High Influenza Incidence and Disease Severity Among Children and Adolescents Aged <18 Years - United States, 2022-23 Season.

During the 2022-23 influenza season, early increases in influenza activity, co-circulation of influenza with other respiratory viruses, and high influenza-associated hospitalization rates, particularly among children and adolescents, were observed. This report describes the 2022-23 influenza season among children and adolescents aged <18 years, including the seasonal severity assessment; estimates of U.S. influenza-associated medical visits, hospitalizations, and deaths; and characteristics of influenza-associated hospitalizations. The 2022-23 influenza season had high severity among children and adolescents compared with thresholds based on previous seasons' influenza-associated outpatient visits, hospitalization rates, and deaths. Nationally, the incidences of influenza-associated outpatient visits and hospitalization for the 2022-23 season were similar for children aged <5 years and higher for children and adolescents aged 5-17 years compared with previous seasons. Peak influenza-associated outpatient and hospitalization activity occurred in late November and early December. Among children and adolescents hospitalized with influenza during the 2022-23 season in hospitals participating in the Influenza Hospitalization Surveillance Network, a lower proportion were vaccinated (18.3%) compared with previous seasons (35.8%-41.8%). Early influenza circulation, before many children and adolescents had been vaccinated, might have contributed to the high hospitalization rates during the 2022-23 season. Among symptomatic hospitalized patients, receipt of influenza antiviral treatment (64.9%) was lower than during pre-COVID-19 pandemic seasons (80.8%-87.1%). CDC recommends that all persons aged ≥6 months without contraindications should receive the annual influenza vaccine, ideally by the end of October.

Targeting patients for early COVID-19 therapy; Pre-infection metabolic dysfunction, polycystic ovary syndrome and risk of severe disease in patients under 65: A Massachusetts community-based observational study.

INTRODUCTION: The demographics of those developing severe coronavirus disease (COVID-19) outcomes are shifting to younger patients. In an observational study utilizing electronic health records from a Massachusetts group medical practice, we identified 5025 patients with confirmed COVID-19 from March 1 to December 18, 2020. Of these, 3870 were under 65 years of age. We investigated the hypothesis that pre-infection metabolic or immunologic dysregulation including polycystic ovary syndrome (PCOS) increased risk of serious COVID-19 outcomes in patients under 65 years of age. MATERIALS AND METHODS: We compared those with COVID-19 related hospitalization or mortality to all other COVID-19 patients, using a case control approach. Using logistic regression and propensity score modeling, we evaluated risk of developing severe COVID-19 outcomes (hospitalization or death) in those with pre-infection comorbidities, metabolic risk factors, or PCOS. RESULTS: Overall, propensity score matched analyses demonstrated pre-infection elevated liver enzymes alanine aminotransferase (ALT) >40, aspartate aminotransferase (AST) >40 and blood glucose ≥215 mg/dL were associated with more severe COVID-19 outcomes, OR = 1.74 (95% CI 1.31, 2.31); OR = 1.98 (95% CI 1.52, 2.57), and OR = 1.55 (95% CI 1.08, 2.23) respectively. Elevated hemoglobin A1C or blood glucose levels were even stronger risk factors for severe COVID-19 outcomes among those aged < 65, OR = 2.31 (95% CI 1.14, 4.66) and OR = 2.42 (95% CI 1.29, 4.56), respectively. In logistic regression models, women aged < 65 with PCOS demonstrated more than a four-fold increased risk of severe COVID-19, OR 4.64 (95% CI 1.98, 10.88). CONCLUSION: Increased risk of severe COVID-19 outcomes in those < age 65 with pre-infection indicators of metabolic dysfunction heightens the importance of monitoring pre-infection indicators in younger patients for prevention and early treatment. The PCOS finding deserves further investigation. Meanwhile women who suffer from PCOS should be carefully evaluated and prioritized for earlier COVID-19 treatment and vaccination.

Patient and Epidemiological Factors Associated With Influenza Testing in Hospitalized Adults With Acute Respiratory Illnesses, 2016-2017 to 2019-2020.

