator-led, telehealth-based multicomponent strategy to provide proactive care coordination and monitoring of high-risk patients using evidence-driven, post-sepsis care tasks. The purpose of this study is to evaluate the effectiveness of STAR to improve outcomes for sepsis patients and to examine contextual factors that influence STAR implementation. METHODS This study uses a hybrid type I effectiveness-implementation design to concurrently test clinical effectiveness and gather implementation data. The effectiveness evaluation is a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial at eight hospitals in North Carolina comparing clinical outcomes between sepsis survivors who receive Usual Care versus care delivered through STAR. Each hospital begins in a Usual Care control phase and transitions to STAR in a randomly assigned sequence (one every 4 months). During months that a hospital is allocated to Usual Care, all eligible patients will receive usual care. Once a hospital transitions to STAR, all eligible patients will receive STAR during their hospitalization and extending through 90 days from discharge. STAR includes centrally located nurse navigators using telephonic counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted with suspected sepsis, defined by clinical criteria for infection and organ failure, are included. Planned enrollment is 4032 patients during a 36-month period. The primary effectiveness outcome is the composite of all-cause hospital readmission or mortality within 90 days of discharge. A mixed-methods implementation evaluation will be conducted before, during, and after STAR implementation. DISCUSSION This pragmatic evaluation will test the effectiveness of STAR to reduce combined hospital readmissions and mortality, while identifying key implementation factors. Results will provide practical information to advance understanding of how to integrate post-sepsis management across care settings and facilitate implementation, dissemination, and sustained utilization of best-practice post-sepsis management strategies in other heterogeneous healthcare delivery systems. TRIAL REGISTRATION NCT04495946 . Submitted July 7, 2020; Posted August 3, 2020.
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Affiliation(s)
- Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.
| | - Tara Eaton
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.,Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, Charlotte, USA
| | - Aleta Rios
- Ambulatory Care Management, Atrium Health, Charlotte, USA
| | | | - Ryan Burns
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Bella Gutnik
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | | | - Lewis McCurdy
- Division of Infectious Disease, Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Michael Dulin
- Academy for Population Health Innovation, University of North Carolina Charlotte & Mecklenburg County Public Health Department, Charlotte, USA.,Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
| | - Christopher Blanchette
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA.,Health Economics and Outcomes Research Strategy, Novo Nordisk, Plainsboro Township, USA
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Scott Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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Meredith J, Onsrud J, Davidson L, Medaris LA, Kowalkowski M, Fischer K, Priem J, Leonard M, McCurdy L. Successful Use of Telemedicine Infectious Diseases Consultation With an Antimicrobial Stewardship-Led Staphylococcus aureus Bacteremia Care Bundle. Open Forum Infect Dis 2021; 8:ofab229. [PMID: 34189171 PMCID: PMC8231364 DOI: 10.1093/ofid/ofab229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/30/2021] [Indexed: 11/20/2022] Open
Abstract
Background Telemedicine (TM) programs can be implemented to deliver specialty care through virtual platforms and overcome geographic/resource constraints. Few data exist to describe outcomes associated with TM-based infectious diseases (ID) management. The purpose of this study was to compare outcomes associated with TM and onsite standard-of-care (SOC) ID consultation after implementation of an antimicrobial stewardship (AMS)-led Staphylococcus aureus bacteremia (SAB) bundle. Methods A retrospective cohort study was conducted on the effects of a SAB bundle comparing ID consult delivery (SOC or TM) at 10 US hospitals within Atrium Health in adult patients admitted from September 2016 through December 2017. The type of ID consult provided was based on the admitting hospital; no hospital had both modalities. Bundle components included the following: (1) ID consult, (2) appropriate antibiotics, (3) repeat blood cultures until clearance, (4) echocardiogram obtainment, and (5) appropriate antibiotic duration. The AMS facilitated bundle initiation and compliance. The primary outcome was bundle adherence between groups. Differences in clinical outcomes were also assessed. Results We evaluated 738 patients with SAB (576 with SOC, 162 with TM ID). No differences were observed in overall bundle adherence (SOC 86% vs TM 89%, P = .33). In addition, no significant differences resulted between groups for hospital mortality, 30-day SAB-related readmission, persistent bacteremia, and culture clearance. Groups did not differ in 30-day mortality when controlling for demographics, bacteremia source, and physiological measures with multivariable logistic regression. Conclusions Our findings provide evidence to support effective use of TM ID consultation and AMS-led care bundles for SAB management in resource-limited settings.
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Affiliation(s)
- Jacqueline Meredith
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer Onsrud
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina, USA
| | - Lisa Davidson
- Department of Internal Medicine, Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina, USA
| | - Leigh Ann Medaris
- Department of Internal Medicine, Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina, USA
| | - Marc Kowalkowski
- Centers for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Kristin Fischer
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer Priem
- Centers for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Michael Leonard
- Department of Internal Medicine, Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina, USA
| | - Lewis McCurdy
- Department of Internal Medicine, Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina, USA
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Maloney SR, Reinke CE, Nimeri AA, Ayuso SA, Christmas AB, Hetherington T, Kowalkowski M, Sing RF, May AK, Ross SW. The Obesity Paradox in Emergency General Surgery Patients. Am Surg 2021; 88:852-858. [PMID: 33530738 DOI: 10.1177/0003134820968524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.
