Albert G. Crawford

Prevalence of Obesity, Type II Diabetes Mellitus, Hyperlipidemia, and Hypertension in the United States: Findings from the GE Centricity Electronic Medical Record Database

This study analyzed GE Centricity Electronic Medical Record (EMR) data to examine the effects of body mass index (BMI) and obesity, key risk factor components of metabolic syndrome, on the prevalence of 3 chronic diseases: type II diabetes mellitus, hyperlipidemia, and hypertension. These chronic diseases occur with high prevalence and impose high disease burdens. The rationale for using Centricity EMR data is 2-fold. First, EMRs may be a good source of BMI/obesity data, which are often underreported in surveys and administrative databases. Second, EMRs provide an ideal means to track variables over time and, thus, allow longitudinal analyses of relationships between risk factors and disease prevalence and progression. Analysis of Centricity EMR data showed associations of age, sex, race/ethnicity, and BMI with diagnosed prevalence of the 3 conditions. Results include uniform direct correlations between age and BMI and prevalence of each disease; uniformly greater disease prevalence for males than females; varying differences by race/ethnicity (ie, African Americans have the highest prevalence of diagnosed type II diabetes and hypertension, while whites have the highest prevalence of diagnosed hypertension); and adverse effects of comorbidities. The direct associations between BMI and disease prevalence are consistent for males and females and across all racial/ethnic groups. The results reported herein contribute to the growing literature about the adverse effects of obesity on chronic disease prevalence and about the potential value of EMR data to elucidate trends in disease prevalence and facilitate longitudinal analyses.

Comparison of GE Centricity Electronic Medical Record Database and National Ambulatory Medical Care Survey Findings on the Prevalence of Major Conditions in the United States

The study objective was to facilitate investigations by assessing the external validity and generalizability of the Centricity Electronic Medical Record (EMR) database and analytical results to the US population using the National Ambulatory Medical Care Survey (NAMCS) data and results as an appropriate validation resource. Demographic and diagnostic data from the NAMCS were compared to similar data from the Centricity EMR database, and the impact of the different methods of data collection was analyzed. Compared to NAMCS survey data on visits, Centricity EMR data shows higher proportions of visits by younger patients and by females. Other comparisons suggest more acute visits in Centricity and more chronic visits in NAMCS. The key finding from the Centricity EMR is more visits for the 13 chronic conditions highlighted in the NAMCS survey, with virtually all comparisons showing higher proportions in Centricity. Although data and results from Centricity and NAMCS are not perfectly comparable, once techniques are employed to deal with limitations, Centricity data appear more sensitive in capturing diagnoses, especially chronic diagnoses. Likely explanations include differences in data collection using the EMR versus the survey, particularly more comprehensive medical documentation requirements for the Centricity EMR and its inclusion of laboratory results and medication data collected over time, compared to the survey, which focused on the primary reason for that visit. It is likely that Centricity data reflect medical problems more accurately and provide a more accurate estimate of the distribution of diagnoses in ambulatory visits in the United States. Further research should address potential methodological approaches to maximize the validity and utility of EMR databases.

Have Endovascular Procedures Negatively Impacted General Surgery Training

Objective:Technological advances in vascular surgery have changed the field dramatically over the past 10 years. Herein, we evaluate the impact of endovascular procedures on general surgery training. Methods:National operative data from the Residency Review Committee for Surgery were examined from 1997 through 2006. Total major vascular operations, traditional open vascular operations and endovascular procedures were evaluated for mean number of cases per graduating chief general surgery resident (GSR) and vascular surgery fellow (VSF). Results:As endovascular surgical therapies became widespread, GSR vascular case volume decreased 34% over 10 years, but VSF total cases increased 78%. GSR experience in open vascular operations decreased significantly, as evidenced by a 52% decrease (P < 0.0001) in elective open AAA repair. VSFs have also seen significant decreases in open vascular procedures. Experience in endovascular procedures has increased for both general surgery and vascular residents, but the increase has been much larger in absolute number for VSFs. Conclusions:GSR experience in open vascular procedures has significantly decreased as technology has advanced within the field. Unlike VSFs, this loss has not been replaced by direct experience with endovascular training. These data demonstrate the impact technology can have on how we currently train general surgeons. New educational paradigms may be necessary in which either vascular surgery as an essential component is abandoned or training in catheter-based interventions becomes required.

Interactive voice response reminder effects on preventive service utilization.

This study evaluated the effects of interactive voice response (IVR) system reminders to managed care organization (MCO) members to obtain mammograms, Papanicolaou (Pap) tests, and influenza immunizations. The MCO identified 3 member cohorts and sent IVR reminders to get preventive services. Analyses employed claims data to examine relationships between IVR reminders and preventive service use 5 to 9 months postintervention among members without prior utilization. Multivariate logistic regressions controlling for age, gender (for influenza immunizations), and risk stratum confirmed hypothesized relationships between intervention and preventive services: mammograms, odds ratio (OR) = 1.263 (95% confidence interval [CI] = 1.104, 1.444); Pap tests, OR = 1.241 (1.107, 1.391); influenza immunizations, OR = 2.072 (1.665, 2.580). IVR reminders are associated with higher rates of mammograms, Pap tests, and influenza immunizations. Study limitations include unknown generalizability of results and possible self-selection. There is justification for more IVR interventions and research to enhance MCO members’ preventive service utilization.