Background: Data are limited on influenza testing among adults with acute respiratory illness (ARI)-associated hospitalizations. We identified factors associated with influenza testing in adult ARI-associated hospitalizations across the 2016-2017 through 2019-2020 influenza seasons. Methods: Using data from 4 health systems in the United States, we identified hospitalizations that had an ARI discharge diagnosis or respiratory virus test. A hospitalization with influenza testing was based on testing performed within 14 days before through 72 hours after admission. We used random forest analysis to identify patient characteristics and influenza activity indicators that were most important in terms of their relationship to influenza testing. Results: Across 4 seasons, testing rates ranged from 14.8%-19.4% at 3 pooled sites and 60.1%-78.5% at a fourth site with different testing practices. Discharge diagnoses of pneumonia or infectious disease of noninfluenza etiology, presence of ARI signs/symptoms, hospital admission month, and influenza-like illness activity level were consistently among the variables with the greatest relative importance. Conclusions: Select ARI diagnoses and indicators of influenza activity were the most important factors associated with influenza testing among ARI-associated hospitalizations. Improved understanding of which patients are tested may enhance influenza burden estimates and allow for more timely clinical management of influenza-associated hospitalizations.

Identifying and responding to depression in adolescents in primary care: A quality improvement response.

The American Academy of Pediatrics (AAP) recommends adolescent depression screening and subsequent follow-up for those scoring at-risk. The current study assessed the outcomes of a Quality Improvement (QI) project that implemented these guidelines during annual well-child visits in a network of pediatric practices. This project used a two-stage screening process. First, adolescents were screened with the Pediatric Symptom Checklist (PSC-17). Second, adolescents who screened at-risk on the PSC-17 were asked to complete the Patient Health Questionnaire (PHQ-9). QI-participating providers received training on how to categorize the severity of their patient's depression based on PHQ-9 cut-off scores and clinical interview, and to implement and document appropriate options for follow-up. Patients in the QI group were significantly more likely to be screened with both the PSC-17 (93.8% vs. 89.1%, p < .001) and the PHQ-9 (54.8% vs. 16.4%, p < .001) compared to those in the non-QI group. Of the 80 adolescents in the QI group at-risk on the PSC-17 and with a completed PHQ-9, 65 (81.3%) received at least one type of referral for mental health, ranging from behavioral health services to lifestyle interventions. Findings support the feasibility of adolescent depression screening and referrals within pediatric primary care.

A novel household-based patient outreach pilot program to boost late-season influenza vaccination rates during the COVID-19 pandemic.

BACKGROUND: The objective of this study was to test a novel household-based approach to improve late-season influenza vaccine uptake during the 2020-2021 season, using Epic's MyChart patient portal messages and/or interactive voice response telephone calls. METHODS: This study was a non-blinded, quality improvement program using a block randomized design conducted among patients from Reliant Medical Group clinics residing in a traditional household (≥2 individuals clinically active in the Reliant system living at the same address). Households were randomized 1:1:1 into intervention arms: non-tailored communication (messaging based on CDC's seasonal influenza vaccination campaign), tailored communication (comprehensive communication including reinforcement of the importance of influenza vaccination for high-risk individuals), and standard-of-care control. Influenza vaccination during the program was captured via medical records, and the odds of vaccination among communication arms versus the control arm were assessed. A survey assessing influenza vaccination drivers was administered using MyChart. RESULTS: Influenza vaccination increased by 3.3% during the program period, and no significant differences in vaccination were observed in intervention arms relative to the control arm. Study operationalization faced substantial challenges related to the concurrent COVID-19 pandemic. Compared with vaccinated survey respondents, unvaccinated respondents less frequently reported receiving a recommendation for influenza vaccination from their healthcare provider (15.8% vs. 42.3%, p < 0.001) or awareness that vaccination could protect themselves and higher risk contacts (82.3% vs. 92.6%, p < 0.001). CONCLUSIONS: No significant effects of the interventions were observed. Survey results highlighted the importance of healthcare provider recommendations and the need for increased education around the benefits of vaccination.

Trends in breast and prostate cancer screening and diagnostic procedures during the COVID-19 pandemic in central Massachusetts.

PURPOSE: We calculated rates of breast and prostate cancer screening and diagnostic procedures performed during the COVID-19 pandemic through December 2021 compared to the same months in 2019 in a large healthcare provider group in central Massachusetts. METHODS: We included active patients of the provider group between January 2019 and December 2021 aged 30-85 years. Monthly rates of screening mammography and digital breast tomosynthesis, breast MRI, total prostate specific antigen (PSA), and breast or prostate biopsy per 1,000 people were compared by year overall, by age, and race/ethnicity. Completed procedures were identified by relevant codes in electronic health record data. RESULTS: Rates of screening mammography, tomosynthesis, and PSA testing reached the lowest levels in April-May 2020. Breast cancer screening rates decreased 43% in March and 99% in April and May 2020, compared to 2019. Breast cancer screening rates increased gradually beginning in June 2020 through 2021, although more slowly in Black and Hispanic women and in women aged 75-85. PSA testing rates decreased 34% in March, 78% in April, and 53% in May 2020, but rebounded to pre-pandemic levels by June 2020; trends were similar across groups defined by age and race/ethnicity. CONCLUSION: The observed decline in two common screening procedures during the COVID-19 pandemic reflects the impact of the pandemic on cancer early detection and signals potential downstream effects on the prognosis of delayed cancer diagnoses. The slower rate of return for breast cancer screening procedures in certain subgroups should be investigated to ensure all women return for routine screenings.

