Pediatric clinician perspectives on communicating diagnostic uncertainty.

OBJECTIVE: Diagnosis often evolves over time, involves uncertainty, and is vulnerable to errors. We examined pediatric clinicians' perspectives on communicating diagnostic uncertainty to patients' parents and how this occurs. DESIGN: We conducted semi-structured interviews, which were audiotaped, transcribed, and analyzed using content analysis. Two researchers independently coded transcripts and then discussed discrepancies to reach consensus. SETTING: A purposive sample of pediatric clinicians at two large academic medical institutions in Texas. PARTICIPANTS: Twenty pediatric clinicians participated: 18 physicians, 2 nurse practitioners; 7 males, 13 females; 7 inpatient, 11 outpatient, and 2 practicing in mixed settings; with 0-16 years' experience post-residency. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pediatric clinician perspectives on communication of diagnostic uncertainty. RESULTS: Pediatric clinicians commonly experienced diagnostic uncertainty and most were comfortable seeking help and discussing with colleagues. However, when communicating uncertainty to parents, clinicians used multiple considerations to adjust the degree to which they communicated. Considerations included parent characteristics (education, socioeconomic status, emotional response, and culture) and strength of parent-clinician relationships. Communication content included setting expectations, explaining the diagnostic process, discussing most relevant differentials, and providing reassurance. Responses to certain parent characteristics, however, were variable. For example, some clinicians were more open to discussing diagnostic uncertainty with more educated parents- others were less. CONCLUSIONS: While pediatric clinicians are comfortable discussing diagnostic uncertainty with colleagues, how they communicate uncertainty to parents appears variable. Parent characteristics and parent-clinician relationships affect extent of communication and content discussed. Development and implementation of optimal strategies for managing and communicating diagnostic uncertainty can improve the diagnostic process.

Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review.

BACKGROUND: Physicians routinely encounter diagnostic uncertainty in practice. Despite its impact on health care utilization, costs and error, measurement of diagnostic uncertainty is poorly understood. We conducted a systematic review to describe how diagnostic uncertainty is defined and measured in medical practice. METHODS: We searched OVID Medline and PsycINFO databases from inception until May 2017 using a combination of keywords and Medical Subject Headings (MeSH). Additional search strategies included manual review of references identified in the primary search, use of a topic-specific database (AHRQ-PSNet) and expert input. We specifically focused on articles that (1) defined diagnostic uncertainty; (2) conceptualized diagnostic uncertainty in terms of its sources, complexity of its attributes or strategies for managing it; or (3) attempted to measure diagnostic uncertainty. KEY RESULTS: We identified 123 articles for full review, none of which defined diagnostic uncertainty. Three attributes of diagnostic uncertainty were relevant for measurement: (1) it is a subjective perception experienced by the clinician; (2) it has the potential to impact diagnostic evaluation-for example, when inappropriately managed, it can lead to diagnostic delays; and (3) it is dynamic in nature, changing with time. Current methods for measuring diagnostic uncertainty in medical practice include: (1) asking clinicians about their perception of uncertainty (surveys and qualitative interviews), (2) evaluating the patient-clinician encounter (such as by reviews of medical records, transcripts of patient-clinician communication and observation), and (3) experimental techniques (patient vignette studies). CONCLUSIONS: The term "diagnostic uncertainty" lacks a clear definition, and there is no comprehensive framework for its measurement in medical practice. Based on review findings, we propose that diagnostic uncertainty be defined as a "subjective perception of an inability to provide an accurate explanation of the patient's health problem." Methodological advancements in measuring diagnostic uncertainty can improve our understanding of diagnostic decision-making and inform interventions to reduce diagnostic errors and overuse of health care resources.

Outcomes and readmissions after transcatheter and surgical aortic valve replacement in patients with cirrhosis: A propensity matched analysis.

