Using a digital tool to detect early changes in everyday functioning in older adults: A pilot study of the Assessment of Smartphone Everyday Tasks (ASSET)

INTRODUCTION

To investigate the utility of a new digital tool for measuring everyday functioning in preclinical Alzheimer's disease, we piloted the Assessment of Smartphone Everyday Tasks (ASSET) application.

METHODS

Forty-six participants (50.3 ± 27.1 years; 67% female; 20 young unimpaired, 17 old unimpaired, 9 mildly cognitively impaired) completed ASSET 7 times. ASSET comprises two main tasks, simulating a Patient Portal and a Calendar. We assessed ASSET's internal consistency, test-retest reliability, and user experience.

RESULTS

ASSET main tasks correlated with each other (r = 0.75, 95% confidence interval [CI] = [0.58, 0.86]). Performance on ASSET's Patient Portal related to cognition (r = 0.64, 95% CI = [0.42, 0.79]) and observer ratings of everyday functioning (r = 0.57, 95% CI = [0.24, 0.79]). Test-retest reliability was good (intraclass correlation coefficient = 0.87, 95% CI = [0.77, 0.93]). Most participants rated their experience with ASSET neutrally or positively.

DISCUSSION

ASSET is a promising smartphone-based digital assessment of everyday functioning. Future studies may investigate its utility for early diagnosis and evaluation of treatment of Alzheimer's disease.

Trends in 2-1-1 Calls During Public Health Emergencies, Overall and By Gender: Hurricane Irma and COVID-19 in Broward County, Florida

Trends in 2-1-1 calls reflect evolving community needs during public health emergencies (PHEs). The study examined how changes in 2-1-1 call volume after 2 PHEs (Hurricane Irma and the coronavirus disease 2019 [COVID-19] pandemic declaration) in Broward County, Florida, varied by PHE type and whether variations differed by gender and over time. Examining 2-1-1 calls during June to December 2016, June to December 2017, and March 2019 to April 2021, this study measured changes in call volume post-PHEs using interrupted time series analysis. Hurricane Irma and the COVID-19 pandemic were associated with increases in call volume (+81 calls/d and +84 calls/d, respectively). Stratified by gender, these PHEs were associated with larger absolute increases for women (+66 and +57 calls/d vs +15 and +27 calls/d for men) but larger percent increases above their baseline for men (+143% and +174% vs +119% and +138% for women). Calls by women remained elevated longer after Hurricane Irma (5 wk vs 1 wk), but the opposite pattern was observed after the pandemic declaration (8 vs 21 wk). PHEs reduce gender differences in help-seeking around health-related social needs. Findings demonstrate the utility of 2-1-1 call data for monitoring and responding to evolving community needs in the PHE context.

Changes in Poison Center Calls for Intentional Exposure During Public Health Emergencies: COVID-19 and Winter Storm Uri in Dallas County, Texas

OBJECTIVE

This study aimed to: (1) explore changes in the volume of calls to poison control centers (PCs) for intentional exposures (IEs) in Dallas County, Texas, overall and by gender and age, and (2) examine the association between 2 different public health emergencies (PHEs) and changes in IE call volume.

METHODS

PCs categorize calls they receive by intentionality of the exposure, based on information from the caller. We analyzed data on PC calls categorized as intentional in Dallas County, Texas, from March 2019 - April 2021. This period includes the COVID-19 pandemic declaration (March 2020), a surge in COVID-19 cases (July 2020), and Winter Storm Uri (February 2021). Changes in IE call volume (overall and by age and gender), were explored, and interrupted time series analysis was used to examine call volume changes after PHE onset.

RESULTS

The summer surge in COVID-19 cases was associated with 1.9 additional IE calls/day (95% CI 0.7 to 3.1), in the context of a baseline unadjusted mean of 6.2 calls per day (unadjusted) before November 3, 2020. Neither the pandemic declaration nor Winter Storm Uri was significantly associated with changes in call volume. Women, on average, made 1.2 more calls per day compared to men during the study period. IE calls for youth increased after the pandemic declaration, closing the longstanding gap between adults and youth by early 2021.

CONCLUSIONS

Changes in IE call volume in Dallas County varied by gender and age. Calls increased during the local COVID-19 surge. Population-level behavioral health may be associated with local crisis severity.

Barriers to Price and Quality Transparency in Health Care Markets

Consumers of health care in the United States often lack information on the actual prices of the care they receive and can also lack access to information about the quality of their care. RAND researchers gathered information on how health care prices are set, price variation in health care markets, barriers to price and quality transparency for consumers, and the extent to which price and quality information is used in marketing efforts. Public payers typically set prices for physicians and hospitals prospectively, and commercial health plans negotiate with physicians and hospitals to determine prices. Some research has shown substantial variation in negotiated prices, while other research suggests more moderate variation in some markets. Although the government does not directly affect prices paid by commercial health plans, commercial prices tend to be positively correlated with Medicare fee-for-service prices. Medicaid receives mandated rebates from drug manufacturers for dispensed prescriptions. Commercial health plans negotiate both the prices paid to pharmacies and any discounts and rebates received directly from drug manufacturers. Self-pay prices faced by consumers in pharmacies are set by individual pharmacies. The barriers to consumer price and quality transparency identified through this work generally represented limitations of existing tools. Consumer price transparency is being pursued by federal and state governments. Most commercial insurers have created price transparency tools to help members estimate the costs of various services. However, these tools can be difficult to navigate and do not always provide accurate pricing.

Standardized assessment of medication reconciliation in post-acute care

BACKGROUND

Medication reconciliation (MR) facilitates safety during transitions of care, which occur frequently across post-acute care (PAC) settings. Under the intent of the IMPACT Act of 2014, the Centers for Medicare & Medicaid Services contracted with the RAND Corporation to develop and test standardized assessment data elements (SADEs) that assess the MR process.

METHODS

We employed an iterative process that incorporated stakeholder input and three rounds of testing to identify, refine, and evaluate MR SADEs. Testing took place in 186 PAC sites (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 skilled nursing facilities). There were 2951 patients in the final test. Novel MR SADEs, based on the Joint Commission's framework, were refined. The final SADEs assessed whether: patient was taking high-risk medications; an indication was noted for each medication class; discrepancies were identified; patient or family/caregiver was involved in addressing discrepancies; discrepancies were communicated to physician (or designee) within 24 h; recommended physician actions regarding discrepancies were implemented within 24 h after physician response; and the reconciled list was communicated to patient, prescriber, and/or pharmacy. Two assessors per facility collected data for each patient. Analyses described completion time, data missingness, and interrater reliability, as well as feedback on assessor burden.

