Maternal and Fetal Radiation-Induced Cancer Risk From Computed Tomography Pulmonary Angiography During Pregnancy: A Retrospective Cohort Study Across a Multihospital Integrated Health Care Network.

OBJECTIVE: Computed tomography pulmonary angiogram (CTPA) is important to evaluate suspected pulmonary embolism in pregnancy but has maternal/fetal radiation risks. The objective of this study was to estimate maternal and fetal radiation-induced cancer risk from CTPA during pregnancy. METHODS: Simulation modeling via the National Cancer Institute's Radiation Risk Assessment Tool was used to estimate excess cancer risks from 17 organ doses from CTPA during pregnancy, with doses determined by a radiation dose indexing monitoring system. Organ doses were obtained from a radiation dose indexing monitoring system. Maternal and fetal cancer risks per 100,000 were calculated for male and female fetuses and several maternal ages. RESULTS: The 534 CTPA examinations had top 3 maternal organ doses to the breast, lung, and stomach of 17.34, 15.53, and 9.43 mSv, respectively, with a mean uterine dose of 0.21 mSv. The total maternal excess risks of developing cancer per 100,000 were 181, 151, 121, 107, 94.5, 84, and 74.4, respectively, for a 20-, 25-, 30-, 35-, 40-, 45-, and 50-year-old woman undergoing CTPA, compared with baseline cancer risks of 41,408 for 20-year-old patients. The total fetal excess risks of developing cancer per 100,000 were 12.3 and 7.3 for female and male fetuses, respectively, when compared with baseline cancer risks of 41,227 and 48,291. DISCUSSION: Excess risk of developing cancer from CTPA was small relative to baseline cancer risk for pregnant patients and fetuses, decreased for pregnant patients with increasing maternal age, and was greater for female fetuses than male fetuses.

Ten-year trends, disparities, and clinical impact of stroke thrombectomy and thrombolysis: A single center experience 2012-2021.

OBJECTIVES: As indications for acute ischemic stroke treatment expand, it is unclear whether disparities in treatment utilization and outcome still exist. The main objective of this study was to investigate disparities in acute ischemic stroke treatment and determine impact on outcome. MATERIALS AND METHODS: Retrospective observational cohort study of consecutive ischemic stroke admissions to a comprehensive stroke center from 2012-2021 was performed. Primary exposure was intravenous thrombolysis and/or endovascular thrombectomy. Primary end points were discharge modified Rankin Scale, home disposition, and expired/hospice. Multivariable logistic regression analyses were conducted to elucidate disparities in treatment utilization and determine impact on outcome. RESULTS: Of 517,615 inpatient visits, there were 7,540 (1.46 %) ischemic stroke admissions, increasing from 1.14 % to 1.79 % from 2012-2021. Intravenous thrombolysis significantly decreased from 14.4 % to 9.8 % while endovascular thrombectomy significantly increased from 0.8 % to 10.5 %. Both intravenous thrombolysis and endovascular thrombectomy increased odds of discharge home and modified Rankin Scale 0-2, and thrombectomy decreased odds of expired/hospice. After adjusting for covariates, decreased odds of thrombectomy was associated with Medicaid insurance (Odds Ratio [95 % Confidence Interval] 0.55 [0.32-0.93]), age 80+ (0.49 [0.35-0.69]), prior stroke (0.49 [0.31-0.77]), and diabetes mellitus (0.55 [0.39-0.79]), while low median household income (<$80,000/year) increased odds of no acute treatment (1.34 [1.16-1.56]). No sex or racial disparities were observed. Medicaid and low-income were not associated with worse clinical outcomes. CONCLUSIONS: Less endovascular thrombectomy occurred in Medicaid, older, prior stroke, and diabetic patients, while low-income was associated with no treatment. The observed socioeconomic disparities did not impact discharge outcome.

Hypoperfusion Intensity Ratio is Associated with Stroke Mechanism in Patients Undergoing Mechanical Thrombectomy.

