Developing and Validating Models to Predict Progression to Proliferative Diabetic Retinopathy

Purpose

To develop models for progression of nonproliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy (PDR) and determine if incorporating updated information improves model performance.

Design

Retrospective cohort study.

Participants

Electronic health record (EHR) data from a tertiary academic center, University of California San Francisco (UCSF), and a safety-net hospital, Zuckerberg San Francisco General (ZSFG) Hospital were used to identify patients with a diagnosis of NPDR, age ≥ 18 years, a diagnosis of type 1 or 2 diabetes mellitus, ≥ 6 months of ophthalmology follow-up, and no prior diagnosis of PDR before the index date (date of first NPDR diagnosis in the EHR).

Methods

Four survival models were developed: Cox proportional hazards, Cox with backward selection, Cox with LASSO regression and Random Survival Forest. For each model, three variable sets were compared to determine the impact of including updated clinical information: Static₀ (data up to the index date), Static_6m (data updated 6 months after the index date), and Dynamic (data in Static₀ plus data change during the 6-month period). The UCSF data were split into 80% training and 20% testing (internal validation). The ZSFG data were used for external validation. Model performance was evaluated by the Harrell's concordance index (C-Index).

Main Outcome Measures

Time to PDR.

Results

The UCSF cohort included 1130 patients and 92 (8.1%) patients progressed to PDR. The ZSFG cohort included 687 patients and 30 (4.4%) patients progressed to PDR. All models performed similarly (C-indices ∼ 0.70) in internal validation. The random survival forest with Static_6m set performed best in external validation (C-index 0.76). Insurance and age were selected or ranked as highly important by all models. Other key predictors were NPDR severity, diabetic neuropathy, number of strokes, mean Hemoglobin A1c, and number of hospital admissions.

Conclusions

Our models for progression of NPDR to PDR achieved acceptable predictive performance and validated well in an external setting. Updating the baseline variables with new clinical information did not consistently improve the predictive performance.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Understanding the effect of new U.S. cervical cancer screening guidelines and modalities on patients' comprehension and reporting of their cervical cancer screening behavior

With recent shifts in guideline-recommended cervical cancer screening in the U.S., it is important to accurately measure screening behavior. Previous studies have indicated the U.S. National Health Interview Survey (NHIS), a resource for measuring self-reported screening adherence, has lower validity among non-White racial/ethnic groups and non-English speakers. Further, measuring diverse population groups' comprehension of items and attitudes toward HPV self-sampling merits investigation as it is a modality likely to be recommended in the U.S. soon. This study cognitively tested NHIS items assessing recency of and reasons for receiving cervical cancer screening and attitudes toward HPV self-sampling. We conducted cognitive interviews between April 2021 - April 2022 in English and Spanish with individuals screened in the past two years by either a medical center in metropolitan Seattle, Washington or a safety-net healthcare system in Dallas, Texas. Interviews probed understanding of reasons for screening, experiences with abnormal results, and interest in HPV self-sampling. We completed 32 interviews in Seattle and 42 interviews in Dallas. A majority of participants were unaware that two different tests for cervical cancer screening exist (Pap and HPV). Many did not know which type(s) of test they received. Dallas participants had more limited and inaccurate knowledge of HPV compared to Seattle participants, and fewer responded favorably toward HPV self-sampling (32% vs. 55%). To improve comprehension and accurate reporting of cervical cancer screening, we suggest specific refinements to currently used survey questions. Attitudes toward self-sampling should be explored further as differences may exist by region and/or sociodemographic factors.

Poor Neonatal Adaptation After Antidepressant Exposure During the Third Trimester in a Geographically Defined Cohort

Objective

To examine the associations between antidepressant exposure during the third trimester of pregnancy, including individual drugs, drug doses, and antidepressant combinations, and the risk of poor neonatal adaptation (PNA).

Patients and Methods

The Rochester Epidemiology Project medical records-linkage system was used to study infants exposed to selective serotonin reuptake inhibitors (SSRIs; n=1014), bupropion, (n=118), serotonin-norepinephrine reuptake inhibitors (n=80), antidepressant combinations (n=20), or other antidepressants (n=22) during the third trimester (April 11, 2000-December 31, 2013). Poor neonatal adaptation was defined based on a review of medical records. Poisson regression was used to examine the risk of PNA with serotonergic antidepressant and drug combinations compared with that with bupropion monotherapy as well as with high- vs standard-dose antidepressants. When possible, analyses were performed using propensity score (PS) weighting.

Results

Forty-four infants were confirmed cases of PNA. Serotonin-norepinephrine reuptake inhibitor monotherapy, antidepressant combinations, and paroxetine monotherapy were associated with a significantly higher risk of PNA than bupropion monotherapy in unweighted analyses. High-dose SSRI exposure was associated with a significantly increased risk of PNA in unadjusted (relative risk, 2.61; 95% confidence interval, 1.35-5.04) and PS-weighted models (relative risk, 2.29; 95% confidence interval, 1.17-4.48) compared with standard-dose SSRI exposure. The risk of PNA was significantly higher with high-dose paroxetine and sertraline than with standard doses in the PS-weighted analyses. The other risk factors for PNA included maternal anxiety disorders.

Conclusion

Although the frequency of PNA in this cohort was low (3%-4%), the risk of PNA was increased in infants exposed to serotonergic antidepressants, particularly with SSRIs at higher doses, during the third trimester of pregnancy compared with that in infants exposed to standard doses. Potential risk factors for PNA also included third-trimester use of paroxetine (especially at higher doses) and maternal anxiety.

Association of Neutralizing Antispike Monoclonal Antibody Treatment With Coronavirus Disease 2019 Hospitalization and Assessment of the Monoclonal Antibody Screening Score

Objective

To test the hypothesis that the Monoclonal Antibody Screening Score performs consistently better in identifying the need for monoclonal antibody infusion throughout each "wave" of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant predominance during the coronavirus disease 2019 (COVID-19) pandemic and that the infusion of contemporary monoclonal antibody treatments is associated with a lower risk of hospitalization.

Patients and Methods

In this retrospective cohort study, we evaluated the efficacy of monoclonal antibody treatment compared with that of no monoclonal antibody treatment in symptomatic adults who tested positive for SARS-CoV-2 regardless of their risk factors for disease progression or vaccination status during different periods of SARS-CoV-2 variant predominance. The primary outcome was hospitalization within 28 days after COVID-19 diagnosis. The study was conducted on patients with a diagnosis of COVID-19 from November 19, 2020, through May 12, 2022.

