Clinical prediction rules (CPRs) represent well-validated but underutilized evidence-based medicine tools at the point-of-care. To date, an inability to integrate these rules into an electronic ...health record (EHR) has been a major limitation and we are not aware of a study demonstrating the use of CPR's in an ambulatory EHR setting. The integrated clinical prediction rule (iCPR) trial integrates two CPR's in an EHR and assesses both the usability and the effect on evidence-based practice in the primary care setting.
A multi-disciplinary design team was assembled to develop a prototype iCPR for validated streptococcal pharyngitis and bacterial pneumonia CPRs. The iCPR tool was built as an active Clinical Decision Support (CDS) tool that can be triggered by user action during typical workflow. Using the EHR CDS toolkit, the iCPR risk score calculator was linked to tailored ordered sets, documentation, and patient instructions. The team subsequently conducted two levels of 'real world' usability testing with eight providers per group. Usability data were used to refine and create a production tool. Participating primary care providers (n = 149) were randomized and intervention providers were trained in the use of the new iCPR tool. Rates of iCPR tool triggering in the intervention and control (simulated) groups are monitored and subsequent use of the various components of the iCPR tool among intervention encounters is also tracked. The primary outcome is the difference in antibiotic prescribing rates (strep and pneumonia iCPR's encounters) and chest x-rays (pneumonia iCPR only) between intervention and control providers.
Using iterative usability testing and development paired with provider training, the iCPR CDS tool leverages user-centered design principles to overcome pervasive underutilization of EBM and support evidence-based practice at the point-of-care. The ongoing trial will determine if this collaborative process will lead to higher rates of utilization and EBM guided use of antibiotics and chest x-ray's in primary care.
ClinicalTrials.gov Identifier NCT01386047.
Abstract only Background/Significance: There is a national mandate to prevent hospital readmissions. In 2009, CMS began publicly reporting 30-day readmission rates for patients hospitalized with ...pneumonia, acute myocardial infarction, and heart failure. Multiple factors contribute to avoidable readmissions, and can result from: poor quality care, premature discharges, poor coordination and communication between patient and providers. Program: Mount Sinai Hospital (MSH) has created The PACT Program, with the goal of reducing 30 day readmissions. PACT is internally funded and consists of 4 social workers (SW) in the hospital and 2 NP's and 1 SW in the internal medicine clinic. Patients at high risk of readmission are identified in the hospital based on their readmission history. The SW performs a 75 minute patient/caregiver psychosocial assessment. A five week post-discharge care coordination plan follows by the same enrolling SW. This includes intensive phone follow-up and home visits to appraise home safety, environmental hazards, family involvement, medication compliance, nutritional/dietary assessments. Patients with fragmented primary care are referred to the PACT clinic. Patient Profile: Age range from 19-99; 52% are 65+; 8% 85+; 52% women; 48% male; 38% are African-American; 32% Hispanic; 43% have congestive heart failure, 45% diabetes; 16% dialysis, 21% documented mental illness; 66% greater than 2 co-morbidities; 85% Medicare and/or Medicaid; 87% have a family caregiver. Results: 6 month (see table) Conclusions: PACT is engaging the most challenging patients and is successful in reducing 30,60,90 day readmissions. PACT patients represent a diversity of age, gender and ethnicity, are medically complex, enriched in cardiovascular disease and diabetes. PACT includes non-english speaking patients with cognitive impairment, mental illness, which other transitional programs have excluded. The model is replicable, sustainable, and improving quality of care.
Morphine-6-glucuronide (M-6-G) is an active metabolite of morphine that may contribute to drug effects. To understand better the relationship between morphine and M-6-G in cancer patients receiving ...chronic therapy, we employed high performance liquid chromatography with electrochemical detection to measure: (1) morphine and M-6-G plasma concentrations following discontinuation of dosing in 2 patients, one receiving oral therapy and the other an intravenous infusion; (2) morphine and M-6-G concentrations in random blood samples taken at apparent steady state from 8 patients, 7 with normal renal function and 1 with mild renal insufficiency, who were receiving continuous morphine infusions; and (3) morphine and M-6-G concentrations in random blood samples taken over a period of weeks from 4 patients, 2 with stable and 2 with declining renal function. Results demonstrated a slightly slower decline in plasma M-6-G than morphine concentrations following drug discontinuation, as would be expected for metabolite and parent relationship; roughly similar M-6-G: morphine ratios (mean molar ratio = 1.22) across a broad range of morphine doses in patients with normal renal function; and an increase in this ratio over time in patients with progressive renal dysfunction. These data illustrate the kinetics of M-6-G in cancer patients receiving chronic morphine therapy and confirm the importance of renal function in determining the concentration of the metabolite.
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