Three year clinical outcomes in a nationwide, observational, siteless clinical trial of atrial fibrillation screening-mHealth Screening to Prevent Strokes (mSToPS).

BACKGROUND: Atrial fibrillation (AF) is common, often without symptoms, and is an independent risk factor for mortality, stroke and heart failure. It is unknown if screening asymptomatic individuals for AF can improve clinical outcomes. METHODS: mSToPS was a pragmatic, direct-to-participant trial that randomized individuals from a single US-wide health plan to either immediate or delayed screening using a continuous-recording ECG patch to be worn for two weeks and 2 occasions, ~3 months apart, to potentially detect undiagnosed AF. The 3-year outcomes component of the trial was designed to compare clinical outcomes in the combined cohort of 1718 individuals who underwent monitoring and 3371 matched observational controls. The prespecified primary outcome was the time to first event of the combined endpoint of death, stroke, systemic embolism, or myocardial infarction among individuals with a new AF diagnosis, which was hypothesized to be the same in the two cohorts but was not realized. RESULTS: Over the 3 years following the initiation of screening (mean follow-up 29 months), AF was newly diagnosed in 11.4% (n = 196) of screened participants versus 7.7% (n = 261) of observational controls (p<0.01). Among the screened cohort with incident AF, one-third were diagnosed through screening. For all individuals whose AF was first diagnosed clinically, a clinical event was common in the 4 weeks surrounding that diagnosis: 6.6% experienced a stroke,10.2% were newly diagnosed with heart failure, 9.2% had a myocardial infarction, and 1.5% systemic emboli. Cumulatively, 42.9% were hospitalized. For those diagnosed via screening, none experienced a stroke, myocardial infarction or systemic emboli in the period surrounding their AF diagnosis, and only 1 person (2.3%) had a new diagnosis of heart failure. Incidence rate of the prespecified combined primary endpoint was 3.6 per 100 person-years among the actively monitored cohort and 4.5 per 100 person-years in the observational controls. CONCLUSIONS: At 3 years, screening for AF was associated with a lower rate of clinical events and improved outcomes relative to a matched cohort, although the influence of earlier diagnosis of AF via screening on this finding is unclear. These observational data, including the high event rate surrounding a new clinical diagnosis of AF, support the need for randomized trials to determine whether screening for AF will yield a meaningful protection from strokes and other clinical events. TRAIL REGISTRATION: The mHealth Screening To Prevent Strokes (mSToPS) Trial is registered on ClinicalTrials.gov with the identifier NCT02506244.

Treatment Patterns and Health Care Costs of Lupus Nephritis in a United States Payer Population.

OBJECTIVE: To describe the characteristics, treatment patterns, health care resource utilization (HCRU), and cost of care for members of a large United States (US) health insurance plan with lupus nephritis (LN). METHODS: A retrospective observational study was conducted using a health insurance plan database to identify adult members with a diagnosis of LN. Medical and pharmacy claims were used to describe demographics, comorbidities, HCRU, and cost patterns over a 12-month follow-up period for each patient, between January 1, 2014, and December 31, 2016. All study variables were examined descriptively. RESULTS: A total of 1039 patients were available for analysis (median age, 47 years; 83% female). The median Charlson Comorbidity Index (CCI) was 3.3. Less than half (41%) of patients received immunosuppressive therapies commonly used to treat LN. Evidence indicated that 58% of the study population were prescribed corticosteroid therapy, in most cases (73%) for more than 60 days. Adverse events known to be associated with corticosteroid therapy were recorded in 58% of patients. Guideline-recommended preventive therapy with hydroxychloroquine was prescribed for 54% of members with LN. Nearly half (47%) of members with LN did not see a nephrologist and more than one-third (36%) did not see a rheumatologist over 1 year of follow-up. Rates of all-cause hospitalization and emergency department (ED) use were 25% and 35%, respectively. The mean all-cause per-member-per-month (PMPM) medical cost for the study population was $2801, with LN-specific costs accounting for $1147 PMPM. CONCLUSION: Patients with LN who are insured through a large US health plan appeared to underutilize outpatient specialist services and guideline-recommended hydroxychloroquine therapy. Corticosteroid use and adverse events known to be associated with corticosteroids were common in this cohort.

