Stratified split sampling of electronic health records.

Although superficially similar to data from clinical research, data extracted from electronic health records may require fundamentally different approaches for model building and analysis. Because electronic health record data is designed for clinical, rather than scientific use, researchers must first provide clear definitions of outcome and predictor variables. Yet an iterative process of defining outcomes and predictors, assessing association, and then repeating the process may increase Type I error rates, and thus decrease the chance of replicability, defined by the National Academy of Sciences as the chance of "obtaining consistent results across studies aimed at answering the same scientific question, each of which has obtained its own data."[1] In addition, failure to account for subgroups may mask heterogeneous associations between predictor and outcome by subgroups, and decrease the generalizability of the findings. To increase chances of replicability and generalizability, we recommend using a stratified split sample approach for studies using electronic health records. A split sample approach divides the data randomly into an exploratory set for iterative variable definition, iterative analyses of association, and consideration of subgroups. The confirmatory set is used only to replicate results found in the first set. The addition of the word 'stratified' indicates that rare subgroups are oversampled randomly by including them in the exploratory sample at higher rates than appear in the population. The stratified sampling provides a sufficient sample size for assessing heterogeneity of association by testing for effect modification by group membership. An electronic health record study of the associations between socio-demographic factors and uptake of hepatic cancer screening, and potential heterogeneity of association in subgroups defined by gender, self-identified race and ethnicity, census-tract level poverty and insurance type illustrates the recommended approach.

North-Central Florida Clinicians' Human Papillomavirus Vaccine Recommendation Priorities and Practices for 11- to 12-Year-Olds: A Discrete Choice Experiment.

PURPOSE: Within the United States, human papillomavirus (HPV) vaccination rates remain low. We examined HPV vaccine recommendation practices among Florida clinicians by assessing variability in: (1) recommendation priorities by patient characteristics and (2) concordance with best practices. METHODS: In 2018 and 2019, we conducted a cross-sectional survey incorporating a discrete choice experiment among primary care clinicians (MD/DO, APRN, and PA). We used linear mixed-effects models to determine the importance of patient characteristics (age, sex, time in practice, and chronic condition) and parental concerns. We compared clinician endorsement of predetermined constructs with reported vaccine recommendation statements. RESULTS: Among 540 surveys distributed, 272 were returned and 105 reported providing preventive care to 11- to 12-year-olds (43% response rate). Among completing clinicians, 21/99 (21%) did not offer the HPV vaccine. Among clinicians offering the vaccine (n = 78), 35%-37% of each decision to recommend the vaccine was based on the child's age (15 vs. 11 years). For closed-ended questions, most clinicians endorsed best practices including emphasizing cancer prevention (94% for girls and 85% for boys; p = .06), vaccine efficacy (60% both sexes), safety (58% girls and 56% boys), importance at 11-12 years (64% both sexes), and bundling vaccines (35% girls and 31% boys). When clinicians reported their typical recommendation, fewer clinicians incorporated best practices (59% cancer prevention, 5% safety, 8% the importance at 11-12 years, and 8% bundling vaccines). DISCUSSION: HPV vaccination recommendation strategies among Florida clinicians somewhat aligned with best practices. Alignment was higher when clinicians were explicitly asked to endorse constructs versus provide recommendations.

Florida Medicaid Children's Receipt of First-Line Psychosocial Care Prior to Antipsychotic Initiation.

BACKGROUND AND OBJECTIVE: First-line, nonpharmacological therapy is recommended for many pediatric mental health (MH) conditions prior to initiating antipsychotic prescription therapies. Many children do not receive these recommended services, despite the known association between antipsychotic medications and metabolic dysfunction. The main objective of this study was to quantify the association among children's MH diagnosis categories, sociodemographic characteristics and receipt of first-line psychosocial care among children in Florida Medicaid METHODS: Florida Medicaid enrollment, healthcare and pharmacy claims were used for this multivariate analysis. Children were assigned to condition clusters wherein related diagnoses were grouped into clinically relevant categories. A total of 7704 children were included in the final analysis. RESULTS: Twenty-four percent of children in Florida Medicaid do not receive first-line, nonpharmacological psychosocial care. Age was significantly associated with not receiving psychosocial services, with older children less likely to receive. Non-Hispanic White children as well as those living in rural areas had lower odds of receiving behavioral intervention prior to initiating antipsychotics. Children with mood-disorders, behavior problems, anxiety and stress related disorders were more likely to receive first-line psychosocial care. CONCLUSIONS: This study provides an important understanding of the variability in receipt of first-line psychosocial care before antipsychotic medication initiation among children in Medicaid based on sociodemographic and MH health characteristics. These analyses can be used to develop quality improvement initiatives targeted toward children that are most vulnerable for not receiving recommended care.