Results

Of the included 118,936 eligible patients, hospitalization within 28 days of COVID-19 diagnosis occurred in 2.52% (456/18,090) of patients who received monoclonal antibody treatment and 6.98% (7,037/100,846) of patients who did not. Treatment with monoclonal antibody therapies was associated with a lower risk of hospitalization when using stratified data analytics, propensity scoring, and regression and machine learning models with and without adjustments for putative confounding variables, such as advanced age and coexisting medical conditions (eg, relative risk, 0.15; 95% CI, 0.14-0.17).

Conclusion

Among patients with mild to moderate COVID-19, including those who have been vaccinated, monoclonal antibody treatment was associated with a lower risk of hospital admission during each wave of the COVID-19 pandemic.

Assessing Resident Cataract Surgical Outcomes Using Electronic Health Record Data

Objective

To demonstrate that electronic health record (EHR) data can be used in an automated approach to evaluate cataract surgery outcomes.

Design

Retrospective analysis.

Subjects

Resident and faculty surgeons.

Methods

Electronic health record data were collected from cataract surgeries performed at the Johns Hopkins Wilmer Eye Institute, and cases were categorized into resident or attending as primary surgeon. Preoperative and postoperative visual acuity (VA) and unplanned return to operating room were extracted from the EHR.

Main Outcome Measures

Postoperative VA and reoperation rate within 90 days.

Results

This study analyzed 14 537 cataract surgery cases over 32 months. Data were extracted from the EHR using an automated approach to assess surgical outcomes for resident and attending surgeons. Of 337 resident surgeries with both preoperative and postoperative VA data, 248 cases (74%) had better postoperative VA, and 170 cases (51%) had more than 2 lines improvement. There was no statistical difference in the proportion of cases with better postoperative VA or more than 2 lines improvement between resident and attending cases. Attending surgeons had a statistically greater proportion of cases with postoperative VA better than 20/40, but this finding has to be considered in the context that, on average, resident cases started out with poorer baseline VA.A multivariable regression model of VA outcomes vs. resident/attending status that controlled for preoperative VA, patient age, American Society of Anesthesiologists (ASA) score, and estimated income found that resident status, preoperative VA, patient age, ASA score, and estimated income were all significant predictors of VA. The rate of unplanned return to the operating room within 90 days of cataract surgery was not statistically different between resident (1.8%) and attending (1.2%) surgeons.

Conclusions

This study demonstrates that EHR data can be used to evaluate and monitor surgical outcomes in an ongoing way. Analysis of EHR-extracted cataract outcome data showed that preoperative VA, ASA classification, and attending/resident status were important in predicting postoperative VA outcomes. These findings suggest that the utilization of EHR data could enable continuous assessment of surgical outcomes and inform interventions to improve resident training. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

The role of lung cancer risk and comorbidity in lung cancer screening use

Although lung cancer screening (LCS) with low dose computed tomography has been shown to reduce lung cancer mortality, benefits and harms of screening vary among eligible adults. The goal of this study was to evaluate whether LCS is more commonly used among populations most likely to benefit, namely adults with high lung cancer risk and low comorbidity. In this cohort study of patients eligible for LCS, we used data from the electronic health record to evaluate the relationship between lung cancer risk, comorbidity, and receipt of LCS. We also evaluated use of diagnostic chest CT. Analyses used a nonparametric test for trend across quartiles of lung cancer risk and comorbidity. The study sample included 551 LCS-eligible adults who were followed for a mean 2.9 years (SD 1.6 years). A cumulative 190 (34 %) received at least 1 LCS, and 141 (26 %) had a diagnostic chest CT. Receipt of LCS increased across quartiles of lung cancer risk (5 per 100 person years in the lowest quartile vs 13 per 100 person-years in the highest, p < 0.001 for test of trend). LCS receipt decreased across increasing quartiles of comorbidity (14 vs 8 per 100 person-years, p = 0.008). Diagnostic CT was more common in among patient with higher levels of comorbidity (15 vs 5 per 100 person-years, p < 0.001). In conclusion, lung cancer screening was more commonly used in patients with greater lung cancer risk and lower comorbidity. Results suggest that both patient characteristics and use of diagnostic imaging may shape current patterns of LCS use.

Patient characteristics and neighborhood attributes associated with hepatitis C screening and positivity in Philadelphia

Among patients of an urban primary care network in Philadelphia with a universal hepatitis C virus (HCV) screening policy for patients born during 1945-1965, we examined whether being unscreened and HCV positivity were associated with attributes of the census tracts where patients resided, which we considered as proxies for social health determinants. For patients with at least one clinic visit between 2014 and mid-2017, we linked demographic and HCV screening information from electronic health records with metrics that described the census tracts where patients resided. We used generalized estimating equations to estimate adjusted relative risk ratios (aRRs) for being unscreened and HCV positive. Overall, 28% of 6,906 patients were unscreened. Black race, male gender, and residence in census tracts with relatively high levels of violent crime, low levels of educational attainment and household incomes, and evidence of residential segregation by Hispanic ethnicity were associated with lower aRRs for being unscreened. Among screened patients, 9% were HCV positive. Factors associated with lower risks of being unscreened were, in general, associated with higher HCV positivity. Attributes of census tracts where patients reside are probably less apparent to clinicians than patients' gender or race but might reflect unmeasured patient characteristics that affected screening practices, along with preconceptions regarding the likelihood of HCV infection based on prior screening observations or implicit biases. Approaching complete detection of HCV-infected people would be hastened by focusing on residents of census tracts with attributes associated with higher infection levels or, if known, higher infection levels directly.

HPV vaccination coverage for pediatric, adolescent and young adult patients receiving care in a childhood cancer survivor program

Pediatric, adolescent and young adult patients undergoing cancer treatment and/or hematopoietic stem cell transplant are at increased risk for developing a secondary human papillomavirus (HPV)-associated malignancy. The objective of this study was to determine HPV vaccination coverage among individuals participating in a childhood cancer survivor program (CCSP). A retrospective cohort study was conducted among CCSP patients age 11–26 years attending a CCSP visit between 2014 and 2019. Survivors were age-, sex-, and race-matched 1:2 with controls without cancer. Data were abstracted from the electronic health record and state-based vaccination registry. Analysis was limited to Minnesota residents to minimize missing vaccination data. Survivorship care plans (SCPs) were reviewed for vaccine recommendations.

592 patients were included in the analyses (200 CCSP patients; 392 controls). By study design, mean age (18.4 years), race (72 % white), and sex (49 % female) were similar in the two groups. Among CCSP patients 22 % resided in a rural area compared to 3.8 % of controls. Vaccination coverage among CCSP patients was not statistically significantly different from controls [60.0 % vs 66.3 %, OR = 0.82, 95 % CI: (0.55, 1.23), p = 0.35]. Completion of 3 doses was not different between groups even though 3 doses is recommended for all CCSP patients regardless of age at initiation (28.5 % vs 30.1 %, p = 0.09). Only 8.0 % of SCPs recommended HPV vaccination.

