Amy D. Waterman

Accuracy of ICD-9-CM codes for identifying cardiovascular and stroke risk factors.

Objectives:We sought to determine which ICD-9-CM codes in Medicare Part A data identify cardiovascular and stroke risk factors. Design and Participants:This was a cross-sectional study comparing ICD-9-CM data to structured medical record review from 23,657 Medicare beneficiaries aged 20 to 105 years who had atrial fibrillation. Measurements:Quality improvement organizations used standardized abstraction instruments to determine the presence of 9 cardiovascular and stroke risk factors. Using the chart abstractions as the gold standard, we assessed the accuracy of ICD-9-CM codes to identify these risk factors. Main Results:ICD-9-CM codes for all risk factors had high specificity (>0.95) and low sensitivity (≤0.76). The positive predictive values were greater than 0.95 for 5 common, chronic risk factors—coronary artery disease, stroke/transient ischemic attack, heart failure, diabetes, and hypertension. The sixth common risk factor, valvular heart disease, had a positive predictive value of 0.93. For all 6 common risk factors, negative predictive values ranged from 0.52 to 0.91. The rare risk factors—arterial peripheral embolus, intracranial hemorrhage, and deep venous thrombosis—had high negative predictive value (≥0.98) but moderate positive predictive values (range, 0.54–0.77) in this population. Conclusions:Using ICD-9-CM codes alone, heart failure, coronary artery disease, diabetes, hypertension, and stroke can be ruled in but not necessarily ruled out. Where feasible, review of additional data (eg, physician notes or imaging studies) should be used to confirm the diagnosis of valvular disease, arterial peripheral embolus, intracranial hemorrhage, and deep venous thrombosis.

The Attitudes and Experiences of Trainees Regarding Disclosing Medical Errors to Patients

Purpose To measure trainees’ attitudes and experiences regarding medical error and error disclosure. Method In 2003, the authors carried out a cross-sectional survey of 629 medical students (320 in their second year, 309 in their fourth year), 226 interns (159 in medicine, 67 in surgery), and 283 residents (211 in medicine, 72 in surgery), a total 1,138 trainees at two U.S. academic health centers. Results The response rate was 78% (889/1,138). Most trainees (74%; 652/881) agreed that medical error is among the most serious health care problems. Nearly all (99%; 875/884) agreed serious errors should be disclosed to patients, but 87% (774/889) acknowledged at least one possible barrier, including thinking that the patient would not understand the disclosure (59%; 525/889), the patient would not want to know about the error (42%; 376/889), and the patient might sue (33%; 297/889). Personal involvement with medical errors was common among the fourth-year students (78%; 164/209) and the residents (98%; 182/185). Among residents, 45% (83/185) reported involvement in a serious error, 34% (62/183) reported experience disclosing a serious error, and 63% (115/183) had disclosed a minor error. Whereas only 33% (289/880) of trainees had received training in error disclosure, 92% (808/881) expressed interest in such training, particularly at the time of disclosure. Conclusions Although many trainees had disclosed errors to patients, only a minority had been formally prepared to do so. Formal disclosure curricula, coupled with supervised practice, are necessary to prepare trainees to independently disclose errors to patients by the end of their training.

BRIEF REPORT: Hospitalized Patients' Attitudes About and Participation in Error Prevention

BACKGROUND AND OBJECTIVE: Although many patient safety organizations and hospital leaders wish to involve patients in error prevention, it is unknown whether patients will take the recommended actions or whether error prevention involvement affects hospitalization satisfaction.DESIGN AND PARTICIPANTS: Telephone interviews with 2,078 patients discharged from 11 Midwest hospitals.RESULTS: Ninety-one percent agreed that patients could help prevent errors. Patients were very comfortable asking a medication’s purpose (91%), general medical questions (89%), and confirming their identity (84%), but were uncomfortable asking medical providers whether they had washed their hands (46% very comfortable). While hospitalized, many asked questions about their care (85%) and a medication’s purpose (75%), but fewer confirmed they were the correct patient (38%), helped mark their incision site (17%), or asked about handwashing (5%). Multivariate logistic regression revealed that patients who felt very comfortable with error prevention were significantly more likely to take 6 of the 7 error-prevention actions compared with uncomfortable patients.CONCLUSIONS: While patients were generally comfortable with error prevention, their participation varied by specific action. Since patients who were very comfortable were most likely to take action, educational interventions to increase comfort with error prevention may be necessary to help patients become more engaged.

Consensus conference on best practices in live kidney donation: Recommendations to optimize education, access, and care

Live donor kidney transplantation is the best treatment option for most patients with late‐stage chronic kidney disease; however, the rate of living kidney donation has declined in the United States. A consensus conference was held June 5–6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Transplant professionals, patients, and other key stakeholders discussed processes for educating transplant candidates and potential living donors about living kidney donation; efficiencies in the living donor evaluation process; disparities in living donation; and financial and systemic barriers to living donation. We summarize the consensus recommendations for best practices in these educational and clinical domains, future research priorities, and possible public policy initiatives to remove barriers to living kidney donation.