Mortality in Stable Coronary Disease in Patients With Intermediate- or High-Risk Myocardial Perfusion Imaging.

The management of patients with stable coronary disease and intermediate- or high-risk features on single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) continues to be controversial as to whether they should be treated with an initial invasive strategy (catheterization and revascularization when feasible) or medical therapy alone to improve mortality. We performed a retrospective observational study of 1,946 patients with intermediate- or high-risk SPECT MPI scans performed over a 6-year period (from 2014 to 2019). Each patient was followed from the time of SPECT MPI to 16 months after the last patient was enrolled. The primary end point was all-cause mortality and the secondary end point cardiovascular mortality. Of the eligible 1,697 patients, 1,144 had an intermediate-risk scan, 553 a high-risk scan, 915 had medical therapy alone, and 782 went on an initial invasive strategy. All patients were divided into the following three groups: combined SPECT MPI (both intermediate- and high-risk), high-risk SPECT MPI, and intermediate-risk SPECT MPI groups. After propensity score matching, there was a statistically significant difference in cardiovascular death (5.9% vs 2.7%; p = 0.038) in the medical therapy cohort compared with initial invasive cohort in the combined SPECT MPI group, but no difference in all-cause death (15.7% vs 13%; p = 0.318). On subgroup analysis, in intermediate-risk SPECT MPI group, there was no significant difference in either all-cause death (13.8 vs 11.7%; p = 0.583) or cardiac death (5.4% vs 2.5%; p = 0.16) in conservative cohort compared with invasive strategy cohort. In high-risk SPECT MPI group, conservative therapy cohort had higher cardiac death (11.7% vs 2.5%; p = 0.002) compared with initial invasive strategy cohort, but there was no significant difference in all-cause death (24.5% vs 15.3%; p = 0.052). In conclusion, this study supports that patients with intermediate- or high-risk SPECT MPI scans when considered together or only with high-risk features, derive a cardiovascular mortality benefit with an initial invasive strategy. Patients who had undergone intermediate-risk SPECT MPI had similar outcomes with either medical therapy alone or initial invasive evaluation.

Development and Validation of a Healthcare Utilization-Based Algorithm to Identify Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

Introduction: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are important events that may precipitate other adverse outcomes. Accurate AECOPD event identification in electronic administrative data is essential for improving population health surveillance and practice management. Objective: Develop codified algorithms to identify moderate and severe AECOPD in two US healthcare systems using administrative data and electronic medical records, and validate their performance by calculating positive predictive value (PPV) and negative predictive value (NPV). Methods: Data from two large regional integrated health systems were used. Eligible patients were identified using International Classification of Diseases (Ninth Edition) COPD diagnosis codes. Two algorithms were developed: one to identify potential moderate AECOPD by selecting outpatient/emergency visits associated with AECOPD-related codes and antibiotic/systemic steroid prescriptions; the other to identify potential severe AECOPD by selecting inpatient visits associated with corresponding codes. Algorithms were validated via patient chart review, adjudicated by a pulmonologist. To estimate PPV, 300 potential moderate AECOPD and 250 potential severe AECOPD events underwent review. To estimate NPV, 200 patients without any AECOPD identified by the algorithms (100 patients each without moderate or severe AECOPD) during the two years following the index date underwent review to identify AECOPD missed by the algorithm (false negatives). Results: The PPVs (95% confidence interval [CI]) for both moderate and severe AECOPD were high: 293/298 (98.3% [96.1-99.5]) and 216/225 (96.0% [92.5-98.2]), respectively. NPV was lower for moderate AECOPD (75.0% [65.3-83.1]) than for severe AECOPD (95.0% [88.7-98.4]). Results were consistent across both healthcare systems. Conclusion: This study developed healthcare utilization-based algorithms to identify moderate and severe AECOPD in two separate healthcare systems. PPV for both algorithms was high; NPV was lower for the moderate algorithm. Replication and consistency of results across two healthcare systems support the external validity of these findings.

Risk of chemotherapy-induced febrile neutropenia in patients with metastatic cancer not receiving granulocyte colony-stimulating factor prophylaxis in US clinical practice.

