Personalized medicine in a community health system: the NorthShore experience.

Genomic and personalized medicine implementation efforts have largely centered on specialty care in tertiary health systems. There are few examples of fully integrated care systems that span the healthcare continuum. In 2014, NorthShore University HealthSystem launched the Center for Personalized Medicine to catalyze the delivery of personalized medicine. Successful implementation required the development of a scalable family history collection tool, the Genetic and Wellness Assessment (GWA) and Breast Health Assessment (BHA) tools; integrated pharmacogenomics programming; educational programming; electronic medical record integration; and robust clinical decision support tools. To date, more than 225,000 patients have been screened for increased hereditary conditions, such as cancer risk, through these tools in primary care. More than 35,000 patients completed clinical genetic testing following GWA or BHA completion. An innovative program trained more than 100 primary care providers in genomic medicine, activated with clinical decision support and access to patient genetic counseling services and digital healthcare tools. The development of a novel bioinformatics platform (FLYPE) enabled the incorporation of genomics data into electronic medical records. To date, over 4,000 patients have been identified to have a pathogenic or likely pathogenic variant in a gene with medical management implications. Over 33,000 patients have clinical pharmacogenomics data incorporated into the electronic health record supported by clinical decision support tools. This manuscript describes the evolution, strategy, and successful multispecialty partnerships aligned with health system leadership that enabled the implementation of a comprehensive personalized medicine program with measurable patient outcomes through a genomics-enabled learning health system model that utilizes implementation science frameworks.

Can a mobile app technology reduce emergency department visits and readmissions after lung resection? A prospective cohort study.

BACKGROUND: Emergency department (ED) visits and readmissions after thoracic surgery are a major health care problem. We hypothesized that the addition of a novel post-discharge mobile app specific to thoracic surgery to an existing home care program would reduce ED visits and readmissions compared to a home care program alone. METHODS: We conducted a prospective cohort study of patients undergoing major lung resection for malignant disease between November 2016 and May 2018. Patients received either home care alone (control group) or home care plus a patient-input mobile app (intervention group). Primary outcomes were 30-day readmission and ED visit rates. Secondary outcomes included reasons for ED visits and readmissions, perioperative complications, 30-day mortality, anxiety (assessed with the Generalized Anxiety Disorder-7 Scale [GAD-7]) and app-related adverse events. We compared outcomes between the 2 groups, analyzing the data on an intention-to-treat basis. RESULTS: Despite the greater number of open surgery and anatomic resections in the intervention cohort, patients in that group were less likely than those in the control group to visit the ED within 30 days of discharge (24.0% v. 38.8%, p = 0.02). Thirty-day readmission rates were similar between the intervention and control groups (10.1% v. 12.2%, p = 0.6). In a subset of patients, there was no difference between the 2 groups in the proportion of patients with a GAD-7 score of 0 (control group 79.8%, intervention group 79.5%, p = NS), which indicated a similar absence of postdischarge anxiety and depression symptoms in the 2 cohorts. CONCLUSION: The addition of a mobile app to a home care program after thoracic surgery was associated with a reduced frequency of ED visits, in spite of the higher proportions of thoracotomies and anatomic resections in the app cohort. More studies are needed to evaluate the full effect of this new, emerging technology.

Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study.

BACKGROUND: Prolonged air leaks are increasingly treated in the outpatient setting, with patients discharged with chest tubes in place. We evaluated the incidence and risk factors associated with readmission, empyema development and further interventions in this patient population. METHODS: We undertook a retrospective cohort analysis of all patients from 4 tertiary academic centres (January 2014 to December 2017) who were discharged home with a chest tube after lung resection for a postoperative air leak lasting more than 5 days. We analyzed demographics, patient factors, surgical details, hospital readmission, reintervention, antibiotics at discharge, empyema and death. RESULTS: Overall, 253 of 2794 patients were analyzed (9.0% of all resections), including 30 of 759 from centre 1 (4.0%), 67 of 857 from centre 2 (7.8%), 9 of 247 from centre 3 (3.6%) and 147 of 931 from centre 4 (15.8%) (p < 0.001). Our cohort consisted of 56.5% men, and had a median age of 69 (range 19-88) years. Despite similar initial lengths of stay (p = 0.588), 49 patients (19.4%) were readmitted (21%, 0%, 23% and 11% from centres 1 to 4, respectively, p = 0.029), with 18 (36.7%) developing empyema, 11 (22.4%) requiring surgery and 3 (6.1%) dying. Only chest tube duration was a significant predictor of readmission (p < 0.001) and empyema development (p = 0.003), with a nearly threefold increased odds of developing empyema when the chest tube remained in situ for more than 20 days. CONCLUSION: Discharge with chest tube after lung resection is associated with serious adverse events. Given the high risk of empyema development, removal of chest tubes should be considered, when appropriate, within 20 days of surgery. Our data suggest a potential need for proactive postdischarge outpatient management programs to diminish risk of morbidity and death.