Patient-Facing Clinical Decision Support for High Blood Pressure Control: Patient Survey

BACKGROUND

High blood pressure (HBP) affects nearly half of adults in the United States and is a major factor in heart attacks, strokes, kidney disease, and other morbidities. To reduce risk, guidelines for HBP contain more than 70 recommendations, including many related to patient behaviors, such as home monitoring and lifestyle changes. Thus, the patient's role in controlling HBP is crucial. Patient-facing clinical decision support (CDS) tools may help patients adhere to evidence-based care, but customization is required.

OBJECTIVE

Our objective was to understand how to adapt CDS to best engage patients in controlling HBP.

METHODS

We conducted a mixed methods study with two phases: (1) survey-guided interviews with a limited cohort and (2) a nationwide web-based survey. Participation in each phase was limited to adults aged between 18 and 85 years who had been diagnosed with hypertension. The survey included general questions that assessed goal setting, treatment priorities, medication load, comorbid conditions, satisfaction with blood pressure (BP) management, and attitudes toward CDS, and also a series of questions regarding A/B preferences using paired information displays to assess perceived trustworthiness of potential CDS user interface options.

RESULTS

We conducted 17 survey-guided interviews to gather patient needs from CDS, then analyzed results and created a second survey of 519 adults with clinically diagnosed HBP. A large majority of participants reported that BP control was a high priority (83%), had monitored BP at home (82%), and felt comfortable using technology (88%). Survey respondents found displays with more detailed recommendations more trustworthy (56%-77% of them preferred simpler displays), especially when incorporating social trust and priorities from providers and patients like them, but had no differences in action taken.

CONCLUSIONS

Respondents to the survey felt that CDS capabilities could help them with HBP control. The more detailed design options for BP display and recommendations messaging were considered the most trustworthy yet did not differentiate perceived actions.

SOCIAL SUPPORT AND STRAIN AS PREDICTORS OF MULTIMORBIDITY FOLLOWING A MARITAL TRANSITION

Marital transitions (MTs; widowhood or divorce) are stressful events that impact the health of older adults. This study examined the impact of social support and social strain on multimorbidity trajectories using data from the Health and Retirement Study (HRS). Participants were 377 adults age 50+ with a single MT between years 2006 and 2016. We used piecewise growth curve modeling to investigate whether social support and strain from one’s spouse, children, family, or friends, measured prior to transition, predicted trajectories of chronic conditions (count of 8 conditions: hypertension, diabetes, cancer, lung disease, heart disease, stroke, arthritis, and cognitive impairment) following MT. Covariates included sex, age, education, race/ethnicity, and wealth. On average, chronic conditions were increasing before MT, B = .172, SE = .021, p < .001, and after MT, B = .211, SE = .031, p <.001. Participants had an average of 2.2 chronic conditions at MT. Spousal support prior to MT was associated with fewer chronic conditions at MT, B = -.863, SE = .427, p = .043, whereas support and social strain from friends were each associated with more chronic conditions at MT (support: B = .772, SE = .354, p = .025; strain: B = 1.288, SE = .387, p = .001). Support from children was positively associated with more chronic conditions following MT, B = .212, SE = .084, p = .011, which may reflect adult children providing support in response to parental health decline.

MULTIMORBIDITY PROGRESSION AMONG MEDICARE BENEFICIARIES IN THE HEALTH AND RETIREMENT STUDY (1991–2015)

Older adults are at greater risk for developing and accumulating multimorbidity (2+ chronic conditions). This study describes the characteristics of older adults with multimorbidity using Medicare claims over a 24-year period. The HRS-Medicare data (1991-2015, N=17,199, age 67+ years) were used in descriptive analyses. We identified 8,800 (51%) beneficiaries who did not have multimorbidity at first observation (no multimorbidity), 6,270 (36%) with 2-4 conditions at the first observation (low multimorbidity), and 2,129 (12%) with 5+ conditions at the first observation (high multimorbidity). Older respondents (80+ years) had lower levels of multimorbidity at baseline compared with younger respondents (< 70 years); this appeared to be related to differences by birth cohort. Higher proportions of minoritized groups had high multimorbidity (15% non-Hispanic Black; 20% Hispanic; 11% non-Hispanic White). Despite only being 22% of the entire sample, persons with obese body mass index (>30) represented 41% of the high multimorbidity group. Higher incidence rates of disease accumulation were noted for Black (89/1,000 person years [py]) and Hispanic (94/1,000 py) compared with White respondents (82/1,000 py) in the high multimorbidity group. Hospitalization and ED rates increased linearly between the low and high multimorbidity groups. Functional loss was more prevalent in the high multimorbidity group compared with the no multimorbidity group; no difference was observed between no and low multimorbidity. Results highlight sociodemographic differences between Medicare fee-for-service beneficiaries with differing levels of multimorbidity, allowing new insights to guide interventions that address burdensome changes in late life.