Enhancing Quality Measurement With Clinical Information: A Use Case of Body Mass Index Change Among Children Taking Second Generation Antipsychotics.

OBJECTIVE: We sought to examine the extent to which body mass index (BMI) was available in electronic health records for Florida Medicaid recipients aged 5 to 18 years taking Second-Generation Antipsychotics (SGAP). We also sought to illustrate how clinical data can be used to identify children most at-risk for SGAP-induced weight gain, which cannot be done using process-focused measures. METHODS: Electronic health record (EHR) data and Medicaid claims were linked from 2013 to 2019. We quantified sociodemographic differences between children with and without pre- and post-BMI values. We developed a linear regression model of post-BMI to examine pre-post changes in BMI among 4 groups: 1) BH/SGAP+ children had behavioral health conditions and were taking SGAP; 2) BH/SGAP- children had behavioral health conditions without taking SGAP; 3) children with asthma; and 4) healthy children. RESULTS: Of 363,360 EHR-Medicaid linked children, 18,726 were BH/SGAP+. Roughly 4% of linked children and 8% of BH/SGAP+ children had both pre and post values of BMI required to assess quality of SGAP monitoring. The percentage varied with gender and race-ethnicity. The R2 for the regression model with all predictors was 0.865. Pre-post change in BMI differed significantly (P < .0001) among the groups, with more BMI gain among those taking SGAP, particularly those with higher baseline BMI. CONCLUSION: Meeting the 2030 Centers for Medicare and Medicaid Services goal of digital monitoring of quality of care will require continuing expansion of clinical encounter data capture to provide the data needed for digital quality monitoring. Using linked EHR and claims data allows identifying children at higher risk for SGAP-induced weight gain.

The effects of experimentally manipulated social status and subjective social status on physical activity among Hispanic adolescents: An RCT.

BACKGROUND: Low objective socioeconomic status (SES) and subjective social status (SSS), one's perceived social rank, are associated with obesity. This association may be due, in part, to social status-related differences in energy expenditure. Experimental studies are needed to assess the extent to which SES and SSS relate to energy expenditure. OBJECTIVE: Assess the effects of experimentally manipulated social status and SSS on moderate-to-vigorous physical activity (MVPA) and sedentary behaviour. METHODS: One hundred thirty-three Hispanic adolescents aged 15-21 were randomized to a high or low social status position, facilitated through a rigged game of Monopoly™. SSS was assessed with MacArthur Scales. Post-manipulation 24-h MVPA and sedentary behaviour were assessed via accelerometry. Analyses were conducted with general linear regression models. RESULTS: Experimentally manipulated social status did not significantly affect the total time spent in MVPA or sedentary behaviour; however, identifying as low SSS was significantly associated with less MVPA (p = 0.0060; 18.76 min less). CONCLUSIONS: Tewnty-four-hour MVPA and sedentary behaviour are not affected by an acute experimental manipulation of social status. However, low SSS, independent of SES, was associated with clinically significant differences in MVPA. SSS may be a better predictor of MVPA than SES among Hispanic adolescents, potentially influencing obesity, and other health-related outcomes.

Do patients at high risk for Hepatitis C receive recommended testing? A retrospective cohort study of statewide Medicaid claims linked with OneFlorida clinical data.

