Venous thromboembolism and mortality associated with recombinant erythropoietin and darbepoetin administration for the treatment of cancer-associated anemia

CONTEXT

The erythropoiesis-stimulating agents (ESAs) erythropoietin and darbepoetin are licensed to treat chemotherapy-associated anemia in patients with nonmyeloid malignancies. Although systematic overviews of trials have identified venous thromboembolism (VTE) risks, none have identified mortality risks with ESAs.

OBJECTIVE

To evaluate VTE and mortality rates associated with ESA administration for the treatment of anemia among patients with cancer.

DATA SOURCES

A published overview from the Cochrane Collaboration (search dates: January 1, 1985-April 1, 2005) and MEDLINE and EMBASE databases (key words: clinical trial, erythropoietin, darbepoetin, and oncology), the public Web site of the US Food and Drug Administration and ESA manufacturers, and safety advisories (search dates: April 1, 2005-January 17, 2008).

STUDY SELECTION

Phase 3 trials comparing ESAs with placebo or standard of care for the treatment of anemia among patients with cancer.

DATA EXTRACTION

Mortality rates, VTE rates, and 95% confidence intervals (CIs) were extracted by 3 reviewers from 51 clinical trials with 13 611 patients that included survival information and 38 clinical trials with 8172 patients that included information on VTE.

DATA SYNTHESIS

Patients with cancer who received ESAs had increased VTE risks (334 VTE events among 4610 patients treated with ESA vs 173 VTE events among 3562 control patients; 7.5% vs 4.9%; relative risk, 1.57; 95% CI, 1.31-1.87) and increased mortality risks (hazard ratio, 1.10; 95% CI, 1.01-1.20).

CONCLUSIONS

Erythropoiesis-stimulating agent administration to patients with cancer is associated with increased risks of VTE and mortality. Our findings, in conjunction with basic science studies on erythropoietin and erythropoietin receptors in solid cancers, raise concern about the safety of ESA administration to patients with cancer.

Racial/ethnic differences in multimorbidity development and chronic disease accumulation for middle-aged adults

Background

Multimorbidity–having two or more coexisting chronic conditions–is highly prevalent, costly, and disabling to older adults. Questions remain regarding chronic diseases accumulation over time and whether this differs by racial and ethnic background. Answering this knowledge gap, this study identifies differences in rates of chronic disease accumulation and multimorbidity development among non-Hispanic white, non-Hispanic black, and Hispanic study participants starting in middle-age and followed up to 16 years.

Methods and findings

We analyzed data from the Health and Retirement Study (HRS), a biennial, ongoing, publicly-available, longitudinal nationally-representative study of middle-aged and older adults in the United States. We assessed the change in chronic disease burden among 8,872 non-Hispanic black, non-Hispanic white, and Hispanic participants who were 51–55 years of age at their first interview any time during the study period (1998–2014) and all subsequent follow-up observations until 2014. Multimorbidity was defined as having two or more of seven somatic chronic diseases: arthritis, cancer, heart disease (myocardial infarction, coronary heart disease, angina, congestive heart failure, or other heart problems), diabetes, hypertension, lung disease, and stroke. We used negative binomial generalized estimating equation models to assess the trajectories of multimorbidity burden over time for non-Hispanic black, non-Hispanic white, and Hispanic participants. In covariate-adjusted models non-Hispanic black respondents had initial chronic disease counts that were 28% higher than non-Hispanic white respondents (IRR 1.279, 95% CI 1.201, 1.361), while Hispanic respondents had initial chronic disease counts that were 15% lower than non-Hispanic white respondents (IRR 0.852, 95% CI 0.775, 0.938). Non-Hispanic black respondents had rates of chronic disease accumulation that were 1.1% slower than non-Hispanic whites (IRR 0.989, 95% CI 0.981, 0.998) and Hispanic respondents had rates of chronic disease accumulation that were 1.5% faster than non-Hispanic white respondents (IRR 1.015, 95% CI 1.002, 1.028). Using marginal effects commands, this translates to predicted values of chronic disease for white respondents who begin the study period with 0.98 chronic diseases and end with 2.8 chronic diseases; black respondents who begin the study period with 1.3 chronic diseases and end with 3.3 chronic diseases; and Hispanic respondents who begin the study period with 0.84 chronic diseases and end with 2.7 chronic diseases.