BACKGROUND: Hypoperfusion Intensity Ratio (HIR), defined as Tmax >10s/Tmax >6s on computed tomography perfusion (CTP), and stroke mechanisms have been independently correlated with angiographic collaterals and patient outcomes. Slowly developing atherosclerotic stenosis may foster collateral development, whereas cardioembolic occlusion may occur before collaterals mature. We hypothesized that favorable HIR is associated with large artery atherosclerosis (LAA) stroke mechanism and good clinical outcome. METHODS: Retrospective study of consecutive endovascularly-treated stroke patients with intracranial ICA or MCA M1/M2 occlusions, who underwent CTP before intervention, between January 2018 and August 2021. Patients were dichotomized into LAA+ or LAA- based on presence of LAA on angiography. HIR was dichotomized into favorable (HIR+) or unfavorable (HIR-) groups based on published thresholds. Good early outcome was defined as discharge mRS of 0-2. Bivariate and multivariable logistic regression were performed. RESULTS: 143 patients met inclusion. 21/143 were LAA+ (15%) and 65/143 (45%) were HIR+. HIR+ was significantly more frequent in LAA+ patients (67% vs. 42%, p= 0.035). Controlling for demographics, stroke severity, imaging findings, and medical comorbidities, LAA+ remained independently associated with HIR+ (OR 5.37 [95% CI 1.43 - 20.14]; p=0.013) as did smaller infarction core volume (<30 mL of CBF <30%: OR 7.92 [95% CI 2.27 - 27.64]; p = 0.001). HIR+ was not associated with good clinical outcome. CONCLUSIONS: Large artery atherosclerosis was independently associated with favorable HIR in patients undergoing mechanical thrombectomy. While favorable HIR was associated with smaller pre-treatment core infarcts, reflecting more robust collaterals, it was not associated with good clinical outcome.

Clinical Outcomes and Costs of Recurrent Ischemic Stroke: A Systematic Review.

OBJECTIVE: Recurrent stroke patients suffer significant morbidity and mortality, representing almost 30% of the stroke population. Our objective was to determine the clinical outcomes and costs of recurrent ischemic stroke (recurrent-IS). METHODS: Our study protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020192709). Following PRISMA guidelines, our medical librarian conducted a search in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL (last performed on August 25, 2020). INCLUSION CRITERIA: (1) Studies reporting clinical outcomes and/or costs of recurrent-IS; (2) Original research published in English in year 2010 or later; (3) Study participants aged ≥18 years. EXCLUSION CRITERIA: (1) Case reports/studies, abstracts/posters, Editorial letters/reviews; (2) Studies analyzing interventions other than intravenous thrombolysis and thrombectomy. Four independent reviewers selected studies with review of titles/abstracts and full-text, and performed data extraction. Discrepancies were resolved by a senior independent arbitrator. Risk-of-bias was assessed using the Mixed Methods Appraisal Tool. RESULTS: Initial search yielded 20,428 studies. Based on inclusion/exclusion criteria, 9 studies were selected, consisting of 24,499 recurrent-IS patients. In 5 studies, recurrent-IS ranged from 4.4-56.8% of the ischemic stroke cohorts at 3 or 12 months, or undefined follow-up. Mean age was 60-80 years and female proportions were 38.5-61.1%. Clinical outcomes included mortality 11.6-25.9% for in-hospital, 30-days, or 4-years (3 studies). In one study from the U.S., mean in-hospital costs were $17,121(SD-$53,693) and 1-year disability costs were $34,639(SD-$76,586) per patient. CONCLUSIONS: Our study highlights the paucity of data on clinical outcomes and costs of recurrent-IS and identifies gaps in existing literature to direct future research.

Using community priorities and misconceptions about asthma as a vessel for community-led education among Hispanics.

