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1.
Pharmacogenomics J ; 2019 Sep 11.
Artículo en Inglés | MEDLINE | ID: mdl-31506565

RESUMEN

The importance of genetic ancestry characterization is increasing in genomic implementation efforts, and clinical pharmacogenomic guidelines are being published that include population-specific recommendations. Our aim was to test the ability of focused clinical pharmacogenomic SNP panels to estimate individual genetic ancestry (IGA) and implement population-specific pharmacogenomic clinical decision-support (CDS) tools. Principle components and STRUCTURE were utilized to assess differences in genetic composition and estimate IGA among 1572 individuals from 1000 Genomes, two independent cohorts of Caucasians and African Americans (AAs), plus a real-world validation population of patients undergoing pharmacogenomic genotyping. We found that clinical pharmacogenomic SNP panels accurately estimate IGA compared to genome-wide genotyping and identify AAs with ≥70 African ancestry (sensitivity >82%, specificity >80%, PPV >95%, NPV >47%). We also validated a new AA-specific warfarin dosing algorithm for patients with ≥70% African ancestry and implemented it at our institution as a novel CDS tool. Consideration of IGA to develop an institutional CDS tool was accomplished to enable population-specific pharmacogenomic guidance at the point-of-care. These capabilities were immediately applied for guidance of warfarin dosing in AAs versus Caucasians, but also provide a real-world model that can be extended to other populations and drugs as actionable genomic evidence accumulates.

2.
Sleep ; 42(11)2019 Oct 21.
Artículo en Inglés | MEDLINE | ID: mdl-31310317

RESUMEN

STUDY OBJECTIVES: Although sleep disturbance is common in acutely ill patients during and after a hospitalization, how hospitalization affects sleep in general medicine patients has not been well characterized. We describe how sleep and activity patterns vary during and after hospitalization in a small population of older, predominately African American general medicine patients. METHODS: Patients wore a wrist accelerometer during hospitalization and post-discharge to provide objective measurements of sleep duration, efficiency, and physical activity. Random effects linear regression models clustered by subject were used to test associations between sleep and activity parameters across study days from hospitalization through post-discharge. RESULTS: We recorded 404 nights and 384 days from 54 patients. Neither nighttime sleep duration nor sleep efficiency increased from hospitalization through post-discharge (320.2 vs. 320.2 min, p = 0.99; 74.0% vs. 71.7%, p = 0.24). Daytime sleep duration also showed no significant change (26.3 vs. 25.8 min/day, p = 0.5). Daytime physical activity was significantly less in-hospital compared to post-discharge (128.6 vs. 173.2 counts/min, p < 0.01) and increased 23.3 counts/min (95% CI = 16.5 to 30.6, p < 0.01) per hospital day. A study day and post-discharge period interaction was observed demonstrating slowed recovery of activity post-discharge (ß 3 = -20.8, 95% CI = -28.8 to -12.8, p < 0.01). CONCLUSIONS: Nighttime sleep duration and efficiency and daytime sleep duration were similar in-hospital and post-discharge. Daytime physical activity, however, was greater post-discharge and increased more rapidly during hospitalization than post-discharge. Interventions, both in hospital and at home, to restore patient sleep and sustain activity improvements may improve patient recovery from illness.