RESULTS

Time to complete the MR SADEs was 3.2 min. Missing data were <5%. Interrater reliability was moderate to high (κ: 0.42 [whether a reconciled list was communicated to prescribers] to 0.89 [identifying patients taking hypoglycemics]). For identifying high-risk medication classes, interrater reliability was high (κ: 0.72-0.89). There were minimal differences by setting.

CONCLUSIONS

This is the first set of MR SADEs that have been assessed across the PAC settings. Results demonstrate feasibility, based on missing data and completion time, and moderate to strong reliability, based on interrater comparisons, of assessing MR.

Assessment of Patient Preferences for Telehealth in Post-COVID-19 Pandemic Health Care

Importance

Telehealth use greatly increased in 2020 during the first year of the COVID-19 pandemic. Patient preferences for telehealth or in-person care are an important factor in defining the role of telehealth in the postpandemic world.

Objective

To ascertain patient preferences for video visits after the ongoing COVID-19 public health emergency and to identify patient perceptions of the value of video visits and the role of out-of-pocket cost in changing patient preference for each visit modality.

Design, Setting, and Participants

This survey study was conducted using a nationally representative sample of adult members of the RAND American Life Panel. The data were obtained from the American Life Panel Omnibus Survey, which was fielded between March 8 and 19, 2021.

Main Outcomes and Measures

Preferences for video visits vs in-person care were analyzed in the survey. The first question was about participants' baseline preference for an in-person or a video visit for a nonemergency health issue. The second question entailed choosing between the preferred visit modality with a cost of $30 and another modality with a cost of $10. Questions also involved demographic characteristics, experience with video visits, willingness to use video visits, and preferences for the amount of telehealth use after the COVID-19 pandemic.

Results

A total of 2080 of 3391 sampled panel members completed the survey (participation rate, 61.3%). Participants in the weighted sample had a mean (SE) age of 51.1 (0.67) years and were primarily women (1079 [51.9%]). Most participants (66.5%) preferred at least some video visits in the future, but when faced with a choice between an in-person or a video visit for a health care encounter that could be conducted either way, more than half of respondents (53.0%) preferred an in-person visit. Among those who initially preferred an in-person visit when out-of-pocket costs were not a factor, 49.8% still preferred in-person care and 23.5% switched to a video visit when confronted with higher relative costs for in-person care. In contrast, among those who initially preferred a video visit, only 18.9% still preferred a video visit and 61.7% switched to in-person visit when confronted with higher relative costs for video visits.

Conclusions and Relevance

This survey study found that participants were generally willing to use video visits but preferred in-person care, and those who preferred video visits were more sensitive to paying out-of-pocket cost. These results suggest that understanding patient preferences will help identify telehealth's role in future health care delivery.

Barriers to using clinical decision support in ambulatory care: Do clinics in health systems fare better?

OBJECTIVE

We quantify the use of clinical decision support (CDS) and the specific barriers reported by ambulatory clinics and examine whether CDS utilization and barriers differed based on clinics' affiliation with health systems, providing a benchmark for future empirical research and policies related to this topic.

MATERIALS AND METHODS

Despite much discussion at the theoretic level, the existing literature provides little empirical understanding of barriers to using CDS in ambulatory care. We analyze data from 821 clinics in 117 medical groups, based on in Minnesota Community Measurement's annual Health Information Technology Survey (2014-2016). We examine clinics' use of 7 CDS tools, along with 7 barriers in 3 areas (resource, user acceptance, and technology). Employing linear probability models, we examine factors associated with CDS barriers.

RESULTS

Clinics in health systems used more CDS tools than did clinics not in systems (24 percentage points higher in automated reminders), but they also reported more barriers related to resources and user acceptance (26 percentage points higher in barriers to implementation and 33 points higher in disruptive alarms). Barriers related to workflow redesign increased in clinics affiliated with health systems (33 points higher). Rural clinics were more likely to report barriers to training.

CONCLUSIONS

CDS barriers related to resources and user acceptance remained substantial. Health systems, while being effective in promoting CDS tools, may need to provide further assistance to their affiliated ambulatory clinics to overcome barriers, especially the requirement to redesign workflow. Rural clinics may need more resources for training.

Health information technology for ambulatory care in health systems

OBJECTIVES

The adoption and use of health information technology (IT) by health systems in ambulatory care can be an important driver of care quality. We examine recent trends in health IT adoption by health system-affiliated ambulatory clinics in the context of the federal government's Meaningful Use and Promoting Interoperability programs.

STUDY DESIGN

We analyzed a national sample of 17,861 ambulatory clinics affiliated with 1711 health systems, using longitudinal data (2014-2016) from the HIMSS Analytics annual surveys.

METHODS

We used descriptive analyses and linear probability models to examine the adoption of electronic health records (EHRs), as well as 16 specific functionalities, at the clinic level and the system level. We compared the differential trends of adoption by various characteristics of health systems.

RESULTS

We find that the adoption of an EHR certified by the Office of the National Coordinator for Health IT (ONC) increased from 73% to 91%. However, in 2016, only 38% of clinics reported having all 16 health IT functionalities included in this study. Small health systems lag behind large systems in ambulatory health IT adoption. Patient-facing functionalities were less likely to be adopted than those oriented toward physicians. Health information exchange capabilities are still low among ambulatory clinics, pointing to the importance of the ONC's recent Promoting Interoperability initiative.

CONCLUSIONS

The relatively low uptake of health IT functionalities important to care improvement suggests substantial opportunities for further improving adoption of ambulatory health IT even among the current EHR users.

Reflections on the 7th international Jerusalem conference on health policy in the wake of the Covid-19 outbreak

In 2019, a conference in Israel showcased new frontiers in technology in healthcare, highlighting research conducted in Israel as well as across the globe. At the time, no one realized how critical—and ubiquitous—some of these technologies would become. In the wake of a global pandemic, the ability to provide healthcare remotely has become ever more important. We explore some Israeli innovations and consider how healthcare may be permanently changed.

Optimizing health IT to improve health system performance: A work in progress

BACKGROUND

Despite significant investments in health information technology (IT), the technology has not yielded the intended performance effects or transformational change. We describe activities that health systems are pursuing to better leverage health IT to improve performance.