BACKGROUND: The data on the comparative outcomes and readmissions after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with cirrhosis are limited. We compared mortality, complications, discharge disposition, 30-day readmission rates, length of stay, and cost of hospitalization in cirrhotic patients undergoing TAVR and SAVR. METHODS: The National Inpatient Sample (NIS) and the National Readmission Database (NRD) were used for the study. The International Classification of Diseases-9th version was used to define cohorts of patients undergoing TAVR and SAVR. Patients undergoing concomitant other valve or coronary bypass surgery were excluded. Propensity-score matching was used to compare the outcomes between the groups. RESULTS: From 2012 to 2014, a total of 126 and 157 patients with cirrhosis underwent TAVR and SAVR, respectively. Of the 283 patients, 16 (5.7%) died during the same hospitalization. We found 345 patients with cirrhosis who had undergone an aortic valve replacement (156 with TAVR, and 189 with SAVR) in the 2013 and 2014 NRD. On propensity matching, there were no significant differences between the in-hospital mortality, readmissions, hospitalization costs, and discharges to home within the TAVR and SAVR groups. However, post-procedure length of stay (6.3 vs. 10.2 days; P < 0.001) and blood transfusion rates (22% vs. 58%; P < 0.001) were significantly lower in TAVR patients. CONCLUSIONS: Cirrhotic patients undergoing TAVR has high, but similar mortality and 30-day readmission rates when compared to SAVR; however, has shorter length of stay and lower blood transfusion rates.

Patient perspectives on how physicians communicate diagnostic uncertainty: An experimental vignette study.

OBJECTIVE: We evaluated the effects of three different strategies for communicating diagnostic uncertainty on patient perceptions of physician competence and visit satisfaction. DESIGN/SETTING: Experimental vignette-based study design involving pediatric cases presented to a convenience sample of parents living in a large US city. PARTICIPANTS/INTERVENTION(S): Three vignettes were developed, each describing one of three different ways physicians communicated diagnostic uncertainty to parents-(i) explicit expression of uncertainty ('not sure' about diagnosis), (ii) implicit expression of uncertainty using broad differential diagnoses and (iii) implicit expression of uncertainty using 'most likely' diagnoses. Participants were randomly assigned to one of the three vignettes and then answered a 37-item web-based questionnaire. MAIN OUTCOME MEASURE(S): Outcome variables included parent-perceived technical competence of physician, trust and confidence, visit satisfaction and adherence to physician instructions. Differences between the three groups were compared using analysis of variance, followed by individual post hoc analyses with Bonferroni correction. RESULTS: Seventy-one participants completed the vignette questions. Demographic characteristics and scores on activation (parent activation measure [PAM]) and intolerance to uncertainty were similar across the three groups. Explicit expression of uncertainty was associated with lower perceived technical competence, less trust and confidence, and lower patient adherence as compared to the two groups with implicit communication. These latter two groups had comparable outcomes. CONCLUSION: Parents may react less negatively in terms of perceived competence, physician confidence and trust, and intention to adhere when diagnostic uncertainty is communicated using implicit strategies, such as using broad differential diagnoses or most likely diagnoses. Evidence-based strategies to communicate diagnostic uncertainty to patients need further development.

Early readmissions after transcatheter and surgical aortic valve replacement.

OBJECTIVES: We aimed to determine and compare the prevalence, and predictors of readmissions after the transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). BACKGROUND: There are limited data on the readmission rates after TAVR in comparison with SAVR. METHODS: We analyzed the data from 2013 National Readmission Database. Propensity-matched pairs were used to analyze differences in readmission rates between TAVR and SAVR for patients aged ≥65. RESULTS: A total of 24,020 (TAVR-transfemoral 3,469, TAVR-transapical 1,433, SAVR 19,118) patients were included. The readmission rates were not statistically different for all propensity-matched TAVR and SAVR patients (17.2% vs. 20.6%, P = 0.28). However, in subgroup analysis, transapical TAVR had the highest readmission rate (22.8% vs. 16.5% vs. 16.0%, P < 0.001, respectively) and readmission leading to death (7.1% vs. 5.3% vs. 3.9%, P = 0.022, respectively) when compared with transfemoral TAVR and SAVR. In all the groups, two-thirds of readmissions were due to noncardiac causes. Congestive heart failure (CHF) and arrhythmia were the most frequent cardiac etiologies. The independent predictors of readmission were female sex, CHF, and chronic obstructive pulmonary disease. Patients who received care in teaching hospitals had lower probability of readmission. CONCLUSIONS: One of six patients were readmitted within 30 days after the aortic valve replacement. On propensity score analysis, there were no significant differences between the early readmission rates between TAVR and SAVR groups. However, the patients undergoing transapical TAVR were at higher risk for readmission, and subsequent deaths when compared with transfemoral TAVR and SAVR. © 2017 Wiley Periodicals, Inc.

