Albert Hoang

Predicting response to adjuvant and radiation therapy in patients with early stage breast carcinoma

Screening and surveillance is increasing the detection of early stage breast carcinoma. The ability to predict accurately the response to adjuvant therapy (chemotherapy or tamoxifen therapy) or postlumpectomy radiation therapy in these patients can be vital to their survival, because this prediction determines the best postsurgical therapy for each patient.

Electronic health records improve clinical note quality

Background and objective The clinical note documents the clinicians information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes. Materials and methods A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes. Results The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval. Conclusions The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.

Clinical and laboratory evaluation of all-trans retinoic acid modulation of chemotherapy in patients with acute myelogenous leukaemia.

All‐trans retinoic acid (ATRA) is synergistic with chemotherapy in leukaemia cell lines. We treated 53 patients with newly diagnosed acute myelogenous leukaemia (AML) with high‐dose cytarabine‐based chemotherapy followed by ATRA. Peripheral blood and bone marrow samples were obtained to study the effect of in vitro exposure to ATRA and to measure apoptosis and bcl‐2. The response rate was 72% for patients under age 60 years and 46% for patients aged 60 years or above. There was no difference in the percentage of responding patients, time to recurrence or overall survival for patients receiving chemotherapy with ATRA vs. historical controls receiving chemotherapy without ATRA. After in vitro exposure of day 3 bone marrow samples to ATRA, there was an increase in apoptotic cells in 25% of patient samples compared with samples not exposed to ATRA. Later date of peak apoptosis in peripheral blood and higher percentage of apoptotic cells in bone marrow on day 3 of treatment were associated with lack of clinical response to treatment. Increased bcl‐2 in patient samples was associated with shorter time to recurrence and poor cytogenetic risk. The addition of ATRA to chemotherapy did not improve patient outcome. However, evidence of in vitro response to ATRA in 25% of patients suggests that retinoid pathways should be studied further in patients with AML.

Long-term survival of patients with resistant lymphoma treated with tandem stem cell transplant

Dose-intensive chemotherapy with autologous stem cell support is commonly used in resistant/refractory cases of Hodgkins disease (HD) and non-Hodgkins lymphoma (NHL). The purpose of this study was to evaluate the role of tandem transplantation in these patients. We used non cross-resistant conditioning regimens with thiotepa, mitoxantrone and carboplatin (TMJ) followed by ifosphamide, carboplatin and etoposide (ICE) with autologous stem cell rescue in an attempt to maximize dose intensity and achieve long-term remission. Seventy-six patients were included in this study. Twenty-nine patients with HD and 47 with NHL underwent autologous stem cell transplant using TMJ as the conditioning regimen for the first transplant. Of these, 49 patients proceeded to the second transplant using ICE as the conditioning regimen. In 57 patients, only peripheral blood cells were used and in 11 patients both bone marrow and peripheral stem cells were used. Twelve patients died due to treatment-related toxicity. On an intent to treat basis, 32.14% of patients with HD refractory to initial or subsequent therapy survived long term as opposed to 12.76% of patients with NHL. With a median follow-up of 83 months (range 25 - 110 months), the median disease-free survival of patients with HD was 7 months, as opposed to 2 months for patients with NHL. Multivariate analysis identified that patients with HD had a superior outcome if they were less than 35 years of age and did not have B symptoms. Dose-intensive chemotherapy with tandem transplantation is an option in patients with resistant/refractory lymphoma who have very limited treatment options and poor prognosis.

QNOTE: an instrument for measuring the quality of EHR clinical notes

Background and objective The outpatient clinical note documents the clinicians information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole. Materials and methods Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ. Results The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04). Conclusions We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.