Clinical, social, and policy factors in COVID-19 cases and deaths: methodological considerations for feature selection and modeling in county-level analyses

BACKGROUND

There is a need to evaluate how the choice of time interval contributes to the lack of consistency of SDoH variables that appear as important to COVID-19 disease burden within an analysis for both case counts and death counts.

METHODS

This study identified SDoH variables associated with U.S county-level COVID-19 cumulative case and death incidence for six different periods: the first 30, 60, 90, 120, 150, and 180 days since each county had COVID-19 one case per 10,000 residents. The set of SDoH variables were in the following domains: resource deprivation, access to care/health resources, population characteristics, traveling behavior, vulnerable populations, and health status. A generalized variance inflation factor (GVIF) analysis was used to identify variables with high multicollinearity. For each dependent variable, a separate model was built for each of the time periods. We used a mixed-effect generalized linear modeling of counts normalized per 100,000 population using negative binomial regression. We performed a Kolmogorov-Smirnov goodness of fit test, an outlier test, and a dispersion test for each model. Sensitivity analysis included altering the county start date to the day each county reached 10 COVID-19 cases per 10,000.

RESULTS

Ninety-seven percent (3059/3140) of the counties were represented in the final analysis. Six features proved important for both the main and sensitivity analysis: adults-with-college-degree, days-sheltering-in-place-at-start, prior-seven-day-median-time-home, percent-black, percent-foreign-born, over-65-years-of-age, black-white-segregation, and days-since-pandemic-start. These variables belonged to the following categories: COVID-19 related, vulnerable populations, and population characteristics. Our diagnostic results show that across our outcomes, the models of the shorter time periods (30 days, 60 days, and 900 days) have a better fit.

CONCLUSION

Our findings demonstrate that the set of SDoH features that are significant for COVID-19 outcomes varies based on the time from the start date of the pandemic and when COVID-19 was present in a county. These results could assist researchers with variable selection and inform decision makers when creating public health policy.

Synergies between centralized and federated approaches to data quality: a report from the national COVID cohort collaborative

OBJECTIVE

In response to COVID-19, the informatics community united to aggregate as much clinical data as possible to characterize this new disease and reduce its impact through collaborative analytics. The National COVID Cohort Collaborative (N3C) is now the largest publicly available HIPAA limited dataset in US history with over 6.4 million patients and is a testament to a partnership of over 100 organizations.

MATERIALS AND METHODS

We developed a pipeline for ingesting, harmonizing, and centralizing data from 56 contributing data partners using 4 federated Common Data Models. N3C data quality (DQ) review involves both automated and manual procedures. In the process, several DQ heuristics were discovered in our centralized context, both within the pipeline and during downstream project-based analysis. Feedback to the sites led to many local and centralized DQ improvements.

RESULTS

Beyond well-recognized DQ findings, we discovered 15 heuristics relating to source Common Data Model conformance, demographics, COVID tests, conditions, encounters, measurements, observations, coding completeness, and fitness for use. Of 56 sites, 37 sites (66%) demonstrated issues through these heuristics. These 37 sites demonstrated improvement after receiving feedback.

DISCUSSION

We encountered site-to-site differences in DQ which would have been challenging to discover using federated checks alone. We have demonstrated that centralized DQ benchmarking reveals unique opportunities for DQ improvement that will support improved research analytics locally and in aggregate.

CONCLUSION

By combining rapid, continual assessment of DQ with a large volume of multisite data, it is possible to support more nuanced scientific questions with the scale and rigor that they require.

Joint Trajectories of Multimorbidity, Function, Cognition, and Depression in the HRS (1998-2016)

There is substantial heterogeneity in the impact of multimorbidity on functional, cognitive, and emotional health. Few studies, however, have examined this simultaneously across these multiple domains. We used finite mixture modeling to identify latent clusters of individuals following similar joint trajectories of multimorbidity, functional ability, cognitive performance, and depressive symptoms among 11,841 HRS respondents aged 65+ from 1998 to 2014. We identified four distinct clusters of joint trajectories: (1) 32.5% of the sample were characterized by low multimorbidity (mean = 0.60 conditions at age 65; 2.2 conditions at age 90), minimal deterioration in functional or cognitive ability, and low depressive symptoms; (2) 33.5%, had increased multimorbidity compared with the first group (mean = 2.3 at age 65; 4.0 at age 90) but minimal functional or cognitive impairment and low depressive symptoms; (3) 19.9%, had relatively low multimorbidity (mean = 1.3 at age 65 increasing to 2.8 at age 90), but exhibited worsening cognitive performance, increasing functional limitations, and moderate depressive symptoms ; and (4) 14.1%, had higher multimorbidity (mean = 3.3 at age 65 increasing to 4.6 at age 90), worsening cognitive performance, substantial functional limitation, and high depressive symptoms. Black and Hispanic race/ethnicity, lower levels of income and education, male gender, and smoking history were significantly associated with membership in classes characterized by higher multimorbidity, cognitive and functional impairment, and greater depressive symptoms. This study provides insight into the heterogenous trajectories of aging and helps identify older individuals at higher risk for poor aging outcomes across multiple health domains.