Living kidney donor follow-up: State-of-the-art and future directions, conference summary and recommendations

In light of continued uncertainty regarding postkidney donation medical, psychosocial and socioeconomic outcomes for traditional living donors and especially for donors meeting more relaxed acceptance criteria, a meeting was held in September 2010 to (1) review limitations of existing data on outcomes of living kidney donors; (2) assess and define the need for long‐term follow‐up of living kidney donors; (3) identify the potential system requirements, infrastructure and costs of long‐term follow‐up for living kidney donor outcomes in the United States and (4) explore practical options for future development and funding of United States living kidney donor data collection, metrics and endpoints. Conference participants included prior kidney donors, physicians, surgeons, medical ethicists, social scientists, donor coordinators, social workers, independent donor advocates and representatives of payer organizations and the federal government. The findings and recommendations generated at this meeting are presented.

Modifiable Patient Characteristics and Racial Disparities in Evaluation Completion and Living Donor Transplant

BACKGROUND AND OBJECTIVES To reduce racial disparities in transplant, modifiable patient characteristics associated with completion of transplant evaluation and receipt of living donor kidney transplant must be identified. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS From 2004 to 2007, 695 black and white patients were surveyed about 15 less-modifiable and 10 more-modifiable characteristics at evaluation onset; whether they had completed evaluation within 1 year and received living donor kidney transplants by 2010 was determined. Logistic regression and competing risks time-to-event analysis were conducted to determine the variables that predicted evaluation completion and living donor kidney transplant receipt. RESULTS Not adjusting for covariates, blacks were less likely than whites to complete evaluation (26.2% versus 51.8%, P<0.001) and receive living donor kidney transplants (8.7% versus 21.9%, P<0.001). More-modifiable variables associated with completing evaluation included more willing to be on the waiting list (odds ratio=3.4, 95% confidence interval=2.1, 5.7), more willing to pursue living donor kidney transplant (odds ratio=2.7, 95% confidence interval=1.8, 4.0), having access to more transplant education resources (odds ratio=2.2, 95% confidence interval=1.5, 3.2), and having greater transplant knowledge (odds ratio=1.8, 95% confidence interval=1.2, 2.7). Patients who started evaluation more willing to pursue living donor kidney transplant (hazard ratio=4.3, 95% confidence interval=2.7, 6.8) and having greater transplant knowledge (hazard ratio=1.2, 95% confidence interval=1.1, 1.3) were more likely to receive living donor kidney transplants. CONCLUSIONS Because patients who began transplant evaluation with greater transplant knowledge and motivation were ultimately more successful at receiving transplants years later, behavioral and educational interventions may be very successful strategies to reduce or overcome racial disparities in transplant.

Depression diagnoses after living kidney donation: linking U.S. Registry data and administrative claims.

Background Limited data exist on correlates of psychological outcomes after kidney donation. Methods We used a database integrating Organ Procurement and Transplantation Network registrations for 4650 living kidney donors from 1987 to 2007 with administrative data of a U.S. private health insurer (2000–2007 claims) to identify depression diagnoses among prior living donors. The burden and demographic correlates of depression after enrollment in the insurance plan were estimated by Cox regression. Graft failure and death of the donor’s recipient were examined as time-varying exposures. Results After start of insurance benefits, the cumulative frequency of depression diagnosis was 4.2% at 1 year and 11.5% at 5 years, and depression among donors was less common than among age- and gender-matched general insurance beneficiaries (rate ratio, 0.70; 95% confidence intervals [CI], 0.60–0.81). Demographic and clinical correlates of increased likelihood of depression diagnoses among the prior donors included female gender, white race, and some perioperative complications. After adjustment for donor demographic factors, recipient death (adjusted hazard ratio (aHR), 2.23; 95% CI, 1.11–4.48) and death-censored graft failure (aHR, 3.30; 95% CI, 1.49–7.34) were associated with two to three times the relative risk of subsequent depression diagnosis among nonspousal unrelated donors. There were trends toward increased depression diagnoses after recipient death and graft failure among spousal donors but no evidence of associations of these recipient events with the likelihood of depression diagnosis among related donors. Conclusions Recipient death and graft loss predict increased depression risk among unrelated living donors in this privately insured sample. Informed consent and postdonation care should consider the potential impact of recipient outcomes on the psychological health of the donor.