ABSTRACT: Hepatitis C virus (HCV) infection is a leading risk factor for hepatocellular carcinoma.We employed a retrospective cohort study design and analyzed 2012-2018 Medicaid claims linked with electronic health records data from the OneFlorida Data Trust, a statewide data repository containing electronic health records data for 15.07 million Floridians from 11 health care systems. Only adult patients at high-risk for HCV (n = 30,113), defined by diagnosis of: HIV/AIDS (20%), substance use disorder (64%), or sexually transmitted infections (22%) were included. Logistic regression examined factors associated with meeting the recommended sequence of HCV testing.Overall, 44.1% received an HCV test. The odds of receiving an initial test were significantly higher for pregnant females (odds ratio [OR]1.99; 95% confidence interval [CI] 1.86-2.12; P < .001) and increased with age (OR 1.01; 95% CI 1.00-1.01; P < .001).Among patients with low Charlson comorbidity index (CCI = 1), non-Hispanic (NH) black patients (OR 0.86; 95% CI 0.81-0.9; P < .001) had lower odds of getting an HCV test; however, NH black patients with CCI = 10 had higher odds (OR 1.41; 95% CI 1.21-1.66; P < .001) of receiving a test. Of those who tested negative during initial testing, 17% received a second recommended test after 6 to 24 months. Medicaid-Medicare dual eligible patients, those with high CCI (OR 1.14; 95% CI 1.11-1.17; P < .001), NH blacks (OR 1.93; 95% CI 1.61-2.32; P < .001), and Hispanics (OR 1.49; 95% CI 1.08-2.06; P = .02) were significantly more likely to have received a second HCV test, while pregnant females (OR 0.71; 95% CI 0.57-0.89; P = .003), had lower odds of receiving it. The majority of patients who tested positive during the initial test (97%) received subsequent testing.We observed suboptimal adherence to the recommended HCV testing among high-risk patients underscoring the need for tailored interventions aimed at successfully navigating high-risk individuals through the HCV screening process. Future interventional studies targeting multilevel factors, including patients, clinicians and health systems are needed to increase HCV screening rates for high-risk populations.

Human Papillomavirus Vaccination and Human Papillomavirus-Associated Cancer Rates Within Florida Counties.

INTRODUCTION: To direct interventions, the Florida counties with the greatest risk of current and future human papillomavirus‒associated cancers were identified by estimating county-level (1) percentages of adolescents aged 13-17 years who initiated (≥1 dose) and were up to date (2-3 doses) for the human papillomavirus vaccine and (2) human papillomavirus‒associated cancer incidence rates. METHODS: Records were obtained for human papillomavirus vaccinations from the Florida immunization registry (2006-2019), incident cancer cases from the Florida registry (2013-2017), and annual population counts from the Florida Department of Health (2006-2019). In 2020, annual county-level human papillomavirus vaccine initiation, human papillomavirus vaccine up-to-date, and age-adjusted human papillomavirus‒associated cancer incidence rates were estimated. RESULTS: Among adolescents aged 13-17 years, average 2018-2019 county-specific human papillomavirus vaccine initiation ranged from 38% to 100% for females and from 34% to 96% for males. Up-to-date estimates ranged from 20% to 72% for females and from 24% to 77% for males. The majority (78%) of counties with initiation and up-to-date estimates within the lowest tercile were located in Northern Florida. County-specific 2013-2017 annualized, adjusted human papillomavirus‒associated cancer incidence rates ranged from 0 to 29.8 per 100,000 among females and from 5.4 to 24.1 per 100,000 among males. Counties within the highest tercile for human papillomavirus‒associated cancers were primarily (90% for females and 77% for males) located in Northern Florida. CONCLUSIONS: Human papillomavirus‒associated cancer risk varies widely across Florida counties, with particularly high risk within Northern Florida. Targeting interventions toward counties with low vaccination and high cancer rates may reduce human papillomavirus‒associated cancers.

Psychological Resilience, Experimentally Manipulated Social Status, and Dietary Intake among Adolescents.

Relative to other racial/ethnic groups in the United States, Hispanic American (HA) youth have higher rates of overweight and obesity. Previous work suggests that low perceived social status (SS) promotes excess caloric intake and, thereby, development of obesity. Psychological resilience may play a role in reducing adverse eating behaviors and risk for obesity. The objective of this study was to investigate whether resilience (as measured by the Connor Davidson Resilience Scale) interacts with experimentally manipulated SS to affect dietary intake among HA adolescents (n = 132). Using a rigged game of Monopoly (Hasbro, Inc.), participants were randomized to a high or low SS condition. Following the Monopoly game, participants consumed an ad libitum lunch and their dietary intake was assessed. There was a significant interaction between resilience and experimentally manipulated SS for total energy intake (p = 0.006), percent energy needs consumed (p = 0.005), and sugar intake (p = 0.004). For the high SS condition, for each increase in resilience score, total energy intake decreased by 7.165 ± 2.866 kcal (p = 0.014) and percent energy needs consumed decreased by 0.394 ± 0.153 (p = 0.011). In the low SS condition, sugar intake increased by 0.621 ± 0.240 g for each increase in resilience score (p = 0.011). After correction for multiple comparisons, the aforementioned interactions, but not simple slopes, were statistically significant.

