Evgenia Teal

Association of refill adherence and health care use among adults with hypertension in an urban health care system

Study Objectives. To determine the rates of undersupply appropriate supply, and oversupply of antihypertensive drugs, as measured by refill adherence, among patients with complicated and uncomplicated hypertension (i.e., patients who have and have not, respectively, experienced hypertension‐related target organ damage), and to examine the association of refill adherence with hospitalization and health care costs among these patients.

Effect of Rosiglitazone on Serum Liver Biochemistries in Diabetic Patients with Normal and Elevated Baseline Liver Enzymes

OBJECTIVES:Thiazolidinediones (TZD) are recommended to be used cautiously in diabetics with mild elevations in liver enzymes and not to be used in those with alanine aminotransferase >2.5 upper limit normal (ULN). However, studies are not adequate that evaluated the risk of TZD hepatotoxicity in diabetics with elevated liver enzymes. We conducted a study to test if diabetics with elevated liver enzymes have increased risk for hepatotoxicity from rosiglitazone (only TZD available on our formulary).METHODS:This study consisted of two cohorts of patients prescribed rosiglitazone since January 2000. Cohort 1: 210 diabetics with elevated baseline liver enzymes (aspartate aminotransferase (AST) >40 IU/L and/or alanine aminotransferase (ALT) >35 IU/L) who received rosiglitazone, and cohort 2: 628 diabetics with normal liver enzymes who received rosiglitazone. Elevations in liver biochemistries over a 12-month period after initiating rosiglitazone were characterized into mild to moderate or severe elevations and into “Hys rule” based on published criteria.RESULTS:Compared to cohort 2, patients in cohort 1 did not have higher incidence of mild to moderate (10% vs 6.6%, p= 0.2) or severe elevations (0.9% vs 0.6%, p= 0.9) in liver biochemistries. Similarly, the incidence of liver biochemistry abnormalities meeting the Hys Rule was statistically not different between the two cohorts (0% vs 0.3%, p= 0.9). The frequency of discontinuing rosiglitazone therapy during the follow-up was similar between cohorts 1 and 2 (8.6% vs 8.1%, p= 1.0).CONCLUSIONS:These results suggest that diabetics with elevated baseline liver enzymes do not have a higher risk of hepatotoxicity from rosiglitazone than those with normal enzymes.

Lower provider volume is associated with higher failure rates for endoscopic retrograde cholangiopancreatography

Background:Among physicians who perform endoscopic retrograde cholangiopancreatography (ERCP), the relationship between procedure volume and outcome is unknown. Objective:Quantify the ERCP volume-outcome relationship by measuring provider-specific failure rates, hospitalization rates, and other quality measures. Research Design:Retrospective cohort. Subjects:A total of 16,968 ERCPs performed by 130 physicians between 2001 and 2011, identified in the Indiana Network for Patient Care. Measures:Physicians were classified by their average annual Indiana Network for Patient Care volume and stratified into low (<25/y) and high (≥25/y). Outcomes included failed procedures, defined as repeat ERCP, percutaneous transhepatic cholangiography or surgical exploration of the bile duct⩽7 days after the index procedure, hospitalization rates, and 30-day mortality. Results:Among 15,514 index ERCPs, there were 1163 (7.5%) failures; the failure rate was higher among low (9.5%) compared with high volume (5.7%) providers (P<0.001). A second ERCP within 7 days (a subgroup of failure rate) occurred more frequently when the original ERCP was performed by a low-volume (4.1%) versus a high-volume physician (2.3%, P=0.013). Patients were more frequently hospitalized within 24 hours when the ERCP was performed by a low-volume (28.3%) versus high-volume physician (14.8%, P=0.002). Mortality within 30 days was similar (low=1.9%, high=1.9%). Among low-volume physicians and after adjusting, the odds of having a failed procedure decreased 3.3% (95% confidence interval, 1.6%–5.0%, P<0.001) with each additional ERCP performed per year. Conclusions:Lower provider volume is associated with higher failure rate for ERCP, and greater need for postprocedure hospitalization.

Structure, Functions, and Activities of a Research Support Informatics Section

The authors describe a research group that supports the needs of investigators seeking data from an electronic medical record system. Since its creation in 1972, the Regenstrief Medical Records System has captured and stored more than 350 million discrete coded observations on two million patients. This repository has become a central data source for prospective and retrospective research. It is accessed by six data analysts--working closely with the institutional review board--who provide investigators with timely and accurate data while protecting patient and provider privacy and confidentiality. From January 1, 1999, to July 31, 2002, data analysts tracked their activities involving 47,559 hours of work predominantly for physicians (54%). While data retrieval (36%) and analysis (25%) were primary activities, data analysts also actively collaborated with researchers. Primary objectives of data provided to investigators were to address disease-specific (35.4%) and drug-related (12.2%) questions, support guideline implementation (13.1%), and probe various aspects of clinical epidemiology (5.7%). Outcomes of these endeavors included 117 grants (including 300,000 US dollars per year salary support for data analysts) and 139 papers in peer-reviewed journals by investigators who rated the support provided by data analysts as extremely valuable.