Conclusions

Middle-aged non-Hispanic black adults start at a higher level of chronic disease burden and develop multimorbidity at an earlier age, on average, than their non-Hispanic white counterparts. Hispanics, on the other hand, accumulate chronic disease at a faster rate relative to non-Hispanic white adults. Our findings have important implications for improving primary and secondary chronic disease prevention efforts among non-Hispanic black and Hispanic Americans to stave off greater multimorbidity-related health impacts.

Problem list completeness in electronic health records: A multi-site study and assessment of success factors

OBJECTIVE

To assess problem list completeness using an objective measure across a range of sites, and to identify success factors for problem list completeness.

METHODS

We conducted a retrospective analysis of electronic health record data and interviews at ten healthcare organizations within the United States, United Kingdom, and Argentina who use a variety of electronic health record systems: four self-developed and six commercial. At each site, we assessed the proportion of patients who have diabetes recorded on their problem list out of all patients with a hemoglobin A1c elevation>=7.0%, which is diagnostic of diabetes. We then conducted interviews with informatics leaders at the four highest performing sites to determine factors associated with success. Finally, we surveyed all the sites about common practices implemented at the top performing sites to determine whether there was an association between problem list management practices and problem list completeness.

RESULTS

Problem list completeness across the ten sites ranged from 60.2% to 99.4%, with a mean of 78.2%. Financial incentives, problem-oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture were identified as success factors at the four hospitals with problem list completeness at or near 90.0%.

DISCUSSION

Incomplete problem lists represent a global data integrity problem that could compromise quality of care and put patients at risk. There was a wide range of problem list completeness across the healthcare facilities. Nevertheless, some facilities have achieved high levels of problem list completeness, and it is important to better understand the factors that contribute to success to improve patient safety.

CONCLUSION

Problem list completeness varies substantially across healthcare facilities. In our review of EHR systems at ten healthcare facilities, we identified six success factors which may be useful for healthcare organizations seeking to improve the quality of their problem list documentation: financial incentives, problem oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture.

Use of Health-Related, Quality-of-Life Metrics to Predict Mortality and Hospitalizations in Community-Dwelling Seniors

OBJECTIVES

To investigate whether health-related quality-of-life (HRQoL) scores in a primary care population can be used as a predictor of future hospital utilization and mortality.

DESIGN

Prospective cohort study measuring Short Form 12 (SF-12) scores obtained using a mailed survey. SF-12 scores, age, and a comorbidity score were used to predict hospitalization and mortality rate using multivariable logistic regression and Cox proportional hazards during the ensuing 28-month period for elderly patients.

SETTING

Intermountain Health Care, a large integrated-delivery network serving a population of more than 150,000 seniors.

PARTICIPANTS

Participants were senior patients who had one or more chronic diseases, were community dwelling, and were initially treated in primary care clinics.

MEASUREMENTS

SF-12 survey Version 1.

RESULTS

Seven thousand seventy-six surveys were sent to eligible participants; 3,042 (43%) were returned. Of the returned surveys, 2,166 (71%) were complete and scoreable. For the respondent group, a multivariable analysis demonstrated that older age, male sex, higher comorbidity score, and lower mental and physical summary measures of SF-12 predicted higher mortality and hospitalization. On average, nonresponders were older and had higher comorbidity scores and mortality rates than responders.

CONCLUSION

The SF-12 survey provided additional predictive ability for future hospitalizations and mortality. Such predictive ability might facilitate preemptive interventions that would change the course of disease in this segment of the population. However, nonresponder bias may limit the utility of mailed SF-12 surveys in certain populations.

The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors

OBJECTIVES

To explore changes in mortality and hospital usage for chronically ill seniors enrolled in a multidisease care management program, Care Management Plus (CMP).

DESIGN

Controlled clinical trial with seven intervention and six control clinics with additional patient-level matching.

SETTING

Intermountain Health Care, a large health system in Utah; seven intervention and six control clinics.

PARTICIPANTS

Three thousand four hundred thirty-two senior patients (>or=65) enrolled in Medicare.