Effects of conformance to type 2 diabetes guidelines on health care resource utilization, clinical outcomes, and cost: A retrospective claims analysis.

OBJECTIVES: To determine if there is a difference in the outcomes of diabetes patients managed with high, intermediate, or low conformance to diabetes guidelines. STUDY DESIGN: Retrospective database analysis. METHODS: This was a retrospective database analysis of adults diagnosed with type 2 diabetes and with glycated hemoglobin (HbA1c) ≥7% (53 mmol/mol) who were commercially insured by, or receiving Medicare benefits through, Aetna. Subjects were classified as having high, intermediate, or low conformance to current guidelines. Six, 12, and 18 months later, health care resource utilization, clinical outcomes, and costs were assessed using multivariable regression analysis to determine whether differences existed between patients with high, intermediate, and low conformance. Regression models were adjusted using pre-index variables, and the results were expressed as incidence rate ratios (IRRs) with 95% confidence intervals (CIs). RESULTS: A total of 21,171 individuals were included in the analysis. In analyses of patients with low versus high conformance, pharmacy costs were significantly lower over 18 months of outcome assessment (P < 0.001), but diabetes-related outpatient costs were significantly higher (P < 0.001). In analyses of patients with intermediate versus high conformance, diabetes-related outpatient costs were significantly greater at 12 and 18 months (P < 0.001 for both). CONCLUSIONS: Reduced conformance to guidelines leads to higher diabetes-related costs.

Healthcare resource utilization following ECG sensor patch screening for atrial fibrillation.

BACKGROUND: Screening for asymptomatic, undiagnosed atrial fibrillation (AF) has the potential to allow earlier treatment, possibly resulting in prevention of strokes, but also to increase medical resource utilization. OBJECTIVE: To compare healthcare utilization rates during the year following initiation of screening among participants screened for AF by electrocardiogram (ECG) sensor patch compared with a matched observational control group. METHODS: A total of 1718 participants recruited from a health care plan based on age and comorbidities who were screened with an ECG patch (actively monitored group) as part of a prospective, pragmatic research trial were matched by age, sex, and CHA2DS2-VASc score with 3371 members from the same health plan (observational control group). Healthcare utilization, including visits, prescriptions, procedures, and diagnoses, during the 1 year following screening was compared between the groups using health plan claims data. RESULTS: Overall, the actively monitored group had significantly higher rates of cardiology visits (adjusted incidence rate ratio [aIRR] [95% confidence interval (CI)]: 1.43 [1.27, 1.60]), no difference in primary care provider visits (aIRR [95% CI]: 1.0 [0.95, 1.05]), but lower rates of emergency department (ED) visits and hospitalizations (aIRR [95% CI]: 0.80 [0.69, 0.92]) compared with controls. Among those with newly diagnosed AF, the reduction in ED visits and hospitalizations was even greater (aIRR [95% CI]: 0.27 [0.17, 0.43]). CONCLUSION: AF screening in an asymptomatic, moderate-risk population with an ECG patch was associated with an increase in cardiology outpatient visits but also significantly lower rates of ED visits and hospitalizations over the 1 year following screening.

Digital recruitment and enrollment in a remote nationwide trial of screening for undiagnosed atrial fibrillation: Lessons from the randomized, controlled mSToPS trial.