Although patients participating in a CCSP did not have significantly different HPV vaccination coverage compared to controls, HPV vaccination initiation and 3-dose series completion are still suboptimal in a patient population at high-risk of a secondary HPV-associated cancer.

Evaluation of Atherosclerotic Cardiovascular Risk Prediction Models in China: Results From the CHERRY Study

BACKGROUND

Updated American or Chinese guidelines recommended calculating atherosclerotic cardiovascular disease (ASCVD) risk using the Pooled Cohort Equations (PCE) or Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) models; however, evidence on performance of both models in Asian populations is limited.

OBJECTIVES

The authors aimed to evaluate the accuracy of the PCE or China-PAR models in a Chinese contemporary cohort.

METHODS

Data were extracted from the CHERRY (CHinese Electronic health Records Research in Yinzhou) study. Participants aged 40 to 79 years without prior ASCVD at baseline from 2010 to 2016 were included. ASCVD was defined as nonfatal or fatal stroke, nonfatal myocardial infarction, and cardiovascular death. Models were assessed for discrimination and calibration.

RESULTS

Among 226,406 participants, 5362 (2.37%) adults developed a first ASCVD event during a median of 4.60 years of follow-up. Both models had good discrimination: C-statistics in men were 0.763 (95% confidence interval [CI]: 0.754-0.773) for PCE and 0.758 (95% CI: 0.749-0.767) for China-PAR; C-statistics in women were 0.820 (95% CI: 0.812-0.829) for PCE and 0.811 (95% CI: 0.802-0.819) for China-PAR. The China-PAR model underpredicted risk by 20% in men and by 40% in women, especially in the highest-risk groups. However, PCE overestimated by 63% in men and inversely underestimated the risk by 34% in women with poor calibration (both P < 0.001). After recalibration, observed and predicted risks by recalibrated PCE were better aligned.

CONCLUSIONS

In this large-scale population-based study, both PCE and China-PAR had good discrimination in 5-year ASCVD risk prediction. China-PAR outperformed PCE in calibration, whereas recalibration equalized the performance of PCE and China-PAR. Further specific models are needed to improve accuracy in the highest-risk groups.

Association between atopic dermatitis and COVID-19 infection: A case-control study in the All of Us research program

BACKGROUND

There is an incomplete understanding of the risk of COVID-19 infection in atopic dermatitis (AD) patients.

OBJECTIVE

To evaluate the risk of COVID-19 infection in AD patients in a large, diverse cohort.

METHODS

A case-control study of the All of Us cohort to analyze the association between AD and COVID-19. Comorbidities and risk factors were compared between cases and controls using multivariable analyses.

RESULTS

In a cohort of 11,752 AD cases with 47,008 matched controls, AD patients were more likely to have a COVID-19 diagnosis (4.2% vs 2.8%, P < .001). AD remained significantly associated with COVID-19 in multivariable analysis (odds ratio, 1.29; P < .001) after adjusting for demographic factors and comorbidities.

LIMITATIONS

Ascertainment of AD and COVID-19 cases using electronic health records and lack of clinical data on AD severity or therapy and COVID-19 outcomes.

CONCLUSION

AD is associated with increased odds of COVID-19 infection even after controlling for common comorbidities.

The West Philadelphia asthma care implementation study (NHLBI#

Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5-13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.

Genomic Screening for Pathogenic Transthyretin Variants Finds Evidence of Underdiagnosed Amyloid Cardiomyopathy From Health Records

BACKGROUND

New treatments for transthyretin amyloidosis improve survival, but diagnosis remains challenging. Pathogenic or likely pathogenic (P/LP) variants in the transthyretin (TTR) gene are one cause of transthyretin amyloidosis, and genomic screening has been proposed to identify at-risk individuals. However, data on disease features and penetrance are lacking to inform the utility of such population-based genomic screening for TTR.

OBJECTIVES

This study characterized the prevalence of P/LP variants in TTR identified through exome sequencing and the burden of associated disease from electronic health records for individuals with these variants from a large (N = 134,753), primarily European-ancestry cohort.

METHODS

We compared frequencies of common disease features and cardiac imaging findings between individuals with and without P/LP TTR variants.

RESULTS

We identified 157 of 134,753 (0.12%) individuals with P/LP TTR variants (43% male, median age 52 [Q1-Q3: 37-61] years). Seven P/LP variants accounted for all observations, the majority being V122I (p.V142I; 113, 0.08%). Approximately 60% (n = 91) of individuals with P/LP TTR variants (all V122I) had African ancestry. Diagnoses of amyloidosis were limited (2 of 157 patients), although related heart disease diagnoses, including cardiomyopathy and heart failure, were significantly increased in individuals with P/LP TTR variants who were aged >60 years. Fourteen percent (7 of 49) of individuals aged ≥60 or older with a P/LP TTR variant had heart disease and ventricular septal thickness >1.2 cm, only one of whom was diagnosed with amyloidosis.

CONCLUSIONS

Individuals with P/LP TTR variants identified by genomic screening have increased odds of heart disease after age 60 years, although amyloidosis is likely underdiagnosed without knowledge of the genetic variant.

Physician Well-being and the Future of Health Information Technology

The issue of clinician burnout has become a growing concern in health care, with an increased emphasis on health information technology as a contributing factor. Technology-mediated stresses have arisen with the electronic health record, and we can anticipate new and different impacts from future information tools. This article discusses technology's pivotal role in physician well-being, not only in the quality of its design but also through its capacity to enable future models of care that are more manageable for physicians and more effective for patients. Three general aims along with specific efforts are proposed to benefit physician well-being in technology-mediated work.

Improving the Delivery of Function-Directed Care During Acute Hospitalizations: Methods to Develop and Validate the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT)

OBJECTIVE

To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) establish clinically actionable score strata that link to easily implemented mobility preservation plans.

DESIGN

This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics.

SETTING

A large (2000-bed) Midwestern Medical Center.

PARTICIPANTS

The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization.

CONCLUSIONS

The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.

Coronary artery bypass graft surgery outcomes in the United States: Impact of the coronavirus disease 2019 (COVID-19) pandemic

Objective

There has been a substantial decline in patients presenting for emergent and routine cardiovascular care in the United States after the onset of the coronavirus disease 2019 (COVID-19) pandemic. We sought to assess the risk of adverse clinical outcomes among patients undergoing coronary artery bypass graft (CABG) surgery during the 2020 COVID-19 pandemic period and compare the risks with those undergoing CABG before the pandemic in the year 2019.

