Trends in Utilization of Electronic Consultations Associated With Patient Payer and Language Among US Academic Medical Centers During the COVID-19 Pandemic

IMPORTANCE

Electronic consultations (eConsultations) are increasingly used to obtain specialist guidance, avoiding unnecessary face-to-face patient visits for certain clinical questions. During the COVID-19 pandemic, when in-person care was limited, eConsultations may have helped clinicians obtain specialist input to guide patient care.

OBJECTIVE

To understand how the use of eConsultations changed during the COVID-19 pandemic and whether trends in eConsultation utilization differed based on patient's payer and primary language.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted at 6 academic medical centers in the United States, all participating in the Association of American Colleges Coordinating Optimal Referral Experiences program. Participants included adult patients who had an outpatient visit, referral, or eConsultation during the study period. Data were analyzed from June 4, 2019, to July 28, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was the eConsultation proportion of specialty contact, defined as the number of completed eConsultations divided by the sum of the number of completed eConsultations and specialty referrals, expressed as a percentage. eConsultation percentages of specialty contact were further stratified by payer type and language. Payers included commercial, Medicare, Medicaid, self-pay or uninsured, and other. Primary language included English and non-English languages.

RESULTS

A total of 14 545 completed eConsultations and 189 776 referrals were included. More eConsultations were completed for English-speaking patients (11 363 eConsultations [95.0%]) than non-English-speaking patients (597 eConsultations [5.0%]). Patients with commercial insurance represented the highest number of completed eConsultations (8848 eConsultations [60.8%]) followed by Medicare (3891 eConsultations [26.8%]), Medicaid (930 eConsultations [6.4%]), other insurance (745 eConsultations [5.1%]), and self-pay or no insurance (131 eConsultations [0.9%]). At the start of the pandemic, across all academic medical centers, the percentage of specialty contact conducted via eConsultation significantly increased by 6.21% (95% CI, 4.97%-7.44%; P < .001). When stratified by payer and language, the percentage of specialty contact conducted via eConsultation significantly increased at the beginning of the pandemic for both English-speaking patients (change, 6.09% (95% CI, 4.82% to 7.37%; P < .001) and non-English-speaking patients (change, 8.48% [95% CI, 5.79% to 11.16%]; P < .001) and for all payers, except self-pay and uninsured patients (change, -0.21% [95% CI, [-1.35% to 0.92%]; P = .70).

CONCLUSIONS AND RELEVANCE

This retrospective cohort study found that eConsultations provided an accessible mechanism for clinicians to receive specialist input when in-person care was limited.

Clinical Use of an Electronic Pre-Visit Questionnaire Soliciting Patient Visit Goals and Interim History: A Retrospective Comparison Between Safety-net and Non-Safety-net Clinics

Introduction/Objectives

We examined an initial step towards co-generation of clinic notes by inviting patients to complete a pre-visit questionnaire that could be inserted into clinic notes by providers and describe the experience in a safety-net and non-safety-net clinic.

Methods

We sent an electronic pre-visit questionnaire on visit goals and interim history to patients at a safety-net clinic and a non-safety-net clinic before clinic visits. We compared questionnaire utilization between clinics during a one-year period and performed a chart review of a sample of patients to examine demographics, content and usage of patient responses to the questionnaire.

Results

While use was low in both clinics, it was lower in the safety-net clinic (3%) compared to the non-safety-net clinic (10%). We reviewed a sample of respondents and found they were more likely to be White compared to the overall clinic populations ( p < 0.05). There were no statistically significant differences in patient-typed notes (word count and number of visit goals) between the safety-net and non-safety-net samples however, patients at the safety-net clinic were less likely to have all of their goals addressed within the PCP documentation, compared to the non-safety-net clinic.

Conclusions

Given potential benefits of this questionnaire as a communication tool, addressing barriers to use of technology among vulnerable patients is needed, including access to devices and internet, and support from caregivers or culturally concordant peer navigators.

Care partners reading patients' visit notes via patient portals: Characteristics and perceptions

BACKGROUND

Care partners are key members of patients' health care teams, yet little is known about their experiences accessing patient information via electronic portals.

OBJECTIVE

To better understand the characteristics and perceptions of care partners who read patients' electronic visit notes.

PATIENT INVOLVEMENT

Focus groups with diverse patients from a community health center provided input into survey development.

METHODS

We contacted patient portal users at 3 geographically distinct sites in the US via email in 2017 for an online survey including open ended questions which we qualitatively analyzed.

RESULTS

Respondents chose whether to answer as care partners (N = 874) or patients (N = 28,782). Among care partner respondents, 44% were spouses, 43% children/other family members, and 14% friends/neighbors/other. Both care partners and patients reported that access to electronic notes was very important for promoting positive health behaviors, but care partners' perceptions of importance were consistently more positive than patients' perceptions of engagement behaviors. Open-ended comments included positive benefits such as: help with remembering the plan for care, coordinating care with other doctors, decreasing stress of care giving, improving efficiency of visits, and supporting patients from a geographical distance. They also offered suggestions for improving electronic portal and note experience for care partners such as having a separate log on for care partners; having doctors avoid judgmental language in their notes; and the ability to prompt needed medical care for patients.

DISCUSSION

Care partners value electronic access to patients' health information even more than patients. The majority of care partners were family members, whose feedback is important for improving portal design that effectively engages these care team members.

PRACTICAL VALUE

Patient care in the time of COVID-19 increasingly requires social distancing which may place additional burden on care partners supporting vulnerable patients. Access to patient notes may promote quality of care by keeping care partners informed, and care partner's input should be used to optimize portal design and electronic access to patient information.

Patients Contributing to Visit Notes: Mixed Methods Evaluation of OurNotes

Background

Secure patient portals are widely available, and patients use them to view their electronic health records, including their clinical notes. We conducted experiments asking them to cogenerate notes with their clinicians, an intervention called OurNotes.

Objective

This study aims to assess patient and provider experiences and attitudes after 12 months of a pilot intervention.

Methods

Before scheduled primary care visits, patients were asked to submit a word-constrained, unstructured interval history and an agenda for what they would like to discuss at the visit. Using site-specific methods, their providers were invited to incorporate the submissions into notes documenting the visits. Sites served urban, suburban, and rural patients in primary care practices in 4 academic health centers in Boston (Massachusetts), Lebanon (New Hampshire), Denver (Colorado), and Seattle (Washington). Each practice offered electronic access to visit notes (open notes) to its patients for several years. A mixed methods evaluation used tracking data and electronic survey responses from patients and clinicians. Participants were 174 providers and 1962 patients who submitted at least 1 previsit form. We asked providers about the usefulness of the submissions, effects on workflow, and ideas for the future. We asked patients about difficulties and benefits of providing the requested information and ideas for future improvements.

Results

Forms were submitted before 9.15% (5365/58,652) eligible visits, and 43.7% (76/174) providers and 26.76% (525/1962) patients responded to the postintervention evaluation surveys; 74 providers and 321 patients remembered receiving and completing the forms and answered the survey questions. Most clinicians thought interim patient histories (69/74, 93%) and patient agendas (72/74, 97%) as good ideas, 70% (52/74) usually or always incorporated them into visit notes, 54% (40/74) reported no change in visit length, and 35% (26/74) thought they saved time. Their most common suggestions related to improving notifications when patient forms were received, making it easier to find the form and insert it into the note, and educating patients about how best to prepare their submissions. Patient respondents were generally well educated, most found the history (259/321, 80.7%) and agenda (286/321, 89.1%) questions not difficult to answer; more than 92.2% (296/321) thought sending answers before the visit a good idea; 68.8% (221/321) thought the questions helped them prepare for the visit. Common suggestions by patients included learning to write better answers and wanting to know that their submissions were read by their clinicians. At the end of the pilot, all participating providers chose to continue the OurNotes previsit form, and sites considered expanding the intervention to more clinicians and adapting it for telemedicine visits.

Conclusions

OurNotes interests patients, and providers experience it as a positive intervention. Participation by patients, care partners, clinicians, and electronic health record experts will facilitate further development.

Retinopathy develops at similar glucose levels but higher HbA1c levels in people with black African ancestry compared to white European ancestry: evidence for the need to individualize HbA1c interpretation

AIMS

To examine the association of HbA_1c and glucose levels with incident diabetic retinopathy according to black African or white European ancestry.

METHODS

In this retrospective cohort study of 202 500 US Veterans with diabetes (2000-2014), measures included HbA_1c , outpatient random serum/plasma glucose, and incident retinopathy [conversion from negative to ≥2 positive evaluations (ICD-9 codes), without a subsequent negative].

