Development and validation of an asthma exacerbation prediction model using electronic health record (EHR) data.

Objective: Asthma exacerbations are associated with significant morbidity, mortality, and cost. Accurately identifying asthma patients at risk for exacerbation is essential. We sought to develop a risk prediction tool based on routinely collected data from electronic health records (EHRs).Methods: From a repository of EHRs data, we extracted structured data for gender, race, ethnicity, smoking status, use of asthma medications, environmental allergy testing BMI status, and Asthma Control Test scores (ACT). A subgroup of this population of patients with asthma that had available prescription fill data was identified, which formed the primary population for analysis. Asthma exacerbation was defined as asthma-related hospitalization, urgent/emergent visit or oral steroid use over a 12-month period. Univariable and multivariable statistical analysis was completed to identify factors associated with exacerbation. We developed and tested a risk prediction model based on the multivariable analysis.Results: We identified 37,675 patients with asthma. Of those, 1,787 patients with asthma and fill data were identified, and 979 (54.8%) of them experienced an exacerbation. In the multivariable analysis, smoking (OR = 1.69, CI: 1.08-2.64), allergy testing (OR = 2.40, CI: 1.54-3.73), obesity (OR = 1.66, CI: 1.29-2.12), and ACT score reflecting uncontrolled asthma (OR = 1.66, CI: 1.10-2.29) were associated with increased risk of exacerbation. The area-under-the-curve (AUC) of our model in a combined derivation and validation cohort was 0.67.Conclusion: Despite use of rigorous methodology, we were unable to produce a predictive model with an acceptable degree of accuracy and AUC to be clinically useful.

Methodological Standards for Meta-Analyses and Qualitative Systematic Reviews of Cardiac Prevention and Treatment Studies: A Scientific Statement From the American Heart Association.

Meta-analyses are becoming increasingly popular, especially in the fields of cardiovascular disease prevention and treatment. They are often considered to be a reliable source of evidence for making healthcare decisions. Unfortunately, problems among meta-analyses such as the misapplication and misinterpretation of statistical methods and tests are long-standing and widespread. The purposes of this statement are to review key steps in the development of a meta-analysis and to provide recommendations that will be useful for carrying out meta-analyses and for readers and journal editors, who must interpret the findings and gauge methodological quality. To make the statement practical and accessible, detailed descriptions of statistical methods have been omitted. Based on a survey of cardiovascular meta-analyses, published literature on methodology, expert consultation, and consensus among the writing group, key recommendations are provided. Recommendations reinforce several current practices, including protocol registration; comprehensive search strategies; methods for data extraction and abstraction; methods for identifying, measuring, and dealing with heterogeneity; and statistical methods for pooling results. Other practices should be discontinued, including the use of levels of evidence and evidence hierarchies to gauge the value and impact of different study designs (including meta-analyses) and the use of structured tools to assess the quality of studies to be included in a meta-analysis. We also recommend choosing a pooling model for conventional meta-analyses (fixed effect or random effects) on the basis of clinical and methodological similarities among studies to be included, rather than the results of a test for statistical heterogeneity.

A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients.

PURPOSE: The goal of this study was to develop a technology-based strategy to identify patients with undiagnosed hypertension in 23 primary care practices and integrate this innovation into a continuous quality improvement initiative in a large, integrated health system. METHODS: In phase 1, we reviewed electronic health records (EHRs) using algorithms designed to identify patients at risk for undiagnosed hypertension. We then invited each at-risk patient to complete an automated office blood pressure (AOBP) protocol. In phase 2, we instituted a quality improvement process that included regular physician feedback and office-based computer alerts to evaluate at-risk patients not screened in phase 1. Study patients were observed for 24 additional months to determine rates of diagnostic resolution. RESULTS: Of the 1,432 patients targeted for inclusion in the study, 475 completed the AOBP protocol during the 6 months of phase 1. Of the 1,033 at-risk patients who remained active during phase 2, 740 (72%) were classified by the end of the follow-up period: 361 had hypertension diagnosed, 290 had either white-coat hypertension, prehypertension, or elevated blood pressure diagnosed, and 89 had normal blood pressure. By the end of the follow-up period, 293 patients (28%) had not been classified and remained at risk for undiagnosed hypertension. CONCLUSIONS: Our technology-based innovation identified a large number of patients at risk for undiagnosed hypertension and successfully classified the majority, including many with hypertension. This innovation has been implemented as an ongoing quality improvement initiative in our medical group and continues to improve the accuracy of diagnosis of hypertension among primary care patients.