Methods

A retrospective cross-sectional analysis of the TriNetX Research Network database was performed. Patients undergoing CABG between January 20, 2019, and September 15, 2019, contributed to the 2019 cohort, and those undergoing CABG between January 20, 2020, and September 15, 2020, contributed to the 2020 cohort. Propensity-score matching was performed, and the odds of mortality, acute kidney injury, stroke, acute respiratory distress syndrome, and mechanical ventilation occurring by 30 days were evaluated.

Results

The number of patients undergoing CABG in 2020 declined by 35.5% from 5534 patients in 2019 to 3569 patients in 2020. After propensity-score matching, 3569 patient pairs were identified in the 2019 and the 2020 cohorts. Compared with those undergoing CABG in 2019, the odds of mortality by 30 days were 0.96 (95% confidence interval [CI], 0.69-1.33; P = .80) in those undergoing CABG in 2020. The odds for stroke (odds ratio [OR], 1.201; 95% CI, 0.96-1.39), acute kidney injury (OR, 0.76; 95% CI, 0.59-1.08), acute respiratory distress syndrome (OR, 1.01; 95% CI, 0.60-2.42), and mechanical ventilation (OR, 1.11; 95% CI, 0.94-1.30) were similar between the 2 cohorts.

Conclusions

The number of patients undergoing CABG in 2020 has substantially declined compared with 2019. Similar odds of adverse clinical outcomes were seen among patients undergoing CABG in the setting of COVID-19 compared with those in 2019.

Usability of a Digital Registry to Promote Secondary Prevention for Peripheral Artery Disease Patients

Objective

To evaluate usability of a quality improvement tool that promotes guideline-based care for patients with peripheral arterial disease (PAD).

Patients and Methods

The study was conducted from July 19, 2018, to August 21, 2019. We compared the usability of a PAD cohort knowledge solution (CKS) with standard management supported by an electronic health record (EHR). Two scenarios were developed for usability evaluation; the first for the PAD-CKS while the second evaluated standard EHR workflow. Providers were asked to provide opinions about the PAD-CKS tool and to generate a System Usability Scale (SUS) score. Metrics analyzed included time required, number of mouse clicks, and number of keystrokes.

Results

Usability evaluations were completed by 11 providers. SUS for the PAD-CKS was excellent at 89.6. Time required to complete 21 tasks in the CKS was 4 minutes compared with 12 minutes for standard EHR workflow (median, P = .002). Completion of CKS tasks required 34 clicks compared with 148 clicks for the EHR (median, P = .002). Keystrokes for CKS task completion was 8 compared with 72 for EHR (median, P = .004). Providers indicated that overall they found the tool easy to use and the PAD mortality risk score useful.

Conclusions

Usability evaluation of the PAD-CKS tool demonstrated time savings, a high SUS score, and a reduction of mouse clicks and keystrokes for task completion compared to standard workflow using the EHR. Provider feedback regarding the strengths and weaknesses also created opportunities for iterative improvement of the PAD-CKS tool.

Managing Patients in the COVID-19 Pandemic: A Virtual Multidisciplinary Approach

Objective

To study the impact of a 60-day pilot of an innovative virtual-care model using general internal medicine physicians and nurses to respond rapidly to more than 1200 coronavirus disease-2019 (COVID-19)-positive nasopharyngeal polymerase chain reaction tests.

Patients and Methods

The current study was approved by the Mayo Clinic COVID-19 Research Committee and the Mayo Clinic Institutional Review Board. The data for all SARS-CoV-2–positive patients treated by our team were entered into a prospectively maintained internal research electronic data capture database. We searched this database retrospectively for the first 60 days of our program (March 23, 2020 to May 22, 2020). The data included basic deidentified demographics; symptoms at intake into the program; date of symptom onset; risk factors; location; and outcomes including hospitalization, admission to intensive care unit, and death.

Results

Patients were contacted, on average, 6.3 hours after their results became available. There was a total of 138 ED visits. Of these, 40% were admitted to the hospital, with 36% of those admitted requiring intensive care unit level of care. Of the 849 patients in this sample, there were only 2 deaths (0.23%) at 60 days.

Conclusion

Our innovative multidisciplinary COVID team provided excellent clinical care for patients with COVID, with a very low mortality rate compared with the national average. Although data are not available on a national scale for time to contact patient, our team was able to contact patients within the established recommendation for contact within 48 hours of testing, which is optimal.

Digital Health Surveillance Strategies for Management of Coronavirus Disease 2019

Objective

To describe the design, implementation, and utilization of electronic health record (EHR)-based digital health surveillance strategies used to manage the coronavirus disease 2019 (COVID-19) pandemic and to ensure delivery of high-quality clinical care, such as case identification, remote monitoring, telemedicine services, and recruitment to clinical trials at Mayo Clinic.

Methods

The design and implementation work described in this report was performed at Mayo Clinic, a large multistate integrated health care system with more than 1.5 million annual patient visits that uses the Epic EHR system. Rule-based live registries were designed in the EHR system to classify patients who currently test positive for COVID-19, patients who test positive but have recovered from COVID-19, patients who are thought to have COVID-19 but do not yet meet clinical diagnostic criteria, patients who test negative for COVID-19, and patients who exceed a risk score for serious complications from COVID-19.

Results

By use of registries, custom dashboards and operational reports were developed to provide a daily high-level summary for clinical practice use and up-to-date information to manage individual patients affected by COVID-19, including support of case identification, contact isolation, and other care management tasks.

Conclusion

We developed and implemented a systematic approach to the use of EHR patient registries to manage the COVID-19 pandemic that proved feasible and useful in a large multistate group clinical practice. The key to harnessing the potential of digital surveillance tools to promote patient-centered care during the COVID-19 pandemic was to use the registry data, reports, and dashboards as informatics tools to inform decision-making.

Are Antimotility Agents Safe for Use in Clostridioides difficile Infections? Results From an Observational Study in Malignant Hematology Patients

Objectives

To evaluate the safety of antimotility agents (AAs) in a population of patients with hematologic malignancies and concurrent Clostridioides difficile infection (CDI) and to describe the outcomes of AA use in a hospital setting.

Patients and Methods

We used the electronic health record to identify patients who were hospitalized in the adult malignant hematology service who had 1 or more toxin-positive C difficile stool assay between April 1, 2012, and September 21, 2017. We reviewed medical charts to obtain information on the use of AAs and any subsequent gastrointestinal complications.

Results

There were 339 patients who were stool toxin positive for CDI during the study period. Of those, 94 patients (27%) were prescribed AAs within 14 days of CDI diagnosis. All patients received CDI antimicrobial therapy within the first 24 hours. There were 2 adverse gastrointestinal events in the group that received AAs and 6 in the group that did not receive AAs. The risk of adverse events did not differ between patients who received AAs and those who did not (adjusted odds ratio, 0.36; 95% CI, 0.06 to 2.10). The mean age of the full cohort was 52.7±15.5 years, and the mean length of stay was 26.7±22.6 days. Early AA use (<48 hours of diagnosis) was not associated with increased adverse effects.

