Analytics to monitor local impact of the Protecting Access to Medicare Act's imaging clinical decision support requirements.

OBJECTIVE: This study aimed is to: (1) extend the Integrating the Biology and the Bedside (i2b2) data and application models to include medical imaging appropriate use criteria, enabling it to serve as a platform to monitor local impact of the Protecting Access to Medicare Act's (PAMA) imaging clinical decision support (CDS) requirements, and (2) validate the i2b2 extension using data from the Medicare Imaging Demonstration (MID) CDS implementation. MATERIALS AND METHODS: This study provided a reference implementation and assessed its validity and reliability using data from the MID, the federal government's predecessor to PAMA's imaging CDS program. The Star Schema was extended to describe the interactions of imaging ordering providers with the CDS. New ontologies were added to enable mapping medical imaging appropriateness data to i2b2 schema. z-Ratio for testing the significance of the difference between 2 independent proportions was utilized. RESULTS: The reference implementation used 26 327 orders for imaging examinations which were persisted to the modified i2b2 schema. As an illustration of the analytical capabilities of the Web Client, we report that 331/1192 or 28.1% of imaging orders were deemed appropriate by the CDS system at the end of the intervention period (September 2013), an increase from 162/1223 or 13.2% for the first month of the baseline period, December 2011 (P = .0212), consistent with previous studies. CONCLUSIONS: The i2b2 platform can be extended to monitor local impact of PAMA's appropriateness of imaging ordering CDS requirements.

One size does not fit all: Factors associated with increased frequency of radiation overexposure alerts based on fixed-alert thresholds.

OBJECTIVES: Quantify the expected rate of CT radiation dose alerts for three body regions using accepted radiation dose benchmarks and assess key determinants of alert frequency. METHODS: This IRB-approved retrospective cohort study evaluated consecutive CT examinations performed between July and December 2013 within an academic medical system. CTDIvol x-ray tube output metrics were compared to the body-region-specific benchmark levels, Achievable Doses (AD), Diagnostic Reference Levels (DRL), and Dose Notification Values (DNV). A logistic regression model for the simulated alerts was fit as a function of the independent predictors: scanner, body region, gender, weight, and age. RESULTS: For 17,000 exams, the proportion of events triggering alerts increased with patient weight. Significant covariates were scanner, body region, patient weight and patient age (all p < 0.0001). Odds of alert generation for the AD, DRL, and DNV benchmarks increased by 7.6%, 6.6% and 2.9% per kilogram, respectively, and by 0.8%, 1.1% and -2.7% per year of age (all p < 0.0001). Compared to the most highly optimized scanner, odds of alert generation varied by a factor of 595 for AD, 1126 for DRL, and 13 for DNV. CONCLUSION: Alert frequency was significantly correlated with weight, age, body region and scanner. Controllable factors include scanner functionality and associated protocol optimization. Patient factors driving alert frequency are predominantly weight, and to a lesser degree, age. Size-agnostic fixed dose thresholds can frequently produce false positive alerts in appropriately performed exams of large patients, while missing opportunities to identify outlier scans of higher-than-expected dose in small patients.

A Case-control Study of Major Genetic Predisposition Risk Alleles in Developing DDD in the Northeast US Population: Effects of Gene-gene Interactions.

