Lipika Samal

Predictive value of factor V leiden and prothrombin G20210A in adults with venous thromboembolism and in family members of those with a mutation: a systematic review

CONTEXT Testing for genetic risks for venous thromboembolism (VTE) is common, but the safety and utility of such testing need review. OBJECTIVES To define rates of recurrent VTE among adults with VTE with a factor V Leiden (FVL) or prothrombin G20210A mutation compared with those without such mutations; to define rates of VTE among family members of adults with a FVL or prothrombin G20210A mutation according to presence or absence of a mutation; and to assess whether testing adults with VTE for FVL or prothrombin G20210A improves outcomes. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo through December 2008. STUDY SELECTION Studies were included if they assessed rates of VTE in individuals with a history of VTE who were tested for FVL or prothrombin G20210A or in family members of individuals with these mutations. Studies assessing the harms and benefits associated with testing were also included. DATA EXTRACTION Two investigators abstracted data and assessed study quality. We pooled the odds of VTE associated with the mutations using random-effects models. We assessed the strength of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. RESULTS We reviewed 7777 titles and included 46 articles. Heterozygosity (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.14-2.12) and homozygosity (OR, 2.65; 95% CI, 1.2-6.0) for FVL in probands are predictive of recurrent VTE compared with individuals without FVL. Heterozygosity for FVL predicts VTE in family members (OR, 3.5; 95% CI, 2.5-5.0), as does homozygosity for FVL (OR, 18; 95% CI, 7.8-40) compared with family members of adults without FVL. Heterozygosity for prothrombin G20210A is not predictive of recurrent VTE in probands compared with individuals without prothrombin G20210A (OR, 1.45; 95% CI, 0.96-2.2). Evidence is insufficient regarding the predictive value of prothrombin G20210A homozygosity for recurrent VTE and the risk of VTE in family members of individuals with prothrombin G20210A. High-grade evidence supports that anticoagulation reduces recurrent VTE events in probands with either mutation. Low-grade evidence supports that this risk reduction is similar to that in individuals with a history of VTE and without mutations. CONCLUSIONS Patients with FVL are at increased risk of recurrent VTE compared with patients with VTE without this mutation. However, it is unknown whether testing for FVL or prothrombin G20210A improves outcomes in adults with VTE or in family members of those with a mutation.

Summarization of clinical information: A conceptual model

BACKGROUND To provide high-quality and safe care, clinicians must be able to optimally collect, distill, and interpret patient information. Despite advances in text summarization, only limited research exists on clinical summarization, the complex and heterogeneous process of gathering, organizing and presenting patient data in various forms. OBJECTIVE To develop a conceptual model for describing and understanding clinical summarization in both computer-independent and computer-supported clinical tasks. DESIGN Based on extensive literature review and clinical input, we developed a conceptual model of clinical summarization to lay the foundation for future research on clinician workflow and automated summarization using electronic health records (EHRs). RESULTS Our model identifies five distinct stages of clinical summarization: (1) Aggregation, (2) Organization, (3) Reduction and/or Transformation, (4) Interpretation and (5) Synthesis (AORTIS). The AORTIS model describes the creation of complex, task-specific clinical summaries and provides a framework for clinical workflow analysis and directed research on test results review, clinical documentation and medical decision-making. We describe a hypothetical case study to illustrate the application of this model in the primary care setting. CONCLUSION Both practicing physicians and clinical informaticians need a structured method of developing, studying and evaluating clinical summaries in support of a wide range of clinical tasks. Our proposed model of clinical summarization provides a potential pathway to advance knowledge in this area and highlights directions for further research.

The Medicare Electronic Health Record Incentive Program: Provider Performance on Core and Menu Measures

OBJECTIVE To measure performance by eligible health care providers on CMSs meaningful use measures. DATA SOURCE Medicare Electronic Health Record Incentive Program Eligible Professionals Public Use File (PUF), which contains data on meaningful use attestations by 237,267 eligible providers through May 31, 2013. STUDY DESIGN Cross-sectional analysis of the 15 core and 10 menu measures pertaining to use of EHR functions reported in the PUF. PRINCIPAL FINDINGS Providers in the dataset performed strongly on all core measures, with the most frequent response for each of the 15 measures being 90-100 percent compliance, even when the threshold for a particular measure was lower (e.g., 30 percent). PCPs had higher scores than specialists for computerized order entry, maintaining an active medication list, and documenting vital signs, while specialists had higher scores for maintaining a problem list, recording patient demographics and smoking status, and for providing patients with an after-visit summary. In fact, 90.2 percent of eligible providers claimed at least one exclusion, and half claimed two or more. CONCLUSIONS Providers are successfully attesting to CMSs requirements, and often exceeding the thresholds required by CMS; however, some troubling patterns in exclusions are present. CMS should raise program requirements in future years.

Consumer health informatics: results of a systematic evidence review and evidence based recommendations

An increasing array of technology based tools are available for patient and consumer utilization which claim to facilitate health improvement. The efficacy of these Consumer Health Informatics tools has not previously been systematically reviewed. As such a systematic evidence review of the efficacy of consumer health informatics tools was conducted. This review also sought evidence of any barriers to future widespread utilization of these tools and evidence of economic impact of these tools on health care costs. The findings of this review indicate that while more work needs to be done, the available literature does suggest a positive impact of consumer health informatics tools on select health conditions and outcomes. Many barriers remain that must be overcome prior to widespread utilization of these tools. There was insufficient data regarding economic impact of consumer health informatics tools on healthcare costs.