Patient-Reported Attributions for Missed Colonoscopy Appointments in Two Large Healthcare Systems.

BACKGROUND: Missed colonoscopy appointments (no-shows) can lead to wasted resources and delays in colorectal cancer diagnosis, an area of special concern in public health systems that often provide care for vulnerable patients. Our objective was to identify reasons for missed colonoscopy appointments in patients seeking care at two large public health systems in Houston, TX. METHODS: We conducted a telephone survey of patients who missed their colonoscopy appointments at two tertiary care health systems. Using a structured survey instrument, we collected information on patient-specific and health services barriers. Patient-specific barriers included perceived procedural-related factors (e.g., difficulty in preparation), cognitive-emotional factors (e.g., fear or concern about modesty), and changes in health status (e.g., improvement or worsening of health). Health services barriers included logistical factors (e.g., travel-related difficulties) and appointment scheduling problems (inconvenient date or time). We examined differences in attributions for missed appointments between the two study sites. RESULTS: Of 160 unique patients (102 Site A and 58 Site B) who missed their appointment during the study period, 153 (95.6 %) attributed their no-show to at least one of the listed barriers. Most respondents (125; 78.1 %) cited travel-related issues or scheduling problems as reasons for their missed appointment. Not having a ride or a travel companion was the most commonly reported travel-related issue. We also found significant differences for barriers between the two sites. CONCLUSIONS: Most missed colonoscopy appointments resulted from potentially preventable travel- and scheduling-related issues. Because barriers to keeping colonoscopy appointments are different across health systems, each health system might need to develop unique interventions to reduce missed colonoscopy appointments.

The use of a tablet computer platform to optimize the care of patients receiving peritoneal dialysis: a pilot study.

BACKGROUND: Peritoneal dialysis (PD) affords patients increased independence and improved quality of life. However, the lack of more frequent monitoring may compromise outcomes and decrease wider uptake of this modality. This study uses a novel tablet computer-based interface to allow real-time monitoring and two-way communication to better link PD patients with a dialysis center and care providers. METHODS: A tablet computer with an application that allows enhanced monitoring of all aspects of PD was given to patients to assess their usage in a pilot trial. The interface allows patients to review sterility techniques, enter vital signs and exchange data, upload media such as photos and video clips, synchronize data to be viewed by medical staff, and allow real-time adjustments to the PD prescription. Satisfaction with the interface and comments for enhancement were analyzed using a simple self-administered questionnaire. RESULTS: Six continuous ambulatory PD patients were enrolled in this pilot study. A total number of 1,172 exchanges were recorded over a period of 251 days. Compliance with the applications ranged from 51 to 92%. No major adverse events were recorded. The overall impression of the interface was 5.2 out of 10. The major criticism was that the application needs to be adjusted depending upon the experience level of the patient and that data entry needs to be simplified and automated. CONCLUSION: A tablet computer platform is a feasible concept for continuous ambulatory PD. The major components include flexibility, advanced infrastructure, two-way communication, and real-time interaction. This may encourage more patients to take up PD as their preferred modality of therapy for end-stage renal disease. Modifications to enhance use will be incorporated in subsequent versions.

Application of Human Factors Methods to Understand Missed Follow-up of Abnormal Test Results.

OBJECTIVE: This study demonstrates application of human factors methods for understanding causes for lack of timely follow-up of abnormal test results ("missed results") in outpatient settings. METHODS: We identified 30 cases of missed test results by querying electronic health record data, developed a critical decision method (CDM)-based interview guide to understand decision-making processes, and interviewed physicians who ordered these tests. We analyzed transcribed responses using a contextual inquiry (CI)-based methodology to identify contextual factors contributing to missed results. We then developed a CI-based flow model and conducted a fault tree analysis (FTA) to identify hierarchical relationships between factors that delayed action. RESULTS: The flow model highlighted barriers in information flow and decision making, and the hierarchical model identified relationships between contributing factors for delayed action. Key findings including underdeveloped methods to track follow-up, as well as mismatches, in communication channels, timeframes, and expectations between patients and physicians. CONCLUSION: This case report illustrates how human factors-based approaches can enable analysis of contributing factors that lead to missed results, thus informing development of preventive strategies to address them.

