Impact of homecare electronic health record on timeliness of clinical documentation, reimbursement, and patient outcomes.

BACKGROUND: Homecare is an important and effective way of managing chronic illnesses using skilled nursing care in the home. Unlike hospitals and ambulatory settings, clinicians visit patients at home at different times, independent of each other. Twenty-nine percent of 10,000 homecare agencies in the United States have adopted point-of-care EHRs. Yet, relatively little is known about the growing use of homecare EHRs. OBJECTIVE: Researchers compared workflow, financial billing, and patient outcomes before and after implementation to evaluate the impact of a homecare point-of-care EHR. METHODS: The design was a pre/post observational study embedded in a mixed methods study. The setting was a Philadelphia-based homecare agency with 137 clinicians. Data sources included: (1) clinician EHR documentation completion; (2) EHR usage data; (3) Medicare billing data; (4) an EHR Nurse Satisfaction survey; (5) clinician observations; (6) clinician interviews; and (7) patient outcomes. RESULTS: Clinicians were satisfied with documentation timeliness and team communication. Following EHR implementation, 90% of notes were completed within the 1-day compliance interval (n = 56,702) compared with 30% of notes completed within the 7-day compliance interval in the pre-implementation period (n = 14,563; OR 19, p <. 001). Productivity in the number of clinical notes documented post-implementation increased almost 10-fold compared to pre-implementation. Days to Medicare claims fell from 100 days pre-implementation to 30 days post-implementation, while the census rose. EHR implementation impact on patient outcomes was limited to some behavioral outcomes. DISCUSSION: Findings from this homecare EHR study indicated clinician EHR use enabled a sustained increase in productivity of note completion, as well as timeliness of documentation and billing for reimbursement with limited impact on improving patient outcomes. As EHR adoption increases to better meet the needs of the growing population of older people with chronic health conditions, these results can inform homecare EHR development and implementation.

Changes in eating, physical activity and related behaviors in a primary care-based weight loss intervention.

OBJECTIVE: To examine changes in eating behaviors and physical activity, as well as predictors of weight loss success, in obese adults who participated in a 2-year behavioral weight loss intervention conducted in a primary care setting. DESIGN: A longitudinal, randomized controlled, multisite trial. SUBJECTS: Three hundred ninety obese (body mass index, 30-50 kg m(-2)) adults, ≥ 21 years, in the Philadelphia region. METHODS: Participants were assigned to one of three interventions: (1) Usual Care (quarterly primary care provider (PCP) visits that included education on diet and exercise); (2) Brief Lifestyle Counseling (quarterly PCP visits plus monthly lifestyle counseling (LC) sessions about behavioral weight control); or (3) Enhanced Brief LC (the previous intervention with a choice of meal replacements or weight loss medication). RESULTS: At month 24, participants in both Brief LC and Enhanced Brief LC reported significantly greater improvements in mean (± s.e.) dietary restraint than those in Usual Care (4.4 ± 0.5, 4.8 ± 0.5 and 2.8 ± 0.5, respectively; both P-values ≤ 0.016). The percentage of calories from fat, along with fruit and vegetable consumption, did not differ significantly among the three groups. At month 24, both the Brief LC and Enhanced Brief LC groups reported significantly greater increases than usual care in energy expenditure (kcal per week) from moderately vigorous activity (+593.4 ± 175.9, +415.4 ± 179.6 and -70.4 ± 185.5 kcal per week, respectively; both P-values ≤ 0.037). The strongest predictor of weight loss at month 6 (partial R(2)=33.4%, P<0.0001) and at month 24 (partial R(2)=19.3%, P<0.001) was food records completed during the first 6 months. Participants who achieved a 5% weight loss at month 6 had 4.7 times greater odds of maintaining a ≥ 5% weight loss at month 24. CONCLUSIONS: A behavioral weight loss intervention delivered in a primary care setting can result in significant weight loss, with corresponding improvements in eating restraint and energy expenditure. Moreover, completion of food records, along with weight loss at month 6, is a strong predictor of long-term weight loss.

Effect of lifestyle intervention on cardiometabolic risk factors: results of the POWER-UP trial.

