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BACKGROUND: Although racial and ethnic identities are associated with a multitude of disparate medical outcomes, surveillance of these subpopulations in the occupational clinic setting could benefit enormously from a more detailed and nuanced recognition of racial and ethnic identity. METHODS: The research group designed a brief questionnaire to capture several dimensions of this identity and collected data from patients seen for work-related conditions in four occupational medicine clinics from May 2019 through March 2020. Responses were used to calculate the sensitivity and specificity of extant racial/ethnic identity data within our electronic health records system, and were compared to participants' self-reported industry and occupation, coded according to North American Industry Classification System and Standard Occupational Classification System listings. RESULTS: Our questionnaire permitted collection of data that defined our patients' specific racial/ethnic identity with far greater detail, identified patients with multiple ethnic identities, and elicited their preferred language. Response rate was excellent (94.2%, n = 773). Non-White participants frequently selected a racial/ethnic subcategory (78.1%-92.2%). Using our race/ethnicity data as a referent, the electronic health record (EHR) had a high specificity (>87.1%), widely variable sensitivity (11.8%-82.2%), and poorer response rates (75.1% for race, 82.5% for ethnicity, as compared to 93.8% with our questionnaire). Additional analyses revealed some industries and occupations disproportionately populated by patients of particular racial/ethnic identities. CONCLUSIONS: Our project demonstrates the usefulness of a questionnaire which more effectively identifies racial/ethnic subpopulations in an occupational medicine clinic, permitting far more detailed characterization of their occupations, industries, and diagnoses.
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Etnicidad , Ocupaciones , Humanos , Estados UnidosRESUMEN
BACKGROUND: Minnesota has an ethnically diverse labor force, with the largest number of refugees per capita in the United States. In recent years, Minnesota has been and continues to be a major site for immigrant and refugee resettlement in the United States, with a large population of both immigrant and native born Hmong, Hispanic, and East Africans. This study seeks to evaluate the injury risk among the evolving minority workforce in the Minnesota Twin Cities region. METHODS: A retrospective cohort study identifying work-related injuries following pre-employment examinations was performed using electronic health records from a large multi-clinic occupational medicine practice. Preplacement examinations and subsequent work-related injuries were pulled from the electronic health record using representative ICD-10 codes for surveillance examinations and injuries. This study included patient records collected over a 2-year period from January 1, 2015, through December, 2016. The patients in this cohort worked in a wide-array of occupations including production, assembly, construction, law enforcement, among others. RESULTS: Hispanic minority workers were twice as likely to be injured at work compared with White workers. Hispanics were 2.89 times more likely to develop back injuries compared with non-Hispanic workers, and 1.86 times more likely to develop upper extremity injuries involving the hand, wrist, or elbow. CONCLUSION: Clinical practice data shows that Hispanic workers are at increased risk for work-related injuries in Minnesota. They were especially susceptible to back and upper extremity injuries. Lower injury rates in non-Hispanic minority workers, may be the result of injury underreporting and require further investigation.
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Traumatismos del Brazo/etnología , Asiático/estadística & datos numéricos , Traumatismos de la Espalda/etnología , Negro o Afroamericano/estadística & datos numéricos , Traumatismos de la Mano/etnología , Hispánicos o Latinos/estadística & datos numéricos , Traumatismos Ocupacionales/etnología , Lesiones del Hombro/etnología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Grupos Minoritarios/estadística & datos numéricos , Medicina del Trabajo , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Población Blanca/estadística & datos numéricos , Adulto JovenRESUMEN
Minnesota's immunization information system excels at population health surveillance.
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Sistemas de Información en Salud/organización & administración , Programas de Inmunización/organización & administración , Inmunización/estadística & datos numéricos , Vigilancia de la Población/métodos , Recolección de Datos/estadística & datos numéricos , Humanos , MinnesotaRESUMEN
OBJECTIVE: We discuss the implementation and outcomes of a diabetic ketoacidosis (DKA) critical care pathway (CCP) at a 462-bed teaching hospital. METHODS: A multi-disciplinary team implemented a DKA CCP that was translated into 3 computerized physician order entry (CPOE) order sets corresponding to the phases of DKA care. Historical and postintervention data were obtained via automated queries of the electronic medical record (EMR) and further analyzed by manual chart review. RESULTS: Average length of stay decreased from 104.3 to 72.9 hours (P = .0003) after implementation of a DKA CCP. CONCLUSION: Outcome data supports the use of a DKA CCP at our institution. ABBREVIATIONS: DKA = diabetic ketoacidosis CCP = critical care pathway EMR = electronic medical record CPOE = computerized physician order entry ICD-9 = International Classification of Diseases, ninth revision LoS = length of stay SQL = standard query language.