National trend of utilization, clinical and economic outcomes of transcatheter aortic valve replacement among patients with chronic obstructive pulmonary disease.

Objectives: We aimed to trend the utilization of transcatheter aortic valve replacement (TAVR) among COPD patients, compare its outcomes to surgical aortic valve replacement (SAVR) and assess any social disparities in its outcomes. Background: Patients with chronic obstructive pulmonary disease (COPD) have been increasingly undergoing TAVR, but studies to evaluate the national trend of TAVR utilization and outcomes are still lacking. Methods: We conducted a retrospective observational study using a nationally representative database, the National Inpatient Sample (NIS). Results: From 2010 to 2014, the proportion of TAVR among COPD patients has increased from <1% to >50%. Patients who underwent TAVR were older, more likely to be women or white, carried more public insurance and had more comorbidities. There was no overall difference in mortality between TAVR and SAVR (2.74% vs. 2.59%, p = .860), and it has been consistently similar over time. However, patients with TAVR had shorter length of stay in the hospital after the procedure and were more likely to be discharged home than the SAVR group. Among the TAVR group, there were no gender, race or insurance disparities for in-hospital mortality, but female gender was related to lower discharge home rate, higher cost and longer stay in hospital. Conclusions: The rate of TAVR among COPD patients has been increasing nationally since 2011. In spite of higher comorbidities, TAVR did not show a difference in hospital mortality compared to SAVR but demonstrated shorter length of stay and more home discharges. This suggests that TAVR is a viable and potentially better option for patients with COPD.

An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.

BACKGROUND: Methods to identify preventable adverse events typically have low yield and efficiency. We refined the methods of Institute of Healthcare Improvement's Global Trigger Tool (GTT) application and leveraged electronic health record (EHR) data to improve detection of preventable adverse events, including diagnostic errors. METHODS: We queried the EHR data repository of a large health system to identify an 'index hospitalization' associated with care escalation (defined as transfer to the intensive care unit (ICU) or initiation of rapid response team (RRT) within 15 days of admission) between March 2010 and August 2015. To enrich the record review sample with unexpected events, we used EHR clinical data to modify the GTT algorithm and limited eligible patients to those at lower risk for care escalation based on younger age and presence of minimal comorbid conditions. We modified the GTT review methodology; two physicians independently reviewed eligible 'e-trigger' positive records to identify preventable diagnostic and care management events. RESULTS: Of 88 428 hospitalisations, 887 were associated with care escalation (712 ICU transfers and 175 RRTs), of which 92 were flagged as trigger-positive and reviewed. Preventable adverse events were detected in 41 cases, yielding a trigger positive predictive value of 44.6% (reviewer agreement 79.35%; Cohen's kappa 0.573). We identified 7 (7.6%) diagnostic errors and 34 (37.0%) care management-related events: 24 (26.1%) adverse drug events, 4 (4.3%) patient falls, 4 (4.3%) procedure-related complications and 2 (2.2%) hospital-associated infections. In most events (73.1%), there was potential for temporary harm. CONCLUSION: We developed an approach using an EHR data-based trigger and modified review process to efficiently identify hospitalised patients with preventable adverse events, including diagnostic errors. Such e-triggers can help overcome limitations of currently available methods to detect preventable harm in hospitalised patients.

National Trends in Smoking Cessation Medication Prescriptions for Smokers With Chronic Obstructive Pulmonary Disease in the United States, 2007-2012.

OBJECTIVES: Smoking cessation decreases morbidity and mortality due to chronic obstructive pulmonary disease (COPD). Pharmacotherapy for smoking cessation is highly effective. However, the optimal prescription rate of smoking cessation medications among smokers with COPD has not been systemically studied. The purpose of this study was to estimate the national prescription rates of smoking cessation medications among smokers with COPD and to examine any disparities therein. METHODS: We conducted a retrospective study using National Ambulatory Medical Care Survey data from 2007 to 2012. We estimated the national prescription rate for any smoking cessation medication (varenicline, bupropion, and nicotine replacement therapy) each year. Multiple survey logistic regression was performed to characterize the effects of demographic variables and comorbidities on prescriptions. RESULTS: The average prescription rate of any smoking cessation medication over 5 years was 3.64%. The prescription rate declined each year, except for a slight increase in 2012: 9.91% in 2007, 4.47% in 2008, 2.42% in 2009, 1.88% in 2010, 1.46% in 2011, and 3.67% in 2012. Hispanic race and depression were associated with higher prescription rates (odds ratio [OR], 5.15; 95% confidence interval [CI], 1.59 to 16.67 and OR, 2.64; 95% CI, 1.26 to 5.51, respectively). There were no significant differences according to insurance, location of the physician, or other comorbidities. The high OR among Hispanic population and those with depression was driven by the high prescription rate of bupropion. CONCLUSIONS: The prescription rate of smoking cessation medications among smokers with COPD remained low throughout the study period. Further studies are necessary to identify barriers and to develop strategies to overcome them.