Social Support and Social Strain as Predictors of Depressive Symptom Trajectories Following a Marital Transition

We investigated trajectories of depressive symptoms over 10 years following a marital transition (widowed or divorced) using data from the Health and Retirement Study (N = 377, mean age = 67.55 years; years 2006-2016). Piecewise growth curve models were estimated to investigate whether social support and strain from one’s spouse, measured prior to transition, predicted depressive symptom trajectories following the transition. Covariates included sex, age, education, race/ethnicity, wealth, and chronic conditions. Overall, trajectories of depressive symptoms after a marital transition were significantly negative, indicating a decrease in depressive symptoms over time. Findings did not differ significantly between participants who were widowed and those who were divorced. Spousal social support was associated with an increase in depressive symptoms and spousal social strain was associated with a decrease in depressive symptoms following a marital transition in separate models: support: b = .250, SE = .062, p <.001; strain: b = -.209, SE = .095, p <.05. However, social strain was not significant when examined jointly with social support. Depressive symptoms declined significantly for low (b = -.370, SE = .100, p <.001) and average levels of social support (b = -.113, SE = .037, p <.01), but not for high levels of spouse social support (b = .143, SE = .109, p = .188). These results suggest those with the highest levels of spousal support prior to the transition, whether divorced or widowed, experienced a more difficult recovery and may be targets for additional mental health support following a marital transition.

Multimorbidity Trajectory Classes as Predicted by Race, Ethnicity, and Social Relationship Quality

Growth mixture modeling was used to classify multimorbidity (≥2 chronic conditions) trajectories over a 10-year period (2006-2016) in the Health and Retirement Study (N = 7,151, mean age = 68.6 years). Race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White) and social relationship quality (positive social support and negative social exchanges, such as criticisms) were then used to predict trajectory class membership, controlling for age, sex, education, and wealth. We identified three trajectory classes: initial low levels and rapid accumulation of multimorbidity (increasing: 12.6%), initial high levels and gradual accumulation of multimorbidity (high: 19.5%), and initial low levels and gradual accumulation of multimorbidity (low: 67.9%). Blacks were more than twice as likely to be in the increasing (OR = 2.04, CI[1.29,3.21]) and high (OR = 2.28 CI[1.58,3.206]) multimorbidity groups compared with Whites, but there were no significant differences between Hispanics and Whites for either trajectory class (OR = .84 CI[.47,1.51]and OR = .74 CI[.41,1.34], respectively). Increments in perceived support were associated with significantly lower risk of membership in the increasing (OR = .59, CI[.46,.78]) and high classes (OR = .54 CI[.42,.69]), and increments in negative exchanges were associated with significantly higher risk of membership in the increasing (OR = 1.64 CI[1.19,2.25]) and high classes (OR = 2.22 CI[1.64,3.00]). These results provide important new information for understanding health disparities and the role of social relationships associated with multimorbidity in middle and later life that may aid in identifying those most at risk and suggesting possible interventions for mitigating that risk.

Multimorbidity Progression among Medicare Beneficiaries in the Health and Retirement Study (1992-2014)

Older adults are at greater risk for developing and accumulating multimorbidity, defined as 2 or more chronic diseases. This study describes the characteristics of multimorbidity progression-based groups using Medicare claims chronic condition warehouse algorithms over a 24-year period. The HRS-Medicare linked data (1991-2015, N=17,895, age 67 years and older) were used in descriptive analyses presented as a Sankey flow diagram. We identified 1,293 (7.2%) beneficiaries who had not yet developed multimorbidity by the end of the observation period (no multimorbidity), 7,552 (42.2%) who started without but developed multimorbidity over the course of observation (incident multimorbidity), and 9,050 (50.6%) who had multimorbidity upon study entry (prevalent multimorbidity). There were notable differences between multimorbidity progression-based groups. Beneficiaries with prevalent multimorbidity were younger at baseline (73.1% in youngest age category [67-69] vs. 50.3% for incident and 66.7% for no multimorbidity), had proportionately higher levels of cognitive impairment (21.6% CIND/dementia vs. 15.4% for incident and 16.8% for no multimorbidity), and greater mean levels of functional impairment and healthcare utilization. Non-Hispanic Black beneficiaries were more represented in prevalent multimorbidity (15.4%) than in the incident (11.8%) and no multimorbidity groups (13.4%). Non-Hispanic White beneficiaries were more represented in the incident (83.5%) than the prevalent (77.2%) and the no multimorbidity (77.7%). Hispanic beneficiaries were more represented in the no (8.9%) than the prevalent (7.4%) and incident multimorbidity groups (4.7%). Results highlight beneficiaries who experience clinically-meaningful transitions to multimorbidity states in late life, allowing new insights and informing interventions to address burdensome changes to their chronic disease status.

