Development and Validation of Trigger Algorithms to Identify Delays in Diagnostic Evaluation of Gastroenterological Cancer.

BACKGROUND & AIMS: Colorectal cancer (CRC) and hepatocellular cancer (HCC) are common causes of death and morbidity, and patients benefit from early detection. However, delays in follow-up of suspicious findings are common, and methods to efficiently detect such delays are needed. We developed, refined, and tested trigger algorithms that identify patients with delayed follow-up evaluation of findings suspicious of CRC or HCC. METHODS: We developed and validated two trigger algorithms that detect delays in diagnostic evaluation of CRC and HCC using laboratory, diagnosis, procedure, and referral codes from the Department of Veteran Affairs National Corporate Data Warehouse. The algorithm initially identified patients with positive test results for iron deficiency anemia or fecal immunochemical test (for CRC) and elevated α-fetoprotein results (for HCC). Our algorithm then excluded patients for whom follow-up evaluation was unnecessary, such as patients with a terminal illness or those who had already completed a follow-up evaluation within 60 days. Clinicians reviewed samples of both delayed and nondelayed records, and review data were used to calculate trigger performance. RESULTS: We applied the algorithm for CRC to 245,158 patients seen from January 1, 2013, through December 31, 2013 and identified 1073 patients with delayed follow up. In a review of 400 randomly selected records, we found that our algorithm identified patients with delayed follow-up with a positive predictive value of 56.0% (95% CI, 51.0%-61.0%). We applied the algorithm for HCC to 333,828 patients seen from January 1, 2011 through December 31, 2014, and identified 130 patients with delayed follow-up. During manual review of all 130 records, we found that our algorithm identified patients with delayed follow-up with a positive predictive value of 82.3% (95% CI, 74.4%-88.2%). When we extrapolated the findings to all patients with abnormal results, the algorithm identified patients with delayed follow-up evaluation for CRC with 68.6% sensitivity (95% CI, 65.4%-71.6%) and 81.1% specificity (95% CI, 79.5%-82.6%); it identified patients with delayed follow-up evaluation for HCC with 89.1% sensitivity (95% CI, 81.8%-93.8%) and 96.5% specificity (95% CI, 94.8%-97.7%). Compared to nonselective methods, use of the algorithm reduced the number of records required for review to identify a delay by more than 99%. CONCLUSIONS: Using data from the Veterans Affairs electronic health record database, we developed an algorithm that greatly reduces the number of record reviews necessary to identify delays in follow-up evaluations for patients with suspected CRC or HCC. This approach offers a more efficient method to identify delayed diagnostic evaluation of gastroenterological cancers.

Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health Care.

PURPOSE: We previously developed electronic triggers to automatically flag records for patients experiencing potential delays in diagnostic evaluation for certain cancers. Because of the unique clinical, logistic, and legal aspects of mammography, this study was conducted to evaluate the effectiveness of a trigger to flag delayed follow-up on mammography. METHODS: An algorithm was developed to detect delays in follow-up of abnormal mammographic results (>60 days for BI-RADS® 0, 4, and 5 and >7 months for BI-RADS 3) using clinical data in the electronic health record. Flagged records were then manually reviewed to determine the trigger's performance characteristics (positive and negative predictive value, sensitivity, and specificity). The frequency of delays and patient communication related to abnormal results, reasons for lack of follow-up, and whether patients were subsequently diagnosed with breast cancer were also assessed. RESULTS: Of 365,686 patients seen between January 1, 2010, and May 31, 2015, the trigger identified 2,129 patients with abnormal findings on mammography, of whom it flagged 552 as having delays in follow-up. From these, review of 400 randomly selected records revealed 283 true delays (positive predictive value, 71%; 95% confidence interval, 66%-75%), including 280 records without any documented plan and three patients with plans that were not adhered to. Transcription and reporting inconsistencies were identified in 27% of externally performed mammographic reports. Only 335 records (84%) contained specific documentation that the patient was informed of the abnormal result. CONCLUSIONS: Care delays appear to continue despite federal laws requiring patient notification of mammographic results within 30 days. Clinical application of mammography-related triggers could help detect these delays.

Effect of meal size and texture on gastric pouch emptying and glucagon-like peptide 1 after gastric bypass surgery.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) accelerates gastric pouch emptying, enhances postprandial glucagon-like peptide 1 (GLP-1) and insulin, and lowers glucose concentrations. To prevent discomfort and reactive hypoglycemia, it is recommended that post-RYGB patients eat small, frequent meals and avoid caloric drinks. However, the effect of meal size and texture on GLP-1 and metabolic response has not been studied. OBJECTIVES: To demonstrate that frequent minimeals and solid meals (S) elicit less GLP-1 and insulin release and less reactive hypoglycemia and are better tolerated compared with a single isocaloric liquid meal (L). SETTING: A university hospital. METHODS: In this prospective study, 32 RYGB candidates were enrolled and randomized to L or S groups before gastric bypass. Each subject received an L or S 600-kcal single meal (SM) administered at hour 0 or three 200-kcal minimeals administered at hours 0, 2, and 4 on 2 separate days. Twenty-one patients were retested 1 year after RYGB. Blood and visual analogue scale measurements were collected up to 6 hours postprandially. Outcome measures included gastric pouch emptying, glucose, insulin, and GLP-1; hunger, fullness, and stomach discomfort were measured by visual analogue scale. RESULTS: Twenty-one were patients retested after RYGB (L: n = 12; S: n = 9). Meal texture had a significant effect on peak GLP-1 (L-SM: 106.1 ± 67.2 versus S-SM: 45.3 ± 25.2 pM, P = .004), peak insulin, and postprandial glucose. Hypoglycemia was more frequent after the L-SM meal compared with the S-SM. Gastric pouch emptying was 2.4 times faster after RYGB but was not affected by texture. CONCLUSIONS: Meal texture and size have significant impact on tolerance and metabolic response after RYGB.