OBJECTIVES: In New York City, asthma prevalence is greater in Hispanics than non-Hispanics for both children (10.9% vs. 7.4%) and adults (9.0% vs. 6.3%). Disparities in asthma management among Hispanics are found to arise, in part, from a limited education about asthma. Using elements of Community Based Participatory Research (CBPR), we worked with the community to identify asthma priorities and misconceptions among Hispanics and used that information to develop a tailored asthma educational tool-the Asthma Training Modules (ATMs). METHODS: Over the past 3 years (2016, 2017, and 2018), we conducted educational asthma workshops to collect and analyze information to develop the ATMs and a summary of the ATMs in an Asthma Educational Card (AEC). We trained 6 Asthma-Community-Leaders using the ATMs, who assembled community members for teaching sessions using the AEC. Participants completed a pre-and-post asthma knowledge questionnaire. RESULTS: We identified asthma priorities and misconceptions themed on: culturally relevant resources for Hispanics, symptom and trigger recognition, and treatments. A total of 104 participants attended the teaching sessions led by Asthma-Community-Leaders and participants' mean knowledge score increased from 64% pre-teaching to 85% post-teaching, (p < 0.01). CONCLUSION: Our community-led education, which included a tailored asthma educational tool and trained Asthma-Community-Leaders, successfully improved asthma knowledge among Hispanics. Further studies are warranted to determine whether these results are reproducible among a larger cohort and what the comparative effectiveness of our intervention as compared to other education-based interventions.

Sociodemographic predictors and transportation patterns of COVID-19 infection and mortality.

BACKGROUND: The United States Centers for Disease Control and Prevention (CDC)-sanctioned prevention strategies have included frequent handwashing with soap and water, covering the mouth and nose with a mask when around others, cleaning and disinfecting maintaining a distance of at least 6 feet from others, etc. Although many of these recommendations are based upon observation and past infection control practices, it is important to combine and explore public data sets to identify predictors of infection, morbidity and mortality to develop more finely honed interventions, based on sociodemographic factors. METHOD: Cross-sectional study of both states in the US and counties in NY state. RESULTS: Population density was found to be significantly associated with state-level coronavirus infection and mortality rate (b = 0.49, 95% confidence interval (CI): 0.34, 0.64, P < .0001). States that have lower socioeconomic status, lower mean age and denser populations are associated with higher incidence rates. In regard to NY state, counties with a higher percentage of minority residents had higher COVID-19 mortality rates (b = 2.61, 95% CI: 0.36, 4.87, P = 0.023). Larger population cohorts were associated with lower COVID-19 mortality rates after adjusting for other variables in the model (b = -1.39, 95% CI: -2.07, -0.71, P < 0.001). Population density was not significantly associated with COVID-19 mortality rates after adjustment across counties in the NY state. Public ridership was not indicative of cases or mortality across states in the USA; however, it is a significant factor associated with incidence (but not mortality) in NY counties. CONCLUSION: Population density was the only significant predictor of mortality across states in the USA. Lower mean age, lower median household incomes and more densely populated states were at higher risk of COVID-19 infection. Population density was not found to be a significant independent variable compared to minority status and socioeconomic factors in the New York epicenter. Meanwhile, public ridership was found to be a significant factor associated with incidence in New York counties.

Early Thrombectomy Outcomes in Transfer Patients.

OBJECTIVE: The optimal patient transportation destination of acute ischemic stroke (AIS) patients remains uncertain. The purpose of this study was to evaluate the predictive variables that determine stroke outcomes depending on the patient transportation destination. METHODS: We performed a retrospective study using an AIS database consisting of patients who underwent thrombectomy admitted to our institution from November 1, 2011, through October 1, 2018. RESULTS: A total of 171 patients were included in the statistical analysis; 42.1% (72/171) of patients were in the mothership group (directly admitted) and 57.9% (99/171) in the drip-and-ship group (transferred). Multivariable logistic regression revealed the predictive factors for favorable outcomes were driving distance (expressed in miles) between the patient's home and a comprehensive stroke center (CSC) (odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.90-0.99; P = .035), absence of diabetes mellitus (OR = 3.60; 95% CI, 1.20-10.82; P = .022), lower National Institutes of Health Stroke Scale score at admission (OR = 0.91; 95% CI, 0.85-0.97; P = .003), and shorter symptom onset to CSC arrival time (expressed in hours) (OR = 0.84; 95% CI, 0.72-0.99; P = .038). CONCLUSIONS: Our study revealed that a shorter driving distance between the patient's home and CSC, absence of diabetes, lower National Institutes of Health Stroke Scale score, and shorter onset to hospital arrival time positively impacted the outcomes of endovascularly treated AIS patients.

