Studies of the effects of electronic health records (EHRs) have had mixed findings, which may be attributable to unmeasured confounders such as individual variability in use of EHR features.
To ...capture physician-level variations in use of EHR features, associations with other predictors, and usage intensity over time.
Retrospective cohort study of primary care providers eligible for meaningful use at a network of federally qualified health centers, using commercial EHR data from January 2010 through June 2013, a period during which the organization was preparing for and in the early stages of meaningful use.
Data were analyzed for 112 physicians and nurse practitioners, consisting of 430,803 encounters with 99,649 patients. EHR usage metrics were developed to capture how providers accessed and added to patient data (eg, problem list updates), used clinical decision support (eg, responses to alerts), communicated (eg, printing after-visit summaries), and used panel management options (eg, viewed panel reports). Provider-level variability was high: for example, the annual average proportion of encounters with problem lists updated ranged from 5% to 60% per provider. Some metrics were associated with provider, patient, or encounter characteristics. For example, problem list updates were more likely for new patients than established ones, and alert acceptance was negatively correlated with alert frequency.
Providers using the same EHR developed personalized patterns of use of EHR features. We conclude that physician-level usage of EHR features may be a valuable additional predictor in research on the effects of EHRs on healthcare quality and costs.
Objectives Contemporary electronic health records (EHRs) offer a wide variety of features, creating opportunities to influence healthcare quality in different ways. This study was designed to assess ...the relationship between physician use of individual EHR functions and healthcare quality.
Materials and Methods Sixty-five providers eligible for “meaningful use” were included. Data were abstracted from office visit records during the study timeframe (183 095 visits with 61 977 patients). Three EHR functions were considered potential predictors: acceptance of best practice alerts, use of order sets, and viewing panel-level reports. Eighteen clinical quality measures from the “meaningful use” program were abstracted.
Results Use of condition-specific best-practice alerts and order sets was associated with better scores on clinical quality measures capturing processes in diabetes, cancer screening, tobacco cessation, and pneumonia vaccination. For example, providers above the median in use of tobacco-related alerts had higher performance on tobacco cessation intervention metrics (median 80.6% vs. 66.7%; P < .001), and providers above the median in use of diabetes order sets had higher quality on diabetes low density lipoprotein (LDL) testing (68.2% vs. 59.5%; P == .001). Post hoc examination of the results showed that the positive associations were with measures of healthcare processes (such as rates of LDL testing), whereas there were no positive associations with measures of healthcare outcomes (such as LDL levels).
Discussion Among primary care providers in the ambulatory setting using a single EHR, intensive use of certain EHR functions was associated with increased adherence to recommended care as measured by performance on electronically reported “meaningful use” quality measures. This study is relevant to current policy as it uses quality metrics constructed by contemporary certified EHR technology, and quantitative EHR use metrics rather than self-reported use.
Conclusion In the early stages of the “meaningful use” program, use of specific EHR functions was associated with higher performance on healthcare process metrics.
Abstract
Objective
Few studies have examined the use of embedded validity indicators (EVIs) in criminal-forensic practice settings, where judgements regarding performance validity can carry severe ...consequences for the individual and society. This study sought to examine how various EVIs perform in criminal defendant populations, and determine relationships between EVI scores and intrapersonal variables thought to influence performance validity.
Method
Performance on 16 empirically established EVI cutoffs were examined in a sample of 164 criminal defendants with valid performance who were referred for forensic neuropsychological evaluation. Subsequent analyses examined the relationship between EVI scores and intrapersonal variables in 83 of these defendants.
Results
Half of the EVIs (within the Wechsler Adult Intelligence Scale Digit Span Total, Conners’ Continuous Performance Test Commissions, Wechsler Memory Scale Logical Memory I and II, Controlled Oral Word Association Test, Trail Making Test Part B, and Stroop Word and Color) performed as intended in this sample. The EVIs that did not perform as intended were significantly influenced by relevant intrapersonal variables, including below-average intellectual functioning and history of moderate–severe traumatic brain injury and neurodevelopmental disorder.
