Francis X. Campion

Electronic Support for Public Health: Validated Case Finding and Reporting for Notifiable Diseases Using Electronic Medical Data

Health care providers are legally obliged to report cases of specified diseases to public health authorities, but existing manual, provider-initiated reporting systems generally result in incomplete, error-prone, and tardy information flow. Automated laboratory-based reports are more likely accurate and timely, but lack clinical information and treatment details. Here, we describe the Electronic Support for Public Health (ESP) application, a robust, automated, secure, portable public health detection and messaging system for cases of notifiable diseases. The ESP application applies disease specific logic to any complete source of electronic medical data in a fully automated process, and supports an optional case management workflow system for case notification control. All relevant clinical, laboratory and demographic details are securely transferred to the local health authority as an HL7 message. The ESP application has operated continuously in production mode since January 2007, applying rigorously validated case identification logic to ambulatory EMR data from more than 600,000 patients. Source code for this highly interoperable application is freely available under an approved open-source license at http://esphealth.org.

Advancing Performance Measurement in Oncology: Quality Oncology Practice Initiative Participation and Quality Outcomes

The American health care system, including the cancer care system, is under pressure to improve patient outcomes and lower the cost of care. Government payers have articulated an interest in partnering with the private sector to create learning communities to measure quality and improve the value of health care. In 2006, the American Society for Clinical Oncology (ASCO) unveiled the Quality Oncology Practice Initiative (QOPI), which has become a key component of the measurement system to promote quality cancer care. QOPI is a physician-led, voluntary, practice-based, quality-improvement program, using performance measurement and benchmarking among oncology practices across the United States. Since its inception, ASCOs QOPI has grown steadily to include 973 practices as of November 2010. One key area that QOPI has addressed is end-of-life care. During the most recent data collection cycle in the Fall of 2010, those practices completing multiple data collection cycles had better performance on care of pain compared with sites participating for the first time (62.61% v 46.89%). Similarly, repeat QOPI participants demonstrated meaningfully better performance than their peers in the rate of documenting discussions of hospice and palliative care (62.42% v 54.65%) and higher rates of hospice enrollment. QOPI demonstrates how a strong performance measurement program can lead to improved quality and value of care for patients.

Reducing the Prescribing of Heavily Marketed Medications: A Randomized Controlled Trial

ContextPrescription drug costs are a major component of health care expenditures, yet resources to support evidence-based prescribing are not widely available.ObjectiveTo evaluate the effectiveness of computerized prescribing alerts, with or without physician-led group educational sessions, to reduce the prescribing of heavily marketed hypnotic medications.DesignCluster-randomized controlled trial.SettingWe randomly allocated 14 internal medicine practice sites to receive usual care, computerized prescribing alerts alone, or alerts plus group educational sessions.MeasurementsProportion of heavily marketed hypnotics prescribed before and after the implementation of computerized alerts and educational sessions.Main ResultsThe activation of computerized alerts held the prescribing of heavily marketed hypnotic medications at pre-intervention levels in both the alert-only group (adjusted risk ratio [RR] 0.97; 95% CI 0.82–1.14) and the alert-plus-education group (RR 0.98; 95% CI 0.83–1.17) while the usual-care group experienced an increase in prescribing (RR 1.31; 95% CI 1.08–1.60). Compared to the usual-care group, the relative risk of prescribing heavily marketed medications was less in both the alert-group (Ratio of risk ratios [RRR] 0.74; 95% CI 0.57–0.96) and the alert-plus-education group (RRR 0.74; 95% CI 0.58–0.97). The prescribing of heavily marketed medications was similar in the alert-group and alert-plus-education group (RRR 1.02; 95% CI 0.80–1.29). Most clinicians reported that the alerts provided useful prescribing information (88%) and did not interfere with daily workflow (70%).ConclusionsComputerized decision support is an effective tool to reduce the prescribing of heavily marketed hypnotic medications in ambulatory care settings.Trial Registrationclinicaltrials.gov Identifier: NCT00788346.