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BACKGROUND: We assessed the utilization rationale behind provider ordering of cardiac troponin I (cTnI) testing for the diagnosis of myocardial infarction after implementation of a hospital-wide serial order protocol. METHODS: During 2 months in 2013, any request for additional cTnI testing within 30 days of the initial serial cTnI order prompted an electronic health record best practice alert (BPA), which included clinical decision support that could be bypassed by giving a clinical indication. cTnI orders were not limited (timing, number), and upon BPA, trigger data was collected for clinical indications and actions, patient stay (duration, location), International Classification of Diseases, Revision 9 diagnosis, cTnI orders, and timing of cTnI measurements. RESULTS: The BPA was triggered 1477 times by 423 providers who cared for 702 patients. There were a mean of 3.6 cTnI results per patient, 2.1 BPAs per patient, and 1.2 visits per patient. Providers (42% of whom were residents) acknowledged and overrode the BPA 97% of the time. In response to the BPA, 65% of providers selected a prepared rationale: 64% acute coronary syndrome/ST-elevation myocardial infarction/non-ST-elevation myocardial infarction; 30% demand ischemia; and 6% non-ACS myocardial necrosis. Of the remaining 35% of providers, 71% listed no rationale for their additional cTnI orders. Of patients with a BPA, 93% had non-ACS-related primary International Classification of Diseases, Revision 9 diagnosis, and 58% of the time, patients' cTnI results never increased during their stay. In 53% of cases, BPAs were generated by a request for an additional cTnI series when <2 results were available. CONCLUSIONS: Providers largely ignored the BPA that warned of potential overutilization of cTnI testing independent of diagnosis, including ACS.
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Registros Electrónicos de Salud , Infarto del Miocardio/diagnóstico , Troponina I/sangre , Procedimientos Innecesarios/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Humanos , Masculino , Sistemas de Entrada de Órdenes Médicas , Persona de Mediana Edad , Infarto del Miocardio/sangre , Adulto JovenRESUMEN
BACKGROUND: The computerized order for red blood cell (RBC) transfusion within our electronic health record was redesigned with integrated clinical decision support (CDS) to reinforce our restrictive transfusion policy. These changes encouraged 1-unit (1U) RBC orders, clarified hemoglobin (Hb) transfusion triggers, and discouraged unnecessary orders. This study assessed whether these changes resulted in durable effects on provider practices. STUDY DESIGN AND METHODS: The study compared three 1-year subperiods from August 2011 to August 2014, with each year corresponding to a historical control period, preintervention and postintervention years. This study analyzed ratios of 1U versus 2-unit (2U) orders and the absolute rate of RBC orders, units charged, Hb transfusion triggers, repeat transfusion orders, and selected clinical indications both institution-wide and across several subpopulations. RESULTS: Our institution-wide ratio of 1U versus 2U orders increased from 0.50 to 1.20 (p < 0.0001) in the pre- to postintervention subperiods, respectively. The number of units charged per day decreased from 15.68 to 13.53 (p < 0.001), while rates of initial and repeat orders remained stable. Proportion of clinical indications used and mean Hb triggers demonstrated generally positive results. The changes observed between the pre- and postintervention years were far greater than changes between historical control versus preintervention years, reinforcing attribution of results to computerized physician order entry changes. CONCLUSION: Use of computerized orders and CDS encouraged a restrictive transfusion policy, which was highly successful in changing provider practices. We also succeeded in decreasing mean Hb triggers and overall utilization of RBCs. These findings persisted across many subpopulations.