METHODS

We conducted semi-structured telephone interviews with C-suite executives from 24 U.S. health systems in four states during 2017-2019 and analyzed the data using a qualitative thematic approach.

RESULTS

Health systems reported two broad categories of activities: laying the foundation to improve performance with IT and using IT to improve performance. Within these categories, health systems were engaged in similar activities but varied greatly in their progress. The most substantial effort was devoted to the first category, which enabled rather than directly improved performance, and included consolidating to a single electronic health record (EHR) platform and common data across the health system, standardizing data elements, and standardizing care processes before using the EHR to implement them. Only after accomplishing such foundational activities were health systems able to focus on using the technology to improve performance through activities such as using data and analytics to monitor and provide feedback, improving uptake of evidence-based medicine, addressing variation and overuse, improving system-wide prevention and population health management, and making care more convenient.

CONCLUSIONS AND IMPLICATIONS

Leveraging IT to improve performance requires significant and sustained effort by health systems, in addition to significant investments in hardware and software. To accelerate change, better mechanisms for creating and disseminating best practices and providing advanced technical assistance are needed.

Prevalence and Characteristics of Telehealth Utilization in the United States

IMPORTANCE

Telehealth services, which allow patients to communicate with a remotely located clinician, are increasingly available; however, prevalence of telehealth use, including videoconferencing visits, remains unclear.

OBJECTIVE

To measure the use of and willingness to use telehealth modalities across the US population.

DESIGN, SETTING, AND PARTICIPANTS

This survey study, conducted between February 2019 and April 2019, asked participants about their use of different telehealth modalities, reasons for not using videoconferencing visits, and willingness to use videoconferencing visits. Questions were continuously posed to panel members and closed after 2555 responses were obtained, at which point 3932 panel members had been invited, for a 65.0% response rate.

EXPOSURES

Demographic characteristics (ie, age, sex, race, rural/urban residency, education level, and income).

MAIN OUTCOMES AND MEASURES

Self-reported use of specific telehealth modalities, reasons for nonuse, and willingness to use videoconferencing in the future.

RESULTS

A total of 2555 individuals completed the survey with a mean (SD) age of 57.2 (14.2) years; 1453 respondents (weighted percentage, 51.9%) were women, and 2043 (weighted percentage, 73.4%) were White individuals. Overall, 1343 respondents (weighted percentage, 50.8%) reported use of a nontelephone telehealth modality, ranging from 873 respondents (weighted percentage, 31.9%) for patient portals and 89 respondents (weighted percentage, 4.2%) for videoconferencing visits. Although 1309 respondents (weighted percentage, 49.2%) overall answered that they were willing or very willing to use videoconferencing visits, respondents who were Black individuals (OR, 0.58; 95% CI, 0.38-0.91), aged older than 65 years (OR, 0.51; 95% CI, 0.40-0.66), or had less education (high school or less vs advanced degrees: OR, 0.37; 95% CI, 0.25-0.56) were less likely to express willingness.

CONCLUSIONS AND RELEVANCE

Despite the focused policy attention on videoconferencing visits, the results of this survey study suggest that other forms of telehealth were more dominant prior to 2020. Targeted efforts may be necessary for videoconferencing visits to reach patient groups who are older or have less education, and payer policies supporting other forms of telemedicine may be appropriate to enhance access.

Trends in the use of computerized physician order entry by health-system affiliated ambulatory clinics in the United States, 2014-2016

BACKGROUND

Computerized provider order entry (CPOE) can help providers deliver better quality care. We aimed to understand recent trends in use of CPOE by health system-affiliated ambulatory clinics.

METHODS

We analyzed longitudinal data (2014-2016) for 19,109 ambulatory clinics that participated in all 3 years of the Healthcare Information and Management Systems Society Analytics survey to assess use of CPOE and identify characteristics of clinics associated with CPOE use. We calculated descriptive statistics to examine overall trends in use, location of order entry (bedside vs. clinical station), and system-level use CPOE across all clinics. We used linear probability models to explore the association between clinic characteristics (practice size, practice type, and health system type) and two outcomes of interest: CPOE use at any point between 2014 and 2016, and CPOE use beginning in 2015 or 2016.

RESULTS

Between 2014 and 2016, use of CPOE increased more than 9 percentage points from 58 to 67%. Larger clinics and those affiliated with multi-hospital health systems were more likely to have reported use of CPOE. We found no difference in CPOE use by primary care versus specialty care clinics. When used, most clinics reported using CPOE for most or all of their orders. Health systems that used CPOE usually did so for all system-affiliated clinics.

CONCLUSIONS

Small practice size or not being part of a multi-hospital system are associated with lower use of CPOE between 2014 and 2016. Less than optimal use in these environments may be harming patient outcomes.

Visualization of Electronic Health Record Data for Decision-Making in Diabetes and Congestive Heart Failure

Objective The aim of this study is to study the impact of graphical representation of health record data on physician decision-making to inform the design of health information technology.

Materials and Methods We conducted a within participants crossover design study using a simulated electronic health record (EHR) in which we presented cases with and without visualized data designed to highlight important clinical trends or relationships, followed by assessment of the impact on decision-making about next steps for patients with chronic diseases. We then asked whether trends were observed and about usability and satisfaction using validated usability questions and asked open-ended questions as well. Time to answer questions was also collected.

Results Twenty-one primary care providers participated in the study, including five for testing only and sixteen for the full study. Questions about clinical assessment or next actions were answered correctly 55% of the time. Regarding objective trends in the data, participants described noticing the trends 85% of the time. Differences in noticing trends or difficulty level of questions were not statistically significant. Satisfaction with the tool was high and participants agreed strongly that it helped them make better decisions without adding to the time it took.

Discussion The simulation allowed us to test the impact of a visualization on clinician practice in a realistic setting. Designers of EHRs should consider the ways information presentation can affect decision-making.

Conclusion Testing visualization tools can be done in a clinically realistic context. Providers desire visualizations and believe that they help them make better and faster decisions.

