Designing audit and feedback dashboards for dentists to monitor their opioid prescribing.

BACKGROUND AND OBJECTIVE: Prescription drug abuse is a major factor leading to drug overdose deaths in the US and dentists are one of the leading prescribers of opioid pain medication. Knowing that Audit & Feedback (A&F) dashboards are an effective tool and are used as quality improvement interventions, we aimed to develop such dashboards personalized for dental providers which could allow them to monitor their own opioid prescribing performance. METHODS: In this paper we report on the process for designing the A&F dashboards for dentists which were developed by using an iterative human-centered design process. The results obtained from each iteration were used to enrich the information needs analyses, provide function testing, and guide the design decisions of the next iteration. RESULTS: Engaging dentists in the development and refinement of the dashboards while using the think-aloud protocol for user-testing, provided rapid feedback and identified areas that were confusing and needed either a redesign or additional explanatory content. The final version of dashboards consisted of displaying necessary information through easy to interpret visualizations and interactive features. These included providing access to current national and organizational prescribing guidelines, displaying changes in individual prescribing behavior over time, comparing individual prescribing rate to peer group rate and target rate, displaying procedure specific prescribing, integrating patient reported post-operative dental pain experience and providing navigation and interpretation tips for users. The dashboards were easy to learn and understand for the dentists and were deemed as worth using often in dental practice. CONCLUSION: Our research was able to demonstrate the creation of useful and usable A&F dashboards using data from electronic dental records and patient surveys, for dentists to effectively monitor their opioid prescribing behavior. Efficacy of the dashboards will be tested in future work.

Translating periodontal data to knowledge in a learning health system.

BACKGROUND: A learning health system (LHS) is a health system in which patients and clinicians work together to choose care on the basis of best evidence and to drive discovery as a natural outgrowth of every clinical encounter to ensure the right care at the right time. An LHS for dentistry is now feasible, as an increased number of oral health care encounters are captured in electronic health records (EHRs). METHODS: The authors used EHRs data to track periodontal health outcomes at 3 large dental institutions. The 2 outcomes of interest were a new periodontitis case (for patients who had not received a diagnosis of periodontitis previously) and tooth loss due to progression of periodontal disease. RESULTS: The authors assessed a total of 494,272 examinations (new periodontitis outcome: n = 168,442; new tooth loss outcome: n = 325,830), representing a total of 194,984 patients. Dynamic dashboards displaying performance on both measures over time allow users to compare demographic and risk factors for patients. The incidence of new periodontitis and tooth loss was 4.3% and 1.2%, respectively. CONCLUSIONS: Periodontal disease, diagnosis, prevention, and treatment are particularly well suited for an LHS model. The results showed the feasibility of automated extraction and interpretation of critical data elements from the EHRs. The 2 outcome measures are being implemented as part of a dental LHS. The authors are using this knowledge to target the main drivers of poorer periodontal outcomes in a specific patient population, and they continue to use clinical health data for the purpose of learning and improvement. PRACTICAL IMPLICATIONS: Dental institutions of any size can conduct contemporaneous self-evaluation and immediately implement targeted strategies to improve oral health outcomes.

Dashboard visualizations: Supporting real-time throughput decision-making.

Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizations for ED through a discussion of the development of our prototype Throughput Dashboard and the potential it holds for supporting real-time decision-making.

Parathyroidectomy improves functional capacity in "asymptomatic" older patients with primary hyperparathyroidism: a randomized control trial.

OBJECTIVE: We tested the hypothesis that parathyroidectomy would improve functional/physical capacity, an underlying determinant of the ability to perform activities of daily living (ADL), in older patients with asymptomatic primary hyperparathyroidism (PHPT). SUMMARY OF BACKGROUND DATA: PHPT patients often present with nonspecific, subjective symptoms including proximal muscle weakness, fatigue, and reduced physical functional. Although qualitative data suggest that parathyroidectomy reduces these symptoms in asymptomatic PHPT patients, there are no quantitative data confirming this potential surgical benefit. METHODS: Eighteen asymptomatic older (>50 years) patients with biochemically confirmed PHPT who did not meet National Institutes of Health consensus conference criteria for undergoing a parathyroidectomy were randomly assigned to either a surgical group (parathyroidectomy) or a control group (observed for 6 months). All patients underwent functional testing (6-minute walk test, 50-foot walk test, and repeated sit-to-stand test) at baseline/presurgery and at 6 weeks and 6 months after surgery or baseline. This study is registered at clinicaltrials.gov (Registration# 2007-0220 ID#NCT00501215). RESULTS: The surgery and control groups were functionally similar at baseline. Six-minute walk distance increased in the surgery group by 184 ft, a distance that is both significant (P<0.05) and clinically meaningful. Fifty foot walk and repeated sit-to-stand times in this group remain unchanged from presurgical levels. All functional measures for the control group remained unchanged over time. As anticipated, parathyroidectomy reduced serum calcium and intact parathyroid hormone levels. CONCLUSIONS: The improvement in 6-minute walk distance observed in the surgery group suggests that parathyroidectomy can improve functional capacity, and hence the performance of ADLs in asymptomatic, older PHPT patients.