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Sistemas de Apoyo a Decisiones Clínicas/normas , Transfusión de Eritrocitos , Eritrocitos , Sistemas de Entrada de Órdenes Médicas/normas , Sistemas de Atención de Punto/normas , Femenino , Humanos , Masculino , Estudios Retrospectivos , Centros TraumatológicosRESUMEN
Objective: Natural language processing (NLP) can generate diagnoses codes from imaging reports. Meanwhile, the International Classification of Diseases (ICD-10) codes are the United States' standard for billing/coding, which enable tracking disease burden and outcomes. This cross-sectional study aimed to test feasibility of an NLP algorithm's performance and comparison to radiologists' and physicians' manual coding. Methods: Three neuroradiologists and one non-radiologist physician reviewers manually coded a randomly-selected pool of 200 craniospinal CT and MRI reports from a pool of >10,000. The NLP algorithm (Radnosis, VEEV, Inc., Minneapolis, MN) subdivided each report's Impression into "phrases", with multiple ICD-10 matches for each phrase. Only viewing the Impression, the physician reviewers selected the single best ICD-10 code for each phrase. Codes selected by the physicians and algorithm were compared for agreement. Results: The algorithm extracted the reports' Impressions into 645 phrases, each having ranked ICD-10 matches. Regarding the reviewers' selected codes, pairwise agreement was unreliable (Krippendorff α = 0.39-0.63). Using unanimous reviewer agreement as "ground truth", the algorithm's sensitivity/specificity/F2 for top 5 codes was 0.88/0.80/0.83, and for the single best code was 0.67/0.82/0.67. The engine tabulated "pertinent negatives" as negative codes for stated findings (e.g. "no intracranial hemorrhage"). The engine's matching was more specific for shorter than full-length ICD-10 codes (p = 0.00582x10-3). Conclusions: Manual coding by physician reviewers has significant variability and is time-consuming, while the NLP algorithm's top 5 diagnosis codes are relatively accurate. This preliminary work demonstrates the feasibility and potential for generating codes with reliability and consistency. Future works may include correlating diagnosis codes with clinical encounter codes to evaluate imaging's impact on, and relevance to care.
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Aerotoxic syndrome is a rarely recognized and poorly defined illness resulting from exposure to products of oil combustion in commercial aircraft bleed air systems. The pathophysiology of this syndrome is not well understood. A 42-year-old male pilot developed duty-limiting symptoms consistent with aerotoxic syndrome following exposure to airline cabin fumes and recurrence of symptoms following re-exposure despite apparent full recovery from the initial exposure event. Given his persistent symptoms and concern for immediate debilitation/incapacitation if re-exposed, the pilot was deemed medically unqualified for return to commercial piloting duties and a disability determination was made. Consideration of aerotoxic syndrome in aircrew members with unusual or episodic symptoms of neuro/cognitive dysfunction is essential for further characterizing this occupational illness, guiding medical management, and understanding its impact on aviation workforce health.
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Aviación , Disfunción Cognitiva , Masculino , Humanos , Adulto , AeronavesRESUMEN
ABSTRACT: Occupational and environmental medicine (OEM) is an ACGME-accredited preventive medicine specialty focused on work as a social determinant of health and population health. OEM providers recognize and mitigate workplace and environmental hazards, treat resultant injuries and illnesses, and promote the health, wellness and resiliency of workers and communities. Multidisciplinary residency training in clinical medicine, epidemiology, public and population health, toxicology, exposure and risk assessment, and emergency preparedness equips them with the skill set needed for leadership roles in diverse settings. These include clinical practice, academia, corporate settings, and governmental agencies. Despite robust job opportunities, a shortage of formally trained OEM physicians remains and is expected to worsen given a declining number of training programs. We examine root causes of the system-level issues impacting the supply of OEM physicians and potential solutions.
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Medicina Ambiental , Internado y Residencia , Humanos , Agencias GubernamentalesRESUMEN
PROBLEM: The World Health Organization calls on all with quality medical information to share it with the public and combat health misinformation; however, U.S. medical schools do not currently teach students effective communication with lay audiences about health. Most physicians have inadequate training in mass communication strategies. APPROACH: In August 2018, a novel 90-minute class at the University of Minnesota Medical School introduced fourth-year medical students to basic skills for communicating with lay audiences through mass media. Instructors were physicians with experience interacting with the general public via radio, op-ed articles, social media, print media, television, and community and legislative advocacy. After a 20-minute lecture and sharing of instructors' personal experiences, students completed two 30-minute small-group activities. They identified communications objectives and talking points for a health topic, drafting these as Tweets or an op-ed article outline, then presented talking points in a mock press conference with their peers, practicing skills just learned. Pre- and postsurveys documented students' previous engagement and comfort with future engagement with mass media messaging. OUTCOMES: Over 1 week, 142 students participated in 6 separate classes, and 127 completed both pre- and postsurveys. Before the course, only 6% (7/127) of students had comfortably engaged with social media and 14% (18/127) had engaged with traditional media in their professional roles. After the course, students self-reported an increase in their comfort, perceived ability, and likelihood of using specific communications skills to advocate for their patients (all P < .001). NEXT STEPS: The course will be expanded into a 5-session thread for third- and fourth-year medical students spread over 2 years. This thread will include meeting physicians who engage with lay audiences, identifying best practices for mass health communication, identifying bias and misinformation, "dos and don'ts" of social media, and communication skills for legislative advocacy.