3.
J Clin Pharm Ther ; 44(4): 579-587, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31152684

RESUMEN

WHAT IS KNOWN AND OBJECTIVE: The use of generic oral contraceptives (OCPs) can improve adherence and reduce healthcare costs, yet scepticism of generic drugs remains a barrier to generic OCP discussion and prescription. An educational web module was developed to reduce generic scepticism related to OCPs, improve knowledge of generic drugs and increase physician willingness to discuss and prescribe generic OCPs. METHODS: A needs assessment was completed using in-person focus groups at American College of Physicians (ACP) Annual Meeting and a survey targeting baseline generic scepticism. Insights gained were used to build an educational web module detailing barriers and benefits of generic OCP prescription. The module was disseminated via email to an ACP research panel who completed our baseline survey. Post-module evaluation measured learner reaction, knowledge and intention to change behaviour along with generic scepticism. RESULTS AND DISCUSSION: The module had a response rate of 56% (n = 208/369). Individuals defined as generic sceptics at baseline were significantly less likely to complete our module compared to non-sceptics (responders 9.6% vs non-responders 16.8%, P = 0.04). The majority (85%, n = 17/20) of baseline sceptics were converted to non-sceptics (P < 0.01) following completion of the module. Compared to non-sceptics, post-module generic sceptics reported less willingness to discuss (sceptic 33.3% vs non-sceptic 71.5%, P < 0.01), but not less willingness to prescribe generic OCPs (sceptic 53.3% vs non-sceptic 67.9%, P = 0.25). Non-white physicians and international medical graduates (IMG) were more likely to be generic sceptics at baseline (non-white 86.9% vs white 69.9%, P = 0.01, IMG 13.0% vs USMG 5.0% vs unknown 18.2%, P = 0.03) but were also more likely to report intention to prescribe generic OCPs as a result of the module (non-white 78.7% vs white 57.3%, P < 0.01, IMG 76.1% vs USMG 50.3% vs unknown 77.3%, P = 0.03). WHAT IS NEW AND CONCLUSION: A brief educational web module can be used to promote prescribing of generic OCPs and reduce generic scepticism.

4.
Artículo en Inglés | MEDLINE | ID: mdl-31004223

RESUMEN

A fundamental activity in hospital operations is patient assignment, which we define as the process of assigning hospital patients to specific physician services and clinical units based on their diagnosis. When the preferred assignment is not possible, typically due to capacity limits, hospitals often allow for overflow, which is the assignment of patients to other services and/or units. Overflow accelerates assignment, but can also reduce care quality and increase length of stay. This paper develops a discrete-event simulation model to evaluate different assignment strategies. Using a simulation-based optimization approach, we evaluate and heuristically optimize these strategies accounting for expected hospital and physician profit, care quality and patient waiting time. We apply the model using data from the University of Chicago Medical Center. We find that the strategies that use heuristically optimized designation of overflow services and units increase expected profit relative to the capacity-based strategy in which overflow patients are assigned to a service and unit with the most available capacity. We also find further improvement in the strategy that uses heuristically optimized overflow services and units as well as a holding unit that holds patients until a bed in their primary or secondary unit becomes available. Additionally, we demonstrate the effects of these strategies on other performance measures such as patient concentration, waiting time, and outcomes.

5.
Medicine (Baltimore) ; 98(12): e14871, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30896632

RESUMEN

To explain prior literature showing that married Medicare beneficiaries achieve better health outcomes at half the per person cost of single beneficiaries, we examined different patterns of healthcare utilization as a potential driver.Using the Medicare Current Beneficiary Survey (MCBS) data, we sought to understand utilization patterns in married versus currently-not-married Medicare beneficiaries. We analyzed the relationship between marital status and healthcare utilization (classified based on setting of care utilization into outpatient, inpatient, and skilled nursing facility (SNF) use) using logistic regression modeling. We specified models to control for possible confounders based on the Andersen model of healthcare utilization.Based on 13,942 respondents in the MCBS dataset, 12,929 had complete data, thus forming the analytic sample, of whom 6473 (50.3%) were married. Of these, 58% (vs. 36% of those currently-not-married) were male, 45% (vs. 47%) were age >75, 24% (vs. 70%) had a household income below $25,000, 18% (vs. 14%) had excellent self-reported general health, and 56% (vs. 36%) had private insurance. Compared to unmarried respondents, married respondents had a trend toward higher odds of having a recent outpatient visit (unadjusted odds ratio (OR) 1.11, 95% confidence interval (CI) 1.04-1.19, adjusted odds ratio (AOR) 1.10, (CI) 0.99-1.22), and lower odds in the year prior to have had an inpatient stay (AOR 0.84, CI 0.72-0.99) or a SNF stay (AOR 0.55, CI 0.40-0.75).Based on MCBS data, odds of self-reported inpatient and SNF use were lower among married respondents, while unadjusted odds of outpatient use were higher, compared to currently-not-married beneficiaries.


