Background and Objectives
Use of algorithms to identify patients with high data‐continuity in electronic health records (EHRs) may increase study validity. Practical experience with this approach ...remains limited.
Methods
We developed and validated four algorithms to identify patients with high data continuity in an EHR‐based data source. Selected algorithms were then applied to a pharmacoepidemiologic study comparing rates of COVID‐19 hospitalization in patients exposed to insulin versus noninsulin antidiabetic drugs.
Results
A model using a short list of five EHR‐derived variables performed as well as more complex models to distinguish high‐ from low‐data continuity patients. Higher data continuity was associated with more accurate ascertainment of key variables. In the pharmacoepidemiologic study, patients with higher data continuity had higher observed rates of the COVID‐19 outcome and a large unadjusted association between insulin use and the outcome, but no association after propensity score adjustment.
Discussion
We found that a simple, portable algorithm to predict data continuity gave comparable performance to more complex methods. Use of the algorithm significantly impacted the results of an empirical study, with evidence of more valid results at higher levels of data continuity.
Plain Language Summary
When doing research using electronic health records, one big problem is that sometimes information is missing or not consistently recorded. There are methods (algorithms) that can help identify which patients' records are more complete and reliable. However, it's not clear how much these methods actually improve the results of studies about how drugs affect populations (pharmacoepidemiologic studies). This manuscript demonstrates that using a straightforward and easy‐to‐use method seems to make the results of such a drug study more accurate.
MRI characterization of carotid plaque has been studied recently as a potential tool to predict stroke caused by carotid atherosclerosis. We performed a systematic review and meta-analysis to ...summarize the association of MRI-determined intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap with subsequent ischemic events.
We performed a comprehensive literature search evaluating the association of carotid plaque composition on MRI with ischemic outcomes. We included cohort studies examining intraplaque hemorrhage, lipid-rich necrotic core, or thinning/rupture of the fibrous cap with mean follow-up of ≥1 month and an outcome measure of ipsilateral stroke or transient ischemic attack. A meta-analysis using a random-effects model with assessment of study heterogeneity and publication bias was performed.
Of the 3436 articles screened, 9 studies with a total of 779 subjects met eligibility for systematic review. The hazard ratios for intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap as predictors of subsequent stroke/transient ischemic attack were 4.59 (95% confidence interval, 2.91-7.24), 3.00 (95% confidence interval, 1.51-5.95), and 5.93 (95% confidence interval, 2.65-13.20), respectively. No statistically significant heterogeneity or publication bias was present in the 3 main meta-analyses performed.
The presence of intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap on MRI of carotid plaque is associated with increased risk of future stroke or transient ischemic attack in patients with carotid atherosclerotic disease. Dedicated MRI of plaque composition offers stroke risk information beyond measurement of luminal stenosis in carotid atherosclerotic disease.
Aims
To examine the association between baseline glucose control and risk of COVID‐19 hospitalization and in‐hospital death among patients with diabetes.
Methods
We performed a retrospective cohort ...study of adult patients in the INSIGHT Clinical Research Network with a diabetes diagnosis and haemoglobin A1c (HbA1c) measurement in the year prior to an index date of March 15, 2020. Patients were divided into four exposure groups based on their most recent HbA1c measurement (in mmol/mol): 39–46 (5.7%–6.4%), 48–57 (6.5%–7.4%), 58–85 (7.5%–9.9%), and ≥86 (10%). Time to COVID‐19 hospitalization was compared in the four groups in a propensity score‐weighted Cox proportional hazards model adjusting for potential confounders. Patients were followed until June 15, 2020. In‐hospital death was examined as a secondary outcome.
Results
Of 168,803 patients who met inclusion criteria; 50,016 patients had baseline HbA1c 39–46 (5.7%–6.4%); 54,729 had HbA1c 48–57 (6.5–7.4%); 47,640 had HbA1c 58–85 (7.5^%–9.9%) and 16,418 had HbA1c ≥86 (10%). Compared with patients with HbA1c 48–57 (6.5%–7.4%), the risk of hospitalization was incrementally greater for those with HbA1c 58–85 (7.5%–9.9%) (adjusted hazard ratio aHR 1.19, 95% confidence interval CI 1.06–1.34) and HbA1c ≥86 (10%) (aHR 1.40, 95% CI 1.19–1.64). The risk of COVID‐19 in‐hospital death was increased only in patients with HbA1c 58–85 (7.5%–9.9%) (aHR 1.29, 95% CI 1.06, 1.61).
Conclusions
Diabetes patients with high baseline HbA1c had a greater risk of COVID‐19 hospitalization, although association between HbA1c and in‐hospital death was less consistent. Preventive efforts for COVID‐19 should be focused on diabetes patients with poor glucose control.
BACKGROUND AND PURPOSE—Ultrasonographic plaque echolucency has been studied as a stroke risk marker in carotid atherosclerotic disease. We performed a systematic review and meta-analysis to summarize ...the association between ultrasound-determined carotid plaque echolucency and future ipsilateral stroke risk.
METHODS—We searched the medical literature for studies evaluating the association between carotid plaque echolucency and future stroke in asymptomatic patients. We included prospective observational studies with stroke outcome ascertainment after baseline carotid plaque echolucency assessment. We performed a meta-analysis and assessed study heterogeneity and publication bias. We also performed subgroup analyses limited to patients with stenosis ≥50%, studies in which plaque echolucency was determined via subjective visual interpretation, studies with a relatively lower risk of bias, and studies published after the year 2000.