OBJECTIVE: To investigate the effects of three weight loss interventions on cardiometabolic risk factors, including blood pressure, lipids, glucose and markers of insulin resistance and inflammation. We also examined whether categories of incremental weight change conferred greater improvements on these parameters. METHODS: This 2-year trial was conducted in a primary care setting and included 390 obese participants who were randomly assigned to one of three interventions: (1) Usual Care (quarterly primary care provider (PCP) visits that included education about weight management); (2) Brief Lifestyle Counseling (quarterly PCP visits plus monthly behavioral counseling provided by a trained auxiliary health-care provider); or (3) Enhanced Brief Lifestyle Counseling (the same care as described for the previous intervention, plus weight loss medications or meal replacements). The primary outcome was change in cardiometabolic risk factors among groups. RESULTS: At month 24, participants in Enhanced Brief Lifestyle Counseling lost significantly more weight than those in Usual Care (4.6 vs 1.7 kg), with no other significant differences between groups. Enhanced Brief Lifestyle Counseling produced significantly greater improvements in high-density lipoprotein (HDL) cholesterol and triglyceride levels at one or more assessments, compared with the other two interventions. Markers of insulin resistance also improved significantly more in this group throughout the 2 years. Collapsing across the three groups, greater weight loss was associated with greater improvements in triglycerides, HDL cholesterol and markers of insulin resistance and inflammation at month 24, but was not significantly associated with reductions in blood pressure, total cholesterol and low-density lipoprotein cholesterol at any time. CONCLUSIONS: Enhanced Brief Lifestyle Counseling, which produced the largest weight loss, was generally associated with the greatest improvements in cardiovascular risk factors. These findings suggest that an intensive weight loss intervention, delivered in a primary care setting, can help obese individuals improve some cardiometabolic risk factors.

The impact of a primary care-based weight loss intervention on the quality of life.

OBJECTIVE: This study investigated changes in the quality of life of men and women who participated in a primary care-based weight loss intervention program. METHODS: Participants were enrolled in a 2-year randomized clinical trial (POWER-UP) conducted at the University of Pennsylvania and in six affiliated primary care practices. Inclusion criteria included the presence of obesity (body mass index of 30-50 kg m(-2)) and at least two components of the metabolic syndrome. MAIN OUTCOME MEASURES: Quality of life was assessed by three measures: the Short Form Health Survey (SF-12); the Impact of Weight on Quality of Life-Lite; and the EuroQol-5D. RESULTS: Six months after the onset of treatment, and with a mean weight loss of 3.9 ± 0.3 kg, participants reported significant improvements on all measures of interest with the exception of the Mental Component Score of the SF-12. These changes remained significantly improved from baseline to month 24, with the exception of the EuroQol-5D. Many of these improvements were correlated with the magnitude of weight loss and, for the most part, were consistent across gender and ethnic group. CONCLUSIONS: Individuals with obesity and components of the metabolic syndrome reported significant improvements in most domains of the quality of life with a modest weight loss of 3.7% of initial weight, which was achieved within the first 6 months of treatment. The majority of these improvements were maintained at month 24, when participants had lost 3.0% of their weight.

A serum proteomics approach to the diagnosis of ectopic pregnancy.

An ectopic pregnancy (EP) occurs when implantation of the embryo occurs outside of the uterus. If left untreated, the developing fetus will continue to grow, leading to life-threatening consequences for the mother. A major difficulty with the diagnosis of ectopic pregnancy is that methods of detection are limited, and some, such as ultrasound, are not very reliable in the earliest days of gestation. Currently, no effective serum test exists to distinguish an ectopic pregnancy from a normal intrauterine pregnancy. The incidence of ectopic pregnancy is increasing and has doubled in the last 20 years. It is now the second most common cause of maternal death in the first trimester of pregnancy. To address this issue, we initiated a project to identify serum markers of ectopic pregnancy. The subjects for these studies presented at the Hospital of the University of Pennsylvania. We obtained over 140 serum samples from women with suspected ectopic pregnancy: women presenting with pain and/or bleeding in the first trimester of pregnancy. The approximate racial breakdown of the subjects is as follows: African American, 36%; Caucasian, 3%; Asian, 2%; Hispanic, 1%; unknown, 58%. Serum samples from 139 women (62 with ectopic pregnancy and 77 with a normal intrauterine pregnancy) were applied to WCX2 (weak ion exchange) protein chip surfaces and analyzed for serum markers using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS). Several proteins in the 7500-18,000 Da mass range were identified that may discriminate an ectopic pregnancy from an intrauterine pregnancy. The most promising markers were analyzed using classification and regression tree analysis (CART) with and without clinical variables (serum hCG value, length of amenorrhea). Two different algorithms were developed that classify the patients on the basis of sensitivity (number of EPs who screen positive/# of EPs) or specificity (# of healthy patients who screen negative/# of healthy). Our current approach is to refine these two "rule sets" to segregate patients into three groups: those who need immediate intervention for a probable ectopic pregnancy, those who appear to have a normal pregnancy, and those who need further monitoring for diagnosis.