Defining and Evaluating Patient-Empowered Approaches to Improving Record Matching

Despite widespread adoption of electronic health records and increasing exchange of health care data, the benefits of interoperability and health information technology have been hampered by the inability to reliably match patients and their records. The Pew Charitable Trusts contracted with the RAND Corporation to investigate "patient-empowered" approaches to record matching-solutions that have some additional, voluntary role for patients beyond simply supplying demographics to their health care providers-and to select a promising solution for further development and pilot testing. After extensive consultation with a variety of experts, researchers did not identify a "silver bullet" or achieve consensus on a single solution. Instead, this study recommends adopting a three-stage approach that aims to improve the quality of identity information, establish new smartphone app functionality to facilitate bidirectional exchange of identity information and health care data between patients and providers, and create advanced functionality to further improve value. The study also suggests that because the solution contains multiple components involving diverse stakeholders, a governance mechanism likely will be needed to provide leadership, track pilot tests, and evaluation, as well as to convene key stakeholders to build consensus where consensus is needed.

Common Laboratory Results Frequently Misunderstood by a Sample of Mechanical Turk Users

OBJECTIVES

More patients are receiving their test results via patient portals. Given test results are written using medical jargon, there has been concern that patients may misinterpret these results. Using sample colonoscopy and Pap smear results, our objective was to assess how frequently people can identify the correct diagnosis and when a patient should follow up with a provider.

METHODS

We used Mechanical Turk-a crowdsourcing tool run by Amazon that enables easy and fast gathering of users to perform tasks like answering questions or identifying objects-to survey individuals who were shown six sample test results (three colonoscopy, three Pap smear) ranging in complexity. For each case, respondents answered multiple choice questions on the correct diagnosis and recommended return time.

RESULTS

Among the three colonoscopy cases (n = 642) and three Pap smear cases (n = 642), 63% (95% confidence interval [CI]: 60-67%) and 53% (95% CI: 49-57%) of the respondents chose the correct diagnosis, respectively. For the most complex colonoscopy and Pap smear cases, only 29% (95% CI: 23-35%) and 9% (95% CI: 5-13%) chose the correct diagnosis.

CONCLUSION

People frequently misinterpret colonoscopy and Pap smear test results. Greater emphasis needs to be placed on assisting patients in interpretation.

Level of agreement on health information technology adoption and use in survey data: a mixed-methods analysis of ambulatory clinics in 1 US state

Objective

Adoption of health information technology (HIT) is often assessed in surveys of organizations. The validity of data from such surveys for ambulatory clinics has not been evaluated. We compared level of agreement between 1 ambulatory statewide survey and 2 other data sources: a second survey and interviews with survey respondents.

Materials and methods

We used 2016 data from 2 surveys of ambulatory providers in Minnesota-the Healthcare Information and Management Systems Society (HIMSS) survey and the Minnesota HIT Ambulatory Clinic Survey-and primary data collected through qualitative interviews with survey respondents. We conducted a concurrent triangulation mixed-methods assessment of the Minnesota HIT survey by assessing level of agreement between it and HIMSS, and a thematic analysis of interview data to assess the respondent's understanding of what was being asked and their approach to responding.

Results

We find high agreement between the 2 surveys on questions related to common HIT functionalities-such as computerized provider order entry, medication-based decision support, and e-prescribing-which were widely adopted by respondents' organizations. Qualitative data suggest respondents found wording of items about these functionalities clear but encountered multiple challenges including interpreting items for less commonly adopted functionalities, estimating degree of HIT usage, and indicating relevant barriers. Respondents identified multiple errors in responses and likely reported greater within-group homogeneity than actually existed.

Conclusions

Survey items related to the presence or absence of widely adopted HIT functionalities may be more valid than items about less common functionalities, degree of usage, and barriers.

A mixed-methods evaluation of an Integrated Medication Management program and implications for implementation

BACKGROUND

Improving medication adherence is a common and challenging issue. Taking medications as prescribed becomes particularly difficult for individuals with multiple chronic conditions. Poor adherence can lead to exacerbated health issues and prolonged disease severity. Medication Therapy Management is increasingly being used to help clinics improve medication adherence and reduce adverse events, but factors that enable implementation of such programs are not well identified.

OBJECTIVE

To describe the factors associated with implementation of an innovative pharmacy program and to measure the impact of the intervention.

METHODS

This mixed-methods cohort study in a federal qualified health center with its own pharmacy examined the implementation and the impact of a broad program including MTM. The intervention included appointments with pharmacists, communication between pharmacists and physicians, and, for some, monthly pre-packaged medications. Semi-structured interviews with patients and staff were recorded, transcribed, and analyzed for themes relating to implementation, satisfaction, and challenges. Quantitative methods using data collected by the pharmacists at each visit were used to compare the first visit to those at later visits and provided measures of impact on diabetes control, statin use, and medication-related problems (MRPs).

RESULTS

Qualitative interviews identified enabling factors that contributed to successful implementation of this program, including: program factors such as data access, communication with patients, and dedicated staff; organizational factors such as culture of integration, leadership support, and staffing; and lastly, environmental factors such as the availability of 340B funding. Quantitative analyses were limited by poor retention and lack of a similarly-documented comparison group. Health outcomes were not found to be significantly better, though there was a significant decrease in some kinds of MRPs. This program was well received by patients and staff and demonstrated some clinical impact.

CONCLUSION

The program's implementation was enabled by design as well as organizational and external factors. Financial and leadership support allowed for flexibility and creativity, which contributed to successful implementation. Alternative delivery models beyond fee-for-service payments may make this kind of program more feasible.

Supporting Veterans in Massachusetts: An Assessment of Needs, Well-Being, and Available Resources

Massachusetts is home to approximately 380,000 of the nation's more than 21 million veterans, but there has been little research on the resources available to this population at the state level. There are numerous resources available to veterans and other military-affiliated groups in Massachusetts, but there are still pockets of unmet need in the areas of education, employment, health care, housing, financial, and legal services-particularly for newer veterans and current National Guard/reserve members. Although Massachusetts veterans fare better overall than their peers in other states, they lag behind other Massachusetts residents in terms of health and financial status. Massachusetts veterans and National Guard/reserve members who need support and services face such barriers as a lack of knowledge about how to access services, a lack of awareness about eligibility, and geographic distance from service providers. As the veteran population changes both nationally and in Massachusetts, it will be important for public- and private-sector providers serving Massachusetts veterans and service members to continue addressing unmet needs while ensuring that resources are responsive to shifts in these populations. A better understanding of the unique needs of Massachusetts veterans can help inform investments in initiatives that target these populations and guide efforts to remedy barriers to accessing available support services and other resources.