Conclusion

There was no increase in the incidence of gastrointestinal events in the arm that used AAs compared with the control arm. The evidence suggests that for patients with hematologic malignancies and CDI, the addition of AAs to appropriate antimicrobial therapy poses no additional risk.

Pharmacist-Driven MRSA Nasal PCR Screening and the Duration of Empirical Vancomycin Therapy for Suspected MRSA Respiratory Tract Infections

Objective

To assess the effect of a pharmacist-driven, polymerase chain reaction (PCR)−based nasal screening protocol for methicillin-resistant Staphylococcus aureus (MRSA) on vancomycin therapy duration and on rates of adverse drug events and 30-day hospital readmission.

Patients and Methods

From July 8, 2017, through January 31, 2019, we performed a retrospective, multicenter, preimplementation-postimplementation study. Patients with a vancomycin order to treat lower respiratory tract infection (LRTI) underwent MRSA PCR screening; tests were ordered by health care providers, including physicians, physician assistants, and advanced practice registered nurses. During the preimplementation period (July 8, 2017, through September 30, 2018), pharmacists could order MRSA PCR screening only after receiving a verbal order from a health care provider. During the postimplementation period (October 1, 2018, through January 31, 2019), a collaborative practice agreement allowed pharmacists to order MRSA PCR screening tests.

Results

The preimplementation group included 241 patients, and the postimplementation group included 74 patients. Of these patients, 124 in the preimplementation group and 62 in the postimplementation group received MRSA PCR screening. Twenty patients (16.1%) in the preimplementation group and 9 (14.5%) in the postimplementation group had a positive MRSA PCR screening test result (between-group difference, 1.6%; P=.80). Duration of therapy was significantly shorter in the postimplementation group (median [interquartile range], 14.3 [5.0-28.6] hours vs 24.0 [12.4-47.0] hours; P<.001).

Conclusion

Vancomycin therapy carries a risk of adverse events and may increase health care costs. A pharmacist-driven protocol for MRSA nasal swab PCR screening effectively reduces the duration of vancomycin therapy for patients with lower respiratory tract infection.

Patient Preparation for Outpatient Blood Work and the Impact of Surreptitious Fasting on Diagnoses of Diabetes and Prediabetes

Objective

To describe patient preparation for routine outpatient blood work and examine the implications of surreptitious fasting on interpretation of glucose results.

Patients and Methods

We designed a survey and administered it between September 1, 2016, and April 30, 2017, to assess fasting behaviors in a convenience sample of 526 adults presenting for outpatient blood work in 2 health systems between 7 am and 12 pm. We reviewed the electronic health records to extract glucose results. We describe the frequency of clinician-directed fasting and surreptitious fasting. In those surreptitiously fasting, we describe the frequency of missed diagnoses of prediabetes and diabetes.

Results

Of 526 participants, 330 (62.7%) self-identified as fasting, and 304 (92.1%) of those fasting met American Diabetes Association fasting criteria. Only 131 (24.9%) of those fasting were told to fast by their health care team. Almost 50% (257 of 526) believed it was important to fast for every blood test. Of the 64 patients with diabetes who were taking insulin, 37 (57.8%) fasted and took their insulin as prescribed. Among the 89 patients without diabetes who fasted without knowledge of their health care team and had glucose tested, 2 (2.2%) had a missed diagnosis of diabetes and 18 (20.2%) had a missed diagnosis of prediabetes.

Conclusion

Fasting for outpatient blood work is common, and patients frequently fast without awareness of their health care team. Failure to capture fasting status at the time of glucose testing is a missed opportunity to identify undiagnosed cases of diabetes and prediabetes.

Association Between Dehydration and Falls

Objective

To determine whether there is an association between dehydration and falls in adults 65 years and older.

Patients and Methods

We used University of Wisconsin Health electronic health records from October 1, 2011 to September 30, 2015 to conduct a retrospective cohort study of Midwestern patients 65 years and older and examined the association between dehydration at baseline (defined as serum urea nitrogen to creatinine ratio > 20, sodium level > 145 mg/dL, urine specific gravity > 1.030, or serum osmolality > 295 mOsm/kg) and falls within 3 years after baseline while accounting for prescriptions of loop diuretic, antidepression, anticholinergic, antipsychotic, and benzodiazepine/hypnotic medications and demographic characteristics, using logistic regression.

Results

Of 30,634 patients, 37.9% (n=11,622) were dehydrated, 11.4% (n=3483) had a fall during follow-up, and 11.7% (n=3572) died during the follow-up period. We found a positive association of dehydration with falls alone (odds ratio [OR], 1.13; P=.002). For the outcome of falls or death, dehydration was positively associated (OR, 1.13; P=.001), along with loop diuretics (OR, 1.26; P<.001) and antipsychotic medications (OR, 1.52; P<.001).

Conclusion

More than one-third of older adults in this cohort were dehydrated, with a strong association between dehydration and falls. Understanding and addressing the risks associated with dehydration, including falls, has potential for improving quality of life for patients as they age.

Cerebral Palsy Research Network Clinical Registry: Methodology and Baseline Report

Objective

To apply practice-based evidence to clinical management of cerebral palsy (CP). The process of establishing purpose, structure, logistics, and elements of a multi-institutional registry and the baseline characteristics of initial enrollees are reported.

Design

A consensus-building process among consumers, clinicians, and researchers used a participatory action process.

Setting

Community, hospitals, and universities.

Participants

More than 100 clinicians, researchers, and consumers and more than 1858 enrollees in the registry.

Main Outcome Measures

Not applicable.

Results

Consensus was that the purpose of registry was to (1) quantify practice variation, (2) facilitate quality improvement (QI), and (3) perform comparative effectiveness research (CER). Collecting data during routine clinical care using the electronic medical record was determined to be a sustainable plan for data acquisition and management. Clinicians from multiple disciplines defined salient characteristics of individuals and interventions for the registry elements. The registry was central to the clinical research network, and a leadership structure was created. A leading electronic health record platform adopted the registry elements. Twenty-four sites have initiated the data collection process and agreed to export data to the registry. Currently 12 are collecting data. Number of enrollees and characteristics were similar to other population registers.

Conclusions

This is the first multi-institutional CP registry that contains the patient and treatment characteristics needed for QI and CER. The Cerebral Palsy Research Network registry elements are implemented in a versatile electronic platform and minimize burden to clinicians. The resultant registry is available for any institution to participate and is growing rapidly.