Ventral Hernia Repairs: 10-Year Single-Institution Review at Thomas Jefferson University Hospital

w s a h s t ostoperative incisional hernias remain a common comlication of abdominal surgery. “Any abdominal wall ap with or without bulge in the area of a postoperative car perceptible or palpable by clinical examination or maging” is an accepted definition of an incisional heria. Recurrent ventral hernias after open suture repair an occur with a reported frequency of 31% to 49%. he adjunctive use of a prosthetic material to the repair ppears to attenuate this rate to 0 to 10%. The recurence rate of incisional hernias increases to 20% after astric bypass or weight loss. Despite the great morbidty associated with incisional hernia, no consensus exists n the best means for treatment. Ramirez and coleagues first described the use of a bilateral, innervated ectus abdominus-internal oblique muscle flap that is ransposed medially to repair the central abdominal all. Subsequent work has since validated the use of this echnique to reduce the incidence of postoperative ernia. Our group first reported on the relative success of the liding rectus abdominus myofascial flap in 1996. The echnique of midline advancement and onlay mesh renforcement is illustrated in Figure 1 and Figure 2, espectively. Recurrence of herniation was found in only 3 of 35 atients, a failure rate of 8.5%. In the current retrospecively review, 3,028 ventral hernia repairs were performed. s illustrated in Figures 1 and 2, the external oblique fascia as released without violating the posterior rectus sheath. nly the midline anterior rectus sheath was reinforced ith the midline onlay. Release of the posterior rectus heath for additional advancement in the underlay or inerposition techniques was not used in this series. Two

Active Breathing Coordinator reduces radiation dose to the heart and preserves local control in patients with left breast cancer: Report of a prospective trial

PURPOSE Incidental radiation dose to the heart and lung during breast radiation therapy (RT) has been associated with an increased risk of cardiopulmonary morbidity. We conducted a prospective trial to determine if RT with the Active Breathing Coordinator (ABC) can reduce the mean heart dose (MHD) by ≥20% and dose to the lung. METHODS AND MATERIALS Patients with stages 0-III left breast cancer (LBC) were enrolled and underwent simulation with both free breathing (FB) and ABC for comparison of dosimetry. ABC was used during the patients RT course if the MHD was reduced by ≥5%. The median prescription dose was 50.4 Gy plus a boost in 77 patients (90%). The primary endpoint was the magnitude of MHD reduction when comparing ABC to FB. Secondary endpoints included dose reduction to the heart and lung, procedural success rate, and adverse events. RESULTS A total of 112 patients with LBC were enrolled from 2002 to 2011 and 86 eligible patients underwent both FB and ABC simulation. Ultimately, 81 patients received RT using ABC, corresponding to 72% procedural success. The primary endpoint was achieved as use of ABC reduced MHD by 20% or greater in 88% of patients (P < .0001). The median values for absolute and relative reduction in MHD were 1.7 Gy and 62%, respectively. RT with ABC provided a statistically significant dose reduction to the left lung. After a median follow up of 81 months, 8-year estimates of locoregional relapse, disease-free, and overall survival were 7%, 90%, and 96%, respectively. CONCLUSIONS ABC was well tolerated and significantly reduced MHD while preserving local control. Use of the ABC device during RT should be considered to reduce the risk of ischemic heart disease in populations at risk.

Quality of Care for 2 Common Pediatric Conditions Treated by Convenient Care Providers

Rates of adherence to 2 quality measures, modeled after Heathcare Effectiveness Data and Information Set (HEDIS) measures, were evaluated in a pediatric population in a convenient care (retail medicine) clinic setting. The measures were appropriate testing for children with pharyngitis and appropriate treatment for children with upper-respiratory infection (URI). The convenient care clinic (CCC) achieved a ranking above the HEDIS 90th percentile for the pharyngitis measure and approximately midway between the 50th and 90th percentiles for the URI measure for the 2007 reporting period. This represents the third major study reporting quality of care for pharyngitis in a CCC setting and the first study for URIs. Other aspects of quality—namely access, follow-up, and equity—are also reported on for the population in question.

Disaster Preparedness What Training Do Our Interns Receive During Medical School

Disaster preparedness training is a critical component of medical student education. Despite recent natural and man-made disasters, there is no national consensus on a disaster preparedness curriculum. The authors designed a survey to assess prior disaster preparedness training among incoming interns at an academic teaching hospital. In 2010, the authors surveyed incoming interns (n = 130) regarding the number of hours of training in disaster preparedness received during medical school, including formal didactic sessions and simulation, and their level of self-perceived proficiency in disaster management. Survey respondents represented 42 medical schools located in 20 states. Results demonstrated that 47% of interns received formal training in disaster preparedness in medical school; 64% of these training programs included some type of simulation. There is a need to improve the level of disaster preparedness training in medical school. A national curriculum should be developed with aspects that promote knowledge retention.

Implementing the physician quality reporting system in an academic multispecialty group practice: lessons learned and policy implications.

The Centers for Medicare and Medicaid Services (CMS) introduced the Physician Quality Reporting System (PQRS) in 2007. PQRS was developed as a value-based, pay-for-reporting initiative intended to increase quality and decrease costs. Jefferson University Physicians (JUP) was an early participant in this voluntary program. In this article, the policy context for CMS’s launch of PQRS and JUP’s implementation strategy, lessons learned, and an account of benefits and barriers to participation are reviewed. In 2010, JUP achieved 94% provider participation and an average incentive of

Quality Measurement in Diabetes Care

772 per participating provider. Net incentives earned across JUP in 2010 topped