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Affiliation(s)
- Sean R Maloney
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | - Sullivan A Ayuso
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | - Marc Kowalkowski
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Ronald F Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Samuel Wade Ross
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Sitammagari K, Murphy S, Kowalkowski M, Chou SH, Sullivan M, Taylor S, Kearns J, Batchelor T, Rivet C, Hole C, Hinson T, McCreary P, Brown R, Dunn T, Neuwirth Z, McWilliams A. Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic. Ann Intern Med 2021; 174:192-199. [PMID: 33175567 PMCID: PMC7711652 DOI: 10.7326/m20-4076] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pandemics disrupt traditional health care operations by overwhelming system resource capacity but also create opportunities for care innovation. OBJECTIVE To describe the development and rapid deployment of a virtual hospital program, Atrium Health hospital at home (AH-HaH), within a large health care system. DESIGN Prospective case series. SETTING Atrium Health, a large integrated health care organization in the southeastern United States. PATIENTS 1477 patients diagnosed with coronavirus disease 2019 (COVID-19) from 23 March to 7 May 2020 who received care via AH-HaH. INTERVENTION A virtual hospital model providing proactive home monitoring and hospital-level care through a virtual observation unit (VOU) and a virtual acute care unit (VACU) in the home setting for eligible patients with COVID-19. MEASUREMENTS Patient demographic characteristics, comorbid conditions, treatments administered (intravenous fluids, antibiotics, supplemental oxygen, and respiratory medications), transfer to inpatient care, and hospital outcomes (length of stay, intensive care unit [ICU] admission, mechanical ventilation, and death) were collected from electronic health record data. RESULTS 1477 patients received care in either the AH-HaH VOU or VACU or both settings, with a median length of stay of 11 days. Of these, 1293 (88%) patients received care in the VOU only, with 40 (3%) requiring inpatient hospitalization. Of these 40 patients, 16 (40%) spent time in the ICU, 7 (18%) required ventilator support, and 2 (5%) died during their hospital admission. In total, 184 (12%) patients were ever admitted to the VACU, during which 21 patients (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required respiratory inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted as an inpatient to a conventional hospital. Of these 24 patients, 10 (42%) required ICU admission, 1 (3%) required a ventilator, and none died during their hospital admission. LIMITATION Generalizability is limited to patients with a working telephone and the ability to comply with the monitoring protocols. CONCLUSION Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond. PRIMARY FUNDING SOURCE Atrium Health.
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Affiliation(s)
- Kranthi Sitammagari
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Stephanie Murphy
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
| | - Matthew Sullivan
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Stephanie Taylor
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - James Kearns
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Thomas Batchelor
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Carly Rivet
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Colleen Hole
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Tony Hinson
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Pamela McCreary
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Ryan Brown
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Todd Dunn
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Zeev Neuwirth
- Atrium Health, Charlotte, North Carolina (K.S., S.M., M.S., S.T., J.K., T.B., C.R., C.H., T.H., P.M., R.B., T.D., Z.N.)
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina (M.K., S.C., A.M.)
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Taylor SP, Kowalkowski M. Dear qSOFA, We Would Like to Get to Know You Better…. Chest 2020; 157:232-233. [PMID: 31916958 DOI: 10.1016/j.chest.2019.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC
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Taylor SP, Kowalkowski M. Collaborator Conundrums. J Gen Intern Med 2019; 34:2903-2905. [PMID: 31621046 PMCID: PMC6854146 DOI: 10.1007/s11606-019-05411-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/20/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Stephanie Parks Taylor
- Department of Internal Medicine, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
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Gentry E, Kowalkowski M, Burns R, Sweeney C, Collins C, Ann Medaris L, Spencer M, Handy E, Davidson L. 1879. A 20/20 Vision: Successful Integration of a Prescribing Dashboard for Outpatient Antimicrobial Stewardship to Target 20% Reduction by the Year 2020. Open Forum Infect Dis 2019. [PMCID: PMC6809427 DOI: 10.1093/ofid/ofz359.109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background At least 30% of antibiotics prescribed in the ambulatory setting are unnecessary, including high rates of overuse for acute respiratory infections (ARI). We designed and evaluated whether a multifaceted outpatient stewardship program leveraging multidisciplinary stakeholder engagement, education tools, and an innovative prescribing dashboard decreased antibiotic prescribing in ARI. Methods In November 2017, the Carolinas HealthCare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN) launched an antibiotic awareness campaign in over 150 ambulatory practices in the Charlotte metropolitan area, reaching over one million patients. The campaign included online and in-person tools for patients and providers, targeted education at meetings, and social and mass media exposure. In March 2018, a provider level prescribing dashboard was introduced to target inappropriate antibiotic prescribing in ARI (acute sinusitis, nonsuppurative otitis media, nonbacterial pharyngitis, URI, cough, allergy, and influenza). Data were collected for family medicine (FM), internal medicine (IM), urgent care (UC) and pediatric medicine (PM); 10% and 20% relative reduction targets (years 2019 and 2020, respectively) were set for each service line. We compared pre (April 2016–March 2018) vs. post (April 2018–March 2019) intervention prescribing rates (calculated as the number of encounters with antibiotics vs. total) as rate ratios and used segmented regression models to assess change over time. Results There were 1,001,335 pre and 448,390 post-intervention encounters. Postintervention prescribing rates (antibiotics per 100 encounters) decreased for all service lines, FM (49.4 to 39.3), IM (49.7 to 41.2), UC (49.8 to 44.4), and PM (40.6 to 36.1) vs. pre-intervention (all rate ratios, P ≤ 0.01). All service lines met the target 2019 10% reduction goals. Post-implementation, FM and IM showed immediate decreases in prescribing (figure). After an initial increase, UC showed a significant month-to-month decrease (figure). Conclusion Integration of a prescribing dashboard within a multifaceted antibiotic awareness campaign reduced inappropriate outpatient antibiotic prescribing for ARI and achieved interim targets consistent with 2020 reduction goals. ![]()
Disclosures All Authors: No reported Disclosures.