OBJECTIVES: The advent of large databases, wearable technology, and novel communications methods has the potential to expand the pool of candidate research participants and offer them the flexibility and convenience of participating in remote research. However, reports of their effectiveness are sparse. We assessed the use of various forms of outreach within a nationwide randomized clinical trial being conducted entirely by remote means. METHODS: Candidate participants at possibly higher risk for atrial fibrillation were identified by means of a large insurance claims database and invited to participate in the study by their insurance provider. Enrolled participants were randomly assigned to one of two groups testing a wearable sensor device for detection of the arrhythmia. RESULTS: Over 10 months, the various outreach methods used resulted in enrollment of 2659 participants meeting eligibility criteria. Starting with a baseline enrollment rate of 0.8% in response to an email invitation, the recruitment campaign was iteratively optimized to ultimately include website changes and the use of a five-step outreach process (three short, personalized emails and two direct mailers) that highlighted the appeal of new technology used in the study, resulting in an enrollment rate of 9.4%. Messaging that highlighted access to new technology outperformed both appeals to altruism and appeals that highlighted accessing personal health information. CONCLUSIONS: Targeted outreach, enrollment, and management of large remote clinical trials is feasible and can be improved with an iterative approach, although more work is needed to learn how to best recruit and retain potential research participants. TRIAL REGISTRATION: Clinicaltrials.govNCT02506244. Registered 23 July 2015.

Effect of a Home-Based Wearable Continuous ECG Monitoring Patch on Detection of Undiagnosed Atrial Fibrillation: The mSToPS Randomized Clinical Trial.

Importance: Opportunistic screening for atrial fibrillation (AF) is recommended, and improved methods of early identification could allow for the initiation of appropriate therapies to prevent the adverse health outcomes associated with AF. Objective: To determine the effect of a self-applied wearable electrocardiogram (ECG) patch in detecting AF and the clinical consequences associated with such a detection strategy. Design, Setting, and Participants: A direct-to-participant randomized clinical trial and prospective matched observational cohort study were conducted among members of a large national health plan. Recruitment began November 17, 2015, and was completed on October 4, 2016, and 1-year claims-based follow-up concluded in January 2018. For the clinical trial, 2659 individuals were randomized to active home-based monitoring to start immediately or delayed by 4 months. For the observational study, 2 deidentified age-, sex- and CHA2DS2-VASc-matched controls were selected for each actively monitored individual. Interventions: The actively monitored cohort wore a self-applied continuous ECG monitoring patch at home during routine activities for up to 4 weeks, initiated either immediately after enrolling (n = 1364) or delayed for 4 months after enrollment (n = 1291). Main Outcomes and Measures: The primary end point was the incidence of a new diagnosis of AF at 4 months among those randomized to immediate monitoring vs delayed monitoring. A secondary end point was new AF diagnosis at 1 year in the combined actively monitored groups vs matched observational controls. Other outcomes included new prescriptions for anticoagulants and health care utilization (outpatient cardiology visits, primary care visits, or AF-related emergency department visits and hospitalizations) at 1 year. Results: The randomized groups included 2659 participants (mean [SD] age, 72.4 [7.3] years; 38.6% women), of whom 1738 (65.4%) completed active monitoring. The observational study comprised 5214 (mean [SD] age, 73.7 [7.0] years; 40.5% women; median CHA2DS2-VASc score, 3.0), including 1738 actively monitored individuals from the randomized trial and 3476 matched controls. In the randomized study, new AF was identified by 4 months in 3.9% (53/1366) of the immediate group vs 0.9% (12/1293) in the delayed group (absolute difference, 3.0% [95% CI, 1.8%-4.1%]). At 1 year, AF was newly diagnosed in 109 monitored (6.7 per 100 person-years) and 81 unmonitored (2.6 per 100 person-years; difference, 4.1 [95% CI, 3.9-4.2]) individuals. Active monitoring was associated with increased initiation of anticoagulants (5.7 vs 3.7 per 100 person-years; difference, 2.0 [95% CI, 1.9-2.2]), outpatient cardiology visits (33.5 vs 26.0 per 100 person-years; difference, 7.5 [95% CI, 7.2-7.9), and primary care visits (83.5 vs 82.6 per 100 person-years; difference, 0.9 [95% CI, 0.4-1.5]). There was no difference in AF-related emergency department visits and hospitalizations (1.3 vs 1.4 per 100 person-years; difference, 0.1 [95% CI, -0.1 to 0]). Conclusions and Relevance: Among individuals at high risk for AF, immediate monitoring with a home-based wearable ECG sensor patch, compared with delayed monitoring, resulted in a higher rate of AF diagnosis after 4 months. Monitored individuals, compared with nonmonitored controls, had higher rates of AF diagnosis, greater initiation of anticoagulants, but also increased health care resource utilization at 1 year. Trial Registration: ClinicalTrials.gov Identifier: NCT02506244.