OBJECTIVES: To evaluate the use of granulocyte colony-stimulating factor (G-CSF) prophylaxis in US patients with selected metastatic cancers and chemotherapy-induced febrile neutropenia (FN) incidence and associated outcomes among the subgroup who did not receive prophylaxis. METHODS: This retrospective cohort study was conducted at four US health systems and included adults with metastatic cancer (breast, colorectal, lung, non-Hodgkin lymphoma [NHL]) who received myelosuppressive chemotherapy (2009-2017). Patients were stratified by FN risk level based on risk factors and chemotherapy (low/unclassified risk, intermediate risk without any risk factors, intermediate risk with ≥ 1 risk factor [IR + 1], high risk [HR]). G-CSF use was evaluated among all patients stratified by FN risk, and FN/FN-related outcomes were evaluated among patients who did not receive first-cycle G-CSF prophylaxis. RESULTS: Among 1457 metastatic cancer patients, 20.5% and 28.1% were classified as HR and IR + 1, respectively. First-cycle G-CSF prophylaxis use was 48.5% among HR patients and 13.9% among IR + 1 patients. In the subgroup not receiving first-cycle G-CSF prophylaxis, FN incidence in cycle 1 was 7.8% for HR patients and 4.8% for IR + 1 patients; during the course, corresponding values were 16.9% and 15.9%. Most (> 90%) FN episodes required hospitalization, and mortality risk ranged from 7.1 to 26.9% across subgroups. CONCLUSION: In this retrospective study, the majority of metastatic cancer chemotherapy patients for whom G-CSF prophylaxis is recommended did not receive it; FN incidence in this subgroup was notably high. Patients with elevated FN risk should be carefully identified and managed to ensure appropriate use of supportive care.

Hypertension, medications, and risk of severe COVID-19: A Massachusetts community-based observational study.

It remains uncertain whether the hypertension (HT) medications angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) mitigate or exacerbate SARS-CoV-2 infection. We evaluated the association of ACEi and ARB with severe coronavirus disease 19 (COVID-19) as defined by hospitalization or mortality among individuals diagnosed with COVID-19. We investigated whether these associations were modified by age, the simultaneous use of the diuretic thiazide, and the health conditions associated with medication use. In an observational study utilizing data from a Massachusetts group medical practice, we identified 1449 patients with a COVID-19 diagnosis. In our study, pre-infection comorbidities including HT, cardiovascular disease, and diabetes were associated with increased risk of severe COVID-19. Risk was further elevated in patients under age 65 with these comorbidities or cancer. Twenty percent of those with severe COVID-19 compared to 9% with less severe COVID-19 used ACEi, 8% and 4%, respectively, used ARB. In propensity score-matched analyses, use of neither ACEi (OR = 1.30, 95% CI 0.93 to 1.81) nor ARB (OR = 0.94, 95% CI 0.57 to 1.55) was associated with increased risk of severe COVID-19. Thiazide use did not modify this relationship. Beta blockers, calcium channel blockers, and anticoagulant medications were not associated with COVID-19 severity. In conclusion, cardiovascular-related comorbidities were associated with severe COVID-19 outcomes, especially among patients under age 65. We found no substantial increased risk of severe COVID-19 among patients taking antihypertensive medications. Our findings support recommendations against discontinuing use of renin-angiotensin system (RAS) inhibitors to prevent severe COVID-19.

Electronic Health Record Portal Messages and Interactive Voice Response Calls to Improve Rates of Early Season Influenza Vaccination: Randomized Controlled Trial.