INTERVENTION

The intervention employed nurse care managers supported by specialized information technology in primary care to manage chronically ill patients (2002-2005).

MEASUREMENTS

Mortality and hospitalization data were collected from clinical records and Medicare billing.

RESULTS

One thousand one hundred forty-four intervention patients were matched to 2,288 controls. Average age was 76.2; average comorbidity score was 2.3+/-1.1; 75% of patients had two or more chronic diseases. Survival analyses showed lower mortality and slightly more emergency department visits for care managed patients than for controls. In patients with diabetes mellitus, the intervention resulted in significantly lower mortality at 1 year (6.2%, vs 10.6% for controls) and at 2 years (12.9% vs 18.2%). Hospitalization rate was lower (21.0%, vs. 24.2% for controls) at 1 year and substantially more so at the 2-year follow-up.

CONCLUSION

CMP was successful in reducing death for all patients. For complex patients with diabetes mellitus in the intervention group, death and hospital usage were lower. Per clinic, hypothesized savings from decreased hospitalizations was $17,384 to $70,349.

Elastosis of the lamina cribrosa in glaucomatous optic neuropathy

The purpose of this study was to determine whether elastotic degeneration of the elastin component of the lamina cribrosa occurs in optic neuropathy associated with different types of glaucoma. Human optic nerve heads with primary open-angle, neovascular, chronic angle closure and pseudoexfoliation glaucoma, and with varying duration of disease were compared with age-matched normal eyes, using electron microscopy and immunogold labeling of elastin. The percent area occupied by immunogold-labeled elastin material was determined using a digital image analysis system. In all eyes with a history of glaucoma, elastosis was found in the lamina cribrosa and there was a significantly greater percentage of area occupied by elastin compared with age-matched control eyes (P<0.0001). Among the glaucomatous eyes, pseudoexfoliation glaucoma had the largest area of elastosis, followed by primary open-angle and secondary glaucoma (neovascular and chronic angle closure). In all glaucoma samples, large, confluent elastin aggregates of irregular and varied shapes (elastosis) were observed in the lamina cribrosa and insertion region. These results demonstrate that glaucomatous optic neuropathy is associated with elastosis of the lamina cribrosa, which may contribute to the changes in compliance of the optic nerve heads of glaucomatous eyes.

Potentially inappropriate medication prescribing in outpatient practices: prevalence and patient characteristics based on electronic health records

BACKGROUND

Some older adults receive potentially inappropriate medications (PIMs), increasing their risk for adverse events. A literature search did not find any US multicenter studies that measured the prevalence of PIMs in outpatient practices based on data from electronic health records (EHRs), using both the Beers and Zhan criteria.

OBJECTIVES

The aims of the present study were to compare the prevalence of PIMs using standard drug terminologies at 2 disparate institutions using EHRs and to identify characteristics of elderly patients who have a PIM on their active-medication lists.

METHODS

This cross-sectional study of outpatients' active-medication lists from April 1, 2006, was conducted using data from 2 outpatient primary care settings: Intermountain Healthcare, Salt Lake City, Utah (center 1), and the Cleveland Clinic, Cleveland, Ohio (center 2). Data were included from patients who were aged > or =65 years at the time of the last office visit and had > or =2 documented clinic visits within the previous 2 years. The primary end point was prevalence of PIMs, measured according to the 2002 Beers criteria or the 2001 Zhan criteria.

RESULTS

Data from 61,251 patients were included (36,663 women, 24,588 men; center 1: 37,247 patients; center 2: 24,004). A total of 8693 (23.3%) and 5528 (23.0%) patients at centers 1 and 2, respectively, were documented as receiving a PIM as per the Beers criteria; this difference was not statistically significant. Per the Zhan criteria (P < 0.001), these values were 6036 (16.2%) and 4160 (17.3%). Eight of the most common PIMs were the same at both institutions, with propoxyphene and fluoxetine (once daily) being the most prescribed. Female sex, polypharmacy (> or =6 medications), and multiple primary care visits were significantly associated with PIM prescribing.

CONCLUSIONS

In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations. Female sex, polypharmacy, and number of primary care visits were significantly associated with PIM prescribing. In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations.