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Educación de Pregrado en Medicina , Medios de Comunicación Sociales , Estudiantes de Medicina , Comunicación , Humanos , Aprendizaje , Rol ProfesionalRESUMEN
BACKGROUND: A team approach is one of the most effective ways to lower blood pressure (BP) in uncontrolled hypertension, but different models for organizing team-based care have not been compared directly. METHODS: A pragmatic, cluster-randomized trial compared 2 interventions in adult patients with moderately severe hypertension (BP≥150/95 mm Hg): (1) clinic-based care using best practices and face-to-face visits with physicians and medical assistants; and (2) telehealth care using best practices and adding home BP telemonitoring with home-based care coordinated by a clinical pharmacist or nurse practitioner. The primary outcome was change in systolic BP over 12 months. Secondary outcomes were change in patient-reported outcomes over 6 months. RESULTS: Participants (N=3071 in 21 primary care clinics) were on average 60 years old, 47% male, and 19% Black. Protocol-specified follow-up within 6 weeks was 32% in clinic-based care and 27% in telehealth care. BP decreased significantly during 12 months of follow-up in both groups, from 157/92 to 139/82 mm Hg in clinic-based care patients (adjusted mean difference -18/-10 mm Hg) and 157/91 to 139/81 mm Hg in telehealth care patients (adjusted mean difference -19/-10 mm Hg), with no significant difference in systolic BP change between groups (-0.8 mm Hg [95% CI, -2.84 to 1.32]). Telehealth care patients were significantly more likely than clinic-based care patients to report frequent home BP measurement, rate their BP care highly, and report that BP care visits were convenient. CONCLUSIONS: Telehealth care that includes extended team care is an effective and safe alternative to clinic-based care for improving patient-centered care for hypertension. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02996565.
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Hipertensión , Telemedicina , Adulto , Humanos , Masculino , Persona de Mediana Edad , Femenino , Farmacéuticos , Hipertensión/terapia , Hipertensión/tratamiento farmacológico , Presión Sanguínea/fisiología , Determinación de la Presión Sanguínea , Antihipertensivos/uso terapéutico , Antihipertensivos/farmacologíaRESUMEN
OBJECTIVE: To address which body composition (BC) measures best correlate with cardiorespiratory fitness (CRF) in firefighters and develop a model for accurate CRF estimation compared with traditional methods. METHODS: Career firefighters had body mass index (BMI) and waist circumference (WC) measured in addition to body fat percentage (FM%) by dual-energy x-ray absorptiometry (DXA). CRF as maximum oxygen uptake (VO2max) was estimated by rowing machine and measured by indirect calorimetry in a treadmill exercise test. RESULTS: Fifty two firefighters participated (92.3% men). Univariate correlations with BMI were best with WC. Univariate correlations with VO2max were best with FM%. Obesity classifications by BC measures agreed weakly at best. Multivariate analysis of several variables yielded an improved VO2max estimate (R2â=â0.70). CONCLUSIONS: Fire departments may benefit from more sophisticated measures of BC and CRF to evaluate firefighter fitness.