Cerebrovascular Complications of COVID-19.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) evolved quickly into a global pandemic with myriad systemic complications, including stroke. We report the largest case series to date of cerebrovascular complications of COVID-19 and compare with stroke patients without infection. METHODS: Retrospective case series of COVID-19 patients with imaging-confirmed stroke, treated at 11 hospitals in New York, between March 14 and April 26, 2020. Demographic, clinical, laboratory, imaging, and outcome data were collected, and cases were compared with date-matched controls without COVID-19 from 1 year prior. RESULTS: Eighty-six COVID-19-positive stroke cases were identified (mean age, 67.4 years; 44.2% women). Ischemic stroke (83.7%) and nonfocal neurological presentations (67.4%) predominated, commonly involving multivascular distributions (45.8%) with associated hemorrhage (20.8%). Compared with controls (n=499), COVID-19 was associated with in-hospital stroke onset (47.7% versus 5.0%; P<0.001), mortality (29.1% versus 9.0%; P<0.001), and Black/multiracial race (58.1% versus 36.9%; P=0.001). COVID-19 was the strongest independent risk factor for in-hospital stroke (odds ratio, 20.9 [95% CI, 10.4-42.2]; P<0.001), whereas COVID-19, older age, and intracranial hemorrhage independently predicted mortality. CONCLUSIONS: COVID-19 is an independent risk factor for stroke in hospitalized patients and mortality, and stroke presentations are frequently atypical.

Ultrasound-assisted versus conventional catheter-directed thrombolysis for acute pulmonary embolism: A multicenter comparison of patient-centered outcomes.

Both catheter-directed thrombolysis (CDT) and ultrasound-assisted thrombolysis (USAT) are novel treatment modalities for patients presenting with acute pulmonary embolism (PE). The objective of this study was to compare clinical and quality-of-life (QOL) outcomes for patients undergoing either treatment modality. We retrospectively studied 70 consecutive patients treated with either CDT or USAT over 3 years at a multicenter health system. The primary clinical efficacy endpoint was right ventricular systolic pressure (RVSP) reduction post-procedurally. Safety endpoints were mortality and bleeding incidents based on Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO) criteria. Long-term QOL was assessed using the 36-Item Short-Form Health Survey (SF-36) via phone interview. Thirty-seven patients (53%) in our study underwent USAT and 33 (47%) patients were treated with conventional CDT. Among all patients studied, 96% had echocardiographic evidence for right ventricular strain on admission. Mean RVSP decreased by 18 ± 13 mmHg in the USAT group post-procedurally as compared to 14 ± 16 mmHg in the CDT group, without significant difference between groups ( p = 0.31). Rates of moderate and severe bleeding were largely identical between USAT and CDT groups (USAT: 3%; CDT: 0%; p = 0.09). There was no death in either group during admission. At long-term follow-up, there was no significant difference in QOL between both treatment modalities in all eight functional domains of SF-36. Our retrospective study demonstrated using USAT over conventional CDT for acute submassive or massive PE did not yield additional clinical, safety, or long-term QOL benefit.

Assessment of warfarin algorithms for hospitalized adults: searching for a safe dosing strategy.

This study evaluates three warfarin dosing algorithms (Kimmel, Dawson, High Dose ≥ 2.5 mg) for hospitalized older adults. A random selection of 250 patients with overshoots (INR ≥ 5 after 48 h of hospitalization) and 250 patients without overshoots were accessed from a database of 12,107 inpatients ≥ 65 years treated with chronic warfarin during hospitalization between January 1, 2014 and June 30, 2016. Algorithms were retrospectively applied to patients 2 days prior to overshoots in the overshoot group, and 2 days prior to the maximum INR reached after 48 h of hospitalization in the non-overshoot group. Patients were categorized as overdosed or not overdosed and compared using descriptive statistics. Logistic regression modeling determined predictors for overshoots. There was no significant difference between overdose and non-overdose groups for progressing to overshoots by the Kimmel (51.0% vs. 48.7%, p = 0.67) or Dawson (48.5 vs. 57.9%, p = 0.19) algorithms. The Low Dose Group (≤ 2.5 mg) was significantly more likely to experience an overshoot than the High Dose Group (56.6% vs. 45.5%, p = 0.04). The Low Dose Group was more likely to be older (81.4% vs. 71.1%, p = 0.02), female (63.5% vs. 49.8%, p = 0.02), weigh less (71.3 ± 21.9 vs. 79 ± 23.1, p = 0.002), and be prescribed amiodarone (16.6% vs. 8.1%, p = 0.01). While none of the algorithms predicted overshoots in logistic regression modeling, weight over 70 kg and black race remained protective. The High Dose Algorithm revealed that providers appropriately gave lower doses to patients at highest risk for warfarin sensitivity. Future studies are needed to investigate tools for inpatient warfarin dosing in older adults.