Racial differences in treatment preferences among lupus patients: a two-site study.

OBJECTIVES: To identify the demographic, clinical and psychosocial characteristics associated with racial differences in willingness to receive cyclophosphamide (CYC) or participate in a research clinical trial (RCT) among patients with systemic lupus erythematosus (SLE). METHODS: Data from 163 African-American (AA) and 180 white (WH) SLE patients were evaluated. Structured interviews and chart reviews were conducted to determine treatment preferences in hypothetical situations and identify variables that may affect preferences. Logistic regression models were performed to evaluate the relationship between patient preferences and race, adjusted for patient characteristics. RESULTS: Among patients who had never received CYC (n=293), 62.9% AAs compared to 87.6% WHs were willing to receive the medication (p<0.001). This difference persisted (OR 0.37 [95% CI, 0.16-0.87]) after adjusting for socio-demographics, clinical characteristics, and perceptions about CYC and physicians. Income and higher perception of CYC effectiveness were other determinants of willingness to receive CYC. Among patients who had never participated in an RCT (n=326), 64.9% AAs compared to 84.3% WHs were willing to do so (p<0.001). This difference persisted (OR 0.41 [95% CI, 0.20-0.83]) after adjusting for socio-demographics, clinical context and patients' perceptions of physicians. SLE damage score, number of immunosuppressive medications and higher trust in physicians were also independently associated with willingness to participate in an RCT. CONCLUSIONS: Race remains an independent determinant of treatment preferences after adjustment for income, medications, medication efficacy expectations and trust in physicians. While some factors related to racial differences in preferences are relatively fixed, others that may alleviate these differences also exist, including medication beliefs and provider trust.

A study of racial/ethnic differences in treatment preferences among lupus patients.

OBJECTIVES: To determine whether there are racial/ethnic differences in the willingness of SLE patients to receive CYC or participate in clinical trials, and whether demographic, psychosocial and clinical characteristics contribute to these differences. METHODS: Data from 120 African-American and 62 white lupus patients were evaluated. Structured telephone interviews were conducted to determine treatment preferences, as well as to study characteristics and beliefs that may affect these preferences. Data were analysed using serial hierarchical multivariate logistic regression and deviances were calculated from a saturated model. RESULTS: Compared with their white counterparts, African-American SLE patients expressed less willingness to receive CYC (67.0% vs 84.9%, P = 0.02) if their lupus worsened. This racial/ethnic difference remained significant after adjusting for socioeconomic and psychosocial variables. Logistic regression analysis showed that African-American race [odds ratio (OR) 0.29, 95% CI 0.10, 0.80], physician trust (OR 1.05, 95% CI 1.00, 1.12) and perception of treatment effectiveness (OR 1.40, 95% CI 1.22, 1.61) were the most significant determinants of willingness to receive CYC. A trend in difference by race/ethnicity was also observed in willingness to participate in a clinical trial, but this difference was not significant. CONCLUSION: This study demonstrated reduced likelihood of accepting CYC in African-American lupus patients compared with white lupus patients. This racial/ethnic variation was associated with belief in medication effectiveness and trust in the medical provider, suggesting that education about therapy and improved trust can influence decision-making among SLE patients.

Evolution and Evaluation of a Quality and Patient Safety Fellowship for Practicing Health Professionals.

Developing clinical quality champions is an important strategy for improving health care quality. The NorthShore Quality and Patient Safety Fellowship was a yearlong program for practicing physicians devoting 4 hours/wk to a didactic curriculum and quality practicum. Thirty-seven clinicians completed the Fellowship from 2011 to 2018. Sixty percent of graduates reported a significant impact on their quality-related career trajectory, with 44% of early graduates and 64% of recent graduates reporting a new quality role or responsibility as a result of the Fellowship. Fifty-four percent of practicum projects were adopted or adapted by the organization. The Fellowship has been an effective framework to identify and train future quality champions and has led to further quality leadership opportunities for many graduates. Evolution of the Fellowship aligned practicum projects with organizational quality priorities. This curricular framework may be useful for other organizations that seek to develop quality champions among practicing physicians.