Electronic health record reviews to measure diagnostic uncertainty in primary care.

RATIONALE, AIMS AND OBJECTIVES: Diagnostic uncertainty is common in primary care. Because it is challenging to measure, there is inadequate scientific understanding of diagnostic decision-making during uncertainty. Our objective was to understand how diagnostic uncertainty was documented in the electronic health record (EHR) and explore a strategy to retrospectively identify it using clinician documentation. METHODS: We reviewed the literature to identify documentation language that could identify both direct expression and indirect inference of diagnostic uncertainty and designed an instrument to facilitate record review. Direct expression included clinician's use of question marks, differential diagnoses, symptoms as diagnosis, or vocabulary such as "probably, maybe, likely, unclear or unknown," while describing the diagnosis. Indirect inference included absence of documented diagnosis at the end of the visit, ordering of multiple consultations or diagnostic tests to resolve diagnostic uncertainty, and use of suspended judgement, test of treatment, and risk-averse disposition. Two physician-reviewers independently reviewed notes on a sample of outpatient visits to identify diagnostic uncertainty at the end of the visit. Documented Ninth Revision of the International Classification of Diseases (ICD-9) diagnosis codes and note quality were assessed. RESULTS: Of 389 patient records reviewed, 218 had evidence of diagnostic activity and were included. In 156 visits (71.6%), reviewers identified clinicians who experienced diagnostic uncertainty with moderate inter-reviewer agreement (81.7%; Cohen's kappa: 0.609). Most cases (125, 80.1%) showed evidence of both direct expression and indirect inference. Uncertainty was directly expressed in 139 (89.1%) cases, most commonly by using symptoms as diagnosis (98, 62.8%), and inferred in 144 (92.3%). In more than 1/3 of visits (58, 37.2%), diagnostic uncertainty was recorded inappropriately using ICD-9 codes. CONCLUSIONS: While current diagnosis coding mechanisms (ICD-9 and ICD-10) are unable to capture uncertainty, our study finds that review of EHR documentation can help identify diagnostic uncertainty with moderate reliability. Better measurement and understanding of diagnostic uncertainty could help inform strategies to improve the safety and efficiency of diagnosis.

Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records.

PURPOSE: With this study, we set out to identify missed opportunities in diagnosis of spinal epidural abscesses to outline areas for process improvement. METHODS: Using a large national clinical data repository, we identified all patients with a new diagnosis of spinal epidural abscess in the Department of Veterans Affairs (VA) during 2013. Two physicians independently conducted retrospective chart reviews on 250 randomly selected patients and evaluated their records for red flags (eg, unexplained weight loss, neurological deficits, and fever) 90 days prior to diagnosis. Diagnostic errors were defined as missed opportunities to evaluate red flags in a timely or appropriate manner. Reviewers gathered information about process breakdowns related to patient factors, the patient-provider encounter, test performance and interpretation, test follow-up and tracking, and the referral process. Reviewers also determined harm and time lag between red flags and definitive diagnoses. RESULTS: Of 250 patients, 119 had a new diagnosis of spinal epidural abscess, 66 (55.5%) of which experienced diagnostic error. Median time to diagnosis in error cases was 12 days, compared with 4 days in cases without error (P <.01). Red flags that were frequently not evaluated in error cases included unexplained fever (n = 57; 86.4%), focal neurological deficits with progressive or disabling symptoms (n = 54; 81.8%), and active infection (n = 54; 81.8%). Most errors involved breakdowns during the patient-provider encounter (n = 60; 90.1%), including failures in information gathering/integration, and were associated with temporary harm (n = 43; 65.2%). CONCLUSION: Despite wide availability of clinical data, errors in diagnosis of spinal epidural abscesses are common and involve inadequate history, physical examination, and test ordering. Solutions should include renewed attention to basic clinical skills.