Cost-Effectiveness of the Wellness Incentives and Navigation (WIN) Program.

OBJECTIVES: Promoting patient involvement in managing co-occurring physical and mental health conditions is increasingly recognized as critical to improving outcomes and controlling costs in this growing chronically ill population. The main objective of this study was to conduct an economic evaluation of the Wellness Incentives and Navigation (WIN) intervention as part of a longitudinal randomized pragmatic clinical trial for chronically ill Texas Medicaid enrollees with co-occurring physical and mental health conditions. METHODS: The WIN intervention used a personal navigator, motivational interviewing, and a flexible wellness expense account to increase patient activation, that is, the patient's knowledge, skills, and confidence in managing their self-care and co-occurring physical and mental health conditions. Regression models were fit to both participant-level quality-adjusted life years (QALYs) and total costs of care (including the intervention) controlling for demographics, health status, poverty, Medicaid managed care plan, intervention group, and baseline health utility and costs. Incremental costs and QALYs were calculated based on the difference in predicted costs and QALYs under intervention versus usual care and were used to calculate the incremental cost-effectiveness ratios (ICERs). Confidence intervals were calculated using Fieller's method, and sensitivity analyses were performed. RESULTS: The mean ICER for the intervention compared with usual care was $12 511 (95% CI $8971-$16 842), with a sizable majority of participants (70%) having ICERs below $40 000. The WIN intervention also produced higher QALY increases for participants who were sicker at baseline compared to those who were healthier at baseline. CONCLUSION: The WIN intervention shows considerable promise as a cost-effective intervention in this challenging chronically ill population.

Experimentally Manipulated Low Social Status and Food Insecurity Alter Eating Behavior Among Adolescents: A Randomized Controlled Trial.

OBJECTIVE: This randomized trial experimentally manipulated social status to assess effects on acute eating behavior and 24-hour energy balance. METHODS: Participants (n = 133 Hispanics; age 15-21 years; 60.2% females) were randomized to low social status ("LOW") or high social status ("HIGH") conditions in a rigged game of Monopoly (Hasbro, Inc.). Acute energy intake in a lunchtime meal was measured by food scales. Twenty-four-hour energy balance was assessed via summation of resting metabolic rate (metabolic cart), physical activity energy expenditure (accelerometer), thermic effect of food, and subtraction of twenty-four-hour energy intake (food diary). RESULTS: In the total sample, no significant differences were observed by study condition at lunchtime. LOW females consumed a greater percent of lunchtime daily energy needs (37.5%) relative to HIGH females (34.3%); however, this difference was not statistically significant (P = 0.291). In males, however, LOW consumed significantly less (36.5%) of their daily energy needs relative to HIGH males (45.8%; P = 0.001). For 24-hour energy balance, sex differences were nearly significant (P = 0.057; LOW females: surplus +200 kcal; HIGH males: surplus +445 kcal). Food-insecure individuals consumed a nearly significant greater lunchtime percent daily energy than those with food security (40.7% vs. 36.3%; P = 0.0797). CONCLUSIONS: The data demonstrate differential acute and 24-hour eating behavior responses between Hispanic male and female adolescents in experimentally manipulated conditions of low social status.

Radiation therapy combined with intracerebral convection-enhanced delivery of cisplatin or carboplatin for treatment of the F98 rat glioma.