Quality metrics of warfarin initiation in hospitalized older adults.

Achieving therapeutic international normalized ratio (INRs) in warfarin naïve older adults can be complicated due to sensitivity factors. While multiple tools exist for warfarin initiation in the outpatient setting, there is a dearth of guidance for inpatient initiation. This study aims to: (1) describe a large health system's initiation warfarin quality metrics in older inpatients, defined by INR overshoots greater than or equal to 5.0; (2) identify intrinsic and extrinsic patient factors associated with overshoots; and (3) explore the association between inpatient overshoots and clinical outcomes. Data on inpatients ≥ 65 years initiated on warfarin 1/1/2014-6/30/2016 were extracted through retrospective chart review. The primary outcome was prevalence of overshoots (INR ≥ 5). Logistic regression modeling determined the risk factors for overshoots. Multivariate analysis was employed to associate overshoots with length of stay (LOS), bleeding, and mortality. Additional analysis of the impact of patient weight (kg) on overshoots was achieved through chi square analysis. Of 4556 inpatients initiated on warfarin, 8% experienced overshoots. Non-black race, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), mild liver disease, low weight, and no statin use were found to be predictive of overshoots. Compared to the group without overshoots, the group with overshoots experienced a significantly increased LOS (13 days vs. 8 days, < 0.001), higher bleed rate (30.1% vs. 6.5%, adjusted OR 6.2, p < 0.001), and higher mortality rate (13.8% vs. 3.4%, adjusted OR 4.4, p < 0.001). Inpatient warfarin initiation was associated with frequent overshoots and poor outcomes. Future studies should focus on strategies to improve hospital warfarin initiation safety.

Challenges and strategies for hypertension management: qualitative analysis of small primary care practices with varying blood pressure control.

BACKGROUND: Electronic health record (EHR) data on blood pressure (BP) control among patients with hypertension show that practices' rates vary greatly. This suggests providers use different approaches in managing hypertension, and so we aimed to explore challenges small primary care practice providers face and strategies they use to manage patients' BP. We explored differences between providers with high and low BP control rates to help inform future quality improvement work. METHODS: In 2015, we recruited practices in New York City with five or fewer providers. We employed a stratified purposeful sampling method, using EHR data to categorize small practices into groups based on the proportion of patients with hypertension whose last BP was <140/90: high control (>= 80%), average control (60-80%) and low control (<60%). We conducted semi-structured qualitative interviews with clinicians from 23 practices-7 high control, 10 average control and 6 low control-regarding hypertension management. We used a combined inductive/deductive approach to identify key themes, and these themes guided a comparison of high and low BP control providers. RESULTS: Small practice providers reported treatment non-adherence as one of the primary challenges in managing patients' hypertension, and described using patient education, relationship building and self-management tools to address this issue. Providers differed qualitatively in the way they described using these strategies; high BP control providers described more actively engaging and listening to patients than low control providers did. CONCLUSIONS: How providers communicate with patients may impact outcomes-future quality improvement initiatives should consider trainings to improve patient-provider communication.

Performance of the Gemini Planet Imager's adaptive optics system.

The Gemini Planet Imager's adaptive optics (AO) subsystem was designed specifically to facilitate high-contrast imaging. A definitive description of the system's algorithms and technologies as built is given. 564 AO telemetry measurements from the Gemini Planet Imager Exoplanet Survey campaign are analyzed. The modal gain optimizer tracks changes in atmospheric conditions. Science observations show that image quality can be improved with the use of both the spatially filtered wavefront sensor and linear-quadratic-Gaussian control of vibration. The error budget indicates that for all targets and atmospheric conditions AO bandwidth error is the largest term.