Application of Electronic Algorithms to Improve Diagnostic Evaluation for Bladder Cancer.

BACKGROUND: Strategies to ensure timely diagnostic evaluation of hematuria are needed to reduce delays in bladder cancer diagnosis. OBJECTIVE: To evaluate the performance of electronic trigger algorithms to detect delays in hematuria follow-up. METHODS: We developed a computerized trigger to detect delayed follow-up action on a urinalysis result with high-grade hematuria (>50 red blood cells/high powered field). The trigger scanned clinical data within a Department of Veterans Affairs (VA) national data repository to identify all patient records with hematuria, then excluded those where follow-up was unnecessary (e.g., terminal illness) or where typical follow-up action was detected (e.g., cystoscopy). We manually reviewed a randomly-selected sample of flagged records to confirm delays. We performed a similar analysis of records with hematuria that were marked as not delayed (non-triggered). We used review findings to calculate trigger performance. RESULTS: Of 310,331 patients seen between 1/1/2012-12/31/2014, the trigger identified 5,857 patients who experienced high-grade hematuria, of which 495 experienced a delay. On manual review of 400 randomly-selected triggered records and 100 non-triggered records, the trigger achieved positive and negative predictive values of 58% and 97%, respectively. CONCLUSIONS: Triggers offer a promising method to detect delays in care of patients with high-grade hematuria and warrant further evaluation in clinical practice as a means to reduce delays in bladder cancer diagnosis.

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.

Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial.

PURPOSE: We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer. METHODS: We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months. RESULTS: We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58). CONCLUSION: Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions.

Case report: renal lymphangiectasia.

Renal lymphangiectasia is a rare renal condition. We present a case of bilateral renal lymphangiectasia in a 52-year-old man who presented with bilateral flank pain and gross hematuria. The clinical features, diagnosis and characteristic imaging findings are reviewed. This condition should be considered in the differential diagnosis of cystic renal masses in both children and adults.

Organ-confined prostate cancer: effect of prior transrectal biopsy on endorectal MRI and MR spectroscopic imaging.

OBJECTIVE: Our aim was to determine the effect of prior transrectal biopsy on endorectal MRI and MR spectroscopic imaging findings in patients with organ-confined prostate cancer. MATERIALS AND METHODS: Endorectal MRI and MR spectroscopic imaging were performed in 43 patients with biopsy-proven prostate cancer before radical prostatectomy confirming organ-confined disease. For each sextant, two independent reviewers scored the degree of hemorrhage on a scale from 1 to 5 and recorded the presence or absence of capsular irregularity. A spectroscopist recorded the number of spectrally degraded voxels in the peripheral zone. The outcome variables of capsular irregularity and spectral degradation were correlated with the predictor variables of time from biopsy and degree of hemorrhage after biopsy. RESULTS: Capsular irregularity was unrelated to time from biopsy or to degree of hemorrhage. Spectral degradation was inversely related to time from biopsy (p < 0.01); the mean percentage of degraded peripheral zone voxels was 18.5% within 8 weeks of biopsy compared with 7% after 8 weeks. Spectral degradation was unrelated to the degree of hemorrhage. CONCLUSION: In organ-confined prostate cancer, capsular irregularity can be seen at any time after biopsy and is independent of the degree of hemorrhage, whereas spectral degradation is seen predominantly in the first 8 weeks after biopsy. MRI staging criteria and guidelines for scheduling studies after biopsy may require appropriate modification.

Endometriosis in the canal of Nuck: Atypical manifestations in an unusual location.

The canal of Nuck is an embryological remnant of the processus vaginalis and has been described as a site for endometriosis seeding. Endometriosis localized to the canal of Nuck is exceedingly rare with three cases reported. The case of a 31-year-old woman with an endometrioma in the canal of Nuck, made diagnostically challenging by atypical imaging and clinical findings, is described.

Le canal de Nuck est un vestige embryologique du processus vaginalis et est décrit comme un foyer d'essaimage de l'endométriose. L'endométriose située dans le canal de Nuck est d'une extrême rareté, puisque trois cas ont été déclarés. Le cas d'une femme de 31 ans atteinte d'endométriose du canal de Nuck, dont le diagnostic a été compliqué par une imagerie et des observations cliniques atypiques, est présenté.

MR imaging of retained products of conception.

OBJECTIVE: The objective of this article is to describe the MR imaging appearances of retained products of conception. CONCLUSION: Retained products of conception appear on MR imaging as an intracavitary uterine soft-tissue mass with variable amounts of enhancing tissue and variable degrees of myometrial thinning and obliteration of the junctional zone. These findings should not be misinterpreted as indicating gestational trophoblastic disease, particularly in the setting of a postpartum patient with a normal or minimally elevated beta-human chorionic gonadotropin level. MR imaging may also be helpful in showing anatomic variants that hinder successful instrumentation of the uterine cavity in patients with suspected retained products of conception.