Use of personal medical records for research purposes

Copper concentrations are prevalently associated with antithrombin III, but also with prothrombin time and fibrinogen in patients with liver cirrhosis: A cross-sectional retrospective study

BACKGROUND

Concerning the link between copper excess and the pathogenesis of chronic liver diseases, its retention is reckoned to develop as a complication of cholestasis. Recently, it has been found that cholestatic liver injury involves largely inflammatory cell-mediated liver cell necrosis, with consequent reduced hepatic mass, more than occurring through direct bile acid-induced apoptosis. On the other hand, interference with protein synthesis could be expected to result, ending in an altered ability of the liver to retain copper. Little is known about the association between serum copper and clotting factors in cirrhotics. We aimed at studying a possible relationship between increased levels of copper and an aspect of the haemostatic process in liver cirrhosis patients, assessing an index of protein synthesis (albumin) and parameters of protein synthesis/coagulation/fibrinolysis, such as prothrombin time (PT), antithrombin (AT) III and fibrinogen.

METHODS

Records from 85 patients suffering from liver cirrhosis of various aetiology and different severity were retrospectively examined. Serum concentrations of copper were determined by atomic absorption spectrophotometer. An index of protein synthesis, such as albumin and parameters of both synthesis and coagulation/hypercoagulation such as PT %, AT III%, levels of fibrinogen were taken into account to study possible correlations to serum copper. The severity of cirrhosis was evaluated by the Child-Pugh (C-P) classification. The relationship among variables were studied by linear regression.

RESULTS

Copper levels of patients suffering from liver cirrhosis were increased respect to those of controls, 102.7+/-28.7 versus 80.4+/-19.5 mcg/dL, (P = .0009), independently from disease severity, and were positively predicted by PT% (P = 0. 017), fibrinogen (P = 0.007) and AT III% (P = 0.000), at linear regression. Among the previous parameters, to which serum albumin was added, the unique predictor of copper levels was AT III%, at multiple regression (P = 0. 010); AT III% was negatively predicted by the C-P classification (P = 0.000); copper levels, adjusted for C-P classification, were predicted by AT III% (P = 0.020) and fibrinogen concentrations, but not by PT% (P = 0.09).

CONCLUSION

The copper concentration is reckoned as responsible for production of the hydroxyl radicals. On the basis that oxidants may enhance the activity of the extrinsic coagulation cascade, ultimately leading to thrombin formation, via their combined effects on stimulation of tissue factor activity and inhibition of fibrinolytic pathways, the positive relationship of copper to coagulation/hypercoagulation parameters (mainly AT III) in our research could find a plausible interpretation.

Can patients with low health literacy be identified from routine primary care health records? A cross-sectional and prospective analysis

Background

People with low health literacy (HL) are at increased risk of poor health outcomes, and receive less benefit from healthcare services. However, healthcare practitioners can effectively adapt healthcare information if they are aware of their patients’ HL. Measurements are available to assess HL levels but may not be practical for use within primary care settings. New alternative methods based on demographic indicators have been successfully developed, and we aim to test if such methodology can be applied to routinely collected consultation records.

Methods

Secondary analysis was carried out from a recently completed prospective cohort study that investigated a primary care population who had consulted about a musculoskeletal pain problem. Participants completed questionnaires (assessing general health, HL, pain, and demographic information) at baseline and 6 months, with linked data from the participants’ consultation records. The Single Item Literacy Screener was used as a benchmark for HL. We tested the performance of an existing demographic assessment of HL, whether this could be refined/improved further (using questionnaire data), and then test the application in primary care consultation data. Tests included accuracy, sensitivity, specificity, and area under the curve (AUC). Finally, the completed model was tested prospectively using logistic regression producing odds ratios (OR) in the prediction of poor health outcomes (physical health and pain intensity).

Results

In total 1501 participants were included within the analysis and 16.1% were categorised as having low HL. Tests for the existing demographic assessment showed poor performance (AUC 0.52), refinement using additional components derived from the questionnaire improved the model (AUC 0.69), and the final model using data only from consultation data remained improved (AUC 0.64). Tests of this final consultation model in the prediction of outcomes showed those with low HL were 5 times more likely to report poor health (OR 5.1) and almost 4 times more likely to report higher pain intensity (OR 3.9).

Conclusions

This study has shown the feasibility of the assessment of HL using primary care consultation data, and that people indicated as having low HL have poorer health outcomes. Further refinement is now required to increase the accuracy of this method.

Research on medical records without informed consent

Observational research involving access to personally identifiable data in medical records has often been conducted without informed consent, owing to practical barriers to soliciting consent and concerns about selection bias. Nevertheless, medical records research without informed consent appears to conflict with basic ethical norms relating to clinical research and personal privacy. This article analyzes the scope of these norms and provides an ethical justification for research using personally identifiable medical information without consent.