RESULTS

At baseline, the study population had a mean age of 59.3 years, their mean BMI was 31.9 kg/m² , HbA_1c level was 57 mmol/mol (7.4%) and glucose level was 8.8 mmol/l, and 77% were of white European ancestry (white individuals) and 21% of black African ancestry (black individuals). HbA_1c was 0.3% higher in black vs white individuals (P < 0.001), adjusting for baseline age, sex, BMI, estimated glomerular filtration rate (eGFR), haemoglobin, and average systolic blood pressure and glucose. Over 11 years, incident retinopathy occurred in 9% of black and 7% of white individuals, but black individuals had higher HbA_1c , glucose, and systolic blood pressure (all P < 0.001); adjusted for these factors, incident retinopathy was reduced in black vs white individuals (P < 0.001). The population incidence of retinopathy (7%) was associated with higher mean baseline HbA_1c in individuals with black vs white ancestry [63 mmol/mol (7.9%) vs 58 mmol/mol (7.5%); P < 0.001)], but with similar baseline glucose levels (9.0 vs 9.0 mmol/l; P = 0.660, all adjusted for baseline age, sex and BMI).

CONCLUSIONS

Since retinopathy occurs at higher HbA_1c levels in black people for a given level of average plasma glucose, strategies may be needed to individualize the interpretation of HbA_1c measurements.

Racial differences in performance of HbA1c for the classification of diabetes and prediabetes among US adults of non-Hispanic black and white race

AIM

To characterize differences between black and white people in optimal HbA_1c thresholds for diagnoses of diabetes and prediabetes.

METHODS

Data were included from the National Health and Nutrition Examination Survey, 2005-2014. Black and white adults (age 18-70 years) who underwent an oral glucose tolerance test and had available fasting plasma glucose, 2-h plasma glucose and HbA_1c measurements were eligible for inclusion. Diabetes or prediabetes status was defined by fasting plasma glucose and 2-h plasma glucose using American Diabetes Association criteria. Classification of diabetes, prediabetes and dysglycaemia by HbA_1c was evaluated for a range of HbA_1c thresholds, with optimal thresholds defined as those values that maximized the sum of sensitivity and specificity (Youden's index).

RESULTS

In 5324 black (32.3%) and white (67.7%) individuals, Youden's index (optimal) thresholds for HbA_1c were ≥42 mmol/mol (6.0%) and ≥39 mmol/mol (5.7%) for discriminating diabetes vs non-diabetes, ≥ 44 mmol/mol (6.2%) and ≥39 mmol/mol (5.7%) for discriminating diabetes vs prediabetes (excluding normoglycaemia), ≥39 mmol/mol (5.7%) and ≥37 mmol/mol (5.5%) for discriminating dysglycaemia vs normoglycaemia, and ≥39 mmol/mol (5.7%) and ≥37 mmol/mol (5.5%) for discriminating prediabetes vs normoglycaemia (excluding diabetes), in black and white people, respectively.

CONCLUSIONS

Consistently higher optimal HbA_1c thresholds in black people than in white people suggest a need to individualize HbA_1c relative to glucose levels if HbA_1c is used to diagnose diabetes and prediabetes.

Effect of lowering initiation thresholds in a primary care-based buprenorphine treatment program

BACKGROUND

Office-based buprenorphine treatment is effective for opioid use disorder. Scant research has examined programmatic factors impacting successful initiation of treatment. To increase initiation of eligible patients, our buprenorphine program implemented changes to lower treatment thresholds. Most notable among these was elimination of a requirement that patients demonstrate abstinence from stimulants prior to initiating buprenorphine.

METHODS

This observational, retrospective study included patients screened for primary care-based buprenorphine treatment under high- and low-threshold conditions from 2015 to 2017. Background characteristics and treatment data were extracted from the electronic medical record and clinical registry. Chi-squared tests were used to compare proportions of patients initiated within 90 days of screening and retained to 60 days after initiation, under both conditions. Multivariate logistic regression was employed to compare relative odds of buprenorphine initiation after adjustment for several covariates. All analyses were stratified by recent stimulant use.

RESULTS

The sample of 168 patients included 96 in the high-threshold group and 72 in the low-threshold group. Among patients with recent stimulant use, low-threshold conditions were associated with a higher proportion of patients initiated (69% versus 35%, p = 0.002) and higher relative odds of initiation (aOR = 7.01, 95% CI = 2.26-21.80) but also with a lower proportion of patients retained (63% versus 100%, p = 0.004). Among patients without recent stimulant use, low-threshold conditions did not change these measures by a statistically significant margin.

CONCLUSIONS

Lower-threshold policies may increase buprenorphine treatment initiation for patients with co-occurring stimulant use. However, patients using stimulants may require additional supports to remain engaged.

Communicating with Vulnerable Patient Populations: A Randomized Intervention to Teach Inpatients to Use the Electronic Patient Portal

BACKGROUND

Patient portals are expanding as a means to engage patients and have evidence for benefit in the outpatient setting. However, few studies have evaluated their use in the inpatient setting, or with vulnerable patient populations.

OBJECTIVE

This article assesses an intervention to teach hospitalized vulnerable patients to access their discharge summaries using electronic patient portals.

METHODS

Patients at a safety net hospital were randomly assigned to portal use education or usual care. Surveys assessed perceptions of discharge paperwork and the electronic portal.

RESULTS

Of the 202 prescreened eligible patients (e.g., deemed mentally competent, spoke English, and had a telephone), only 43% had working emails. Forty-four percent of participants did not remember receiving or reading discharge paperwork. Patients trained in portal use (n = 47) or receiving usual care (n = 23) preferred hospitals with online record access (85 and 83%, respectively), and felt that online access would increase their trust in doctors (85 and 87%) and satisfaction with care (91% each). Those who received training in portal use were more likely to register for the portal (48% vs. 11%; p < 0.01).

CONCLUSION

Patients had positive perceptions of portals, and education increased portal use. Lack of email access is a notable barrier to electronic communication with vulnerable patients.

Will use of patient portals help to educate and communicate with patients with diabetes?

OBJECTIVE

Chronic disease management can require daily attention, and increased levels of patient activation and engagement. We examined whether patients with diabetes perceive a greater benefit to having electronic access to their doctors' clinic notes compared to patients without diabetes. We hypothesized that easy electronic access to these notes may help patients with self-care by improving education and communication.

METHODS

Survey of patients with and without diabetes in Massachusetts and Pennsylvania about perceptions of potential benefits and risks of reading their visit notes via an electronic patient information portal. Administrative data were used to identify patients with diabetes; we compared their perceptions to those of patients without diabetes.

RESULTS

The majority of patients (both with and without diabetes) perceived a positive impact of using the portal. Patients with diabetes were significantly more likely to believe that having access to and reading their notes would help them take their medication better and take better care of themselves.

CONCLUSIONS

Patients with chronic diseases such as diabetes might receive an even greater benefit from access to their doctors' notes than the general patient population.

PRACTICE IMPLICATIONS

Doctors should encourage their patients with diabetes (or other chronic diseases) to use patient portals.

Patients' perceptions of their doctors' notes and after-visit summaries: A mixed methods study of patients at safety-net clinics

Background

Patients are increasingly offered electronic access to their doctors' notes, and many consistently receive paper After‐Visit Summaries. Specific feedback from patients about notes and summaries are lacking, particularly within safety‐net settings.

Design

A mixed methods study

Setting and Participants

Patients with poorly controlled diabetes attending two urban safety‐net primary care clinics in Washington State.

Methods

Patients read their own most recent clinic note and After‐Visit Summary, then completed a brief survey followed by a focus group discussion (3 groups in a large general medicine teaching clinic and 1 in an HIV/AIDS clinic) about their perceptions of the clinic note and After‐Visit Summary.

Results

Twenty‐seven patients participated; 70% were male, 41% were Black, 48% were unemployed or disabled, 56% reported fair/poor health, and 37% had accessed the electronic patient portal. A majority of patients felt their note content was useful (89%); a minority reported that their notes were not accurate (19%), had too much medical jargon (29%), or were too long (26%). Themes identified from the discussions included reliance on the provider to explain confusing content; a desire for more rather than less detail; and perceived inaccuracies, particularly in heavily templated notes. In each focus group, one or more portal users were enthusiastically willing to teach other patients.

Conclusions

The majority of focus group participants at this safety‐net site had not accessed the electronic patient portal, but those who had were willing to promote the portal benefits and assist others. Patients identified specific opportunities to improve clinic notes and After‐Visit Summaries.