A meta-analysis of interventions to reduce loneliness.

Social and demographic trends are placing an increasing number of adults at risk for loneliness, an established risk factor for physical and mental illness. The growing costs of loneliness have led to a number of loneliness reduction interventions. Qualitative reviews have identified four primary intervention strategies: (a) improving social skills, (b) enhancing social support, (c) increasing opportunities for social contact, and (d) addressing maladaptive social cognition. An integrative meta-analysis of loneliness reduction interventions was conducted to quantify the effects of each strategy and to examine the potential role of moderator variables. Results revealed that single-group pre-post and nonrandomized comparison studies yielded larger mean effect sizes relative to randomized comparison studies. Among studies that used the latter design, the most successful interventions addressed maladaptive social cognition. This is consistent with current theories regarding loneliness and its etiology. Theoretical and methodological issues associated with designing new loneliness reduction interventions are discussed.

Effect of Monoclonal Antibody Treatment on Clinical Outcomes in Ambulatory Patients With Coronavirus Disease 2019.

We compared rates of emergency department visits or hospitalizations among ambulatory coronavirus disease 2019 (COVID-19) patients treated with monoclonal antibody (mAb) therapy (n = 305) vs untreated patients (n = 6354). Treatment was associated with decreased encounters within 30 days (adjusted odds ratio, 0.23 [95% confidence interval, .15-.36]). Our findings support treatment of acute COVID-19 with mAbs.

Using the RE-AIM framework to evaluate internal and external validity of mobile phone-based interventions in diabetes self-management education and support.

OBJECTIVE: We evaluated the extent to which studies that tested short message service (SMS)- and application (app)-based interventions for diabetes self-management education and support (DSMES) report on factors that inform both internal and external validity as measured by the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework. MATERIALS AND METHODS: We systematically searched PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), and IEEE Xplore Digital Library for articles from January 1, 2009, to February 28, 2019. We carried out a multistage screening process followed by email communications with study authors for missing or discrepant information. Two independent coders coded eligible articles using a 23-item validated data extraction tool based on the RE-AIM framework. RESULTS: Twenty studies (21 articles) were included in the analysis. The comprehensiveness of reporting on the RE-AIM criteria across the SMS- and app-based DSMES studies was low. With respect to internal validity, most interventions were well described and primary clinical or behavioral outcomes were measured and reported. However, gaps exist in areas of attrition, measures of potential negative outcomes, the extent to which the protocol was delivered as intended, and description on delivery agents. Likewise, we found limited information on external validity indicators across adoption, implementation, and maintenance domains. CONCLUSIONS: Reporting gaps were found in internal validity but more so in external validity in the current SMS- and app-based DSMES literature. Because most studies in this review were efficacy studies, the generalizability of these interventions cannot be determined. Future research should adopt the RE-AIM dimensions to improve the quality of reporting and enhance the likelihood of translating research to practice.

Perceptions of breast cancer treatment among African-American women and men: implications for interventions.

BACKGROUND: While breast cancer mortality has declined in recent years, the mortality gap between African-American and white women continues to grow. Current strategies to reduce this disparity focus on logistical and information needs, but contextual factors, such as concerns about racism and treatment side effects, may also represent significant barriers to improved outcomes. OBJECTIVE: To characterize perceptions of breast cancer treatment among African-American women and men. DESIGN: A qualitative study of African-American adults using focus group interviews. PARTICIPANTS: Two hundred eighty women and 165 men who live in one of 15 contiguous neighborhoods on Chicago's South Side. APPROACH: Transcripts were systematically analyzed using qualitative techniques to identify emergent themes related to breast cancer treatment. RESULTS: The concerns expressed most frequently were mistrust of the medical establishment and federal government, the effect of racism and lack of health insurance on quality of care, the impact of treatment on intimate relationships, and the negative effects of surgery, radiation therapy, and chemotherapy. CONCLUSIONS: In addition to providing logistical and information support, strategies to reduce the breast cancer mortality gap should also address contextual factors important to quality of care. Specific interventions are discussed, including strategies to enhance trust, reduce race-related treatment differences, minimize the impact of treatment on intimate relationships, and reduce negative perceptions of breast cancer surgery, radiation therapy, and chemotherapy.

