Emerging opportunities to harness real world data: An introduction to data sources, concepts, and applications.

While randomized controlled trials (RCTs) are the gold standard for comparative effectiveness research, they are unable to provide the answers to all pertinent clinical and research questions. Real world evidence (RWE), that is, clinical evidence obtained outside RCTs and often through routine clinical practice, offers the potential to conduct observational studies that accelerate advances in care, improve outcomes for patients, and provide important insights that can answer important questions. Once appropriate information technology is available, real world data can be cost-effective to generate. RWE serves a vital role in the evaluation of treatment strategies for which there are no RCTs and for describing patterns of care. RWE also serves as an important adjunct to RCTs and can be used to determine if benefits seen in RCTs extend to clinical practice, provide insight into the findings of RCTs, generate hypotheses for future RCTs, and inform the design of future RCTs. These potential benefits must be balanced against some of the important limitations of RWE, including variable data quality, lack of granularity for important clinical variables, and the potential for bias and confounding. By using appropriate analytic techniques and study design, these limitations can be minimized but not eliminated. Going forward, RWE studies may be enhanced by using rigorous data quality standards, incorporating randomization, developing more prospective registries, and better leveraging data from electronic health records.

Keeping care connected: e-Consultation program improves access to nephrology care.

INTRODUCTION: Health systems are seeking innovative solutions to improve specialty care access. Electronic consultations (eConsults) allow specialists to provide formal clinical recommendations to primary care providers (PCPs) based on patient chart review, without a face-to-face visit. METHODS: We implemented a nephrology eConsult pilot program within a large, academic primary care practice to facilitate timely communication between nephrologists and PCPs. We used primary care referral data to compare wait times and completion rates between traditional referrals and eConsults. We surveyed PCPs to assess satisfaction with the program. RESULTS: For traditional nephrology referrals placed during the study period (July 2016-March 2017), there was a 51-day median appointment wait time and a 40.9% referral completion rate. For eConsults, there was a median nephrologist response time of one day and a 100% completion rate; 67.5% of eConsults did not require a subsequent face-to-face specialty appointment. For eConsults that were converted to an in-person visit, the median wait time and completion rate were 40 days and 73.1%, respectively. Compared to traditional referrals placed during the study period, eConsults converted to in-person visits were more likely to be completed ( p = 0.001). Survey responses revealed that PCPs were highly satisfied with the program and consider the quick turnaround time as the greatest benefit. DISCUSSION: Our eConsult pilot program reduced nephrology wait times and significantly increased referral completion rates. In large integrated health systems, eConsults have considerable potential to improve access to specialty care, reduce unnecessary appointments, and optimize the patient population being seen by specialists.

Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System.

PURPOSE: Ideally, a referral from a primary care physician (PCP) to a specialist results in a completed specialty appointment with results available to the PCP. This is defined as "closing the referral loop." As health systems grow more complex, regulatory bodies increase vigilance, and reimbursement shifts towards value, closing the referral loop becomes a patient safety, regulatory, and financial imperative. OBJECTIVE/DESIGN: To assess the ability of a large health system to close the referral loop, we used electronic medical record (EMR)-generated data to analyze referrals from a large primary care network to 20 high-volume specialties between July 1, 2015 and June 30, 2016. MAIN MEASURES: The primary metric was documented specialist appointment completion rate. Explanatory analyses included documented appointment scheduling rate, individual clinic differences, appointment wait times, and geographic distance to appointments. KEY RESULTS: Of the 103,737 analyzed referral scheduling attempts, only 36,072 (34.8%) resulted in documented complete appointments. Low documented appointment scheduling rates (38.9% of scheduling attempts lacked appointment dates), individual clinic differences in closing the referral loop, and significant differences in wait times and distances to specialists between complete and incomplete appointments drove this gap. Other notable findings include high variation in wait times among specialties and correlation between high wait times and low documented appointment completion rates. CONCLUSIONS: The rate of closing the referral loop in this health system is low. Low appointment scheduling rates, individual clinic differences, and patient access issues of wait times and geographic proximity explain much of the gap. This problem is likely common among large health systems with complex provider networks and referral scheduling. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve rates of closing the referral loop. More research is necessary to determine the impact of these changes and other potential driving factors.

Lipid arrays identify myelin-derived lipids and lipid complexes as prominent targets for oligoclonal band antibodies in multiple sclerosis.

The presence of oligoclonal bands of IgG (OCB) in cerebrospinal fluid (CSF) is used to establish a diagnosis of multiple sclerosis (MS), but their specificity has remained an enigma since its first description over forty years ago. We now report that the use of lipid arrays identifies heteromeric complexes of myelin derived lipids as a prominent target for this intrathecal B cell response.