Patient Characteristics Associated With Smoking Cessation Interventions and Quit Attempt Rates Across 10 Community Health Centers With Electronic Health Records.

OBJECTIVES: We used electronic health record (EHR) data to determine rates and patient characteristics in offering cessation interventions (counseling, medications, or referral) and initiating quit attempts. METHODS: Ten community health centers in New York City contributed 30 months of de-identified patient data from their EHRs. RESULTS: Of 302 940 patients, 40% had smoking status recorded and only 34% of documented current smokers received an intervention. Women and younger patients were less likely to have their smoking status documented or to receive an intervention. Patients with comorbidities that are exacerbated by smoking were more likely to have status documented (82.2%) and to receive an intervention (52.1%), especially medication (10.8%). Medication, either alone (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.5, 2.3) or combined with counseling (OR = 1.8; 95% CI = 1.5, 2.3), was associated with higher quit attempts compared with no intervention. CONCLUSIONS: Data from EHRs demonstrated underdocumentation of smoking status and missed opportunities for cessation interventions. Use of data from EHRs can facilitate quality improvement efforts to increase screening and intervention delivery, with the potential to improve smoking cessation rates.

Maternal depressive symptoms and parenting practices 3-months postpartum.

Using data from two postpartum depression randomized trials, we examined the association between postpartum depressive symptoms and parenting practices among a diverse group of mothers. We examined the association between safety practices (back sleep position, car seat use, smoke alarm), feeding practices (breastfeeding, infant intake of cereal, juice, water), and health care practices (routine well child and Emergency Room (ER) visits) with 3-month postpartum depressive symptoms assessed using the Edinburgh Depression Scale (EPDS ≥10). Fifty-one percent of mothers were black or Latina, 33 % had Medicaid, and 30 % were foreign born. Depressed mothers were less likely to have their infant use back sleep position (60 vs. 79 %, p < .001), always use a car seat (67 vs. 84 %, p < .001), more likely to feed their infants water, juice, or cereal (36 vs. 25 %, p = .04 respectively), and to bring their babies for ER visits (26 vs. 16 %, p = .03) as compared with non-depressed mothers. In multivariable model, depressed mothers remained less likely to have their infant use the back sleep position, to use a car seat, and to have a working smoke alarm in the home. Findings suggest the need to intervene early among mothers with depressive symptoms and reinforce positive parenting practices.

Developing Composite Quality Measures for EHR-Enabled Primary Care Practices in New York City.

We describe the process of developing composite quality measures (CQMs). During the initial consultative process, we grouped quality measures based on the associated clinical workflow and difficulty, and then confirmed the groupings with factor analysis. The CQMs are estimated as the mean of the measures for each group. We used analysis of variance followed by a post hoc analysis to assess: (1) performance among the different CQMs each year; and (2) the performance trend for each of the composite measures from 2009 to 2011. The four CQMs were Control-BP, Control-Other, Assessment, and Screening. Performance was highest at baseline for Control-BP (58%, SD 15.07), followed by Control-Other (48.04%, SD 22.75), Screening (46.49%, SD 20.21), and Assessment (42.15%, SD 19.08). Performance on the CQMs increased significantly with time, whereas the gap between the CQMs decreased significantly over time. The CQMs reflect the clinical care domains, and practice performance is influenced by electronic health record functionality, clinician workflow, and clinical difficulty.

The intended and unintended consequences of quality improvement interventions for small practices in a community-based electronic health record implementation project.