Barriers to Engagement in Collaborative Care Treatment of Uncontrolled Diabetes in a Safety-Net Clinic

Purpose The purpose of the study was to evaluate patient factors associated with nonengagement in a Diabetes Collaborative Care Team (DCCT) program in a safety-net clinic. Methods The first 18 months of a multidisciplinary care, team-based diabetes care management program in a safety-net primary care clinic were studied. Nonengagement was defined as fewer than 2 visits with a team member during the 18 months of the program. Patients who did not engage in the program were compared with those who did engage on demographics, comorbid medical and psychiatric diagnoses, and cardiovascular risk factors, using univariate and multivariable analyses. Results Of the 151 patients referred to the DCCT, 68 (45%) were nonengaged. In unadjusted analyses, patients who did not engage were more likely to be female and have higher baseline A1C values; they were less likely to have major depressive disorder, anxiety disorder, any depression diagnosis, and hyperlipidemia. Female gender and chronic pain were independently associated with nonengagement after multivariable adjustment. Conclusions The findings suggest that among patients with uncontrolled diabetes in an urban safety-net primary care clinic, there is a need to address barriers to engagement for female patients and to integrate chronic pain management strategies within multicondition collaborative care models.

Glucose challenge test screening for prediabetes and early diabetes

AIMS

To test the hypothesis that a 50-g oral glucose challenge test with 1-h glucose measurement would have superior performance compared with other opportunistic screening methods.

METHODS

In this prospective study in a Veterans Health Administration primary care clinic, the following test performances, measured by area under receiver-operating characteristic curves, were compared: 50-g oral glucose challenge test; random glucose; and HbA_1c level, using a 75-g oral glucose tolerance test as the 'gold standard'.

RESULTS

The study population was comprised of 1535 people (mean age 56 years, BMI 30.3 kg/m² , 94% men, 74% black). By oral glucose tolerance test criteria, diabetes was present in 10% and high-risk prediabetes was present in 22% of participants. The plasma glucose challenge test provided area under receiver-operating characteristic curves of 0.85 (95% CI 0.78-0.91) to detect diabetes and 0.76 (95% CI 0.72-0.80) to detect high-risk dysglycaemia (diabetes or high-risk prediabetes), while area under receiver-operating characteristic curves for the capillary glucose challenge test were 0.82 (95% CI 0.75-0.89) and 0.73 (95% CI 0.69-0.77) for diabetes and high-risk dysglycaemia, respectively. Random glucose performed less well [plasma: 0.76 (95% CI 0.69-0.82) and 0.66 (95% CI 0.62-0.71), respectively; capillary: 0.72 (95% CI 0.65-0.80) and 0.64 (95% CI 0.59-0.68), respectively], and HbA_1c performed even less well [0.67 (95% CI 0.57-0.76) and 0.63 (95% CI 0.58-0.68), respectively]. The cost of identifying one case of high-risk dysglycaemia with a plasma glucose challenge test would be $42 from a Veterans Health Administration perspective, and $55 from a US Medicare perspective.

CONCLUSIONS

Glucose challenge test screening, followed, if abnormal, by an oral glucose tolerance test, would be convenient and more accurate than other opportunistic tests. Use of glucose challenge test screening could improve management by permitting earlier therapy.

Patients Typing Their Own Visit Agendas Into an Electronic Medical Record: Pilot in a Safety-Net Clinic

Collaborative visit agenda setting between patient and doctor is recommended. We assessed the feasibility, acceptability, and utility of patients attending a large primary care safety-net clinic typing their agendas into the electronic visit note before seeing their clinicians. One hundred and one patients and their 28 clinicians completed post-visit surveys. Patients and clinicians agreed that the agendas improved patient-clinician communication (patients 79%, clinician 74%), and wanted to continue having patients type agendas in the future (73%, 82%). Enabling patients to type visit agendas may enhance care by engaging patients and giving clinicians an efficient way to prioritize patients' concerns.

A collaborative care team to integrate behavioral health care and treatment of poorly-controlled type 2 diabetes in an urban safety net primary care clinic

OBJECTIVE

Demonstrate the feasibility of implementing a collaborative care program for poorly-controlled type 2 diabetes and complex behavioral health disorders in an urban academically-affiliated safety net primary care clinic.

METHODS

This retrospective cohort study evaluates multidisciplinary team care approach to diabetes in a safety net clinic, and included 634 primary care clinic patients with hemoglobin A1c (HbA1c)>9%. HbA1c, blood pressure, and depression severity were assessed at the initial visit and at the end of treatment, and compared to those of patients who were not referred to the team.

RESULTS

The 151 patients referred to the program between March 2013 and November 2014 had a higher initial mean HbA1c: 10.6% vs. 9.4%, and were more likely to have depression (p=0.006), anxiety (p=0.04), and bipolar disorder (p=0.03), compared to the 483 patients who were not referred. During the 18-month study period, there was a mean decrease in HbA1c of 0.9 (10.6 to 9.4) among those referred to the team, compared to a mean decrease of 0.2 (9.4 to 9.2) among those not referred. This was a significantly greater percent change in HbA1c (p=0.008).

CONCLUSION

The integration of behavioral healthcare into chronic care management of patients with diabetes is a promising strategy to improve outcomes among the high risk population in safety net settings.

Diagnostic Reproducibility: What Happens When the Same Pathologist Interprets the Same Breast Biopsy Specimen at Two Points in Time?

BACKGROUND

Surgeons may receive a different diagnosis when a breast biopsy is interpreted by a second pathologist. The extent to which diagnostic agreement by the same pathologist varies at two time points is unknown.

METHODS

Pathologists from eight U.S. states independently interpreted 60 breast specimens, one glass slide per case, on two occasions separated by ≥9 months. Reproducibility was assessed by comparing interpretations between the two time points; associations between reproducibility (intraobserver agreement rates); and characteristics of pathologists and cases were determined and also compared with interobserver agreement of baseline interpretations.

RESULTS

Sixty-five percent of invited, responding pathologists were eligible and consented; 49 interpreted glass slides in both study phases, resulting in 2940 interpretations. Intraobserver agreement rates between the two phases were 92% [95% confidence interval (CI) 88-95] for invasive breast cancer, 84% (95% CI 81-87) for ductal carcinoma-in-situ, 53% (95% CI 47-59) for atypia, and 84% (95% CI 81-86) for benign without atypia. When comparing all study participants' case interpretations at baseline, interobserver agreement rates were 89% (95% CI 84-92) for invasive cancer, 79% (95% CI 76-81) for ductal carcinoma-in-situ, 43% (95% CI 41-45) for atypia, and 77% (95% CI 74-79) for benign without atypia.

CONCLUSIONS

Interpretive agreement between two time points by the same individual pathologist was low for atypia and was similar to observed rates of agreement for atypia between different pathologists. Physicians and patients should be aware of the diagnostic challenges associated with a breast biopsy diagnosis of atypia when considering treatment and surveillance decisions.

Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study

OBJECTIVE

 To evaluate the potential effect of second opinions on improving the accuracy of diagnostic interpretation of breast histopathology.

DESIGN

 Simulation study.

SETTING

 12 different strategies for acquiring independent second opinions.

PARTICIPANTS

 Interpretations of 240 breast biopsy specimens by 115 pathologists, one slide for each case, compared with reference diagnoses derived by expert consensus.

MAIN OUTCOME MEASURES

 Misclassification rates for individual pathologists and for 12 simulated strategies for second opinions. Simulations compared accuracy of diagnoses from single pathologists with that of diagnoses based on pairing interpretations from first and second independent pathologists, where resolution of disagreements was by an independent third pathologist. 12 strategies were evaluated in which acquisition of second opinions depended on initial diagnoses, assessment of case difficulty or borderline characteristics, pathologists' clinical volumes, or whether a second opinion was required by policy or desired by the pathologists. The 240 cases included benign without atypia (10% non-proliferative, 20% proliferative without atypia), atypia (30%), ductal carcinoma in situ (DCIS, 30%), and invasive cancer (10%). Overall misclassification rates and agreement statistics depended on the composition of the test set, which included a higher prevalence of difficult cases than in typical practice.

RESULTS

 Misclassification rates significantly decreased (P<0.001) with all second opinion strategies except for the strategy limiting second opinions only to cases of invasive cancer. The overall misclassification rate decreased from 24.7% to 18.1% when all cases received second opinions (P<0.001). Obtaining both first and second opinions from pathologists with a high volume (≥10 breast biopsy specimens weekly) resulted in the lowest misclassification rate in this test set (14.3%, 95% confidence interval 10.9% to 18.0%). Obtaining second opinions only for cases with initial interpretations of atypia, DCIS, or invasive cancer decreased the over-interpretation of benign cases without atypia from 12.9% to 6.0%. Atypia cases had the highest misclassification rate after single interpretation (52.2%), remaining at more than 34% in all second opinion scenarios.

