1
|
Connolly JJ, Berner ES, Smith M, Levy S, Terek S, Harr M, Karavite D, Suckiel S, Holm IA, Dufendach K, Nelson C, Khan A, Chisholm RL, Allworth A, Wei WQ, Bland HT, Clayton EW, Soper ER, Linder JE, Limdi NA, Miller A, Nigbur S, Bangash H, Hamed M, Sherafati A, Lewis ACF, Perez E, Orlando LA, Rakhra-Burris TK, Al-Dulaimi M, Cifric S, Scherr CL, Wynn J, Hakonarson H, Sabatello M. Education and electronic medical records and genomics network, challenges, and lessons learned from a large-scale clinical trial using polygenic risk scores. Genet Med 2023; 25:100906. [PMID: 37246632 PMCID: PMC10527667 DOI: 10.1016/j.gim.2023.100906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/30/2023] Open
Abstract
Polygenic risk scores (PRS) have potential to improve health care by identifying individuals that have elevated risk for common complex conditions. Use of PRS in clinical practice, however, requires careful assessment of the needs and capabilities of patients, providers, and health care systems. The electronic Medical Records and Genomics (eMERGE) network is conducting a collaborative study which will return PRS to 25,000 pediatric and adult participants. All participants will receive a risk report, potentially classifying them as high risk (∼2-10% per condition) for 1 or more of 10 conditions based on PRS. The study population is enriched by participants from racial and ethnic minority populations, underserved populations, and populations who experience poorer medical outcomes. All 10 eMERGE clinical sites conducted focus groups, interviews, and/or surveys to understand educational needs among key stakeholders-participants, providers, and/or study staff. Together, these studies highlighted the need for tools that address the perceived benefit/value of PRS, types of education/support needed, accessibility, and PRS-related knowledge and understanding. Based on findings from these preliminary studies, the network harmonized training initiatives and formal/informal educational resources. This paper summarizes eMERGE's collective approach to assessing educational needs and developing educational approaches for primary stakeholders. It discusses challenges encountered and solutions provided.
Collapse
Affiliation(s)
- John J Connolly
- Center for Applied Genomics, Children's Hospital of Philadelphia, PA.
| | - Eta S Berner
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL
| | - Maureen Smith
- Center for Genetic Medicine, Department of Medicine, Northwestern University, Chicago, IL
| | - Samuel Levy
- Center for Applied Genomics, Children's Hospital of Philadelphia, PA
| | - Shannon Terek
- Center for Applied Genomics, Children's Hospital of Philadelphia, PA
| | - Margaret Harr
- Center for Applied Genomics, Children's Hospital of Philadelphia, PA
| | - Dean Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, PA
| | - Sabrina Suckiel
- The Institute for Genomic Health, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ingrid A Holm
- Division of Genetics and Genomics, Boston Children's Hospital; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin Dufendach
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Catrina Nelson
- Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Atlas Khan
- Division of Nephrology, Dept of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY
| | - Rex L Chisholm
- Center for Genetic Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Aimee Allworth
- Department of Medical Genetics, University of Washington, Seattle, WA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Harris T Bland
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Ellen Wright Clayton
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, TN; Vanderbilt University Law School, Nashville, TN
| | - Emily R Soper
- The Institute for Genomic Health, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Genomic Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jodell E Linder
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Nita A Limdi
- Department of Neurology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Alexandra Miller
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Clinical Genomics, Mayo Clinic, Rochester, MN
| | - Scott Nigbur
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Hana Bangash
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Marwan Hamed
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Alborz Sherafati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Anna C F Lewis
- Edmond and Lily Safra Center for Ethics, Harvard, MA; Brigham and Women's Hospital, Boston, MA
| | - Emma Perez
- Mass General Brigham Personalized Medicine, Brigham and Women's Hospital, Boston, MA
| | | | | | | | - Selma Cifric
- Department of Biology, The College of Idaho, Caldwell, ID
| | - Courtney Lynam Scherr
- School of Communication | Department of Communication Studies, Northwestern University, Chicago, IL
| | - Julia Wynn
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, PA; Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maya Sabatello
- Center for Precision Medicine & Genomics, Department of Medicine, Columbia University Irving Medical Center, New York, NY; Division of Ethics, Department of Medical Humanities & Ethics, Columbia University Irving Medical Center, New York, NY.
| |
Collapse
|
2
|
Linder JE, Allworth A, Bland HT, Caraballo PJ, Chisholm RL, Clayton EW, Crosslin DR, Dikilitas O, DiVietro A, Esplin ED, Forman S, Freimuth RR, Gordon AS, Green R, Harden MV, Holm IA, Jarvik GP, Karlson EW, Labrecque S, Lennon NJ, Limdi NA, Mittendorf KF, Murphy SN, Orlando L, Prows CA, Rasmussen LV, Rasmussen-Torvik L, Rowley R, Sawicki KT, Schmidlen T, Terek S, Veenstra D, Velez Edwards DR, Absher D, Abul-Husn NS, Alsip J, Bangash H, Beasley M, Below JE, Berner ES, Booth J, Chung WK, Cimino JJ, Connolly J, Davis P, Devine B, Fullerton SM, Guiducci C, Habrat ML, Hain H, Hakonarson H, Harr M, Haverfield E, Hernandez V, Hoell C, Horike-Pyne M, Hripcsak G, Irvin MR, Kachulis C, Karavite D, Kenny EE, Khan A, Kiryluk K, Korf B, Kottyan L, Kullo IJ, Larkin K, Liu C, Malolepsza E, Manolio TA, May T, McNally EM, Mentch F, Miller A, Mooney SD, Murali P, Mutai B, Muthu N, Namjou B, Perez EF, Puckelwartz MJ, Rakhra-Burris T, Roden DM, Rosenthal EA, Saadatagah S, Sabatello M, Schaid DJ, Schultz B, Seabolt L, Shaibi GQ, Sharp RR, Shirts B, Smith ME, Smoller JW, Sterling R, Suckiel SA, Thayer J, Tiwari HK, Trinidad SB, Walunas T, Wei WQ, Wells QS, Weng C, Wiesner GL, Wiley K, Peterson JF. Returning integrated genomic risk and clinical recommendations: The eMERGE study. Genet Med 2023; 25:100006. [PMID: 36621880 PMCID: PMC10085845 DOI: 10.1016/j.gim.2023.100006] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Assessing the risk of common, complex diseases requires consideration of clinical risk factors as well as monogenic and polygenic risks, which in turn may be reflected in family history. Returning risks to individuals and providers may influence preventive care or use of prophylactic therapies for those individuals at high genetic risk. METHODS To enable integrated genetic risk assessment, the eMERGE (electronic MEdical Records and GEnomics) network is enrolling 25,000 diverse individuals in a prospective cohort study across 10 sites. The network developed methods to return cross-ancestry polygenic risk scores, monogenic risks, family history, and clinical risk assessments via a genome-informed risk assessment (GIRA) report and will assess uptake of care recommendations after return of results. RESULTS GIRAs include summary care recommendations for 11 conditions, education pages, and clinical laboratory reports. The return of high-risk GIRA to individuals and providers includes guidelines for care and lifestyle recommendations. Assembling the GIRA required infrastructure and workflows for ingesting and presenting content from multiple sources. Recruitment began in February 2022. CONCLUSION Return of a novel report for communicating monogenic, polygenic, and family history-based risk factors will inform the benefits of integrated genetic risk assessment for routine health care.