Autonomic tone and C-reactive protein: a prospective population-based study.

OBJECTIVES: To examine the cross-sectional and longitudinal relationships between cardiac autonomic tone and serum CRP and to investigate potential causal links between these measures. METHODS: A population-based sample of 188 home-dwelling, middle-aged and older adults (104 women, mean age 59 years) from Cook County, IL, participated in this prospective cohort study. High-frequency heart rate variability (HF) and pre-ejection period (PEP) served as markers of cardiac parasympathetic and sympathetic tone, respectively. Cardiac autonomic balance (CAB) was defined as the arithmetic difference between normalized values of HF and PEP. Multivariate regression and autoregressive cross-lagged panel analyses were used to investigate cross-sectional and longitudinal relationships, respectively. High-sensitivity enzyme immunoassay measured serum CRP. RESULTS: After removing three cases with CRP values suggesting acute inflammation, the mean CRP value was 1.43 mg/L (range 0.02-7.96 mg/L, SD = 1.55). In models that adjusted for gender, age, race/ethnicity, education, body mass index, smoking, exercise, systolic blood pressure and health conditions including diabetes and hypertension, HF (B = -0.15, SE = 0.04, P < 0.01) and CAB (B = -0.14, SE = 0.04, P < 0.01) were significantly associated with natural log (ln) CRP. In longitudinal analysis, higher CRP levels in any one year predicted greater increases in HF in the subsequent year. INTERPRETATION: The inverse relationship between HF and CRP in cross-sectional analysis is consistent with previous studies, while the longitudinal results suggest that cardiac parasympathetic tone may increase over time as a result of higher circulating CRP.

From social structural factors to perceptions of relationship quality and loneliness: the Chicago health, aging, and social relations study.

OBJECTIVE: The objective of this study was to test a conceptual model of loneliness in which social structural factors are posited to operate through proximal factors to influence perceptions of relationship quality and loneliness. METHODS: We used a population-based sample of 225 White, Black, and Hispanic men and women aged 50 through 68 from the Chicago Health, Aging, and Social Relations Study to examine the extent to which associations between sociodemographic factors and loneliness were explained by socioeconomic status, physical health, social roles, stress exposure, and, ultimately, by network size and subjective relationship quality. RESULT: Education and income were negatively associated with loneliness and explained racial/ethnic differences in loneliness. Being married largely explained the association between income and loneliness, with positive marital relationships offering the greatest degree of protection against loneliness. Independent risk factors for loneliness included male gender, physical health symptoms, chronic work and/or social stress, small social network, lack of a spousal confidant, and poor-quality social relationships. DISCUSSION: Longitudinal research is needed to evaluate the causal role of social structural and proximal factors in explaining changes in loneliness.

WHEN LESS IS MORE IN PUBLIC HEALTH.

With obesity, diabetes, and cardiovascular disease reaching epidemic proportions and health-care cost costs spiraling out of control, policy experts in the United States are taking a closer look at alternatives to the medical model of health care. James C. Riley demonstrates that the public health model, with its emphasis on education, disease prevention, and skill development, effectively controlled infectious diseases in many poor countries during the 20th century. The countries Riley profiles have yet to attain economic success, yet each now boasts relatively low chronic disease rates and life expectancies that are at or near those in the United States. Riley's book provides evidence that demand for high-cost interventions can be controlled when populations have the knowledge, skills, and motivation they need to stay healthy.

Text Messaging to Improve Disease Management in Patients With Painful Diabetic Peripheral Neuropathy.