Integrating Patient-Generated Health Data Into Clinical Care Settings or Clinical Decision-Making: Lessons Learned From Project HealthDesign

Background

Patient-generated health data (PGHD) are health-related data created or recorded by patients to inform their self-care and understanding about their own health. PGHD is different from other patient-reported outcome data because the collection of data is patient-driven, not practice- or research-driven. Technical applications for assisting patients to collect PGHD supports self-management activities such as healthy eating and exercise and can be important for preventing and managing disease. Technological innovations (eg, activity trackers) are making it more common for people to collect PGHD, but little is known about how PGHD might be used in outpatient clinics.

Objective

The objective of our study was to examine the experiences of health care professionals who use PGHD in outpatient clinics.

Methods

We conducted an evaluation of Project HealthDesign Round 2 to synthesize findings from 5 studies funded to test tools designed to help patients collect PGHD and share these data with members of their health care team. We conducted semistructured interviews with 13 Project HealthDesign study team members and 12 health care professionals that participated in these studies. We used an immersion-crystallization approach to analyze data. Our findings provide important information related to health care professionals’ attitudes toward and experiences with using PGHD in a clinical setting.

Results

Health care professionals identified 3 main benefits of PGHD accessibility in clinical settings: (1) deeper insight into a patient’s condition; (2) more accurate patient information, particularly when of clinical relevance; and (3) insight into a patient’s health between clinic visits, enabling revision of care plans for improved health goal achievement, while avoiding unnecessary clinic visits. Study participants also identified 3 areas of consideration when implementing collection and use of PGHD data in clinics: (1) developing practice workflows and protocols related to PGHD collection and use; (2) data storage, accessibility at the point of care, and privacy concerns; and (3) ease of using PGHD data.

Conclusions

PGHD provides value to both patients and health care professionals. However, more research is needed to understand the benefit of using PGHD in clinical care and to identify the strategies and clinic workflow needs for optimizing these tools.

Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

Contralateral effect of topical beta-adrenergic antagonists in initial one-eyed trials in the ocular hypertension treatment study

PURPOSE

To evaluate the magnitude of the contralateral effect of topically administered beta-blockers on intraocular pressure.

METHODS

The Ocular Hypertension Treatment Study enrolled 1,636 subjects. Of these, 817 subjects were randomized to receive topical ocular hypotensive medication and 819 subjects were randomized to close observation (i.e., no topical medication). We compared the intraocular pressure of the contralateral eye of subjects at the baseline visit and after an initial one-eyed therapeutic trial of topical beta-blockers. We examined differences between baseline and follow-up intraocular pressure in untreated eyes of subjects randomized to close observation.

RESULTS

The mean reduction in intraocular pressure in the beta-blocker-treated eyes was -5.9 +/- 3. 4 mm Hg (-22% +/- 12%; Student t test, P <.0001). In the contralateral eyes, mean intraocular pressure reduction was -1.5 +/- 3.0 mm Hg (-5.8% +/- 12%; P <.0001). Of the contralateral eyes, 35% showed a reduction of 3 mm Hg or more, and 10% showed a reduction of 6 mm Hg or more. The contralateral effect of the relatively selective beta-blocker betaxolol did not differ from that of any of the nonselective beta-blockers. Factors associated with the magnitude of the contralateral effect were the degree of intraocular pressure reduction in the treated eye and baseline intraocular pressure of the contralateral eye. In the close observation group, no significant reduction in intraocular pressure was noted between the baseline and follow-up visit.

CONCLUSIONS

The contralateral effect is important in clinical practice and in clinical trials when the hypotensive effect of a topical beta-blocker is evaluated by means of a one-eyed therapeutic trial.

Use of electronic health records to support a public health response to the COVID-19 pandemic in the United States: a perspective from 15 academic medical centers

Our goal is to summarize the collective experience of 15 organizations in dealing with uncoordinated efforts that result in unnecessary delays in understanding, predicting, preparing for, containing, and mitigating the COVID-19 pandemic in the US. Response efforts involve the collection and analysis of data corresponding to healthcare organizations, public health departments, socioeconomic indicators, as well as additional signals collected directly from individuals and communities. We focused on electronic health record (EHR) data, since EHRs can be leveraged and scaled to improve clinical care, research, and to inform public health decision-making. We outline the current challenges in the data ecosystem and the technology infrastructure that are relevant to COVID-19, as witnessed in our 15 institutions. The infrastructure includes registries and clinical data networks to support population-level analyses. We propose a specific set of strategic next steps to increase interoperability, overall organization, and efficiencies.

