Assessment of Machine Learning Methods to Predict Massive Blood Transfusion in Trauma.

BACKGROUND: Accurately predicting which patients are most likely to benefit from massive transfusion protocol (MTP) activation may help patients while saving blood products and limiting cost. The purpose of this study is to explore the use of modern machine learning (ML) methods to develop and validate a model that can accurately predict the need for massive blood transfusion (MBT). METHODS: The institutional trauma registry was used to identify all trauma team activation cases between June 2015 and August 2019. We used an ML framework to explore multiple ML methods including logistic regression with forward and backward selection, logistic regression with lasso and ridge regularization, support vector machines (SVM), decision tree, random forest, naive Bayes, XGBoost, AdaBoost, and neural networks. Each model was then assessed using sensitivity, specificity, positive predictive value, and negative predictive value. Model performance was compared to that of existing scores including the Assessment of Blood Consumption (ABC) and the Revised Assessment of Bleeding and Transfusion (RABT). RESULTS: A total of 2438 patients were included in the study, with 4.9% receiving MBT. All models besides decision tree and SVM attained an area under the curve (AUC) of above 0.75 (range: 0.75-0.83). Most of the ML models have higher sensitivity (0.55-0.83) than the ABC and RABT score (0.36 and 0.55, respectively) while maintaining comparable specificity (0.75-0.81; ABC 0.80 and RABT 0.83). CONCLUSIONS: Our ML models performed better than existing scores. Implementing an ML model in mobile computing devices or electronic health record has the potential to improve the usability.

Lipid Droplets in Lung Cancers Are Crucial for the Cell Growth and Starvation Survival.

For rapid and unlimited cell growth and proliferation, cancer cells require large quantities of nutrients. Many metabolic pathways and nutrient uptake systems are frequently reprogrammed and upregulated to meet the demand from cancer cells, including the demand for lipids. The lipids for most adult normal cells are mainly acquired from the circulatory system. Whether different cancer cells adopt identical mechanisms to ensure sufficient lipid supply, and whether the lipid demand and supply meet each other, remains unclear, and was investigated in lung cancer cells. Results showed that, despite frequent upregulation in de novo lipogenesis and the lipid transporter system, different lung cancer cells adopt different proteins to acquire sufficient lipids, and the lipid supply frequently exceeds the demand, as significant amounts of lipids stored in the lipid droplets could be found within lung cancer cells. Lipid droplet surface protein, PLIN3, was found frequently overexpressed since the early stage in lung cancer tissues. Although the expression is not significantly associated with a specific gender, age, histology type, disease stage, and smoking habit, the frequently elevated expression of PLIN3 protein indicates the importance of lipid droplets for lung cancer. These lipid droplets are not only for nutrient storage, but are also crucial for tumor growth and proliferation, as well as survival in starvation. These results suggest that manipulation of lipid droplet formation or TG storage in lung cancer cells could potentially decrease the progression of lung cancer. Further exploration of lipid biology in lung cancer could help design novel treatment strategies.

Effect of a Coordinated Community and Chronic Care Model Team Intervention vs Usual Care on Systolic Blood Pressure in Patients With Stroke or Transient Ischemic Attack: The SUCCEED Randomized Clinical Trial.

Importance: Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations. Objective: To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay). Design, Setting, and Participants: This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020. Interventions: Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials. Main Outcomes and Measures: The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use. Results: Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose. Conclusions and Relevance: This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT01763203.

Efficacy and Safety of a Single Intra-articular Injection of Platelet-rich Plasma on Pain and Physical Function in Patients With Ankle Osteoarthritis-A Prospective Study.

Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. The aim was to evaluate the efficacy and safety of a single intraarticular injection of platelet-rich plasma (PRP) for patients with ankle OA. In a prospective study done in a university-affiliated tertiary care medical center, 44 patients with symptomatic ankle OA for at least 6 months were recruited. Patients received a single injection of PRP (3 mL) into symptomatic ankles. The primary outcome was the change from baseline in the visual analog scale (VAS) pain (0-10 cm) at 6 months. Secondary outcomes included the Ankle Osteoarthritis Scale (AOS) score, American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle score, single-leg stance test (SLS), rescue analgesics consumption and patient satisfaction. Thirty-nine participants (88.64%) completed the study. Significantly improvement in the VAS and AOS was noted at 1-, 3-, and 6-month follow-ups (p < .001). The mean VAS pain decreased significantly from 4.1 ± 1.7 at baseline to 2.2 ± 1.9, 1.7 ± 1.5, and 1.8 ± 1.6 at 1, 3, and 6 months (p < .001). The mean total AOS score reduced by 1.5, 2.2, and 2.1 from baseline respectively postinjection (p < .001). The mean AOFAS hindfoot-ankle score improved from 80.3 points at baseline to 87.2, 91.6, and 89.7 points at 1, 3, and 6 months (p < .001). SLS tests improved significantly (p < .001) at each follow-up. Acetaminophen consumption dropped significantly (p < .001) and no serious adverse events occurred. The study showed promise for a single intraarticular injection of PRP in the treatment of ankle OA.

Comparing efficacy of intraarticular single crosslinked Hyaluronan (HYAJOINT Plus) and platelet-rich plasma (PRP) versus PRP alone for treating knee osteoarthritis.

Intraarticular hyaluronan or platelet-rich plasma (PRP) is widely used in the treatment of knee osteoarthritis (OA). The efficacy of combined hyaluronan with PRP remained inconclusive. This study aimed to investigate the efficacy of combined a single crosslinked hyaluronan (HYAJOINT Plus) and a single PRP versus a single PRP in patients with knee OA. In a prospective randomized-controlled trial, 85 patients with knee OA (Kellgren-Lawrence 2) were randomized to receive a single intraarticular injection of HYAJOINT Plus (3 ml, 20 mg/ml) followed by 3 ml PRP (the combined-injection group, N = 43) or a single injection of 3 ml PRP (the one-injection group, N = 42). The primary outcome was the change from baseline in the visual analog scale (VAS) pain (0-00 mm) at 6 months. Secondary outcomes included The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, Likert Scale), Lequesne index, single leg stance test (SLS), use of rescue analgesics and patient satisfaction at 1, 3 and 6 months. Seventy-eight patients were available for the intention-to-treat analysis at 6 months. Both groups improved significantly in VAS pain, WOMAC, Lequesne index and SLS at each follow-up visit (p < 0.001). Patients receiving a single PRP experienced significantly greater improvements in VAS pain than patients receiving combined injections at 1-month follow-up (adjusted mean difference: - 5.6; p = 0.017). There were no significant between-group differences in several of the second outcomes at each follow-up visit, except the WOMAC-pain and WOMAC-stiffness scores favoring the one-injection group at 1 month (p = 0.025 and p = 0.011). However, at 6-month follow-up, the combined-injection group achieved significantly better VAS pain reduction (p = 0.020). No serious adverse events occurred following injections. In conclusion, either combined injections of HYAJOINT Plus and PRP or a single PRP alone was safe and effective for 6 months in patients with Kellgren-Lawrence 2 knee OA. Combined injections of HYAJOINT Plus and PRP achieved better VAS pain reduction than a single PRP at 6 months. The results indicating a long term benefit effect of a combination of HYAJOINT Plus and PRP in a particular subset of patients with moderate knee OA need to be replicated in larger trials.ClinicalTrials.gov number NCT04315103.

Longitudinal Effects of an Intergenerational mHealth Program for Older Type 2 Diabetes Patients in Rural Taiwan.

PURPOSE: The purpose of the study is to test the longitudinal efficacy of a mHealth intervention (Intergenerational Mobile Technology Opportunities Program, IMTOP) for older type 2 diabetes mellitus (T2DM) patients in rural Taiwan. Few mHealth programs targeted rural older adults and the longitudinal effects are unknown. METHODS: Ninety-seven T2DM patients aged 55+ were recruited from an outpatient in Hualien, Taiwan. The intervention comprised 8-week technology and diabetes self-management training and 4-week technical support. College student tutors facilitated T2DM patients to learn technology. Participants used a diabetes self-management app to track health behaviors. Outcomes measured at baseline and at 4 and 8 months including patient-reported self-care behaviors, T2DM symptoms, clinical outcomes, health resource utilization, and medical expenditure. Linear mixed-effect regressions of repeated measures were conducted for each outcome. RESULTS: At 4 months, improvements in self-care behaviors were reported in diet, exercise, smoking, and blood glucose testing. Patients paid less endocrinology clinic visits, spent less on endocrinology medications, and improvements in fasting blood glucose and total cholesterol were observed. At 8 months, the statistical significance of improvements in diet and smoking were maintained, and the averaged endocrinology clinic visits remained less than baseline. However, more frequent occurrence of diabetes symptoms were reported at both follow-ups. CONCLUSIONS: IMTOP had lasting effects on diet and decreased smoking behavior, clinic visits, and medication costs over 8 months. Self-monitoring through an app increased awareness and may explain the increased reporting of diabetes symptoms. IMTOP is a promising model for promoting T2DM self-management in rural areas.

