External Validation of the eRADAR Risk Score for Detecting Undiagnosed Dementia in Two Real-World Healthcare Systems.

BACKGROUND: Fifty percent of people living with dementia are undiagnosed. The electronic health record (EHR) Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) was developed to identify older adults at risk of having undiagnosed dementia using routinely collected clinical data. OBJECTIVE: To externally validate eRADAR in two real-world healthcare systems, including examining performance over time and by race/ethnicity. DESIGN: Retrospective cohort study PARTICIPANTS: 129,315 members of Kaiser Permanente Washington (KPWA), an integrated health system providing insurance coverage and medical care, and 13,444 primary care patients at University of California San Francisco Health (UCSF), an academic medical system, aged 65 years or older without prior EHR documentation of dementia diagnosis or medication. MAIN MEASURES: Performance of eRADAR scores, calculated annually from EHR data (including vital signs, diagnoses, medications, and utilization in the prior 2 years), for predicting EHR documentation of incident dementia diagnosis within 12 months. KEY RESULTS: A total of 7631 dementia diagnoses were observed at KPWA (11.1 per 1000 person-years) and 216 at UCSF (4.6 per 1000 person-years). The area under the curve was 0.84 (95% confidence interval: 0.84-0.85) at KPWA and 0.79 (0.76-0.82) at UCSF. Using the 90th percentile as the cut point for identifying high-risk patients, sensitivity was 54% (53-56%) at KPWA and 44% (38-51%) at UCSF. Performance was similar over time, including across the transition from International Classification of Diseases, version 9 (ICD-9) to ICD-10 codes, and across racial/ethnic groups (though small samples limited precision in some groups). CONCLUSIONS: eRADAR showed strong external validity for detecting undiagnosed dementia in two health systems with different patient populations and differential availability of external healthcare data for risk calculations. In this study, eRADAR demonstrated generalizability from a research sample to real-world clinical populations, transportability across health systems, robustness to temporal changes in healthcare, and similar performance across larger racial/ethnic groups.

A Comparison of Electronic Patient-Portal Use Among Patients with Resident and Attending Primary Care Providers.

BACKGROUND: Electronic patient-portals offer the potential to enhance patient-physician communication and health outcomes but differential use may create or worsen disparities. While prior studies identified patient characteristics associated with patient-portal use, the role of physician factors is less known. We investigated differences in overall and patterns of portal use for patients with resident and attending primary care providers (PCPs). METHODS: Cross-sectional study of all established patients with a resident or attending PCP seen at an academic internal medicine practice (two sites) between May 1, 2014, and April 30, 2015. We defined patient-portal use as having accessed any "active" (secure messaging, medication refill request), or "passive" (viewing labs, after visit summaries, or appointments) patient-portal function more than once over the study period. We used generalized linear models clustered on PCP to examine the odds of patient-portal use by PCP type, adjusted for patient age, gender, preferred language, race/ethnicity, insurance, and visits. Among patient-portal users, we examined the association of PCP type with "active use" utilizing the same method. RESULTS: The mean patient age (n = 17,699) was 54.2 (SD 17.5), with 47.2% White, 23.6% Asian, 8.8% Black, 8.4% Latino, and 12% other/unknown. The majority (61.8%) had private insurance, and attending PCPs (76.9%). Although 72.3% enrolled in the patient-portal, only 53.4% were portal users; 40.0% were active users. There were 47 attending and 62 resident physicians. Patients with resident PCPs had lower odds of using the portal compared to those with attending PCPs (OR = 0.54, 95% CI 0.50-0.59). Similarly, among portal users, residents' patients had lower odds of being active users of the portal (OR = 0.76, 95% CI 0.68-0.87). CONCLUSION: Given the lower patient-portal use among residents' patients, residency programs should develop curricula to bolster trainee competence in using the patient-portal for communication and to enhance the patient-physician relationship. Future research should explore additional physician factors that impact portal use.

Development of a Multistep Hypertension Quality Improvement Program in an Academic General Medicine Practice.

Hypertension is a common problem and a major risk factor for cardiovascular disease. It is unclear whether efforts to control blood pressure (BP) known to be effective in integrated healthcare systems can be successfully implemented in an academic setting. We describe our experience implementing a multistep quality improvement program within an academic general medicine practice aimed at improving BP among patients with uncontrolled hypertension. Ensuring medical assistants were correctly measuring BP provided the basis for accurate data entry into the electronic medical record (EMR); our EMR-based registry data allowed us to feedback primary care provider (PCP) level data on BP control for panel management, which resulted in improvements in BP for a substantial proportion of patients, particularly for those with more practice visits. However, due to PCP, patient, and system barriers, our initial attempt to integrate a pharmacist into our team for hypertension management was only successful for a small number of patients who engaged in pharmacist in-person visits. Future improvement efforts will focus on addressing the barriers to more intensive BP management, integrating lessons from this experience. As chronic disease management shifts to a population-based model, team change will be a necessary component for achieving clinical improvement.