Gender Differences in the Trends of Hospitalizations for Acute Stroke Among Patients With Atrial Fibrillation in the United States: 2005 to 2014.

Female gender was included in stroke prediction algorithms in an attempt to improve anticoagulation rates in women with atrial fibrillation (AF). It is unclear if these efforts reduced stroke burden in women with AF. To bridge this literature gap, using the Nationwide Inpatient Sample, we assessed gender differences in the trends of hospitalizations for stroke among patients with AF in the United States in 2005 to 2014. International classification of diseases, 9th revision, clinical modification codes were used to abstract AF and stroke diagnoses. From 2005 to 2014, 18,413,291 hospitalizations of women with AF and 18,035,866 hospitalizations of men with AF were reported. Of these, 740,635 hospitalizations in women and 595,730 hospitalizations in men had stroke as the primary diagnosis. Age-adjusted stroke hospitalizations increased in women (443 per million in 2005 to 495 per million in 2014) as well as in men (351 per million in 2005 to 453 per million in 2014) (p trend < 0.001). Further, anticoagulation rates increased in women (11.5% in 2005 to 24.0% in 2014) as well as in men (11.7% in 2005 to 24.9% in 2014). Stroke hospitalizations involving anticoagulated patients with AF decreased in women (411 per million in 2005 to 347 per million in 2014) as well as in men (402 per million in 2005 to 311 per million in 2014) (p trend < 0.001). In conclusion, although we noted an increasing trend of stroke hospitalizations in both genders, it is reassuring to note that stroke hospitalizations involving anticoagulated patients with AF is decreasing in both genders and in particular among women.

Sex-Specific Associations of Oral Anticoagulant Use and Cardiovascular Outcomes in Patients With Atrial Fibrillation.

BACKGROUND: Sex-specific effectiveness of rivaroxaban (RIVA), dabigatran (DABI), and warfarin in reducing myocardial infarction (MI), heart failure (HF), and all-cause mortality among patients with atrial fibrillation are not known. We assessed sex-specific associations of RIVA, DABI, or warfarin use with the risk of MI, HF, and all-cause mortality among patients with atrial fibrillation. METHODS AND RESULTS: Medicare beneficiaries (men: 65 734 [44.8%], women: 81 135 [55.2%]) with atrial fibrillation who initiated oral anticoagulants formed the study cohort. Inpatient admissions for MI, HF, and all-cause mortality were compared between the 3 drugs separately for men and women using 3-way propensity-matched samples. In men, RIVA use was associated with a reduced risk of MI admissions compared with warfarin use (hazard ratio [95% confidence interval (CI): 0.59 [0.38-0.91]), with a trend towards reduced risk compared with DABI use (0.67 [0.44-1.01]). In women, there were no significant differences in the risk of MI admissions across all 3 anticoagulants. In both sexes, RIVA use and DABI use were associated with reduced risk of HF admissions (men: RIVA; 0.75 [0.63-0.89], DABI; 0.81 [0.69-0.96]) (women: RIVA; 0.64 [0.56-0.74], DABI; 0.73 [0.63-0.83]) and all-cause mortality (men: RIVA; 0.66 [0.53-0.81], DABI; 0.75 [0.61-0.93]) (women: RIVA; 0.76 [0.63-0.91], DABI; 0.77 [0.64-0.93]) compared with warfarin use. CONCLUSIONS: RIVA use and DABI use when compared with warfarin use was associated with a reduced risk of HF admissions and all-cause mortality in both sexes. However, reduced risk of MI admissions noted with RIVA use appears to be limited to men.

Computerized Triggers of Big Data to Detect Delays in Follow-up of Chest Imaging Results.