Evaluation of serious adverse drug reactions: a proactive pharmacovigilance program (RADAR) vs safety activities conducted by the Food and Drug Administration and pharmaceutical manufacturers

BACKGROUND

The Food and Drug Administration (FDA) and pharmaceutical manufacturers conduct most postmarketing pharmaceutical safety investigations. These efforts are frequently based on data mining of databases. In 1998, investigators initiated the Research on Adverse Drug events And Reports (RADAR) project to investigate reports of serious adverse drug reactions (ADRs) and prospectively obtain information on these cases. We compare safety efforts for evaluating serious ADRs conducted by the FDA and pharmaceutical manufacturers vs the RADAR project.

METHODS

We evaluated the completeness of serious ADR descriptions in the FDA and RADAR databases and the comprehensiveness of notifications disseminated by pharmaceutical manufacturers and the RADAR investigators. A serious ADR was defined as an event that led to death or required intensive therapies to reverse.

RESULTS

The RADAR investigators evaluated 16 serious ADRs. Compared with descriptions of these ADRs in FDA databases (2296 reports), reports in RADAR databases (472 reports) had a 2-fold higher rate of including information on history and physical examination (92% vs 45%; P<.001) and a 9-fold higher rate of including basic science findings (34% vs 4%; P = .08). Safety notifications were disseminated earlier by pharmaceutical suppliers (2 vs 4 years after approval, respectively), although notifications were less likely to include information on incidence (46% vs 93%; P = .02), outcomes (8% vs 100%; P<.001), treatment or prophylaxis (25% vs 93%; P<.001), or references (8% vs 80%; P<.001).

CONCLUSION

Proactive safety efforts conducted by the RADAR investigators are more comprehensive than those conducted by the FDA and pharmaceutical manufacturers, but dissemination of related safety notifications is less timely.

Impact of generalist care managers on patients with diabetes

OBJECTIVE

To determine how the addition of generalist care managers and collaborative information technology to an ambulatory team affects the care of patients with diabetes.

STUDY SETTING

Multiple ambulatory clinics within Intermountain Health Care (IHC), a large integrated delivery network.

STUDY DESIGN

A retrospective cohort study comparing diabetic patients treated by generalist care managers with matched controls was completed. Exposure patients had one or more contacts with a care manager; controls were matched on utilization, demographics, testing, and baseline glucose control. Using role-specific information technology to support their efforts, care managers assessed patients' readiness for change, followed guidelines, and educated and motivated patients.

DATA COLLECTION

Patient data collected as part of an electronic patient record were combined with care manager-created databases to assess timely testing of glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels and changes in LDL and HbA1c levels.

PRINCIPAL FINDINGS

In a multivariable model, the odds of being overdue for testing for HbA1c decreased by 21 percent in the exposure group (n=1,185) versus the control group (n=4,740). The odds of being tested when overdue for HbA1c or LDL increased by 49 and 26 percent, respectively, and the odds of HbA1c <7.0 percent also increased by 19 percent in the exposure group. The average HbA1c levels decreased more in the exposure group than in the controls. The effect on LDL was not significant.

CONCLUSIONS

Generalist care managers using computer-supported diabetes management helped increase adherence to guidelines for testing and control of HbA1c levels, leading to improved health status of patients with diabetes.

Design and implementation of a medication reconciliation kiosk: the Automated Patient History Intake Device (APHID)

Errors associated with medication documentation account for a substantial fraction of preventable medical errors. Hence, the Joint Commission has called for the adoption of reconciliation strategies at all United States healthcare institutions. Although studies suggest that reconciliation tools can reduce errors, it remains unclear how best to implement systems and processes that are reliable and sensitive to clinical workflow. The authors designed a primary care process that supported reconciliation without compromising clinic efficiency. This manuscript describes the design and implementation of Automated Patient History Intake Device (APHID): ambulatory check-in kiosks that allow patients to review the names, dosage, frequency, and pictures of their medications before their appointment. Medication lists are retrieved from the electronic health record and patient updates are captured and reviewed by providers during the clinic session. Results from the roll-in phase indicate the device is easy for patients to use and integrates well with clinic workflow.

