Impact of EHR-based clinical decision support on adherence to guidelines for patients on NSAIDs: a randomized controlled trial.

PURPOSE: Electronic health records (EHRs) with clinical decision support hold promise for improving quality of care, but their impact on management of chronic conditions has been mixed. This study examined the impact of EHR-based clinical decision support on adherence to guidelines for reducing gastrointestinal complications in primary care patients on nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS: This randomized controlled trial was conducted in a national network of primary care offices using an EHR and focused on patients taking traditional NSAIDs who had factors associated with a high risk for gastrointestinal complications (a history of peptic ulcer disease; concomitant use of anticoagulants, anti-platelet medications [including aspirin], or corticosteroids; or an age of 75 years or older). The offices were randomized to receive EHR-based guidelines and alerts for high-risk patients on NSAIDs, or usual care. The primary outcome was the proportion of patients who received guideline-concordant care during the 1-year study period (June 2007-June 2008), defined as having their traditional NSAID discontinued (including a switch to a lower-risk medication), having a gastroprotective medication coprescribed, or both. RESULTS: Participants included 27 offices with 119 clinicians and 5,234 high-risk patients. Intervention patients were more likely than usual care patients to receive guideline-concordant care (25.4% vs 22.4%, adjusted odds ratio = 1.19; 95% confidence interval, 1.01-1.42). For individual high-risk groups, patients on low-dose aspirin were more likely to receive guideline-concordant care with the intervention vs usual care (25.0% vs 20.8%, adjusted odds ratio = 1.30; 95% confidence interval, 1.04-1.62), but there was no significant difference for patients in other high-risk groups. CONCLUSIONS: This study showed only a small impact of EHR-based clinical decision support for high-risk patients on NSAIDs in primary care offices. These results add to the growing literature about the complexity of EHR-based clinical decision support for improving quality of care.

Defining and measuring the patient-centered medical home.

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

An electronic medical record-based intervention to improve quality of care for gastro-esophageal reflux disease (GERD) and atypical presentations of GERD.

BACKGROUND: Gastro-esophageal reflux disease (GERD) is common in primary care but is often underdiagnosed and untreated. GERD can also present with atypical symptoms like chronic cough and asthma, and physicians may be unaware of this presentation. We aimed to implement and evaluate an intervention to improve diagnosis and treatment for GERD and atypical GERD in primary care. METHOD: This was a randomised controlled trial in primary care office practice using a national network of US practices (the Medical Quality Improvement Consortium - MQIC) that share the same electronic medical record (EMR). Thirteen offices with 53 providers were randomised to the intervention of EMR-based prompts and education, and 14 offices with 66 providers were randomised to the control group totalling over 67 000 patients and examining outcomes of GERD diagnosis and appropriate treatment. RESULTS: Among patients who did not have GERD at baseline, new diagnoses of GERD increased significantly in the intervention group (3.1%) versus the control group (2.3%) (P<0.01). This remained significant after controlling for clustering with an odds of diagnosis of 1.33 (95% CI 1.13-1.56) for the intervention group. For patients with atypical symptoms, those in the intervention group had both higher odds of being diagnosed with GERD (OR 2.02, 95% CI 1.41-2.88) and of being treated for GERD (OR 1.40, 95% CI 1.08-1.83) than those in the control group. CONCLUSIONS: GERD diagnosis and treatment in primary care, particularly among patients with atypical symptoms, can be improved through the use of an EMR-based tool incorporating decision support and education. However, significant room for improvement exists in use of appropriate treatment.

How can primary care cross the quality chasm?