Pharmacogenetic testing among patients with mood and anxiety disorders is associated with decreased utilization and cost: A propensity-score matched study.

BACKGROUND: Naturalistic and small randomized trials have suggested that pharmacogenetic testing may improve treatment outcomes in depression, but its cost-effectiveness is not known. There is growing enthusiasm for personalized medicine, relying on genetic variation as a contributor to heterogeneity of treatment effects. We sought to examine the relationship between a commercial pharmacogenetic test for psychotropic medications and 6-month cost of care and utilization in a large commercial health plan. METHODS: We performed a propensity-score matched case-control analysis of longitudinal health claims data from a large US insurer. Individuals with a mood or anxiety disorder diagnosis (N = 817) who received genetic testing for pharmacokinetic and pharmacodynamic variation were matched to 2,745 individuals who did not receive such testing. Outcomes included number of outpatient visits, inpatient hospitalizations, emergency room visits, and prescriptions, as well as associated costs over 6 months. RESULTS: On average, individuals who underwent testing experienced 40% fewer all-cause emergency room visits (mean difference 0.13 visits; P < 0.0001) and 58% fewer inpatient all-cause hospitalizations (mean difference 0.10 visits; P < 0.0001) than individuals in the control group. The two groups did not differ significantly in number of psychotropic medications prescribed or mood-disorder related hospitalizations. Overall 6-month costs were estimated to be $1,948 (SE 611) lower in the tested group. CONCLUSIONS: Pharmacogenetic testing represents a promising strategy to reduce costs and utilization among patients with mood and anxiety disorders.

Synthesis Of Research On Patient-Centered Medical Homes Brings Systematic Differences Into Relief.

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.

Electronic health records and health care quality over time in a federally qualified health center.

The longitudinal effects of electronic health records (EHRs) on ambulatory quality are not clear. It is not known whether adoption and meaningful use of EHRs result in a brief period of quality improvement that then plateaus, or whether with ongoing use quality improvement continues. We studied health care quality at six sites of a Federally Qualified Health Center in New York State over 3 years (2008-2010) for 25 290 unique patients. Patients were twice as likely to receive recommended care on a set of 12 quality measures (11 of which are included in Stage 1 Meaningful Use) 3 years post-EHR implementation, compared to 1-year post-implementation (odds ratio 1.97; 95% confidence interval, 1.91-2.03). The magnitude of absolute improvement ranged from 5% to 20% per measure. EHRs were associated with continuing improvement in health care quality for at least 3 years post-implementation in the safety-net setting of a Federally Qualified Health Center.

Health information exchange system usage patterns in three communities: practice sites, users, patients, and data.

