Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

We sought proof of concept of a Big Data Solution incorporating longitudinal structured and unstructured patient-level data from electronic health records (EHR) to predict graft loss (GL) and mortality. For a quality improvement initiative, GL and mortality prediction models were constructed using baseline and follow-up data (0-90 days posttransplant; structured and unstructured for 1-year models; data up to 1 year for 3-year models) on adult solitary kidney transplant recipients transplanted during 2007-2015 as follows: Model 1: United Network for Organ Sharing (UNOS) data; Model 2: UNOS & Transplant Database (Tx Database) data; Model 3: UNOS, Tx Database & EHR comorbidity data; and Model 4: UNOS, Tx Database, EHR data, Posttransplant trajectory data, and unstructured data. A 10% 3-year GL rate was observed among 891 patients (2007-2015). Layering of data sources improved model performance; Model 1: area under the curve (AUC), 0.66; (95% confidence interval [CI]: 0.60, 0.72); Model 2: AUC, 0.68; (95% CI: 0.61-0.74); Model 3: AUC, 0.72; (95% CI: 0.66-077); Model 4: AUC, 0.84, (95 % CI: 0.79-0.89). One-year GL (AUC, 0.87; Model 4) and 3-year mortality (AUC, 0.84; Model 4) models performed similarly. A Big Data approach significantly adds efficacy to GL and mortality prediction models and is EHR deployable to optimize outcomes.

Patients seen in a dermatology clinic have unmet preventive health care needs.

Dermatologists provide special expertise in the care of patients with skin disease, whereas primary care providers have special expertise in preventive care. Patients bypassing their primary care provider to use dermatologists directly may miss an opportunity for identification of preventive health needs. We conducted a pilot study to determine whether patients seeing a dermatologist have unmet general preventive health care needs. A 1-page assessment was developed in accordance with the US Preventive Services Task Force guidelines and was distributed to a convenience sample of 161 patients in a dermatology clinic. Unmet needs were identified in the areas of screening tests, counseling, immunizations, vitamins, and replacement hormones. Of subjects aged 25 to 64 years, 94% without a primary care provider had unmet needs compared with 28% of subjects with a primary care provider. We found that patients seeing a dermatologist often had unmet preventive health needs. Dermatologists and primary care providers must work together to provide optimal skin care and preventive health care needs for the patient.

Factors influencing use of the prostate-specific antigen screening test in primary care.

OBJECTIVE: To evaluate the use of the prostate-specific antigen (PSA) test and digital rectal examination (DRE) in prostate cancer screening by primary care physicians. STUDY DESIGN: Physician survey and retrospective medical record review. METHODS: We randomly selected and reviewed the medical records of 3 cross-sectional samples of male patients and surveyed their primary care physicians at 1-year intervals. All the physicians practiced in Colorado. The study spanned 3 years, including late 1992, when the American Cancer Society recommended the use of PSA in a prostate cancer screening guideline. RESULTS: We reviewed the medical records of 4772 male patients and surveyed 109 primary care physicians. We found that PSA testing for men aged 50 or older increased significantly from 1992 to 1994, from 24% in 1992 to 35% in 1993 and 40% in 1994 (overall odds ratio, 2.94; P < .05). Over the same time period, the DRE rate remained relatively unchanged (39% in 1992, 41% in 1993, and 36% in 1994). Overall PSA use was positively associated with patient age greater than 59 years, patient non-smoking status, physician "readiness to change cancer screening behavior," private insurance status, and nonsolo practice. Before the release of a prostate cancer screening guideline, participating physicians cited the American Cancer Society as the organization that most influenced their practice with respect to cancer screening. The magnitude of the reported influence of the American Cancer Society was correlated with the subsequent use of PSA in 1994 by primary care physicians after adjustment for change in DRE and baseline PSA rates, although the association did not reach statistical significance in multivariable regression models. CONCLUSIONS: Primary care physicians in Colorado significantly increased their use of the PSA test from 1992 to 1994, during which time the American Cancer Society issued a guideline recommending the use of PSA for prostate cancer screening. The reported influence of the American Cancer Society on cancer screening practices correlated with the subsequent increase in PSA testing.

