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Honaker SM, Street A, Daftary AS, Downs SM. The Use of Computer Decision Support for Pediatric Obstructive Sleep Apnea Detection in Primary Care. J Clin Sleep Med 2019; 15:453-462. [PMID: 30853049 DOI: 10.5664/jcsm.7674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/15/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To (1) describe outcomes from a computer decision support system (CDSS) for pediatric obstructive sleep apnea (OSA) detection in primary care; and (2) identity the prevalence of children meeting criteria for an OSA referral. METHODS A CDSS for OSA was implemented in two urban primary care clinics. Parents of children (age 2 to 11 years) presenting to the clinic were asked if their child snored regularly, with a positive response resulting in six additional OSA screening items. Primary care providers (PCPs) received a prompt for all snoring children, listing applicable OSA signs and symptoms and recommending further evaluation and referral for OSA. RESULTS A total of 2,535 children were screened for snoring, identifying 475 snoring children (18.7%). Among snoring children, PCPs referred 40 (15.4%) for further evaluation. The prevalence of additional OSA signs and symptoms ranged from 3.5% for underweight to 43.7% for overweight. A total of 74.7% of snoring children had at least one additional sign or symptom and thus met American Academy of Pediatrics guidelines criteria for an OSA referral. CONCLUSIONS A CDSS can be used to support PCPs in identifying children at risk for OSA. Most snoring children met criteria for further evaluation. It will be important to further evaluate this referral threshold as well as the readiness of the sleep medicine field to meet this need. CLINICAL TRIALS REGISTRATION Registry: ClinicalTrials.gov, Title: Evidence-based Diagnosis and Management of Pediatric Obstructive Sleep Apnea in Primary Care, Identifier: NCT02781376, URL: https://clinicaltrials.gov/ct2/show/NCT02781376.
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Affiliation(s)
- Sarah M Honaker
- Pulmonology, Allergy, and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana.,Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ashley Street
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ameet S Daftary
- Pulmonology, Allergy, and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephen M Downs
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
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Honaker SM, Dugan T, Daftary A, Davis S, Saha C, Baye F, Freeman E, Downs SM. Unexplained Practice Variation in Primary Care Providers' Concern for Pediatric Obstructive Sleep Apnea. Acad Pediatr 2018; 18:418-424. [PMID: 29391284 DOI: 10.1016/j.acap.2018.01.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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] [Received: 07/06/2017] [Revised: 01/12/2018] [Accepted: 01/23/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine primary care provider (PCP) screening practice for obstructive sleep apnea (OSA) and predictive factors for screening habits. A secondary objective was to describe the polysomnography completion proportion and outcome. We hypothesized that both provider and child health factors would predict PCP suspicion of OSA. METHODS A computer decision support system that automated screening for snoring was implemented in 5 urban primary care clinics in Indianapolis, Indiana. We studied 1086 snoring children aged 1 to 11 years seen by 26 PCPs. We used logistic regression to examine the association between PCP suspicion of OSA and child demographics, child health characteristics, provider characteristics, and clinic site. RESULTS PCPs suspected OSA in 20% of snoring children. Factors predicting PCP concern for OSA included clinic site (P < .01; odds ratio [OR] = 0.13), Spanish language (P < .01; OR = 0.53), provider training (P = .01; OR = 10.19), number of training years (P = .01; OR = 4.26) and child age (P < .01), with the youngest children least likely to elicit PCP concern for OSA (OR = 0.20). No patient health factors (eg, obesity) were significantly predictive. Proportions of OSA suspicion were variable between clinic sites (range, 6-28%) and between specific providers (range, 0-63%). Of children referred for polysomnography (n = 100), 61% completed the study. Of these, 67% had OSA. CONCLUSIONS Results suggest unexplained small area practice variation in PCP concern for OSA among snoring children. It is likely that many children at risk for OSA remain unidentified. An important next step is to evaluate interventions to support PCPs in evidence-based OSA identification.