Using Behavioral Economics and Technology to Improve Outcomes in Cardio-Oncology

Patients with cancer are often at elevated risk for cardiovascular disease due to overlapping risk factors and cardiotoxic anticancer treatments. Their cancer diagnoses may be the predominant focus of clinical care, with less of an emphasis on concurrent cardiovascular risk management. Widely adopted technology platforms, including electronic health records and mobile devices, can be leveraged to improve the cardiovascular outcomes of these patients. These technologies alone may be insufficient to change behavior and may have greater impact if combined with behavior change strategies. Behavioral economics is a scientific field that uses insights from economics and psychology to help explain why individuals are often predictably irrational. Combining insights from behavioral economics with these scalable technology platforms can positively impact medical decision-making and sustained healthy behaviors. This review focuses on the principles of behavioral economics and how "nudges" and scalable technology can be used to positively impact clinician and patient behaviors.

Risk Factors for Unnecessary Antibiotic Prescribing for Acute Respiratory Tract Infections in Primary Care

Objective

To determine independent risk factors for inappropriate antibiotic prescribing for acute respiratory tract infections (ARIs) in internal medicine (IM) residency–based primary care offices.

Patients and Methods

A retrospective study was conducted to measure antibiotic prescribing rates, and multivariable analysis was utilized to identify predictors of inappropriate prescribing among patients presenting to IM residency–based primary care office practices. Patients with an office visit at either of 2 IM residency–based primary care office practices from January 1, 2016, through December 31, 2016, with a primary encounter diagnosis of ARI were included.

Results

During the study period, 911 unique patient encounters were included with 518 for conditions for which antibiotics were considered always inappropriate. Antibiotics were not indicated in 85.8% (782 of 911) of encounters. However, antibiotics were prescribed in 28.4% (222 of 782) of these encounters. Inappropriate antibiotic prescribing occurred in 111 of 518 (21.4%) encounters for conditions for which antibiotics are always inappropriate. Using multivariable logistic regression analysis to assess for independent risk factors when adjusted for other potential risk factors for office visits at which antibiotics were not indicated, IM resident–associated visits (odds ratio, 0.25; 95% CI, 0.18-0.36) was the only variable independently associated with lower risk of inappropriate antibiotic prescribing.

Conclusion

For ARI visits at which antibiotics were not indicated, IM resident comanagement was associated with lower rates of inappropriate prescribing.

Beta-lactam antibiotic test doses in the emergency department

Background

Facilitating beta-lactam antibiotic use in patients reporting beta-lactam allergies in acute care settings is important to individual patient outcomes and public health; however, few initiatives have targeted the Emergency Department (ED) setting.

Methods

We implemented pathways for patients reporting prior penicillin and/or cephalosporin hypersensitivity as part of a hospital guideline in the ED of a large academic medical center in the United States. We described beta-lactam test doses, pathway compliance, hypersensitivity reactions (HSRs), and allergy record updating associated with ED-administered beta-lactam test doses from October 2016 to June 2018.

Results

310 beta-lactam antibiotic test doses were administered to patients with penicillin and/or cephalosporin allergy histories in the study period (average volume 15/month [standard deviation 4]). Test doses were to cephalosporins (85%), penicillins (12%), and carbapenems (4%). 219 (71%) of test doses were compliant with the pathways. Ten patients (3.2%; 95% CI 1.6%-5.9%) had HSRs; five HSR patients (50%) had beta-lactams administered that were not pathway compliant. The allergy record was updated in 146 (47%) of patients, with improvement over the study period (p < 0.001).

Conclusions

Inpatient approaches to prescribing beta-lactams in patients reporting beta-lactam allergies can be operationalized in the ED. Additional efforts are required to ensure guideline compliance and appropriate allergy documentation.

Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review

To assess the impact of organization-directed workplace interventions on physician burnout, including stress or job satisfaction in all settings, we conducted a systematic review of the literature published from January 1, 2007, to October 3, 2018, from multiple databases. Manual searches of grey literature and bibliographies were also performed. Of the 633 identified citations, 50 met inclusion criteria. Four unique categories of organization-directed workplace interventions were identified. Teamwork involved initiatives to incorporate scribes or medical assistants into electronic health record (EHR) processes, expand team responsibilities, and improve communication among physicians. Time studies evaluated the impact of schedule adjustments, duty hour restrictions, and time-banking initiatives. Transitions referred to workflow changes such as process improvement initiatives or policy changes within the organization. Technology related to the implementation or improvement of EHRs. Of the 50 included studies, 35 (70.0%) reported interventions that successfully improved the 3 measures of physician burnout, job satisfaction, and/or stress. The largest benefits resulted from interventions that improved processes, promoted team-based care, and incorporated the use of scribes/medical assistants to complete EHR documentation and tasks. Implementation of EHR interventions to improve clinical workflows worsened burnout, but EHR improvements had positive effects. Time interventions had mixed effects on burnout. The results of our study suggest that organization-directed workplace interventions that improve processes, optimize EHRs, reduce clerical burden by the use of scribes, and implement team-based care can lessen physician burnout. Benefits of process changes can enhance physician resiliency, augment care provided by the team, and optimize the coordination and communication of patient care and health information.

Creation of a Patient-Centered Journey Map to Improve the Patient Experience: A Mixed Methods Approach

Objective

To use a mixed methods approach to focus quality improvement efforts to enhance patient experience through human-centered design.

Patients and Methods

A mixed method approach began with returned Press Ganey Medical Practice Surveys from a large, multidisciplinary, outpatient medicine practice from July 1, 2016, through June 30, 2017, using correlation and gap analysis. The second phase deployed human-centered design approaches to process map patient journeys and generate opportunities for care improvement and to generate a theoretical framework for designing optimal care experiences.

Results

Our outpatient medical practices have the greatest ability to improve patient experience scores by focusing on how care teams deliver and educate patients on medications, instructions for follow-up care, and explanations about problems or conditions. By leveraging communication, the expertise of our care team members, and connection between patients and care team members, we can employ a variety of observed opportunities to enhance patient experience. Specific opportunities include leveraging tools in the electronic health record, fostering connection through empathy between patients and members of the care team, and capitalizing on the expertise of nurses on the care team.

Conclusion

A mixed methods approach to the analysis and observation of clinical care and business operations allows for the detection of opportunities with the highest potential impact for improvement when resources are constrained.

Mayo Clinic Registry of Operational Tasks (ROOT): A Paradigm Shift in Electronic Health Reco Implementation Evaluation

OBJECTIVE

To systematically examine clinical workflows before and after a major electronic health record (EHR) implementation, we performed this study. EHR implementation and/or conversion are associated with many challenges, which are barriers to optimal care. Clinical workflows may be significantly affected by EHR implementations and conversions, resulting in provider frustration and reduced efficiency.