Asunto(s)
Estado Civil/estadística & datos numéricos , Medicare/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Modelos Logísticos , Masculino , Limitación de la Movilidad , Oportunidad Relativa , Factores Socioeconómicos , Estados Unidos
6.
Pharmacogenomics J ; 19(6): 528-537, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-30713337

RESUMEN

Effective doctor-patient communication is critical for disease management, especially when considering genetic information. We studied patient-provider communications after implementing a point-of-care pharmacogenomic results delivery system to understand whether pharmacogenomic results are discussed and whether medication recall is impacted. Outpatients undergoing preemptive pharmacogenomic testing (cases), non-genotyped controls, and study providers were surveyed from October 2012-May 2017. Patient responses were compared between visits where pharmacogenomic results guided prescribing versus visits where pharmacogenomics did not guide prescribing. Provider knowledge of pharmacogenomics, before and during study participation, was also analyzed. Both providers and case patients frequently reported discussions of genetic results after visits where pharmacogenomic information guided prescribing. Importantly, medication changes from visits where pharmacogenomics influenced prescribing were more often recalled than non-pharmacogenomic guided medication changes (OR = 3.3 [1.6-6.7], p = 0.001). Case patients who had separate visits where pharmacogenomics did and did not, respectively, influence prescribing more often remembered medication changes from visits where genomic-based guidance was used (OR = 3.4 [1.2-9.3], p = 0.02). Providers also displayed dramatic increases in personal genomic understanding through program participation (94% felt at least somewhat informed about pharmacogenomics post-participation, compared to 61% at baseline, p = 0.04). Using genomic information during prescribing increases patient-provider communications, patient medication recall, and provider understanding of genomics, important ancillary benefits to clinical use of pharmacogenomics.

7.
J Hosp Med ; 14(1): 38-41, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30667409

RESUMEN

We created Sleep for Inpatients: Empowering Staff to Act (SIESTA), which combines electronic "nudges" to forgo nocturnal vitals and medications with interprofessional education on improving patient sleep. In one "SIESTAenhanced unit," nurses received coaching and integrated SIESTA into daily huddles; a standard unit did not. Six months pre- and post-SIESTA, sleep-friendly orders rose in both units (foregoing vital signs: SIESTA unit, 4% to 34%; standard, 3% to 22%, P < .001 both; sleeppromoting VTE prophylaxis: SIESTA, 15% to 42%; standard, 12% to 28%, P < .001 both). In the SIESTAenhanced unit, nighttime room entries dropped by 44% (-6.3 disruptions/room, P < .001), and patients were more likely to report no disruptions for nighttime vital signs (70% vs 41%, P = .05) or medications (84% vs 57%, P = .031) than those in the standard unit. The standard unit was not changed. Although sleep-friendly orders were adopted in both units, a unit-based nursing empowerment approach was associated with fewer nighttime room entries and improved patient experience.