Clinical research during the COVID-19 pandemic: The role of virtual visits and digital approaches

Clinical trials are a fundamental tool in evaluating the safety and efficacy of new drugs, medical devices, and health system interventions. Clinical trial visits generally involve eligibility assessment, enrollment, intervention administration, data collection, and follow-up, with many of these steps performed during face-to-face visits between participants and the investigative team. Social distancing, which emerged as one of the mainstay strategies for reducing the spread of SARS-CoV-2, has presented a challenge to the traditional model of clinical trial conduct, causing many research teams to halt all in-person contacts except for life-saving research. Nonetheless, clinical research has continued during the pandemic because study teams adapted quickly, turning to virtual visits and other similar methods to complete critical research activities. The purpose of this special communication is to document this rapid transition to virtual methodologies at Clinical and Translational Science Awards hubs and highlight important considerations for future development. Looking beyond the pandemic, we envision that a hybrid approach, which implements remote activities when feasible but also maintains in-person activities as necessary, will be adopted more widely for clinical trials. There will always be a need for in-person aspects of clinical research, but future study designs will need to incorporate remote capabilities.

Physical Activity as a Mediator in the Relationship Between Race or Ethnicity and Changes in Multimorbidity

Racial/ethnic disparities in multimorbidity (≥2 chronic conditions) and their rate of accumulation over time have been established. Studies report differences in physical activity across racial/ethnic groups. We investigated whether racial/ethnic differences in accumulation of multimorbidity over a 10-year period (2004-2014) were mediated by physical activity using data from the Health and Retirement Study (N = 10,724, mean age = 63.5 years). Structural equation modeling was used to estimate a latent growth curve model of changes in the number of self-reported chronic conditions (of nine) and investigate whether the relationship of race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White) to change in the number of chronic conditions was mediated by physical activity after controlling for age, sex, education, marital status, personal wealth, and insurance coverage. Results indicated that Blacks engaged in significantly lower levels of physical activity than Whites (b = -.171, □ = -.153, p < .001), but there were no differences between Hispanics and Whites (b = -.010, □ = -.008, ns). Physical activity also significantly predicted both lower initial levels of multimorbidity (b = -1.437, □ = -.420, p < .001) and greater decline in multimorbidity (b = -.039, □ = -.075, p < .001). The indirect (mediational) effect for the Black vs. White comparison was significant (b = .007, □ = .011, 95% CI [.004,.010]). These results provide important new information for understanding how modifiable lifestyle factors may help explain disparities in multimorbidity in middle and later life, suggesting greater need to reduce sedentary behavior and increase activity.

Racial or Ethnic and Multimorbidity Differences in Functional Limitation Trajectories Among Older Americans

Racial/ethnic minority groups in the U.S. are at risk for greater co-existing chronic disease (multimorbidity) burden and experience greater functional limitations relative to non-Hispanic white peers. To target programs designed to preserve functional independence, this study aims to identify temporal trends of functional limitation among race/ethnic groups and within the context of multimorbidity. Data from the Health & Retirement Study (2000-2014, N=16,959, 65 years of age and older, community-dwelling adults) were used in generalized estimating equation (GEE) models to assess changes in functional limitations over time (combined activities of daily living [ADL] and instrumental activities of daily living [IADL], range 0-11). Models were adjusted for race/ethnicity (non-Hispanic black, Hispanic, non-Hispanic white), self-reported chronic disease categories (no/one, ≥2 somatic, somatic-depression; of arthritis, cancer, diabetes, heart disease, high depressive symptoms [CES-D8≥4], hypertension, lung disease, stroke), age at baseline, sex, body-mass index, education, partnered, net worth, and time. In adjusted GEE models, Hispanic and black respondents experience 1.4 times greater counts of functional limitations, respectively, relative to white respondents (incidence rate ratio [IRR]= 1.4, 95% CI[1.17, 1.66], IRR=1.4, CI[1.26, 1.61]); however, temporal trends were similar. With regard to multimorbidity categories, somatic or somatic-depression multimorbidity were each associated with 2.2 or 3.5 times greater functional limitations, respectively, relative to having no/one condition (IRR=2.2, CI[2.06, 2.39], IRR=3.5, CI[3.18, 3.74]). There are marked differences in functional limitation levels between minority ethnic and white groups, as well as among chronic disease combination groups, suggesting the need to intervene in middle-age to reduce disparities.