Collapse
Affiliation(s)
- Jodell E Linder
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Aimee Allworth
- Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Harris T Bland
- Department of Biomedical Informatics and Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Pedro J Caraballo
- Department of Internal Medicine and Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Rex L Chisholm
- Center for Genetic Medicine, Northwestern University, Chicago, IL
| | - Ellen Wright Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - David R Crosslin
- Division of Biomedical Informatics and Genomics, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Ozan Dikilitas
- Mayo Clinician Investigator Training Program, Department of Internal Medicine and Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Alanna DiVietro
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | | | - Sophie Forman
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Robert R Freimuth
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN
| | - Adam S Gordon
- Department of Pharmacology, Feinberg School of Medicine, and Center for Genetic Medicine, Northwestern University, Chicago, IL
| | - Richard Green
- Department of Biomedical Informatics and Medical Education, University of Washington Medical Center, Seattle, WA
| | | | - Ingrid A Holm
- Division of Genetics and Genomics and Manton Center for Orphan Diseases Research, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Gail P Jarvik
- Division of Medical Genetics, Department of Medicine and Department of Genome Science, University of Washington Medical Center, Seattle, WA
| | - Elizabeth W Karlson
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Sofia Labrecque
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | | | - Nita A Limdi
- Department of Neurology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kathleen F Mittendorf
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Shawn N Murphy
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Lori Orlando
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
| | - Cynthia A Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Luke V Rasmussen
- Department of Preventive Medicine, Northwestern University, Chicago, IL
| | | | - Robb Rowley
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, MD
| | - Konrad Teodor Sawicki
- Department of Cardiology and Center for Genetic Medicine, Northwestern University, Chicago, IL
| | | | - Shannon Terek
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Veenstra
- School of Pharmacy, University of Washington, Seattle, WA
| | - Digna R Velez Edwards
- Division of Quantitative Science, Department of Obstetrics and Gynecology, Department of Biomedical Sciences, Vanderbilt University Medical Center, Nashville, TN
| | | | - Noura S Abul-Husn
- Institute for Genomic Health, Department of Medicine, Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Hana Bangash
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mark Beasley
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Jennifer E Below
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Eta S Berner
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL
| | - James Booth
- Department of Emergency Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University Irving Medical Center, Columbia University, New York, NY
| | - James J Cimino
- Division of General Internal Medicine and the Informatics Institute, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - John Connolly
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Patrick Davis
- Department of Biomedical Informatics and Medical Education, University of Washington Medical Center, Seattle, WA
| | - Beth Devine
- School of Pharmacy, University of Washington, Seattle, WA
| | - Stephanie M Fullerton
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
| | | | - Melissa L Habrat
- Department of Biomedical Informatics and Medical Education, University of Washington Medical Center, Seattle, WA
| | - Heather Hain
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Margaret Harr
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Christin Hoell
- Department of Obstetrics & Gynecology and Center for Genetic Medicine, Northwestern University, Chicago, IL
| | - Martha Horike-Pyne
- Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Irving Medical Center, Columbia University, New York, NY
| | - Marguerite R Irvin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | | | - Dean Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Eimear E Kenny
- Institute for Genomic Health, Department of Medicine, Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Atlas Khan
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Bruce Korf
- Department of Genetics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Leah Kottyan
- The Center for Autoimmune Genomics and Etiology, Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Iftikhar J Kullo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Katie Larkin
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Cong Liu
- Department of Biomedical Informatics, Columbia University Irving Medical Center, Columbia University, New York, NY
| | | | - Teri A Manolio
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, MD
| | - Thomas May
- Elson S. Floyd College of Medicine, Washington State University, Vancouver, WA
| | | | - Frank Mentch
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexandra Miller
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington Medical Center, Seattle, WA
| | - Priyanka Murali
- Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Brenda Mutai
- Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Naveen Muthu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bahram Namjou
- The Center for Autoimmune Genomics and Etiology, Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Emma F Perez
- Department of Medicine, Brigham and Women's Hospital, Mass General Brigham Personalized Medicine, Boston, MA
| | - Megan J Puckelwartz
- Department of Pharmacology, Feinberg School of Medicine, and Center for Genetic Medicine, Northwestern University, Chicago, IL
| | | | - Dan M Roden
- Departments of Medicine, Pharmacology, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Elisabeth A Rosenthal
- Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | | | - Maya Sabatello
- Division of Nephrology, Department of Medicine & Division of Ethics, Department of Medical Humanities and Ethics, Columbia University Irving Medical Center, New York, NY
| | - Dan J Schaid
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Baergen Schultz
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, MD
| | - Lynn Seabolt
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Gabriel Q Shaibi
- Center for Health Promotion and Disease Prevention, Arizona State University, Phoenix, AZ
| | - Richard R Sharp
- Biomedical Ethics Program, Department of Quantitative Health Science, Mayo Clinic, Rochester, MN
| | - Brian Shirts
- Department of Laboratory Medicine & Pathology, University of Washington Medical Center, Seattle, WA
| | - Maureen E Smith
- Department of Cardiology and Center for Genetic Medicine, Northwestern University, Chicago, IL
| | - Jordan W Smoller
- Department of Psychiatry and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
| | - Rene Sterling
- Division of Genomics and Society, National Human Genome Research Institute, Bethesda, MD
| | - Sabrina A Suckiel
- The Institute for Genomic Health, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeritt Thayer
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hemant K Tiwari
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Susan B Trinidad
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
| | - Theresa Walunas
- Department of Medicine and Center for Health Information Partnerships, Northwestern University, Chicago, IL
| | - Wei-Qi Wei
- Department of Biomedical Informatics and Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Quinn S Wells
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University Irving Medical Center, Columbia University, New York, NY
| | - Georgia L Wiesner
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Ken Wiley
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, MD
| | - Josh F Peterson
- Center for Precision Medicine, Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN.
| |
Collapse
|
3
|
Thayer JG, Ferro DF, Miller JM, Karavite D, Grundmeier RW, Utidjian L, Zorc JJ. Human-centered development of an electronic health record-embedded, interactive information visualization in the emergency department using fast healthcare interoperability resources. J Am Med Inform Assoc 2021; 28:1401-1410. [PMID: 33682004 DOI: 10.1093/jamia/ocab016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 01/21/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Develop and evaluate an interactive information visualization embedded within the electronic health record (EHR) by following human-centered design (HCD) processes and leveraging modern health information exchange standards. MATERIALS AND METHODS We applied an HCD process to develop a Fast Healthcare Interoperability Resources (FHIR) application that displays a patient's asthma history to clinicians in a pediatric emergency department. We performed a preimplementation comparative system evaluation to measure time on task, number of screens, information retrieval accuracy, cognitive load, user satisfaction, and perceived utility and usefulness. Application usage and system functionality were assessed using application logs and a postimplementation survey of end users. RESULTS Usability testing of the Asthma Timeline Application demonstrated a statistically significant reduction in time on task (P < .001), number of screens (P < .001), and cognitive load (P < .001) for clinicians when compared to base EHR functionality. Postimplementation evaluation demonstrated reliable functionality and high user satisfaction. DISCUSSION Following HCD processes to develop an application in the context of clinical operations/quality improvement is feasible. Our work also highlights the potential benefits and challenges associated with using internationally recognized data exchange standards as currently implemented. CONCLUSION Compared to standard EHR functionality, our visualization increased clinician efficiency when reviewing the charts of pediatric asthma patients. Application development efforts in an operational context should leverage existing health information exchange standards, such as FHIR, and evidence-based mixed methods approaches.
Collapse
Affiliation(s)
- Jeritt G Thayer
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daria F Ferro
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey M Miller
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dean Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Levon Utidjian
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph J Zorc
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Orenstein EW, Yun K, Warden C, Westerhaus MJ, Mirth MG, Karavite D, Mamo B, Sundar K, Michel JJ. Development and dissemination of clinical decision support across institutions: standardization and sharing of refugee health screening modules. J Am Med Inform Assoc 2021; 26:1515-1524. [PMID: 31373356 DOI: 10.1093/jamia/ocz124] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We developed and piloted a process for sharing guideline-based clinical decision support (CDS) across institutions, using health screening of newly arrived refugees as a case example. MATERIALS AND METHODS We developed CDS to support care of newly arrived refugees through a systematic process including a needs assessment, a 2-phase cognitive task analysis, structured preimplementation testing, local implementation, and staged dissemination. We sought consensus from prospective users on CDS scope, applicable content, basic supported workflows, and final structure. We documented processes and developed sharable artifacts from each phase of development. We publically shared CDS artifacts through online dissemination platforms. We collected feedback and implementation data from implementation sites. RESULTS Responses from 19 organizations demonstrated a need for improved CDS for newly arrived refugee patients. A guided multicenter workflow analysis identified 2 main workflows used by organizations that would need to be supported by shared CDS. We developed CDS through an iterative design process, which was successfully disseminated to other sites using online dissemination repositories. Implementation sites had a small-to-modest analyst time commitment but reported a good match between CDS and workflow. CONCLUSION Sharing of CDS requires overcoming technical and workflow barriers. We used a guided multicenter workflow analysis and online dissemination repositories to create flexible CDS that has been adapted at 3 sites. Organizations looking to develop sharable CDS should consider evaluating the workflows of multiple institutions and collecting feedback on scope, design, and content in order to make a more generalizable product.