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Affiliation(s)
- Sarah Morsbach Honaker
- Pulmonology, Allergy, and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind.
| | - Tamara Dugan
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind
| | - Ameet Daftary
- Pulmonology, Allergy, and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind
| | - Stephanie Davis
- Pulmonology, Allergy, and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind
| | - Chandan Saha
- Department of Biostatistics, Richard M. Fairbanks School of Public Health, Indiana University School of Medicine, Indianapolis, Ind
| | - Fitsum Baye
- Department of Biostatistics, Richard M. Fairbanks School of Public Health, Indiana University School of Medicine, Indianapolis, Ind
| | | | - Stephen M Downs
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind
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Zimet G, Dixon BE, Xiao S, Tu W, Kulkarni A, Dugan T, Sheley M, Downs SM. Simple and Elaborated Clinician Reminder Prompts for Human Papillomavirus Vaccination: A Randomized Clinical Trial. Acad Pediatr 2018; 18:S66-71. [PMID: 29502640 DOI: 10.1016/j.acap.2017.11.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/30/2017] [Accepted: 11/11/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the effects of simple and elaborated health care provider (HCP) reminder prompts on human papillomavirus (HPV) vaccine initiation rates. METHODS Twenty-nine pediatric HCPs serving 5 pediatric clinics were randomized to 1 of 3 arms: 1) usual practice control, 2) simple reminder prompt, and 3) elaborated reminder prompt, which included suggested language for recommending the early adolescent platform vaccines. Prompts were delivered via a computer-based clinical decision support system deployed in the 5 clinics. Eligible patients were ages 11 to 13 years, had not received HPV vaccine, and were due for meningococcal ACWY (MenACWY) vaccine and/or the tetanus, diphtheria, and pertussis booster (Tdap). Receipt of HPV vaccine was determined via automated queries sent to the Indiana immunization registry. Data were analyzed via logistic regression models, with generalized estimating equations used to account for the clustering of patients within HCPs. RESULTS Ten HCPs in the control group saw 301 patients, 8 HCPs in the simple prompt group saw 124, and 11 HCPs in the elaborated prompt group saw 223. The elaborated prompt arm had a higher rate of HPV vaccination (62%) than the control arm (45%): adjusted odds ratio, 2.76; 95% confidence interval, 1.07 to 7.14. The simple prompt arm did not differ significantly from the control arm with respect to HPV vaccine initiation, which might have been because of the small sample size for this arm. MenACWY and Tdap rates did not vary across the 3 arms. CONCLUSIONS Results suggest that an elaborated HCP-targeted reminder prompt, with suggested recommendation language, might improve rates of HPV vaccine initiation.
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Deegan PE, Carpenter-Song E, Drake RE, Naslund JA, Luciano A, Hutchison SL. Enhancing Clients' Communication Regarding Goals for Using Psychiatric Medications. Psychiatr Serv 2017; 68:771-775. [PMID: 28366118 DOI: 10.1176/appi.ps.201600418] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 11/30/2022]
Abstract
OBJECTIVE Discordance between psychiatric care providers' and clients' goals for medication treatment is prevalent and is a barrier to person-centered care. Power statements-short self-advocacy statements prepared by clients in response to a two-part template-offer a novel approach to help clients clarify and communicate their personal goals for using psychiatric medications. This study described the power statement method and examined a sample of power statements to understand clients' goals for medication treatment. METHODS More than 17,000 adults with serious mental illness at 69 public mental health clinics had the option to develop power statements by using a Web application located in the clinic waiting areas. A database query determined the percentage of clients who entered power statements into the Web application. The authors examined textual data from a random sample of 300 power statements by using content analysis. RESULTS Nearly 14,000 (79%) clients developed power statements. Of the 277 statements in the sample deemed appropriate for content analysis, 272 statements had responses to the first part of the template and 230 had responses to the second part. Clients wanted psychiatric medications to help control symptoms in the service of improving functioning. Common goals for taking psychiatric medications (N=230 statements) were to enhance relationships (51%), well-being (32%), self-sufficiency (23%), employment (19%), hobbies (15%), and self-improvement (10%). CONCLUSIONS People with serious mental illness typically viewed medications as a means to pursue meaningful life goals. Power statements appear to be a simple and scalable technique to enhance clients' communication of their goals for psychiatric medication treatment.