RESULTS—We analyzed data from 7 studies on 7557 subjects with a mean follow-up of 37.2 months. We found a significant positive relationship between predominantly echolucent (compared with predominantly echogenic) plaques and the risk of future ipsilateral stroke across all stenosis severities (0% to 99%; relative risk, 2.31; 95% confidence interval, 1.58–3.39; P<0.001) and in subjects with ≥50% stenosis (relative risk, 2.61; 95% confidence interval, 1.47–4.63; P=0.001). A statistically significant increased relative risk for future stroke was preserved in all additional subgroup analyses. No statistically significant heterogeneity or publication bias was present in any of the meta-analyses.
CONCLUSIONS—The presence of ultrasound-determined carotid plaque echolucency provides predictive information in asymptomatic carotid artery stenosis beyond luminal stenosis. However, the magnitude of the increased risk is not sufficient on its own to iden tify patients likely to benefit from surgical revascularization.
Background: In 2016, metformin’s prescribing label was revised to permit it to be started with estimated glomerular filtration rate (eGFR) 45-60 ml/min and continued with eGFR 30-44 ml/min. We ...examined whether subsequent metformin prescribing in these groups increased.
Methods: We conducted an interrupted time series study using data from the New York City Clinical Data Research Network. We identified episodes from 2014-2017 in which adult patients with HbA1c ≥6.5% received outpatient antidiabetic prescriptions ≤7 days after an eGFR measurement. Trends in the proportion of episodes that included metformin were examined using linear regression in 4 eGFR subgroups: ≥60 (reference), 45-59, 30-44, and <30 ml/min. Sensitivity analysis examined episodes with no antidiabetic prescription in the prior 180 days.
Results: We identified 10,608 prescribing episodes among 6,505 patients. Lower eGFR was associated with less metformin prescribing. In the eGFR 30-44 ml/min group, there were significant increases in metformin prescribing after the label change (p<0.001). In sensitivity analysis, an increasing trend in metformin prescriptions in the 45-59 ml/min eGFR group started before the label change (p=0.04) and leveled off.
Conclusion: Metformin prescribing for patients with eGFR 30-60 ml/min was increasing prior to the label change. Rates of metformin use at eGFR 30-45 ml/min remain relatively low.
Disclosure
J. Min: None. X. Wu: None. J. Orloff: None. A.I. Mushlin: None. J. Flory: None.
Funding
Patient-Centered Outcomes Research Institute (CER-9230)
Background
Failure of THA or TKA to meet a patient’s expectations may result in patient disappointment and litigation. However, there is little evidence to suggest that surgeons can consistently ...anticipate which patients will benefit from those interventions.
Questions/purposes
To determine the ability of surgeons to identify, in advance of surgery, patients who will benefit from THA or TKA and those who will not, where ‘benefit’ is defined as a clinically important improvement in a validated patient-reported outcomes score.
Methods
In this prospective study, eight high-volume orthopaedic surgeons completed validated THA and TKA expectations questionnaires (score 0–100, 100 being the highest expectation) as part of preoperative assessment of all their patients scheduled for a THA or TKA and enrolled in the Hospital for Special Surgery institutional registry. Enrolled patients completed the WOMAC preoperatively and at 2 years. Successful outcomes were defined as achieving the minimum clinically important difference (MCID) in WOMAC pain and function subscales. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to evaluate the ability of surgeons’ expectation scores to identify patients likely to achieve the MCID on the WOMAC scale. Analyses were run separately for patients having THA and TKA. We enrolled 259 patients undergoing THA and 247 undergoing TKA, of whom 77% (n = 200) and 77% (n = 191) completed followup surveys 2 years after their procedures, respectively.
Results
Surgeons’ expectation scores effectively anticipated patients who would improve after THA, but they were no better than chance in identifying patients who would achieve the MCID on the WOMAC score 2 years after TKA. For patients having THA, the areas under the ROC curve were 0.67 (95% CI, 0.53–0.82; p = 0.02) and 0.74 (95% CI, 0.63–0.85; p < 0.01) for WOMAC function and pain outcomes, respectively, indicating good accuracy. Sensitivity and specificity were maximized on WOMAC pain and function scores (sensitivity = 0.69, specificity = 0.72, both for pain and function) at an expectations score of 83 or greater of 100. Surgeons’ expectations were more accurate for patients who were men, who had a BMI less than 30 kg/m
2
, who had more than one comorbidity, and who were older than 65 years. For patients having TKA, surgeons’ expectation scores were not better than chance for identifying those who would experience a clinically important improvement on the WOMAC scale (area under ROC curve: Function = 0.51, 95% CI, 0.42–0.61, p = 0.78; Pain = 0.51, 95% CI, 0.40–0.61, p = 0.92).
Conclusions
Most patients having THA and TKA achieved the MCID improvement after surgery. However, the inability of surgeons’ expectation scores to discriminate accurately between patients who benefit and those who do not among patients scheduled for THA who are young, with no comorbidities, and with elevated BMIs, and among all patients scheduled for TKA, calls for surgeons to spend more time with these patients to fully understand and address their needs and expectations. Using standardized assessment tools to compare surgeons’ expectations and those of their patients may help focus the surgeon-patient discussion further, and address patients’ expectations more effectively.
Level of Evidence
Level II, therapeutic study.
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