BACKGROUND: Patient reminders for influenza vaccination, delivered via an electronic health record patient portal and interactive voice response calls, offer an innovative approach to engaging patients and improving patient care. OBJECTIVE: The goal of this study was to test the effectiveness of portal and interactive voice response outreach in improving rates of influenza vaccination by targeting patients in early September, shortly after vaccinations became available. METHODS: Using electronic health record portal messages and interactive voice response calls promoting influenza vaccination, outreach was conducted in September 2015. Participants included adult patients within a large multispecialty group practice in central Massachusetts. Our main outcome was electronic health record-documented early influenza vaccination during the 2015-2016 influenza season, measured in November 2015. We randomly assigned all active portal users to 1 of 2 groups: (1) receiving a portal message promoting influenza vaccinations, listing upcoming clinics, and offering online scheduling of vaccination appointments (n=19,506) or (2) receiving usual care (n=19,505). We randomly assigned all portal nonusers to 1 of 2 groups: (1) receiving interactive voice response call (n=15,000) or (2) receiving usual care (n=43,596). The intervention also solicited patient self-reports on influenza vaccinations completed outside the clinic. Self-reported influenza vaccination data were uploaded into the electronic health records to increase the accuracy of existing provider-directed electronic health record clinical decision support (vaccination alerts) but were excluded from main analyses. RESULTS: Among portal users, 28.4% (5549/19,506) of those randomized to receive messages and 27.1% (5294/19,505) of the usual care group had influenza vaccinations documented by November 2015 (P=.004). In multivariate analysis of portal users, message recipients were slightly more likely to have documented vaccinations when compared to the usual care group (OR 1.07, 95% CI 1.02-1.12). Among portal nonusers, 8.4% (1262/15,000) of those randomized to receive calls and 8.2% (3586/43,596) of usual care had documented vaccinations (P=.47), and multivariate analysis showed nonsignificant differences. Over half of portal messages sent were opened (10,112/19,479; 51.9%), and over half of interactive voice response calls placed (7599/14,984; 50.7%) reached their intended target, thus we attained similar levels of exposure to the messaging for both interventions. Among portal message recipients, 25.4% of message openers (2570/10,112) responded to a subsequent question on receipt of influenza vaccination; among interactive voice response recipients, 72.5% of those reached (5513/7599) responded to a similar question. CONCLUSIONS: Portal message outreach to a general primary care population achieved a small but statistically significant improvement in rates of influenza vaccination (OR 1.07, 95% CI 1.02-1.12). Interactive voice response calls did not significantly improve vaccination rates among portal nonusers (OR 1.03, 95% CI 0.96-1.10). Rates of patient engagement with both modalities were favorable. TRIAL REGISTRATION: ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277.

Clinical Characteristics of Early-Onset Gout in Outpatient Setting.

OBJECTIVE: The objective of this study is to investigate the clinical characteristics and treatment of patients with early-onset gout. METHODS: We retrospectively reviewed 327 adult patients with a first diagnosis of gout from 2008 to 2016 using the database of a multispecialty group practice in New England. Patients were classified into the following groups: age 30 years or younger at first diagnosis (group 1), age 31-40 years (group 2), and age over 40 years (group 3). The clinical characteristics and treatment of gout were compared among the three groups. RESULTS: We identified 87 patients in group 1 and 140 patients in group 2. Group 3 included 100 patients randomly chosen from the 7216 patients with a first diagnosis at age over 40 years. Patients within group 1 had significantly higher serum uric acid (sUA) levels at the time of diagnosis and a more prominent family history of gout. Younger patients (groups 1 and 2) had a significantly higher body mass index than patients over 40 years of age (group 3). A substantial number of younger patients also had hypertension or hyperlipidemia. The majority of younger patients met the 2012 American College of Rheumatology (ACR) guidelines for initiating urate-lowering therapy (ULT) on the basis of frequency of gout attacks, whereas the majority of patients over 40 years of age met the guidelines for ULT on the basis of chronic kidney disease. Patients over 40 years of age were more likely to achieve an sUA level less than 6.0 mg/dl. CONCLUSION: Patients with a first diagnosis of gout at age 40 years or younger frequently had cardiovascular risk factors and were less likely to achieve an sUA level less than 6.0 mg/dl compared with patients over 40 years of age who were treated in routine clinical practice. Clinicians should be aware that patients with early-onset gout may be an undertreated population with poor adherence to ULT and increased risk of recurrent gout and cardiovascular diseases.

Adherence to Blood Cholesterol Treatment Guidelines Among Physicians Managing Patients With Atherosclerotic Cardiovascular Disease.

The ACC/AHA blood cholesterol treatment guidelines recommend statin therapy for all patients after experiencing an acute cardiovascular event. Previous analyses have shown that physicians have been slow to adopt guidelines, and many patients remain untreated or undertreated with statins after a cardiovascular event. However, reasons for this remain unknown. This analysis used electronic medical records and patient chart data from Reliant Medical Group (Worcester, Massachusetts) to evaluate physician adherence to the 2013 ACC/AHA blood cholesterol guidelines when treating patients with evidence of acute atherosclerotic cardiovascular disease and the reasons for the observed treatment decisions. Less than 50% of acute atherosclerotic cardiovascular disease patients were treated according to the ACC/AHA guidelines. Nearly 42% of patients not treated according to guidelines received a lower statin intensity than recommended. The most common reason cited by 41.8% of physicians for treating with a statin intensity below the recommended intensity was low-density lipoprotein cholesterol stable or at goal, despite ACC/AHA guidelines recommending specific statin intensities rather than specific low-density lipoprotein cholesterol levels. In conclusion, physician and patient education on the importance of maximizing lipid-lowering therapy in this high-risk patient population should be emphasized.