Collapse
Affiliation(s)
- Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Katherine Yun
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clara Warden
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael J Westerhaus
- Department of Medicine, HealthPartners Center for International Health, Minneapolis, Minnesota, USA
| | - Morgan G Mirth
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dean Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Blain Mamo
- Minnesota Department of Public Health, Minneapolis, Minnesota, USA
| | - Kavya Sundar
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeremy J Michel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
5
|
Orenstein EW, Boudreaux J, Rollins M, Jones J, Bryant C, Karavite D, Muthu N, Hike J, Williams H, Kilgore T, Carter AB, Josephson CD. Formative Usability Testing Reduces Severe Blood Product Ordering Errors. Appl Clin Inform 2019; 10:981-990. [PMID: 31875648 DOI: 10.1055/s-0039-3402714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Medical errors in blood product orders and administration are common, especially for pediatric patients. A failure modes and effects analysis in our health care system indicated high risk from the electronic blood ordering process. OBJECTIVES There are two objectives of this study as follows:(1) To describe differences in the design of the original blood product orders and order sets in the system (original design), new orders and order sets designed by expert committee (DEC), and a third-version developed through user-centered design (UCD).(2) To compare the number and type of ordering errors, task completion rates, time on task, and user preferences between the original design and that developed via UCD. METHODS A multidisciplinary expert committee proposed adjustments to existing blood product order sets resulting in the DEC order set. When that order set was tested with front-line users, persistent failure modes were detected, so orders and order sets were redesigned again via formative usability testing. Front-line users in their native clinical workspaces were observed ordering blood in realistic simulated scenarios using a think-aloud protocol. Iterative adjustments were made between participants. In summative testing, participants were randomized to use the original design or UCD for five simulated scenarios. We evaluated differences in ordering errors, time on task, and users' design preference with two-sample t-tests. RESULTS Formative usability testing with 27 providers from seven specialties led to 18 changes made to the DEC to produce the UCD. In summative testing, error-free task completion for the original design was 36%, which increased to 66% in UCD (30%, 95% confidence interval [CI]: 3.9-57%; p = 0.03). Time on task did not vary significantly. CONCLUSION UCD led to substantially different blood product orders and order sets than DEC. Users made fewer errors when ordering blood products for pediatric patients in simulated scenarios when using the UCD orders and order sets compared with the original design.
Collapse
Affiliation(s)
- Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States.,Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Jeanne Boudreaux
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States.,Aflac Cancer and Blood Disorders Program, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Margo Rollins
- Aflac Cancer and Blood Disorders Program, Children's Healthcare of Atlanta, Atlanta, Georgia, United States.,Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Jennifer Jones
- Aflac Cancer and Blood Disorders Program, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Christy Bryant
- Information Services and Technology, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Dean Karavite
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Naveen Muthu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Jessica Hike
- Information Services and Technology, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Herb Williams
- Information Services and Technology, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Tania Kilgore
- Information Services and Technology, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Alexis B Carter
- Department of Pathology and Laboratory Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Cassandra D Josephson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States.,Aflac Cancer and Blood Disorders Program, Children's Healthcare of Atlanta, Atlanta, Georgia, United States.,Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, United States.,Department of Pathology and Laboratory Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| |
Collapse
|
6
|
Ratwani RM, Savage E, Will A, Fong A, Karavite D, Muthu N, Rivera AJ, Gibson C, Asmonga D, Moscovitch B, Grundmeier R, Rising J. Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings. Health Aff (Millwood) 2019; 37:1752-1759. [PMID: 30395517 DOI: 10.1377/hlthaff.2018.0699] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pediatric populations are uniquely vulnerable to the usability and safety challenges of electronic health records (EHRs), particularly those related to medication, yet little is known about the specific issues contributing to hazards. To understand specific usability issues and medication errors in the care of children, we analyzed 9,000 patient safety reports, made in the period 2012-17, from three different health care institutions that were likely related to EHR use. Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm. The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing.
Collapse
Affiliation(s)
- Raj M Ratwani
- Raj M. Ratwani ( ) is director of the National Center for Human Factors in Healthcare, MedStar Health, and an assistant professor of emergency medicine, Department of Emergency Medicine, Georgetown University School of Medicine, both in Washington, D.C
| | - Erica Savage
- Erica Savage is a manager in Ambulatory Quality and Safety, MedStar Health
| | - Amy Will
- Amy Will is a research program manager at the National Center for Human Factors in Healthcare, MedStar Health
| | - Allan Fong
- Allan Fong is a research scientist at the National Center for Human Factors in Healthcare, MedStar Health
| | - Dean Karavite
- Dean Karavite is principal human computer interaction specialist, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, in Pennsylvania
| | - Naveen Muthu
- Naveen Muthu is director of the Cognitive Informatics Group, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and an instructor of pediatrics, University of Pennsylvania Perelman School of Medicine
| | - A Joy Rivera
- A. Joy Rivera is a senior human factors system engineer at the Children's Hospital of Wisconsin, in Milwaukee
| | - Cori Gibson
- Cori Gibson is a safety specialist at the Children's Hospital of Wisconsin
| | - Don Asmonga
- Don Asmonga is an officer in the Health Information Technology Initiative, Pew Charitable Trusts, in Washington, D.C
| | - Ben Moscovitch
- Ben Moscovitch is the project director of the Health Information Technology Initiative, Pew Charitable Trusts
| | - Robert Grundmeier
- Robert Grundmeier is director of clinical informatics, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, and an assistant professor of pediatrics, University of Pennsylvania Perelman School of Medicine
| | - Josh Rising
- Josh Rising is director of Healthcare Programs, Pew Health Group, Pew Charitable Trusts
| |
Collapse
|
7
|
Tremoulet P, Krishnan R, Karavite D, Muthu N, Regli SH, Will A, Michel J. A Heuristic Evaluation to Assess Use of After Visit Summaries for Supporting Continuity of Care. Appl Clin Inform 2018; 9:714-724. [PMID: 30208496 DOI: 10.1055/s-0038-1668093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Outpatient providers often do not receive discharge summaries from acute care providers prior to follow-up visits. These outpatient providers may use the after-visit summaries (AVS) that are given to patients to obtain clinical information. It is unclear how effectively AVS support care coordination between clinicians. OBJECTIVES Goals for this effort include: (1) developing usability heuristics that may be applied both for assessment and to guide generation of medical documents in general, (2) conducting a heuristic evaluation to assess the use of AVS for communication between clinicians, and (3) providing recommendations for generating AVS that effectively support both patient/caregiver use and care coordination. METHODS We created a 17-item heuristic evaluation instrument for assessing usability of medical documents. Eight experts used the instrument to assess each of four simulated AVS. The simulations were created using examples from two hospitals and two pediatric patient cases developed by the National Institute of Standards and Technology. RESULTS Experts identified 224 unique usability problems ranging in severity from mild to catastrophic. Content issues (e.g., missing medical history, marital status of a 2-year-old) were rated as most severe, but widespread formatting and structural problems (e.g., inconsistent indentation, fonts, and headings; confusing ordering of information) were so distracting that they significantly reduced readers' ability to efficiently use the documents. Overall, issues in the AVS from Hospital 2 were more severe than those in the AVS from Hospital 1. CONCLUSION The new instrument allowed for quick, inexpensive evaluations of AVS. Usability issues such as unnecessary information, poor organization, missing information, and inconsistent formatting make it hard for patients, caregivers, and clinicians to use the AVS. The heuristics in the new instrument may be used as guidance to adapt electronic health record systems so that they generate more useful and usable medical documents.