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Affiliation(s)
- Patricia E Deegan
- Dr. Deegan is with Pat Deegan Ph.D. & Associates, L.L.C., Byfield, Massachusetts (e-mail: ). Dr. Carpenter-Song is with the Department of Anthropology and Dr. Drake and Mr. Naslund are with the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire. Dr. Luciano is with the Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina. Ms. Hutchison is with the Community Care Behavioral Health Organization, Pittsburgh
| | - Elizabeth Carpenter-Song
- Dr. Deegan is with Pat Deegan Ph.D. & Associates, L.L.C., Byfield, Massachusetts (e-mail: ). Dr. Carpenter-Song is with the Department of Anthropology and Dr. Drake and Mr. Naslund are with the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire. Dr. Luciano is with the Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina. Ms. Hutchison is with the Community Care Behavioral Health Organization, Pittsburgh
| | - Robert E Drake
- Dr. Deegan is with Pat Deegan Ph.D. & Associates, L.L.C., Byfield, Massachusetts (e-mail: ). Dr. Carpenter-Song is with the Department of Anthropology and Dr. Drake and Mr. Naslund are with the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire. Dr. Luciano is with the Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina. Ms. Hutchison is with the Community Care Behavioral Health Organization, Pittsburgh
| | - John A Naslund
- Dr. Deegan is with Pat Deegan Ph.D. & Associates, L.L.C., Byfield, Massachusetts (e-mail: ). Dr. Carpenter-Song is with the Department of Anthropology and Dr. Drake and Mr. Naslund are with the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire. Dr. Luciano is with the Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina. Ms. Hutchison is with the Community Care Behavioral Health Organization, Pittsburgh
| | - Alison Luciano
- Dr. Deegan is with Pat Deegan Ph.D. & Associates, L.L.C., Byfield, Massachusetts (e-mail: ). Dr. Carpenter-Song is with the Department of Anthropology and Dr. Drake and Mr. Naslund are with the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire. Dr. Luciano is with the Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina. Ms. Hutchison is with the Community Care Behavioral Health Organization, Pittsburgh
| | - Shari L Hutchison
- Dr. Deegan is with Pat Deegan Ph.D. & Associates, L.L.C., Byfield, Massachusetts (e-mail: ). Dr. Carpenter-Song is with the Department of Anthropology and Dr. Drake and Mr. Naslund are with the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, New Hampshire. Dr. Luciano is with the Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina. Ms. Hutchison is with the Community Care Behavioral Health Organization, Pittsburgh
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Bennett P, Hardiker NR. The use of computerized clinical decision support systems in emergency care: a substantive review of the literature. J Am Med Inform Assoc 2017; 24:655-668. [PMID: 28031285 PMCID: PMC7651902 DOI: 10.1093/jamia/ocw151] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 09/26/2016] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES : This paper provides a substantive review of international literature evaluating the impact of computerized clinical decision support systems (CCDSSs) on the care of emergency department (ED) patients. MATERIAL AND METHODS : A literature search was conducted using Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase electronic resources, and gray literature. Studies were selected if they compared the use of a CCDSS with usual care in a face-to-face clinical interaction in an ED. RESULTS : Of the 23 studies included, approximately half demonstrated a statistically significant positive impact on aspects of clinical care with the use of CCDSSs. The remaining studies showed small improvements, mainly around documentation. However, the methodological quality of the studies was poor, with few or no controls to mitigate against confounding variables. The risk of bias was high in all but 6 studies. DISCUSSION : The ED environment is complex and does not lend itself to robust quantitative designs such as randomized controlled trials. The quality of the research in ∼75% of the studies was poor, and therefore conclusions cannot be drawn from these results. However, the studies with a more robust design show evidence of the positive impact of CCDSSs on ED patient care. CONCLUSION This is the first review to consider the role of CCDSSs in emergency care and expose the research in this area. The role of CCDSSs in emergency care may provide some solutions to the current challenges in EDs, but further high-quality research is needed to better understand what technological solutions can offer clinicians and patients.