The adoption of an electronic health record did not improve A1c values in Type 2 diabetes

Background A major justification for the clinical adoption of electronic health records (EHRs) was the expectation that it would improve the quality of medical care. No longitudinal study has tested this assumption. Objective We used hemoglobin A1c, a recognized clinical quality measure directly related to diabetes outcomes, to assess the effect of EHR use on clinical quality. Methods We performed a five-and-one-half-year multicentre longitudinal retrospective study of the A1c values of 537 type 2 diabetic patients. The same patients had to have been seen on at least three occasions: once approximately six months prior to EHR adoption (before-EHR), once approximately six months after EHR adoption (after-EHR) and once approximately five years after EHR adoption (five-years), for a total of 1,611 notes. Results The overall mean confidence interval (CI) A1c values for the before-EHR, after-EHR and five-years were 7.07 (6.91 – 7.23), 7.33 (7.14 – 7.52) and 7.19 (7.06 – 7.32), respectively. There was a small but significant increase in A1c values between before-EHR and after-EHR, p = .04; there were no other significant differences. There was a significant decrease in notes missing at least one A1c value, from 42% before-EHR to 16% five-years (p < .001). Conclusion We found that based on patient’s A1c values, EHRs did not improve the clinical quality of diabetic care in six months and five years after EHR adoption. To our knowledge, this is the first longitudinal study to directly assess the relationship between the use of an EHR and clinical quality.

Intravenous Bolus Topotecan in Patients with Myelodysplastic Syndrome

We treated 16 patients with myelodysplastic syndromes with 24 courses of bolus topotecan. Patients received topotecan as a daily 15 minute infusion for 5 days at 3 dose levels (4.0 mg/m2/d, 2.0 mg/m2/d or 2.5 mg/m2/d). There was one complete response and one partial response (overall response rate 12%). Toxicity included myelosuppression, diarrhea, ileus and mucositis. There were 3 treatment-related deaths. The results of this schedule of topotecan appeared to be inferior to that reported with infusional topotecan in patients with MDS.

Point-of-Care Estimated Radiation Exposure and Imaging Guidelines Can Reduce Pediatric Radiation Burden

Introduction: The steady increase in the use of computed tomography (CT) has particular concerns for children. Family physicians must often select pediatric imaging without any decision support. We hypothesized that point-of-care decision support would lead to the selection of imaging that lowered radiation exposure and improved guideline congruence. Methods: Our double-blind, randomized simulation included family physicians in the Military Health System. Participants initially reviewed a pediatric hematuria scenario and selected imaging without decision support. Participants were subsequently randomized to either receive imaging-appropriateness guidelines and then estimated radiation exposure information or receive estimated radiation information then guidelines; imaging selections were required after each step. The primary outcome was the selected imaging modality with point-of-care decision support. Results: The first arm increased CT ordering after viewing the guidelines (P = .008) but then decreased it after reviewing radiation exposure information (P = .007). In the second arm radiation information decreased CT and plain film use (P = not significant), with a subsequent increase in ultrasound and CT after the guideline presentation (P = .05). Conclusions: Decision support during a simulated pediatric scenario helped family physicians select imaging that lowered radiation exposure and was aligned with current guidelines, especially when presented with radiation information after guideline review. This information could help inform electronic medical record design.

Assessing the usability by clinicians of VISION: A hierarchical display of patient-collected physiological information to clinicians

BackgroundThe inability of patients to accurately and completely recount their clinical status between clinic visits reduces the clinician’s ability to properly manage their patients. One way to improve this situation is to collect objective patient information while the patients are at home and display the collected multi-day clinical information in parallel on a single screen, highlighting threshold violations for each channel, and allowing the viewer to drill down to any analog signal on the same screen, while maintaining the overall physiological context of the patient. All this would be accomplished in a way that was easy for the clinician to view and use.MethodsPatients used five mobile devices to collect six heart failure-related clinical variables: body weight, systolic and diastolic blood pressure, pulse rate, blood oxygen saturation, physical activity, and subjective input. Fourteen clinicians practicing in a heart failure clinic rated the display using the System Usability Scale that, for acceptability, had an expected mean of 68 (SD, 12.5). In addition, we calculated the Intraclass Correlation Coefficient of the clinician responses using a two-way, mixed effects model, ICC (3,1).ResultsWe developed a single-screen temporal hierarchical display (VISION) that summarizes the patient’s home monitoring activities between clinic visits. The overall System Usability Scale score was 92 (95% CI, 87-97), p < 0.0001; the ICC was 0.89 (CI, 0.79-0.97), p < 0.0001.ConclusionClinicians consistently found VISION to be highly usable. To our knowledge, this is the first single-screen, parallel variable, temporal hierarchical display of both continuous and discrete information acquired by patients at home between clinic visits that presents clinically significant information at the point of care in a manner that is usable by clinicians.