Collapse
Affiliation(s)
- Patrice Tremoulet
- Health Devices Department, ECRI Institute, Plymouth Meeting, Pennsylvania, United States.,Department of Psychology, Rowan University, Glassboro, New Jersey, United States
| | - Ramya Krishnan
- Health Devices Department, ECRI Institute, Plymouth Meeting, Pennsylvania, United States
| | - Dean Karavite
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Naveen Muthu
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Division of General Pediatrics, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Susan Harkness Regli
- Department of Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States
| | - Amy Will
- National Center for Human Factors in Healthcare, MedStar Health, Washington, District of Columbia, United States
| | - Jeremy Michel
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Division of General Pediatrics, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,ECRI Institute Technology Assessment, Plymouth Meeting, Pennsylvania, United States
| |
Collapse
|
8
|
Michel J, Utidjian L, Karavite D, Hogan A, Ramos M, Miller J, Shiffman R, Grundmeier R. Rapid Adjustment of Clinical Decision Support in Response to Updated Recommendations for Palivizumab Eligibility. Appl Clin Inform 2017. [DOI: 10.4338/aci-2016-10-ra-0173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
SummaryBackground: Palivizumab is effective at reducing hospitalizations due to respiratory syncytial virus among high-risk children, but is indicated for a small population. Identification of patients eligible to receive palivizumab is labor-intensive and error-prone. To support patient identification we developed Clinical Decision Support (CDS) based on published recommendations in 2012. This CDS was developed using a systematic process, which directly linked computer code to a recommendation’s narrative text. In 2014, updated recommendations were published, which changed several key criteria used to determine eligible patients.Objective: Assess the effort required to update CDS in response to new palivizumab recommendations and identify factors that impacted these efforts.Methods: We reviewed the updated American Academy of Pediatrics (AAP) policy statement from Aug 2014 and identified areas of divergence from the prior publication. We modified the CDS to account for each difference. We recorded time spent on each activity to approximate the total effort required to update the CDS.Results: Of the 15 recommendations in the initial policy statement, 7 required updating. The CDS update was completed in 11 person-hours. Comparison of old and new recommendations was facilitated by the AAP policy statement structure and required 3 hours. Validation of the revised logic required 2 hours by a clinical domain expert. An informaticist required 3 hours to update and test the CDS. This included adding 24 lines and deleting 37 lines of code. Updating relevant data queries took an additional 3 hours and involved 10 edits.Conclusion: We quickly adapted CDS in response to changes in recommendations for palivizumab administration. The consistent AAP policy statement structure and the link we developed between these statements and the CDS rules facilitated our efforts. We recommend that CDS implementers establish linkages between published narrative recommendations and their executable rules to facilitate maintenance efforts.Citation: Michel J, Utidjian LH, Karavite D, Hogan A, Ramos MJ, Miller J, Shiffman RN, Grundmeier RW. Rapid adjustment of clinical decision support in response to updated recommendations for palivizumab eligibility. Appl Clin Inform 2017; 8: 581–592 https://doi.org/10.4338/ACI-2016-10-RA-0173
Collapse
|
9
|
Green R, Goddard K, Jarvik G, Amendola L, Appelbaum P, Berg J, Bernhardt B, Biesecker L, Biswas S, Blout C, Bowling K, Brothers K, Burke W, Caga-anan C, Chinnaiyan A, Chung W, Clayton E, Cooper G, East K, Evans J, Fullerton S, Garraway L, Garrett J, Gray S, Henderson G, Hindorff L, Holm I, Lewis M, Hutter C, Janne P, Joffe S, Kaufman D, Knoppers B, Koenig B, Krantz I, Manolio T, McCullough L, McEwen J, McGuire A, Muzny D, Myers R, Nickerson D, Ou J, Parsons D, Petersen G, Plon S, Rehm H, Roberts J, Robinson D, Salama J, Scollon S, Sharp R, Shirts B, Spinner N, Tabor H, Tarczy-Hornoch P, Veenstra D, Wagle N, Weck K, Wilfond B, Wilhelmsen K, Wolf S, Wynn J, Yu JH, Amaral M, Amendola L, Appelbaum P, Aronson S, Arora S, Azzariti D, Barsh G, Bebin E, Biesecker B, Biesecker L, Biswas S, Blout C, Bowling K, Brothers K, Brown B, Burt A, Byers P, Caga-anan C, Calikoglu M, Carlson S, Chahin N, Chinnaiyan A, Christensen K, Chung W, Cirino A, Clayton E, Conlin L, Cooper G, Crosslin D, Davis J, Davis K, Deardorff M, Devkota B, De Vries R, Diamond P, Dorschner M, Dugan N, Dukhovny D, Dulik M, East K, Rivera-Munoz E, Evans B, Evans J, Everett J, Exe N, Fan Z, Feuerman L, Filipski K, Finnila C, Fishler K, Fullerton S, Ghrundmeier B, Giles K, Gilmore M, Girnary Z, Goddard K, Gonsalves S, Gordon A, Gornick M, Grady W, Gray D, Gray S, Green R, Greenwood R, Gutierrez A, Han P, Hart R, Heagerty P, Henderson G, Hensman N, Hiatt S, Himes P, Hindorff L, Hisama F, Ho C, Hoffman-Andrews L, Holm I, Hong C, Horike-Pyne M, Hull S, Hutter C, Jamal S, Jarvik G, Jensen B, Joffe S, Johnston J, Karavite D, Kauffman T, Kaufman D, Kelley W, Kim J, Kirby C, Klein W, Knoppers B, Koenig B, Kong S, Krantz I, Krier J, Lamb N, Lambert M, Le L, Lebo M, Lee A, Lee K, Lennon N, Leo M, Leppig K, Lewis K, Lewis M, Lindeman N, Lockhart N, Lonigro B, Lose E, Lupo P, Rodriguez L, Lynch F, Machini K, MacRae C, Manolio T, Marchuk D, Martinez J, Masino A, McCullough L, McEwen J, McGuire A, McLaughlin H, McMullen C, Mieczkowski P, Miller J, Miller V, Mody R, Mooney S, Moore E, Morris E, Murray M, Muzny D, Myers R, Ng D, Nickerson D, Oliver N, Ou J, Parsons W, Patrick D, Pennington J, Perry D, Petersen G, Plon S, Porter K, Powell B, Punj S, Breitkopf C, Raesz-Martinez R, Raskind W, Rehm H, Reigar D, Reiss J, Rich C, Richards C, Rini C, Roberts S, Robertson P, Robinson D, Robinson J, Robinson M, Roche M, Romasko E, Rosenthal E, Salama J, Scarano M, Schneider J, Scollon S, Seidman C, Seifert B, Sharp R, Shirts B, Sholl L, Siddiqui J, Silverman E, Simmons S, Simons J, Skinner D, Spinner N, Stoffel E, Strande N, Sunyaev S, Sybert V, Taber J, Tabor H, Tarczy-Hornoch P, Taylor D, Tilley C, Tomlinson A, Trinidad S, Tsai E, Ubel P, Van Allen E, Vassy J, Vats P, Veenstra D, Vetter V, Vries R, Wagle N, Walser S, Walsh R, Weck K, Werner-Lin A, Whittle J, Wilfond B, Wilhelmsen K, Wolf S, Wynn J, Yang Y, Young C, Yu JH, Zikmund-Fisher B. Clinical Sequencing Exploratory Research Consortium: Accelerating Evidence-Based Practice of Genomic Medicine. Am J Hum Genet 2016; 99:246. [PMID: 27392080 DOI: 10.1016/j.ajhg.2016.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
10
|
Fiks AG, DuRivage N, Mayne SL, Finch S, Ross ME, Giacomini K, Suh A, McCarn B, Brandt E, Karavite D, Staton EW, Shone LP, McGoldrick V, Noonan K, Miller D, Lehmann CU, Pace WD, Grundmeier RW. Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study. J Med Internet Res 2016; 18:e172. [PMID: 27357835 PMCID: PMC4945817 DOI: 10.2196/jmir.5610] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/11/2016] [Accepted: 03/28/2016] [Indexed: 12/25/2022] Open
Abstract
Background Patient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established. Objective We evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success. Methods We conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework. Results We invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success. Conclusions Although use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children. ClinicalTrial Clinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3)
Collapse
Affiliation(s)
- Alexander G Fiks
- The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Utidjian LH, Hogan A, Michel J, Localio AR, Karavite D, Song L, Ramos MJ, Fiks AG, Lorch S, Grundmeier RW. Clinical Decision Support and Palivizumab: A Means to Protect from Respiratory Syncytial Virus. Appl Clin Inform 2015; 6:769-84. [PMID: 26767069 DOI: 10.4338/aci-2015-08-ra-0096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 11/08/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Palivizumab can reduce hospitalizations due to respiratory syncytial virus (RSV), but many eligible infants fail to receive the full 5-dose series. The efficacy of clinical decision support (CDS) in fostering palivizumab receipt has not been studied. We sought a comprehensive solution for identifying eligible patients and addressing barriers to palivizumab administration. METHODS We developed workflow and CDS tools targeting patient identification and palivizumab administration. We randomized 10 practices to receive palivizumab-focused CDS and 10 to receive comprehensive CDS for premature infants in a 3-year longitudinal cluster-randomized trial with 2 baseline and 1 intervention RSV seasons. RESULTS There were 356 children eligible to receive palivizumab, with 194 in the palivizumab-focused group and 162 in the comprehensive CDS group. The proportion of doses administered to children in the palivizumab-focused intervention group increased from 68.4% and 65.5% in the two baseline seasons to 84.7% in the intervention season. In the comprehensive intervention group, proportions of doses administered declined during the baseline seasons (from 71.9% to 62.4%) with partial recovery to 67.9% during the intervention season. The palivizumab-focused group improved by 19.2 percentage points in the intervention season compared to the prior baseline season (p < 0.001), while the comprehensive intervention group only improved 5.5 percentage points (p = 0.288). The difference in change between study groups was significant (p = 0.05). CONCLUSIONS Workflow and CDS tools integrated in an EHR may increase the administration of palivizumab. The support focused on palivizumab, rather than comprehensive intervention, was more effective at improving palivizumab administration.