Developing a Strategic Program for Chilean Health Information Technology: Environmental Scan and Key Informant Interviews

As part of an effort to assist Chile in developing a strategic program to foster the development of the health information technology (health IT) sector over the next five to ten years, this study assesses the current state of health IT adoption and implementation in Chile, as well as the challenges and opportunities facing the sector over the coming years. The authors conducted an environmental scan and ten key informant interviews and found that there are a number of successful health IT projects and strategies for further development currently underway in Chile, but that the successful projects are generally localized within specific health care providers and lack integration. These and other challenges suggest significant potential for the Ministry of Economy and other stakeholders to take specific actions designed to encourage further development of the health IT sector in Chile over the coming years. The next phase of this effort will use the results from this study to develop a roadmap for the Ministry of Economy to encourage health IT development in Chile over the short, medium, and long terms.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

Factors associated with ordering laboratory monitoring of high-risk medications

BACKGROUND

Knowledge about factors associated with provider ordering of appropriate testing is limited.

OBJECTIVE

To determine physician factors associated with ordering recommended laboratory monitoring tests for high-risk medications.

METHODS

Retrospective cohort study of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between 1 January 2008 and 31 December 2008. Analyses are based on administrative claims and electronic medical records. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables are physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. Additional variables are patient characteristics such as age, gender, comorbidity burden, whether the medication requiring monitoring is new or chronic, and drug-test characteristics such as inclusion in black box warnings. We used multivariable logistic regression, accounting for clustering of drugs within patients and patients within providers.

RESULTS

Physician orders for laboratory testing varied across drug-test pairs and ranged from 9% (Primidone-Phenobarbital level) to 97% (Azathioprine-CBC), with half of the drug-test pairs in the 85-91% ordered range. Test ordering was associated with higher provider prescribing volume for study drugs and specialist status (primary care providers were less likely to order tests than specialists). Patients with higher comorbidity burden and older patients were more likely to have appropriate tests ordered. Drug-test combinations with black box warnings were more likely to have tests ordered.

CONCLUSIONS

Interventions to improve laboratory monitoring should focus on areas with the greatest potential for improvement: providers with lower frequencies of prescribing medications with monitoring recommendations and those prescribing these medications for healthier and younger patients; patients with less interaction with the health care system are at particular risk of not having tests ordered. Black box warnings were associated with higher ordering rates and may be a tool to increase appropriate test ordering.

Home medication support for childhood cancer: family-centered design and testing

PURPOSE

Errors in the use of medications at home by children with cancer are common, and interventions to support correct use are needed. We sought to (1) engage stakeholders in the design and development of an intervention to prevent errors in home medication use, and (2) evaluate the acceptability and usefulness of the intervention.

METHODS

We convened a multidisciplinary team of parents, clinicians, technology experts, and researchers to develop an intervention using a two-step user-centered design process. First, parents and oncologists provided input on the design. Second, a parent panel and two oncology nurses refined draft materials. In a feasibility study, we used questionnaires to assess usefulness and acceptability. Medication error rates were assessed via monthly telephone interviews with parents.

RESULTS

We successfully partnered with parents, clinicians, and IT experts to develop Home Medication Support (HoMeS), a family-centered Web-based intervention. HoMeS includes a medication calendar with decision support, a communication tool, adverse effect information, a metric conversion chart, and other information. The 15 families in the feasibility study gave HoMeS high ratings for acceptability and usefulness. Half recorded information on the calendar to indicate to other caregivers that doses were given; 34% brought it to the clinic to communicate with their clinician about home medication use. There was no change in the rate of medication errors in this feasibility study.

CONCLUSION

We created and tested a stakeholder-designed, Web-based intervention to support home chemotherapy use, which parents rated highly. This tool may prevent serious medication errors in a larger study.

Acceptance and use of health information technology by community-dwelling elders

OBJECTIVES

With the worldwide population growing in age, information technology may help meet important needs to prepare and support patients and families for aging. We sought to explore the use and acceptance of information technology for health among the elderly by reviewing the existing literature.

METHODS

Review of literature using PubMed and Google Scholar, references from relevant papers, and consultation with experts.

RESULTS

Elderly people approach the Internet and health information technology differently than younger people, but have growing rates of adoption. Assistive technology, such as sensors or home monitors, may help 'aging in place', but these have not been thoroughly evaluated. Elders face many barriers in using technology for healthcare decision-making, including issues with familiarity, willingness to ask for help, trust of the technology, privacy, and design challenges.

CONCLUSIONS

Barriers must be addressed for these tools to be available to this growing population. Design, education, research, and policy all play roles in addressing these barriers to acceptance and use.

Patient completion of laboratory tests to monitor medication therapy: a mixed-methods study

BACKGROUND

Little is known about the contribution of patient behavior to incomplete laboratory monitoring, and the reasons for patient non-completion of ordered laboratory tests remain unclear.

OBJECTIVE

To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests.

DESIGN

Mixed-Methods study including a quantitative assessment of the frequency of patient completion of ordered monitoring tests combined with qualitative, semi-structured, patient interviews.

PARTICIPANTS

Quantitative assessment included patients 18 years or older from a large multispecialty group practice, who were prescribed a medication requiring monitoring. Qualitative interviews included a subset of show and no-show patients prescribed a cardiovascular, anticonvulsant, or thyroid replacement medication.

MAIN MEASURES

Proportion of recommended monitoring tests for each medication not completed, factors associated with patient non-completion, and patient-reported reasons for non-completion.

KEY RESULTS

Of 27,802 patients who were prescribed one of 34 medications, patient non-completion of ordered tests varied (range: 0-24 %, by drug-test pair). Factors associated with higher odds of test non-completion included: younger patient age (< 40 years vs. ≥ 80 years, adjusted odds ratio [AOR] 1.52, 95 % confidence interval [95 % CI] 1.27-1.83); lower medication burden (one medication vs. more than one drug, AOR for non-completion 1.26, 95 % CI 1.15-1.37), and lower visit frequency (0-5 visits/year vs. ≥ 19 visits/year, AOR 1.41, 95 % CI 1.25 to 1.59). Drug-test pairs with black box warning status were associated with greater odds of non-completion, compared to drugs without a black box warning or other guideline for testing (AOR 1.91, 95 % CI 1.66-2.19). Qualitative interviews, with 16 no-show and seven show patients, identified forgetting as the main cause of non-completion of ordered tests.