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Affiliation(s)
- Paula Bennett
- Greater Manchester Academic Health Science Network, Citylabs, Manchester, UK
| | - Nicholas R Hardiker
- School of Nursing, Midwifery, Social Work, and Social Sciences, University of Salford, Salford, UK
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Walsh BK, Smallwood C, Rettig J, Kacmarek RM, Thompson J, Arnold JH. Daily Goals Formulation and Enhanced Visualization of Mechanical Ventilation Variance Improves Mechanical Ventilation Score. Respir Care 2017; 62:268-278. [PMID: 28073993 DOI: 10.4187/respcare.04873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/05/2022]
Abstract
BACKGROUND The systematic implementation of evidence-based practice through the use of guidelines, checklists, and protocols mitigates the risks associated with mechanical ventilation, yet variation in practice remains prevalent. Recent advances in software and hardware have allowed for the development and deployment of an enhanced visualization tool that identifies mechanical ventilation goal variance. Our aim was to assess the utility of daily goal establishment and a computer-aided visualization of variance. METHODS This study was composed of 3 phases: a retrospective observational phase (baseline) followed by 2 prospective sequential interventions. Phase I intervention comprised daily goal establishment of mechanical ventilation. Phase II intervention was the setting and monitoring of daily goals of mechanical ventilation with a web-based data visualization system (T3). A single score of mechanical ventilation was developed to evaluate the outcome. RESULTS The baseline phase evaluated 130 subjects, phase I enrolled 31 subjects, and phase II enrolled 36 subjects. There were no differences in demographic characteristics between cohorts. A total of 171 verbalizations of goals of mechanical ventilation were completed in phase I. The use of T3 increased by 87% from phase I. Mechanical ventilation score improved by 8.4% in phase I and 11.3% in phase II from baseline (P = .032). The largest effect was in the low risk VT category, with a 40.3% improvement from baseline in phase I, which was maintained at 39% improvement from baseline in phase II (P = .01). mechanical ventilation score was 9% higher on average in those who survived. CONCLUSIONS Daily goal formation and computer-enhanced visualization of mechanical ventilation variance were associated with an improvement in goal attainment by evidence of an improved mechanical ventilation score. Further research is needed to determine whether improvements in mechanical ventilation score through a targeted, process-oriented intervention will lead to improved patient outcomes. (ClinicalTrials.gov registration NCT02184208.).
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Affiliation(s)
- Brian K Walsh
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Craig Smallwood
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jordan Rettig
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Robert M Kacmarek
- Department of Anesthesia, Critical Care and Pain Medicine, and Respiratory Care Services, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - John Thompson
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - John H Arnold
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
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Walsh BK, Smallwood CD, Rettig JS, Thompson JE, Kacmarek RM, Arnold JH. Categorization in Mechanically Ventilated Pediatric Subjects: A Proposed Method to Improve Quality. Respir Care 2016; 61:1168-78. [PMID: 27303050 DOI: 10.4187/respcare.04723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Thousands of children require mechanical ventilation each year. Although mechanical ventilation is lifesaving, it is also associated with adverse events if not properly managed. The systematic implementation of evidence-based practice through the use of guidelines and protocols has been shown to mitigate risk, yet variation in care remains prevalent. Advances in health-care technology provided the ability to stream data about mechanical ventilation and therapeutic response. Through these advances, a computer system was developed to enable the coupling of physiologic and ventilation data for real-time interpretation. Our aim was to assess the feasibility and utility of a newly developed patient categorization and scoring system to objectively measure compliance with standards of care. METHODS We retrospectively categorized the ventilation and oxygenation statuses of subjects within our pediatric ICU utilizing 15 rules-based algorithms. Targets were predetermined based on generally accepted practices. All patient categories were calculated and presented as a percent score (0-100%) of acceptable ventilation, acceptable oxygenation, barotrauma-free, and volutrauma-free states. RESULTS Two hundred twenty-two subjects were identified and analyzed encompassing 1,578 d of mechanical ventilation. Median age was 3 y, median ideal body weight was 14.7 kg, and 63% were male. The median acceptable ventilation score was 84.6%, and the median acceptable oxygenation score was 70.1% (100% being maximally acceptable). Potential for ventilator-induced lung injury was broken into 2 components: barotrauma and volutrauma. There was very little potential for barotrauma, with a median barotrauma-free state of 100%. Median potential for a volutrauma-free state was 56.1%. CONCLUSIONS We demonstrate the first patient categorization system utilizing a coordinated data-banking system and analytics to determine patient status and a surveillance of mechanical ventilation quality. Further research is needed to determine whether interventions such as visual display of variance from goal and patient categorization summaries can improve outcomes. (ClinicalTrials.gov registration NCT02184208.).