Collapse
Affiliation(s)
- L H Utidjian
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biomedical and Health, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - A Hogan
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - J Michel
- Department of Biomedical and Health, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - A R Localio
- Departments of Biostatics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - D Karavite
- Department of Biomedical and Health, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - L Song
- Healthcare Analytics Unit, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - M J Ramos
- Department of Biomedical and Health, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - A G Fiks
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biomedical and Health, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - S Lorch
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - R W Grundmeier
- Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biomedical and Health, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Tarczy-Hornoch P, Amendola L, Aronson SJ, Garraway L, Gray S, Grundmeier RW, Hindorff LA, Jarvik G, Karavite D, Lebo M, Plon SE, Van Allen E, Weck KE, White PS, Yang Y. A survey of informatics approaches to whole-exome and whole-genome clinical reporting in the electronic health record. Genet Med 2013; 15:824-32. [PMID: 24071794 PMCID: PMC3951437 DOI: 10.1038/gim.2013.120] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/09/2013] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Genome-scale clinical sequencing is being adopted more broadly in medical practice. The National Institutes of Health developed the Clinical Sequencing Exploratory Research (CSER) program to guide implementation and dissemination of best practices for the integration of sequencing into clinical care. This study describes and compares the state of the art of incorporating whole-exome and whole-genome sequencing results into the electronic health record, including approaches to decision support across the six current CSER sites. METHODS The CSER Medical Record Working Group collaboratively developed and completed an in-depth survey to assess the communication of genome-scale data into the electronic health record. We summarized commonalities and divergent approaches. RESULTS Despite common sequencing platform (Illumina) adoptions, there is a great diversity of approaches to annotation tools and workflow, as well as to report generation. At all sites, reports are human-readable structured documents available as passive decision support in the electronic health record. Active decision support is in early implementation at two sites. CONCLUSION The parallel efforts across CSER sites in the creation of systems for report generation and integration of reports into the electronic health record, as well as the lack of standardized approaches to interfacing with variant databases to create active clinical decision support, create opportunities for cross-site and vendor collaborations.
Collapse
Affiliation(s)
- Peter Tarczy-Hornoch
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- University of Washington, Seattle, Washington, USA
| | - Laura Amendola
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- University of Washington, Seattle, Washington, USA
| | - Samuel J. Aronson
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- Partners HealthCare Center for Personalized Genetic Medicine, Boston, Massachusetts, USA
| | - Levi Garraway
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Stacy Gray
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Robert W. Grundmeier
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Biomedical Informatics, The Children's Hospital Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lucia A. Hindorff
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Gail Jarvik
- University of Washington, Seattle, Washington, USA
| | - Dean Karavite
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- Center for Biomedical Informatics, The Children's Hospital Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew Lebo
- Partners HealthCare Center for Personalized Genetic Medicine, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sharon E. Plon
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Eliezer Van Allen
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Karen E. Weck
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Peter S. White
- National Institutes of Health National Human Genome Research Institute Clinical Sequencing Exploratory Research Electronic Medical Records Working Group, Bethesda, Maryland, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Biomedical Informatics, The Children's Hospital Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yaping Yang
- Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
13
|
Fiks AG, Grundmeier RW, Mayne S, Song L, Feemster K, Karavite D, Hughes CC, Massey J, Keren R, Bell LM, Wasserman R, Localio AR. Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt. Pediatrics 2013; 131:1114-24. [PMID: 23650297 PMCID: PMC3666111 DOI: 10.1542/peds.2012-3122] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To improve human papillomavirus (HPV) vaccination rates, we studied the effectiveness of targeting automated decision support to families, clinicians, or both. METHODS Twenty-two primary care practices were cluster-randomized to receive a 3-part clinician-focused intervention (education, electronic health record-based alerts, and audit and feedback) or none. Overall, 22, 486 girls aged 11 to 17 years due for HPV vaccine dose 1, 2, or 3 were randomly assigned within each practice to receive family-focused decision support with educational telephone calls. Randomization established 4 groups: family-focused, clinician-focused, combined, and no intervention. We measured decision support effectiveness by final vaccination rates and time to vaccine receipt, standardized for covariates and limited to those having received the previous dose for HPV #2 and 3. The 1-year study began in May 2010. RESULTS Final vaccination rates for HPV #1, 2, and 3 were 16%, 65%, and 63% among controls. The combined intervention increased vaccination rates by 9, 8, and 13 percentage points, respectively. The control group achieved 15% vaccination for HPV #1 and 50% vaccination for HPV #2 and 3 after 318, 178, and 215 days. The combined intervention significantly accelerated vaccination by 151, 68, and 93 days. The clinician-focused intervention was more effective than the family-focused intervention for HPV #1, but less effective for HPV #2 and 3. CONCLUSIONS A clinician-focused intervention was most effective for initiating the HPV vaccination series, whereas a family-focused intervention promoted completion. Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt.
Collapse
Affiliation(s)
- Alexander G. Fiks
- The Pediatric Research Consortium,,PolicyLab,,Center for Pediatric Clinical Effectiveness,,Center for Biomedical Informatics, and,Departments of Pediatrics, and
| | - Robert W. Grundmeier
- The Pediatric Research Consortium,,Center for Biomedical Informatics, and,Departments of Pediatrics, and
| | | | - Lihai Song
- PolicyLab,,Center for Pediatric Clinical Effectiveness
| | - Kristen Feemster
- PolicyLab,,Center for Pediatric Clinical Effectiveness,,Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;,Departments of Pediatrics, and
| | | | | | | | - Ron Keren
- Center for Pediatric Clinical Effectiveness,,Departments of Pediatrics, and,Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Louis M. Bell
- The Pediatric Research Consortium,,Departments of Pediatrics, and
| | - Richard Wasserman
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
| | - A. Russell Localio
- Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| |
Collapse
|
14
|
Mayne S, Karavite D, Grundmeier RW, Localio R, Feemster K, DeBartolo E, Hughes CC, Fiks AG. The implementation and acceptability of an HPV vaccination decision support system directed at both clinicians and families. AMIA Annu Symp Proc 2012; 2012:616-624. [PMID: 23304334 PMCID: PMC3540460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We developed an electronic medical record (EMR)-based HPV vaccine decision support intervention targeting clinicians, (immunization alerts, education, and feedback) and families (phone reminders and referral to an educational website). Through telephone surveys completed by 162 parents of adolescent girls, we assessed the acceptability of the family-focused intervention and its effect on information-seeking behavior, communication, and HPV vaccine decision-making. The intervention was acceptable to parents and 46% remembered receiving the reminder call. Parents reported that the call prompted them to seek out information regarding the HPV vaccine, discuss the vaccine with friends and family, and reach a decision. Parents whose adolescent girls attended practices receiving the clinician-focused intervention were more likely to report that their clinician discussed the HPV vaccine at preventive visits. The results of this study demonstrate the acceptability and potential impact on clinical care of a comprehensive decision support system directed at both clinicians and families.