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Shah S, Blanchette CM, Coyle JC, Kowalkowski M, Arthur ST, Howden R. Survival associated with chronic obstructive pulmonary disease among SEER-Medicare beneficiaries with non-small-cell lung cancer. Int J Chron Obstruct Pulmon Dis 2019; 14:893-903. [PMID: 31118599 PMCID: PMC6503488 DOI: 10.2147/copd.s185837] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 02/22/2019] [Indexed: 12/02/2022] Open
Abstract
Objective: We investigated the impact of preexisting COPD and its subtypes, chronic bronchitis and emphysema, on overall survival among Medicare enrollees diagnosed with non-small-cell lung cancer (NSCLC). Methods: Using SEER-Medicare data, we included patients ≥66 years of age diagnosed with NSCLC at any disease stage between 2006 and 2010 and continuously enrolled in Medicare Parts A and B in the 12 months prior to diagnosis. Preexisting COPD in patients with NSCLC were identified using ICD-9 codes. Kaplan–Meier method and log-rank tests were used to examine overall survival by COPD status and COPD subtype. Multivariable Cox proportional hazards models were fit to assess the risk of death after cancer diagnosis. Results: We identified 66,963 lung cancer patients. Of these, 22,497 (33.60%) had documented COPD before NSCLC diagnosis. For each stage of NSCLC, median survival was shorter in the COPD compared to the non-COPD group (Stage I: 692 days vs 1,130 days, P<0.0001; Stage II: 473 days vs 627 days, P<0.0001; Stage III: 224 days vs 229 days; P<0.0001; Stage IV: 106 days vs 112 days, P<0.0001). For COPD subtype, median survival for patients with preexisting chronic bronchitis was shorter compared to emphysema across all stages of NSCLC (Stage I: 672 days vs 811 days, P<0.0001; Stage II 582 days vs 445 days, P<0.0001; Stage III: 255 days vs 229 days, P<0.0001; Stage IV: 105 days vs 112 days, P<0.0001). In Cox proportional hazard model, COPD patients exhibited 11% increase in risk of death than non-COPD patients (HR: 1.11, 95%CI: 1.09–1.13). Conclusion: NSCLC patients with preexisting COPD had shorter survival with marked differences in early stages of lung cancer. Chronic bronchitis demonstrated a greater association with time to death than emphysema.
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Affiliation(s)
- Shweta Shah
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Christopher M Blanchette
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Joseph C Coyle
- Department of Kinesiology, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Marc Kowalkowski
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Susan T Arthur
- Department of Kinesiology, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Reuben Howden
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA.,Department of Kinesiology, University of North Carolina at Charlotte, Charlotte, NC, USA
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Davidson L, Medaris LA, Agner T, Kowalkowski M, Sullivan DM. 183. Alerting and Education via the Electronic Health Record (EHR) Decreases Inappropriate Fluoroquinolone prescribing in the Emergency Department of a Large Integrated Hospital Network. Open Forum Infect Dis 2018. [PMCID: PMC6253976 DOI: 10.1093/ofid/ofy210.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Emergency department (ED) providers frequently use fluoroquinolones (FQs) as first-line therapy for common infections in discharged patients. In 2016 the FDA issued a warning against FQ use for three common conditions: cystitis, bronchitis, and sinusitis. This study evaluated the effect of an electronic health record (EHR) clinical decision support alert followed by targeted provider education on FQ prescribing in the ED. Methods We performed a nonrandomized, single arm, pre–post study of FQ prescribing in target indications before (November 2015–October 2016) and after (January 2017–December 2017) implementation of an EHR alert at 19 hospital-based and free-standing EDs in the Charlotte NC area. Providers were alerted when a patient was discharged from the ED on an FQ with a target diagnosis (infections identified as being inappropriate for FQ) without additional exclusions (e.g., penicillin allergy) (Figure 1). Initial provider education on appropriate FQ use accompanied EHR alert implementation at all 19 participating EDs in November 2016. Targeted follow-up education was delivered in August 2017. We compared overall FQ prescribing rates in pre- vs. post-alert intervals using chi-squared tests. We compared FQ prescription volume following alert failure by indication for high alert failure diagnoses (ICD10 codes with ≥75 alerts) in Q1 2017 vs. Q4 2017. Results Target population ED discharges remained stable pre- and post-alert implementation (n = 37,975; n = 37,731). FQ prescribing decreased 53% from pre (n = 13,796, 36%) to post alert (n = 7,289, 19%; P < 0.01). While total orders avoided after alert firing remained low, the total prescriptions (i.e., alert overrides) dropped from 789 in January 2017 to 397 in December 2017 (Figure 2). The largest decrease was observed after repeat provider education in August 2017. Diagnosis categories with high volume alert failures decreased from 15 unique ICD10 diagnosis (n = 1,534 prescriptions) in Q1 2017 to 3 (diverticulitis, pneumonia, gastroenteritis/colitis; n = 419 prescriptions) in Q4 2017. Conclusion Effective EHR alert implementation combined with timely and targeted provider education on appropriate prescribing reduces inappropriate ED provider FQ prescribing by more than 50%. ![]()
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Disclosures L. Davidson, Duke Endowment: Grant Investigator, Grant recipient
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Affiliation(s)
- Lisa Davidson
- Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina
| | - Leigh Ann Medaris
- Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina
| | - Tammi Agner
- IAS and Enterprise Information Management, Atrium Health, Charlotte, North Carolina
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina
| | - D Matthew Sullivan
- IAS and Enterprise Information Management, Atrium Health, Charlotte, North Carolina
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Isip J, Medaris LA, McCurdy L, Kowalkowski M, Fischer K, Onsrud J, Davidson L. 1868. Successful Use of Telemedicine vs. On-site Infectious Diseases Consultation After Implementation of a System-Wide Antimicrobial Stewardship-Led Staphylococcus aureus Bacteremia Care Bundle. Open Forum Infect Dis 2018. [PMCID: PMC6252934 DOI: 10.1093/ofid/ofy210.1524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Telemedicine (TM) programs have been effectively implemented to deliver specialty care through virtual platforms to overcome geographic and resource constraints. Yet, few data exist to describe outcomes associated with TM-based management of patients with infectious diseases (ID). The purpose of this study was to compare adherence and other outcomes associated with TM and on-site (SOC) ID consultation (IDC) implementation strategies of an antimicrobial stewardship (ASP)-led S. aureus bacteremia (SAB) bundle. Methods We launched an SAB bundle at 10 acute care hospitals in the metro Charlotte, NC area in September 2016 for adult patients admitted with SAB and conducted a retrospective cohort study using data collected through 2017. Bundle components included (1) mandatory IDC, (2) appropriate antibiotics within 24 hours of S. aureus speciation, (3) repeat blood cultures at least every 72 hours until clearance, (4) obtainment of an echocardiogram, and (5) appropriate duration of intravenous antibiotic therapy based on SAB severity. ASP facilitated bundle initiation and assisted with compliance for all patients. The primary outcome was bundle adherence. Secondary outcomes included time to culture clearance and persistent SAB (i.e., positive blood cultures for >7 days). We used Wilcoxon rank-sum and chi-squared tests to compare outcomes. Results We evaluated 872 patients with SAB during the study interval. After excluding 126 patients (prematurely discharged or died/transitioned to comfort care within 48 hours of S. aureus speciation), we analyzed 583 SOC and 163 TM group patients. There were no differences observed in overall SAB bundle adherence (SOC 86% vs. TM 88%, P = 0.52), or its individual components. No differences were found in time to culture clearance (median days: SOC = 2.9 vs. TM = 2.8, P = 0.96) and persistent SAB (SOC 11% vs. TM 11%, P = 0.77). Conclusion Our findings provide preliminary evidence to support TM-based strategies for IDC and ASP-led care bundles in resource-limited settings. Future analyses will compare mortality and hospital readmission outcomes. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Jacqueline Isip
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina
| | - Leigh Ann Medaris
- Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina
| | - Lewis McCurdy
- Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina
| | - Kristin Fischer
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina
| | - Jennifer Onsrud
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina
| | - Lisa Davidson
- Antimicrobial Support Network, Atrium Health, Charlotte, North Carolina
- Division of Infectious Diseases, Atrium Health, Charlotte, North Carolina
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Kowalkowski M, Schmidt M, Kester S, Fischer K, Passaretti C. 457. Relationship Between Healthcare Worker (HCW) Perception of Safety and Rates of Healthcare-Associated Infections (HAI) and Hand Hygiene (HH) Compliance. Open Forum Infect Dis 2018. [PMCID: PMC6253688 DOI: 10.1093/ofid/ofy210.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Abstract
AIM To estimate the healthcare utilization and costs in elderly lung cancer patients with and without pre-existing chronic obstructive pulmonary disease (COPD). METHODS Using Surveillance, Epidemiology and End Results (SEER)-Medicare data, this study identified patients with lung cancer between 2006-2010, at least 66 years of age, and continuously enrolled in Medicare Parts A and B in the 12 months prior to cancer diagnosis. The diagnosis of pre-existing COPD in lung cancer patients was identified using ICD-9 codes. Healthcare utilization and costs were categorized as inpatient hospitalizations, skilled nursing facility (SNF) use, physician office visits, ER visits, and outpatient encounters for every stage of lung cancer. The adjusted analysis was performed using a generalized linear model for healthcare costs and a negative binomial model for healthcare utilization. RESULTS Inpatient admissions in the COPD group increased for each stage of non-small cell lung cancer (NSCLC) compared to the non-COPD group per 100 person-months (Stage I: 14.67 vs 9.49 stays, p < .0001; Stage II: 14.13 vs 10.78 stays, p < .0001; Stage III: 28.31 vs 18.91 stays, p < .0001; Stage IV: 49.5 vs 31.24 stays, p < .0001). A similar trend was observed for outpatient visits, with an increase in utilization among the COPD group (Stage I: 1136.04 vs 796 visits, p < .0001; Stage II: 1325.12 vs 983.26 visits, p < .0001; Stage III: 2025.47 vs 1656.64 visits, p < .0001; Stage IV: 2825.73 vs 2422.26 visits, p < .0001). Total direct costs per person-month in patients with pre-existing COPD were significantly higher than the non-COPD group across all services ($54,799.16 vs $41,862.91). Outpatient visits represented the largest cost category across all services in both groups, with higher costs among the COPD group ($41,203 vs $31,140.08). CONCLUSION Healthcare utilization and costs among lung cancer patients with pre-existing COPD was ∼2-3-times higher than the non-COPD group.