Text Messaging as a Screening Tool for Depression and Related Conditions in Underserved, Predominantly Minority Safety Net Primary Care Patients: Validity Study.

BACKGROUND: SMS text messaging is an inexpensive, private, and scalable technology-mediated assessment mode that can alleviate many barriers faced by the safety net population to receive depression screening. Some existing studies suggest that technology-mediated assessment encourages self-disclosure of sensitive health information such as depressive symptoms while other studies show the opposite effect. OBJECTIVE: This study aimed to evaluate the validity of using SMS text messaging to screen depression and related conditions, including anxiety and functional disability, in a low-income, culturally diverse safety net primary care population. METHODS: This study used a randomized design with 4 study groups that permuted the order of SMS text messaging and the gold standard interview (INTW) assessment. The participants for this study were recruited from the participants of the prior Diabetes-Depression Care-management Adoption Trial (DCAT). Depression was screened by using the 2-item and 8-item Patient Health Questionnaire (PHQ-2 and PHQ-8, respectively). Anxiety was screened by using the 2-item Generalized Anxiety Disorder scale (GAD-2), and functional disability was assessed by using the Sheehan Disability Scale (SDS). Participants chose to take up the assessment in English or Spanish. Internal consistency and test-retest reliability were evaluated by using Cronbach alpha and intraclass correlation coefficient (ICC), respectively. Concordance was evaluated by using an ICC, a kappa statistic, an area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. A regression analysis was conducted to examine the association between the participant characteristics and the differences in the scores between the SMS text messaging and INTW assessment modes. RESULTS: Overall, 206 participants (average age 57.1 [SD 9.18] years; females: 119/206, 57.8%) were enrolled. All measurements except the SMS text messaging-assessed PHQ-2 showed Cronbach alpha values ≥.70, indicating acceptable to good internal consistency. All measurements except the INTW-assessed SDS had ICC values ≥0.75, indicating good to excellent test-retest reliability. For concordance, the PHQ-8 had an ICC of 0.73 and AUROC of 0.93, indicating good concordance. The kappa statistic, sensitivity, and specificity for major depression (PHQ-8 ≥8) were 0.43, 0.60, and 0.86, respectively. The concordance of the shorter PHQ-2, GAD-2, and SDS scales was poor to fair. The regression analysis revealed that a higher level of personal depression stigma was associated with reporting higher SMS text messaging-assessed PHQ-8 and GAD-2 scores than the INTW-assessed scores. The analysis also determined that the differences in the scores were associated with marital status and personality traits. CONCLUSIONS: Depression screening conducted using the longer PHQ-8 scale via SMS text messaging demonstrated good internal consistency, test-retest reliability, and concordance with the gold standard INTW assessment mode. However, care must be taken when deploying shorter scales via SMS text messaging. Further regression analysis supported that a technology-mediated assessment, such as SMS text messaging, may create a private space with less pressure from the personal depression stigma and therefore encourage self-disclosure of depressive symptoms. TRIAL REGISTRATION: ClinicalTrials.gov NCT01781013; https://clinicaltrials.gov/ct2/show/NCT01781013. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/12392.

Is mortality-to-incidence ratio associated with health disparity in pancreatic cancer? A cross-sectional database analysis of 57 countries.