Collapse
Affiliation(s)
- Stephanie Mayne
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Moscucci M, Muller DW, Watts CM, Bahl V, Bates ER, Werns SW, Kline-Rogers E, Karavite D, Eagle KA. Reducing costs and improving outcomes of percutaneous coronary interventions. Am J Manag Care 2003; 9:365-72. [PMID: 12744298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To describe cost reduction and quality improvement efforts in our percutaneous coronary intervention (PCI) program and how risk adjustment was used to assess the effects of these changes. STUDY DESIGN Single center registry analysis. PATIENTS AND METHODS Data were collected on 2158 PCIs performed between July 1, 1994, and June 30, 1997. Of these, 1126 PCIs reflected care provided after implementation of competitive bidding for catheterization lab supplies, and efforts to reduce the use of postprocedure heparin and to implement early arterial sheaths removal (postbidding period). Hospital costs were estimated using a microcost accounting method. In-hospital mortality rates during the 2 time periods were compared using standardized mortality ratio estimated with a previously validated risk adjustment model for in-hospital mortality. RESULTS Compared with the prebidding period, the postbidding period was characterized by a significantly higher utilization of new technology (coronary stents and atherectomy devices 46% vs 25%; abciximab 19.1% vs 3.7, P<.01), and an overall increase in case complexity. Despite these changes, the average and median postbidding cost per case was dollars 1223 and dollars 1444 lower, respectively, than in the prebidding period. After adjustment for comorbidities, procedure variables, complications, and length of hospital stay, multivariate regression modeling identified the postbidding period as an independent predictor of lower hospital costs (P<.001) with an estimated adjusted cost savings of dollars 460. These cost savings were associated with trends toward a lower observed mortality rate, a higher predicted mortality rate, and a significantly lower standardized mortality ratio (SMR .71; 95% CI 0.48-0.9; P<.05). CONCLUSION Despite an increase in case complexity and utilization of new technology, cost reductions can be achieved through competitive bidding for supplies and modifications of periprocedure care. Risk adjustment appears to be a valid tool for assessing the effectiveness of these efforts independently from changes in case mix.
Collapse
Affiliation(s)
- Mauro Moscucci
- Division of Cardiology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, 48109-0119, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Froehlich JB, Karavite D, Russman PL, Erdem N, Wise C, Zelenock G, Wakefield T, Stanley J, Eagle KA. American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery. J Vasc Surg 2002; 36:758-63. [PMID: 12368719 DOI: 10.1067/mva.2002.127344] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Methods used for evaluation of cardiac risk before noncardiac surgery vary widely. We evaluated the effect over time on practice and resource utilization of implementing the American College of Cardiology/American Heart Association Guidelines on Preoperative Risk Assessment. METHODS We compared 102 historical control patients who underwent elective abdominal aortic surgery (from January 1993 to December 1994) with 94 consecutive patients after guideline implementation (from July 1995 to December 1996) and 104 patients in a late after guideline implementation (from July 1, 1997, to September 30, 1998). Resource use (testing, revascularization, and costs) and outcomes (perioperative death and myocardial infarction) were examined. Patients with and without clinical markers of risk for perioperative cardiac complications were compared. RESULTS The use of preoperative stress testing (88% to 47%; P <.00001), cardiac catheterization (24% to 11%; P <.05), and coronary revascularization (25% to 2%; P <.00001) decreased between control and postguideline groups, respectively. These changes persisted in the late postguideline group. Mean preoperative evaluation costs also fell ($1087 versus $171; P <.0001). Outcomes of death (4% versus 3% versus 2%) and myocardial infarction (7% versus 3% versus 5%) were not significantly different between control, postguideline, and late postguideline groups, respectively. Stress test rates were similar for patients at low risk versus high risk in the historical control group (84% versus 91%; P =.29) but lower for patients at low risk after guideline implementation (31% versus 61%; P =.003). CONCLUSION Implementation of the American College of Cardiology/American Heart Association cardiac risk assessment guidelines appropriately reduced resource use and costs in patients who underwent elective aortic surgery without affecting outcomes. This effect was sustained 2 years after guideline implementation.
Collapse
Affiliation(s)
- James B Froehlich
- Department of Medicine and Surgery, University of Massachusetts Medical Center, Worchester, MA 01655, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Kline-Rogers E, Share D, Bondie D, Rogers B, Karavite D, Kanten S, Wren P, Bodurka C, Fisk C, McGinnity J, Wright S, Fox S, Eagle KA, Moscucci M. Development of a multicenter interventional cardiology database: the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) experience. J Interv Cardiol 2002; 15:387-92. [PMID: 12440182 DOI: 10.1111/j.1540-8183.2002.tb01072.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The technical challenges in the development of a quality-controlled registry of percutaneous coronary interventions (PCIs) are currently unknown. This article describes the authors' experience in the development of a regional, quality-controlled PCI registry. In 1996, 16 centers in Michigan were invited to participate in a multicenter PCI registry. Nine centers agreed to a pilot data collection and, as of July 2001, eight centers are still actively collecting data. An Oracle database was developed by the coordinating center. A common data collection form and a standard set of definitions were agreed on during several meetings. Data validity was insured through review of each form by a trained nurse, by automatic database diagnostic routines, and by site visits that included a review of the catheterization laboratory logs and a review of randomly selected charts. The average number of forms requiring query resolution was 33% in 1997 (range 7-76%), and it decreased to 5% in 1999 (range 1.4-10%). The most commonly queried variables were outcomes prior to discharge, lesion category, lesion complexity, date of birth, device used, gender, postprocedural percent stenosis, presence of left main disease, and MI date. Invalid dates, identification of the doctor, the presence of duplicate forms, and of duplicate outcomes were additional common queries generated by the internal diagnostic routines. In conclusion, the number of queries and diagnostic reports generated in the database suggests that the development of a quality-controlled PCI registry requires the institution of a careful diagnostic and data quality assessment system.
Collapse
Affiliation(s)
- Eva Kline-Rogers
- University of Michigan, Division of Cardiology, Blue Cross Blue Shield of Michigan Cardiovascular Consortium Coordinating Center, Ann Arbor, Michigan, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
BACKGROUND The purpose of this study was to assess frequency, risk factors, treatment, and complications of very young patients with acute myocardial infarction (MI) at the University of Michigan Medical Center (UMMC). METHODS From a database of 976 consecutive patients admitted to the UMMC with acute MI between 1995 and 1998, we compared care and outcomes of patients divided into 3 age categories: <46 years, 46-54 years, and >54 years. Risk factors, presenting symptoms, type of MI, management, complications, and hospital outcomes of the 3 groups were evaluated. RESULTS Young patients represented >10% of all patients with acute MI, and >25% of these individuals were women, a number considerably higher than seen in previous studies. This group of young patients was more likely to have Q-wave MI and risk factors such as family history and tobacco use and less likely to have a history of angina. Although all 3 groups received similar inpatient treatment, there was more attention paid to risk factor modification such as smoking cessation and referral to cardiac rehabilitation in younger individuals. Young patients had fewer in-hospital complications and a lower mortality rate. CONCLUSIONS At the University of Michigan, >1 in 10 with acute MI is <46 years old. Data suggest that current management and aggressive risk factor modification are quite good in this particular group, and overall the mortality rate is very low.