CONCLUSION

 Second opinions can statistically significantly improve diagnostic agreement for pathologists' interpretations of breast biopsy specimens; however, variability in diagnosis will not be completely eliminated, especially for breast specimens with atypia.

Variability in Pathologists' Interpretations of Individual Breast Biopsy Slides: A Population Perspective

BACKGROUND

The effect of physician diagnostic variability on accuracy at a population level depends on the prevalence of diagnoses.

OBJECTIVE

To estimate how diagnostic variability affects accuracy from the perspective of a U.S. woman aged 50 to 59 years having a breast biopsy.

DESIGN

Applied probability using Bayes' theorem.

SETTING

B-Path (Breast Pathology) Study comparing pathologists' interpretations of a single biopsy slide versus a reference consensus interpretation from 3 experts.

PARTICIPANTS

115 practicing pathologists (6900 total interpretations from 240 distinct cases).

MEASUREMENTS

A single representative slide from each of the 240 cases was used to estimate the proportion of biopsies with a diagnosis that would be verified if the same slide were interpreted by a reference group of 3 expert pathologists. Probabilities of confirmation (predictive values) were estimated using B-Path Study results and prevalence of biopsy diagnoses for women aged 50 to 59 years in the Breast Cancer Surveillance Consortium.

RESULTS

Overall, if 1 representative slide were used per case, 92.3% (95% CI, 91.4% to 93.1%) of breast biopsy diagnoses would be verified by reference consensus diagnoses, with 4.6% (CI, 3.9% to 5.3%) overinterpreted and 3.2% (CI, 2.7% to 3.6%) underinterpreted. Verification of invasive breast cancer and benign without atypia diagnoses is highly probable; estimated predictive values were 97.7% (CI, 96.5% to 98.7%) and 97.1% (CI, 96.7% to 97.4%), respectively. Verification is less probable for atypia (53.6% overinterpreted and 8.6% underinterpreted) and ductal carcinoma in situ (DCIS) (18.5% overinterpreted and 11.8% underinterpreted).

LIMITATIONS

Estimates are based on a testing situation with 1 slide used per case and without access to second opinions. Population-adjusted estimates may differ for women from other age groups, unscreened women, or women in different practice settings.

CONCLUSION

This analysis, based on interpretation of a single breast biopsy slide per case, predicts a low likelihood that a diagnosis of atypia or DCIS would be verified by a reference consensus diagnosis. This diagnostic grey zone should be considered in clinical management decisions in patients with these diagnoses.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Intervention fidelity for a complex behaviour change intervention in community pharmacy addressing cardiovascular disease risk

Delivery of cardiovascular disease (CVD) prevention programs by community pharmacists appears effective and enhances health service access. However, their capacity to implement complex behavioural change processes during patient counselling remains largely unexplored. This study aims to determine intervention fidelity by pharmacists for behavioural components of a complex educational intervention for CVD prevention. After receiving training to improve lifestyle and medicines adherence, pharmacists recruited 70 patients aged 50-74 years without established CVD, and taking antihypertensive or lipid lowering therapy. Patients received five counselling sessions, each at monthly intervals. Researchers assessed biomedical and behavioural risk factors at baseline and six months. Pharmacists documented key outcomes from counselling after each session. Most patients (86%) reported suboptimal cardiovascular diets, 41% reported suboptimal medicines adherence, and 39% were physically inactive. Of those advised to complete the intervention, 85% attended all five sessions. Pharmacists achieved patient agreement with most recommended goals for behaviour change, and overwhelmingly translated goals into practical behavioural strategies. Barriers to changing behaviours were regularly documented, and pharmacists reported most behavioural strategies as having had some success. Meaningful improvements to health behaviours were observed post-intervention. Findings support further exploration of pharmacists' potential roles for delivering interventions with complex behaviour change requirements.

Characteristics of Patients Who Report Confusion After Reading Their Primary Care Clinic Notes Online

Patient access to online electronic medical records (EMRs) is increasing and may offer benefits to patients. However, the inherent complexity of medicine may cause confusion. We elucidate characteristics and health behaviors of patients who report confusion after reading their doctors' notes online. We analyzed data from 4,528 patients in Boston, MA, central Pennsylvania, and Seattle, WA, who were granted online access to their primary care doctors' clinic notes and who viewed at least one note during the 1-year intervention. Three percent of patients reported confusion after reading their visit notes. These patients were more likely to be at least 70 years of age (p < .0001), have fewer years of education (p < .0017), be unemployed (p < .0001), have lower levels of self-reported health (p < .0043), and worry more after reading visit notes (relative risk [RR] 4.83; confidence interval [CI] 3.17, 7.36) compared to patients who were not confused. In adjusted analyses, they were less likely to report feeling more in control of their health (RR 0.42; CI 0.25, 0.71), remembering their care plan (RR 0.26; CI 0.17, 0.42), and understanding their medical conditions (RR 0.32; CI 0.19, 0.54) as a result of reading their doctors' notes compared to patients who were not confused. Patients who were confused by reading their doctors' notes were less likely to report benefits in health behaviors. Understanding this small subset of patients is a critical step in reducing gaps in provider-patient communication and in efforts to tailor educational approaches for patients.

Patients who share transparent visit notes with others: characteristics, risks, and benefits

BACKGROUND

Inviting patients to read their primary care visit notes may improve communication and help them engage more actively in their health care. Little is known about how patients will use the opportunity to share their visit notes with family members or caregivers, or what the benefits might be.

OBJECTIVE

Our goal was to evaluate the characteristics of patients who reported sharing their visit notes during the course of the study, including their views on associated benefits and risks.

METHODS

The OpenNotes study invited patients to access their primary care providers' visit notes in Massachusetts, Pennsylvania, and Washington. Pre- and post-intervention surveys assessed patient demographics, standardized measures of patient-doctor communication, sharing of visit notes with others during the study, and specific health behaviors reflecting the potential benefits and risks of offering patients easy access to their visit notes.

RESULTS

More than half (55.43%, 2503/4516) of the participants who reported viewing at least one visit note would like the option of letting family members or friends have their own Web access to their visit notes, and 21.70% (980/4516) reported sharing their visit notes with someone during the study year. Men, and those retired or unable to work, were significantly more likely to share visit notes, and those sharing were neither more nor less concerned about their privacy than were non-sharers. Compared to participants who did not share clinic notes, those who shared were more likely to report taking better care of themselves and taking their medications as prescribed, after adjustment for age, gender, employment status, and study site.

CONCLUSIONS

One in five OpenNotes patients shared a visit note with someone, and those sharing Web access to their visit notes reported better adherence to self-care and medications. As health information technology systems increase patients' ability to access their medical records, facilitating access to caregivers may improve perceived health behaviors and outcomes.

Aging is associated with increased HbA1c levels, independently of glucose levels and insulin resistance, and also with decreased HbA1c diagnostic specificity

AIM

To determine whether using HbA1c for screening and management could be confounded by age differences, whether age effects can be explained by unrecognized diabetes and prediabetes, insulin resistance or postprandial hyperglycaemia, and whether the effects of aging have an impact on diagnostic accuracy.

METHODS

We conducted a cross-sectional analysis in adults without known diabetes in the Screening for Impaired Glucose Tolerance (SIGT) study 2005-2008 (n=1573) and the National Health and Nutrition Examination Survey (NHANES) 2005-2006 (n=1184).

RESULTS

Both glucose intolerance and HbA(1c) levels increased with age. In univariate analyses including all subjects, HbA(1c) levels increased by 0.93 mmol/mol (0.085%) per 10 years of age in the SIGT study and by 1.03 mmol/mol (0.094%) per 10 years in the NHANES; in both datasets, the HbA(1c) increase was 0.87 mmol/mol (0.08%) per 10 years in subjects without diabetes, and 0.76 mmol/mol (0.07%) per 10 years in subjects with normal glucose tolerance, all P<0.001. In multivariate analyses of subjects with normal glucose tolerance, the relationship between age and HbA(1c) remained significant (P<0.001) after adjustment for covariates including race, BMI, waist circumference, sagittal abdominal diameter, triglyceride/HDL ratio, and fasting and 2-h plasma glucose and other glucose levels, as assessed by an oral glucose tolerance test. In both datasets, the HbA(1c) of an 80-year-old individual with normal glucose tolerance would be 3.82 mmol/mol (0.35%) greater than that of a 30-year-old with normal glucose tolerance, a difference that is clinically significant. Moreover, the specificity of HbA(1c) -based diagnostic criteria for prediabetes decreased substantially with increasing age (P<0.0001).