Prospective, randomized, controlled trial of parathyroidectomy versus observation in patients with "asymptomatic" primary hyperparathyroidism.

BACKGROUND: Disruptions in cognitive function have been described in the constellation of symptoms associated with "asymptomatic" primary hyperparathyroidism (PHPT). The aim of this study was to determine the impact of parathyroidectomy (PTX) on brain function and sleep in "asymptomatic" PHPT patients. METHODS: We conducted a prospective, randomized trial comparing immediate PTX with observation in patients with asymptomatic PHPT. We performed functional magnetic resonance imaging (fMRI) of the brain, sleep assessment, and validated neuropsychological battery at baseline, 6 weeks, and 6 months. Wilcoxon rank-sum and Pearson and Spearman correlations were used. RESULTS: A total of 18 patients were randomized. Subjective sleepiness correlated with worse performance on executive function tests during fMRI at 6 weeks (Pearson, -0.473; P = .047) and 6 months (Pearson, -0.673; P = .002). Total sleep time correlated with PTH levels at both 6 weeks (Pearson, 0.518; P = .048) and 6 months (Pearson, 0.567; P = .018). At 6 weeks, hypersomnolence as measured subjectively was decreased in the PTX group, but increased in those observed (-2.56 vs 2.22; P = .03) CONCLUSION: This prospective, randomized trial for asymptomatic PHPT patients demonstrated an association of sleep with brain function. Sleep seemed to be an indicator of brain activation in the anterior cingulate gyrus and precentral cortex. Subjective sleepiness was associated with executive function. The results of this pilot study suggest that decreased serum PTH levels correlate with improved sleep and that PTX decreases sleepiness in patients with asymptomatic PHPT.

Viability of cryopreserved parathyroid tissue: when is continued storage versus disposal indicated?

BACKGROUND: Parathyroid cryopreservation is used for potential autografting in patients who are rendered hypocalcemic following surgery. Cryopreservation employs multiple resources and carries a significant cost for processing and storage of tissue. Importantly, the length of time that parathyroid tissue remains functional after cryopreservation is not known. The goal of our study was to assess ex-vivo viability of parathyroid tissue in relation to the length of time in storage. We sought to define the appropriate time frame for tissue utilization and disposal to assist with long-term surgical planning. METHODS: From 1991 to 2006, 501 parathyroid specimens from 149 patients were cryopreserved at -80 degrees C according to standardized techniques. A single trained technician assessed viability, using a hemacytometer to count viable (clear cell) and nonviable (blue cell) tissue. Univariate analysis was performed to correlate length of preservation, diagnosis with viability. RESULTS: We evaluated 106 random parathyroid specimens. Samples were divided into two groups: those stored>24 months and those stored24 months (p<0.001). CONCLUSIONS: Viability of cryopreserved parathyroid cells is associated with duration of storage. Parathyroids preserved for greater than 24 months are unlikely to be viable. It seems reasonable to limit parathyroid cryopreservation to 24 months when frozen at -80 degrees C. Further studies are needed to optimize the process of cryopreservation to enhance cell viability.

Relationship between vascular access flow and hemodynamically significant stenoses in arteriovenous grafts.

BACKGROUND: Vascular access dysfunction is a major source of hemodialysis patient morbidity. The NKF K/DOQI Guidelines promote access flow monitoring as the most preferred access surveillance method and have established access flow thresholds for fistulography: an absolute threshold of 600 ml/min and a dynamic threshold of flow less than 1000 ml/min that has decreased by more than 25% over 4 months. The Guidelines apply universally to accesses of different types, sizes, locations, and initial flow rates. METHODS: This article studies the application of access flow guidelines with human experimental data, animal experimental data, and a mathematical model of the arteriovenous graft system. RESULTS AND CONCLUSIONS: Analysis of experimental data and the mathematical model shows that a 20 to 30% and greater decrease in graft flow generally suggests the appearance of hemodynamically significant stenosis as defined by flow criteria. The model suggests that not all 50 to 60% stenoses may be hemodynamically significant or the most flow limiting. The mathematical model also suggests that positive predictive value of access surveillance may be increased for high-flow upper arm grafts by increasing the dynamic K/DOQI threshold from 1000 ml/min to 1200 ml/min.