Perceived or actual barriers to warfarin use in atrial fibrillation based on electronic medical records

Compared with usual practice, clinical trials often exclude patients with relative contraindications. A study of real-world warfarin use could help inform trials of new medications that could potentially replace warfarin. The objective of this study was to describe potential barriers to warfarin use among patients with atrial fibrillation. This was a retrospective study of electronic medical records (1998–2007) from an inner-city public hospital and affiliated primary care clinics and included adults aged 18 years or more with atrial fibrillation. Exclusions included mitral or aortic valve replacement, hyperthyroidism, or no clinical encounter within 1 year after first diagnosis. Warfarin exposure was defined by electronic pharmacy or physician order data or, in a second definition, international normalized ratio > 1.3. A history of potential barriers to warfarin was defined by International Classification of Diagnoses, 9th revision codes or electronic medical record “dictionary” terms. Among 3329 patients, CHADS2 scores were 0 (17%), 1 (26%), 2–6 (57%). Among 1276 patients with CHADS2 scores >0 who were prescribed warfarin, rates of potential barriers to warfarin were gastrointestinal or genitourinary hemorrhage (20%), alcohol abuse (16%), renal insufficiency (15%), predisposition to falls (8%), cirrhosis/hepatitis (5%), intracranial hemorrhage (1%), other hemorrhage (6%), and age 75 years or more (23%). Among 1475 patients with CHADS2 scores >0 who were not prescribed warfarin, these rates differed by not >3% except for predisposition to falls (16%) and age 75 years or more (43%). In real-world practice, many patients given warfarin have contraindications that would exclude them from clinical trials, and many patients apparently eligible for warfarin do not receive it.

A regional informatics platform for coordinated antibiotic-resistant infection tracking, alerting, and prevention

BACKGROUND We developed and assessed the impact of a patient registry and electronic admission notification system relating to regional antimicrobial resistance (AMR) on regional AMR infection rates over time. We conducted an observational cohort study of all patients identified as infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE) on at least 1 occasion by any of 5 healthcare systems between 2003 and 2010. The 5 healthcare systems included 17 hospitals and associated clinics in the Indianapolis, Indiana, region. METHODS We developed and standardized a registry of MRSA and VRE patients and created Web forms that infection preventionists (IPs) used to maintain the lists. We sent e-mail alerts to IPs whenever a patient previously infected or colonized with MRSA or VRE registered for admission to a study hospital from June 2007 through June 2010. RESULTS Over a 3-year period, we delivered 12 748 e-mail alerts on 6270 unique patients to 24 IPs covering 17 hospitals. One in 5 (22%-23%) of all admission alerts was based on data from a healthcare system that was different from the admitting hospital; a few hospitals accounted for most of this crossover among facilities and systems. CONCLUSIONS Regional patient registries identify an important patient cohort with relevant prior antibiotic-resistant infection data from different healthcare institutions. Regional registries can identify trends and interinstitutional movement not otherwise apparent from single institution data. Importantly, electronic alerts can notify of the need to isolate early and to institute other measures to prevent transmission.

Outpatient adverse drug events identified by screening electronic health records

Objectives: Relatively little is known about rates of outpatient adverse drug events (ADEs), and most health systems do not routinely identify them. We developed a computerized ADE measurement process and used it to detect ADEs from electronic health records and then categorized them according to type, preventability, and severity. Methods: The rules used represent combinations of variables including coded medication names, laboratory results, diagnoses, and specific items such as symptoms from free text clinician notes, all obtained from electronic health records. Rules targeted various diagnostic and laboratory abnormalities potentially caused by a broad range of outpatient medications commonly used in primary care. The rules were run on 4 months of data on primary care patients seen in the outpatient setting in 2 large health systems; possible incidents were identified by chart review and validated as ADEs by clinician reviewers, then rated by severity and preventability. Results: The rates of ADEs were 75 ADEs/1000 person-years and 198/1000 person-years at the 2 sites, respectively. The overall rate was 138 ADEs/1000 person-years across the 2 sites. Eleven percent of ADEs were preventable, with a rate of 15 preventable ADEs/1000 person-years across sites. Approximately one-fourth of ADEs were serious or life threatening at both sites. The highest yield rules for identifying preventable ADEs included rules based on drug classes and symptoms, and drug-laboratory rules. Conclusions: Adverse drug events occurred frequently in routine outpatient care, and many were serious and preventable. Computerized monitoring represents an efficacious approach for identifying ambulatory ADEs, although it needs additional refinement. In addition, site-specific variations need further exploration.