OBJECTIVE: The colorectal cancer mortality-to-incidence ratio (MIR) can reflect healthcare disparities. However, a similar association has not yet been established between the MIR of pancreatic cancer and healthcare disparities. METHODS: In this study, the incidence and mortality rates of pancreatic cancer were obtained from the GLOBOCAN 2012 database. The WHO rankings and total expenditures on health/gross domestic product (e/GDP) were obtained from a public database. Linear regression was performed to determine correlations between the variables. RESULTS: 57 countries met the inclusion criteria according to the data quality. Developed regions (Europe and the Americas) had high pancreatic cancer incidence and mortality rates. The MIRs were over 0.90 in all regions. No significant correlation was found between MIRs and the WHO rankings, e/GDP or per capita total expenditure on health for analysis in the 57 countries, indicating no association between MIRs and cancer care disparities for pancreatic cancer. CONCLUSIONS: The MIR variations for pancreatic cancer do not correlate with healthcare disparities among countries. Further investigation is necessary to confirm this observation with secondary analysis of databases.

Promotora assisted depression and self-care management among predominantly Latinos with concurrent chronic illness: Safety net care system clinical trial results.

The study evaluated depression and self-care management among patients with diabetes and/or heart disease in a 12-month randomized trial conducted in Los Angeles County Department of Health Services (LAC-DHS) community clinics. We compared LAC-DHS clinic usual care (UC) versus A-Helping-Hand (AHH) intervention in which bilingual promotoras, hired and supervised by the research project, provided 6 weekly psychoeducational sessions followed by boosters. Of 1957 screened, 348 depressed patients (PHQ-9 score≥10) were enrolled, randomized to AHH (n=178) or UC (n=170) after baseline interview assessing mental health, treatment receipt, co-morbid illness, self-care management, and environmental stressors. Comprehensive assessments were repeated at 6 and 12months by an independent interviewer blind to the study group. Patients (85% diabetes, 4% heart disease, 11% both) were predominantly female (85%), Latino (99%), born outside of the US (91%). Study attrition at 12months was 30% (AHH 31%, UC 28%, P=0.51). No baseline characteristics were associated with attrition. Half of AHH patients received 4 or more sessions. Intend-to-treat analysis found study groups did not vary significantly at 6 and 12months. Before-after paired t-tests showed significant improvements in most measures in each group. During the trial, LAC-DHS activated healthcare improvements including depression screening, referral to clinic staff including community health workers (with the same role as the promotoras) to improve patient care management. Both patient groups performed equally well which may be a function of the enhanced healthcare model. Future research should replicate the promotora-integrated care model with other groups and care settings with similar comorbid conditions.

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).

BACKGROUND: Recurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population. METHODS/DESIGN: In this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care. DISCUSSION: If this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01763203 .

Development of a Clinical Forecasting Model to Predict Comorbid Depression Among Diabetes Patients and an Application in Depression Screening Policy Making.

INTRODUCTION: Depression is a common but often undiagnosed comorbid condition of people with diabetes. Mass screening can detect undiagnosed depression but may require significant resources and time. The objectives of this study were 1) to develop a clinical forecasting model that predicts comorbid depression among patients with diabetes and 2) to evaluate a model-based screening policy that saves resources and time by screening only patients considered as depressed by the clinical forecasting model. METHODS: We trained and validated 4 machine learning models by using data from 2 safety-net clinical trials; we chose the one with the best overall predictive ability as the ultimate model. We compared model-based policy with alternative policies, including mass screening and partial screening, on the basis of depression history or diabetes severity. RESULTS: Logistic regression had the best overall predictive ability of the 4 models evaluated and was chosen as the ultimate forecasting model. Compared with mass screening, the model-based policy can save approximately 50% to 60% of provider resources and time but will miss identifying about 30% of patients with depression. Partial-screening policy based on depression history alone found only a low rate of depression. Two other heuristic-based partial screening policies identified depression at rates similar to those of the model-based policy but cost more in resources and time. CONCLUSION: The depression prediction model developed in this study has compelling predictive ability. By adopting the model-based depression screening policy, health care providers can use their resources and time better and increase their efficiency in managing their patients with depression.

Demographic, clinical and psychosocial factors identify a high-risk group for depression screening among predominantly Hispanic patients with Type 2 diabetes in safety net care.