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Affiliation(s)
- Shweta Shah
- a Department of Public Health Sciences , University of North Carolina at Charlotte , NC , USA
| | | | - Joseph C Coyle
- b Department of Kinesiology , University of North Carolina at Charlotte , NC , USA
| | - Marc Kowalkowski
- c Levine Cancer Institute, Carolinas Healthcare System , Charlotte , NC , USA
| | - Susan T Arthur
- b Department of Kinesiology , University of North Carolina at Charlotte , NC , USA
| | - Reuben Howden
- a Department of Public Health Sciences , University of North Carolina at Charlotte , NC , USA
- b Department of Kinesiology , University of North Carolina at Charlotte , NC , USA
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Shah S, Blanchette CM, Kowalkowski M, Arthur ST, Coyle JP, Howden R. Survival associated with chronic obstructive pulmonary disease among elderly patients with non-small cell lung cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e18107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18107 Background: Lung cancer and chronic obstructive pulmonary disease (COPD) are among leading causes of morbidity and mortality worldwide. The association between pre-existing COPD and overall survival (OS) among patients with non-small cell lung cancer (NSCLC) remains unclear. We investigated the impact of pre-existing COPD and its subtypes: chronic bronchitis and emphysema on OS in elderly patients diagnosed with NSCLC at different stages. Methods: Using SEER-Medicare data, we identified patients diagnosed with NSCLC between January 1, 2006 and December 31, 2010, > 66 years of age, and continuously enrolled in Medicare Parts A and B in the 12 months prior to diagnosis. Pre-existing COPD in patients with NSCLC were identified using ICD-9 codes. Kaplan Meier method and log-rank tests were used to examine OS by COPD status and COPD subtype. Cox proportional hazards models were fit to assess the risk of death after cancer diagnosis while adjusting for baseline factors. Results: We identified 66,963 patients with NSCLC. Of these, 22,497 (33.60%) had documented COPD before NSCLC diagnosis. For each stage of NSCLC, median OS was shorter in the COPD compared to the non-COPD group (stage I: 692 vs 1130 days, P < 0.0001; stage II: 473 vs 627 days, P < 0.0001; stage III: 224 vs 229 days; P < 0.0001; stage IV: 106 vs 112 days, P < 0.0001). For COPD subtype, median OS for patients with pre-existing chronic bronchitis was shorter compared to emphysema across all stages of NSCLC (stage I: 672 vs 811 days, P < 0.0001; stage II 582 vs 445 days, P < 0.0001; stage III: 255 vs 229 days, P < 0.0001; stage IV: 105 vs 112 days, P < 0.0001). After multivariable adjustment, COPD patients exhibited an 11% shorter time to death compared to non-COPD patients (Hazard Ratio: 1.11, 95% Confidence Interval: 1.09—1.13). Conclusions: There were marked differences in early stage NSCLC, with a decrease in OS from stage I to stage IV in the COPD group. Patients with chronic bronchitis had shorter OS at every stage of NSCLC compared to emphysema. The results may help inform early detection strategies for NSCLC and treatment selection in early and advanced cancer.
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Affiliation(s)
- Shweta Shah
- University of North Carolina at Charlotte, Charlotte, NC
| | | | | | - Susan T Arthur
- University of North Carolina at Charlotte, Charlotte, NC
| | - Joseph P Coyle
- University of North Carolina at Charlotte, Charlotte, NC
| | - Reuben Howden
- University of North Carolina at Charlotte, Charlotte, NC
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Abstract
e18303 Background: Acute care utilization is a key component of health care cost among oncology patients, particularly at advanced stages. Oncology nurse navigation (NN) was developed to improve access to quality cancer care but little is known about the impact of NN on acute care reliance (ACR) among patients with advanced cancer. Methods: A cohort study was conducted among adults (≥18) diagnosed with advanced-stage (III/IV) first primary solid tumor (10 most common solid tumors by annual incidence - bladder, breast, colon, kidney, lung, melanoma, pancreas, prostate, thyroid, uterus) from January 2013-December 2015. For inclusion, NN patients had to initiate NN services ≤30 days after diagnosis and all patients must have had ≥30 days of follow-up. The primary outcome was ACR, defined as the proportion of total health care utilization received in an acute care setting (hospital inpatient/observation, emergency department), from diagnosis through 1 year, calculated per 30-day interval to adjust for follow-up variance. To assess the effect of NN receipt on ACR, generalized linear models were fit specifying a gamma distribution and a log-link function, adjusted for patient and clinical characteristics at diagnosis. Subgroup analyses were conducted in patients surviving < 6 and ≥6 months. Results: 2950 patients with advanced cancer were followed (NN = 970 [33%]). Lung (37%), prostate (13%) and breast (12%) cancers were most common. 944 (32%) patients died during the 1-year interval. Patients averaged 1.7 health care encounters per 30-day interval. Those who received NN had lower mean ACR than patients who did not, overall (0.18 vs 0.30; p < 0.001) and in each individual cancer type (p < 0.05) except melanoma (p = 0.4). In multivariable models, NN receipt was associated with decreased ACR (RR = 0.65 95%CI = 0.60-0.70). The effect of NN on ACR was consistent in subgroups defined by survival duration. Conclusions: Patients with advanced cancer who received NN were less reliant on acute care than patients who did not receive NN. Given the role of acute care in driving health care cost and the inverse association between increased ACR and health care quality, our findings may have important implications for improving value in oncology care.