Purpose The purpose of the study was to determine the impact of educational text messages on diabetes self-management activities and outcomes in patients with painful diabetic peripheral neuropathy (pDPN). Methods Patients with pDPN identified from a large integrated health system who agreed to participate were randomized to 6 months of usual care (UC) or UC plus twice-daily diabetes self-management text messages (UC+TxtM). Outcomes included the Pain Numerical Rating Scale, Summary of Diabetes Self-Care Activities (SDSCA), questions on diabetes health beliefs, and glycated hemoglobin (A1C). Changes from baseline were evaluated at 6 months and compared between groups. Results Demographic characteristics were balanced between groups (N = 62; 53% female, mean age = 63 years, 94% type 2 diabetes), as were baseline measures. After 6 months, pain decreased with UC+TxtM from 6.3 to 5.5 and with UC from 6.5 to 6.0, with no difference between groups. UC+TxtM but not UC was associated with significant improvements from baseline on all SDSCA subscales. On diabetes health beliefs, UC+TxtM patients reported significantly increased benefits and reduced barriers and susceptibility relative to UC at 6 months. A1C declined in both groups, but neither change was significant relative to baseline. Conclusions Patients with pDPN who receive twice-daily text messages regarding diabetes management reported reduced pain relative to baseline, although this change was not significant compared with usual care. In addition, text messaging was associated with increased self-management activities and improved diabetes health beliefs and total self-care. These results warrant further investigation.

Interventions to enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority women.

The authors conduct a systematic review of the literature to identify interventions designed to enhance breast cancer screening, diagnosis, and treatment among minority women. Most trials in this area have focused on breast cancer screening, while relatively few have addressed diagnostic testing or breast cancer treatment. Among patient-targeted screening interventions, those that are culturally tailored or addressed financial or logistical barriers are generally more effective than reminder-based interventions, especially among women with fewer financial resources and those without previous mammography. Chart-based reminders increase physician adherence to mammography guidelines but are less effective at increasing clinical breast examination. Several trials demonstrate that case management is an effective strategy for expediting diagnostic testing after screening abnormalities have been found. Additional support for these and other proven health care organization-based interventions appears justified and may be necessary to eliminate racial and ethnic breast cancer disparities.

Neighborhood economic disadvantage, violent crime, group density, and pregnancy outcomes in a diverse, urban population.

Prior research has established associations between pregnancy outcomes and specific neighborhood characteristics, including economic disadvantage, violent crime, and racial/ethnic segregation. Recently, associations have also been found between various health outcomes and group density, the degree to which an individual is a racial or ethnic majority in his or her local community. The objective of this study was to determine the extent to which census tract economic disadvantage, violent crime rate, and group density are associated with pregnancy outcomes among White, Black, and Hispanic infants in a large metropolitan setting. This cross-sectional study utilized 1990 census data, 1991 crime data, and 1991 birth certificate information for singleton live births in Chicago, Illinois. Results show substantial racial segregation in Chicago, with 35% of census tracts having more than 90% Black residents and 45% of census tracts having fewer than 10% Black residents. After stratifying by maternal race/ethnicity, we used multilevel analyses to model pregnancy outcomes as a function of individual and census tract characteristics. Among all racial/ethnic groups, violent crime rate accounted for most of the negative association between tract economic disadvantage and birth weight. Group density was also associated with birth weight but this association was stronger among Whites and Hispanics than among Blacks. Further analysis revealed that group density was more strongly associated with preterm birth while violent crime rate was more strongly associated with small for gestational age. These results suggest that group density and violent crime may impact birth weight via different mechanisms.

Respiratory sinus arrhythmia and diseases of aging: obesity, diabetes mellitus, and hypertension.

Associations between respiratory sinus arrhythmia (RSA) and several chronic diseases, including obesity, diabetes mellitus, and hypertension, have been documented in recent years. Although most evidence suggests reduced RSA is the result of chronic disease rather than the cause, some studies have documented reduced RSA among at-risk individuals prior to disease onset. These results raise the possibility that decreased vagal tone may play a role in the pathogenesis of certain chronic diseases. Presented here is a brief overview of studies which examine the relationship between vagal tone, as measured by RSA and baroreflex gain, and diseases of aging, including obesity, diabetes mellitus, and hypertension. Mechanisms by which vagal tone may be related to disease processes are discussed. In addition, we present results from a population-based study of RSA and hypertension in older adults. Consistent with previous studies, we found an inverse relationship between RSA and age, cigarette use, and diabetes. In logistic regression models which control for age, cigarette use, and diabetes, we found RSA was a significant negative predictor of hypertension. We conclude that the relationship between RSA and hypertension is somewhat independent of the age-related decline in parasympathetic activity.