OBJECTIVES: Public and private organizations are implementing systems for query-based health information exchange (HIE), the electronic aggregation of patient data from multiple institutions. However, existing studies of query-based HIE system usage have addressed a limited number of settings. Our goal was to quantify the breadth and depth of usage of a query-based HIE system implemented across multiple communities with diverse care settings and patient populations. METHODS: We performed a cross-sectional study in three communities in New York State using system access log files from January 2009 to May 2011 to measure usage patterns of a query-based HIE web portal system with respect to practice sites, users, patients, and data. RESULTS: System access occurred from 60% (n=200) of practice sites registered to use the system in Community A, 59% (n=156) in Community B, and 82% (n=28) in Community C. In Communities A and B, users were primarily non-clinical staff in outpatient settings, while in Community C inpatient physicians were the main users. Across communities, proportions of patients whose data were accessed varied with 5% (n=11,263) in Community A, 60% (n=212,586) in Community B, and 1% (n=1107) in Community C. In Community B, users updated patient consent through the HIE portal, whereas in the other communities, users updated patient consent through a separate system. Across communities, users most frequently accessed only patient summary data displayed by default followed by detailed laboratory and radiology data. CONCLUSIONS: This study is among the first to illustrate large-scale usage of a query-based HIE system implemented across multiple communities. Patient summary data displayed by default may be an important feature of query-based HIE systems. User role, practice site type, and patient consent workflow may affect patterns of query-based HIE web portal system usage in the communities studied and elsewhere.

Lives saved by expanding HIV treatment availability in resource-limited settings: the example of Haiti.

BACKGROUND: Guidelines recommend antiretroviral therapy (ART) initiation at CD4 <350 cells per microliter for HIV-infected individuals in resource-limited settings. However, funding for treatment expansion remains uncertain. We forecast the mortality impact of ART expansion alternatives in Haiti. METHODS: We used data from Haiti to develop a country-specific model of HIV disease. The model projects the mortality, total number of HIV-infected individuals, and number and coverage (percentage of those eligible) on ART by simulating cohorts of HIV-infected individuals over 10 years. Five ART expansion scenarios, ranging from fully expanded ART (best case) to No New ART (worst case), were assessed. RESULTS: By 2010, the model predicts 103,500 individuals living with HIV in Haiti, of whom 27,300 were estimated to receive ART. Continuing ART initiation at current rates requires increasing the number on ART to 43,300 by 2020 (56% coverage), with 89,700 deaths estimated between 2010 and 2020. The number on ART could increase by 7400 (+17.1%, best case) or decrease by 25,600 (-59.1%, worst case), resulting in 19,500 deaths averted and 9900 fewer in care awaiting ART (best versus worst case). Results are sensitive to untreated disease progression and pre-ART loss from care. Increased HIV testing, linkage to care, and retention in care can avert additional deaths and achieve nearly 80% ART coverage with optimal policy improvements. CONCLUSIONS: In resource-limited settings, continued improvements in HIV treatment access will save lives. Efforts to efficiently expand ART access should remain a global priority.

Accuracy of electronically reported "meaningful use" clinical quality measures: a cross-sectional study.

BACKGROUND: The federal Electronic Health Record Incentive Program requires electronic reporting of quality from electronic health records, beginning in 2014. Whether electronic reports of quality are accurate is unclear. OBJECTIVE: To measure the accuracy of electronic reporting compared with manual review. DESIGN: Cross-sectional study. SETTING: A federally qualified health center with a commercially available electronic health record. PATIENTS: All adult patients eligible in 2008 for 12 quality measures (using 8 unique denominators) were identified electronically. One hundred fifty patients were randomly sampled per denominator, yielding 1154 unique patients. MEASUREMENTS: Receipt of recommended care, assessed by both electronic reporting and manual review. Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and absolute rates of recommended care were measured. RESULTS: Sensitivity of electronic reporting ranged from 46% to 98% per measure. Specificity ranged from 62% to 97%, positive predictive value from 57% to 97%, and negative predictive value from 32% to 99%. Positive likelihood ratios ranged from 2.34 to 24.25 and negative likelihood ratios from 0.02 to 0.61. Differences between electronic reporting and manual review were statistically significant for 3 measures: Electronic reporting underestimated the absolute rate of recommended care for 2 measures (appropriate asthma medication [38% vs. 77%; P < 0.001] and pneumococcal vaccination [27% vs. 48%; P < 0.001]) and overestimated care for 1 measure (cholesterol control in patients with diabetes [57% vs. 37%; P = 0.001]). LIMITATION: This study addresses the accuracy of the measure numerator only. CONCLUSION: Wide measure-by-measure variation in accuracy threatens the validity of electronic reporting. If variation is not addressed, financial incentives intended to reward high quality may not be given to the highest-quality providers. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Health care consumers' preferences around health information exchange.