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Affiliation(s)
- Brian K Walsh
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital and Pediatric Anesthesia, Harvard Medical School, Boston, Massachusetts.
| | - Craig D Smallwood
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital and Pediatric Anesthesia, Harvard Medical School, Boston, Massachusetts. Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jordan S Rettig
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital and Pediatric Anesthesia, Harvard Medical School, Boston, Massachusetts
| | - John E Thompson
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital and Pediatric Anesthesia, Harvard Medical School, Boston, Massachusetts
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts
| | - John H Arnold
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital and Pediatric Anesthesia, Harvard Medical School, Boston, Massachusetts
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Schmiege SJ, Gance-Cleveland B, Gilbert L, Aldrich H, Gilbert KC, Barton A. Identifying patterns of obesity risk behavior to improve pediatric primary care. J SPEC PEDIATR NURS 2016; 21:18-28. [PMID: 26412397 DOI: 10.1111/jspn.12131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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] [Received: 04/16/2015] [Revised: 08/04/2015] [Accepted: 08/20/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE To develop profiles of obesity risk behaviors for children and adolescents. DESIGN AND METHODS Risk assessments were obtained from patients (n = 971) at a school-based health center. Latent class analysis was used to create subgroups based on seven indicators measuring diet, activity, and screen time. RESULTS Four classes emerged, with 44% classified as the "Healthiest," 8% as the "Least Healthy," 37% as "Mixed Diet/Low Activity/Low Screen Time," and 11% as "Mixed Diet/High Activity/High Screen Time." Several demographic predictors distinguished the classes. PRACTICE IMPLICATIONS Obesity risk factor profiles may help providers identify strengths and risks, tailor counseling, and plan interventions with families.
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Affiliation(s)
- Sarah J Schmiege
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Bonnie Gance-Cleveland
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lynn Gilbert
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Heather Aldrich
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Amy Barton
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
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Evans RS, Olson JA, Stenehjem E, Buckel WR, Thorell EA, Howe S, Wu X, Jones PS, Lloyd JF. Use of computer decision support in an antimicrobial stewardship program (ASP). Appl Clin Inform 2015; 6:120-35. [PMID: 25848418 DOI: 10.4338/aci-2014-11-ra-0102] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 11/04/2014] [Accepted: 01/20/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Document information needs, gaps within the current electronic applications and reports, and workflow interruptions requiring manual information searches that decreased the ability of our antimicrobial stewardship program (ASP) at Intermountain Healthcare (IH) to prospectively audit and provide feedback to clinicians to improve antimicrobial use. METHODS A framework was used to provide access to patient information contained in the electronic medical record, the enterprise-wide data warehouse, the data-driven alert file and the enterprise-wide encounter file to generate alerts and reports via pagers, emails and through the Centers for Diseases and Control's National Healthcare Surveillance Network. RESULTS Four new applications were developed and used by ASPs at Intermountain Medical Center (IMC) and Primary Children's Hospital (PCH) based on the design and input from the pharmacists and infectious diseases physicians and the new Center for Diseases Control and Prevention/National Healthcare Safety Network (NHSN) antibiotic utilization specifications. Data from IMC and PCH now show a general decrease in the use of drugs initially targeted by the ASP at both facilities. CONCLUSIONS To be effective, ASPs need an enormous amount of "timely" information. Members of the ASP at IH report these new applications help them improve antibiotic use by allowing efficient, timely review and effective prioritization of patients receiving antimicrobials in order to optimize patient care.