OBJECTIVE: Identify biopsychosocial factors associated with depression for patients with Type 2 diabetes. METHOD: A quasi-experimental clinical trial of 1293 patients was predominantly Hispanic (91%) female (62%), mean age 53 and average diabetes duration 10 years; 373 (29%) patients were depressed and assessed by Patient Health Questionnaire-9. Demographic, baseline clinical and psychosocial variables were compared between depressed and nondepressed patients. RESULTS: Bivariate analyses found depression significantly associated (p<0.05) with female gender, diabetes emotional burden and regimen distress, BMI ≥ 30, lack of an A1C test, diabetes duration, poor self-care, number of diabetes symptoms and complications, functional and physical characteristics (pain, self-rated health condition, Short-Form Health Survey SF-physical, disability score and comorbid illnesses), as well as higher number of ICD-9 diagnoses and emergency room use. A multivariable regression model with stepwise selection identified six key risk factors: greater disability, diabetes symptoms and regimen distress, female gender, less diabetes self-care and lack of A1C. In addition, after controlling for identified six factors, the number of psychosocial stressors significantly associated with increased risk of depression (adjusted odds ratio=1.37, 95% confidence intervals: 1.18-1.58, p<.0001). CONCLUSION: Knowing biopsychosocial factors could help primary care physicians and endocrinologists identify a high-risk group of patients needing depression screening.

Exploring the uncertainties of early detection results: model-based interpretation of mayo lung project.

BACKGROUND: The Mayo Lung Project (MLP), a randomized controlled clinical trial of lung cancer screening conducted between 1971 and 1986 among male smokers aged 45 or above, demonstrated an increase in lung cancer survival since the time of diagnosis, but no reduction in lung cancer mortality. Whether this result necessarily indicates a lack of mortality benefit for screening remains controversial. A number of hypotheses have been proposed to explain the observed outcome, including over-diagnosis, screening sensitivity, and population heterogeneity (initial difference in lung cancer risks between the two trial arms). This study is intended to provide model-based testing for some of these important arguments. METHOD: Using a micro-simulation model, the MISCAN-lung model, we explore the possible influence of screening sensitivity, systematic error, over-diagnosis and population heterogeneity. RESULTS: Calibrating screening sensitivity, systematic error, or over-diagnosis does not noticeably improve the fit of the model, whereas calibrating population heterogeneity helps the model predict lung cancer incidence better. CONCLUSIONS: Our conclusion is that the hypothesized imperfection in screening sensitivity, systematic error, and over-diagnosis do not in themselves explain the observed trial results. Model fit improvement achieved by accounting for population heterogeneity suggests a higher risk of cancer incidence in the intervention group as compared with the control group.

Systematic review: impact of health information technology on quality, efficiency, and costs of medical care.

BACKGROUND: Experts consider health information technology key to improving efficiency and quality of health care. PURPOSE: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care. DATA SOURCES: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005. STUDY SELECTION: Descriptive and comparative studies and systematic reviews of health information technology. DATA EXTRACTION: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs. DATA SYNTHESIS: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited. LIMITATIONS: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited. CONCLUSIONS: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.

The value of screening for sexually transmitted diseases in an HIV clinic.

Because bacterial sexually transmitted diseases (STDs) facilitate HIV transmission, screening for and treatment of STDs among HIV-infected persons should prevent HIV spread to partners. Before screening programs for gonorrhea and Chlamydia infection should be widely established in HIV clinics, it is useful to know the prevalence of these infections. This study analyzed the results of a urine-based screening program for gonorrhea and Chlamydia in a New Orleans HIV clinic and compared the positivity rates to the prevalence in the local community. Among persons screened in the HIV clinic, 1.7% (46/2629) had gonorrhea and 2.1% (56/2629) had Chlamydia infection. Among persons aged 18-29 years, the test positivity for gonorrhea was similar in the HIV clinic to that of persons in sociodemographically similar community samples (3.1 versus 2.4%, adjusted odds ratio 1.6, P = 0.11) and the test positivity for Chlamydia infection was lower (5.4% versus 10.5%, adjusted odds ratio 0.6, P < 0.01). Based on a previously published mathematical model, it was estimated that treatment of all 46 gonorrhea and 56 Chlamydia infections in the HIV clinic may have averted 9 HIV infections among sex partners and saved far more in future medical costs than the cost of the screening. Routine screening for gonorrhea and Chlamydia infection should be considered in HIV clinics.