CONCLUSIONS

In two large datasets, using different methods to measure HbA(1c), the association of age with higher HbA(1c) levels: was consistent and similar; was both statistically and clinically significant; was unexplained by features of aging; and reduced diagnostic specificity. Age should be taken into consideration when using HbA(1c) for the diagnosis and management of diabetes and prediabetes.

Patient Access to Online Visit Notes: Perceptions of Doctors and Patients at an Urban HIV/AIDS Clinic

Patients living with HIV/AIDS face large societal and medical challenges. Inviting patients to read their doctors' visit notes via secure electronic portals may empower patients and improve health. We investigated whether utilization and perceptions about access to doctors' notes differed among doctors and patients in an HIV/AIDS clinic versus primary care setting. We analyzed pre- and 1-year postintervention data from 99 doctors and 3819 patients. HIV clinic patients did not report differences in perceived risks and benefits compared to primary care clinic patients, however, they were more likely to share notes with friends (33% versus 9%, P=.002), other health professionals (24% versus 8%, P=.03), or another doctor (38% versus 9%, P<.0001). HIV clinic doctors were less likely than primary care doctors to change the level of candor in visit notes (P<.04). Our findings suggest that HIV clinic patients and doctors are ready to share visit notes online.

Are radiologists' goals for mammography accuracy consistent with published recommendations?

RATIONALE AND OBJECTIVES

Mammography quality assurance programs have been in place for more than a decade. We studied radiologists' self-reported performance goals for accuracy in screening mammography and compared them to published recommendations.

MATERIALS AND METHODS

A mailed survey of radiologists at mammography registries in seven states within the Breast Cancer Surveillance Consortium (BCSC) assessed radiologists' performance goals for interpreting screening mammograms. Self-reported goals were compared to published American College of Radiology (ACR) recommended desirable ranges for recall rate, false-positive rate, positive predictive value of biopsy recommendation (PPV2), and cancer detection rate. Radiologists' goals for interpretive accuracy within desirable range were evaluated for associations with their demographic characteristics, clinical experience, and receipt of audit reports.

RESULTS

The survey response rate was 71% (257 of 364 radiologists). The percentage of radiologists reporting goals within desirable ranges was 79% for recall rate, 22% for false-positive rate, 39% for PPV2, and 61% for cancer detection rate. The range of reported goals was 0%-100% for false-positive rate and PPV2. Primary academic affiliation, receiving more hours of breast imaging continuing medical education, and receiving audit reports at least annually were associated with desirable PPV2 goals. Radiologists reporting desirable cancer detection rate goals were more likely to have interpreted mammograms for 10 or more years, and >1000 mammograms per year.

CONCLUSION

Many radiologists report goals for their accuracy when interpreting screening mammograms that fall outside of published desirable benchmarks, particularly for false-positive rate and PPV2, indicating an opportunity for education.

Vitamin B12 deficiency in Australian residential aged care facilities

OBJECTIVE

To determine the prevalence of undiagnosed vitamin B12 deficiency among residential aged care facility residents in southern Tasmania, Australia, and to identify associated risk factors.

DESIGN AND SETTING

Cross-sectional study of residents from five southern Tasmanian residential aged care facilities.

PARTICIPANTS

Two hundred and fifty-nine residents without a prior diagnosis of vitamin B12 deficiency or recorded serum B12 level within the past 6 months were approached to have their serum B12 level tested. One hundred and sixty (61%) residents consented and their doctors were contacted for further consent. A total of 130 (50%) residents completed the study.

MEASUREMENTS

Clinical and demographic characteristics, and serum B12 level.

RESULTS

Of the 130 residents tested, 18 residents (14%) were considered vitamin B12 deficient (serum level <150 pmol/L), 47 (36%) were equivocal (150 pmol/L to 250 pmol/L) and 65 (50%) had normal serum B12 levels (>250 pmol/L). There was a weak negative correlation between age and serum B12 level in those residents not taking a multivitamin (n=120, r=-0.19, p<0.05). The use of a multivitamin or antipsychotic drug were associated with altered mean serum B12 levels (+137 pmol/L, p<0.001 and -70 pmol/L, p<0.001 respectively).

CONCLUSION

As vitamin B12 deficiency can manifest in a range of symptoms that are frequently misdiagnosed, the finding of undetected deficiency in 14% of residents is a cause for concern. Oral multivitamin supplementation may help prevent deficiency, and potentially treat existing deficiencies in older institutionalised people.

Warfarin management after discharge from hospital: a qualitative analysis

WHAT IS KNOWN AND OBJECTIVE

Warfarin is recognized as a high-risk medication for adverse events, and the risks are particularly heightened in the period immediately following a patient's discharge from hospital. This qualitative study aimed to explore the experiences of Australian patients and healthcare professionals of warfarin management in the post-discharge period and identify the benefits and deficiencies of existing systems, to inform the development of a model for a new collaborative post-discharge warfarin management service.

METHODS

Healthcare professionals, professional organization representatives and patients recently discharged from hospital taking warfarin (consumers) were recruited via purposive, criterion-based sampling within two Australian states. Semi-structured telephone interviews were conducted between August and October 2008 using standard discussion guides. Data were manually analyzed to identify emergent themes using a phenomenological approach.

RESULTS

Forty-seven participants were involved in the telephone interviews. Three major themes emerged: (i) appropriate warfarin education is integral to effective warfarin management, (ii) problems occur in communication along the continuum of care and (iii) home-delivered services are valuable to both patients and healthcare professionals.

DISCUSSION

Although high-quality warfarin education and effective communication at the hospital-community interface were identified as important in post-discharge warfarin management, deficiencies were perceived within current systems. The role of home-delivered services in ensuring timely follow-up and promoting continuity of care was recognized. Previous studies exploring anticoagulation management in other settings have identified similar themes. Post-discharge management should therefore focus on providing patients with a solid foundation to minimize future problems.

WHAT IS NEW AND CONCLUSION

Addressing the three identified facets of care within a new, collaborative post-discharge warfarin management service may address the perceived deficiencies in existing systems. Improvements may result in the short- and longer-term health outcomes of patients discharged from hospital taking warfarin, including a reduction in their risk of adverse events.

Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program

BACKGROUND

Despite the proven effectiveness of antithrombotic therapy for atrial fibrillation (AF), the treatment remains suboptimal. The aim of this study was to implement and evaluate a system to improve the appropriate use of antithrombotics for stroke prevention in AF utilizing a clinical pharmacist as a stroke risk assessor.

METHOD

Hospital in-patients with AF were prospectively identified and they received a formal stroke risk assessment from a pharmacist. The patients' risk of stroke was assessed and documented according to Australian guidelines and a recommendation regarding antithrombotic therapy was made to the medical team on a specially designed stroke risk assessment form.

RESULTS

One hundred and thirty-four stroke risk assessments were performed during the intervention period. For those patients at high risk of stroke and with no contraindication present (warfarin-eligible patients), 98% were receiving warfarin on discharge from hospital compared to 74% on admission (P < 0.001). Of the 50 (37%) assessments that recommended a change of therapy, 44 (88%) resulted in a change in the patient's current antithrombotic therapy compared to their admission therapy. Thirty (68%) of the assessments resulted in an 'upgrade' to more-effective treatment options for example from no therapy to any agent or from aspirin to warfarin.

DISCUSSION AND CONCLUSION

The pharmacist-led stroke risk assessment program resulted in a significant increase in the proportion of patients receiving appropriate thromboprophylaxis for stroke prevention in AF. The methods used in this study should be evaluated in a larger trial, in multiple hospitals, with different pharmacists performing the intervention.

Variability in interpretive performance at screening mammography and radiologists' characteristics associated with accuracy

PURPOSE

To identify radiologists' characteristics associated with interpretive performance in screening mammography.

MATERIALS AND METHODS

The study was approved by institutional review boards of University of Washington (Seattle, Wash) and institutions at seven Breast Cancer Surveillance Consortium sites, informed consent was obtained, and procedures were HIPAA compliant. Radiologists who interpreted mammograms in seven U.S. regions completed a self-administered mailed survey; information on demographics, practice type, and experience in and perceptions of general radiology and breast imaging was collected. Survey data were linked to data on screening mammograms the radiologists interpreted between January 1, 1998, and December 31, 2005, and included patient risk factors, Breast Imaging Reporting and Data System assessment, and follow-up breast cancer data. The survey was returned by 71% (257 of 364) of radiologists; in 56% (205 of 364) of the eligible radiologists, complete data on screening mammograms during the study period were provided; these data were used in the final analysis. An evaluation of whether the radiologists' characteristics were associated with recall rate, false-positive rate, sensitivity, or positive predictive value of recall (PPV(1)) of the screening examinations was performed with logistic regression models that were adjusted for patients' characteristics and radiologist-specific random effects.