Conclusions
This study identifies multiple EVIs appropriate for use in criminal-forensic settings. However, based on these findings, practitioners may wish to be selective in choosing and interpreting EVIs for forensic evaluations of criminal court defendants.
Anticholinergic burden (ACB) from medications impairs cognition in schizophrenia. Cognition is a predictor of functional capacity; however, little is known about ACB effect on functional capacity in ...this population. This study assesses the relationship between ACB and functional capacity across the life span in individuals with schizophrenia after controlling for ACB effect on cognition. A cross-sectional analysis was performed with data collected from 6 academic tertiary health centers. Two hundred and twenty-three community-dwelling participants with schizophrenia or schizoaffective disorder were included in this study. Main variables were ACB, antipsychotic olanzapine equivalents, functional capacity, cognition, and negative symptoms. Simultaneous linear regression analyses were performed to assess the association between ACB, functional capacity, and cognition and then between ACB and cognition. A mediation analysis was then performed to examine whether cognition mediated ACB effect on functional capacity if there was an association between ACB and cognition. Mean age of participants was 49.0 years (SD = 13.1, range 19-79), and 63.7% of participants had severe ACB, ie, a total score of 3 or above. Regression analyses revealed that ACB, age, education, and cognition independently predicted functional capacity and that ACB predicted cognition among those aged 55 years and older. Mediation analysis showed that cognition did partially mediate the effect of ACB on functional capacity in this older cohort. In conclusion, people with schizophrenia are exposed to severe ACB that can have a direct negative impact on functional capacity after controlling for its impact on cognition. Reducing ACB could improve functional capacity and potentially real-world function in schizophrenia.
Study objective For out-of-hospital cardiac arrest, authoritative, evidence-based recommendations have been made for regionalization of postarrest care. However, system-wide implementation of these ...guidelines has not been evaluated. Our hypothesis is that statewide regionalization of postarrest interventions, combined with emergency medical services (EMS) triage bypass, is associated with improved survival and neurologic outcome. Methods This was a prospective before-after observational study comparing patients admitted to cardiac receiving centers before implementation of the interventions (“before”) versus those admitted after (“after”). In December 2007, the Arizona Department of Health Services began officially recognizing cardiac receiving centers according to commitment to provide specified postarrest care. Subsequently, the State EMS Council approved protocols allowing preferential EMS transport to these centers. Participants were adults (≥18 years) experiencing out-of-hospital cardiac arrest of presumed cardiac cause who were transported to a cardiac receiving center. Interventions included (1) implementation of postarrest care at cardiac receiving centers focusing on provision of therapeutic hypothermia and coronary angiography or percutaneous coronary interventions (catheterization/PCI); and (2) implementation of EMS bypass triage protocols. Main outcomes included discharged alive from the hospital and cerebral performance category score at discharge. Results During the study (December 1, 2007, to December 31, 2010), 31 hospitals were recognized as cardiac receiving centers statewide. Four hundred forty patients were transported to cardiac receiving centers before and 1,737 after. Provision of therapeutic hypothermia among patients with return of spontaneous circulation increased from 0% (before: 0/145; 95% confidence interval CI 0% to 2.5%) to 44.0% (after: 300/682; 95% CI 40.2, 47.8). The post return of spontaneous circulation catheterization PCI rate increased from 11.7% (17/145; 95% CI 7.0, 18.1) before to 30.7% (210/684; 95% CI 27.3, 34.3) after. All-rhythm survival increased from 8.9% (39/440) to 14.4% (250/1,734; adjusted odds ratio aOR=2.22; 95% CI 1.47 to 3.34). Survival with favorable neurologic outcome (cerebral performance category score=1 or 2) increased from 5.9% (26/439) to 8.9% (153/1,727; aOR=2.26 95% CI 1.37, 3.73). For witnessed shockable rhythms, survival increased from 21.4% (21/98) to 39.2% (115/293; aOR=2.96 95% CI 1.63, 5.38) and cerebral performance category score=1 or 2 increased from 19.4% (19/98) to 29.8% (87/292; aOR=2.12 95% CI 1.14, 3.93). Conclusion Implementation of a statewide system of cardiac receiving centers and EMS bypass was independently associated with increased overall survival and favorable neurologic outcome. In addition, these outcomes improved among patients with witnessed shockable rhythms.