Physician and patient predictors of health maintenance visits.

BACKGROUND: Because of a strong association between health maintenance visits (HMVs) and cancer screening, knowledge of the predictors of an HMV have implications for screening. OBJECTIVE: To examine the association of an HMV with patient, physician, and practice characteristics in the primary care setting. DESIGN: A statewide study of cancer screening was conducted in Colorado to determine concordance with the National Cancer Institute's guidelines for screening for breast, cervical, prostate, and skin cancer. Medical records form patients were randomly chosen from primary care practices. Predictors of an HMV were determined by fitting a logistic model to baseline data, adjusting for the cluster sampling of patients within practices. SETTING: Nonacademic primary care practices in Colorado. PARTICIPANTS: A total of 5746 patients aged 42 to 74 years from 132 primary care practices. MAIN OUTCOME MEASURE: Whether a patient had an HMV in the previous year. RESULTS: Of all patients, 31% had an HMV in the previous year. Patient characteristics associated with having HMVs included nonsmoking status, odds ratio (OR) (95% confidence interval [CI]) of 1.27 (1.11-1.46), age, and sex. Women aged 50 to 69 years were significantly more likely to have an HMV than men aged 50 to 69 years (OR, 1.30; 95% CI, 1.10-1.54). Among adults aged 70 years and older, there were no significant sex differences in receiving HMVs. Physician and practice characteristics associated with providing HMVs included practice size (> or = 3 full-time physicians) (OR, 1.34; 95% CI, 1.01-1.77), physician contemplation of changing approaches to cancer screening (OR, 1.33; 95% CI, 1.04-1.70), and physician female sex (OR, 1.33; 95% CI, 1.04-1.70). Physician age and specialty (general internist or family physician) were not associated with the level of health maintenance delivery. CONCLUSION: Certain subgroups, such as smokers, patients in smaller practices, and physicians not yet considering changing their approach to cancer screening, could be targeted in future intervention studies designed to provide preventive services in primary care settings.

Physicians in training as quality managers: survival strategy for academic health centers.

Being responsible for medical education places academic health centers at a disadvantage in competing for managed care contracts. Although many suggestions have been made for changing medical education to produce physicians who are better prepared for the managed care environment, few studies have shown how physicians in training can actually contribute to the competitiveness of an academic health center. We present three examples of engaging trainees in projects with a population-based perspective that demonstrate how quality improvement for the academic health center can be operationalized and even led by physicians in training. In addition to gaining experience in a managed care skill that is increasingly important for future employment, physicians in training can simultaneously improve the quality of care delivered through the academic health center.

Increasing influenza immunization among high-risk patients: education or financial incentive?

PURPOSE: To determine whether an educational brochure or a lottery-type incentive increases influenza immunization rates. PATIENTS AND METHODS: In a prospective, single-blind factorial design randomized trial at an urban community health center, all high-risk patients (n = 797) seen in the preceding 18 months were randomly assigned to one of four groups: a control group; a group mailed a large print, illustrated educational brochure emphasizing factors important to patients in making a decision about influenza immunization; a group mailed a lottery-type incentive announcing that all patients receiving influenza immunization would be eligible for grocery gift certificates; and a group mailed both educational brochure and incentive. Immunization was free, available without an appointment, and recorded by a computerized tracking system. RESULTS: The group mailed the brochure was more likely to be immunized than control (odds ratio [OR] = 2.29, 95% confidence interval [CI] 1.45 to 3.61), as was the group mailed the incentive (OR = 1.68, 95% CI 1.05 to 2.68), but there was no difference between the group mailed both interventions and the control group. The effectiveness of the brochure was more striking for individuals who had not accepted immunization in the prior year (OR = 4.21, 95% CI 2.48 to 7.14), suggesting a true educational effect rather than simply a reminder. CONCLUSION: In this community health center setting, an illustrated educational brochure increased influenza immunization among high-risk patients, a lottery-type incentive was much less effective, and both together was not effective.