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Ruban C, Kowalkowski M, Blanchette CM. Regional variation in high-resource utilization among lung cancer-related emergency department visits in the United States. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e20038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e20038 Background: Regional variation is common in oncology care but is not defined for emergency department (ED) care for cancer patients, particularly patients with lung cancer (LC) who regularly utilize EDs for management of acute cancer or treatment related illness. This study analyzed regional variation and other factors associated with high total episodic charge (≥75th percentile; HTC) among LC patients evaluated in the ED in relation to discharge or admission. Methods: A retrospective study of LC-related ED visits in the US was conducted using the 2013 Nationwide ED Sample. LC-related ED visits among adults were identified by LC-specific Clinical Classification Software codes (CCS = 19; mapping to ICD-9 = 162.x, 209.21, 231.2, V10.11). Multivariable logistic regression analyzed the association between patient and hospital factors and HTC, weighted to represent ED visits nationwide. Results: Among 373,761 LC-related ED visits, 134,838 (36%) were treated and discharged and 238,923 (64%) were admitted (ranging from 51% (West [W]) to 76% (South [S]). HTC was ≥$5,655 (median = $2,993) for ED discharges and ≥$54,760 (median = $29,590) for admissions. The proportion of visits with HTC differed by region and admission status (discharged: 7% [W] to 27% [S]; admitted: 20% [Midwest] to 39% [W]). After adjusting for clinical and hospital factors associated with increased HTC odds (metastases, common acute comorbid disorder [chest and abdominal pain, pneumonia, sepsis, respiratory failure], diagnostic radiology use, thoracic/other surgery, chemo/radiotherapy, length of stay, primary payer, and hospital ownership, location and teaching status), significant HTC variation remained by hospital region with opposing relative HTC odds among discharged and admitted patients (discharged: W v S OR = 0.3 95%CI = 0.2-0.6, Northeast v S OR = 0.5 95%CI = 0.3-0.7; admitted: W v S OR = 3.8 95%CI = 2.5-5.7). Conclusions: Regional variation in HTC suggest differences in ED use and management patterns for LC and may reflect quality of care concerns. Clinical outcome linkage (including ED revisit tracking) is needed to better define the impact of variation and develop strategies to improve care for patients with LC.
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Affiliation(s)
- Cynthiya Ruban
- University of North Carolina at Charlotte, Charlotte, NC
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Tschudy MM, Raphael JL, Nehal US, O'Connor KG, Kowalkowski M, Stille CJ. Barriers to Care Coordination and Medical Home Implementation. Pediatrics 2016; 138:peds.2015-3458. [PMID: 27507894 DOI: 10.1542/peds.2015-3458] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatricians are central in leading the family-centered medical home (FCMH), yet little is known about how provider-perceived barriers to and attitudes toward the FCMH affect implementation. This study aims to assess the relationship between pediatrician-perceived barriers to and attitudes toward FCMH and reported care coordination. METHODS Pediatricians working in ambulatory care responded to the American Academy of Pediatrics Periodic Survey of Fellows #79 (N = 572, response rate, 59%). Our primary care coordination outcomes were whether pediatricians were: (1) leading a multidisciplinary team; (2) developing care plans; and (3) connecting with support services. Independent variables included barriers to FCMH implementation (lack of communication skills, support services, and time). Associations between outcomes and barriers were assessed by multivariate logistic regression, controlling for pediatrician and practice characteristics. RESULTS Lack of sufficient personnel was significantly associated with fewer care coordination activities: leading a multidisciplinary team (odds ratio [OR], 0.53), developing care plans (OR, 0.51), and connecting with support services (OR, 0.42). Lacking communication skills was significantly associated with lower odds of development of care plans (OR, 0.56) and assistance with support services (OR, 0.64). Lack of time was significantly associated with lower odds of leading a multidisciplinary team (OR, 0.53). A pediatrician's belief that the FCMH encourages the use of preventive services was significantly associated with increased support services (OR, 2.06). CONCLUSIONS Pediatricians report a need for sufficient personnel and communication skills to provide care coordination, a core component of the FCMH. Interventions to boost FCMH implementation should focus on providing resources to develop these characteristics.