The chasm between knowledge and practice decried by the Institute of Medicine (IOM) is the result of other chasms that have not been addressed. They include the chasm between what we know and what we need to know to improve care; the chasm between those who provide primary care and those who do not fund, study, support, or publish practical primary care studies; and the chasm between research and quality improvement (QI). These chasms are a result of problematic concepts, attitudes, traditions, time frames, and financing approaches among the various participants. If we are to facilitate the production and use of the knowledge needed for primary care to cross IOM's chasm, major changes are needed. These changes include the following: (1) admission by all primary care professions that we have quality problems that require our unified attention and action; (2) conversion of the paradigm from "translate research into practice" to "optimizing health and health care through research and QI"; (3) development and facilitation of more partnerships among clinicians, researchers, and care delivery leaders for engaged scholarship in both research and QI; (4) modification of the agendas and methods of funders and researchers so they emphasize the problems of patients and patient care and support practical time frames and research designs; and (5) facilitation by funders and journals of the dissemination and implementation of lessons from QI and practical research.

Quality of lipid management in outpatient care: a national study using electronic health records.

To examine lipid management in a large national outpatient network, a cross-sectional study was conducted that included 1,385,242 active patients ages 20 to 79 years of age in a national network of over 5000 providers using electronic health records (EHRs). Adequate lipid testing, achievement of lipid goals, and appropriate use of lipid-lowering medication were defined according to National Cholesterol Education Program (NCEP) guidelines. Lipid testing was adequate for 62% of high-risk, 67% of moderate-risk, and 36% of low-risk patients. Lipid goals were achieved in 65%, 66%, and 90% of these 3 risk groups; 35%, 45%, and 32% achieved adequate testing and optimal goals. Medications were appropriately prescribed for 70%, 47%, and 48%. There is significant room for improvement in lipid management, particularly among high-risk patients. National EHR networks are excellent vehicles for large outpatient quality of care studies, particularly for measuring clinical outcomes such as lipid levels.

Antihypertensive prescribing practices: impact of the antihypertensive and lipid-lowering treatment to prevent heart attack trial.

This national study examines the impact of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) on the prescribing of thiazide-type diuretics and other antihypertensive medications for patients with newly diagnosed hypertension. A cross-sectional analysis was conducted using data from a national network of electronic health records for 2 groups with newly diagnosed hypertension and started on antihypertensive medications: one a year before and the other a year after the publication of ALLHAT. The percentage of new hypertensives started on thiazides increased from 29% pre-ALLHAT to 39% post-ALLHAT. An increase was also seen for angiotensin receptor blockers, while prescribing for angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta-blockers declined. There was no significant change in prescriptions for alpha-blockers. Prescriptions for thiazides for patients with newly diagnosed hypertension increased after the publication of ALLHAT. Data from large national trials can have a considerable impact on prescribing practices.

Quality of outpatient care for diabetes mellitus in a national electronic health record network.

This retrospective cohort study examined quality of care for diabetes in a large national network of electronic health record users. Of 10572 patients with diabetes included in the study, 55% had at least 2 hemoglobin A1c (HbA1c) tests, 95% had at least 1 systolic and diastolic blood pressure test, and 52% had at least 1 low-density lipoprotein (LDL) cholesterol test over a 1-year period. Of those tested, 41% had an HbA1c<7.0, 28% had a blood pressure<130/80 mm Hg, and 44% had an LDL cholesterol level<100 mg/dL. Of those not adequately controlled, 99% were prescribed hypoglycemic medications, 85% were prescribed antihypertensive medications, and 71% were prescribed lipid-lowering medications. These results suggest that there is significant room for improvement in testing and control of risk factors for persons with diabetes and that the electronic health record has a significant potential for conducting practice-based quality-of-care studies across large numbers of outpatient practices.

Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study.

BACKGROUND AND OBJECTIVES: Studies have suggested that antibiotics are often inappropriately used in the treatment of acute upper respiratory tract infections (URIs). This study examined antibiotic use for adult URIs in a large national network of offices that use electronic health records (EHRs). METHODS: Using the Medical Quality Improvement Consortium (MQIC) database, URI episodes were identified for patients ages 18 to 65 years from January 1, 1998, to March 31, 2003. The percentage of episodes for which antibiotics were prescribed and the proportion of antibiotics that were broad spectrum were calculated. RESULTS: Of the 52,135 URI episodes identified, 65% received antibiotics. Antibiotics were prescribed for 78% of acute bronchitis episodes, 65% of acute pharyngitis episodes, 81% of acute sinusitis episodes, and 33% of nonspecific URI episodes. The proportion of antibiotics that were broad spectrum was 56% for all URI episodes, 68% for acute bronchitis, 55% for acute sinusitis and nonspecific URI, and 40% for pharyngitis. CONCLUSIONS: This study demonstrates overuse of antibiotics for adult URIs in a large national ambulatory care network, with particular overuse of broad-spectrum antibiotics. The study also illustrates the enormous potential of EHR data for conducting practice-based research across large national office networks.