PATIENTS AND METHODS

Our institution completed a large EHR conversion and workflow standardization converting from 3 EHRs (GE Centricity and 2 versions of Cerner) to a system-wide Epic platform. To study this quantitatively and qualitatively, we collected and curated clinical workflows through rapid ethnography, workflow observation, video ethnography, and log-file analyses of hundreds of providers, patients, and more than 100,000 log files. The study included 5 geographic sites in 4 states (Arizona, Minnesota, Florida, and Wisconsin). This project began in April 2016, and will be completed by December 2019. Our study began on May 1, 2016, and is ongoing.

RESULTS

Salient themes include the importance of prioritizing clinical areas with the most intensive EHR use, the value of tools to identify bottlenecks in workflow that cause delays, and desire for additional training to optimize navigation. Video microanalyses identified marked differences in patterns of workflow and EHR navigation patterns across sites. Log-file analyses and social network analyses identified differences in personnel roles, which led to differences in patient-clinician interaction, time spent using the EHR, and paper-based artifacts.

CONCLUSION

Assessing and curating workflow data before and after EHR conversion may provide opportunities for unexpected efficiencies in workflow optimization and information-system redesign. This project may be a model for capturing significant new knowledge in using EHRs to improve patient care, workflow efficiency, and outcomes.

Provider Survey on Automated Clinical Decision Support for Cardiovascular Risk Assessment

OBJECTIVE

To investigate provider opinions regarding a clinical decision support (CDS) system for cardiovascular risk assessment and for the creation of a replacement system.

METHODS

From March to April 2018, an invitation letter with a link to a self-administered web-based survey was sent via e-mail to 279 providers with primary appointment in the Department of Cardiovascular Medicine, Mayo Clinic, Rochester. The e-mail was sent to providers on March 8, 2018 and the survey closed on April 16, 2018.

RESULTS

One hundred providers responded to the survey yielding an overall response rate of 35.8%. Of these, 52 (52%) indicated they had used the cardiovascular (CV) risk profile CDS system and were classified as users and prompted to continue the survey. Among users, 42 (80.8%) indicated use of the CDS was either important (25; 48.1%) or very important (17; 32.7%) in their clinical practice; 45 (86.5%) responded that the system was very easy (17; 32.7%) or easy (28; 53.8%) to use. In addition, 48 (96.0%) users indicated that the CV risk profile supported their thought process at the point-of-care; 47 (97.9%) users indicated similar functionalities should be implemented into the new electronic health record system and 41 (85.4%) users reported new functionalities should also be incorporated.

CONCLUSIONS

For most users, the CDS system was easy to use and supported clinical thought process at the point-of-care. Users also felt their practice was supported and should continue to be supported by CDS systems providing individualized patient information at the point-of-care.

A Model for Improving Adherence to Prescribing Guidelines for Chronic Opioid Therapy in Rural Primary Care

Objective

To describe the steps taken and results obtained by a rural primary care practice to effectively implement opioid prescribing guidelines.

Patients and Methods

Between December 1, 2014, and May 30, 2017, a quality improvement project was undertaken. Elements included prescribing registries, a nurse coordinator, and an Opioid Use Review Panel. Clinic workflow was redesigned to more consistently incorporate these and other guideline recommendations into practice. The effect on opioid prescribing was measured as well as patient outcomes.

Results

There were 462 patients meeting inclusion criteria before implementation. At the conclusion, 16 patients (3%) had died, 9 patients (2%) were no longer seeing clinicians participating in the project, and 2 patients (0.4%) had transitioned to hospice or long-term care facilities. Of the remaining 435 patients, 96 (22.1%; 95% CI, 18.4-26.2) had decreased prescribing below the threshold for inclusion or were no longer receiving opioid prescriptions. Originally, 64 patients (13.9%; 95% CI, 11.0-17.3) were using average daily doses equal to or greater than 90 morphine milligram equivalents. After implementation, 54 of 435 patients (12.4%; 95% CI, 9.6-15.8) were still using equal to or greater than 90 morphine milligram equivalents per day after accounting for death or loss to follow-up.

Conclusion

A change in clinic process to implement guidelines for prescribing of chronic opioid therapy was completed. It was associated with a decrease in the number of patients using chronic opioid therapy, primarily at lower doses. This was accomplished in a rural practice with very limited resources in pain medicine, psychiatry, and addiction medicine.

A Clinical Decision Support Tool for Familial Hypercholesterolemia Based on Physician Input

OBJECTIVE

To develop clinical decision support (CDS) for familial hypercholesterolemia (FH), based on physician input obtained by a mixed methods approach.

INTRODUCTION

Awareness, detection, and control of FH-a relatively common genetic disorder-is low. Clinical decision support could address knowledge gaps and provide point-of-care guidance for the management of FH.

METHODS

A 16-question survey that assessed familiarity with FH and sought input on potential content of the CDS tool was emailed to 1161 clinicians including 208 cardiologists. In addition, 4 physician focus groups were held to gather input on the structure and form of the CDS tool. This study took place between September 12, 2016, and January 16, 2017.

RESULTS

The response rate to the survey was 18.1%. Clinicians were overwhelmingly (97.6%) in favor of a CDS tool that assists in managing patients with FH at the point of care and this was confirmed in the focus group discussions. Key themes emerged during the focus groups including providers' knowledge and understanding of FH, facilitators and barriers to implementing a CDS tool, and suggestions for its design and content.

CONCLUSION

Clinicians were supportive of development of a CDS tool to assist with the evaluation and treatment of FH and provided feedback related to the design and implementation of such a tool.

Effect of Postdismissal Pharmacist Visits for Patients Using High-Risk Medications

Objective

To determine whether a pharmacist visit after hospital dismissal for patients taking at least 1 medication that places patients at high risk for emergent hospital admissions (termed high-risk medication) would decrease the risk of hospital readmission at 30 days compared with usual care.

Patients and Methods

This was a retrospective study at a tertiary care center conducted from July 26, 2013, through April 1, 2016. We reviewed outcomes among patients who did or did not have a post–hospital dismissal pharmacist visit immediately before a clinician visit. We included patients who were at least 18 years old and were taking at least 10 total medications at hospital dismissal, 1 or more of which were high-risk medications. A Cox proportional hazards model was used to compare the risk of 30-day readmission between the groups.

Results

The study cohort included 502 patients in each group (pharmacist + clinician group and clinician-only group). After adjusting for differences in background demographic characteristics, patients in the pharmacist + clinician group were significantly less likely to be readmitted to the hospital within 30 days postdismissal compared with the clinician-only group (hazard ratio, 0.49; 95% CI, 0.35-0.69; P<.001).

Conclusion

Patients seen by a pharmacist immediately before a clinician visit after hospital dismissal had a lower risk of readmission than patients who had a clinician-only visit. Patients taking high-risk medications for hospital admissions are ideal candidates for pharmacist involvement.