Collapse
Affiliation(s)
- Michele Doughty
- University of Michigan Heart Care Program and the Consortium for Health Care Outcomes, Innovation, and Cost Effectiveness Studies, Ann Arbor, Mich, USA.
| | | | | | | | | | | | | |
Collapse
|
19
|
Mehta RH, Bruckman D, Das S, Tsai T, Russman P, Karavite D, Monaghan H, Sonnad S, Shea MJ, Eagle KA, Deeb GM. Implications of increased left ventricular mass index on in-hospital outcomes in patients undergoing aortic valve surgery. J Thorac Cardiovasc Surg 2001; 122:919-28. [PMID: 11689797 DOI: 10.1067/mtc.2001.116558] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Increased left ventricular mass index has been shown to be associated with higher mortality in epidemiologic studies. However, the effect of increased left ventricular mass index on outcomes in patients undergoing aortic valve replacement is unknown. METHODS We studied 473 consecutive patients undergoing elective aortic valve replacement to assess the influence of left ventricular mass index on outcomes in patients having this procedure. Echocardiographic left ventricular dimensions were used to calculate left ventricular mass index (considered increased if >134 g/m(2) in male patients and >110 g/m(2) in female patients). RESULTS Left ventricular mass index was increased in 24% of patients undergoing aortic valve replacement. Postprocedural complications (respiratory failure, renal insufficiency, congestive heart failure, and atrial and ventricular arrhythmias), length of stay in the intensive care unit, and in-hospital mortality were increased in patients with increased left ventricular mass index. Multivariable analysis identified prior valve surgery (odds ratio, 4.3; 95% confidence interval, 1.2-15.7; P =.030), left ventricular ejection fraction (odds ratio, 1.07; 95% confidence interval, 1.01-1.14; P =.020), history of hypertension (odds ratio, 8.2; 95% confidence interval, 2.2-30.4; P =.002), history of liver disease (odds ratio, 50.4; 95% confidence interval, 4.2-609.0; P =.002), and increased left ventricular mass index (odds ratio, 38; 95% confidence interval, 9.3-154.1; P <.001) as independent predictors of in-hospital mortality. Furthermore, low output syndrome was identified as the most common mode of death (36%) after aortic valve replacement in patients with increased left ventricular mass index. CONCLUSIONS Increased left ventricular mass index is associated with increased adverse in-hospital clinical outcomes in patients undergoing aortic valve replacement. Although this finding warrants special modification in perioperative management, further studies are needed to address whether outcomes in asymptomatic patients with aortic valve disease could be improved by earlier aortic valve replacement before a significant increase in left ventricular mass index.
Collapse
Affiliation(s)
- R H Mehta
- Division of Cardiology and Section of Adult Cardiac Surgery, Heart Care Program, University of Michigan, Ann Arbor, MI48109-0348, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Freeman RV, Eagle KA, Bates ER, Werns SW, Kline-Rogers E, Karavite D, Moscucci M. Comparison of artificial neural networks with logistic regression in prediction of in-hospital death after percutaneous transluminal coronary angioplasty. Am Heart J 2000; 140:511-20. [PMID: 10966555 DOI: 10.1067/mhj.2000.109223] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Our objective was to compare artificial neural networks (ANNs) with logistic regression for prediction of in-hospital death after percutaneous transluminal coronary angioplasty and to assess the impact of guiding initial ANN variable selection with univariate analysis. BACKGROUND ANNs can detect complex patterns within data. Criticisms include the unpredictability of variable selection. They have not previously been applied to outcomes modeling for percutaneous coronary interventions. METHODS A database of consecutive (n = 3019) percutaneous transluminal coronary angioplasty procedures from an academic tertiary referral center between July 1994 and July 1997 was used. An ANN was developed for 38 variables (unguided model) (n = 1554). A second model was developed with predictors from an univariate analysis (guided model). Both were compared with a logistic regression model developed from the same database. Model validation was performed on independent data (n = 1465). Model predictive accuracy was assessed by the area under receiver operating characteristic curves. Goodness of fit was assessed with the Hosmer-Lemeshow statistic. RESULTS Sixty unguided and guided ANNs were developed. Predictive accuracy and model calibration for all models were similar for training data but were significantly better for logistic regression for independent validation data. Overestimation of event rate in higher risk patients accounted for the majority of discrepancy in model calibration for the ANNs. This difference was partially amended by guiding variable selection. CONCLUSION ANNs were able to model in-hospital death after percutaneous transluminal coronary angioplasty when guiding variable selection. However, performance was not better than traditional modeling techniques. Further investigations are needed to understand the impact of this methodology on outcomes analysis.
Collapse
Affiliation(s)
- R V Freeman
- University of Michigan Medical Center, Ann Arbor, MI 48109-0366, USA
| | | | | | | | | | | | | |
Collapse
|
21
|
Day SM, Younger JG, Karavite D, Bach DS, Armstrong WF, Eagle KA. Usefulness of hypotension during dobutamine echocardiography in predicting perioperative cardiac events. Am J Cardiol 2000; 85:478-83. [PMID: 10728954 DOI: 10.1016/s0002-9149(99)00775-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study was undertaken to determine the prognostic significance of hypotension induced during preoperative dobutamine stress echocardiography (DSE) before vascular and noncardiac thoracic surgery. Wall motion abnormality during DSE predicts perioperative risk. Although hypotension during DSE has not been shown to correlate with the presence or severity of coronary artery disease, its significance in perioperative risk assessment is unknown. We retrospectively studied 300 patients who had DSE within 6 months of noncardiac surgery. Perioperative events including death, myocardial infarction, ischemia, and arrhythmias were recorded. Odds ratios with 95% confidence intervals were used to examine the association between clinical and echocardiographic variables and perioperative events. A hypotensive response during DSE was seen in 85 patients (28%). Forty-eight patients (16%) had 54 perioperative complications including 4 cardiac-related deaths, 10 myocardial infarctions, 12 myocardial ischemic events, and 28 arrhythmias. Hypotension during DSE was predictive of the combined end point of perioperative cardiac mortality, myocardial infarction, and ischemia (odds ratio 4.04, 95% confidence interval 1.72 to 9.51). In a multivariate logistic regression model, hypotension during DSE remained a significant predictor (odds ratio 4.10, p<0.01). DSE-related hypotension was predictive of perioperative cardiac events and therefore may have a role in risk stratification before vascular or noncardiac thoracic surgery.
Collapse
Affiliation(s)
- S M Day
- Department of Emergency Medicine, University of Michigan Medical Center, Ann Arbor, USA
| | | | | | | | | | | |
Collapse
|
22
|
Moscucci M, O'Connor GT, Ellis SG, Malenka DJ, Sievers J, Bates ER, Muller DW, Werns SW, Rogers EK, Karavite D, Eagle KA. Validation of risk adjustment models for in-hospital percutaneous transluminal coronary angioplasty mortality on an independent data set. J Am Coll Cardiol 1999; 34:692-7. [PMID: 10483949 DOI: 10.1016/s0735-1097(99)00266-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We sought to validate recently proposed risk adjustment models for in-hospital percutaneous transluminal coronary angioplasty (PTCA) mortality on an independent data set of high risk patients undergoing PTCA. BACKGROUND Risk adjustment models for PTCA mortality have recently been reported, but external validation on independent data sets and on high risk patient groups is lacking. METHODS Between July 1, 1994 and June 1, 1996, 1,476 consecutive procedures were performed on a high risk patient group characterized by a high incidence of cardiogenic shock (3.3%) and acute myocardial infarction (14.3%). Predictors of in-hospital mortality were identified using multivariate logistic regression analysis. Two external models of in-hospital mortality, one developed by the Northern New England Cardiovascular Disease Study Group (model NNE) and the other by the Cleveland Clinic (model CC), were compared using receiver operating characteristic (ROC) curve analysis. RESULTS In this patient group, an overall in-hospital mortality rate of 3.4% was observed. Multivariate regression analysis identified risk factors for death in the hospital that were similar to the risk factors identified by the two external models. When fitted to the data set, both external models had an area under the ROC curve >0.85, indicating overall excellent model discrimination, and both models were accurate in predicting mortality in different patient subgroups. There was a trend toward a greater ability to predict mortality for model NNE as compared with model CC, but the difference was not significant. CONCLUSIONS Predictive models for PTCA mortality yield comparable results when applied to patient groups other than the one on which the original model was developed. The accuracy of the two models tested in adjusting for the relatively high mortality rate observed in this patient group supports their application in quality assessment or quality improvement efforts.