BACKGROUND: A "trigger" algorithm was used to identify delays in follow-up of abnormal chest imaging results in a large national clinical data warehouse of electronic health record (EHR) data. METHODS: We applied a trigger in a repository hosting EHR data from all Department of Veterans Affairs health-care facilities and analyzed data from seven facilities. Using literature reviews and expert input, we refined previously developed trigger criteria designed to identify patients potentially experiencing delays in diagnostic evaluation of chest imaging flagged as "suspicious for malignancy." The trigger then excluded patients in whom further evaluation was unnecessary (eg, those with terminal illnesses or with already completed biopsies). The criteria were programmed into a computerized algorithm. Reviewers examined a random sample of trigger-positive (ie, patients with trigger-identified delay) and trigger-negative (ie, patients with an abnormal imaging result but no delay) records and confirmed the presence or absence of delay or need for additional tracking (eg, repeat imaging in 6 months). Analysis included calculating the trigger's diagnostic performance (ie, positive predictive value, negative predictive value, sensitivity, specificity). RESULTS: On application to 208,633 patients seen between January 1, 2012, and December 31, 2012, a total of 40,218 chest imaging tests were performed; 1,847 of the results were suspicious for malignancy, and 655 (35%) were trigger-positive. Review of 400 randomly selected trigger-positive patients found 158 (40%) with confirmed delays and 84 (21%) requiring additional tracking (positive predictive value, 61% [95% CI, 55.5-65.3]). Review of 100 trigger-negative patients identified 97 without delay (negative predictive value, 97%; [95% CI, 90.8-99.2]). Sensitivity and specificity were 99% (95% CI, 96.2-99.7) and 38% (95% CI, 32.1-44.3), respectively. CONCLUSIONS: Application of triggers on "big" EHR data may aid in identifying patients experiencing delays in diagnostic evaluation of chest imaging results suspicious for malignancy.

Screening for latent tuberculosis in refugees with renal failure.

Refugee camps are prone for easy spread of infections of various kinds and tuberculosis (TB) is no exception. Refugees with renal failure are often a vulnerable group because they are immunocompromised due to reasons such as poor nutrition, overcrowding and immune suppression due to renal failure. Latent pulmonary TB is a particular problem in this patient population as it is not easily diagnosed and has immense potential for spread. Tuberculin Skin Test (TST), although easy to perform and is cost-effective, suffers from the limitations of giving false positive results due to cross-reaction with the vaccination. Chest radiography though cheap, has not yet been validated in refugee populations for this purpose. Sputum analysis shows promise due to ease of performing but again has not been validated in refugees. Newer assays such as IF-γ show great promise but needs large scale studies for validation and cheaper assays need to be developed for use in resource poor refugee setting. In short, an ideal tool for effective screening of latent TB in refugees with renal failure is lacking. Future studies are required to identify this ideal tool.

Prevalence of Subclinical Hypothyroidism in Patients with End-Stage Renal Disease and the Role of Serum Albumin: A Cross-Sectional Study from South India.

BACKGROUND/AIM: Subclinical hypothyroidism (SCH) and end-stage renal disease (ESRD) are independent risk factors for cardiovascular mortality. We aimed to study the prevalence of SCH in ESRD patients and assessed its associated risk factors. METHODS: This cross-sectional study was conducted at 2 tertiary-care centers in Chennai, India, over a 3-year period. The study group comprised 137 patients with ESRD on thrice weekly regular maintenance hemodialysis. Free thyroxine (FT(4)) and thyroid-stimulating hormone (TSH) were measured using an electrochemiluminescence immunoassay. SCH was defined as TSH ranging between 4.5 and 10 mIU/l with normal FT(4) (0.93-1.7 ng/dl). Patients with overt hypothyroidism, SCH and overt hyperthyroidism, those on medications affecting thyroid function and pregnant women were excluded from the study. RESULTS: Of 137 ESRD patients (mean age: 43 ± 13.38 years), 107 were males (78.1%), 45 diabetics (32.8%), 127 hypertensives (92.7%), and 38 smokers (27.7%). Prevalence of SCH was 24.8%. In unadjusted (OR: 3.37, 95% CI: 1.91-5.21) and adjusted (for age, gender, HbA(1C), and albumin/creatinine ratio; OR: 3.11, 95% CI: 2.15-4.98) logistic regression analysis, serum albumin was significantly associated with SCH. Further, multiple linear regression identified that for every 1 g/dl drop in serum albumin TSH increased by 4.61 mIU/l (95% CI: 2.75-5.92). CONCLUSION: We observed a high prevalence of SCH in our ESRD patients. Also, serum albumin was significantly associated with SCH in our study.