8.
Pharmacogenet Genomics ; 29(2): 31-38, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30531377

RESUMEN

OBJECTIVE: The objective of this study was to study provider attitudes of and perceived barriers to the clinical use of pharmacogenomics before and during participation in an implementation program. PARTICIPANTS AND METHODS: From 2012 to 2017, providers were recruited. After completing semistructured interviews (SSIs) about pharmacogenomics, providers received training on and access to a clinical decision support tool housing patient-specific pharmacogenomic results. Thematic analysis of SSI was conducted (inter-rater reliability κ≥0.75). Providers also completed surveys before and during study participation, and provider-perceived barriers to pharmacogenomic implementation were analyzed. RESULTS: Seven themes emerged from the SSI (listed from most frequent to least): decision-making, concerns with pharmacogenomic adoption, outcome expectancy, provider knowledge of pharmacogenomics, patient attitudes, individualized treatment, and provider interest in pharmacogenomics. Although there was prestudy enthusiasm among all providers, concerns with clinical utility, time, results accession, and knowledge of pharmacogenomics were frequently stated at baseline. Despite this, adoption of pharmacogenomics was robust, as patient-specific results were accessed at 64% of visits, and medication changes were influenced by provided pharmacogenomic information 42% of the time. Providers reported they had enough time to evaluate the information and the results were easily understood on 74 and 98% of surveys, respectively. Nevertheless, providers consistently felt there was insufficient pharmacogenomic information for most drugs they prescribed and clear guidelines for using pharmacogenomic information were lacking. CONCLUSION: Despite initial concerns about adequate time and knowledge for adoption, providers frequently utilized pharmacogenomic results. Provider-perceived barriers to wider use included lack of clear guidelines and evidence for most drugs, highlighting important considerations for the field of pharmacogenomics.

9.
Pharmacogenet Genomics ; 29(2): 23-30, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30531378

RESUMEN

INTRODUCTION: In-hospital adverse medication events result in increased morbidity and mortality. Many implicated drugs carry pharmacogenomic information. We hypothesized that comprehensive pre-emptive pharmacogenomic profiling could have high relevance for in-hospital prescribing. PATIENTS AND METHODS: We retrospectively analyzed the in-hospital medications of a genotyped outpatient cohort admitted at our institution from 2012 to 2015. The endpoints were medication changes (new medications initiated, dose adjustments, or medications discontinued) involving drugs with pharmacogenomic annotations from three sources: Clinical Pharmacogenetics Implementation Consortium guidance, Food and Drug Administration label information, and drugs with clinical decision supports in our institutional pharmacogenomic Genomic Prescribing System. RESULTS: Of 867 genotyped outpatients, 20 were hospitalized (mean: 78.2 years, 65% male). This hospitalized cohort was significantly older (78.2 vs. 61.3 years, P<0.0001) and took more medications (8.9 vs. 5.0 medications, P<0.0001). Out of 159 medication changes made, most (67.9%) were new medications (average: 2.5/hospitalization) with one-third of these having clinically annotated pharmacogenomic information. Half of all hospitalizations involved at least one pharmacogenomic medication. Over half (55%) of the hospitalized cohort was newly prescribed at least one of eight key pharmacogenomic medications, including high-risk drugs such as clopidogrel, codeine, and warfarin. CONCLUSION: Our study suggested that older patients and those with polypharmacy were at increased risk for hospitalizations, where many new prescriptions included frequently used pharmacogenomic drugs. Targeting this group for pre-emptive genotyping would facilitate the delivery of highly relevant information to inform inpatient prescribing.

10.
Clin Transl Sci ; 12(3): 209-217, 2019 May.
Artículo en Inglés | MEDLINE | ID: mdl-30592548

RESUMEN

The majority of pharmacogenomic (PGx) studies have been conducted on European ancestry populations, thereby excluding minority populations and impeding the discovery and translation of African American-specific genetic variation into precision medicine. Without accounting for variants found in African Americans, clinical recommendations based solely on genetic biomarkers found in European populations could result in misclassification of drug response in African American patients. To address these challenges, we formed the Transdisciplinary Collaborative Center (TCC), African American Cardiovascular Pharmacogenetic Consortium (ACCOuNT), to discover novel genetic variants in African Americans related to clinically actionable cardiovascular phenotypes and to incorporate African American-specific sequence variations into clinical recommendations at the point of care. The TCC consists of two research projects focused on discovery and translation of genetic findings and four cores that support the projects. In addition, the largest repository of PGx information on African Americans is being established as well as lasting infrastructure that can be utilized to spur continued research in this understudied population.