BACKGROUND: Despite the rapid rise in the implementation of electronic health records (EHR), commensurate improvements in health care quality have not been consistently observed. OBJECTIVES: To evaluate whether the implementation of EHRs and complementary interventions-including clinical decision support, technical assistance, and financial incentives-improved quality of care. RESEARCH DESIGN: The study included 143 practices that implemented EHRs as part of the Primary Care Information Project-a long-standing community-based EHR implementation initiative. A total of 71 practices were randomized to receive financial incentives and quality feedback and 72 were randomized to feedback alone. All practices received technical assistance and had clinical decision support in their EHR. Using data from 2009 to 2011, we estimated measure-level fixed effects models to evaluate the association between exposure to clinical decision support, technical assistance, financial incentives, and quality of care. Associations were estimated separately for 4 cardiovascular measures that were rewarded by the financial incentive program and 4 measures that were not rewarded by incentives. RESULTS: Financial incentives for quality were consistently associated with higher performance for the incentivized measures [+10.1 percentage points at 18 mo of exposure (approximately +22%), P<0.05] and lower performance for the unincentivized measures [-8.3 percentage points at 12 mo of exposure (approximately -20%), P<0.05]. Technical assistance was associated with higher quality for the unincentivized measures, but not for the incentivized measures. CONCLUSIONS: Technical assistance and financial incentives-alongside EHR implementation-can improve quality of care. Financial incentives for quality may not result in similar improvements for incentivized and unincentivized measures.

Does it get easier to use an EHR? Report from an urban regional extension center.

BACKGROUND: Little is known about whether more experience with an electronic health record (EHR) makes it easier for providers to meaningfully use EHRs. OBJECTIVE: To assess whether the length of time that small practice providers have been using the EHR is associated with greater ease in performing meaningful use-related tasks and fewer EHR-related concerns. DESIGN/PARTICIPANTS: We administered a web-based survey to 400 small practice providers in medically underserved communities in New York City participating in an EHR implementation and technical assistance project. We used logistic regression to estimate the association between the length of time a provider had been using the EHR (i.e., "live") and the ease of performing meaningful use-related tasks and EHR-related concerns, controlling for provider and practice characteristics. KEY RESULTS: Compared to providers who had been live 6 to 12 months, providers who had been live 2 years or longer had 2.02 times greater odds of reporting it was easy to e-prescribe new prescriptions (p < 0.05), 2.12 times greater odds of reporting it was easy to e-prescribe renewal prescriptions (p < 0.05), 2.02 times greater odds of reporting that quality measures were easy to report (p < 0.05), 2.64 times greater odds of reporting it was easy to incorporate lab results as structured data (p < 0.001), and 2.00 times greater odds of reporting it was easy to generate patient lists by condition (p < 0.05). Providers who had been live 2 years or longer had 0.40 times lower odds of reporting financial costs were a concern (p < 0.001), 0.46 times lower odds of reporting that productivity loss was a concern (p < 0.05), 0.54 times lower odds of reporting that EHR unreliability was a concern (p < 0.05), and 0.50 times lower odds of reporting that privacy/security was a concern (p < 0.05). CONCLUSIONS: Providers can successfully adjust to the EHR and over time are better able to meaningfully use the EHR.

Preliminary evaluation of a comprehensive provider feedback report.

Provider feedback reports (PFRs) offer one way for providers to use their electronic health record (EHR) data to understand aspects of their clinical performance and improve quality of care. The Primary Care Information Project (PCIP) serves as a bureau of the New York City Department of Health and Mental Hygiene and as a Regional Extension Center that helps area healthcare providers adopt and achieve Meaningful Use of EHR systems. This study analyzes improvement on multiple quality measures pre- and post-receipt of a comprehensive, EHR-based PFR that PCIP created for its member providers. We analyzed improvement among low- versus high-performing providers pre- and post-receipt of the PFR. Pre-PFR receipt, improvement between high and low performers varied per measure. Post-PFR receipt, low performers improved more than high performers on all measures, and more than themselves in the pre-PFR period. Findings suggest PFRs derived directly from provider EHRs may particularly assist lower-performing providers to improve performance.

Effect of an electronic alert on treatment of skin and soft tissue infections.

This is a prospective intervention study conducted between 2007 and 2011 to evaluate whether an electronic alert can influence provider practice in treatment of skin and soft tissue infections (SSTIs). A best-practice alert (BPA) was programmed to appear for intervention ICD-9 SSTI diagnoses. Controls were patients who had other SSTI ICD-9 codes where the BPA was not programmed to fire. Rate of culture taken in patients was compared between patients in the intervention and control groups. We found that cultures were taken among 13.5% of the intervention group and 5.4% of the control group (p <.0001). A logistic regression analysis controlling for covariates showed the odds of the intervention group having a culture taken was 2.6 times that of the control group. The results of this study support the use of BPAs for improving the management of SSTIs.