Multimorbidity Accumulation by Race or Ethnicity and Body-Weight Status Among Middle-Aged and Older Americans

Obesity and multimorbidity are more prevalent among U.S. racial/ethnic minority groups. Evaluating racial/ethnic disparities in multimorbidity accumulation according to body-mass index (BMI) may guide interventions to reduce multimorbidity burden in vulnerable racial/ethnic groups. Data from the 1998-2016 Health & Retirement Study (N=8,106, 51-55 years at baseline) and generalized estimating equations models with inverse probability weights estimated the accumulation of seven chronic diseases (arthritis, cancer, diabetes, heart disease, hypertension, lung disease, and stroke) between racial/ethnic groups [Non-Hispanic White (reference; 64.2%), Non-Hispanic Black (21.6%), Hispanic (14.2%)]. Overweight and obesity were more prevalent in Black (82.3%) and Hispanic (78.9%) than White (70.9 %) participants at baseline. Initial burden of morbidity was higher among Black participants [risk ratio (RR) =1.3, p<0.001] but similar among Hispanic compared with White participants; and higher in overweight or greater BMI categories compared with normal BMI (RR=1.07, 1.15, 1.22, p<0.001, for overweight, obese 1, and obese 2/3 BMI, respectively). Disease accumulation did not differ among racial/ethnic groups. Higher BMI was associated with less disease accumulation compared with the normal BMI category (RR=0.99, 0.98, 0.97, all p<0.001, for overweight, obese 1, and obese 2/3 BMI, respectively, per two-year interval). Black participants crossed the threshold of multimorbidity (≥2 diseases) 4-6 years earlier than White and Hispanic participants. There are substantial differences in initial disease burden between Black and White middle-aged/older adults, but not in the accumulation of disease, suggesting the need to intervene prior to entering middle age to reduce disparities in the burden of multimorbidity among vulnerable racial minorities.

Identifying Patients with Significant Problems Related to Social Determinants of Health with Natural Language Processing

Social and behavioral factors influence health but are infrequently recorded in electronic health records (EHRs). Here, we demonstrate that psychosocial vital signs can be extracted from EHR data. We processed structured and unstructured EHR data using expert-driven queries and Natural Language Processing (NLP), validating results through structured annotation. We found that although these vital signs are present in EHRs, with 681 structured entries identified for psychosocial concepts, NLP identified a nearly 90-fold increase in patients.

Protocol for a Cluster Randomized Trial Comparing Team-Based to Clinician-Focused Implementation of Advance Care Planning in Primary Care

Introduction: For many patients, primary care is an appropriate setting for advance care planning (ACP). ACP focuses on what matters most to patients and ensuring health care supports patient-defined goals. ACP may involve interactions between a clinician and a patient, but for seriously ill patients ACP could be managed by a team. Methods: We are conducting a cluster randomized trial comparing team-based to clinician-focused ACP using the Serious Illness Care Program (SICP) in 42 practices recruited from 7 practice-based research networks (PBRNs). Practices were randomized to one of the two models. Patients are referred to the study after engaging in ACP in primary care. Our target enrollment is 1260 subjects. Patient data are collected at enrollment, six months and one year. Primary outcomes are patient-reported goal-concordant care and days at home. Secondary outcomes include additional patient measures, clinician/team experience, and practice-level measures of SICP implementation. Study Implementation: This trial was designed and is conducted by the Meta-network Learning and Research Center (Meta-LARC), a consortium of PBRNs focused on integrating engagement with patients, families, and other stakeholders into primary care research and practice. The trial pairs a comparative effectiveness study with implementation of a new program and is designed to balance fidelity to the assigned model with flexibility to allow each practice to adapt implementation to their environment and priorities. Our dissemination will report the results of comparing the two models and the implementation experience of the practices to create guidance for the spread of ACP in primary care.