STUDY DESIGN: A case-control study of risk alleles for degenerative disc disease (DDD) using magnetic resonance (MR) imaging for phenotyping. OBJECTIVE: We aim to provide the first statistically adequately powered study of the relationship between the presence of common risk alleles and occurrence of DDD in Eastern US population. SUMMARY OF BACKGROUND DATA: Many genetic predisposing factors have been identified in elevating the risk of DDD, including common variants in VDR, COL1A1, AGC1, COL9A2/3 genes. METHODS: We utilized the Mass General Brigham (MGB) Biobank in which subjects' Medical Record is linked with genotyped data from single-nucleotide polymorphism (SNP) arrays. Subjects with lumbosacral spine MR imaging studies were used to construct the Cases cohort; the Biobank's Controls cohort was used as the Control cohort. Odds ratios (OR) and False-discovery-rate (FDR) q values from multiple-hypotheses-testing corrections were used to assess the likelihood of DDD given occurrence of the listed DDD risk alleles. RESULTS: Four-hundred-fourteen subjects (mean age = 64, range = 27 to 94) were Cases and 925 Controls (mean age = 46, range = 21-61). A systematic search has identified 25 SNPs in 18 genes in the SNP arrays. At univariate level, rs1544410 in VDR was significantly associated with DDD for male subjects (odds ratio [OR] = 0.594, P = 0.011). After adjustment for all significant variants and demographics, three predictor variables had a significant association with the outcome, age (OR = 1.130, q < 0.0001), rs143383 (OR = 1.951, q = 0.056), and rs3737821 (OR = 2.701, q = 0.069). A novel variant-to-variant correlation rs143383:rs763110 had a significant adjusted OR = 7.933, q = 0.070). CONCLUSION: In this large-scale study of common variants' correlation with the presence of DDD in the Northeast United States, we have found a novel and significant variant-to-variant interaction to be associated with the risk of developing DDD, corroborating and necessitating the inclusion of gene-gene interactions in predictive risk model development for DDD.Level of Evidence: 4.

Assessment of Coronary Artery Disease With Computed Tomography Angiography and Inflammatory and Immune Activation Biomarkers Among Adults With HIV Eligible for Primary Cardiovascular Prevention.

Importance: Cardiovascular disease (CVD) is increased among people with HIV (PWH), but little is known regarding the prevalence and extent of coronary artery disease (CAD) and associated biological factors in PWH with low to moderate traditional CVD risk. Objectives: To determine unique factors associated with CVD in PWH and to assess CAD by coronary computed tomography angiography (CTA) and critical pathways of arterial inflammation and immune activation. Design, Setting, and Participants: This cohort study among male and female PWH, aged 40 to 75 years, without known CVD, receiving stable antiretroviral therapy, and with low to moderate atherosclerotic cardiovascular disease (ASCVD) risk according to the 2013 American College of Cardiology/American Heart Association pooled cohort equation, was part of the Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE), a large, ongoing primary prevention trial of statin therapy among PWH conducted at 31 US sites. Participants were enrolled from May 2015 to February 2018. Data analysis was conducted from May to December 2020. Exposure: HIV disease. Main Outcomes and Measures: The primary outcome was the prevalence and composition of CAD assessed by coronary CTA and, secondarily, the association of CAD with traditional risk indices and circulating biomarkers, including insulin, monocyte chemoattractant protein 1 (MCP-1), interleukin (IL) 6, soluble CD14 (sCD14), sCD163, lipoprotein-associated phospholipase A2 (LpPLA2), oxidized low-density lipoprotein (oxLDL), and high-sensitivity C-reactive protein (hsCRP). Results: The sample included 755 participants, with a mean (SD) age of 51 (6) years, 124 (16%) female participants, 267 (35%) Black or African American participants, 182 (24%) Latinx participants, a low median (interquartile range) ASCVD risk (4.5% [2.6%-6.8%]), and well-controlled viremia. Overall, plaque was seen in 368 participants (49%), including among 52 of 175 participants (30%) with atherosclerotic CVD (ASCVD) risk of less than 2.5%. Luminal obstruction of at least 50% was rare (25 [3%]), but vulnerable plaque and high Leaman score (ie, >5) were more frequently observed (172 of 755 [23%] and 118 of 743 [16%], respectively). Overall, 251 of 718 participants (35%) demonstrated coronary artery calcium score scores greater than 0. IL-6, LpPLA2, oxLDL, and MCP-1 levels were higher in those with plaque compared with those without (eg, median [IQR] IL-6 level, 1.71 [1.05-3.04] pg/mL vs 1.45 [0.96-2.60] pg/mL; P = .008). LpPLA2 and IL-6 levels were associated with plaque in adjusted modeling, independent of traditional risk indices and HIV parameters (eg, IL-6: adjusted odds ratio, 1.07; 95% CI, 1.02-1.12; P = .01). Conclusions and Relevance: In this study of a large primary prevention cohort of individuals with well-controlled HIV and low to moderate ASCVD risk, CAD, including noncalcified, nonobstructive, and vulnerable plaque, was highly prevalent. Participants with plaque demonstrated higher levels of immune activation and arterial inflammation, independent of traditional ASCVD risk and HIV parameters.