RESULTS

Study radiologists interpreted 1 036 155 screening mammograms; 4961 breast cancers were detected. Median percentages and interquartile ranges, respectively, were as follows: recall rate, 9.3% and 6.3%-13.2%; false-positive rate, 8.9% and 5.9%-12.8%; sensitivity, 83.8% and 74.5%-92.3%; and PPV(1), 4.0% and 2.6%-5.9%. Wide variability in sensitivity was noted, even among radiologists with similar false-positive rates. In adjusted regression models, female radiologists or fellowship-trained radiologists had significantly higher recall and false-positive rates (P < .05, all). Fellowship training in breast imaging was the only characteristic significantly associated with improved sensitivity (odds ratio, 2.32; 95% confidence interval: 1.42, 3.80; P < .001) and the overall accuracy parameter (odds ratio, 1.61; 95% confidence interval: 1.05, 2.45; P = .028).

CONCLUSION

Fellowship training in breast imaging may lead to improved cancer detection, but it is associated with higher false-positive rates.

Variability of interpretive accuracy among diagnostic mammography facilities

BACKGROUND

Interpretive performance of screening mammography varies substantially by facility, but performance of diagnostic interpretation has not been studied.

METHODS

Facilities performing diagnostic mammography within three registries of the Breast Cancer Surveillance Consortium were surveyed about their structure, organization, and interpretive processes. Performance measurements (false-positive rate, sensitivity, and likelihood of cancer among women referred for biopsy [positive predictive value of biopsy recommendation {PPV2}]) from January 1, 1998, through December 31, 2005, were prospectively measured. Logistic regression and receiver operating characteristic (ROC) curve analyses, adjusted for patient and radiologist characteristics, were used to assess the association between facility characteristics and interpretive performance. All statistical tests were two-sided.

RESULTS

Forty-five of the 53 facilities completed a facility survey (85% response rate), and 32 of the 45 facilities performed diagnostic mammography. The analyses included 28 100 diagnostic mammograms performed as an evaluation of a breast problem, and data were available for 118 radiologists who interpreted diagnostic mammograms at the facilities. Performance measurements demonstrated statistically significant interpretive variability among facilities (sensitivity, P = .006; false-positive rate, P < .001; and PPV2, P < .001) in unadjusted analyses. However, after adjustment for patient and radiologist characteristics, only false-positive rate variation remained statistically significant and facility traits associated with performance measures changed (false-positive rate = 6.5%, 95% confidence interval [CI] = 5.5% to 7.4%; sensitivity = 73.5%, 95% CI = 67.1% to 79.9%; and PPV2 = 33.8%, 95% CI = 29.1% to 38.5%). Facilities reporting that concern about malpractice had moderately or greatly increased diagnostic examination recommendations at the facility had a higher false-positive rate (odds ratio [OR] = 1.48, 95% CI = 1.09 to 2.01) and a non-statistically significantly higher sensitivity (OR = 1.74, 95% CI = 0.94 to 3.23). Facilities offering specialized interventional services had a non-statistically significantly higher false-positive rate (OR = 1.97, 95% CI = 0.94 to 4.1). No characteristics were associated with overall accuracy by ROC curve analyses.

CONCLUSIONS

Variation in diagnostic mammography interpretation exists across facilities. Failure to adjust for patient characteristics when comparing facility performance could lead to erroneous conclusions. Malpractice concerns are associated with interpretive performance.

A comparison of planar, laser-induced fluorescence, and high-sensitivity interferometry techniques for gas-puff nozzle density measurements

The distribution of argon gas injected by a 12-cm-diameter triple-shell nozzle was characterized using both planar, laser-induced fluorescence (PLIF) and high-sensitivity interferometry. PLIF is used to measure the density distribution at a given time by detecting fluorescence from an acetone tracer added to the gas. Interferometry involves making time-dependent, line-integrated gas density measurements at a series of chordal locations that are then Abel inverted to obtain the gas density distribution. Measurements were made on nominally identical nozzles later used for gas-puff Z-pinch experiments on the Saturn pulsed-power generator. Significant differences in the mass distributions obtained by the two techniques are presented and discussed, along with the strengths and weaknesses of each method.

Harm minimization strategies: opinions of health professionals in rural and remote Australia

BACKGROUND AND OBJECTIVE

There is some evidence that the problem of illicit drug use (IDU) is increasing in rural areas of Australia. Lack of access to harm minimization (HM) strategies is potentially exacerbated by a shortage of health care facilities and health care professionals in rural areas. This study was conducted to determine barriers to implementation, access to, and success of HM strategies, as seen by health professionals presently working in rural Australia.

METHODS

Four hundred rural pharmacists Australia-wide and 425 doctors in rural Victoria and Tasmania were sent postal surveys to assess their opinions on the level of IDU in their area, the types of drugs commonly used, the adequacy of HM strategies and facilities, and the barriers faced by doctors, pharmacists and clients.

RESULTS

The overall response rate was almost 50%. Slightly less than half of surveyed health professionals felt that IDU was increasing in their area, with heroin perceived to be the most prevalent drug used in all States except Tasmania and the Northern Territory. Both methadone prescribers and dispensers believed the methadone maintenance programmes were highly valuable to the community, but not without problems (e.g. risk of overdose). A lack of time or staff was the greatest influence on doctors not participating in the methadone programmes, whereas safety concerns were prominent with pharmacists. The majority of doctors felt HM facilities were inadequate, with needle-syringe exchange being the most frequently nominated HM strategy lacking.

CONCLUSION

Despite best intentions, there are still problems with HM strategies in these areas. Improving the number and expertise of health professionals in rural areas, and providing adequate support for them, would address some of these problems.

Development of an intelligent decision support system for medication review

BACKGROUND AND OBJECTIVE

The aim was to develop and evaluate a pilot version of a knowledge-based system that can identify existing and potential medication-related problems from patient information. This intelligent system could directly support pharmacists and other health professionals providing medication reviews.

METHODS

Rather than being based on static rules to trigger alerts, this system utilizes a multiple classification ripple-down rules approach, which allows the user to build rules incrementally and improve the accuracy of the knowledge base in identifying medication-related problems while the system is in use, with no outside assistance or training. The system contextualizes the potential drug therapy problems by taking into consideration the patient's demographics, and other medical condition and drugs. The system is capable of both being instructed in the domain of medication review through its routine use by an expert, and acting similarly to the expert when analysing genuine medication review cases. The system was handed over to an experienced clinical pharmacist (expert), with no knowledge or conclusions preloaded into the system. The expert was then able to add the case details and generate the rules required for 126 actual medication review cases.

RESULTS

Over 250 rules were generated from the review cases, incorporating demographics, medical history, symptoms, medications and pathology results from these cases. At the completion of the cases, more than 80% of the potential medication-related problems identified by the expert were also detected by the system. The false positive rate, or number of incorrect medication-related problems identified by the system, was <10% overall and was zero for the last 15 cases analysed. The system found significantly more potential medication-related problems than the expert, with the system consistently remaining at least one finding ahead. There was a high incidence of missed potential medication-related problems by the expert, which were automatically repaired by the system.

CONCLUSIONS

The knowledge-based system has already demonstrated that the technique employed is well suited to a domain of this nature and has furthermore demonstrated that it is capable of improving the quality of service that the medication reviewer can provide. The system will be further enhanced and tested prior to use in the field. It should help pharmacists in the provision of medication reviews, improving their clinical and time management capabilities, and enhancing their ability to contribute to the quality use of medications.

Predictors of urinary incontinence in a prospective cohort of postmenopausal women

OBJECTIVE

To prospectively assess risk factors associated with occurrence of urinary incontinence among postmenopausal women.

METHODS

We followed up 1,017 postmenopausal health maintenance organization enrollees, aged 55 to 75 years, for 2 years. The primary outcome measures were any urinary incontinence and severe incontinence reported at 12- or 24-month follow-up visits.