The effectiveness of a secure email reminder system for colorectal cancer screening

This study looks at the effectiveness of using a secure email system linked to an electronic health record to send reminders to patients in an effort to increase colorectal cancer (CRC) screening rates; 1397 subjects were randomized to receive usual care, a letter reminder or an email reminder which invited patients to pick up a fecal occult blood test at the lab for CRC screening. The number of completed CRC screenings was tallied after a 3 month study period. Rates of CRC screening in the 3 groups were 7.8% in the usual care group, 23.6% in the letter reminder group and 22.7% in the email group. Significant statistical difference was seen between usual care group and letter reminders (p<0.0005) and between usual care and email reminders (p<0.0005) but not between the letter reminders and the email reminders (p=7.11). Email reminders are as effective as letter reminders in increasing CRC screening rates.

New IRB guidelines: Will cancer patient safety improve?

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Background: Beginning in the 1990s, drug companies increasingly sent reports of all serious adverse events (AEs) to any Institutional Review Board (IRB) overseeing a trial using the agent involved, whether or not the same study was underway at that IRB site and regardless of the likelihood of a causal link between the event and agent. This led to a flood of AE reports and a small signal-to-noise ratio. Recent federal draft guidance emphasizes that regulations require investigators to notify IRBs only when there are “unanticipated problems involving risks to subjects or others. Consequently, many IRBs relaxed their reporting requirements, focusing only on unanticipated events. The objective of this study is to estimate how adoption of the new guidance affects IRB workload and patient safety. Methods: We reviewed AEs reported since 2004 to the IRB at Oregon Health & Science University for eight oncology drugs: bevacizumab, gefitinib, imatinib mesylate, oxaliplatin, bortezomib, sorafenib, sunitinib, and cetuximab. We defined unanticipated AE as any AE not included in the patient consent forms. Results: Forty-seven studies were reviewed with 885 unique AEs reported for the eight drugs. Of these, 494 were unanticipated, meaning the event was not described in the consent form. Thus, the IRB workload would decrease by 44% under the new guidance. Twenty-six AEs led to actual consent form changes, suggesting these signal events represented serious, related, but previously unknown toxicities of the study drug. This led to a signal-to-noise ratio improvement from 3% to 5.3%. For imatinib mesylate, the signal-to-noise ratio improved from 4.1% (14 signals out of 339 reports) to 7.8% (14 signals out of 179 reports), the largest improvement of the drugs studied. Conclusions: These results suggest that adoption of the new guidance may improve signal detection capabilities of local IRBs while decreasing workload. More empirical evidence is needed to ensure patient safety. Enhanced pharmacovigilance practices at the IRB level should lead to improved detection of serious AEs during clinical trials - before the drug is approved and widely available to veterans. In addition, improving the signal-to-noise ratio should allow IRBs to improve the welfare of cancer research subjects.

[Table: see text]

Informatics systems to promote improved care for chronic illness: a literature review

OBJECTIVE

To understand information systems components important in supporting team-based care of chronic illness through a literature search.

DESIGN

Systematic search of literature from 1996-2005 for evaluations of information systems used in the care of chronic illness.

MEASUREMENTS

The relationship of design, quality, information systems components, setting, and other factors with process, quality outcomes, and health care costs was evaluated.

RESULTS

In all, 109 articles were reviewed involving 112 information system descriptions. Chronic diseases targeted included diabetes (42.9% of reviewed articles), heart disease (36.6%), and mental illness (23.2%), among others. System users were primarily physicians, nurses, and patients. Sixty-seven percent of reviewed experiments had positive outcomes; 94% of uncontrolled, observational studies claimed positive results. Components closely correlated with positive experimental results were connection to an electronic medical record, computerized prompts, population management (including reports and feedback), specialized decision support, electronic scheduling, and personal health records. Barriers identified included costs, data privacy and security concerns, and failure to consider workflow. CONCLUSION The majority of published studies revealed a positive impact of specific health information technology components on chronic illness care. Implications for future research and system designs are discussed.

Durable treatment-free remission after high-dose cyclophosphamide therapy for previously untreated severe aplastic anemia

BACKGROUND

Severe aplastic anemia is a life-threatening bone marrow failure disorder. High-dose cyclophosphamide therapy followed by allogeneic bone marrow transplantation cures the disease. However, it requires a suitable donor and carries the risk for graft-versus-host disease. A small pilot study demonstrated that high-dose cyclophosphamide therapy without bone marrow transplantation leads to durable, treatment-free complete remission.

OBJECTIVE

To confirm the safety and efficacy of high-dose cyclophosphamide therapy alone in patients with severe aplastic anemia.

DESIGN

Uncontrolled clinical trial.

SETTING

Three tertiary care hospitals.

PATIENTS

19 patients with untreated severe aplastic anemia.

INTERVENTION

Cyclophosphamide, 50 mg/kg of body weight per day for 4 consecutive days.