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Affiliation(s)
- R S Evans
- Medical Informatics, Intermountain Healthcare, University of Utah , Salt Lake City, Utah ; Biomedical Informatics, University of Utah, University of Utah , Salt Lake City, Utah
| | - J A Olson
- Pharmacy, Primary Children's Medical Center, University of Utah , Salt Lake City, Utah
| | - E Stenehjem
- Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, University of Utah , Salt Lake City, Utah
| | - W R Buckel
- Pharmacy, Intermountain Medical Center, University of Utah , Salt Lake City, Utah
| | - E A Thorell
- Pediatric Infectious Diseases, University of Utah , Salt Lake City, Utah
| | - S Howe
- Medical Informatics, Intermountain Healthcare, University of Utah , Salt Lake City, Utah
| | - X Wu
- Medical Informatics, Intermountain Healthcare, University of Utah , Salt Lake City, Utah
| | - P S Jones
- Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, University of Utah , Salt Lake City, Utah
| | - J F Lloyd
- Medical Informatics, Intermountain Healthcare, University of Utah , Salt Lake City, Utah
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Tamblyn R, Ernst P, Winslade N, Huang A, Grad R, Platt RW, Ahmed S, Moraga T, Eguale T. Evaluating the impact of an integrated computer-based decision support with person-centered analytics for the management of asthma in primary care: a randomized controlled trial. J Am Med Inform Assoc 2015; 22:773-83. [PMID: 25670755 PMCID: PMC4482273 DOI: 10.1093/jamia/ocu009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/23/2014] [Indexed: 11/28/2022] Open
Abstract
Background Computer-based decision support has been effective in providing alerts for preventive care. Our objective was to determine whether a personalized asthma management computer-based decision support increases the quality of asthma management and reduces the rate of out-of-control episodes. Methods A cluster-randomized trial was conducted in Quebec, Canada among 81 primary care physicians and 4447 of their asthmatic patients. Patients were followed from the first visit for 3–33 months. The physician control group used the Medical Office of the 21st century (MOXXI) system, an integrated electronic health record. A custom-developed asthma decision support system was integrated within MOXXI and was activated for physicians in the intervention group. Results At the first visit, 9.8% (intervention) to 12.9% (control) of patients had out-of-control asthma, which was defined as a patient having had an emergency room visit or hospitalization for respiratory-related problems and/or more than 250 doses of fast-acting β-agonist (FABA) dispensed in the past 3 months. By the end of the trial, there was a significant increase in the ratio of doses of inhaled corticosteroid use to fast-acting β-agonist (0.93 vs. 0.69: difference: 0.27; 95% CI: 0.02–0.51; P = 0.03) in the intervention group. The overall out-of-control asthma rate was 54.7 (control) and 46.2 (intervention) per 100 patients per year (100 PY), a non-significant rate difference of −8.7 (95% CI: −24.7, 7.3; P = 0.29). The intervention’s effect was greater for patients with out-of-control asthma at the beginning of the study, a group who accounted for 44.7% of the 5597 out-of-control asthma events during follow-up, as there was a reduction in the event rate of −28.4 per 100 PY (95% CI: −55.6, −1.2; P = 0.04) compared to patients with in-control asthma at the beginning of the study (−0.08 [95% CI: −10.3, 8.6; P = 0.86]). Discussion This study evaluated the effectiveness of a novel computer-assisted ADS system that facilitates systematic monitoring of asthma control status, follow-up of patients with out of control asthma, and evidence-based, patient-specific treatment recommendations. We found that physicians were more likely to use ADS for out-of-control patients, that in the majority of these patients, they were advised to add an inhaled corticosteroid or a leukotriene inhibitor to the patient s treatment regimen, and the intervention significantly increased the mean ratio of inhaled corticosteroids to FABA during follow-up. It also reduced the rate of out-of-control episodes during follow up among patients whose asthma was out-of-control at the time of study entry. Future research should assess whether coupling patient-specific treatment recommendations, automated follow-up, and home care with comparative feedback on quality and outcomes of care can improve guideline adoption and care outcomes. Conclusions A primary care-personalized asthma management system reduced the rate of out-of-control asthma episodes among patients whose asthma was poorly controlled at the study’s onset. Trial Registration Clinicaltrials.gov Identifier: NCT00170248 http://clinicaltrials.gov/ct2/show/NCT00170248?term=Asthma&spons=McGill+University&state1=NA%3ACA%3AQC&rank=2
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Affiliation(s)
- Robyn Tamblyn
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Nancy Winslade
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Allen Huang
- Division of Geriatric Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Roland Grad
- Herzl Family Practice Centre, Jewish General Hospital, Montreal, QC, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Sara Ahmed
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Teresa Moraga
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Tewodros Eguale
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