Attitudes and Behaviors of African Americans Regarding Early Detection of Kidney Disease

BACKGROUND Chronic kidney disease (CKD) is an African American public health crisis. To inform interventions, the National Kidney Disease Education Program surveyed African Americans about their attitudes and behaviors regarding early detection of kidney disease and screening. STUDY DESIGN Cross-sectional study. SETTING & PARTICIPANTS 2,017 African Americans from 7 states (Georgia, Maryland, Ohio, Mississippi, Louisiana, Missouri, and Tennessee) selected by using a random-digit dialing telephone survey (response rate, 42.4%). PREDICTORS Demographic, risk, knowledge, and behavior variables. OUTCOMES & MEASUREMENTS Perception of CKD as a top health concern, perceived risk of getting kidney disease, and accurate knowledge about CKD and its prevention. RESULTS Only 23.5% of African Americans were screened for kidney disease in the last year. Although almost half (43.7%) of African Americans had a CKD risk factor, only 2.8% reported that CKD was a top health concern. Almost half knew the correct definition of kidney disease (48.6%), but few knew a test to diagnose CKD (23.7%) or that African Americans were at greater risk of developing CKD (18.1%). African Americans who had diabetes (odds ratio [OR], 3.22; 95% confidence interval [CI], 2.17 to 4.76), hypertension (OR, 1.78; 95% CI, 1.28 to 2.44), at least a bachelors degree (OR, 1.77; 95% CI, 1.17 to 2.66), who had spoken with a medical professional (OR, 1.85; 95% CI, 1.19 to 2.85) or their family (OR, 1.61; 95% CI, 1.11 to 2.38) about kidney disease, who knew that a family history of kidney disease is a risk factor (OR, 2.32; 95% CI, 1.08 to 5.0), and who had been tested for CKD in the last year (OR, 1.45; 95% CI, 1.03 to 2.0) were more likely to correctly perceive themselves at increased risk. LIMITATIONS Respondents were primarily African American women from urban areas. CONCLUSIONS Most African Americans have poor knowledge about CKD, do not perceive it as an important health problem, and are not getting screened. To increase early detection of kidney disease through screenings, educational efforts linking kidney disease prevention to other diseases that are health priorities for African Americans are necessary.

Patient and physician satisfaction with a telephone-based anticoagulation service.

AbstractOBJECTIVES: To compare the satisfaction and knowledge of patients who have their warfarin managed by their physician or by a multidisciplinary, telephone-based anticoagulation service (ACS) and to assess referring physicians’ satisfaction with the ACS. DESIGN AND PARTICIPANTS: We surveyed 300 patients taking warfarin (mean age 73 years): 150 at health centers randomized to have access to an ACS, and 150 at control health centers without ACS access. We also surveyed 17 physicians who refer patients to the ACS. SETTING: Eight outpatient health centers in Missouri and Southern Illinois. MEASUREMENTS: We asked patients about the timeliness of international normalized ratio (INR) monitoring, perceived safety of warfarin, overall satisfaction with their warfarin management, and knowledge of what a high INR meant. We asked physicians at ACS-available health centers how many minutes they saved per INR by referring patients to the ACS, their satisfaction with the ACS, and their willingness to recommend the ACS to a colleague. MAIN RESULTS: As compared with patients at control health centers, patients at ACS-available health centers were more satisfied with the timeliness of getting blood test results (mean 4.31 vs 4.03, P=.02), were more likely to know what a safe INR value was (45% vs 15%, P=.001), and felt safer taking warfarin (mean 5.7 vs 5.2, P=.04). Physicians reported that using the ACS saved, on average, four minutes of their time and 13 minutes of their staff’s time, per INR. All physicians recommended use of the ACS to a colleague and were highly satisfied with the ACS. CONCLUSIONS: A telephone-based ACS can be endorsed by primary-care physicians and improve patients’ satisfaction with and knowledge about their antithrombotic therapy.

The "House Calls" Trial: A Randomized Controlled Trial to Reduce Racial Disparities in Live Donor Kidney Transplantation: Rationale and Design☆ , ☆☆

Despite a substantially lower rate of live donor kidney transplantation among Black Americans compared to White Americans, there are few systematic efforts to reduce this racial disparity. This paper describes the rationale and design of a randomized controlled trial evaluating the comparative effectiveness of three different educational interventions for increasing live donor kidney transplantation in Black Americans. This trial is a single-site, urn-randomized controlled trial with a planned enrollment of 180 Black Americans awaiting kidney transplantation. Patients are randomized to receive transplant education in one of three education conditions: through group education at their homes (e.g., House Calls), or through group (Group-Based) or individual education (Individual Counseling) in the transplant center. The primary outcome of the trial is the occurrence of a live donor kidney transplant, with secondary outcomes including living donor inquiries and evaluations as well as changes in patient live donor kidney transplantation readiness, willingness, knowledge, and concerns. Sex, age, dialysis status, and quality of life are evaluated as moderating factors. Findings from this clinical trial have the potential to inform strategies for reducing racial disparities in live donor kidney transplantation. Similar trials have been developed recently to broaden the evaluation of House Calls as an innovative disparity-reducing intervention in kidney transplantation.