MEASUREMENTS

Probability of response and overall survival were measured. Complete remission was defined as normal blood count for age and sex. Partial remission was defined as independence from transfusion and an absolute neutrophil count greater than 0.5 x 10(9) cells/L without growth factor support. Nonresponders were patients who remained transfusion dependent or died. Relapse was defined as no longer meeting criteria for partial or complete remission.

RESULTS

The median time to an absolute neutrophil count of 0.5 x 10(9) cells/L was 49 days. The probability of survival was 84% (95% CI, 59% to 95%) at 24 months. The probability of achieving treatment-free remission was 73% (CI, 51% to 91%) at 24 months, and the probability of achieving complete remission was 65% (CI, 39% to 89%) at 50 months. No responding patients have had relapse or have developed secondary clonal disorders.

CONCLUSIONS

High-dose cyclophosphamide therapy without bone marrow transplantation produces durable treatment-free remission in severe aplastic anemia. This approach deserves further study in patients with severe aplastic anemia who are not suitable candidates for allogeneic bone marrow transplantation.

Concordance of parapapillary chorioretinal atrophy in ocular hypertension with visual field defects that accompany glaucoma development

OBJECTIVE

To determine whether the extent and location of progressive parapapillary chorioretinal atrophy noted in some patients with ocular hypertension are correlated with the extent and location of visual field defects that occur with progression to glaucoma.

STUDY DESIGN

Retrospective cohort study.

PARTICIPANTS

Thirty patients with ocular hypertension who had progressive changes of parapapillary atrophy develop before clinically detectable optic disc or visual field damage.

MAIN OUTCOME MEASURES

Assessment of changes in the parapapillary atrophy and visual field parameters.

METHODS

Baseline and follow-up optic disc photographs and visual field test results were retrospectively analyzed. The relationship between the extent of parapapillary atrophy observed during the ocular hypertension period and initial visual field abnormalities detected after glaucoma development, as well as their spatial relationship, was statistically analyzed.

RESULTS

The extent of progressive changes of the parapapillary atrophy detected during the ocular hypertension period was correlated with the extent of changes in the visual field parameters, including corrected pattern standard deviation and mean deviation measured after glaucoma development (Mantel-Haenszel chi-square test, P = 0.026, P = 0.037, respectively). In addition, the visual field abnormalities occurred in the corresponding quadrants of the progressive parapapillary atrophy. Analysis of the spatial relationship revealed that the location of progressive changes of the parapapillary atrophy was concordant with the location of visual field abnormalities in 78% of the quadrants (94 of 120 quadrants) (chi-square test, P = 0.001).

CONCLUSIONS

The extent and location of visual field abnormalities that develop in ocular hypertensive eyes with progression to glaucoma exhibit a concordance with the extent and location of progressive parapapillary atrophy noted in the ocular hypertension period. This suggests the importance of detailed examination of the parapapillary area in ocular hypertensive eyes.

Approaching psychotherapy of the personality disorders from the Millon perspective

Millon's integrative model for a clinical science begins with a theory that is consistent with current knowledge, establishes a taxonomy for classification, develops a coordinated assessment system, and develops and implements interventions with the guidance of the preceding elements of the model. In recent years, work on the last step of the model, clinical interventions, has accelerated rapidly, and the model now permits the therapist to directly extrapolate specific treatment goals, objective, and techniques to the practice of therapy with the individual patient. This article summarizes how treatment planning and implementation flows logically from the Millon model.

Initial genome scan of the NIMH genetics initiative bipolar pedigrees: chromosomes 1, 6, 8, 10, and 12

A report on an initial genome screen on 540 individuals in 97 families was collected as part of the NIMH Genetics Initiative on Bipolar Disorder. Families were ascertained to be informative for genetic linkage and underwent a common ascertainment and assessment protocol at four clinical sites. The sample was genotyped for 65 highly polymorphic markers from chromosomes 1, 6, 8, 10, and 12. The average intermarker interval was 16 cM. Genotypic data was analyzed using affected sib pair, multipoint affected sib pair, and pedigree analysis methods. Multipoint methods gave lod scores of approximately two on chromosomes 1, 6, and 10. The peak lod score on chromosome 6 occurred at the end of the q-arm, at some distance from the 6p24-22 area previously implicated for schizophrenia. We are currently genotyping additional markers to reduce the intermarker interval around the signals. The interpretation of results from a genome screen of a complex disorder and the problem of achieving a balance between detecting false positive results and the ability to detect genes of modest effect are discussed.