11.
Med Care ; 56(11): 950-955, 2018 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-30234766

RESUMEN

BACKGROUND: Despite widespread use of comorbidities for population health descriptions and risk adjustment, the ideal method for ascertaining comorbidities is not known. We sought to compare the relative value of several methodologies by which comorbidities may be ascertained. METHODS: This is an observational study of 1596 patients admitted to the University of Chicago for community-acquired pneumonia from 1998 to 2012. We collected data via chart abstraction, administrative data, and patient report, then performed logistic regression analyses, specifying comorbidities as independent variables and in-hospital mortality as the dependent variable. Finally, we compared area under the curve (AUC) statistics to determine the relative ability of each method of comorbidity ascertainment to predict in-hospital mortality. RESULTS: Chart review (AUC, 0.72) and administrative data (Charlson AUC, 0.83; Elixhauser AUC, 0.84) predicted in-hospital mortality with greater fidelity than patient report (AUC, 0.61). However, multivariate logistic regression analyses demonstrated that individual comorbidity derivation via chart review had the strongest relationship with in-hospital mortality. This is consistent with prior literature suggesting that administrative data have inherent, paradoxical biases with important implications for risk adjustment based solely on administrative data. CONCLUSIONS: Although comorbidities derived through administrative data did produce an AUC greater than chart review, our analyses suggest a coding bias in several comorbidities with a paradoxically protective effect. Therefore, chart review, while labor and resource intensive, may be the ideal method for ascertainment of clinically relevant comorbidities.

12.
Med Decis Making ; 38(7): 767-777, 2018 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-30248277

RESUMEN

OBJECTIVES: In 2016, the Second Panel on Cost-effectiveness in Health and Medicine updated the seminal work of the original panel from 2 decades earlier. The Second Panel had an opportunity to reflect on the evolution of cost-effectiveness analysis (CEA) and to provide guidance for the next generation of practitioners and consumers. In this article, we present key topics for future research and policy. METHODS: During the course of its deliberations, the Second Panel discussed numerous topics for advancing methods and for improving the use of CEA in decision making. We identify and consider 7 areas for which the panel believes that future research would be particularly fruitful. In each of these areas, we highlight outstanding research needs. The list is not intended as an exhaustive inventory but rather a set of key items that surfaced repeatedly in the panel's discussions. In the online Appendix , we also list and expound briefly on 8 other important topics. RESULTS: We highlight 7 key areas: CEA and perspectives (determining, valuing, and summarizing elements for the analysis), modeling (comparative modeling and model transparency), health outcomes (valuing temporary health and path states, as well as health effects on caregivers), costing (a cost catalogue, valuing household production, and productivity effects), evidence synthesis (developing theory on learning across studies and combining data from clinical trials and observational studies), estimating and using cost-effectiveness thresholds (empirically representing 2 broad concepts: opportunity costs and public willingness to pay), and reporting and communicating CEAs (written protocols and a quality scoring system). CONCLUSIONS: Cost-effectiveness analysis remains a flourishing and evolving field with many opportunities for research. More work is needed on many fronts to understand how best to incorporate CEA into policy and practice.

13.
Vox Sang ; 113(7): 669-677, 2018 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-30182371

RESUMEN

BACKGROUND AND OBJECTIVE: Guidelines suggest that red-blood-cell transfusion decisions for most hospitalized patients be based on haemoglobin (Hb) concentration and the presence of symptoms of anaemia, including fatigue. However, studies differ in whether transfusion is associated with improvements in fatigue. One explanation is that the benefit of transfusion varies by baseline fatigue levels, which existing studies have not examined. The objective of this study was to determine whether the association between transfusion during hospitalization and improvements in fatigue 30 days postdischarge varies by baseline fatigue level. METHODS: A prospective observational study of hospitalized general medicine patients with any Hb <9 g/dl. Patients with sickle cell anaemia and gastrointestinal bleeding were excluded since these diagnoses have alternative transfusion practices. Patients with depression were excluded because their fatigue is not primarily due to anaemia. Fatigue was measured during an in-person interview and a 30-day postdischarge phone interview. Hb values and receipt of a transfusion were collected from hospital administrative data. Linear regression was used to test associations between 'change in fatigue', Hb concentration and receipt of a transfusion. RESULTS: Transfusion interacted with nadir Hb was associated with reduced fatigue postdischarge for patients with higher baseline fatigue (20% most fatigued: ß = 12, P = 0·02; 10% most fatigued: ß = 17, P = 0·02). Patients <50 years old with high baseline fatigue had large reductions in fatigue from transfusion (20%: ß = 23, P = 0·02; 10%: ß = 29, P = 0·03). CONCLUSIONS: Transfusion during hospitalization is associated with reduced fatigue 30 days postdischarge in patients with higher levels of baseline fatigue.