Estrogen metabolites and systolic blood pressure in a population-based sample of postmenopausal women.

CONTEXT: Lower systolic blood pressure (SBP) and lower rates of coronary heart disease among premenopausal women compared with similarly aged men and postmenopausal women suggest that female sex hormones may confer cardiovascular protection. 2-Hydroxyestradiol, a product of 17beta-estradiol oxidative metabolism, inhibits the proliferation of vascular smooth muscle cells in vitro. The other major product of 17beta-estradiol oxidative metabolism, 16alpha-hydroxyestradiol, does not demonstrate similar inhibitory effects. Concentrations of 2-hydroxyestrone (2-OHE) and 16alpha-hydroxyestrone (16-OHE) in urine reflect the relative activity of the 2- and 16alpha-hydroxylation pathways of 17beta-estradiol. OBJECTIVE: The objective of this study was to determine the relationship between SBP and the ratio of 2-OHE to 16-OHE in urine. DESIGN AND PARTICIPANTS: This was a cross-sectional study of 80 postmenopausal women living in Cook County, Illinois. SETTING: This study was performed in an academic clinical laboratory. MAIN OUTCOME MEASURE: The main outcome measure was SBP. RESULTS: Women taking hormone replacement therapy had higher levels of urinary 2-OHE and 16-OHE, but their mean 2:16-OHE ratio and SBP did not differ from that of women not taking hormone replacement therapy. In a multivariate regression model that controlled for age, body mass index, race/ethnicity, and antihypertensive medication use, a sd increase in the 2:16-OHE ratio was associated with a 6.7-mm Hg decrease (P < 0.05) in SBP. CONCLUSIONS: The ratio of urinary 2-OHE to 16-OHE is a significant predictor of SBP among postmenopausal women and may reflect the effects of 2-hydroxyestradiol, a potent inhibitor of vascular smooth muscle cell proliferation.

Loneliness is a unique predictor of age-related differences in systolic blood pressure.

A population-based sample of Caucasians, African Americans, and Latino Americans, 50-68 years of age (M = 57.5), from Cook County, Illinois (N = 229), was tested to examine how loneliness and co-occurring psychosocial factors (depressive symptoms, perceived stress, social support, and hostility) were related to indices of cardiovascular and endocrine functioning. Extending prior research, the authors found that loneliness was associated with elevated systolic blood pressure (SBP) and age-related increases in SBP, net of demographic variables, health behavior variables, and the remaining psychosocial factors. Loneliness was not associated with differences in autonomic or endocrine functioning. Although the results are limited by the cross-sectional methods used, they are consistent with the hypothesis that cardiovascular disease contributes to increased morbidity and mortality among lonely individuals.

The Role Of NOACs in Atrial Fibrillation Management: A Qualitative Study.

Patients with atrial fibrillation (AF) benefit from anticoagulation to reduce stroke risk. However, 30-60% of patients with AF are not anticoagulated. This study explored physicians' reasons for under-treatment of AF, focusing on the role of the novel oral anticoagulants (NOACs). We interviewed primary care physicians and cardiologists involved in AF management in a variety of practice settings. We conducted interviews using a semi-structured format and analyzed the data using the Framework Method. Four themes emerged. First, the likelihood of physicians to prescribe NOACs depends upon their willingness to try new medications and their successful experience with them. Second, physicians typically balance the benefits and risks of anticoagulation in AF patients, although not always accurately. Third, patient convenience and preferences, as well as physician convenience, are important when considering anticoagulation. Finally, concerns regarding the out-of-pocket cost of NOACs deter many physicians from prescribing them. The persistence of under-treatment in AF despite the availability of effective therapies suggests that new strategies are needed to improve physician knowledge and practice. These strategies should enhance physician awareness of AF under-treatment, emphasize accurate assessment of bleeding risk among AF patients, compare the safety, efficacy, and convenience of NOACs relative to warfarin, and address physician concerns regarding the out-of-pocket cost of NOACs. Guidelines and decision supports which promote physician knowledge in these areas have the potential to increase oral anticoagulant use and reduce preventable morbidity and mortality.