Meaningful Use and Quality of Care

Meaningful Use and Quality of Care The American Recovery and Reinvestment Act of 2009 included

Analytic validity of genetic tests to identify factor V Leiden and prothrombin G20210A

30 billion for implementation of the Electronic Health Record (EHR) Meaningful Use (MU) incentive program with a goal of increasing EHR adoption and improving quality of care. Stage 1 of the EHR MU incentive program specified required core objectives, menu objectives, and clinical quality measures.1 We assessed if being a “meaningful user” (defined as meeting 15 core objectives, eg, computerized order entry, safe electronic prescribing, clinical decision support, and providing health information to patients, as well as meeting 5 of 10 optional menu objectives) was associated with improved quality on 7 measures for 5 chronic diseases. (See the eAppendix and eReferences in the Supplement.)

Variation in high-priority drug-drug interaction alerts across institutions and electronic health records.

The objective of this study is to systematically review methods for detecting Factor V Leiden or prothrombin G20210A. English‐language literature from MEDLINE®, EMBASE®, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, PsycInfo©, 2000‐December 2008. Studies assessed methods for detection of these mutations in at least 10 human blood samples and reported concordance, discordance, or reproducibility. Two investigators abstracted data on the sample selection criteria, test operators, DNA extraction, experimental test, reference standard, commercial instruments, concordance rates, explanation of any discordance, and whether discordance resolved after repetition. We assessed strength of the evidence using the GRADE criteria. We reviewed 7,777 titles and included 66 articles. The majority of the reviewed studies used PCR‐RFLP or AS‐PCR as the reference standard. The studies demonstrated that commercially available and precommercial tests have high analytic validity with all having greater than 99% concordance with the reference standard. With a few exceptions, discordance resolved with repetition of the test, suggesting operator or administrative errors were responsible for the discordant results. In the quality assurance studies, greater than 98% of laboratories demonstrated high, even perfect, accuracy when asked to diagnose a sample with a known mutation. The majority of errors came from a limited number of laboratories. Although not all methods may be accurate, there is high‐grade evidence that genetic tests for the detection of FVL and prothrombin G20210A have excellent analytic validity. There is high‐grade evidence that most, but not all, clinical laboratories test for FVL and prothrombin G20210A accurately. Am. J. Hematol., 2010.

Reducing risk with clinical decision support: a study of closed malpractice claims.

Objective: The United States Office of the National Coordinator for Health Information Technology sponsored the development of a “high-priority” list of drug-drug interactions (DDIs) to be used for clinical decision support. We assessed current adoption of this list and current alerting practice for these DDIs with regard to alert implementation (presence or absence of an alert) and display (alert appearance as interruptive or passive). Materials and methods: We conducted evaluations of electronic health records (EHRs) at a convenience sample of health care organizations across the United States using a standardized testing protocol with simulated orders. Results: Evaluations of 19 systems were conducted at 13 sites using 14 different EHRs. Across systems, 69% of the high-priority DDI pairs produced alerts. Implementation and display of the DDI alerts tested varied between systems, even when the same EHR vendor was used. Across the drug pairs evaluated, implementation and display of DDI alerts differed, ranging from 27% (4/15) to 93% (14/15) implementation. Discussion: Currently, there is no standard of care covering which DDI alerts to implement or how to display them to providers. Opportunities to improve DDI alerting include using differential displays based on DDI severity, establishing improved lists of clinically significant DDIs, and thoroughly reviewing organizational implementation decisions regarding DDIs. Conclusion: DDI alerting is clinically important but not standardized. There is significant room for improvement and standardization around evidence-based DDIs.

The Primary Care Perspective on Routine Urine Dipstick Screening to Identify Patients with Albuminuria

OBJECTIVE Identify clinical opportunities to intervene to prevent a malpractice event and determine the proportion of malpractice claims potentially preventable by clinical decision support (CDS). MATERIALS AND METHODS Cross-sectional review of closed malpractice claims over seven years from one malpractice insurance company and seven hospitals in the Boston area. For each event, clinical opportunities to intervene to avert the malpractice event and the presence or absence of CDS that might have a role in preventing the event, were assigned by a panel of expert raters. Compensation paid out to resolve a claim (indemnity), was associated with each CDS type. RESULTS Of the 477 closed malpractice cases, 359 (75.3%) were categorized as substantiated and 195 (54%) had at least one opportunity to intervene. Common opportunities to intervene related to performance of procedure, diagnosis, and fall prevention. We identified at least one CDS type for 63% of substantiated claims. The 41 CDS types identified included clinically significant test result alerting, diagnostic decision support and electronic tracking of instruments. Cases with at least one associated intervention accounted for

Prospective Evaluation of a Multifaceted Intervention to Improve Outcomes in Intensive Care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study*

40.3 million (58.9%) of indemnity. DISCUSSION CDS systems and other forms of health information technology (HIT) are expected to improve quality of care, but their potential to mitigate risk had not previously been quantified. Our results suggest that, in addition to their known benefits for quality and safety, CDS systems within HIT have a potential role in decreasing malpractice payments. CONCLUSION More than half of malpractice events and over