CONCLUSIONS

Patient non-completion contributed to missed opportunities to monitor medications, and was associated with younger patient age, lower medication burden and black box warning status. Interventions to improve laboratory monitoring should target patients as well as physicians.

Parent partnerships in communication and decision making about subspecialty referrals for children with special needs

OBJECTIVE

To describe factors that influence parent-clinician partnerships in information exchange and shared decision making (SDM) when children with special health care needs are referred to subspecialists.

METHODS

We conducted focus groups with parents of children with special health care needs and pediatric primary care and subspecialty clinicians about how to include parents as partners in information exchange and SDM. Five parent and 5 clinician groups were held to identify themes to inform the development of interventions to promote parent partnerships; evaluate a prototype referral care plan and related parent supports as one example of a partnership tool; and compare the views of parents and clinicians. We used investigator triangulation and member checking to improve validity.

RESULTS

Nineteen parents and 23 clinicians participated. Parents discussed partnerships more easily than clinicians did, though clinicians offered more ideas as sessions progressed. Parents and clinicians agreed on the importance of 3-way communication and valued primary care involvement in all stages of referral and consultation. SDM was seen by all as important; clinicians cited difficulties inherent in discussing unclear options, while parents cited insufficient information as a barrier to understanding. Use of a brief referral care plan, with parent coaching, was embraced by all parents and most clinicians. Clinicians cited time pressures and interference with work flow as potential barriers to its use.

CONCLUSIONS

Parents and clinicians endorse partnership in referrals, though relatively greater enthusiasm from parents may signal the need for work in implementing this partnership. Use of a care plan to support parent engagement appears promising as a partnership tool.

Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors

BACKGROUND

Few studies have reported on the utilization and the effect of electronic health records on the education of medical students.

PURPOSE

The purpose of this study was to describe the current use of electronic health records by medical students in the United States and explore the opportunities and challenges of integrating electronic health records into daily teaching of medical students.

METHODS

A survey with 24 questions regarding the use of electronic health records by medical students was developed by the Alliance for Clinical Educators and sent to clerkship directors across the United States. Both quantitative and qualitative responses were collected and analyzed to determine current access to and use of electronic health records by medical students.

RESULTS

This study found that an estimated 64% of programs currently allow student use of electronic health records, of which only two thirds allowed students to write notes within the electronic record. Overall, clerkship directors' opinions on the effects of electronic health records on medical student education were neutral, and despite acknowledging many advantages to electronic health records, there were many concerns raised regarding their use in education.

CONCLUSIONS

Medical students are using electronic health records at higher rates than physicians in practice. Although this is overall reassuring, educators have to be cautious about the limitations being placed on student's documentation in electronic health records as this can potentially have consequences on their training, and they need to explore ways to maximize the benefits of electronic health records in medical education.

Quality measurement of medication monitoring in the "meaningful use" era

OBJECTIVES

While the 2011 implementation of "meaningful use" legislation for certified electronic health records (EHRs) promises to change quality reporting by overcoming data capture issues affecting quality measurement, the magnitude of this effect is unclear. We compared the measured quality of laboratory monitoring of Healthcare Effectiveness Data and Information Set (HEDIS) medications based on specifications that (1) include and exclude patients hospitalized in the measurement year and (2) use physician test orders and patient test completion.

STUDY DESIGN

Cross-sectional study.

METHODS

Among patients 18 years and older in a large multispecialty group practice utilizing a fully implemented EHR between January 1, 2008, and July 31, 2008, we measured the prevalence of ordering and completion of laboratory tests monitoring HEDIS medications (cardiovascular drugs [angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, digoxin, and diuretics] and anticonvulsants [carbamazepine, phenobarbital, phenytoin, and valproic acid]).

RESULTS

Measures excluding hospitalized patients were not statistically significantly different from measures including hospitalized patients, except for digoxin, but this difference was not clinically significant. The prevalence of appropriate monitoring based on test orders typically captured in the EHR was statistically significantly higher than the prevalence based on claims-based test completions for cardiovascular drugs.

CONCLUSIONS

HEDIS quality metrics based on data typically collected from claims undermeasured quality of medication monitoring compared to EHR data. The HEDIS optional specification excluding hospitalized patients from the monitoring measure does not have a significant impact on reported quality. Integration of EHR data into quality measurement may significantly change some organizations' reported quality of care.

Baseline and follow-up laboratory monitoring of cardiovascular medications

BACKGROUND

Laboratory monitoring of medications is typically used to establish safety prior to drug initiation and to detect drug-related injury following initiation. It is unclear whether black box warnings (BBWs) as well as evidence- and consensus-based clinical guidelines increase the likelihood of appropriate monitoring.

OBJECTIVE

To determine the proportion of patients newly initiated on selected cardiovascular medications with baseline assessment and follow-up laboratory monitoring and compare the prevalence of laboratory testing for drugs with and without BBWs and guidelines.

METHODS

This cross-sectional study included patients aged 18 years or older from a large multispecialty group practice who were prescribed a cardiovascular medication (angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, amiodarone, digoxin, lipid-lowering agents, diuretics, and potassium supplements) between January 1 and July 31, 2008. The primary outcome measure was laboratory test ordering for baseline assessment and follow-up monitoring of newly initiated cardiovascular medications.

RESULTS

The number of new users of each study drug ranged from 49 to 1757 during the study period. Baseline laboratory test ordering across study drugs ranged from 37.4% to 94.8%, and follow-up laboratory test ordering ranged from 20.0% to 77.2%. Laboratory tests for drugs with baseline laboratory assessment recommendations in BBWs were more commonly ordered than for drugs without BBWs (86.4% vs 78.0%, p < 0.001). Drugs with follow-up monitoring recommendations in clinical guidelines had a lower prevalence of monitoring (33.1% vs 50.7%, p < 0.001).

CONCLUSIONS

Baseline assessment of cardiovascular medication monitoring is variable. Quality measurement of adherence to BBW recommendations may improve monitoring.

