Jim Nuovo

Treatment outcomes for squamous intraepithelial lesions

Objective: To assess the effectiveness of cone biopsy, cryotherapy, laser ablation and the loop electrosurgical procedure in the treatment of squamous intraepithelial lesions. Method: Systematic review of randomized controlled trials in subjects who underwent treatment of low‐ and high‐grade squamous intraepithelial lesions with these modalities. Main outcome measures included the following: percent resolution and persistence of a lesion and notable complications for each procedure. Result: Pooled rates of resolution for low‐grade, high‐grade, or combined squamous intraepithelial lesions were similar across the different treatment modalities (range 85.2–94.7%), with substantial overlap among the 95% confidence intervals. Significant hemorrhage occurred most frequently in subjects who received cone biopsy (4.6%) (95% CI: 2.15, 6.99), followed by laser ablation (1.75%) (95% CI: 0.70, 2.81), and LEEP (1.35%) (95% CI: 0.24, 2.47). No hemorrhages were reported among subjects who received cryotherapy. Study sample sizes were relatively small. There were no reported cases of progression to invasive cancer, but duration of follow‐up (median follow‐up time for all eligible studies=12 months) was not sufficient to evaluate long‐term outcomes. Conclusions: There were no substantive differences in outcomes regarding persistence and resolution in the treatment of squamous intraepithelial lesions for subjects receiving cone biopsy, cryotherapy, laser ablation, or LEEP.

Using Geographic Information Systems (GIS) to Assess Outcome Disparities in Patients with Type 2 Diabetes and Hyperlipidemia

Objectives: Geographic information systems (GIS) tools can help expand our understanding of disparities in health outcomes within a community. The purpose of this project was (1) to demonstrate the methods to link a disease management registry with a GIS mapping and analysis program, (2) to address the challenges that occur when performing this link, and (3) to analyze the outcome disparities resulting from this assessment tool in a population of patients with type 2 diabetes mellitus. Methods: We used registry data derived from the University of California Davis Health Systems electronic medical record system to identify patients with diabetes mellitus from a network of 13 primary care clinics in the greater Sacramento area. This information was converted to a database file for use in the GIS software. Geocoding was performed and after excluding those who had unknown home addresses we matched 8528 unique patient records with their respective home addresses. Socioeconomic and demographic data were obtained from the Geolytics, Inc. (East Brunswick, NJ), a provider of US Census Bureau data, with 2008 estimates and projections. Patient, socioeconomic, and demographic data were then joined to a single database. We conducted regression analysis assessing A1c level based on each patients demographic and laboratory characteristics and their neighborhood characteristics (socioeconomic status [SES] quintile). Similar analysis was done for low-density lipoprotein cholesterol. Results: After excluding ineligible patients, the data from 7288 patients were analyzed. The most notable findings were as follows: There was, there was found an association between neighborhood SES and A1c. SES was not associated with low-density lipoprotein control. Conclusion: GIS methodology can assist primary care physicians and provide guidance for disease management programs. It can also help health systems in their mission to improve the health of a community. Our analysis found that neighborhood SES was a barrier to optimal glucose control but not to lipid control. This research provides an example of a useful application of GIS analyses applied to large data sets now available in electronic medical records.

Assessing resident's knowledge and communication skills using four different evaluation tools

Purposeu2002 This study assesses the relationship between 4 Accreditation Council for Graduate Medical Education (ACGME) outcome project measures for interpersonal and communication skills and medical knowledge; specifically, monthly performance evaluations, objective structured clinical examinations (OSCEs), the American Board of Family Practice in‐training examination (ABFP–ITE) and the Davis observation code (DOC) practice style profiles.

Interventions to support diabetes self-management: The key role of the patient in diabetes care

More so than most other diseases, effective control of type 2 diabetes (DM) requires that patients are actively engaged in the self-management of their health. In this paper we define and characterize the elements of self-management and review the published literature for the evidence of the benefit of interventions that support patient self-management.

Establishing Electronic Health Record Competency Testing for First-Year Residents

BACKGROUNDnDespite widespread use of electronic health records (EHRs), it is unclear whether residents possess the EHR skills to perform required tasks.nnnOBJECTIVEnWe assessed first-year residents skills on specific EHR tasks.nnnMETHODSnIncoming residents were required to participate in EHR training before starting clinical rotations. The training team developed an assessment tool for 19 EHR tasks. Senior residents used a structured template to assess interns.nnnRESULTSnFor ambulatory workflow skills, most participants (range, 70%-100%) demonstrated competence. The 3 skills for which interns needed the most assistance were (1) creating and routing a result note (17 of 68, 25%), (2) deleting a medication or changing a dose in reconciling medications (10 of 68, 15%), and (3) finding results for the past 90xa0days (10 of 68, 15%). For inpatient workflow skills, most interns (range, 63%-100%) demonstrated competence. The 3 skills in which interns needed the most assistance were (1) placing a referral order at discharge (23 of 68, 34%), (2) finding a temperature on a flow sheet and trending it over time (14 of 68, 21%), and (3) creating a discharge summary, having it reviewed, and forwarding it to the primary care physician (14 of 68, 21%).nnnCONCLUSIONSnOur results should help EHR training teams at other institutions to better understand the strengths and weakness of EHR training approaches and to target training on tasks with the greatest performance deficits as well as toward underperforming individuals or groups.

