Accuracy of Electronic Health Record-Derived Data for the Identification of Incident ADHD

OBJECTIVE

To assess the accuracy of electronic health record (EHR)-derived diagnoses in identifying children with incident (i.e., newly diagnosed) ADHD.

METHOD

In 10 large health care organizations, electronic diagnoses data were used to identify all potential cases of incident ADHD among 3- through 9-year-old children. A random sample of records was manually reviewed to determine whether a diagnosis of ADHD was documented in clinician notes.

RESULTS

From electronic diagnoses data, a total of 7,362 children with incident ADHD were identified. Upon manual review of 500 records, the diagnosis of incident ADHD was confirmed in clinician notes for 71.5% (95% confidence interval [CI] = [56.5, 86.4]) of records for 3- through 5-year-old children and 73.6% (95% CI = [65.6, 81.6]) of records for 6- through 9-year-old children.

CONCLUSION

Studies predicated on the identification of incident ADHD cases will need to carefully consider study designs that minimize the likelihood of case misclassification.

Pharmacotherapy for incident attention-deficit/hyperactivity disorder: practice patterns and quality metrics

INTRODUCTION

This study examines incident treatment patterns for attention-deficit/hyperactivity disorder (ADHD) in children seen in eight integrated healthcare delivery systems and identifies factors associated with adherence to Healthcare Effectiveness Data and Information Set (HEDIS) quality measures developed by the National Committee for Quality Assurance (NCQA).

METHOD

A retrospective cohort analysis using electronic healthcare data from children aged 3 through 17 years with newly diagnosed ADHD between January 1, 2009 and December 31, 2010 was conducted. NCQA quality definitions for initiation and for continuation and maintenance (C&M) of ADHD medications were expanded to include preschoolers and adolescents. Poisson regression models with robust error variance were used to evaluate the association between NCQA HEDIS adherence measures, provider type, patient characteristics and care process measures.

RESULTS

Of 6864 children aged 3-17 years old qualifying for incident treatment analyses, 5538 (80.7%) were started on ADHD medication within a year of diagnosis. Adherence to NCQA HEDIS measures was 49.8% for initiation and 45.8% for C&M, with adherence rates higher for mental health than non-mental health providers, school-aged children than adolescents, and for patients concurrently on other psychotropic medications than those who were not. Of those started on ADHD medication, 62.3% were not eligible for C&M analyses according to HEDIS guidelines, because they did not receive continuous (210 of 300 days) ADHD medication treatment, with adolescents less likely than school-aged children to persist with medications.

CONCLUSION

Study limitations must be considered, including reliance on electronic medical record data, absence of patient race and sociodemographic data, and limited generalizability to other care contexts. Nevertheless, findings suggest novel strategies are needed to improve the quality of ADHD care processes for children of all ages, because even within integrated delivery systems less than half of children with ADHD received care consistent with NCQA HEDIS standards for initiation and C&M care. RESULTS suggest the need to refine quality measures by including follow-up care in those children not receiving or discontinuing medication treatment, a considerable quality concern not currently captured in NCQA HEDIS standards.

Medication exposure in pregnancy risk evaluation program: the prevalence of asthma medication use during pregnancy

Asthma is one of the most common chronic diseases in women of reproductive age, occurring in up to 8 % of pregnancies. The objective of this study is to assess the prevalence of asthma medication use during pregnancy in a large diverse cohort. We identified women aged 15-45 years who delivered a live born infant between 2001 and 2007 across 11 U.S. health plans within the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). Using health plans' administrative and claims data, and birth certificate data, we identified deliveries for which women filled asthma medications from 90 days before pregnancy through delivery. Prevalence (%) was calculated for asthma diagnosis and medication dispensing. There were 586,276 infants from 575,632 eligible deliveries in the MEPREP cohort. Asthma prevalence among mothers was 6.7 %, increasing from 5.5 % in 2001 to 7.8 % in 2007. A total of 9.7 % (n = 55,914) of women were dispensed asthma medications during pregnancy. The overall prevalence of maintenance-only medication, rescue-only medication, and combined maintenance and rescue medication was 0.6, 6.7, and 2.4 % respectively. The prevalence of maintenance-only use doubled during the study period from 0.4 to 0.8 %, while rescue-only use decreased from 7.4 to 5.8 %. In this large population-based pregnancy cohort, the prevalence of asthma diagnoses increased over time. The dispensing of maintenance-only medication increased over time, while rescue-only medication dispensing decreased over time.

Oncologists' attitudes toward KRAS testing: a multisite study

Recent discoveries promise increasingly to help oncologists individually tailor anticancer therapy to their patients’ molecular tumor characteristics. One such promising molecular diagnostic is Kirsten ras (KRAS) tumor mutation testing for metastatic colorectal cancer (mCRC) patients. In the current study, we examined how and why physicians adopt KRAS testing and how they subsequently utilize the information when discussing treatment strategies with patients. We conducted 34 semi-structured in-person or telephone interviews with oncologists from seven different health plans. Each interview was audiotaped, transcribed, and coded using qualitative research methods. Information and salient themes relating to the research questions were summarized for each interview. All of the oncologists in this study reported using the KRAS test at the time of the interview. Most appeared to have adopted the test rapidly, within 6 months of the publication of National Clinical Guidelines. Oncologists chose to administer the test at various time points, although the majority ordered the test at the time their patient was diagnosed with mCRC. While oncologists expressed a range of opinions about the KRAS test, there was a general consensus that the test was useful and provided benefits to mCRC patients. The rapid adoption and enthusiasm for KRAS suggests that these types of tests may be filling an important informational need for oncologists when making treatment decisions. Future research should focus on the informational needs of patients around this test and whether patients feel informed or confident with their physicians’ use of these tests to determine treatment access.