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Affiliation(s)
- Megan M Tschudy
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland;
| | - Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Umbereen S Nehal
- Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Medical School, Quincy, Massachusetts
| | - Karen G O'Connor
- Department of Research, American Academy of Pediatrics, Elk Grove Village, Illinois; and
| | - Marc Kowalkowski
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Christopher J Stille
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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Affiliation(s)
| | - Derek Raghavan
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
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Butler AM, Elkins S, Kowalkowski M, Raphael JL. Shared decision making among parents of children with mental health conditions compared to children with chronic physical conditions. Matern Child Health J 2015; 19:410-8. [PMID: 24880252 DOI: 10.1007/s10995-014-1523-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
High quality care in pediatrics involves shared decision making (SDM) between families and providers. The extent to which children with common mental health disorders experience SDM is not well known. The objectives of this study were to examine how parent-reported SDM varies by child health (physical illness, mental health condition, and comorbid mental and physical conditions) and to examine whether medical home care attenuates any differences. We analyzed data on children (2-17 years) collected through the 2009/2010 National Survey of Children with Special Health Care Needs. The sample consisted of parents of children in one of three child health categories: (1) children with a chronic physical illness but no mental health condition; (2) children with a common mental health condition but no chronic physical condition; and (3) children with comorbid mental and chronic physical conditions. The primary dependent variable was parent-report of provider SDM. The primary independent variable was health condition category. Multivariate linear regression analyses were conducted. Multivariate analyses controlling for sociodemographic variables and parent-reported health condition impact indicated lower SDM among children with a common mental health condition-only (B = -0.40; p < 0.01) and children with comorbid conditions (B = -0.67; p < 0.01) compared to children with a physical condition-only. Differences in SDM for children with a common mental health condition-only were no longer significant in the model adjusting for medical home care. However, differences in SDM for children with comorbid conditions persisted after adjusting for medical home care. Increasing medical home care may help mitigate differences in SDM for children with mental health conditions-only. Other interventions may be needed to improve SDM among children with comorbid mental and physical conditions.
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Affiliation(s)
- Ashley M Butler
- Section of Psychology, Baylor College of Medicine, Houston, TX, USA,
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Blais P, Husain N, Kramer JR, Kowalkowski M, El-Serag H, Kanwal F. Nonalcoholic fatty liver disease is underrecognized in the primary care setting. Am J Gastroenterol 2015; 110:10-4. [PMID: 24890441 DOI: 10.1038/ajg.2014.134] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The prevalence and disease burden of nonalcoholic fatty liver disease (NAFLD) are increasing. Nonetheless, little is known about the processes related to identification, diagnosis, and referral of patients with NAFLD in routine clinical care. METHODS Using automated data, we isolated a random sample of patients in a Veterans Administration facility who had ≥2 alanine transaminase (ALT) values >40 IU/ml >6 months apart in the absence of any positive results for hepatitis C RNA, hepatitis B surface antigen, or screens for excess alcohol use. We conducted a structured medical record review to confirm NAFLD and abstracted data from the primary care providers' notes for (i) recognition of abnormal ALT levels, (ii) mention of NAFLD as a possible diagnosis, (iii) recommendations for diet or exercise, and (d) referral to a specialist for further NAFLD evaluation. Using a multilevel logistic regression model, we identified patient demographic, clinical, comorbidity, and health-care utilization factors associated with recognition and receipt of early NAFLD care. RESULTS Of 251 patients identified with NAFLD by our methods, 99 (39.4%) had documentation in medical record notes of abnormal ALT, 54 (21.5%) had NAFLD mentioned as a possible diagnosis, 37 (14.7%) were counseled regarding diet and exercise, and 26 (10.4%) were referred to a specialist. Only the magnitude of ALT elevation (adjusted odds ratio (OR) for ALT >80 IU/ml vs. <80 IU/ml=4.4, 95% confidence interval (CI)=2.65-7.30) and proportion of elevation (adjusted OR for >50% vs. <50% of ALT values >40 IU/ml=1.8, 95% CI=1.03-3.14) were associated with receiving specified NAFLD care. Only 3% of patients at a high risk of fibrosis (NAFLD fibrosis score >0.675) were referred to specialists. CONCLUSIONS Most patients in care who may have NAFLD are not being recognized and evaluated for this condition. Our data suggest that providers may be using an incorrect heuristic in delivering NAFLD care by concentrating on those with high ALT levels.
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Affiliation(s)
- Pierre Blais
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Nisreen Husain
- 1] Department of Medicine, Baylor College of Medicine, Houston, Texas, USA [2] Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Jennifer R Kramer
- 1] Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [2] Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Marc Kowalkowski
- 1] Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [2] Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hashem El-Serag
- 1] Department of Medicine, Baylor College of Medicine, Houston, Texas, USA [2] Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [3] Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Fasiha Kanwal
- 1] Department of Medicine, Baylor College of Medicine, Houston, Texas, USA [2] Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [3] Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Husain N, Blais P, Kramer J, Kowalkowski M, Richardson P, El-Serag HB, Kanwal F. Nonalcoholic fatty liver disease (NAFLD) in the Veterans Administration population: development and validation of an algorithm for NAFLD using automated data. Aliment Pharmacol Ther 2014; 40:949-54. [PMID: 25155259 PMCID: PMC5331854 DOI: 10.1111/apt.12923] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/04/2014] [Accepted: 07/27/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND In practice, nonalcoholic fatty liver disease (NAFLD) is diagnosed based on elevated liver enzymes and confirmatory liver biopsy or abdominal imaging. Neither method is feasible in identifying individuals with NAFLD in a large-scale healthcare system. AIM To develop and validate an algorithm to identify patients with NAFLD using automated data. METHODS Using the Veterans Administration Corporate Data Warehouse, we identified patients who had persistent ALT elevation (≥2 values ≥40 IU/mL ≥6 months apart) and did not have evidence of hepatitis B, hepatitis C or excessive alcohol use. We conducted a structured chart review of 450 patients classified as NAFLD and 150 patients who were classified as non-NAFLD by the database algorithm, and subsequently refined the database algorithm. RESULTS The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) for the initial database definition of NAFLD were 78.4% (95% CI: 70.0-86.8%), 74.5% (95% CI: 68.1-80.9%), 64.1% (95% CI: 56.4-71.7%) and 85.6% (95% CI: 79.4-91.8%), respectively. Reclassifying patients as having NAFLD if they had two elevated ALTs that were at least 6 months apart but within 2 years of each other, increased the specificity and PPV of the algorithm to 92.4% (95% CI: 88.8-96.0%) and 80.8% (95% CI: 72.5-89.0%), respectively. However, the sensitivity and NPV decreased to 55.0% (95% CI: 46.1-63.9%) and 78.0% (95% CI: 72.1-83.8%), respectively. CONCLUSIONS Predictive algorithms using automated data can be used to identify patients with NAFLD, determine prevalence of NAFLD at the system-wide level, and may help select a target population for future clinical studies in veterans with NAFLD.