Is Cervicography a Useful Diagnostic Test? A Systematic Overview of the Literature

Background: The appropriate approach to women with mild dyskaryotic changes on Papanicolaou smear is subject to controversy. Our aim was to assess the usefulness of cervicography as a diagnostic test in detecting cervical cancer or its precursors. Metbods: We undertook an extensive literature search looking for pertinent studies of cervicography pubUshed between 1966 and 1996. Eligible studies included those in which the reference standard (colposcopy) was done on all patients. The following information was calculated: sensitivity, specificity, positive predictive value, negative predictive value, disease prevalence, and Likelihood ratios. Results: Cervicography has a high false-positive rate. This rate ranged from 8.2 to 61.0 percent (median 42.1 percent) for any dysplasia and 9.8 to 63.4 percent (median 50.6 percent) for high-grade cervical lesions. Likelihood ratios for a positive test result ranged from 1.0 to 10.6. Likelihood ratios for a negative result ranged from 0.02 to 1.0. Conclusions: The usefulness of cervicography is heavily dependent on the approach used to evaluate abnormal findings on a Papanicolaou smear. If a provider typically offers colposcopy to all patients with low-grade cytologic findings on a Papanicolaou smear, cervicography will decrease colposcopy use and allow for detection of cases of high-grade dysplasia missed by the index Papanicolaou smear. If a provider typically uses watchful waiting with repeat Papanicolaou smears for all patients who have low-grade cytologic findings, cervicography will substantially increase the use of colposcopy. Many of these colposcopies will be done as a result of false-positive cervigrams.

The Impact of Planned Visits on Patients with Type 2 Diabetes Mellitus

Objectives To investigate whether planned visits improve glycemic, blood pressure and lipid control among patients with type 2 diabetes mellitus (DM). Methods The study was conducted from July 2007 to February 2008 at a primary care clinic in Rancho Cordova, California. One hundred eighty-three patients were invited to come to a planned visit. On the day of the visit, they were provided a copy of their most recent test results and information on American Diabetes Association recommendations for A1C, lipid, and blood pressure control. Afterwards, they met with their physician for a 15-minute focused appointment. Finally, they met with a diabetic nurse educator. There was no subsequent contact with the nurse educator after the planned visit. We compared the baseline measurements to those from a follow-up visit with the primary care provider at a follow-up over a 6 month period. The comparison group in this study were those who did not accept the invitation for a planned visit. Their outcomes were monitored over the same time horizon. Results One hundred eighty-three patients attended one of a total of five planned visit sessions. There were 212 patients in the comparison group. There were no significant differences for the measured baseline characteristics. There were significant improvements in A1C, LDL-C, and diastolic blood pressure control in the planned visit group. The mean A1C change was –0.61% (95% confidence interval, –0.28, –0.70); P < 0.001). The mean LDL-C change was -8.8 mg/dL (95% confidence interval, –12.2, 6.1); P < 0.05. The mean diastolic blood pressure change was -2.0 mmHg (95% confidence interval, –4.7, 6.7); P < 0.05. Patients who participated in a planned visit also reported a significantly higher frequency of self-care behaviors and greater understanding about diabetes care. Discussion Planned visits led to improvements in glycemic, lipid and blood pressure control over a 6 month observation period. Patients attending planned visits also reported improvements in self-care behaviors and a greater understanding about diabetes care.

Gender Differences in the Selection of an Action Plan for Patients with Type 2 Diabetes Mellitus

AbstractObjective: To assess differences between women and men in developing an action plan for the management of their type 2 diabetes mellitus (DM).n Methods: We chose a convenience sample of the first 153 patients who participated in a four-part educational class focused on the management of type 2 DM. The classes are run by a certified diabetes educator and have a specific format. We use a decision wheel to assist in the development of a patient-generated action plan to address a specific health behavior change. For each patient we documented age, gender, and glycosylated hemoglobin (HbA1c) level.n Results: There was a difference in choice of action plan based on gender (p = 0.014). For women the distribution of action plans was exercise 38%, nutrition 22%, medication 20%, no action plan 13%, and monitoring 7%. For men the distribution of action plans was exercise 26%, nutrition 26%, medication 6%, no action plan 26%, and monitoring 16%. Age did not affect the choice of an action plan (p = 0.964); however, patients with a lower HbA1c level chose exercise more frequently (p < 0.002).n Conclusions: The results of this study suggest there may be gender-based differences affecting the selection of an action plan for patients with type 2 DM. Further research is needed to determine the relative weight of other important factors on the decision for a particular action plan; e.g. sociodemographic factors, stage of readiness to change, and comorbid conditions.