BACKGROUND: The purpose of this review is to summarize our own experimental studies carried out over a 13-year period of time using the F98 rat glioma as model for high grade gliomas. We evaluated a binary chemo-radiotherapeutic modality that combines either cisplatin (CDDP) or carboplatin, administered intracerebrally (i.c.) by means of convection-enhanced delivery (CED) or osmotic pumps, in combination with either synchrotron or conventional X-irradiation. METHODS: F98 glioma cells were implanted stereotactically into the brains of syngeneic Fischer rats. Approximately 14 days later, either CDDP or carboplatin was administered i.c. by CED, followed 24 h later by radiotherapy using either a synchrotron or, subsequently, megavoltage linear accelerators (LINAC). RESULTS: CDDP was administered at a dose of 3 µg in 5 µL, followed 24 h later with an irradiation dose of 15 Gy or carboplatin at a dose of 20 µg in 10 µL, followed 24 h later with 3 fractions of 8 Gy each, at the source at the European Synchrotron Radiation Facility (ESRF). This resulted in a median survival time (MeST) > 180 days with 33% long term survivors (LTS) for CDDP and a MeST > 60 days with 8 to 22% LTS, for carboplatin. Subsequently it became apparent that comparable survival data could be obtained with megavoltage X-irradiation using a LINAC source. The best survival data were obtained with a dose of 72 µg of carboplatin administered by means of Alzet® osmotic pumps over 7 days. This resulted in a MeST of > 180 days, with 55% LTS. Histopathologic examination of all the brains of the surviving rats revealed no residual tumor cells or evidence of significant radiation related effects. CONCLUSIONS: The results obtained using this combination therapy has, to the best of our knowledge, yielded the most promising survival data ever reported using the F98 glioma model.

The Wellness Incentive and Navigation intervention improved health-related quality of life among Medicaid enrollees: A randomized pragmatic clinical trial.

OBJECTIVE: To examine whether the Wellness Incentive and Navigation (WIN) intervention can improve health-related quality of life (HRQOL) among Medicaid enrollees with co-occurring physical and behavioral health conditions. DATA SOURCES: Annual telephone survey data from 2013 to 2016, linked with claims data. STUDY DESIGN: We recruited 1259 participants from the Texas STAR + PLUS managed care program and randomized them into an intervention group that received flexible wellness accounts and navigator services or a control group that received standard care. We conducted 4 waves of telephone surveys to collect data on HRQOL, patient activation, and other participant demographic and clinical characteristics. DATA COLLECTION/EXTRACTION METHODS: The 3M Clinical Risk Grouping Software was used to extract variables from claims data and group participants based on disease severity. PRINCIPAL FINDINGS: Our results showed that the WIN intervention was effective in increasing patient activation and HRQOL among Medicaid enrollees with co-occurring physical and behavioral health conditions. Furthermore, we found that this intervention effect on HRQOL was partially mediated by patient activation. CONCLUSIONS: Providing navigator support with wellness account is effective in improving HRQOL among Medicaid enrollees. The pragmatic nature of the trial maximizes the chance of successfully implementing it in state Medicaid programs.

Exploring the Role of Executive Functioning Capacity in Patient Activation and Health Outcomes Among Medicaid Members With Multiple Comorbidities.

Patient activation, the perceived capacity to manage one's health, is positively associated with better health outcomes and lower costs. Underlying characteristics influencing patient activation are not completely understood leading to gaps in intervention strategies designed to improve patient activation. We suggest that variability in executive functioning influences patient activation and ultimately has an impact on health outcomes. To examine this hypothesis, 440 chronically ill Medicaid enrollees completed measures of executive functioning, patient activation, and health-related quality of life. Mediation analyses revealed that executive functioning: (a) directly affected patient activation and mental health-related quality of life, (b) indirectly affected mental health-related quality of life through patient activation, and (c) was unrelated to physical health-related quality of life. These data indicate that further study of the relationships among neurocognitive processes, patient activation, and health-related quality of life is needed and reinforces previous work demonstrating the association between patient activation and self-reported outcomes.

Higher n-6:n-3 Fatty Acid Intake Is Associated with Decreased Cardiometabolic Risk Factors in a Racially Diverse Sample of Children.