Use of Electronic Health Record Access and Audit Logs to Identify Physician Actions Following Noninterruptive Alert Opening: Descriptive Study.

BACKGROUND: Electronic health record (EHR) access and audit logs record behaviors of providers as they navigate the EHR. These data can be used to better understand provider responses to EHR-based clinical decision support (CDS), shedding light on whether and why CDS is effective. OBJECTIVE: This study aimed to determine the feasibility of using EHR access and audit logs to track primary care physicians' (PCPs') opening of and response to noninterruptive alerts delivered to EHR InBaskets. METHODS: We conducted a descriptive study to assess the use of EHR log data to track provider behavior. We analyzed data recorded following opening of 799 noninterruptive alerts sent to 75 PCPs' InBaskets through a prior randomized controlled trial. Three types of alerts highlighted new medication concerns for older patients' posthospital discharge: information only (n=593), medication recommendations (n=37), and test recommendations (n=169). We sought log data to identify the person opening the alert and the timing and type of PCPs' follow-up EHR actions (immediate vs by the end of the following day). We performed multivariate analyses examining associations between alert type, patient characteristics, provider characteristics, and contextual factors and likelihood of immediate or subsequent PCP action (general, medication-specific, or laboratory-specific actions). We describe challenges and strategies for log data use. RESULTS: We successfully identified the required data in EHR access and audit logs. More than three-quarters of alerts (78.5%, 627/799) were opened by the PCP to whom they were directed, allowing us to assess immediate PCP action; of these, 208 alerts were followed by immediate action. Expanding on our analyses to include alerts opened by staff or covering physicians, we found that an additional 330 of the 799 alerts demonstrated PCP action by the end of the following day. The remaining 261 alerts showed no PCP action. Compared to information-only alerts, the odds ratio (OR) of immediate action was 4.03 (95% CI 1.67-9.72) for medication-recommendation and 2.14 (95% CI 1.38-3.32) for test-recommendation alerts. Compared to information-only alerts, ORs of medication-specific action by end of the following day were significantly greater for medication recommendations (5.59; 95% CI 2.42-12.94) and test recommendations (1.71; 95% CI 1.09-2.68). We found a similar pattern for OR of laboratory-specific action. We encountered 2 main challenges: (1) Capturing a historical snapshot of EHR status (number of InBasket messages at time of alert delivery) required incorporation of data generated many months prior with longitudinal follow-up. (2) Accurately interpreting data elements required iterative work by a physician/data manager team taking action within the EHR and then examining audit logs to identify corresponding documentation. CONCLUSIONS: EHR log data could inform future efforts and provide valuable information during development and refinement of CDS interventions. To address challenges, use of these data should be planned before implementing an EHR-based study.

Improving Rates of Outpatient Influenza Vaccination Through EHR Portal Messages and Interactive Automated Calls: A Randomized Controlled Trial.

BACKGROUND: Patient reminders for influenza vaccination, delivered via electronic health record (EHR) patient portal messages and interactive voice response (IVR) calls, offer an innovative approach to improving patient care. OBJECTIVE: To test the effectiveness of portal and IVR outreach in improving rates of influenza vaccination. DESIGN: Randomized controlled trial of EHR portal messages and IVR calls promoting influenza vaccination. PARTICIPANTS: Adults with no documented influenza vaccination 2 months after the start of influenza season (2014-2015). INTERVENTION: Using a factorial design, we assigned 20,000 patients who were active portal users to one of four study arms: (a) receipt of a portal message promoting influenza vaccines, (b) receipt of IVR call with similar content, (c) both a and b, or (d) neither (usual care). We randomized 10,000 non-portal users to receipt of IVR call or usual care. In all intervention arms, information on pneumococcal vaccination was included if the targeted patient was overdue for pneumococcal vaccine. MAIN MEASURES: EHR-documented influenza vaccination during the 2014-2015 influenza season, measured April 2015. KEY RESULTS: Among portal users, 14.0% (702) of those receiving both portal messages and calls, 13.4% (669) of message recipients, 12.8% (642) of call recipients, and 11.6% (582) of those with usual care received vaccines. On multivariable analysis of portal users, those receiving portal messages alone (OR 1.20, 95% CI 1.06-1.35) or IVR calls alone (OR 1.15 95% CI 1.02-1.30) were more likely than usual care recipients to be vaccinated. Those receiving both messages and calls were also more likely than the usual care group to be vaccinated (ad hoc analysis, using a Bonferroni correction: OR 1.29, 97.5% CI 1.13, 1.48). Among non-portal users, 8.5% of call recipients and 8.6% of usual care recipients received influenza vaccines (p = NS). Pneumococcal vaccination rates showed no significant improvement. CONCLUSIONS: Our outreach achieved a small but significant improvement in influenza vaccination rates. Registration: ClinicalTrials.gov Identifier NCT02266277 ( https://clinicaltrials.gov/ct2/show/NCT02266277 ).

Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets.

BACKGROUND: Time-sensitive alerts are among the many types of clinical notifications delivered to physicians' secure InBaskets within commercial electronic health records (EHRs). A delayed alert review can impact patient safety and compromise care. OBJECTIVE: To characterize factors associated with opening of non-interruptive time-sensitive alerts delivered into primary care provider (PCP) InBaskets. DESIGN AND PARTICIPANTS: We analyzed data for 799 automated alerts. Alerts highlighted actionable medication concerns for older patients post-hospital discharge (2010-2011). These were study-generated alerts sent 3 days post-discharge to InBaskets for 75 PCPs across a multisite healthcare system, and represent a subset of all urgent InBasket notifications. MAIN MEASURES: Using EHR access and audit logs to track alert opening, we performed bivariate and multivariate analyses calculating associations between patient characteristics, provider characteristics, contextual factors at the time of alert delivery (number of InBasket notifications, weekday), and alert opening within 24 h. KEY RESULTS: At the time of alert delivery, the PCPs had a median of 69 InBasket notifications and had received a median of 379.8 notifications (IQR 295.0, 492.0) over the prior 7 days. Of the 799 alerts, 47.1% were opened within 24 h. Patients with longer hospital stays (>4 days) were marginally more likely to have alerts opened (OR 1.48 [95% CI 1.00-2.19]). Alerts delivered to PCPs whose InBaskets had a higher number of notifications at the time of alert delivery were significantly less likely to be opened within 24 h (top quartile >157 notifications: OR 0.34 [95% CI 0.18-0.61]; reference bottom quartile ≤42). Alerts delivered on Saturdays were also less likely to be opened within 24 h (OR 0.18 [CI 0.08-0.39]). CONCLUSIONS: The number of total InBasket notifications and weekend delivery may impact the opening of time-sensitive EHR alerts. Further study is needed to support safe and effective approaches to care team management of InBasket notifications.

A retrospective study to assess clinical characteristics and time to initiation of open-triple therapy among patients with chronic obstructive pulmonary disease, newly established on long-acting mono- or combination therapy.

INTRODUCTION: An incremental approach using open-triple therapy may improve outcomes in patients with chronic obstructive pulmonary disease (COPD). However, there is little sufficient, real-world evidence available identifying time to open-triple initiation. METHODS: This retrospective study of patients with COPD, newly initiated on long-acting muscarinic antagonist (LAMA) monotherapy or inhaled corticosteroid/long-acting ß2-agonist (ICS/LABA) combination therapy, assessed baseline demographics, clinical characteristics, and exacerbations during 12 months prior to first LAMA or ICS/LABA use. Time to initiation of open-triple therapy was assessed for 12 months post-index date. Post hoc analyses were performed to assess the subsets of patients with pulmonary-function test (PFT) information and patients with and without comorbid asthma. RESULTS: Demographics and clinical characteristics were similar between cohorts in the pre-specified and post hoc analyses. In total, 283 (19.3%) and 160 (10.9%) patients had moderate and severe exacerbations at baseline, respectively, in the LAMA cohort, compared with 482 (21.3%) and 289 (12.8%) patients in the ICS/LABA cohort. Significantly more patients initiated open-triple therapy in the LAMA cohort compared with the ICS/LABA cohort (226 [15.4%] versus 174 [7.7%]; P<0.001); results were similar in the post hoc analyses. Mean (standard deviation) time to open-triple therapy was 79.8 (89.0) days in the LAMA cohort and 122.9 (105.4) days in the ICS/LABA cohort (P<0.001). This trend was also observed in the post hoc analyses, though the difference between cohorts was nonsignificant in the subset of patients with PFT information. DISCUSSION: In this population, patients with COPD are more likely to initiate open-triple therapy following LAMA therapy, compared with ICS/LABA therapy. Further research is required to identify factors associated with the need for treatment augmentation among patients with COPD.

Improving Rates of Influenza Vaccination Through Electronic Health Record Portal Messages, Interactive Voice Recognition Calls and Patient-Enabled Electronic Health Record Updates: Protocol for a Randomized Controlled Trial.