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Fox CH, Vest BM, Kahn LS, Dickinson LM, Fang H, Pace W, Kimminau K, Vassalotti J, Loskutova N, Peterson K. Improving evidence-based primary care for chronic kidney disease: study protocol for a cluster randomized control trial for translating evidence into practice (TRANSLATE CKD). Implement Sci 2013; 8:88. [PMID: 23927603 PMCID: PMC3751479 DOI: 10.1186/1748-5908-8-88] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 07/17/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) and end stage renal disease (ESRD) are steadily increasing in prevalence in the United States. While there is reasonable evidence that specific activities can be implemented by primary care physicians (PCPs) to delay CKD progression and reduce mortality, CKD is under-recognized and undertreated in primary care offices, and PCPs are generally not familiar with treatment guidelines. The current study addresses the question of whether the facilitated TRANSLATE model compared to computer decision support (CDS) alone will lead to improved evidence-based care for CKD in primary care offices. METHODS/DESIGN This protocol consists of a cluster randomized controlled trial (CRCT) followed by a process and cost analysis. Only practices providing ambulatory primary care as their principal function, located in non-hospital settings, employing at least one primary care physician, with a minimum of 2,000 patients seen in the prior year, are eligible. The intervention will occur at the cluster level and consists of providing CKD-specific CDS versus CKD-specific CDS plus practice facilitation for all elements of the TRANSLATE model. Patient-level data will be collected from each participating practice to examine adherence to guideline-concordant care, progression of CKD and all-cause mortality. Patients are considered to meet stage three CKD criteria if at least two consecutive estimated glomerular filtration rate (eGFR) measurements at least three months apart fall below 60 ml/min. The process evaluation (cluster level) will determine through qualitative methods the fidelity of the facilitated TRANSLATE program and find the challenges and enablers of the implementation process. The cost-effectiveness analysis will compare the benefit of the intervention of CDS alone against the intervention of CDS plus TRANSLATE (practice facilitation) in relationship to overall cost per quality adjusted years of life. DISCUSSION This study has three major innovations. First, this study adapts the TRANSLATE method, proven effective in diabetes care, to CKD. Second, we are creating a generalizable CDS specific to the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines for CKD. Additionally, this study will evaluate the effects of CDS versus CDS with facilitation and answer key questions regarding the cost-effectiveness of a facilitated model for improving CKD outcomes. The study is testing virtual facilitation and Academic detailing making the findings generalizable to any area of the country. TRIAL REGISTRATION Registered as NCT01767883 on clinicaltrials.gov
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Affiliation(s)
- Chester H Fox
- Department of Family Medicine, State University of New York – University at Buffalo, 77 Goodell St, Buffalo, NY 14203, USA
| | - Bonnie M Vest
- Department of Family Medicine, State University of New York – University at Buffalo, 77 Goodell St, Buffalo, NY 14203, USA
| | - Linda S Kahn
- Department of Family Medicine, State University of New York – University at Buffalo, 77 Goodell St, Buffalo, NY 14203, USA
| | - L Miriam Dickinson
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hai Fang
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Denver, Denver, CO, USA
| | - Wilson Pace
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- American Academy of Family Physicians National Research Network, Leawood, USA
| | - Kim Kimminau
- American Academy of Family Physicians National Research Network, Leawood, USA
- Department of Family Medicine, University of Kansas School of Medicine, Kansas, USA
| | - Joseph Vassalotti
- Division of Nephrology, Mount Sinai Medical Center, New York, USA
- National Kidney Foundation, New York, USA
| | - Natalia Loskutova
- American Academy of Family Physicians National Research Network, Leawood, USA
| | - Kevin Peterson
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Abstract
Glycemic control with intensive insulin therapy (IIT) has received widespread adoption secondary to findings of improved clinical outcomes and survival in the burn population. Severe burn as a model for trauma is characterized by a hypermetabolic state, hyperglycemia, and insulin resistance. In this article, we review the findings of a burn center research facility in terms of understanding glucose management. The conferred benefits from IIT, our findings of poor outcomes associated with glycemic variability, advantages from preserved diurnal variation of glucose and insulin, and impacts of glucometer error and hematocrit correction factor are discussed. We conclude with direction for further study and the need for a reliable continuous glucose monitoring system. Such efforts will further the endeavor for achieving adequate glycemic control in order to assess the efficacy of target ranges and use of IIT.
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Affiliation(s)
- Elizabeth A Mann
- U.S. Army Institute of Surgical Research, Brooke Army Medical Center, San Antonio, Texas 78234-6315, USA.
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