New strategies for diagnosis and management of celiac disease.

Celiac disease is a gastrointestinal disorder characterized by inflammation, leading to injury to the mucosal lining of the small intestine. The inflammation occurs when gliadin, a protein found in such gluten-containing foods as wheat, rye, and barley, is ingested by genetically susceptible individuals. The mucosal damage and subsequent malabsorption of nutrients leads to various complications. Researchers estimate that more than 2 million people in the United States have celiac disease-a prevalence that is greater than was previously believed. Approximately 60,000 Americans are diagnosed annually with celiac disease. Until recently, diagnosis has been complicated by the fact that the indicators of celiac disease are nonspecific. However, because of the development of new, easy-to-administer serology tests, diagnosis has become much less complicated. After conducting a review of the literature, the authors recommend a serologic testing sequence for diagnosis of celiac disease and urge that adults and children with an assortment of symptoms be tested for this disease. Common signs and symptoms of celiac disease include anemia, arthralgia, fatigue, infertility, neuropathy, and weight loss, in addition to such gastrointestinal symptomatology as abdominal pain, anorexia, bloating, constipation, and diarrhea. The only treatment for patients with celiac disease remains a gluten-free diet.

Diagnosis of Lyme disease.

The use of serologic testing and its value in the diagnosis of Lyme disease remain confusing and controversial for physicians, especially concerning persons who are at low risk for the disease. The approach to diagnosing Lyme disease varies depending on the probability of disease (based on endemicity and clinical findings) and the stage at which the disease may be. In patients from endemic areas, Lyme disease may be diagnosed on clinical grounds alone in the presence of erythema migrans. These patients do not require serologic testing, although it may be considered according to patient preference. When the pretest probability is moderate (e.g., in a patient from a highly or moderately endemic area who has advanced manifestations of Lyme disease), serologic testing should be performed with the complete two-step approach in which a positive or equivocal serology is followed by a more specific Western blot test. Samples drawn from patients within four weeks of disease onset are tested by Western blot technique for both immunoglobulin M and immunoglobulin G antibodies; samples drawn more than four weeks after disease onset are tested for immunoglobulin G only. Patients who show no objective signs of Lyme disease have a low probability of the disease, and serologic testing in this group should be kept to a minimum because of the high risk of false-positive results. When unexplained nonspecific systemic symptoms such as myalgia, fatigue, and paresthesias have persisted for a long time in a person from an endemic area, serologic testing should be performed with the complete two-step approach described above.

Transferrin saturation, dietary iron intake, and risk of cancer.

PURPOSE: Transferrin saturation of more than 60% has been identified as a cancer risk factor. It is unclear whether dietary iron intake increases the risk of cancer among individuals with transferrin saturation of less than 60%. The purpose of this study was to examine the association of dietary iron intake and the risk of cancer among adults with increased transferrin saturation. METHODS: Analysis of a cohort study, the National Health and Nutrition Examination Survey I Epidemiologic Follow-Up Study, was performed. US adults (aged 25 to 74 years at baseline) were followed up from baseline in 1971-1974 to 1992 (N = 6,309). RESULTS: A total of 7.3% of the US population had a serum transferrin saturation of more than 45% at baseline. Intake of dietary iron was essentially uncorrelated with transferrin saturation (r = 0.04). Compared with individuals who had normal serum transferrin saturation and low dietary iron intake, individuals whose serum transferrin saturation was more than 45% and who had high dietary iron intake also had an increased adjusted relative risk of cancer (2.24; 95% confidence interval [CI], 1.02-4.89). Increased risk was not found for individuals with a transferrin saturation of more than 45% but a normal dietary iron intake (hazard ratio, 1.02; 95% CI, 0.69-1.49). Transferrin saturation levels could be set as low as 41%, and the individuals with high transferrin saturation and high dietary iron intake would still have an increased adjusted relative risk of cancer (hazard ratio, 2.00; 95% CI, 1.04-3.82). CONCLUSIONS: Among persons with increased transferrin saturation, a daily intake of dietary iron more than 18 mg is associated with an increased risk of cancer. Future research might focus on the benefits of dietary changes in those individuals with increased serum transferrin saturation.