BACKGROUND: Clinical decision support (CDS), including computerized reminders for providers and patients, can improve health outcomes. CDS promoting influenza vaccination, delivered directly to patients via an electronic health record (EHR) patient portal and interactive voice recognition (IVR) calls, offers an innovative approach to improving patient care. OBJECTIVE: To test the effectiveness of an EHR patient portal and IVR outreach to improve rates of influenza vaccination in a large multispecialty group practice in central Massachusetts. METHODS: We describe a nonblinded, randomized controlled trial of EHR patient portal messages and IVR calls designed to promote influenza vaccination. In our preparatory phase, we conducted qualitative interviews with patients, providers, and staff to inform development of EHR portal messages with embedded questionnaires and IVR call scripts. We also provided practice-wide education on influenza vaccines to all physicians and staff members, including information on existing vaccine-specific EHR CDS. Outreach will target adult patients who remain unvaccinated for more than 2 months after the start of the influenza season. Using computer-generated randomization and a factorial design, we will assign 20,000 patients who are active users of electronic patient portals to one of the 4 study arms: (1) receipt of a portal message promoting influenza vaccines and offering online appointment scheduling; (2) receipt of an IVR call with similar content but without appointment facilitation; (3) both (1) and (2); or (4) neither (1) nor (2) (usual care). We will randomize patients without electronic portals (10,000 patients) to (1) receipt of IVR call or (2) usual care. Both portal messages and IVR calls promote influenza vaccine completion. Our primary outcome is percentage of eligible patients with influenza vaccines administered at our group practice during the 2014-15 influenza season. Both outreach methods also solicit patient self-report on influenza vaccinations completed outside the clinic or on barriers to influenza vaccination. Self-reported data from both outreach modes will be uploaded into the EHR to increase accuracy of existing provider-directed EHR CDS (vaccine alerts). RESULTS: With our proposed sample size and using a factorial design, power calculations using baseline vaccination rate estimates indicated that 4286 participants per arm would give 80% power to detect a 3% improvement in influenza vaccination rates between groups (α=.05; 2-sided). Intention-to-treat unadjusted chi-square analyses will be performed to assess the impact of portal messages, either alone or in combination with the IVR call, on influenza vaccination rates. The project was funded in January 2014. Patient enrollment for the project described here completed in December 2014. Data analysis is currently under way and first results are expected to be submitted for publication in 2016. CONCLUSIONS: If successful, this study's intervention may be adapted by other large health care organizations to increase vaccination rates among their eligible patients. CLINICALTRIAL: ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277 (Archived by WebCite at http://www.webcitation.org/6fbLviHLH).

Patient Portals: An Underused Resource for Improving Patient Engagement.

The potential of patient portals to improve patient engagement and health outcomes has been discussed for more than a decade. The slow growth in patient portal adoption rates among patients and providers in the United States, despite external incentives, indicates that this is a complex issue. We examined evidence of patient portal use and effects with a focus on the pulmonary domain. We found a paucity of studies of patient portal use in pulmonary practice, and highlight gaps for future research. We also report on the experience of a pulmonary department using a patient portal to highlight the potential of these systems.

Association of self-monitoring of blood glucose use on glycated hemoglobin and weight in newly diagnosed, insulin-naïve adult patients with type 2 diabetes.

BACKGROUND: Clinical trials have shown that self-monitoring of blood glucose (SMBG) combined with patient education and medication titration can lead to improved glycated hemoglobin (HbA1c) and reduced weight in recently diagnosed non-insulin-treated type 2 diabetes mellitus (T2DM) patients. This retrospective matched cohort study assessed the association of SMBG with achieving long-term clinical outcomes in these patients in a real-world clinical setting. METHODS: Using electronic medical records (2008-2011), we selected a population of adult patients recently diagnosed with T2DM not receiving insulin who were SMBG users and a population of non-SMBG controls with similar demographic and clinical characteristics using propensity score matching. The main study outcomes compared between the two groups were time to achieve (1) HbA1c <7% for patients with baseline HbA1c ≥ 7% and (2) a ≥ 5% reduction in weight from baseline. RESULTS: Of the 589 patients identified in each group, 113 in each group had a baseline HbA1c ≥ 7% (mean, 8.2%). The SMBG users were more likely to achieve an HbA1c <7% (12 months: 58.4% versus 38.9%, p = .0037; 36 months: 84.0% versus 70.0%, p = .0013) and to do so faster (median, 6.5 versus 20.5 months; log-rank p = .0016). Self-monitoring of blood glucose was associated with faster weight reduction (median time to achieve a ≥ 5% reduction, 23.5 versus 35.9 months for SMBG and non-SMBG, respectively; log-rank p = .0005). CONCLUSIONS: In newly diagnosed T2DM insulin-naïve patients, SMBG users had an improved rate of achieving long-term glycemic control and weight loss in a real-world clinical setting.