Cost Analysis of Nursing Home Registered Nurse Staffing Times

OBJECTIVES

To examine potential cost savings from decreased adverse resident outcomes versus additional wages of nurses when nursing homes have adequate staffing.

DESIGN

A retrospective cost study using differences in adverse outcome rates of pressure ulcers (PUs), urinary tract infections (UTIs), and hospitalizations per resident per day from low staffing and adequate staffing nursing homes. Cost savings from reductions in these events are calculated in dollars and compared with costs of increasing nurse staffing.

SETTING

Eighty-two nursing homes throughout the United States.

PARTICIPANTS

One thousand three hundred seventy-six frail elderly long-term care residents at risk of PU development.

MEASUREMENTS

Event rates are from the National Pressure Ulcer Long-Term Care Study. Hospital costs are estimated from Medicare statistics and from charges in the Healthcare Cost and Utilization Project. UTI costs and PU costs are from cost-identification studies. Time horizon is 1 year; perspectives are societal and institutional.

RESULTS

Analyses showed an annual net societal benefit of 3,191 dollars per resident per year in a high-risk, long-stay nursing home unit that employs sufficient nurses to achieve 30 to 40 minutes of registered nurse direct care time per resident per day versus nursing homes that have nursing time of less than 10 minutes. Sensitivity analyses revealed a robust set of estimates, with no single or paired elements reaching the cost/benefit equality threshold.

CONCLUSION

Increasing nurse staffing in nursing homes may create significant societal cost savings from reduction in adverse outcomes. Challenges in increasing nurse staffing are discussed.

Health information technology to improve care for people with multiple chronic conditions

OBJECTIVE

To review evidence regarding the use of Health Information Technology (health IT) interventions aimed at improving care for people living with multiple chronic conditions (PLWMCC) in order to identify critical knowledge gaps.

DATA SOURCES

We searched MEDLINE, CINAHL, PsycINFO, EMBASE, Compendex, and IEEE Xplore databases for studies published in English between 2010 and 2020.

STUDY DESIGN

We identified studies of health IT interventions for PLWMCC across three domains as follows: self-management support, care coordination, and algorithms to support clinical decision making.

DATA COLLECTION/EXTRACTION METHODS

Structured search queries were created and validated. Abstracts were reviewed iteratively to refine inclusion and exclusion criteria. The search was supplemented by manually searching the bibliographic sections of the included studies. The search included a forward citation search of studies nested within a clinical trial to identify the clinical trial protocol and published clinical trial results. Data were extracted independently by two reviewers.

PRINCIPAL FINDINGS

The search yielded 1907 articles; 44 were included. Nine randomized controlled trials (RCTs) and 35 other studies including quasi-experimental, usability, feasibility, qualitative studies, or development/validation studies of analytic models were included. Five RCTs had positive results, and the remaining four RCTs showed that the interventions had no effect. The studies address individual patient engagement and assess patient-centered outcomes such as quality of life. Few RCTs assess outcomes such as disability and none assess mortality.

CONCLUSIONS

Despite a growing body of literature on health IT interventions or multicomponent interventions including a health IT component for chronic disease management, current evidence for applying health IT solutions to improve care for PLWMCC is limited. The body of literature included in this review provides critical information on the state of the science as well as the many gaps that need to be filled for digital health to fulfill its promise in supporting care delivery that meets the needs of PLWMCC.

Clinical decisions support malfunctions in a commercial electronic health record

OBJECTIVES

Determine if clinical decision support (CDS) malfunctions occur in a commercial electronic health record (EHR) system, characterize their pathways and describe methods of detection.

METHODS

We retrospectively examined the firing rate for 226 alert type CDS rules for detection of anomalies using both expert visualization and statistical process control (SPC) methods over a five year period. Candidate anomalies were investigated and validated.