Trends in the use of antiepileptic drugs among pregnant women in the US, 2001-2007: a medication exposure in pregnancy risk evaluation program study

BACKGROUND

Little is known about the extent of antiepileptic drug (AED) use in pregnancy, particularly for newer agents. Our objective was to assess whether AED use has increased among pregnant women in the US, 2001-2007.

METHODS

  We analysed data from the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP) database, 1 January 2001 to 31 December 2007. We identified liveborn deliveries among women, aged 15-45 years on delivery date, who were members of MEPREP health plans (n=585615 deliveries). Pregnancy exposure to AEDs, determined through outpatient pharmacy dispensing files. Older AEDs were available for clinical use before 1993; other agents were considered newer AEDs. Information on sociodemographic and medical/reproductive factors was obtained from linked birth certificate files. Maternal diagnoses were identified based on ICD-9 codes.

RESULTS

  Prevalence of AED use during pregnancy increased between 2001 (15.7 per 1000 deliveries) and 2007 (21.9 per 1000 deliveries), driven primarily by a fivefold increase in the use of newer AEDs. Thirteen per cent of AED-exposed deliveries involved a combination of two or more AEDs. Psychiatric disorders were the most prevalent diagnoses, followed by epileptic and pain disorders, among AED users regardless of AED type, year of conception or gestational period.

CONCLUSIONS

  AED use during pregnancy increased between 2001 and 2007, driven by a fivefold increase in the use of newer AEDs. Nearly one in eight AED-exposed deliveries involved the concomitant use of more than one AED. Additional investigations of the reproductive safety of newer AEDs may be needed.

Development of clinical pharmacy productivity metrics

PURPOSE

The development of an automated tool to quantify decentralized clinical pharmacists' productivity at a large metropolitan hospital is described.

SUMMARY

From 2008 to 2010, pharmacy administration, clinical pharmacy, and information technology (IT) staff at Regions Hospital in St. Paul, Minnesota, developed a tool to identify, abstract, and report measures of clinical pharmacy productivity. The primary goal was to create automated metrics to accurately and comprehensively collect relevant clinical data without adding to the clinical pharmacy or administrative staff workload. Electronically captured measurable clinical activities were identified by staff, and methods to extract these data from the electronic medical record (EMR) were developed by IT staff using existing EMR variables. These activities included verification of orders, entry of oral orders, discontinuation of orders, patient profile review, preparation of progress notes, reporting of unexpected medication events, and responses to emergency resuscitation codes. Decentralized pharmacists were asked to weigh each activity relative to other activities on the basis of the average time and cognitive skill required to complete a specific intervention. Reports were generated and extracted into a database for data analysis, data graphing, and final-report generation.

CONCLUSION

Implementation of an automated tool derived from the EMR and developed by clinical and IT staff allowed decentralized clinical pharmacists' activities to be captured electronically and reported quarterly and annually. Weighted metrics enabled the quantification of pharmacists' clinical activities.

Validation of genomic markers that predict distant recurrence risk via FISH assays in women with early stage breast carcinoma

10506

Background: Biomarkers offer the potential to better predict recurrence risk in early stage invasive breast cancer, especially if adaptable to common assays such as fluorescent in situ hybridization (FISH). We studied the ability of tumor copy numbers (CN) of 3 genes, BIRC5, CYP24, and PDCD6IP, to predict distant recurrence in women with breast cancer. Methods: We conducted a blinded, multi-site study of 350 women with lymph node negative, estrogen/progesterone receptor positive (ER/PR+), invasive ductal carcinomas with archived paraffin-embedded biopsy specimens available. Eligible women received local surgical and radiation treatment only (93) (LTO) or local treatment and tamoxifen therapy only (257), and had distant metastases or no evidence of distant recurrence with at least 5 years follow-up (FU). Tumors were subjected to FISH with DNA probes for the 3 genes to assess CN. A prognostic index (PI) was calculated for each patient based on the 3 genes’ CN. A predetermined threshold (3.0) was used to categorize PI's as low or high. Data were assessed by Fisher's exact analysis and by categorical and continuous Cox modeling. Results: The study included 350 women with Stage I (288) and II (62) disease. FU averaged 7.3 years. Distant recurrence occurred in 32 women (9.1%) overall and in 5.2% of women with Stage I disease. In a multivariate Cox analysis including continuous PI, age, tamoxifen treatment, grade, and tumor size, PI remained a significant predictor of recurrence for Stage I patients: OR=1.56, p=0.019, and Stage I/LTO patients: OR=6.02, p=0.00007. Using the PI as a categorical classifier, the high/low recurrence rates were significantly different: OR=2.24, p= 0.045. Similar results were seen in Stage I patients: OR=3.53, p=0.021 with recurrence rates of 3.5% and 11.5% in the low and high risk groups, respectively, and for the Stage I/LTO patients: OR=5.33, p=0.041. Conclusions: FISH analysis of 3 genes allows metastasis risk prediction in women with early stage ER/PR+ cancers. This may be particularly useful for Stage I cancers traditionally considered low risk. The markers are prognostic in that they predict metastasis in patients receiving only local therapy.

No significant financial relationships to disclose.