Andrew D. Schreiner

Assessing the Burden of Abnormal LFTs and the Role of the Electronic Health Record: A Retrospective Study

Background: Primary care clinicians encounter abnormal liver function tests (LFTs) frequently. This study assesses the prevalence of abnormal LFTs and patient follow‐up patterns in response. Methods: This is a retrospective study from 2007‐2016 of adult patients with abnormal LFTs seen in an internal medicine clinic. The proportion of patients with follow‐up testing and the time (in days) to repeat LFTs were the primary outcomes measured. Results were evaluated before and after the implementation of the institution’s electronic health record (EHR). Results: This study identified a period prevalence for abnormal LFTs of 39%. Of these, 9,545 unique patients met inclusion criteria, with 8,415 patients (88.2%) possessing follow‐up LFTs and no significant difference in the proportion of patients receiving follow‐up by degree of initial abnormality. Median time to follow‐up in mild abnormalities (1‐2 times normal) was 138 days, compared to 21 days for severe abnormalities (>4 times normal, P < 0.0001). Reduced time to repeat testing across all spectrums of abnormality was observed following EHR implementation, but proportions of missing follow‐up did not improve. A multivariable logistic regression model identified younger age, poverty, living over 50 miles from clinic, recent cohort entry and a lower magnitude of abnormality as predictors for missing repeat LFT testing (area under the curve = 0.838 [95% CI: 0.827‐0.849]). Conclusions: Abnormal LFTs were detected in 39% of all patients seen. The degree of LFT abnormality did not influence rates of follow‐up testing, but does appear to play a role in the timing of repeat testing, when obtained. Follow‐up rates did not improve with EHR implementation.

Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003–2014

Background One in 3 US adults has high blood pressure, or hypertension. As prior projections suggest hypertension is the costliest of all cardiovascular diseases, it is important to define the current state of healthcare expenditures related to hypertension. Methods and Results We used a nationally representative database, the Medical Expenditure Panel Survey, to calculate the estimated annual healthcare expenditure for patients with hypertension and to measure trends in expenditure longitudinally over a 12‐year period. A 2‐part model was used to estimate adjusted incremental expenditures for individuals with hypertension versus those without hypertension. Sex, race/ethnicity, education, insurance status, census region, income, marital status, Charlson Comorbidity Index, and year category were included as covariates. The 2003–2014 pooled data include a total sample of 224 920 adults, of whom 36.9% had hypertension. Unadjusted mean annual medical expenditure attributable to patients with hypertension was

Evaluation of liver test abnormalities in a patient-centered medical home: do liver test patterns matter?

9089. Relative to individuals without hypertension, individuals with hypertension had

Associations of Race with Follow-up Patterns After Initial Abnormal Liver Tests in Primary Care

1920 higher annual adjusted incremental expenditure, 2.5 times the inpatient cost, almost double the outpatient cost, and nearly triple the prescription medication expenditure. Based on the prevalence of hypertension in the United States, the estimated adjusted annual incremental cost is

The Structure of Medical Intensive Care Units at Training Institutions

131 billion per year higher for the hypertensive adult population compared with the nonhypertensive population. Conclusions Individuals with hypertension are estimated to face nearly

Endurance swimming and increased risk of atrial fibrillation

2000 higher annual healthcare expenditure compared with their nonhypertensive peers. This trend has been relatively stable over 12 years. Healthcare costs associated with hypertension account for about

Chaos to complexity: leveling the playing field for measuring value in primary care

131 billion. This warrants intense effort toward hypertension prevention and management.

Primary care and chronic disease: the intersection of comfort and specialty involvement – a cross‐sectional study

Abnormal liver tests are extremely common in clinical practice, present with varying patterns and degrees of elevation, and can signal liver injury from a variety of causes. Responding to these abnormalities requires complex medical decision-making and merits investigation in primary care. This retrospective study investigates the association of patterns of liver test abnormality with follow-up in primary care. Using administrative data, this study includes patients with abnormal liver tests seen between 2007 and 2016 in a patient-centered medical home. Liver tests examined include serum bilirubin, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. Patients entered the cohort on the first liver test elevation. The outcome examined was completion of repeat testing, and the proportions of patients without follow-up were compared by patterns of index abnormality. 9545 patients met the inclusion criteria. Of these, 6155 (64.5%) possessed one liver test abnormality and 3390 (35.5%) possessed multiple abnormalities on index testing. Overall 1119 (11.7%) patients did not have repeat testing performed during the study period. A greater proportion of patients with lone abnormalities lacked repeat testing compared with those patients with multiple abnormalities. Differences in repeat testing appeared when comparing clinical patterns of abnormality, with higher proportions of follow-up in patients with testing suggestive of cholestasis. Over 11% of patients with abnormal liver tests did not undergo repeat testing during the study period. Repeat testing occurred more often in patients with multiple abnormalities and in clinical patterns suggestive of cholestasis. This study highlights a potential opportunity to improve quality of care.

Long-Term, Competitive Swimming and the Association with Atrial Fibrillation

Black patients are at higher risk than white patients of having liver diseases such as viral hepatitis, cirrhosis, and hepatocellular carcinoma . Abnormal liver tests occur frequently in the primary care setting, suggesting possible early or previously undiagnosed liver diseases. Current guidelines recommend repeating liver tests as an initial step in response to abnormalities . As such, prompt follow-up of abnormal tests may offer the potential to diagnose and treat liver disease early, reducing the risk of progression to cirrhosis . Little is known about the associations of race with follow-up patterns after initial abnormal liver tests. This was the first study that examined the black-white differences in follow-up testing after the initial abnormalities in primary care.

Trends in Follow-Up Liver Chemistry Testing: A Retrospective Cohort Study

Background: As a result of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour guideline implementation, the structure of intensive care unit (ICU) teams at training institutions has been affected. The impact these changes have had on the current work environment has not been well described. Methods: The authors conducted an online survey of internal medicine program directors in 2016. The survey investigated how training institutions structure their intensive care units in reference to volume, resident housestaff and alternative coverage options, with a focus on changes made after the implementation of the 2011 ACGME duty hour restrictions. Results: Notable differences were found in program director responses to coverage of patients in the ICUs. A total of 62 of the 132 (48%) responding program directors describe coverage of all patients solely by resident housestaff. Since 2011, 54 (41%) programs have increased the number of resident physicians rotating in the ICU per month and initiated or increased the use of nonresident coverage of patients. Use of non‐resident providers is not associated with a decrease in the number of total ICU months per resident or a decrease in educational value. Conclusions: Since the 2011 ACGME duty hour implementation, there is wide variability in the learning environment of medical intensive care units in training institutions.