14.
BMJ Qual Saf ; 2018 Aug 10.
Artículo en Inglés | MEDLINE | ID: mdl-30097490

RESUMEN

OBJECTIVE: Hospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to assess pressure-injury risk. Our objective was to analyse the cost-utility of performing repeated risk-assessment for pressure-injury prevention in all patients or high-risk groups. DESIGN: Cost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon. SETTING: Patient-level longitudinal data on 34 787 encounters from an academic hospital electronic health record (EHR) between 2011 and 2014, including daily Braden scores. Supervised machine learning simulated age-adjusted transition probabilities between risk levels and pressure injuries. PARTICIPANTS: Hospitalised adults with Braden scores classified into five risk levels: very high risk (6-9), high risk (10-11), moderate risk (12-14), at-risk (15-18), minimal risk (19-23). INTERVENTIONS: Standard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations. MAIN OUTCOME MEASURES: Costs (2016 $US) of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio (ICER) at $100 000/QALY willingness-to-pay. Univariate and probabilistic sensitivity analyses tested model uncertainty. RESULTS: Simulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives, equating to ICERs of $2000/QALY and $2142/QALY, respectively. Risk-stratified follow-up in patients with Braden scores <15 dominated standard care. Prevention for all patients was cost-effective in >99% of probabilistic simulations. CONCLUSION: Our analysis using EHR data maintains that pressure-injury prevention for all inpatients is cost-effective. Hospitals should invest in nursing compliance with international prevention guidelines.

15.
Clin Gerontol ; : 1-10, 2018 Mar 02.
Artículo en Inglés | MEDLINE | ID: mdl-29533159

RESUMEN

OBJECTIVES: To examine the prevalence of social isolation among older patients admitted to a hospital, and the effects of sociodemographic and health-related factors on the availability of their family, friends, and neighbor networks. METHODS: Analyses are based on interviews with a sample of 2,449 older patients admitted to an urban academic medical center in the United States. A nine-item version of Lubben's Social Network Scale was developed and used to assess the availability of different social networks. RESULTS: About 47% of the sample was at risk of social isolation. The oldest old and non-White older adults showed greater risk. The availability of family networks was associated with age, sex, marital status, and prior hospitalization; friend networks with age, race, education, prior hospitalization, and functional limitations; neighbor networks with race, education, marital status, and functional limitations. CONCLUSIONS: The risk of social isolation and the availability of social support for hospitalized older adults varies by both patient and network characteristics. Health professionals should attend to this risk and the factors associated with such risk. CLINICAL IMPLICATIONS: By assessing the availability of various types and frequency of support among older patients, health professionals can better identify those who may need additional support after discharge. Such information should be used in discharge planning to help prevent unnecessary complications and potential readmission.