RESULTS

Twenty-one candidate CDS anomalies were identified from 8,300 alert-months. Of these candidate anomalies, four were confirmed as CDS malfunctions, eight as false-positives, and nine could not be classified. The four CDS malfunctions were a result of errors in knowledge management: 1) inadvertent addition and removal of a medication code to the electronic formulary list; 2) a seasonal alert which was not activated; 3) a change in the base data structures; and 4) direct editing of an alert related to its medications. 154 CDS rules (68%) were amenable to SPC methods and the test characteristics were calculated as a sensitivity of 95%, positive predictive value of 29% and F-measure 0.44.

DISCUSSION

CDS malfunctions were found to occur in our EHR. All of the pathways for these malfunctions can be described as knowledge management errors. Expert visualization is a robust method of detection, but is resource intensive. SPC-based methods, when applicable, perform reasonably well retrospectively.

CONCLUSION

CDS anomalies were found to occur in a commercial EHR and visual detection along with SPC analysis represents promising methods of malfunction detection.

Interdisciplinary collaboration in geriatrics: advancing health for older adults

The call for interdisciplinary research, education, and practice is heightened by the recognition of the potential it holds in generating creative solutions to complex problems in health care and to improving quality and effectiveness of care. With the aging of the population and the complex issues in caring for older adults, interdisciplinary collaboration is particularly salient to the field of geriatrics. However, despite interest in this approach for several decades, adoption has been slow and dissemination is not widespread. This article provides examples of recent initiatives and presents driving and restraining forces involved in adoption of interdisciplinary approaches.

Quality of reporting of serious adverse drug events to an institutional review board: a case study with the novel cancer agent, imatinib mesylate

PURPOSE

Serious adverse drug event (sADE) reporting to Institutional Review Boards (IRB) is essential to ensure pharmaceutical safety. However, the quality of these reports has not been studied. Safety reports are especially important for cancer drugs that receive accelerated Food and Drug Administration approval, like imatinib, as preapproval experience with these drugs is limited. We evaluated the quality, accuracy, and completeness of sADE reports submitted to an IRB.

EXPERIMENTAL DESIGN

sADE reports submitted to an IRB from 14 clinical trials with imatinib were reviewed. Structured case report forms, containing detailed clinical data fields and a validated causality assessment instrument, were developed. Two forms were generated for each ADE, the first populated with data abstracted from the IRB reports, and the second populated with data from the corresponding clinical record. Completeness and causality assessments were evaluated for each of the two sources, and then compared. Accuracy (concordance between sources) was also assessed.

RESULTS

Of 115 sADEs reported for 177 cancer patients to the IRB, overall completeness of adverse event descriptions was 2.4-fold greater for structured case report forms populated with information from the clinical record versus the corresponding forms from IRB reports (95.0% versus 40.3%, P < 0.05). Information supporting causality assessments was recorded 3.5-fold more often in primary data sources versus IRB adverse event descriptions (93% versus 26%, P < 0.05). Some key clinical information was discrepant between the two sources.

CONCLUSIONS

The use of structured syndrome-specific case report forms could enhance the quality of reporting to IRBs, thereby improving the safety of pharmaceuticals administered to cancer patients.

Harnessing the Promise of Artificial Intelligence Responsibly

This Viewpoint discusses the benefits and potential harms of using artificial intelligence (AI) algorithms in medicine and proposes the collaborative creation of a Code of Conduct for AI in Health Care.

Integrating systematic chronic care for diabetes into an academic general internal medicine resident-faculty practice

BACKGROUND

The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care.

OBJECTIVE

To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus.

DESIGN

Retrospective cohort study

SUBJECTS

Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice.

MEASUREMENTS

Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care.

MAIN RESULTS

Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7-5.7), urine microalbumin (OR 3.3, 95% CI 2.1-5.5), blood pressure (OR 1.8, 95% CI 1.1-2.8), retinal examination (OR 1.9, 95% CI 1.3-2.7), foot monofilament examination (OR 4.2, 95% CI 3.0-6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0-9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02-3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1-4.5) compared to controls.

CONCLUSIONS

A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved processes of care and some clinical outcomes for diabetic patients. This study provides a model for further hypothesis generation and more rigorous testing of the quality benefits of structured chronic illness care in diverse outpatient practices.