Collapse
Affiliation(s)
- M Moscucci
- Heart Care Program, University of Michigan Medical Center, Ann Arbor 48109-0022, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Eagle KA, Moscucci M, Pagani F, Karavite D, Russman PL, Bruckman D, Kinney C, Deeb GM, Sonnad SS. Resources needed to collect and report data for heart care. J Invasive Cardiol 1999; 11:393-7. [PMID: 10745560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Affiliation(s)
- K A Eagle
- Division of Cardiology, University of Michigan Medical Center, 3910 Tuman Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0366, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Tobin K, Stomel R, Harber D, Karavite D, Sievers J, Eagle K. Validation in a community hospital setting of a clinical rule to predict preserved left ventricular ejection fraction in patients after myocardial infarction. Arch Intern Med 1999; 159:353-7. [PMID: 10030308 DOI: 10.1001/archinte.159.4.353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND A previous study showed that patients with previous myocardial infarction (MI) who meet 4 simple clinical and/or electrocardiographic criteria have a left ventricular ejection fraction (LVEF) of 40% or greater, with a positive predictive value of 98%. The objective of this study was to validate this clinical rule in the community hospital setting. METHODS Retrospective chart review in a 330-bed community hospital. Two hundred thirteen consecutive patients with MI were identified between June 1, 1993, and March 31, 1995. Left ventricular ejection fraction was predicted in a blinded fashion by means of the clinical rule before the actual LVEF test was reviewed. RESULTS We identified 213 patients admitted with the primary discharge diagnosis of acute MI. All patients met standard clinical and enzymatic definitions for acute MI and had at least 1 measure of LVEF, such as echocardiography, ventricular angiography, or gated blood pool scan. The clinical rule predicted that 83 patients (39.0%) would have an LVEF of 40% or greater. Of these 83 patients, 71 had an ejection fraction of 40% or greater, for a positive predictive value of 86%. Of the 12 patients who were incorrectly predicted to have a preserved LVEF, 6 (50%) had an index non-Q-wave anterior MI (P<.001). Reanalyzing the patient population with a fifth variable (anterior non-Q-wave MI) added to the original 4 variables increased the positive predictive value to 91%. CONCLUSION This simple clinical prediction rule has a positive predictive value of 86% when applied in the community hospital setting. Patients with anterior non-Q-wave MI may be 1 group in whom the rule is inaccurate, and expanding the clinical rule to 5 variables may increase the positive predictive value. When a technology-based assessment of left ventricular function is considered in patients after an MI, this prediction rule may allow for a more cost-effective patient selection, and as many as 40% of patients who have had acute MIs may require no testing at all.
Collapse
Affiliation(s)
- K Tobin
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Mich 48086, USA.
| | | | | | | | | | | |
Collapse
|
25
|
Moscucci M, Ricciardi M, Eagle KA, Kline E, Bates ER, Werns SW, Karavite D, Muller DW. Frequency, predictors, and appropriateness of blood transfusion after percutaneous coronary interventions. Am J Cardiol 1998; 81:702-7. [PMID: 9527078 DOI: 10.1016/s0002-9149(97)01018-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Increased awareness of the risks of blood-borne infections has recently led to profound changes in the practice of transfusion medicine. These changes include, among others, the development of guidelines by the American College of Physicians (ACP) for transfusion. Although the incidence and predictors of vascular complications of percutaneous interventions have been well defined, there are currently no data on frequency, risk factors, and appropriateness of blood transfusions. We performed a retrospective analysis of 628 consecutive percutaneous coronary revascularization procedures. Predictors of blood transfusion were identified using multivariate logistic regression analysis. Appropriateness of transfusions was determined using modified ACP guidelines. Transfusions were administered after 8.9% of interventions (56 of 628). Multivariate analysis identified age >70 years, female gender, procedure duration, coronary stenting, acute myocardial infarction, postprocedural use of heparin and intra-aortic balloon pump placement as independent predictors of blood transfusions (all p <0.05). According to the ACP guidelines, 36 of 56 patients (64%) received transfusions inappropriately. Transfusion reactions (fever) occurred in 10% of patients who received tranfusions appropriately and in 5% of patients who received tranfusions inappropriately. The estimated additional costs per procedure related to transfusions were $551 and $419, respectively. In conclusion, unnecessary transfusions were performed frequently after percutaneous coronary interventions. Application of available guidelines could reduce the number of unnecessary transfusions, thus avoiding exposure of patients to additional risks and reducing procedural costs.
Collapse
Affiliation(s)
- M Moscucci
- Heart Care Program, University of Michigan Medical Center, Ann Arbor 48109-0022, USA
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Mehta R, Das S, Nolan E, Kearly G, Karavite D, Russman P, Saran K, Nicklas J, Eagle K. Impact of critical pathway on the management of acute myocardial infarction in the elderly. J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(98)80283-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
27
|
Mehta R, Nolan E, Das S, Kearly G, Karavite D, Russman P, Saran K, Eagle K, Nicklas J. Impact of focal heart attack disclosure document at the time of discharge on the appropriate management of patients with acute myocardial infraction. J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(98)82220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
28
|
Hagan P, Nienaber C, Das S, Evangelista A, Fatton R, Suzuki T, Oh J, Sechtern U, Robles J, Deutsch HJ, Gilon D, Bhakta D, Karavite D, Russman P, Armstrong W, Deeb G, Isselbacher E, Eagle K. Acute aortic dissection: presentation, management and outcomes in 1996 — results from the International Registry for Aortic Dissection (IRAD). J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(98)81580-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
29
|
Dais S, Isselbacher E, Hagan P, Evangelista A, Fatton R, Suzuki T, Oh J, Sechtem U, Marcos J, Robles Y, Deutsch HJ, Gilon D, Bhakta D, Karavite D, Russman P, Armstrong W, Deeb G, Nienaber C, Eagle K. Practice variations in utilization of diagnostic techniques to evaluate acute aortic dissection — results from the international registry of aortic dissection (IRAD). J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(98)80848-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
30
|
Deeb GM, Williams DM, Bolling SF, Quint LE, Monaghan H, Sievers J, Karavite D, Shea M. Surgical delay for acute type A dissection with malperfusion. Ann Thorac Surg 1997; 64:1669-75; discussion 1675-7. [PMID: 9436553 DOI: 10.1016/s0003-4975(97)01100-4] [Citation(s) in RCA: 163] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND An acute type A aortic dissection is considered a surgical emergency. Review of the risk factors for a type A dissection showed that preoperative malperfusion was associated with a 22% (2/9) intraoperative mortality and an 89% (8/9) hospital mortality. Intraoperative deaths were secondary to pulmonary failure resulting from capillary leak; the remaining patients died of multiorgan failure resulting from reperfusion injury. METHODS The surgical delay approach was adopted for malperfused patients, and treatment in these patients included percutaneous reperfusion, with aortic fenestration and branch stenting where appropriate. Twenty patients had a type A dissection and malperfusion shown by pulsed-wave Doppler echocardiography, transesophageal echocardiography, or spiral computed tomographic scanning. Malperfusion was documented by angiography. After reperfusion, all patients' conditions were stabilized in the intensive care unit; intravenous beta-blockers were administered to decrease the maximum rate of increase of left ventricular pressure. Once patients completely recovered from the consequences of malperfusion, surgical repair was performed. Statistical comparison of the non-delay and delay groups was performed using Fisher's exact test and Student's t test. Multiple logistic regression analysis was used to establish independent predictors for mortality. RESULTS The mean delay to repair was 20 days (2 to 67 days). Four (31%) patients were discharged home and readmitted for operation. Three patients (15%) died preoperatively, 1 of retrograde dissection and rupture and 2 of reperfusion injury. Seventeen underwent surgical repair, with two deaths (12%); 15 (75%) were discharged, with an average follow-up of 16.8 months (p < 0.003). Delay was the only independent predictor of outcome. CONCLUSIONS Patients with an acute type A dissection and malperfusion should undergo percutaneous reperfusion, and surgical repair should be delayed until the reperfusion injury resolves.
Collapse
Affiliation(s)
- G M Deeb
- Section of Thoracic Surgery, The University of Michigan Hospitals, Ann Arbor 48109-0344, USA.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Tobin K, Stomel R, Harber D, Karavite D, Eagle K. Validation of a clinical prediction rule for predicting left ventricular function post acute myocardial infarction in a community hospital setting. J Am Coll Cardiol 1996. [DOI: 10.1016/s0735-1097(96)82173-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|