Relationship of trait anxiety to self-esteem of children in grades 4, 5, and 6

This study compared the relation of trait anxiety as measured by the State-Trait Anxiety Inventory for Children and self-esteem as measured by Coopersmith's Self-esteem Inventory in independent samples of children in Grades 4, 5, and 6. Pearson correlations were, respectively, -.51, -.62, and -.71. The differences in correlations between the highest and lowest grades were statistically significant. While trait anxiety and self-esteem summed scores covary robustly, factor analytic studies showed that the two dimensions are largely independent.

The Rorschach Comprehensive System Egocentricity Index in psychiatric inpatients

This paper reports an exploratory study of potential correlates of Exner's Rorschach Egocentricity Index, a measure of self-focusing, in a sample of 70 psychiatric inpatients. We examined the relationship of the Index of the MMPI Ego Strength scale and to other MMPI and Exner Comprehensive System Rorschach variables, using Pearson Product-Moment correlations with partialling of the number of Rorschach responses. There were seven meaningful significant correlations between the Index and Rorschach variables: M, FM, X +%, F +%, Lambda, D, and A%. The Index-MMPI correlations were not significant. Sex differences and differences between these intercorrelations and some reported by Exner (1983) are discussed.

Follow-up of sixty-one physicians after psychiatric treatment

Reported the results of a direct follow-up of 61 physicians who had been hospitalized for emotional impairment during 1969-1978. As of the fall-winter of 1979-1980, 35 physicians were in productive practice; 8 had died of purely medical causes; 5 had committed suicide; 2 were over age 65 and retired; 6 were not practicing for other reasons; 2 were physically disabled; and 3 could not be located. Recovery rate varied from 57% to 71% depending on the criteria used in calculating the ratio. Our outcome rate accords with those reported previously. Interviews with surviving physicians revealed that some important factors in recovery were rest and recuperation; spirituality, AA, and NA; modification in workload; support of colleagues; and constructive use of threat of loss of licensure.

Love and the addicted physician

This paper reviews the cases of two addicted physicians. One is dead and the other alive and well as a result of the heroic and compassionate effort of his friends. We offer speculations regarding the physicians' special vulnerabilities and the role of a tough love in transcending these vulnerabilities.

MMPI profiles of emotionally impaired physicians

Compared MMPI profiles of 36 male physicians hospitalized in a psychiatric institution to MMPI profiles of physicians hospitalized in a drug treatment center and to profiles of health physicians. The sample of 36 physicians manifested more emotional distress than M.D.s in these two comparison groups. Within our sample, physicians nt addicted to drugs or alcohol had significantly higher Male-Female scores than those M.D.s addicted to drugs.

Ward atmosphere and psychiatric nurses' job satisfaction

This study examined the relationship of psychiatric nurses' job satisfaction to perceived therapeutic climate on their wards. Job satisfaction was measured with the Employee Attitude Survey published by Science Research Associates. Therapeutic climate was measured by Moos' Ward Atmosphere Scale. Wards were rated as the nurses perceived them (Real) and as they thought they should be (Ideal). Job Satisfaction scores were correlated with Ward Atmosphere Real and Ideal-Real discrepancy scores. The perceived degree of Practical Orientation was strongly related to nurse morale. Program Clarity, Order and Organization, Support, and Involvement were also notably related. A similar pattern of relationship was found between morale and Ward Atmosphere Ideal-Real discrepancies. As would be expected, System Maintenance factors were important to the nurses but so too were Therapeutic and Communication dimensions reflecting a balanced view of nursing care.

Use of the AML scale to identify adjustment problems in fourth-, fifth-, and sixth-grade children

This paper summarizes a series of studies of the technical merit of the AML scale when used to detect school maladaptation in a sample of 684 fourth, fifth, and sixth-grade children. Teachers, who did the rating, readily accepted this screening device. Preliminary norms are offered. Reliability and factor analytic studies show a reasonable degree of uniqueness and internal consistency among the three AML subscales. Relationships to other children's personality and behavioral indices (State-Trait Anxiety Inventory for Children and Cooper-smith's Self-Esteem Inventory) were found to be modest. The one-item L Scale correlated well (r = .65) with the California Achievement Test. First developed as a measure of school maladaptation in primary grade youngsters, the AML appears to be readily applicable at intermediate grade levels as well.

Correlations between Coopersmith's self-esteem inventory and the California Test of Personality for children in grades four and six

Correlations between scores on Coopersmith's self-esteem inventory and a measure of emotional adjustment, the California Test of Personality, for 214 fourth and 213 sixth grade children, contrary to expectations, were not curvilinear. For n = 427 Coopersmith scores correlated .62, .49, and .59 with the California Personal, Social and Total scores respectively, rs by grade and sex were not substantially different However, for fourth graders, self-esteem scores were more strongly related to Personal Adjustment scores than they were to the Social Adjustment scores, whereas for sixth graders, these rs were about the same.