PURPOSE Consumer buy-in is important for the success of widespread federal initiatives to promote the use of health information exchange (HIE). Little is known, however, of consumers' preferences around the storing and sharing of electronic health information. We conducted a study to better understand consumer preferences regarding the privacy and security of HIE. METHODS In 2008 we conducted a cross-sectional, random digit dial telephone survey of residents in the Hudson Valley of New York State, a state where patients must affirmatively consent to having their data accessed through HIE. RESULTS There was an 85% response rate (N = 170) for the survey. Most consumers would prefer that permission be obtained before various parties, including their clinician, could view their health information through HIE. Most consumers wanted any method of sharing their health information to have safeguards in place to protect against unauthorized viewing (86%). They also wanted to be able to see who has viewed their information (86%), to stop electronic storage of their data (84%), to stop all viewing (83%), and to select which parts of their health information are shared (78%). Among the approximately one-third (n = 54) of consumers who were uncomfortable with automatic inclusion of their health information in an electronic database for HIE, 78% wished to approve all information explicitly, and most preferred restricting information by clinician (83%), visit (81%), or information type (88%). CONCLUSION Consumers in a state with an opt-in consent policy are interested in having greater control over the privacy and security of their electronic health information. These preferences should be considered when developing and implementing systems, standards and policies.

Consumer perceptions of electronic health information exchange.

BACKGROUND: Public support will be critical to the success and long-term sustainability of electronic health information exchange (HIE) initiatives currently promoted by federal policy. PURPOSE: The goal of this study was to assess consumer perceptions of HIE in a state (New York) with a 6-year history of successful HIE organizations. METHODS: The Empire State Poll is a random-digit-dial telephone survey of adult New York State residents conducted annually by the Survey Research Institute at Cornell University. In 2011, it contained 77 items. RESULTS: The survey was conducted and data were analyzed in 2011. Eight hundred respondents participated (71% response rate). Large majorities supported HIE among healthcare providers (69%); thought it would improve quality of care (68%); and supported "break the glass" access to HIE data without need for consent in emergencies (90%). Support was lower among people who rated large corporations as less trustworthy. Privacy and security concerns were expressed by 68%. Respondents were supportive whether the architecture involved a physician sending data to another physician, a physician sending data to a patient who could send it to other physicians, or a physician accessing data from other institutions. CONCLUSIONS: In New York, public support for HIE is strong. Policy and outreach pertaining to this type of exchange may be most effective if it clarifies the roles and responsibilities of large businesses involved in different aspects of the exchange, and privacy and security controls. Differing architectures received similar levels of support.

Factors influencing unexpected disposition after orthopedic ambulatory surgery.

STUDY OBJECTIVE: To analyze whether patient characteristics, ambulatory facility type, anesthesia provider and technique, procedure type, and temporal factors impact the outcome of unexpected disposition after ambulatory knee and shoulder surgery. DESIGN: Retrospective analysis of a national database. SETTING: Freestanding and hospital-based ambulatory surgery facilities. MEASUREMENTS: Ambulatory knee and shoulder surgery cases from 1996 and 2006 were identified through the National Survey of Ambulatory Surgery. The incidence of unexpected disposition status was determined and risk factors for such outcome were analyzed. MAIN RESULTS: Factors independently increasing the risk for unexpected disposition included procedures performed in hospital-based versus freestanding facilities [odds ratio (OR) 6.83 (95% confidence interval [CI] 4.34; 10.75)], shoulder versus knee procedures [OR 3.84 (CI 2.55; 5.77)], anesthesia provided by nonanesthesiology professionals and certified registered nurse-anesthetists versus anesthesiologists [OR 7.33 (CI 4.18; 12.84) and OR 1.80 (CI 1.09; 2.99), respectively]. Decreased risk for unexpected disposition was for procedures performed in 2006 versus 1996 [OR 0.15 (CI 0.10; 0.24)] and the use of anesthesia other than regional or general [OR 0.34 (CI 0.18; 0.68)]. CONCLUSIONS: The decreased risk for unexpected disposition associated with more recent data and with freestanding versus hospital-based facilities may represent improvements in efficiency, while the decreased odds for such disposition status associated with the use of other than general or regional anesthesia may be related to a lower invasiveness of cases. We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. No difference in this outcome was noted when an anesthesia care team provided care.