Enabling Precision Cardiology Through Multiscale Biology and Systems Medicine

The traditional paradigm of cardiovascular disease research derives insight from large-scale, broadly inclusive clinical studies of well-characterized pathologies. These insights are then put into practice according to standardized clinical guidelines. However, stagnation in the development of new cardiovascular therapies and variability in therapeutic response implies that this paradigm is insufficient for reducing the cardiovascular disease burden. In this state-of-the-art review, we examine 3 interconnected ideas we put forth as key concepts for enabling a transition to precision cardiology: 1) precision characterization of cardiovascular disease with machine learning methods; 2) the application of network models of disease to embrace disease complexity; and 3) using insights from the previous 2 ideas to enable pharmacology and polypharmacology systems for more precise drug-to-patient matching and patient-disease stratification. We conclude by exploring the challenges of applying a precision approach to cardiology, which arise from a deficit of the required resources and infrastructure, and emerging evidence for the clinical effectiveness of this nascent approach.

Point-of-care testing to promote cardiovascular disease risk assessment: A proof of concept study

Updated cholesterol guidelines emphasize multivariable cardiovascular disease (CVD) risk estimation to guide treatment decision-making in primary prevention. This study tested the preliminary feasibility, acceptability and efficacy of point-of-care testing (POCT) and quantitative CVD risk assessment in high-risk adults to increase guideline-recommended statin use in primary prevention. Participants were aged 40–75 years, without CVD or diabetes mellitus, and potentially-eligible for consideration of statins based on estimated 10-year CVD risk from last-measured risk factor levels in the electronic health record. We performed POCT to facilitate quantitative CVD risk assessment with the Pooled Cohort Equations immediately before a scheduled primary care provider (PCP) visit. Outcomes were: physician documentation of a CVD risk discussion and statin prescription on the study date. We also assessed acceptability of the intervention through structured questionnaire. We recruited 18 participants (8 from an academic practice and 10 from a federally-qualified health clinic). After the intervention, 83% of participants discussed CVD risk with their PCP, 47% received a statin recommendation from their PCP, and 29% received a new statin prescription during the PCP visit. Participants reported high levels of satisfaction with the intervention. This study demonstrates that in initial testing pre-visit POCT and quantitative CVD risk assessment appears to be a feasible and acceptable intervention that may promote guideline-recommended statin initiation in primary prevention. Future research with an adequately powered trial is warranted to determine the effectiveness of this approach in clinical practice.

Automated Diabetes Case Identification Using Electronic Health Record Data at a Tertiary Care Facility

Objective

To develop and validate a phenotyping algorithm for the identification of patients with type 1 and type 2 diabetes mellitus (DM) preoperatively using routinely available clinical data from electronic health records.

Patients and Methods

We used first-order logic rules (if-then-else rules) to imply the presence or absence of DM types 1 and 2. The “if” clause of each rule is a conjunction of logical and, or predicates that provides evidence toward or against the presence of DM. The rule includes International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes, outpatient prescription information, laboratory values, and positive annotation of DM in patients’ clinical notes. This study was conducted from March 2, 2015, through February 10, 2016. The performance of our rule-based approach and similar approaches proposed by other institutions was evaluated with a reference standard created by an expert reviewer and implemented for routine clinical care at an academic medical center.

Results

A total of 4208 surgical patients (mean age, 52 years; males, 48%) were analyzed to develop the phenotyping algorithm. Expert review identified 685 patients (16.28% of the full cohort) as having DM. Our proposed method identified 684 patients (16.25%) as having DM. The algorithm performed well—99.70% sensitivity, 99.97% specificity—and compared favorably with previous approaches.

Conclusion

Among patients undergoing surgery, determination of DM can be made with high accuracy using simple, computationally efficient rules. Knowledge of patients’ DM status before surgery may alter physicians’ care plan and reduce postsurgical complications. Nevertheless, future efforts are necessary to determine the effect of first-order logic rules on clinical processes and patient outcomes.

Contact networks in the emergency department: Effects of time, environment, patient characteristics, and staff role

Emergency departments play a critical role in the public health system, particularly in times of pandemic. Infectious patients presenting to emergency departments bring a risk of cross-infection to other patients and staff through close proximity interactions or contacts. To understand factors associated with cross-infection risk, we measured close proximity interactions of emergency department staff and patients by radiofrequency identification in a working emergency department. The number of contacts (degree) is not related to patient demographic characteristics. However, the amount of time in close proximity (weighted degree) of patients with ED personnel did differ, with black patients having approximately 15 min more contact with staff than non-white patients. Patients arriving by EMS had fewer contacts with other patients than patients arriving by other means. There are differences in the number of contacts based on staff role and arrival mode. When crowding is low, providers have the most contact time with patients, while administrative staff have the least. However, when crowding is high, this differential is reversed. The effect of arrival mode is modified by the extent of crowding. When crowding is low, patients arriving by EMS had longer contact with administrative staff, compared to patients arriving by other means. However, when crowding is high, patients arriving by EMS had less contact with administrative staff compared to patients arriving by other means. Our findings should help designers of emergency care focus on higher risk situations for transmission of dangerous pathogens in an emergency department. For instance, the effects of arrival and crowding should be considered as targets for engineering or architectural interventions that could artificially increase social distances.

Electronic health record-based assessment of cardiovascular health: The stroke prevention in healthcare delivery environments (SPHERE) study

< 3% of Americans have ideal cardiovascular health (CVH). The primary care encounter provides a setting in which to conduct patient-provider discussions of CVH. We implemented a CVH risk assessment, visualization, and decision-making tool that automatically populates with electronic health record (EHR) data during the encounter in order to encourage patient-centered CVH discussions among at-risk, yet under-treated, populations. We quantified five of the seven CVH behaviors and factors that were available in The Ohio State University Wexner Medical Center's EHR at baseline (May–July 2013) and compared values to those ascertained at one-year (May–July 2014) among intervention (n = 109) and control (n = 42) patients. The CVH of women in the intervention clinic improved relative to the metrics of body mass index (16% to 21% ideal) and diabetes (62% to 68% ideal), but not for smoking, total cholesterol, or blood pressure. Meanwhile, the CVH of women in the control clinic either held constant or worsened slightly as measured using those same metrics. Providers need easy-to-use tools at the point-of-care to help patients improve CVH. We demonstrated that the EHR could deliver such a tool using an existing American Heart Association framework, and we noted small improvements in CVH in our patient population. Future work is needed to assess how to best harness the potential of such tools in order to have the greatest impact on the CVH of a larger patient population.

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Use and adoption of health information technology advances quality in patient care.

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Healthcare systems need tools to enhance primary prevention at the point-of-care.

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Providers and patients have shared accountability for population health metrics.