Should we screen for hemochromatosis? An examination of evidence of downstream effects on morbidity and mortality.

BACKGROUND: Population-based hemochromatosis screening has been suggested with the rationale that identification and treatment of subclinical disease would decrease morbidity and mortality due to hemochromatosis. OBJECTIVE: To examine the prevalence of elevated serum transferrin saturation levels and the burden of illness of hemochromatosis in terms of ambulatory visits, hospitalizations, and death in the United States. PARTICIPANTS AND METHODS: Four nationally representative data sets were used for the analysis of the prevalence of hemochromatosis as well as ambulatory care, hospitalizations, and deaths related to hemochromatosis. Participants included men and nonpregnant women aged 18 years and older in the Third National Health and Nutrition Examination Survey (1988-1994) and the 1996, 1997, and 1998 National Ambulatory Care Survey, National Hospital Discharge Survey, and Underlying Cause-of-Death Mortality Files. The data sets were based on single measurements of serum transferrin saturation levels, serum ferritin levels, and healthcare provider-recorded diagnoses according to the International Classification of Diseases, Ninth Revision, Clinical Modification, code for hemochromatosis. RESULTS: The prevalence of elevated serum transferrin saturation levels ranged from 1% to 6%. When an elevated serum transferrin saturation level of 55% is combined with an elevated serum ferritin level, the prevalence decreases from 1.9% to 0.65%. The proportion of diagnosed hemochromatosis utilization out of total ambulatory visits, hospitalizations, and deaths is stable across the measures and the 3 years of data ranging from 0.01% to 0.03%. When white men were examined separately, the relationships remained the same as those among the general population of adults. CONCLUSIONS: Although a substantial proportion of adults whose condition is not currently diagnosed would be identified in a population-based screening program for subclinical hemochromatosis, diagnosed morbidity or mortality owing to hemochromatosis is considerably lower than would be expected. Recommendations for screening programs may need to be revisited.

Continuity of care and recognition of diabetes, hypertension, and hypercholesterolemia.

BACKGROUND: Continuity of care has been shown to have a variety of health benefits, but the effect of continuity of care on recognition of common chronic diseases has been underinvestigated. OBJECTIVE: To examine the relationship between continuity of care and the recognition of 3 prevalent chronic diseases: diabetes, hypertension, and hypercholesterolemia. METHODS: We analyzed data from the third National Health and Nutrition Examination Survey, a nationally representative sample of 18 162 adult noninstitutionalized residents of the United States collected from 1988 through 1994. We examined the proportion of unrecognized disease among all individuals with diabetes, hypertension, and hypercholesterolemia according to self-reported level of continuity of care. We used logistic regression to control for possible confounders, including number of disease risk factors. RESULTS: Among persons with diabetes, in adjusted models, those with a usual provider of care had a lower likelihood of having unrecognized disease (odds ratio, 0.30; 95% confidence interval, 0.10-0.95) than those with no usual site or provider of care. Unrecognized hypertension had an unadjusted relationship with level of continuity of care, but continuity of care was not a significant predictor after possible confounders were adjusted for. Unrecognized hypercholesterolemia was not predicted by level of continuity of care. CONCLUSIONS: Continuity of care has some benefits in terms of recognizing chronic disease, although benefits appear to be disease specific. More research needs to be conducted to elucidate the complex relationship between continuity and disease recognition.