RESULTS

Baseline prevalence of any amount or frequency of urinary incontinence in the past year was 66%. Among the 345 women without incontinence at baseline, 65 (19%) at 1 year and 66 (19%) at 2 years reported any incontinence. Ninety-two of 672 (14%) and 96 of 672 (14%) women with incontinence at baseline reported no incontinence at years 1 and 2. In an adjusted multiple logistic regression model, independent predictors of any incontinence included white race (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.6), vaginal estrogen cream (OR 2.0, CI 1.1-3.7), vaginal dryness (OR 1.6, CI 1.2-2.2), vaginal discharge (OR 1.5, CI 1.0-2.2), 6 or more lifetime urinary tract infections (OR 1.8, CI 1.2-2.6), and diabetic peripheral neuropathy (OR 1.7, CI 1.0-3.1). In adjusted models, predictors of severe incontinence were history of hysterectomy (OR 1.8, CI 1.1-2.7) and any vaginal symptom (OR 1.7, CI 1.0-2.8).

CONCLUSION

A substantial proportion of incontinence-free postmenopausal women developed urinary incontinence during 2 years of follow-up. Because vaginal symptoms are associated with urinary incontinence, their relationship with other risk factors, including vaginal Escherichia coli colonization and vaginal estrogen cream use, warrant additional study. Similarly, diabetic peripheral neuropathy and hysterectomy associations suggest areas for future investigation.

LEVEL OF EVIDENCE

II-2.

Mucor rouxii ultrastructure: cyclic AMP and actin cytoskeleton

A comparative analysis of the effect of two compounds, dibutyryl-cyclic-AMP (dbcAMP) and latrunculin B, on the morphology and ultrastructure of the dimorphic fungus Mucor rouxii under aerobic growth conditions is presented. dbcAMP acts through the sustained activation of protein kinase A, and latrunculin B through the disruption of the actin cytoskeleton. Upon addition of these compounds to the growth medium at any stage of the germination process, cells lost polarised growth and switched to isodiametric growth. The effect was reversible. The morphologies, visualised by light microscopy or scanning electron microscopy (SEM), were alike. A switch from a rough to a smooth surface was observed by SEM when cells were repolarised by removal of the added compound. Ultrastructural changes under both conditions, as observed by transmission electron microscopy, were similar, the main feature being the enlargement of the cell wall, with irregular depositions, and detachment from the cell membrane. dbcAMP-treated cells showed a decrease in the number of glycogen granules compared with control and latrunculin B-treated cells. F-actin staining with fluorescein isothiocyanate-phalloidin showed that both dbcAMP- and latrunculin B-treated cells displayed a much lower fluorescence than control cells, with only a few pale plaques. The results suggest that the sustained activation of protein kinase A, which impairs polarised growth, might exert its effect through a modification of actin cytoskeleton organisation, very probably also involving an integrinlike pathway, as judged by the cell wall detachment and loss of cell adhesiveness of the dbcAMP-treated isodiametric cells.

Improving the outcomes of anticoagulation in rural Australia: an evaluation of pharmacist-assisted monitoring of warfarin therapy

OBJECTIVE

The aim of this project was to assess whether rural pharmacist involvement in the management of patients receiving warfarin has the potential to lead to safer and more effective anticoagulation, and is valued and welcomed by patients and their general practitioners (GPs).

METHODS

A convenience sample of rural pharmacists was trained in the use of the CoaguChek S International Normalized Ratio (INR) monitor and then conducted pharmacy-based testing for approximately 3 months. Two types of testing were performed in the pharmacy: (i) comparison testing was defined as pharmacy-based tests taken within 4 h of conventional laboratory testing or (ii) additional testing, which was a pharmacy-based test with no direct comparison laboratory test taken. Pharmacists, GPs and patients completed anonymous satisfaction surveys after the completion of the pharmacy-based testing.

RESULTS

Pharmacists from 16 rural pharmacies were trained to use the CoaguChek S monitor. During the trial period, 518 INR tests were performed in the pharmacies on 137 different patients. A total of 120 tests were evaluated against results from laboratory testing. The pharmacy-based INR values were significantly correlated with the laboratory INR values (mean of 2.32+/-0.77 and 2.32+/-0.59 respectively; r=0.88, P<0.0001). A total of 398 additional pharmacy-based tests were conducted in the pharmacy and 8.5% of the additional tests resulted in a subsequent dosage change. The monitoring was well received by pharmacists, GPs and patients.

CONCLUSIONS

The results of the trial were very positive. The CoaguChek S monitor in pharmacy-based testing performed accurately compared with conventional laboratory testing. Further research needs to be conducted on the impact of community pharmacy-conducted INR monitoring on patient care and outcomes.

Urinary incontinence and diabetes in postmenopausal women

OBJECTIVE

This study evaluates diabetes characteristics and other risk factors for urinary incontinence among community-dwelling postmenopausal women.

RESEARCH DESIGN AND METHODS

We performed a cross-sectional analysis of a population-based study of 1,017 postmenopausal women (218 with diabetes), aged 55-75 years, enrolled from a health maintenance organization. Outcomes included any incontinence and severe incontinence in the prior month.

RESULTS

Overall, 60% of women had any incontinence in the prior month and 8% had severe incontinence. Parity and postvoid residual bladder volume were not associated with incontinence. Oral estrogen and vaginal estrogen use were positively associated with a report of any incontinence but not severe incontinence. A history of urinary tract infection (UTI) and measures of general health were associated with both outcomes. Women with diabetes reported disproportionately more severe incontinence, difficulty controlling urination, mixed (stress and urge) incontinence, use of pads, inability to completely empty the bladder, being unaware of leakage, and discomfort with urination (P < or = 0.06). Diabetes duration, treatment type, peripheral neuropathy, and retinopathy were significantly associated with severe incontinence in multiple regression models adjusted for age, education, and history of UTI (P = 0.01-0.06); however, additional adjustment for BMI diminished the strength of association (P = 0.17-0.52).

CONCLUSIONS

Urinary incontinence is highly prevalent among postmenopausal women. Women with diabetes are more likely to experience severe and symptomatic urinary incontinence. UTI history is a major risk factor, postvoid residual bladder volume plays no demonstrable role, and BMI confounds the relationship between diabetes and incontinence among healthy postmenopausal women.

Cancer preventive screening: a cross-border comparison of United States and Canadian Chinese women

OBJECTIVE

To compare screening mammography and Pap testing among Chinese women in Seattle, Washington to Vancouver, and British Columbia.

METHODS

Using community-based sampling methods, trilingual female interviewers surveyed Chinese women in Seattle and Vancouver. Multiple preventive health behaviors and health care access variables were assessed. Mammography analysis included 409 women aged 50-74 years. Pap testing analysis included 973 women aged 20-69 years. Main outcome measures were ever use and use in the last 2 years of screening mammography and Pap testing.

RESULTS

Chinese women in Vancouver were younger, more educated and fluent in English. Unadjusted rates of mammography and Pap testing were similar between the two cities. Provider type was consistently associated with screening in both cities; female providers had the highest rates and Chinese male providers the lowest. Adjusted logistic regression analysis demonstrated similar mammography use in the two cities. However, for Pap testing, women in Seattle had higher odds of screening compared to Vancouver.

CONCLUSION

Despite universal health care coverage and baseline characteristics typically associated with greater utilization of preventive screening services, Chinese women in Vancouver did not have higher rates of screening mammography and Pap testing compared to Chinese women in Seattle.

Predictors of urinary tract infection after menopause: a prospective study

PURPOSE

To describe the incidence of and risk factors for acute cystitis among nondiabetic and diabetic postmenopausal women.

METHODS

We conducted a population-based, prospective cohort study of 1017 postmenopausal women, aged 55 to 75 years, who were enrolled in a health maintenance organization and followed for 2 years. A wide range of behavioral and physiologic exposures were assessed at baseline interview and follow-up clinic visits; the main outcome measure was microbiologically confirmed acute symptomatic cystitis. Follow-up was 87% at 12 months and 81% at 24 months.

RESULTS

During 1773 person-years of follow-up, 138 symptomatic urinary tract infections occurred (incidence, 0.07 per person-year). Independent predictors of infection included insulin-treated diabetes (hazard ratio [HR] = 3.4; 95% confidence interval [CI]: 1.7 to 7.0) and a lifetime history of urinary tract infection (HR for six or more infections = 6.9; 95% CI: 3.5 to 13.6). Borderline associations included a history of vaginal estrogen cream use in the last month (HR = 1.8; 95% CI: 1.0 to 3.4), a history of kidney stones (HR = 1.9; 95% CI: 1.0 to 3.7), and asymptomatic bacteriuria at baseline (HR = 1.8; 95% CI: 0.9 to 3.5). Sexual activity, urinary incontinence, parity, postcoital urination, vaginal dryness, use of cranberry juice, vaginal bacterial flora, and postvoid residual bladder volume were not associated with incident acute cystitis after multivariable adjustment.