Health-related messages in consumer magazine advertising.

OBJECTIVE: To characterize the patterns of health-related messages in consumer advertising from U.S. magazines. DESIGN: Observational survey of advertisements occupying a third of a page or more from the January 1994 issues of the 11 most popular consumer magazines. MEASUREMENTS AND MAIN RESULTS: Health messages were present in 22.8% (85/372) of all the advertisements reviewed. Of the advertisement categories (prescription medication, over-the-counter medication, exercise-related product, health service, health device, diet/health-related food, and other), over-the-counter medications were the most common among the advertisements that had health messages (32.9%, 28/85) (7.5% of the total advertisements, 28/372). The five advertisements for prescription medications were duplications of two different advertisements, one for a hair promotion product and one for hormone replacement therapy. Products related to diet and exercise together represented 29.4% (25/85) of all advertisements with health messages. Three advertisements (3.5%) were for health devices, and five (5.9%) were for health services. CONCLUSIONS: Health-related messages are frequent in consumer advertising. The effects of health marketing on consumer protection, health care costs, and the physician-patient relationship are discussed.

Emergency medical transport of the elderly: a population-based study.

Patterns of utilization of emergency medical services transport (EMS) by the elderly are poorly understood. We determined population-based rates of EMS utilization by the elderly and characterized utilization patterns by age, gender, race, and reason for transport. This observational, population-based study was conducted in Forsyth County, NC, a semi-urban county served by one convalescent ambulance service and one EMS service. Using data on all 1990 EMS transports and the 1990 U.S. census data, age-, gender-, and race-specific transport rates for persons aged 60 or older were calculated. Reasons for transport and frequency of repeat users were established. After exclusion of transports because of an address outside the county, a nonhospital destination, a scheduled transport, or missing data, 4,688 transports (78% of total) remained for analysis. The overall rate of transport was 104/1,000 county residents. Transport rates increased for successively older five-year age groups, demonstrating a 5.7-fold stepwise increase from ages 60-65 to 85+ (51/1,000 to 291/1,000). There was no difference in mean age between patients who were frequent EMS users (more than three transports during the year) (n = 66) and other elderly transportees. Reasons for transport differed little between those 60 to 84 years of age and those 85 years of age and older with the exception of chest pain, cardiac arrest, and seizures, all of which were significantly more prevalent in the younger age group.(ABSTRACT TRUNCATED AT 250 WORDS)

Teleform scannable data entry: an efficient method to update a community-based medical record? Community care coordination network Database Group.

Community-based multi-disciplinary care of chronically ill individuals frequently requires the efforts of several agencies and organizations. The Community Care Coordination Network (CCCN) is an effort to establish a community-based clinical database and electronic communication system to facilitate the exchange of pertinent patient data among primary care, community-based and hospital-based providers. In developing a primary care based electronic record, a method is needed to update records from the field or remote sites and agencies and yet maintain data quality. Scannable data entry with fixed fields, optical character recognition and verification was compared to traditional keyboard data entry to determine the relative efficiency of each method in updating the CCCN database.

Community surveillance of falls among the elderly using computerized EMS transport data.

Because falls are common among the elderly and are associated with high morbidity and mortality, community surveillance has been recommended. The purpose of this study was to characterize the impact of falls among the elderly on emergency medical transport services (EMS) and to explore the potential for community surveillance of falls through the use of computerized EMS data. Computerized EMS data and United States census data for 1990 for persons aged > or = 65 in Forsyth County, NC, were used to produce EMS transport rates for falls and to make comparisons by age, gender, race, and residence (nursing home vs community). A fall was reported as the cause for EMS summons in 15.1% (613 of 4,058) of cases. Transport rates in 1990 for falls were 7.8 per 1,000, 25.4 per 1,000, and 58.5 per 1,000 for the age groups of 65 to 74 years, 75 to 84 years, and 85 years and older. Rates were higher for females than for males (17.1 per 1,000 v 8.1 per 1,000) and higher for whites than for African-Americans (14.3 per 1,000 v 10.3 per 1,000). Rates for nursing home residents were four times that of community residents (70.6 per 1,000 v 16.0 per 1,000). Over 50% of nursing home fallers were transported between midnight and 0400 compared with 25% of community dwellers. EMS summons for older adults reporting a fall accounts for a significant portion (15%) of all transports in this county. Computerized EMS data demonstrated patterns of falls among the elderly that are consistent with known demographic factors. The potential for using computerized EMS data as a practical means of community surveillance should be further explored.