Background The number of patients undergoing implantation of a HeartMate II left ventricular assist device (LVAD; Thoratec Corporation, Pleasanton, Calif) is rising. Ventricular tachyarrhythmia (VA) ...after placement of the device is common, especially among patients with preoperative VA. We sought to determine whether intraoperative cryoablation in select patients reduces the incidence of postoperative VA. Methods From January 2009 through September 2010, 50 consecutive patients undergoing implantation of the HeartMate II LVAD were examined. Fourteen of these patients had recurrent preoperative VA. Of those patients with recurrent VA, half underwent intraoperative cryoablation (Cryo: n = 7) and half did not (NoCryo: n = 7). Intraoperatively, patients underwent localized epicardial and endocardial cryoablation via LVAD ventriculotomy. Cryothermal lesions were created to connect scar to fixed anatomic borders in the region of clinical VA. Demographics, risk factors, intraoperative features, and outcomes were analyzed to investigate the feasibility of cryoablation. Results Thirty-day mortality remained low (n = 1, 2%) among all LVAD recipients. There were no differences in risk factors between groups except that preoperative inotropes were less prevalent in Cryo patients ( P = .09). Compared with NoCryo, the Cryo group had significantly decreased postoperative resource use and complications ( P < .05). Recurrent postoperative VA did not develop in any of the Cryo patients ( P = .02). Conclusions Postoperative VA can be minimized by preoperative risk assessment and intraoperative treatment. Localized cryoablation in select patients offers promising early feasibility when performed during HeartMate II LVAD implantation. Further prospective analysis is required to investigate this novel approach.
Objectives Orthotopic heart transplantation is the standard of care for end-stage heart disease. Left ventricular assist device implantation offers an alternative treatment approach. Left ventricular ...assist device practice has changed dramatically since the 2008 Food and Drug Administration approval of the HeartMate II (Thoratec, Pleasanton, Calif), but at what societal cost? The present study examined the cost and efficacy of both treatments over time. Methods All patients who underwent either orthotopic heart transplantation (n = 9369) or placement of an implantable left ventricular assist device (n = 6414) from 2005 to 2009 in the Nationwide Inpatient Sample were selected. The trends in treatment use, mortality, and cost were analyzed. Results The incidence of orthotopic heart transplantation increased marginally within a 5-year period. In contrast, the annual left ventricular assist device implantation rates nearly tripled. In-hospital mortality from left ventricular assist device implantation decreased precipitously, from 42% to 17%. In-hospital mortality for orthotopic heart transplantation remained relatively stable (range, 3.8%-6.5%). The mean cost per patient increased for both orthotopic heart transplantation and left ventricular assist device placement (40% and 17%, respectively). With the observed increase in both device usage and cost per patient, the cumulative Left ventricular assist device cost increased 232% within 5 years (from $143 million to $479 million). By 2009, Medicare and Medicaid were the primary payers for nearly one half of all patients (orthotopic heart transplantation, 45%; left ventricular assist device, 51%). Conclusions Since Food and Drug Administration approval of the HeartMate II, mortality after left ventricular assist device implantation has decreased rapidly, yet has remained greater than that after orthotopic heart transplantation. The left ventricular assist device costs have continued to increase and have been significantly greater than those for orthotopic heart transplantation. Because of the evolving healthcare economics climate, with increasing emphasis on the costs and comparative effectiveness, a concerted effort at LVAD cost containment and judicious usage is essential to preserve the viability of this invaluable treatment.