Informative Patterns of Health-Care Utilization Prior to the Diagnosis of Pancreatic Ductal Adenocarcinoma

Early-detection tests for pancreatic ductal adenocarcinoma (PDAC) are needed. Since a hypothetical screening test would be applied during antecedent clinical encounters, we sought to define the variability in health-care utilization leading up to PDAC diagnosis. This was a retrospective cohort study that included patients diagnosed with PDAC in the Indianapolis, Indiana, area between 1999 and 2013 with at least 1 health-care encounter during the antecedent 36-month period (n = 1,023). Patients were classified by unique patterns of health-care utilization using a group-based trajectory model. The prevalences of PDAC signals, such as diabetes mellitus (DM) and chronic pancreatitis, were compared. Four distinct trajectories were identified, the most common (42.0%) being having few clinical encounters more than 6 months prior to PDAC diagnosis (late acceleration). In all cases, a minority of persons had DM (30.6%, with 9.5% <1.5 years before PDAC) or any pancreatic disorder (39.9%); these were least common in the late-acceleration group (DM, 14.7%; any pancreatic disorder, 32.1% (P < 0.001)). The most common pattern of antecedent care was having few clinical encounters until shortly before PDAC diagnosis. Since the majority of patients diagnosed with PDAC do not have an antecedent PDAC signal, early-detection strategies limited to these groups may not apply to the majority of cases.

THE ASSOCIATION BETWEEN METFORMIN AND INCIDENT DEMENTIA IN A COHORT OF AFRICAN AMERICANS WITH DIABETES

Diseases and Geriatric Psychiatry, University Hospital Bonn, Bonn, Germany; German Center for Neurodegenerative Diseases, Munich, Germany; Institute for Stroke and Dementia Research, Klinikum der Universit€at M€unchen, Munich, Germany; German Center for Neurodegenerative Diseases, T€ubingen, Germany; Hertie-Institute for Clinical Brain Research, Tuebingen, Germany; German Center for Neurodegenerative Diseases, Magdeburg, Germany; Department of Psychiatry and Psychotherapy, Charit e, Campus Benjamin Franklin, Berlin, Germany; German Center for Neurodegenerative Diseases, Berlin, Germany; Department of Psychiatry, Charit e–Universit€atsmedizin Berlin, Berlin, Germany; Department for Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Bonn, Germany; Department of Neurology, University Hospital of Bonn, Bonn, Germany; Department of Psychiatry, University Hospital Cologne, Cologne, Germany; Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany; Department of Psychosomatic Medicine, Rostock University Medical Center, Rostock, Germany; German Center for Neurodegenerative Diseases, Rostock, Germany; German Center for Neurodegenerative Diseases, Goettingen, Germany; Department of Psychiatry and Psychotherapy, University Medical Center G€ottingen, G€ottingen, Germany; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Medical Psychology, University Hospital Cologne, Cologne, Germany; Institute of Cognitive Neurology and Dementia Research, Otto-von-Guericke University, Magdeburg, Germany. Contact e-mail: sandra.roeske@dzne.de

Pharmacologic Prophylaxis for Venous Thromboembolism Among Patients With Total Joint Replacement: An Electronic Medical Records Study.

Patients who have total hip (THR) or knee (TKR) replacement have an elevated risk of venous thromboembolism (VTE). The American College of Chest Physicians guidelines recommend prophylactic anticoagulation. The aim of the study was to examine pharmacologic prophylaxis against VTE among patients with THR or TKR and to assess demographic and clinical correlates related to VTE prophylaxis. Using 15 years of data (1995–2009) from an electronic medical record system for an inner-city public hospital in the United States, we examined pharmacologic prophylaxis against VTE and associated factors in patients after THR (n = 242) and TKR (n = 317). Before the early 2000s, aspirin was the most common prophylaxis agent (THR, 61% and TKR, 65%), and 26% of patients with THR and 19% of patients with TKR did not receive prophylaxis. Enoxaparin use has increased since 2000, and warfarin is now the most common prophylaxis agent (THR, 70% and TKR, 61%). After controlling for time period, factors associated with prophylaxis pattern included obesity, hip fracture, and the surgeons number of years in practice. VTE prophylaxis medications in patients with total joint replacement have changed over 15 years, in trends generally consistent with the evolution of guidelines. Obesity, history of hip fracture, and physicians experience are associated with the prescription of VTE prophylaxis medications.