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review

Medication errors are a major source of morbidity and mortality. Inadequate laboratory monitoring of high-risk medications after initial prescription is a medical error that contributes to preventable adverse drug events. Health information technology (HIT)-based clinical decision support may improve patient safety by improving the laboratory monitoring of high-risk medications, but the effectiveness of such interventions is unclear. Therefore, the authors conducted a systematic review to identify studies that evaluate the independent effect of HIT interventions on improving laboratory monitoring for high-risk medications in the ambulatory setting using a Medline search from January 1, 1980 through January 1, 2009 and a manual review of relevant bibliographies. All anticoagulation monitoring studies were excluded. Eight articles met the inclusion criteria, including six randomized controlled trials and two pre-post intervention studies. Six of the studies were conducted in two large, integrated healthcare delivery systems in the USA. Overall, five of the eight studies reported statistically significant, but small, improvements in laboratory monitoring; only half of the randomized controlled trials reported statistically significant improvements. Studies that found no improvement were more likely to have used analytic strategies that addressed clustering and confounding. Whether HIT improves laboratory monitoring of certain high-risk medications for ambulatory patients remains unclear, and further research is needed to clarify this important question.

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting

OBJECTIVES

To develop guidelines to monitor high-risk medications and to assess the prevalence of laboratory testing for these medications among a multispecialty group practice.

STUDY DESIGN

Safety intervention trial.

METHODS

We developed guidelines for the laboratory monitoring of high-risk medications as part of a patient safety intervention trial. An advisory committee of national experts and local leaders used a 2-round Internet-based Delphi process to select guideline medications based on the importance of monitoring for efficacy, safety, and drug-drug interactions. Test frequency recommendations were developed by academic pharmacists based on a literature review and local interdisciplinary consensus. To estimate the potential effect of the planned intervention, we determined the prevalence of high-risk drug dispensings and laboratory testing for guideline medications between January 1, 2008, and July 31, 2008.

RESULTS

Consensus on medications to include in the guidelines was achieved in 2 rounds. Final guidelines included 35 drugs or drug classes and 61 laboratory tests. The prevalence of monitoring ranged from less than 50.0% to greater than 90.0%, with infrequently prescribed drugs having a lower prevalence of recommended testing (P <.001 for new dispensings and P <.01 for chronic dispensings, nonparametric test for trend). When more than 1 test was recommended for a selected medication, monitoring within a medication sometimes differed by greater than 50.0%.

CONCLUSIONS

Even among drugs for which there is general consensus that laboratory monitoring is important, the prevalence of monitoring is highly variable. Furthermore, infrequently prescribed medications are at higher risk for poor monitoring.

Identification of bacteria recovered from clinical specimens by 16S rRNA gene sequencing

The sequence of the 16S rRNA gene has been used extensively for phylogenetic classification, identification, and genotypic typing of bacteria. Identification of bacterial isolates by 16S rRNA gene sequencing, though generally performed in reference laboratories, has been recently introduced for routine use in clinical laboratories to identify isolates that cannot be identified by conventional methods. Described in this report is the use of 16S rRNA gene sequencing to identify uncommon bacteria, or bacteria with unusual phenotypic properties, with four brief case presentations to illustrate its clinical application. The feasibility, usefulness and limitations of performing this approach in the clinical laboratory are also discussed.

Comparison of six commercial DNA extraction kits for recovery of cytomegalovirus DNA from spiked human specimens

We evaluated six commercially available DNA extraction kits for their ability to recover DNA from various dilutions of cytomegalovirus (CMV) added to four different specimens: bronchoalveolar lavage, cerebral spinal fluid, plasma, and whole blood. The kits evaluated included the Puregene DNA isolation kit (PG), Generation Capture Column kit, MasterPure DNA purification kit, IsoQuick nucleic acid extraction kit, QIAamp blood kit, and NucliSens isolation kit (NS). All six kits evaluated effectively removed PCR inhibitors from each of the four specimen types and produced consistently positive results down to a spiked concentration of 200 PFU of whole CMV per ml. However, the NS and PG resulted in the most consistently positive results at the lowest concentrations of spiked CMV (4 and 0.4 PFU/ml) and, in this evaluation, offered the most sensitive methods for extracting CMV DNA from the four different spiked specimens. Processing time and cost were also evaluated.

Identification of nocardia species by restriction endonuclease analysis of an amplified portion of the 16S rRNA gene

Identification of clinical isolates of Nocardia to the species level is important for defining the spectrum of disease produced by each species and for predicting antimicrobial susceptibility. We evaluated the usefulness of PCR amplification of a portion of the Nocardia 16S rRNA gene and subsequent restriction endonuclease analysis (REA) for species identification. Unique restriction fragment length polymorphism (RFLP) patterns were found for Nocardia sp. type strains (except for the N. asteroides type strain) and representative isolates of the drug pattern types of Nocardia asteroides (except for N. asteroides drug pattern type IV, which gave inconsistent amplification). A variant RFLP pattern for Nocardia nova was also observed. Twenty-eight clinical isolates were evaluated both by traditional biochemical identification and by amplification and REA of portions of the 16S rRNA gene and the 65-kDa heat shock protein (HSP) gene. There was complete agreement among the three methods on identification of 24 of these isolates. One isolate gave a 16S rRNA RFLP pattern consistent with the biochemical identification but was not identifiable by its HSP gene RFLP patterns. Three isolates gave 16S rRNA RFLP patterns which were inconsistent with the identification obtained by both biochemical tests and HSP gene RFLP; sequence analysis suggested that two of these isolates may belong to undefined species. The PCR and REA technique described appears useful both for the identification of clinical isolates of Nocardia and for the detection of new or unusual species.

Long-term interferon alpha maintenance therapy for chronic hepatitis C infection in a patient with common variable immune deficiency

A 46-year-old woman with common variable immune deficiency acquired acute non-A, non-B hepatitis from contaminated intravenous gamma globulin in 1983. For 6 years she had fluctuating elevations of her serum aminotransferase levels. In 1990 her serum was documented to be hepatitis C virusribonucleic acid positive by polymerase chain reaction, and her liver biopsy revealed chronic hepatitis with early cirrhosis (Knodell score, 15 points). Hepatitis C virus genotyping indicated that she had been infected with the type 3 genotype. She subsequently underwent treatment with interferon alpha (IFN-alpha) for 1 year and experienced biochemical, virologic, and histologic (Knodell score, 9) suppression. She was continued on maintenance therapy for an additional 7 years, with sustained biochemical and virologic suppression. During the sixth year of therapy, complications of portal hypertension were noted with mild ascites and eventually bleeding esophageal varices. This case report documents a favorable biochemical, virologic, and histologic response to IFN-alpha therapy in this setting; supports the notion that the natural progression of hepatitis C virus infection may be more aggressive in patients with common variable immune deficiency; and, although complications of portal hypertension eventually occurred, the suppressive maintenance IFN therapy may have delayed their onset. The future establishment of the long-term effects of IFN therapy on important clinical outcomes is necessary to understand better its therapeutic benefit in chronic hepatitis C infection.