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Affiliation(s)
- Nisreen Husain
- Department of Medicine, Baylor College of Medicine, Houston, Texas,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Peter Blais
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Marc Kowalkowski
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Peter Richardson
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Hashem B. El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, Texas,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Fasiha Kanwal
- Department of Medicine, Baylor College of Medicine, Houston, Texas,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Kowalkowski M, Gould JB, Bose C, Petersen LA, Profit J. Do practicing clinicians agree with expert ratings of neonatal intensive care unit quality measures? J Perinatol 2012; 32:247-52. [PMID: 22241483 PMCID: PMC3963391 DOI: 10.1038/jp.2011.199] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 11/10/2011] [Accepted: 11/29/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the level of agreement when selecting quality measures for inclusion in a composite index of neonatal intensive care quality (Baby-MONITOR) between two panels: one comprised of academic researchers (Delphi) and another comprised of academic and clinical neonatologists (clinician). STUDY DESIGN In a modified Delphi process, a panel rated 28 quality measures. We assessed clinician agreement with the Delphi panel by surveying a sample of 48 neonatal intensive care practitioners. We asked the clinician group to indicate their level of agreement with the Delphi panel for each measure using a five-point scale (much too high, slightly too high, reasonable, slightly too low and much too low). In addition, we asked clinicians to select measures for inclusion in the Baby-MONITOR based on a yes or no vote and a pre-specified two-thirds majority for inclusion. RESULT In all, 23 (47.9%) of the clinicians responded to the survey. We found high levels of agreement between the Delphi and clinician panels, particularly across measures selected for the Baby-MONITOR. Clinicians selected the same nine measures for inclusion in the composite as the Delphi panel. For these nine measures, 74% of clinicians indicated that the Delphi panel rating was 'reasonable'. CONCLUSION Practicing clinicians agree with an expert panel on the measures that should be included in the Baby-MONITOR, enhancing face validity.
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Affiliation(s)
- Marc Kowalkowski
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey VA Medical Center, Houston, TX
| | - Jeffrey B Gould
- California Perinatal Quality Care Collaborative, Palo Alto, CA
- Division of Neonatology, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University, Palo Alto, CA
| | - Carl Bose
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Laura A Petersen
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey VA Medical Center, Houston, TX
| | - Jochen Profit
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey VA Medical Center, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
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Butler AM, Kowalkowski M, Jones HA, Raphael JL. The relationship of reported neighborhood conditions with child mental health. Acad Pediatr 2012; 12:523-31. [PMID: 23009865 PMCID: PMC3640259 DOI: 10.1016/j.acap.2012.06.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 06/13/2012] [Accepted: 06/17/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Although in many studies authors have documented the relationship between neighborhood socioeconomic status and child mental health, few have examined the association between neighborhood conditions and mental health disorders. The objective of this study was to determine whether parent-reported neighborhood conditions are associated with common child mental health disorders. METHODS We analyzed data on children ages 6 to 17 (N = 64,076) collected through the 2007 National Survey of Children's Health. Primary outcome variables were a child being reported to have a diagnosis of (1) anxiety and/or depression and (2) attention-deficit-hyperactivity disorder (ADHD) and/or disruptive behavior. Main independent variables were parent-reported neighborhood amenities (eg, recreation center), poor physical characteristics (eg, dilapidated housing), social support/trust, neighborhood safety, and school safety. Multivariate logistic regression analyses were conducted to examine associations between neighborhood conditions and (1) anxiety/depression and (2) ADHD/disruptive behavior. RESULTS Children living in a neighborhood with 3 poor physical characteristics had greater odds of anxiety/depression (adjusted odds ratio [AOR] 1.58, 95% confidence interval [95% CI] 1.01-2.46) and ADHD/disruptive behavior (AOR 1.44, 95% CI 1.04-1.99) compared with children living in a neighborhood with no poor physical characteristics. Children of parents who reported living in a neighborhood with low social support/trust had greater odds of depression/anxiety (AOR 1.71, 95% CI 1.28-2.30) and ADHD/disruptive behavior (AOR 1.47, 95% CI 1.19-1.81) than children living in a neighborhood with greater social support/trust. CONCLUSIONS Parent perception of neighborhood social support/trust and physical characteristics may be important to assess in clinical settings and should be examined in future study of child mental health burden.
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Affiliation(s)
- Ashley M Butler
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
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