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Capacidad Cardiovascular , Bomberos , Composición Corporal , Índice de Masa Corporal , Femenino , Humanos , Masculino , Oxígeno , Consumo de Oxígeno , Aptitud Física , Circunferencia de la CinturaAsunto(s)
Mal Uso de los Servicios de Salud/economía , Hipocondriasis/diagnóstico , Hipocondriasis/economía , Inmunización/economía , Inmunización/psicología , Salud Pública/economía , Planes Estatales de Salud/economía , Adulto , Diagnóstico Diferencial , Femenino , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Hipocondriasis/psicología , MinnesotaRESUMEN
OBJECTIVE: Posterior reversible encephalopathy syndrome (PRES) is classically characterized as symmetric parietooccipital edema but may occur in other distributions with varying imaging appearances. This study determines the incidence of atypical and typical regions of involvement and unusual imaging manifestations. MATERIALS AND METHODS: Seventy-six patients were eventually included as having confirmed PRES from 111 initially suspected cases, per imaging and clinical follow-up. Two neuroradiologists retrospectively reviewed each MR image. Standard sequences were unenhanced FLAIR and T1- and T2-weighted images in all patients, with diffusion-weighted imaging (n = 75) and contrast-enhanced T1-weighted imaging (n = 69) in most. The regions involved were recorded on the basis of FLAIR findings, and the presence of atypical imaging findings (contrast enhancement, restricted diffusion, hemorrhage) was correlated with the severity (extent) of hyperintensity or mass effect on FLAIR. RESULTS: The incidence of regions of involvement was parietooccipital, 98.7%; posterior frontal, 78.9%; temporal, 68.4%; thalamus, 30.3%; cerebellum, 34.2%; brainstem, 18.4%; and basal ganglia, 11.8%. The incidence of less common manifestations was enhancement, 37.7%; restricted diffusion, 17.3%; hemorrhage, 17.1%; and a newly described unilateral variant, 2.6%. Poor correlation was found between edema severity and enhancement (r = 0.072), restricted diffusion (r = 0.271), hemorrhage (r = 0.267), blood pressure (systolic, r = 0.13; diastolic, r = 0.02). Potentially new PRES causes included contrast-related anaphylaxis and alcohol withdrawal. CONCLUSION: This large series of PRES cases shows that atypical distributions and imaging manifestations of PRES have a higher incidence than commonly perceived, and atypical manifestations do not correlate well with the edema severity.
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Edema Encefálico/epidemiología , Edema Encefálico/patología , Imagen por Resonancia Magnética/estadística & datos numéricos , Medición de Riesgo/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Factores de Riesgo , SíndromeAsunto(s)
Aplicación de la Ley , Justicia Social , Población Negra , Humanos , Policia , Violencia/prevención & controlRESUMEN
OBJECTIVES: To describe (a) a conceptual approach, (b) measurement tools and data collection processes, (c) characteristics of an integrated feedback report and action plan, and (d) experiences of three companies with an integrated measurement approach to worker safety and health. METHODS: Three companies implemented measurement tools designed to create an integrated view of health protection and promotion based on organizational- and individual-level assessments. Feedback and recommended actions were presented following assessments at baseline and 1-year follow-up. Measurement processes included group dialogue sessions, walk-through, online surveys, and focus groups. RESULTS: The approach and measurement tools generated actionable recommendations and documented changes in the physical (eg, safety hazards) and psychosocial (eg, health and safety culture) work environment between baseline and 1-year follow-up. CONCLUSIONS: The measurement tools studied were feasible, acceptable, and meaningful to companies in the SafeWell study.
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Promoción de la Salud , Salud Laboral/normas , Administración de la Seguridad , Humanos , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To evaluate the clinical utility of nonenhanced CT (NECT)-based screening criteria and CTA in detection of blunt vertebral artery injury (BVAI) in trauma patients with C1 and/or C2 fractures. METHODS: We retrospectively reviewed the clinical records of all blunt trauma patients with C1 and/or C2 fractures between 8/2006 and 9/2011. Cervical CTA was prompted by cervical fractures involving/adjacent to a transverse foramen, and/or subluxation on NECT. Two neuroradiologists independently reviewed the CTA studies, and graded the BVAI. RESULTS: 210 patients were included; of these, 124 underwent CTA (21/124 with digital subtraction angiography, DSA), and 2 underwent DSA only. Overall, 30/126 suffered BVAI. Among 21 patients who underwent both CTA and DSA, there was 1 false negative and 1 false positive (both grade 1). There was strong interobserver agreement regarding CTA-based BVAI detection (kappa=0.93, p<0.001) and grading (kappa=0.90, p<0001). Only 3/30 BVAI patients suffered a posterior circulation stroke; none of the patients who had a negative CTA or were not selected for CTA, based on NECT screening criteria, suffered symptomatic stroke. While C1/C2 comminuted fracture was more common in patients with high grade BVAI (p=0.039), simultaneous C3-C7 comminuted fracture increased the overall BVAI risk (p=0.011). CONCLUSION: CTA reliably detects symptomatic BVAI in patients with upper cervical fractures. Utilization of NECT-based screening criteria such as transverse foraminal involvement or subluxation may be adequate in deciding whether to perform CTA, as no patients who were not selected for CTA suffered a symptomatic stroke. However, CTA may miss lower grade, asymptomatic BVAI.