The use of personal data from medical records and biological materials: ethical perspectives and the basis for legal restrictions in health research

This paper discusses the moral justification for using personal data without informed consent, from both medical records and biological materials, in research where subjects are not physically present in the study and will never have any contact with the study investigators. Although the idea of waiving the requirement for informed consent in certain investigations has been mentioned in several ethical guidelines formulated by epidemiologists and physicians since the late 1980s, these guidelines are now of limited use due to legal restrictions on the use of personal data in most western countries. Several misconceptions that form the basis for legal restriction of health research are discussed: lack of knowledge of the need to link personal information from health services with personal information produced outside the health system in many biomedical investigations; the assumption of a deterministic model of disease causation in which the prediction of disease occurrence is based on a genetic association despite the fact that most genotypes for common diseases are incompletely penetrant; the lack of a logical rationale for the recommendation in the Declaration of Helsinki that only research that offers some benefit to study subjects is justified; the great lack of knowledge about research methodology revealed in some alternatives proposed to avoid using personal data; and the lack of a debate about the ethical double standard of institutions and investigators in countries that prohibit the use of personal data but finance and carry out studies in other countries where it is permitted.

Public attitudes towards the use of primary care patient record data in medical research without consent: a qualitative study

OBJECTIVES

Recent legislative changes within the United Kingdom have stimulated professional debate about access to patient data within research. However, there is currently little awareness of public views about such research. The authors sought to explore attitudes of the public, and their lay representatives, towards the use of primary care medical record data for research when patient consent was not being sought.

METHODS

49 members of the public and four non-medical members of local community health councils in South Wales, UK gave their views on the value and acceptability of three current research scenarios, each describing access to data without patient consent.

RESULTS

Among focus group participants, awareness of research in primary care was low, and the appropriateness of general practitioners as researchers was questioned. There was general support for research but also concerns expressed about data collection without consent. These included lack of respect and patient control over the process. Unauthorised access to data by external agencies was a common fear. Current data collection practices, including population based disease registers elicited much anxiety. The key informants were equally critical of the scenarios and generally less accepting.

CONCLUSIONS

This exploratory study has highlighted a number of areas of public concern when medical records are accessed for research without patient consent. Public acceptability regarding the use of medical records in research cannot simply be assumed. Further work is required to determine how widespread such views are and to inform those advising on confidentiality issues.

The use of medical records in research: what do patients want?

In the past ten years, there has been growing interest in and concern about protecting the privacy of personal medical information. Insofar as medical records increasingly are stored electronically, and electronic information can be shared easily and widely, there have been legislative efforts as well as scholarly analyses calling for greater privacy protections to ensure that patients can feel safe disclosing personal information to their health-care providers. At the same time, the volume of biomedical research conducted in this country continues to grow. The budget of the National Institutes of Health, for example, was $20,298 million in 2001, having more than doubled from a budget of $9,218 million 10 years before. This growing body of research includes increased efforts to use stored medical records as a source of data for health services, epidemiologic, and clinical studies.

Methodology used for "software for automated linkage in Italy" (SALI)

Linkage of epidemiological registries can provide cost-effective information on the associations between different diseases or exposures in the population under study and on completeness of surveillance system databases. We describe the program SALI (software for automated linkage in Italy) aimed at matching individual records from medium-sized registries (in the order of 100,000 records), where the desired outcome is to miss as few links as possible and, because of low link-likelihood (< 1%), a manual revision of matched pairs is feasible. SALI, developed in CA-Clipper language, uses registry files in dBase format. It requires only name, surname, and date of birth as key fields, and it allows for spelling errors in Italian or other Latin languages through a specific algorithm. Furthermore, a double-blind procedure ensures data confidentiality. The main linkage procedure is based on four stages, two automatic ones, and two where the operator can decide through specific windows whether to accept stage-selected matches. SALI takes into account possible errors in key fields thus reducing false negatives. It was used to solve the problem of linkage between AIDS and cancer registries in Italy. It can be used with every IBM-compatible computer system, assuring uniquely high portability.

A review of methodologies for assessing drug effectiveness and a new proposal: randomized database studies

The need to evaluate the effects of health technologies in clinical practice is increasingly important. In this article, we review the advantages and limitations of naturalistic randomized clinical trials (RCTs) and database analyses, the two primary methods for evaluating treatment effectiveness. Also, we comment on a newer research strategy, cross-design synthesis, which proposes the complementary use of both experimental RCTs and observational database methodologies to avoid the main weaknesses of each: respectively, the lack of external and internal validity. Finally, we propose a new strategy--randomized database studies--capable of generating results with an acceptable balance between internal and external validity. This strategy consists of the simultaneous use of both experimental and observational tools in the assessment of drugs' effectiveness. Randomization is essential to minimize comparison bias, and one possibility for such studies is that randomization modules could be included in computer-based patient records. Although we identify some of the difficulties in implementing the process, the progressive standardization of clinical practice and the development and widespread adoption of improved computer-based patient records could facilitate the use of randomized database studies as a new method of research.

Medical record confidentiality law, scientific research, and data collection in the information age

Author reviews U.S. federal and state laws on privacy and confidentiality on access and disclosure of health records governing government and private sector data bases. He also examines legislative proposals and recommendations for privacy and confidentiality now before the U.S. Congress.

Acquisition and use of clinical data for audit and research

Acquisition of adequate patient data for clinical management is hard enough, but higher quality patient data are needed for clinical audit and research. This article discusses some of the problems of using routine clinical data for audit and research, aspects of data quality, sources of audit or research data and their problems, methods for improving data quality, the benefits and problems of computer-based systems and current trends in the capture and processing of clinical data.