16.
Appl Clin Inform ; 9(1): 114-121, 2018 01.
Artículo en Inglés | MEDLINE | ID: mdl-29444537

RESUMEN

OBJECTIVE: This article presents and describes our methods in developing a novel strategy for recruitment of underrepresented, community-based participants, for pragmatic research studies leveraging routinely collected electronic health record (EHR) data. METHODS: We designed a new approach for recruiting eligible patients from the community, while also leveraging affiliated health systems to extract clinical data for community participants. The strategy involves methods for data collection, linkage, and tracking. In this workflow, potential participants are identified in the community and surveyed regarding eligibility. These data are then encrypted and deidentified via a hashing algorithm for linkage of the community participant back to a record at a clinical site. The linkage allows for eligibility verification and automated follow-up. Longitudinal data are collected by querying the EHR data and surveying the community participant directly. We discuss this strategy within the context of two national research projects, a clinical trial and an observational cohort study. CONCLUSION: The community-based recruitment strategy is a novel, low-touch, clinical trial enrollment method to engage a diverse set of participants. Direct outreach to community participants, while utilizing EHR data for clinical information and follow-up, allows for efficient recruitment and follow-up strategies. This new strategy for recruitment links data reported from community participants to clinical data in the EHR and allows for eligibility verification and automated follow-up. The workflow has the potential to improve recruitment efficiency and engage traditionally underrepresented individuals in research.


Asunto(s)
Registros Electrónicos de Salud , Selección de Paciente , Características de la Residencia , Investigación Biomédica , Ensayos Clínicos como Asunto , Estudios de Seguimiento , Humanos , Medicina de Precisión
17.
JAMA ; 319(6): 615-616, 2018 02 13.
Artículo en Inglés | MEDLINE | ID: mdl-29450520
18.
Healthc (Amst) ; 6(2): 117-121, 2018 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-28688999

RESUMEN

BACKGROUND: Inpatient service handoffs are a vulnerable transition during a patients' hospitalization. We hypothesized that performing the service handoff at the patients' bedside may be one mechanism to more efficiently transfer patient information between physicians, while further integrating the patient into their hospital care. METHODS: We performed a 6-month prospective study of performing a bedside handoff (BHO) at the service transition on a non-teaching hospitalist service. On a weekly basis, transitioning hospitalists co-rounded at patient's bedsides. Post-handoff surveys assessed for completeness of handoff, communication, missed information, and adverse events. A control group who performed the handoff via email, phone or face-to-face was also surveyed. Chi-square and item-response theory (IRT) analysis assessed for differences between BHO and control groups. Narrative responses were elicited to qualitatively describe the BHO. RESULTS: In total, 21/31 (67%) scheduled BHOs were performed. On average, 4 out of 6 eligible patients experienced a BHO, with a total of 90 patients experiencing a BHO. Of those asked to perform the BHO, 52% stated the service transition took 31-60 min compared to 24% in the control group. Controlling for the nesting of observations within physicians, IRT analysis found that BHO respondents had statistically significant greater odds of: reporting increased patient awareness of the service handoff, more certainty in the plan for each patient, less discovery of missed information, and less time needed to learn about the patient on the first day compared to control methods. Narrative responses described a more patient-centered handoff with improved communication that was time-consuming and often logistically difficult to implement. CONCLUSIONS: Despite its time-intensive nature, performing the service handoff at the patient's bedside may lead to a more complete and efficient service transition.


Asunto(s)
Médicos Hospitalarios/normas , Pase de Guardia/normas , Habitaciones de Pacientes , Centros Médicos Académicos/organización & administración , Adulto , Distribución de Chi-Cuadrado , Continuidad de la Atención al Paciente/normas , Femenino , Médicos Hospitalarios/estadística & datos numéricos , Humanos , Masculino , Estudios Prospectivos , Investigación Cualitativa , Encuestas y Cuestionarios , Recursos Humanos
19.
Circ Cardiovasc Qual Outcomes ; 11(11): e004466, 2018 11 14.
Artículo en Inglés | MEDLINE | ID: mdl-30785252