BACKGROUND: Accumulating evidence implicates diet quality in childhood as playing a significant role in adult cardiometabolic health. Polyunsaturated fatty acids (PUFAs) of the n-6 (ω-6) and n-3 (ω-3) series contribute unique protective effects against cardiometabolic disease. As such, the ratio between n-6 and n-3 PUFAs is a dietary metric of interest in the early life span, although an optimum intake ratio has yet to be determined. OBJECTIVE: This cross-sectional study assesses relations between the ratio of total n-6:n-3 PUFA intake and cardiometabolic risk factors in a racially diverse sample of children (n = 191) from the Admixture Mapping of Ethnic and Racial Insulin Complex Outcomes (AMERICO) study. METHODS: Outcome measures included waist circumference, lipid concentrations, fasting glucose, and two 24-h dietary recalls from boys and girls aged 7-12 y who self-reported as European American (n = 81), African American (n = 55), or Hispanic American (n = 55). Linear regression analyses were used to assess associations between predictors of interest and outcomes after adjusting for covariates. RESULTS: PUFA intake reflected in the n-6:n-3 ratio was inversely associated with concentrations of total and LDL cholesterol [ß ± SE: -0.359 ± 0.107 (P = 0.001) and -0.189 ± 0.069 (P = 0.007), respectively]. Exploratory analyses showed that the intake of total n-6 PUFAs was not significantly predictive of any cardiometabolic risk factor assessed, whereas total n-3 PUFA intake was positively associated with concentrations of HDL cholesterol (ß ± SE: 0.114 ± 0.042; P = 0.007). CONCLUSIONS: Results suggest that the effect of n-6 and n-3 PUFA intake reflected in the ratio may be largely driven by n-3 PUFAs in reducing 2 lipid cardiometabolic risk factors among this multiethnic cohort of children. Until an ideal intake ratio is determined, nutritional counseling should focus on meeting recommended levels of both n-3 and n-6 PUFAs in order to establish beneficial childhood dietary patterns that may positively influence adult cardiometabolic health.

Assessing the reliability of the short form 12 (SF-12) health survey in adults with mental health conditions: a report from the wellness incentive and navigation (WIN) study.

BACKGROUND: Although Short Form (SF)-12 × 2® has been extensively studied and used as a valid measure of health-related quality of life in a variety of population groups, no systematic studies have described the reliability of the measure in patients with behavioral conditions or serious mental illness (SMI). METHODS AND RESULTS: We assessed the internal consistency, split-half reliability and annual test-retest correlations in a sample of 1587 participants with either a combination of physical and behavioral conditions or SMI. The Mosier's alpha was 0.70 for the Physical Composite Scale (PCS) and 0.69 for the Mental Health Composite Scale (MCS), indicating good internal consistency. We observed strong correlations between physical functioning, physical role and body pain scales (r = 0.55-0.56), and between social functioning, emotional role, and mental health (r = 0.53-0.58). We calculated split-half reliabilities to be 0.74 for physical functioning, 0.75 for physical role, 0.73 for emotional role and 0.65 for mental health respectively. We assessed the annual test-retest correlation using intraclass correlation (ICC) and found an ICC of 0.61 for PCS and 0.57 for MCS composite scores, adjusting for age, sex, race/ethnicity, and CRG. We found no decline in the correlations between baseline and the following study years until year 3. CONCLUSIONS: Our results encourage using SF-12v2® to assess health-related quality of life in the Medicaid population with combined physical and behavioral conditions or similar cohorts. TRIAL REGISTRATION: The WIN study was registered with clinicaltrials.gov on April 22, 2015. TRIAL REGISTRATION NUMBER: NCT02440906 . Retrospectively registered.

Colorectal cancer stages transcriptome analysis.

Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related deaths in the United States. The purpose of this study was to evaluate the gene expression differences in different stages of CRC. Gene expression data on 433 CRC patient samples were obtained from The Cancer Genome Atlas (TCGA). Gene expression differences were evaluated across CRC stages using linear regression. Genes with p≤0.001 in expression differences were evaluated further in principal component analysis and genes with p≤0.0001 were evaluated further in gene set enrichment analysis. A total of 377 patients with gene expression data in 20,532 genes were included in the final analysis. The numbers of patients in stage I through IV were 59, 147, 116 and 55, respectively. NEK4 gene, which encodes for NIMA related kinase 4, was differentially expressed across the four stages of CRC. The stage I patients had the highest expression of NEK4 genes, while the stage IV patients had the lowest expressions (p = 9*10-6). Ten other genes (RNF34, HIST3H2BB, NUDT6, LRCh4, GLB1L, HIST2H4A, TMEM79, AMIGO2, C20orf135 and SPSB3) had p value of 0.0001 in the differential expression analysis. Principal component analysis indicated that the patients from the 4 clinical stages do not appear to have distinct gene expression pattern. Network-based and pathway-based gene set enrichment analyses showed that these 11 genes map to multiple pathways such as meiotic synapsis and packaging of telomere ends, etc. Ten of these 11 genes were linked to Gene Ontology terms such as nucleosome, DNA packaging complex and protein-DNA interactions. The protein complex-based gene set analysis showed that four genes were involved in H2AX complex II. This study identified a small number of genes that might be associated with clinical stages of CRC. Our analysis was not able to find a molecular basis for the current clinical staging for CRC based on the gene expression patterns.