Push and pull: physician usage of and satisfaction with health information exchange.

Federal policy toward health information exchange (HIE), the electronic transfer of patient data across organizations, has evolved to support two forms-push, or point-to-point data transmission, and pull, or multisource data aggregation. HIE usage is associated with user satisfaction, but existing quantitative research is limited to settings where only pull HIE is available. To address this gap, we surveyed 99 physicians regarding usage of and satisfaction with push HIE and pull HIE available in their communities as well as effects of HIE on practice and overall HIE satisfaction. In five of nine measures, respondents reported being very satisfied with push HIE more often than pull HIE (p < 0.05). Physicians were at least four times as likely to report being very satisfied with HIE overall if they were pediatricians, were very satisfied with push HIE, or noted that HIE improved their access to complete information. Findings have implications for HIE implementation and policy.

Consumer attitudes toward personal health records in a beacon community.

OBJECTIVE: To characterize consumers' attitudes about personal health records (PHRs), electronic tools that enable consumers to securely access, manage, and share their health information, in a community participating in health information technology initiatives. STUDY DESIGN: Cross-sectional study. METHODS: A random-digit-dial telephone survey about PHRs was conducted among adult residents of New York State's greater Buffalo region. Multivariate regression analyses identified factors associated with potential PHR use. RESULTS: We obtained a 79% (n = 200) response rate. Many respondents (70%) would potentially use PHRs. Consumers wanted PHRs to incorporate an array of information, including immunization records (89%) and providers visited (88%). They expressed interest in several online activities, including accessing their family members' healthcare information (71%). Potential PHR use was associated with perceptions that PHRs would improve privacy and security of medical information (odds ratio [OR] 4.7; 95% confidence interval [CI] 1.1, 20.1), understanding regarding health (OR 3.7; 95% CI 1.3, 11.1), and overall quality of care (OR 3.6; 95% CI 1.2, 10.6). Potential PHR use was associated with annual household income of more than $30,000 (OR 3.9; 95% CI 1.3, 11.9) and experience looking up health information online (OR 3.0; 95% CI 1.1, 8.1). CONCLUSIONS: Consumers expressed great interest in using PHRs and wanted comprehensive PHRs. However, the "digital divide" between those with varying levels of Internet experience and concerns about PHRs' effect on privacy and security of medical information may limit use. Designing PHRs that incorporate consumer preferences and developing policies that address these barriers may increase consumers' PHR use.

Chronic kidney disease, thrombotic microangiopathy, and hypertension following T cell-depleted hematopoietic stem cell transplantation.