CONCLUSION

Insulin-treated diabetes is a potentially modifiable risk factor for incident acute cystitis among postmenopausal women, whereas a lifetime history of urinary tract infection was the strongest predictor. Use of oral or vaginal estrogen was not protective, and a wide range of behavioral and physiologic factors was not associated with acute cystitis episodes in this generally healthy sample.

Improving the outcomes of anticoagulation: an evaluation of home follow-up of warfarin initiation

OBJECTIVES

A number of studies have reported that the risk of bleeding associated with warfarin is highest early in the course of therapy. This study examined the effect of a programme focused on the transition of newly anticoagulated patients from hospital to the community.

DESIGN

Open-label randomized controlled trial.

SETTING

Home-based follow-up of patients discharged from acute care hospital in southern Tasmania, Australia.

SUBJECTS

A total of 128 patients initiated on warfarin in hospital and subsequently discharged to general practitioner (GP) care were enrolled in the study. Sixty were randomized to home monitoring (HM) and 68 received usual care (UC).

INTERVENTIONS

HM patients received a home-visit by the project pharmacist and point-of-care international normalized ratio (INR) testing on alternate days on 4 occasions, with the initial visit two days after discharge. The UC group was solely managed by the GP and only received a visit 8 days after discharge to determine anticoagulant control.

RESULTS

At discharge, 42% of the HM group and 45% of the UC group had a therapeutic INR. At day 8, 67% of the HM patients had a therapeutic INR, compared with 42% of UC patients (P < 0.002). In addition, 26% of UC patients had a high INR, compared with only 4% of HM patients. Bleeding events were assessed 3 months after discharge and occurred in 15% of HM patients, compared with 36% of the UC group (P < 0.01).

CONCLUSIONS

This programme improved the initiation of warfarin therapy and resulted in a significant decrease in haemorrhagic complications in the first 3 months of therapy.

Accuracy, reproducibility and clinical utility of the CoaguChek S portable international normalized ratio monitor in an outpatient anticoagulation clinic

The accuracy and reproducibility of the CoaguChek S, and its clinical agreement with conventional laboratory international normalized ratio (INR) determination, were evaluated in an outpatient anticoagulation clinic setting. Forty-three patients provided 248 paired INR measurements for analysis. The paired results were highly correlated (r = 0.90). The mean coefficient of variation for the CoaguChek S for a random sample of 21 patients with three repeated tests each, was 4%. Clinical applicability was also measured by discrepant INR values, as defined in the literature by expanded and narrow agreement, and by INR values resulting in a different clinical decision by a blinded haematology registrar. Expanded agreement and narrow agreement between the two INR values occurred 90 and 88% of the time, respectively. The stricter criteria set down by the clinician resulted in 73% of paired results producing the same dosage decision. The CoaguChek S displayed good correlation with laboratory determination of INR and compared relatively well with expanded and narrow clinical agreement criteria.

Screening mammography among Chinese Canadian women

BACKGROUND

Though breast cancer is the most common malignancy among Chinese women, screening mammography is underutilized. This study examined barriers and facilitators of screening mammography among Chinese Canadian women.

METHODS

Using community-based sampling, Chinese women in British Columbia were interviewed in 1999 about multiple preventive health behaviours. We included 213 women in the mammography analysis; main outcome measures were ever having a mammogram and routine mammography.

RESULTS

Seventy-five percent of women 50 to 79 years old reported ever having had a mammogram, and 53% had two or more mammograms within the last five years. Receiving a recommendation for a mammogram from medical personnel or from a family member, and believing that cancer cannot be prevented by faith were independently associated with both screening outcomes.

CONCLUSIONS

A multifaceted approach to screening mammography promotion in Chinese Canadian women is suggested. Interventions that include education of and by medical providers and family members should be considered.

Doctors' beliefs on the use of antithrombotic therapy in atrial fibrillation: identifying barriers to stroke prevention

AIMS

To assess the attitudes of Australian doctors towards the use of antithrombotic drug therapy for stroke prevention in patients with non-valvular atrial fibrillation (AF), and investigate the barriers to prescribing warfarin.

METHODS

A postal survey was undertaken among approximately 10% of all registered general practitioners (GPs), cardiologists and physicians in Australia. The anonymous questionnaire used case scenarios to assess doctors' knowledge of current guidelines for the therapeutic management of AF and sought opinions on potential barriers to the use of anticoagulation.

RESULTS

Completed questionnaires were received from 711 doctors (30% response rate). The GPs performed better than the cardiologists and other specialists in estimating the risk of stroke in case scenarios. However, the cardiologists were more likely to select the recommended treatment, with GPs being more hesitant to use anticoagulation and tending to underestimate its reported benefit for stroke prevention in non-valvular AF. The GPs were also more likely to overestimate the reported risk of major bleeds with warfarin. In contrast, over one-third of the cardiologists went as far as to give warfarin to a low-risk patient and they were more likely to overestimate the reported benefit of aspirin and warfarin in AF. Only half the doctors correctly classified a patient without a previous stroke (but with other risk factors) as being at high risk. Increased experience as a registered medical practitioner was generally related to a poorer performance on classifying patients according to the risk of stroke. The principal barriers to the use of anticoagulation were nominated as: (i) active gastrointestinal bleeding, (ii) previous intracranial haemorrhage, (iii) alcoholism, (iv) a history of daily falls, (v) liver disease, (vi) severe anaemia and (vii) concurrent use of non-steroidal anti-inflammatory drugs.

CONCLUSION

There is scope for improvement in doctors' knowledge about the appropriate use of antithrombotic drug therapy in non-valvular AF and awareness of the results of recent clinical trials. Compilation and dissemination of clear guidelines and focused education on some of the other risk factors (apart from previous stroke or transient ischaemic attacks) in patients with non-valvular

Outcomes in the management of atrial fibrillation: clinical trial results can apply in practice

BACKGROUND

The benefits of antithrombotic therapy in chronic atrial fibrillation (AF) have been established in clinical trials, but there is a paucity of data on outcomes in practice.

AIMS

The objective was to establish a large ongoing database of patients with non-valvular AF, to enable the accurate determination of clinical outcomes.

METHODS

A retrospective review of the medical records for consecutive patients who had AF documented on electrocardiogram at the major teaching hospital in Tasmania between 1 January 1997 and 30 June 1999 was performed. An extensive range of demographic and clinical variables was recorded for all patients with chronic or paroxysmal non-valvular AF.

RESULTS

The 505 patients (60% males) included in the database had a median age of 76 years. According to risk stratification criteria, 79% of the patients with previously diagnosed chronic or paroxysmal AF had a high risk of developing stroke at the time of admission to hospital care. However, only one-third (34%) of these patients were receiving warfarin (or warfarin plus aspirin), with almost one-quarter (24%) receiving no antithrombotic agent. The annual incidence of ischaemic strokes was 3.4% (1.5-6.4%; 95% CI) when taking warfarin, compared to 7.0% (5.2-9.4%) for patients not taking warfarin and 7.8% (5.4-11.1%) for patients taking aspirin. The annual incidence of bleeding complications in patients taking warfarin was 14.2% (10.0-19.5%) overall and 3.4% (1.5-6.4%) for major bleeds. In patients not taking warfarin, the overall annual incidence of bleeds was 8.4% (6.3-10.9%) and 3.9% (2.5-5.7%) for major bleeds.

CONCLUSIONS

Warfarin is underused in patients with AF. In clinical practice, warfarin confers a similar stroke risk reduction to that observed in trials, with an increase in incidence of only minor bleeding complications. Aspirin did not appear to reduce the risk of stroke.

CT appearance of disseminated peritoneal adenomucinosis

Disseminated peritoneal adenomucinosis (DPAM) is a relatively rare cause of pseudomyxoma peritonei, marked by peritoneal lesions with abundant extracellular mucin and little cytologic atypia among exfoliated tumor cells, and usually associated with appendiceal adenomas. Peritoneal mucinous carcinomatosis (PMCA) also causes diffuse peritoneal tumor but is marked by neoplastic mucinous epithelium with cytologic features of carcinoma and associated with appendiceal, colon, gastric, or small bowel carcinoma. Compared with PMCA, DPAM has a different distribution of disease and a significantly better prognosis. DPAM is characterized by the lack of lymph node involvement, with primarily superficial peritoneal involvement, and a relatively benign, relapsing course over many years. Dominant primary masses may not be evident in DPAM. Despite considerable overlap in the two main causes of pseudomyxoma peritonei, there are features of the two that may help differentiate between them. We present the computed tomographic appearance of DPAM in a series of seven cases and emphasize characteristics of the disease.