Factors Determining the Persistence or Recurrence of Well-Differentiated Thyroid Cancer Treated by Thyroidectomy and/or Radioiodine in the Boston, Massachusetts Area: A Retrospective Chart Review

ObjectiveTo assess predictors of well-differentiated thyroid cancer (WDTC) persistence/recurrence.DesignThis was a retrospective chart review of thyroid carcinoma patients seen 1979-2007 in a Boston, Massachusetts-area multispecialty group. Of 1,025 patients, 431 met eligibility criteria. Cox proportional hazards models were used to assess predictors (gender, age, ethnicity, tumor size, surgical histology) of WDTC persistence/recurrence (elevated thyroglobulin levels with negative thyroglobulin-antibodies; or positive imaging). Local extension of disease and lymph node involvement could not be assessed.ResultsMean age at initial surgery (n = 431, 74% women, 79% Caucasian) was 45.8 ± 13.5(SD) years. Mean tumor (papillary, 91%; follicular, 5%; Hurthle cell, 2%; ≥1 type, 2%) size was 2.5 ± 1.6(SD) cm. Most tumors were unifocal (57%) and ≥1 cm (89%). Over 2,600 person-years of follow-up, persistence/recurrence occurred in 52 patients (12%) 4.3 years (median; range 0.2-23.2 years) after surgery. Gender, ethnicity, tumor size, multifocality, and histology were not predictive of persistence/recurrence, while older age was predictive in some models.ConclusionsIn WDTC patients treated by total and near total thyroidectomy and radioiodine and analyzed without consideration of local, locoregional, and distant extent of disease, neither size of tumor nor male gender contribute to disease persistence/recurrence. Age at diagnosis seems to have some positive prognostic value even if only patients older than 21 years at diagnosis are considered. Due to the rare occurrence of follicular (also oxyphilic) histotype, this conclusion refers mainly to patients with papillary thyroid cancer.

Unique obstacles to establishing thyroid cancer registries

The establishment of population-based cancer registries requires the use of rigorous methodology in order to ensure complete and timely data ascertainment [1,2]. Developing a thyroid cancer registry poses unique obstacles that are related to the nature of the disease. Because of the relatively indolent nature of most differentiated thyroid cancers, there is typically a long interval between initial diagnosis and disease recurrence, which, in turn, means that lengthy follow-up is necessary in order to ascertain outcomes. Since differentiated thyroid cancer confers a low risk of death, registries need to be targeted instead toward the identification of prognostic factors for tumor persistence and recurrence, as has been previously comprehensively described by Mehra and colleagues regarding their proposal of a Thyroid Cancer Care Collaborative in the U.S. [3]. The number of known risk factors for tumor persistence and recurrence is expanding rapidly, and much of the data currently required for disease prognosis are not readily extractable from medical records. For example, the number and size of all cervical lymph nodes present is not a required part of the College of American Pathologists’ standard pathology report [4]. We recently developed a comprehensive thyroid cancer registry with the intent to capture both retrospective and prospective individual patient data at Harvard Vanguard Medical Associates, Boston, MA. During the timeframe of this study, this integrated health system was comprised of 23 sites across the greater Boston area (now even larger), connected by a robust electronic health record (EHR) that has been in operation for nearly 40 years. Our registry houses over 400 discrete variables related to patients’ demographics, thyroid cancer diagnosis, tumor characteristics, and the multiple aspects of long-term thyroid cancer management, most of which is not extractable without dedicated individual patient-level review. As such, this type of systematic, comprehensive, and complex data capture requires a research assistant to be trained in the specific thyroid cancer terminology documented in the medical records for entry into the registry tool. We look forward to taking advantage of marketplace progress toward EHR and registry interoperability that are envisioned under the Centers for Medicare and Medicaid Services Meaningful Use incentive program. Our hope is to better integrate data collection into the patient care workflow for basic data, allowing research assistants to focus their data collection on specialized data elements, such as family history, pathological staging, and genetic markers. In comparison with the many other types of thyroid cancer registries that have been described [3], our database captures patients within an integrated multi-site institution who reside in a discrete geographic area, collects longitudinal data recorded in a single EHR spanning nearly 4 decades, and incorporates elements advocated in the most recent thyroid nodule and cancer guidelines. Data collection continues to be ongoing, and we share our experience to illustrate the complexities of designing and executing longitudinal thyroid cancer registries, which should be developed in a collaborative fashion. Such thyroid cancer registries need to prospectively include all of the prognostic criteria advocated in the most current thyroid nodule and cancer guidelines [5], and will need to be plastic enough to adapt as guidelines and known risk factors evolve. Genetic characteristics of both tumors and hosts are increasingly important to clinical decision making, and may over time change the definitions and staging of many cancers. Such registries should also include diverse patient populations in order to produce rich, generalizable data. Finally, the development and ongoing maintenance of such registries is an expensive endeavor. Joint partnerships with stakeholders in academia, industry, and government ideally will be required to fund future comprehensive thyroid tumor registries. Despite their complexity and expense, we strongly believe that such registries are needed, as they are able to provide a wealth of data which is not readily available from other sources.