Central venulitis in pediatric liver allografts.

Central venulitis (CV), a distinct histologic lesion described in adult liver transplants, can occur with acute portal tract rejection or in isolation (ICV). Possible etiologies include immunosuppressive drug toxicity, acute cellular rejection, viral hepatitis, ischemic injury, and recurrent disease. This study was designed to characterize ICV and to assess its potential etiology in pediatric liver recipients because this population generally does not develop recurrent disease or viral hepatitis. All posttransplantation liver biopsy specimens that were obtained from children who received liver allografts over a 4-year period were reviewed. ICV was identified in 12 of 127 posttransplantation biopsies and in 7 of 45 allograft recipients. Only 4 liver transplantations were performed for potentially recurrent diseases (primary sclerosing cholangitis). ICV first appeared in posttransplantation biopsy specimens significantly later than did portal rejection alone. The finding of CV was not significantly correlated with elevation of Tacrolimus levels, reason for transplantation, donor/recipient cytomegalovirus (CMV) status or blood type, cold ischemic times, or the incidence of outflow obstruction. The responses of CV to therapy were variable and, although the majority of cases resolved, several episodes persisted or recurred. In conclusion, ICV occurs in 16% of pediatric liver allograft recipients and does not appear to be related to recurrent disease, viral hepatitis, drug toxicity, or graft ischemia. CV may be a variant of acute rejection, but longer follow-up is required to determine the most adequate therapy for this entity.

Comparative effects of carvedilol and metoprolol on left ventricular ejection fraction in heart failure: results of a meta-analysis.

BACKGROUND: Both metoprolol and carvedilol improve cardiac function and prolong survival in patients with heart failure. Carvedilol has broader antiadrenergic effects than metoprolol, but it is not clear whether this characteristic is associated with greater benefits on cardiac function during long-term treatment. STUDY DESIGN: We performed a meta-analysis of all 19 randomized controlled trials of carvedilol or metoprolol that measured left ventricular ejection fraction before and after an average of 8.3 +/- 0.1 months of treatment in 2184 patients with chronic heart failure. The mean daily doses were 58 +/- 1 mg of carvedilol and the equivalent of 162 +/- 1 mg of extended-release metoprolol. In the 15 placebo-controlled trials, the mean ejection fraction increased more in the trials of carvedilol than in the trials of metoprolol (placebo-corrected increases of +0.065 and +0.038, respectively), P = .0002. In the 4 active-controlled trials that compared metoprolol directly with carvedilol, the mean ejection fraction also increased more in the carvedilol groups than in the metoprolol groups (+0.084 on carvedilol and +0.057 on metoprolol, respectively), P = .009. The difference in favor of carvedilol in the active-controlled trials was nearly identical to the difference observed in the placebo-controlled trials and was apparent in patients with and without coronary artery disease. CONCLUSION: Long-term treatment with carvedilol produces greater effects on left ventricular ejection fraction than metoprolol when both drugs are prescribed in doses similar to those that have been shown to prolong life.

Endorectal coil magnetic resonance imaging and clinicopathologic findings in T1c adenocarcinoma of the prostate.

Stage T1c prostate cancer has become the most commonly diagnosed clinical stage of localized prostate cancer. Endorectal coil magnetic resonance imaging (erMRI) can be used in the staging of such patients. The purpose of this study was to correlate the preoperative erMRI findings with the pathologic characteristics of the surgical specimens. A database review of 355 radical prostatectomy specimens revealed 130 patients with T1c disease. Of these patients, 124 were clinically staged with erMRI. Standard sensitivity analysis and multivariable analysis was then applied to determine the utility of erMRI in the staging of patients with T1c prostate cancer. The mean prostate specific antigen (PSA) value was 8.3 (1.0-33.6). Most patients had Gleason score of 5 or 6 (51.6%) or 7 (33.1%), with fewer patients having Gleason scores between 2 and 4 (7.2%) or 8 and 10 (8.1%). The positive predictive value of erMRI for extracapsular disease was 38.7%, negative predictive value was 75.3%, and accuracy was 79%. Multivariable regression analysis demonstrated that erMRI and preoperative PSA were predictive for seminal vesicle involvement. However, erMRI was not predictive in multivariable or univariable analysis for extracapsular extension or margin positivity. Previous investigators demonstrated the utility and independent significance of preoperative erMRI for a select subset of patients. However, it is not a useful staging modality for patients with T1c cancer as a whole. Further stratification of the T1c patients would be necessary to identify patients within this group who may benefit from staging with erMRI.