Chronic kidney disease (CKD) is now an accepted long-term complication of allogeneic hematopoietic stem cell transplantation. Calcineurin inhibitors (CNI), which are used for prophylaxis and treatment of graft-versus-host disease (GVHD), have been associated with the development of nephrotoxicity. Hypertension (HTN) and thrombotic microangiopathy (TMA) are 2 comorbidities linked to CKD. T cell depletion (TCD) of stem cell grafts can obviate the need for the use of CNI. We conducted a retrospective analysis of 100 patients who underwent TCD transplantation: 30 in group A were conditioned without total-body radiation (TBI) and 70 in group B received a TBI containing regimen. None of the patients received CNI. The median age was 55.5 and 45 years for groups A and B, respectively. Eleven patients developed TMA, all in group B. The 2-year cumulative incidence of sustained CKD was 29.2% and 48.8% in group A and group B, respectively, with a mean follow-up of at least 21 months. CKD free survival was better in the non-TBI group (P = .046). Multivariable survival analysis revealed that exposure to TBI, older age, and TMA were risk factors for CKD. The incidence of new onset or worsening HTN was 6.7% and 25.7% (P = .03) in group A and B, respectively. The use of TBI (P = .0182) and diagnosis of TMA (P = .0006) predisposed patients to the development of HTN using univariable logistic regression models. Thus, despite the absence of CNI, a proportion of these older patients in both groups developed CKD and HTN.

Development and validation of a patient self-assessment score for diabetes risk.

BACKGROUND: National guidelines disagree on who should be screened for undiagnosed diabetes. No existing diabetes risk score is highly generalizable or widely followed. OBJECTIVE: To develop a new diabetes screening score and compare it with other available screening instruments (Centers for Disease Control and Prevention, American Diabetes Association, and U.S. Preventive Services Task Force guidelines; 2 American Diabetes Association risk questionnaires; and the Rotterdam model). DESIGN: Cross-sectional data. SETTING: NHANES (National Health and Nutrition Examination Survey) 1999 to 2004 for model development and 2005 to 2006, plus a combined cohort of 2 community studies, ARIC (Atherosclerosis Risk in Communities) Study and CHS (Cardiovascular Health Study), for validation. PARTICIPANTS: U.S. adults aged 20 years or older. MEASUREMENTS: A risk-scoring algorithm for undiagnosed diabetes, defined as fasting plasma glucose level of 7.0 mmol/L (126 mg/dL) or greater without known diabetes, was developed in the development data set. Logistic regression was used to determine which participant characteristics were independently associated with undiagnosed diabetes. The new algorithm and other methods were evaluated by standard diagnostic and feasibility measures. RESULTS: Age, sex, family history of diabetes, history of hypertension, obesity, and physical activity were associated with undiagnosed diabetes. In NHANES (ARIC/CHS), the cut-point of 5 or more points selected 35% (40%) of persons for diabetes screening and yielded a sensitivity of 79% (72%), specificity of 67% (62%), positive predictive value of 10% (10%), and positive likelihood ratio of 2.39 (1.89). In contrast, the comparison scores yielded a sensitivity of 44% to 100%, specificity of 10% to 73%, positive predictive value of 5% to 8%, and positive likelihood ratio of 1.11 to 1.98. LIMITATION: Data during pregnancy were not available. CONCLUSION: This easy-to-implement diabetes screening score seems to demonstrate improvements over existing methods. Studies are needed to evaluate it in diverse populations in real-world settings. PRIMARY FUNDING SOURCE: Clinical and Translational Science Center at Weill Cornell Medical College.

Factors associated with response to a follow-up postal questionnaire in a cohort of American Indians.

OBJECTIVE: The aim of the study was to collect pilot data on response rates to a follow-up postal questionnaire in a cohort of American Indians living in the Southwestern United States. We tested the effect of questionnaire length on response. METHODS: Cohort members were American Indian adults aged 18 and over who completed the baseline study visit. Study participants (N=1587), cohort members who completed the baseline study visit during the first year of enrollment, were randomized into two groups to receive either an 18-page or 3-page follow-up postal questionnaire. Data were collected between October 2005 and March 2006. RESULTS: The response rates after two questionnaire mailings and a reminder postcard were significantly higher for the short versus the long (56.2%, 48.1% p= < 0.01) questionnaire. Being female and being aged 50 or older were associated with returning a completed questionnaire. A reminder postcard and second mailing improved response by 11.7% and 13.4% respectively. CONCLUSIONS: These results show that a postal questionnaire can be used in a cohort of American Indians living in the Southwest, but suggest that questionnaires should be short and repeat mailings are needed.