A practice-based information system for multi-disciplinary care of chronically ill patients: what information do we need? The Community Care Coordination Network Database Group.

Primary care physicians provide longitudinal care for chronically ill individuals in concert with many other community-based disciplines. The care management of these individuals requires data not traditionally collected during the care of well, or acutely ill individuals. These data not only concern the patient, in the form of patient functional status, mental status and affect, but also pertain to the caregiver, home environment, and the formal community health and social service system. The goal of the Community Care Coordination Network is to build a primary care-based information system to share patient data and communicate patient related information among the community-based multi-disciplinary teams. One objective of the Community Care Coordination Network is to create a Community Care Database for chronically ill individuals by identifying those data elements necessary for efficient multi-disciplinary care.

Clinical presentation of meningioma in the elderly.

OBJECTIVE: To compare presenting manifestations of meningioma in elderly patients with those in younger patients. DESIGN: Retrospective survey. SETTING: Tertiary care center. PATIENTS: All hospitalized adult patients with the primary diagnosis of meningioma over a 5-year period (n = 116). Nine patients with recurrence of a previously resected meningioma were excluded. Fifty-two percent (56/107) of patients were > or = 65 years of age. MEASUREMENTS: Presenting symptoms were classified as asymptomatic, focal, non-specific, or both focal and non-specific. Presenting neurologic signs on physical examination were classified as focal, non-focal, or normal. Duration of symptoms was classified as < or = 1 week, 1 week to 1 month, 1 to 6 months, and > 6 months. RESULTS: Older patients presented more commonly with confusion (32% vs 4%) and dystaxia (28% vs 10%) than younger patients and presented less commonly with headache (23% vs 49%) and visual changes (21% vs 43%). While 2% of patients were asymptomatic at presentation, the remainder had symptoms categorized as focal (38%), non-specific (26%), or both (34%). There was no significant difference between older and younger age groups in the proportions of patients having focal symptoms. Duration of symptoms for all patients was categorized as < or = 1 week (15%), 1 week to 1 month (16%), 1 to 6 months (23%), and > 6 months (44%). In general, older patients were diagnosed earlier than younger patients. The presence of focal neurologic signs was not significantly different between older and younger patients. CONCLUSIONS: Presenting manifestations of meningioma differ between older and younger adult patients, but focality of symptoms and signs is similar. In this case series, the duration of symptoms prior to diagnosis was shorter in older than in younger patients.

Implementing computerized tracking at a community health center: challenges and solutions.

A computerized tracking system for both preventive care and chronic disease tracking was implemented at a community health center, using a PC based local area network interfaced with a mainframe scheduling and billing system. Initial database construction used downloads of historical billing data, but ongoing database maintenance is accomplished by using an optical mark-sense scanner to construct both billing and clinical tracking files from custom-designed encounter forms. In this way, expanded clinical data is collected with an actual reduction in manually keyed data, reducing the ongoing cost of the system.

Computer-generated mailed reminders for influenza immunization: a clinical trial.

A randomized, single-blind, controlled trial was performed at a community health center to measure the impact of computer-generated reminders mailed to patients on the rate of influenza immunization. High-risk patients were randomized to one of three groups: 1) usual care, 2) one reminder letter, offering free influenza immunization without an appointment, or 3) two sequential reminder letters, offering the same. The reminders did not significantly affect rates of influenza immunization. Analysis of the combined groups indicates that an appointment with a primary care provider remains the most reliable method of immunizing high-risk patients at this health center.