Development of a PCR assay for diagnosis of Pneumocystis carinii pneumonia based on amplification of the multicopy major surface glycoprotein gene family

We have evaluated a PCR technique using primers based on Pneumocystis carinii major surface glycoprotein (MSG) genes, a multicopy gene family, for utility in detection of P. carinii in BAL and oropharyngeal samples obtained from immunosuppressed patients. These primers were able to detect P. carinii DNA in as little as 16 fg of genomic DNA. PCR using MSG primers detected P. carinii DNA in 7 smear-positive BAL samples (100% sensitivity), and found no P. carinii DNA in 12 smear-negative BAL samples (100% specificity). Mitochondrial ribosomal RNA (mrRNA) primers, commonly used in PCR studies of PCP, detected P. carinii in six of seven positive samples (85.7% sensitivity) and none of 12 were negative samples (100% specificity). Diagnosis of PCP by amplification of 81 oropharyngeal samples using MSG primers had a 50% sensitivity (4/8) and 96% specificity (70/73). PCR with mrRNA primers was 37.5% sensitive (3/8) and 100% specific (73/73). All three false-positive MSG results showed a very low intensity on Southern hybridization. PCR using MSG gene primers should prove valuable in the diagnosis of PCP.

An uncommon Helicobacter isolate from blood: evidence of a group of Helicobacter spp. pathogenic in AIDS patients

An unusual Helicobacter sp. was isolated from the blood of a human immunodeficiency virus (HIV)-infected patient. This organism had spiral morphology, with single amphitrichous flagella, and was negative for hippurate hydrolysis, production of urease, and reduction of nitrate. 16S rRNA gene sequence analysis verified that the isolate was a species of Helicobacter, most closely related to an undescribed Helicobacter-like isolate from Vancouver, British Columbia, Canada, and to Helicobacter westmeadii, a recently described species from Australia. Both organisms had also been isolated from the blood of HIV-infected patients. These blood isolates, along with Helicobacter cinaedi, form a cluster of closely related Helicobacter spp. that may represent an emerging group of pathogens in immunocompromised patients.

Management of a Sabiá virus-infected patients in a US hospital

OBJECTIVE

To describe the hospital precautions used to isolate a Sabiá virus (arenavirus: Arenaviridae)-infected patient in a US hospital and to protect hospital staff and visitors.

DESIGN

Investigation of a single case of arenavirus laboratory-acquired infection and associated case-contacts.

SETTING

A 900-bed, tertiary-care, university-affiliated medical center.

PATIENTS OR OTHER PARTICIPANTS

The case-patient became ill with Sabiá virus infection. The case-contacts consisted of healthcare workers, coworkers, friends, and relatives of the case-patient.

INTERVENTION

Enhanced isolation precautions for treatment of a viral hemorrhagic fever (VHF) patient were implemented in the clinical laboratory and patient-care setting to prevent nosocomial transmission. The enhanced precautions included preventing aerosol spread of the virus from the patient or his clinical specimens. All case-contacts were tested for Sabiá virus antibodies and monitored for signs and symptoms of early disease.

RESULTS

No cases of secondary infection occurred among 142 case-contacts.

CONCLUSIONS

With the frequency of worldwide travel, patients with VHF can be admitted to a local hospital at any time in the United States. The use of enhanced isolation precautions for VHF appeared to be effective in preventing secondary cases by limiting the number of contacts and promoting proper handling of laboratory specimens. Patients with VHF can be managed safely in a local hospital setting, provided that appropriate precautions are planned and implemented.

Optimal activation of isopsoralen to prevent amplicon carryover

We compared the efficiencies of activation of the photochemical isopsoralen compound 10 and its resulting amplicon neutralizations under conditions with a UV transilluminator box at room temperature (RT) and a HRI-300 UV photothermal reaction chamber at RT and at 5 degrees C. Our data suggest that use of the HRI-300 reaction chamber at 5 degrees C results in a statistically significantly higher degree of amplicon neutralization.

Detection of Legionella by PCR in respiratory specimens using a commercially available kit

Using polymerase chain reaction (PCR) for the detection of pathogens that are difficult to grow, such as Legionella species, may reduce difficulties encountered with culture and immunofluorescent staining. We evaluated a commercial PCR and hybridization kit, designed for environmental samples, for the detection of Legionella in respiratory specimens. Sixteen Legionella species cultures tested positive with the Perkin Elmer Legionella EnviroAmp Amplification and Detection kits (Perkin Elmer, Foster City, Calif). The assay detected as few as 100 colony-forming units per milliliter of spiked bronchoalveolar lavage (BAL) fluid, and no false-negative results were obtained. PCR inhibition by blood in the specimens was removed by washing pelleted specimens in sterile distilled water. Of 126 specimens screened with the kit, 1 induced sputum and 3 BAL specimens were positive by PCR. All 4 were validated as true-positive results by culture or serologic testing. The entire PCR and hybridization assay can be completed in less than 6 hours, whereas isolation and identification by culture requires up to 12 days, and serologic conversion may not be demonstrated for weeks. Molecular techniques based on direct extraction and amplification of DNA from respiratory specimens nay be useful for the timely diagnosis of legionellosis.

Hepatitis C virus transmission by intravenous immunoglobulin

The polymerase chain reaction was used to detect hepatitis C virus infection in patients who had previously been reported to have developed non-A, non-B hepatitis after intravenous immunoglobulin infusion. Of the 33 patients with intravenous immunoglobulin associated non-A, non-B hepatitis studied, HCV RNA could be detected in 15 out of 17 patients (88%) who were HCV RNA negative prior to the development of non-A, non-B hepatitis after implicated intravenous immunoglobulin batches. Similarly, eight out of nine patients (89%) in whom no sample was available for polymerase chain reaction testing prior to intravenous immunoglobulin therapy, had detectable HCV RNA after intravenous immunoglobulin therapy with intravenous immunoglobulin batches implicated in non-A, non-B hepatitis transmission. Two of the three intravenous immunoglobulin preparations implicated in non-A, non-B hepatitis transmissions that were available for polymerase chain reaction testing also had detectable HCV RNA, confirming that hepatitis C virus is the implicated virus in intravenous immunoglobulin-associated non-A, non-B hepatitis.