Chronic ingestion of lycopene-rich tomato juice or lycopene supplements significantly increases plasma concentrations of lycopene and related tomato carotenoids in humans.

The bioavailability of lycopene from tomato juice and 2 dietary supplements, each containing 70-75 mg lycopene, was studied in 15 healthy volunteers in a randomized, crossover design. Subjects ingested lycopene-rich tomato juice, tomato oleoresin, lycopene beadlets, and a placebo for 4 wk each while consuming self-selected diets. Treatment periods were separated by 6-wk washout periods. Plasma lycopene concentrations, assessed at baseline and weekly throughout the treatment periods, were significantly higher during tomato juice, oleoresin, and lycopene beadlet ingestion than during placebo ingestion. Mean (+/-SEM) increases in plasma lycopene at week 4 of tomato juice, oleoresin, and lycopene beadlet ingestion were not significantly different: 0.24 +/- 0.07, 0.23 +/- 0.05, and 0.24 +/- 0.06 micromol/L, respectively. Plasma concentrations of phytofluene and phytoene, which were present in small amounts in tomato juice, oleoresin, and lycopene beadlets, increased significantly with ingestion of these 3 products. Beta-carotene, zeta-carotene, and 2,6-cyclolycopene-1,5-diol (a metabolite of lycopene)--also present in tomato juice and supplements--were significantly increased with consumption of the tomato juice and lycopene beadlets, but not with oleoresin consumption. A marked increase in plasma concentrations of an unknown compound was observed; it was detected in trace amounts in tomato juice, oleoresin, and lycopene beadlets, and had a maximum absorbance at 448 nm and a molecular weight of 556. Concentrations of plasma lycopene and other carotenoids with potential for enhancing human health can be increased by ingestion of realistic amounts of tomato juice. Lycopene appears to be equally bioavailable from tomato juice and the supplements used in this study.

Predictors of dropout from psychosocial treatment of cocaine dependence.

The current study assessed demographic, drug and psychiatric predictors of dropout in the pilot/training phase of a large, multi-site psychotherapy outcome study for patients with cocaine dependence. The different predictors of dropout were assessed throughout the phases of the study: screening, intake, stabilization and assessment phase, and following randomization to treatment. Results showed that (1) younger patients were less likely to keep their intake appointment. (2) Of the patients who had an intake visit, those who did not complete high school and with more days of cocaine use in the previous month were less likely to complete an initial stabilization and assessment phase requiring 1 week of abstinence from all drugs. A survival analysis was used to examine time to dropout for the 286 patients randomized to individual treatment. (3) Again, younger age was associated with dropout after randomization. (4) Drug use variables did not predict time to dropout. (5) Presence of any current Axis I disorder was associated with later dropout from treatment. Minority treatment information seekers and treatment initiators were less likely to go on to complete the full treatment program.

Training in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence.

This study assessed the effects of training on the performance of 65 therapists in delivering manual-guided therapies to 202 cocaine-dependent patients. Changes in ratings of therapists' adherence and competence was assessed in 3 treatment modalities: supportive-expressive dynamic therapy (SE), cognitive therapy (CT), and individual drug counseling. Effects of manual-guided training on the therapeutic alliance were also assessed. Training effects were examined through a hierarchical linear modeling approach that examined changes both within cases and across training cases. A large effect across cases was detected for training in CT. Supportive-expressive therapists and individual drug counselors demonstrated statistically significant learning trends over sessions but not over training cases. Training in SE and CT did not have a negative impact on the therapeutic alliance, although alliance scores for trainees in drug counseling initially decreased but then rebounded to initial levels.

Varieties of transference patterns in psychotherapy.

This investigation explored the nature of transference of interpersonal patterns in patients' psychotherapy narratives. The relation between interpersonal patterns with significant others in a patient's life and the pattern with the therapist early in treatment was examined. Cluster analysis was used to categorize similar relationships for each of 35 patients. Many patients revealed multiple interpersonal themes in their relationship narratives. Furthermore, these interpersonal themes correlated significantly with the interpersonal pattern extracted from narratives told about the therapist for many of the patients who discussed the therapeutic relationship during therapy. However, the interpersonal pattern evident in the relationship with the therapist was not necessarily the most pervasive pattern exhibited in the narratives about significant others.