Joan Rimar

Comparison of health-related quality of life questionnaires in ambulatory oncology

The purpose of this study is to compare three commonly used health-related quality of life (HR-QOL) questionnaires for their ease of use, accuracy, and patient preference; identify factors related to patient preference; identify differences in patient completion rates; and to identify factors associated with patient completion of these questionnaires. Three psychometrically sound measures, the Symptom Distress Scale (SDS), Medical Outcome Study Short Form-36 (SF-36), and Functional Assessment of Cancer Therapy (FACT), were tested. Seventy-nine patients completed questionnaires in the ambulatory oncology setting. No significant differences in patient ratings were found in ease of use and accuracy among the questionnaires. All of the questionnaires were rated as easy to use and accurate. Patient ratings on preference were marginally significant (p=0.07). Forty-six percent of participants indicated that they preferred the SDS, whereas 27 and 39 preferred the SF-36 and the FACT. No significant differences in patient completion rates were found among the questionnaires. One hundred percent completion rates ranged from 88.6 for the SDS to 78.5 for the SF-36, and 80 completion rates ranged from 98.7 for the SDS to 94.9 for the SF-36. Administration of standardized HR-QOL questionnaires is feasible in the clinical setting.

Automated analysis of electronic medical record data reflects the pathophysiology of operative complications

PURPOSE We hypothesized that a novel algorithm that uses data from the electronic medical record (EMR) from multiple clinical and biometric sources could provide early warning of organ dysfunction in patients with high risk for postoperative complications and sepsis. Operative patients undergoing colorectal procedures were evaluated. METHODS The Rothman Index (RI) is a predictive model based on heuristic equations derived from 26 variables related to inpatient care. The RI integrates clinical nursing observations, bedside biometrics, and laboratory data into a continuously updated, numeric physiologic assessment, ranging from 100 (unimpaired) to -91. The RI can be displayed within the EMR as a graphic trend, with a decreasing trend reflecting physiologic dysfunction. Patients undergoing colorectal procedures between June and October 2011 were evaluated to determine correlation of initial RI, average inpatient RI, and lowest RI to incidence of complications and/or postoperative sepsis. Patients were stratified by color-coded RI risk group (100-65, blue; 64-40, yellow; <40 red). One-way or repeated-measures analysis of variance was used to compare groups by age, number of complications, and presence of sepsis defined by discharge International Classification of Diseases, 9(th) Revision, codes. Mean direct cost of care and duration of stay also was calculated for each group. RESULTS The overall incidence of perioperative complications in the 124 patient cohort was 51% (n = 64 patients). The 261 complications sustained by this group represented 82 distinct diagnoses. The 10 patients with sepsis (8%) experienced a 40% mortality. Analysis of initial RI for the population stratified by number of complications and/or sepsis demonstrated a risk-related difference. With progressive onset of complications, the RI decreased, suggesting worsening physiologic dysfunction and linear increase in direct cost of care. CONCLUSION These findings demonstrate that EMR data can be automatically compiled into an objective metric that reflects patient risk and changing physiologic state. The automated process of continuous update reflects a physiologic trajectory associated with evolving organ system dysfunction indicative of postoperative complications. Early intervention based on these trends may guide preoperative counseling, enhance pre-emptive management of adverse occurrences, and improve cost-efficiency of care.

Development of Imminent Mortality Predictor for Advanced Cancer (IMPAC), a Tool to Predict Short-Term Mortality in Hospitalized Patients With Advanced Cancer

PURPOSE End-of-life care for patients with advanced cancer is aggressive and costly. Oncologists inconsistently estimate life expectancy and address goals of care. Currently available prognostication tools are based on subjective clinical assessment. An objective prognostic tool could help oncologists and patients decide on a realistic plan for end-of-life care. We developed a predictive model (Imminent Mortality Predictor in Advanced Cancer [IMPAC]) for short-term mortality in hospitalized patients with advanced cancer. METHODS Electronic health record data from 669 patients with advanced cancer who were discharged from Yale Cancer Center/Smilow Cancer Hospital were extracted. Statistical learning techniques were used to develop a tool to estimate survival probabilities. Patients were randomly split into training (70%) and validation (30%) sets 20 times. We tested the predictive properties of IMPAC for mortality at 30, 60, 90, and 180 days past the day of admission. RESULTS For mortality within 90 days at a 40% sensitivity level, IMPAC has close to 60% positive predictive value. Patients estimated to have a greater than 50% chance of death within 90 days had a median survival time of 47 days. Patients estimated to have a less than 50% chance of death had a median survival of 290 days. Area under the receiver operating characteristic curve for IMPAC averaged greater than .70 for all time horizons tested. Estimated potential cost savings per patient was

Impact of Severity-Adjusted Workload on Health Status of Patients Discharge from an ICU

15,413 (95% CI,

MORTALITY REDUCTION ASSOCIATED WITH PROACTIVE USE OF EMR-BASED ACUITY SCORE BY AN RN TEAM AT AN URBAN HOSPITAL

9,162 to

Development and validation of a continuously age-adjusted measure of patient condition for hospitalized children using the electronic medical record

21,665) in 2014 constant dollars. CONCLUSION IMPAC, a novel prognostic tool, can generate life expectancy probabilities in real time and support oncologists in counseling patients about end-of-life care. Potentially avoidable costs are significant.

Development and Validation of a Continuously Age-Adjusted Measure of Patient Condition for Hospitalized Children Using the Electronic Medical Record.

We examine whether workload has an impact on a direct measure of the health status of patients discharged from Intensive Care Units (ICUs). We use data collected from the medical ICU and the surgical ICU of a major teaching hospital and a relatively new measure of patient acuity called the Rothman Index (RI). The RI is frequently updated during a patient’s hospital stay, which enables us to track patients health status very close to the time of their ICU discharge. Leveraging the RI, we measure ICU workload in a novel way that takes into account not only the census but also patient acuity. To our knowledge, this is the first study to show that more acutely ill patients are discharged from an ICU when the severity-adjusted workload is high rather than low. Further, we find that higher severity-adjusted workload is associated with ICU discharge times that start earlier and end later, a shorter ICU length-of-stay (LOS), and an increased likelihood of discharge to a step-down unit. We also find that downstream unit census influences the effect of workload on health status at ICU discharge.