Abstract Background Previous investigations of out-of-hospital cardiac arrest (OHCA) have shown that the waveform characteristic amplitude spectral area (AMSA) can predict successful defibrillation ...and return of spontaneous circulation (ROSC) but has not been studied previously for survival. Objectives To determine whether AMSA computed from the ventricular fibrillation (VF) waveform is associated with pre-hospital ROSC, hospital admission, and hospital discharge. Methods Adults with witnessed OHCA and an initial rhythm of VF from an Utstein style database were studied. AMSA was measured prior to each shock and averaged for each subject (AMSA-avg). Factors such as age, sex, number of shocks, time from dispatch to monitor/defibrillator application, first shock AMSA, and AMSA-avg that could predict pre-hospital ROSC, hospital admission, and hospital discharge were analyzed by logistic regression. Results Eighty-nine subjects (mean age 62 ± 15 years) with a total of 286 shocks were analyzed. AMSA-avg was associated with pre-hospital ROSC (p = 0.003); a threshold of 20.9 mV-Hz had a 95% sensitivity and a 43.4% specificity. Additionally, AMSA-avg was associated with hospital admission (p < 0.001); a threshold of 21 mV-Hz had a 95% sensitivity and a 54% specificity and with hospital discharge (p < 0.001); a threshold of 25.6 mV-Hz had a 95% sensitivity and a 53% specificity. First-shock AMSA was also predictive of pre-hospital ROSC, hospital admission, and discharge. Time from dispatch to monitor/defibrillator application was associated with hospital admission (p = 0.034) but not pre-hospital ROSC or hospital discharge. Conclusions AMSA is highly associated with pre-hospital ROSC, survival to hospital admission, and hospital discharge in witnessed VF OHCA. Future studies are needed to determine whether AMSA computed during resuscitation can identify patients for whom continuing current resuscitation efforts would likely be futile.
Background The efficacy of wearing compression stockings on clinical vessel disappearance following sclerotherapy of telangiectasias and reticular veins has been a matter of debate for half a ...century. Objective To determine the relative efficacy of compression following sclerotherapy and to determine its impact on general quality of life in a prospective randomized open-label trial. Methods Female patients seeking treatment of telangiectasias and reticular veins and presenting comparable areas of telangiectasias on the lateral aspect of the thigh (C1AorS EP AS1 PN ) were randomized to wear medical compression stockings (23 to 32 mm Hg) daily for 3 weeks or no such treatment following a single session of standardized liquid sclerotherapy. Outcome was assessed by patient satisfaction analysis and quantitative evaluation of photographs taken from the lateral aspect of the thigh before and again at 52 days on the average after sclerotherapy by two blinded expert reviewers. Patients completed a quality of life questionnaire (SF-36) before treatment and again at the control. Results Data of 96 of 100 randomized patients could be evaluated. Patient satisfaction with the outcome of treatment was similar in the two groups. Objective assessment of clinical vessel disappearance revealed a benefit of wearing stockings ( P = .026) corresponding to a NNT (number needed to treat) of 4.7 patients to get a vessel disappearance score higher than 6. The interobserver agreement was very high (intraclass correlation coefficient = 0.93). Compression was well tolerated with a low rate of discomfort claims (mean 17.5%). Micro-thrombi were rarely observed in either group, but still less prevalent in the compression group. The rate of pigmentation and matting was low and did not differ significantly between the two groups. Physical and mental quality of life scores in women seeking treatment of telangiectasias were similar to those of a healthy control population. Treatment had no impact on general quality of life. Conclusion Wearing compression stockings (23 to 32 mm Hg) for 3 weeks enhance the efficacy of sclerotherapy of leg telangiectasias by improving clinical vessel disappearance.
PDF