RESUMEN

BACKGROUND: The CTSN (Cardiothoracic Surgical Trials Network) recently reported no difference in left ventricular end-systolic volume index or in survival at 2 years between patients with severe ischemic mitral regurgitation (MR) randomized to mitral valve repair or replacement. However, replacement provided more durable correction of MR and fewer cardiovascular readmissions. Yet, costeffectiveness outcomes have not been addressed. METHODS AND RESULTS: We conducted a cost-effectiveness analysis of the surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair; n=125 for replacement). Patient-level data on readmissions, survival, qualityof- life, and US hospital costs were used to estimate costs and quality-adjusted life years per patient over the trial duration and a 10-year time horizon. We performed microsimulation for extrapolation of outcomes beyond the 2 years of trial data. Bootstrap and deterministic sensitivity analyses were done to address parameter uncertainty. In-hospital cost estimates were $78 216 for replacement versus $72 761 for repair (difference: $5455; 95% uncertainty interval [UI]: −7784­21 193) while 2-year costs were $97 427 versus $96 261 (difference: $1166; 95% UI: −16 253­17 172), respectively. Quality-adjusted life years at 2 years were 1.18 for replacement versus 1.23 for repair (difference: −0.05; 95% UI: −0.17 to 0.07). Over 5 and 10 years, the benefits of reduction in cardiovascular readmission rates with replacement increased, and survival minimally improved compared with repair. At 5 years, cumulative costs and quality-adjusted life years showed no difference on average, but by 10 years, there was a small, uncertain benefit for replacement: $118 023 versus $119 837 (difference: −$1814; 95% UI: −27 144 to 22 602) and qualityadjusted life years: 4.06 versus 3.97 (difference: 0.09; 95% UI: −0.87 to 1.08). After 10 years, the incremental cost-effectiveness of replacement continued to improve. CONCLUSIONS: Our cost-effectiveness analysis predicts potential savings in cost and gains in quality-adjusted survival at 10 years when mitral valve replacement is compared with repair for severe ischemic MR. These projected benefits, however, were small and subject to variability. Efforts to further delineate predictors of long-term outcomes in patients with severe ischemic MR are needed to optimize surgical decisions for individual patients, which should yield more cost-effective care. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00807040.


Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas/economía , Costos de Hospital , Anuloplastia de la Válvula Mitral/economía , Insuficiencia de la Válvula Mitral/economía , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Isquemia Miocárdica/complicaciones , Anciano , Simulación por Computador , Análisis Costo-Beneficio , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Anuloplastia de la Válvula Mitral/efectos adversos , Anuloplastia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/mortalidad , Modelos Económicos , Isquemia Miocárdica/mortalidad , Readmisión del Paciente/economía , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos
20.
J Grad Med Educ ; 9(6): 706-713, 2017 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-29270258

RESUMEN

Background : Advances in information technology have increased remote access to the electronic health record (EHR). Concurrently, standards defining appropriate resident supervision have evolved. How often and under what circumstances inpatient attending physicians remotely access the EHR for resident supervision is unknown. Objective : We described a model of attending remote EHR use for resident supervision, and quantified the frequency and magnitude of use. Methods : Using a mixed methods approach, general medicine inpatient attendings were surveyed and interviewed about their remote EHR use. Frequency of use and supervisory actions were quantitatively examined via survey. Transcripts from semistructured interviews were analyzed using grounded theory to identify codes and themes. Results : A total of 83% (59 of 71) of attendings participated. Fifty-seven (97%) reported using the EHR remotely, with 54 (92%) reporting they discovered new clinical information not relayed by residents via remote EHR use. A majority (93%, 55 of 59) reported that this resulted in management changes, and 54% (32 of 59) reported making immediate changes by contacting cross-covering teams. Six major factors around remote EHR use emerged: resident, clinical, educational, personal, technical, and administrative. Attendings described resident and clinical factors as facilitating "backstage" supervision via remote EHR use. Conclusions : In our study to assess attending remote EHR use for resident supervision, attendings reported frequent remote use with resulting supervisory actions, describing a previously uncharacterized form of "backstage" oversight supervision. Future work should explore best practices in remote EHR use to provide effective supervision and ultimately improve patient safety.


Asunto(s)
Acceso a la Información , Registros Electrónicos de Salud/estadística & datos numéricos , Medicina Interna/educación , Internado y Residencia , Cuerpo Médico de Hospitales , Modelos Educacionales , Adulto , Educación de Postgrado en Medicina , Femenino , Humanos , Entrevistas como Asunto , Masculino , Encuestas y Cuestionarios
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