Perceptions of patients and providers on myocardial perfusion imaging for asymptomatic patients, choosing wisely, and professional liability.

BACKGROUND: Despite efforts by professional societies to reduce low value care, many reports indicate that unnecessary tests, such as nuclear myocardial perfusion imaging (MPI), are commonly used in contemporary practice. The degree to which lack of awareness and professional liability concerns drive these behaviors warrants further study. We sought to investigate patient and provider perceptions about MPI in asymptomatic patients, the Choosing Wisely (CW) campaign, and professional liability concerns. METHODS: We administered an anonymous, paper-based survey with both discrete and open-response queries to subjects in multiple outpatient settings at our facilities. The survey was completed by 456 respondents including 342 patients and 114 physicians and advanced practice providers between May and August 2014. Our outcome was to compare patient and provider perceptions about MPI in asymptomatic patients and related factors. RESULTS: Patients were more likely than providers to report that MPI was justified for asymptomatic patients (e.g. asymptomatic with family history of heart disease 75% versus 9.2%, p < 0.0001). In free responses to the question "What would be an inappropriate reason for MPI?" many responses echoed the goals of CW (for example, "If you don't have symptoms", "If the test is too risky", "For screening or in asymptomatic patients"). A minority of providers were aware of CW while even fewer patients were aware (37.2% versus 2.7%, p < 0.0001). Over one third of providers (38.9%) admitted to ordering MPI out of concern for professional liability including 48.3% of VA affiliated providers. CONCLUSIONS: While some patients and providers are aware of the low value of MPI in patients without symptoms, others are enthusiastic to use it for a variety of scenarios. Concerns about professional liability likely contribute, even in the VA setting. Awareness of the Choosing Wisely campaign is low in both groups.

Explore Care Pathways of Colorectal Cancer Patients with Social Network Analysis.

Patients with colorectal cancer (CRC) often face treatment delays and the exact reasons have not been well studied. This study is to explore clinical workflow patterns for CRC patients using electronic health records (EHR). In particular, we modeled the clinical workflow (provider-provider interactions) of a CRC patient's workup period as a social network, and identified clusters of workflow patterns based on network characteristics. Understanding of these patterns will help guide healthcare policy-making and practice.

Accuracy of weight loss information in Spanish search engine results on the internet.

OBJECTIVE: To systematically assess the quality of online information related to weight loss that Spanish speakers in the U.S. are likely to access. METHODS: This study evaluated the accessibility and quality of information for websites that were identified from weight loss queries in Spanish and compared this with previously published results in English. The content was scored with respect to five dimensions: nutrition, physical activity, behavior, pharmacotherapy, and surgical recommendations. RESULTS: Sixty-six websites met eligibility criteria (21 commercial, 24 news/media, 10 blogs, 0 medical/government/university, 11 unclassified sites). Of 16 possible points, mean content quality score was 3.4 (SD = 2.0). Approximately 1.5% of sites scored greater than 8 (out of 12) on nutrition, physical activity, and behavior. Unsubstantiated claims were made on 94% of the websites. Content quality scores varied significantly by type of website (P < 0.0001) with unclassified websites scoring the highest (mean = 6.3, SD = 1.4) and blogs scoring the lowest (mean = 2.2, SD = 1.2). All content quality scores were lower for Spanish websites relative to English websites. CONCLUSIONS: Weight loss information accessed in Spanish Web searches is suboptimal and relatively worse than weight loss information accessed in English, suggesting that U.S. Spanish speakers accessing weight loss information online may be provided with incomplete and inaccurate information.