Mark A. Nyman

The SAGE Guideline Model: Achievements and Overview

The SAGE (Standards-Based Active Guideline Environment) project was formed to create a methodology and infrastructure required to demonstrate integration of decision-support technology for guideline-based care in commercial clinical information systems. This paper describes the development and innovative features of the SAGE Guideline Model and reports our experience encoding four guidelines. Innovations include methods for integrating guideline-based decision support with clinical workflow and employment of enterprise order sets. Using SAGE, a clinician informatician can encode computable guideline content as recommendation sets using only standard terminologies and standards-based patient information models. The SAGE Model supports encoding large portions of guideline knowledge as re-usable declarative evidence statements and supports querying external knowledge sources.

Modeling guidelines for integration into clinical workflow.

The success of clinical decision-support systems requires that they are seamlessly integrated into clinical workflow. In the SAGE project, which aims to create the technological infra-structure for implementing computable clinical practice guide-lines in enterprise settings, we created a deployment-driven methodology for developing guideline knowledge bases. It involves (1) identification of usage scenarios of guideline-based care in clinical workflow, (2) distillation and disambiguation of guideline knowledge relevant to these usage scenarios, (3) formalization of data elements and vocabulary used in the guideline, and (4) encoding of usage scenarios and guideline knowledge using an executable guideline model. This methodology makes explicit the points in the care process where guideline-based decision aids are appropriate and the roles of clinicians for whom the guideline-based assistance is intended. We have evaluated the methodology by simulating the deployment of an immunization guideline in a real clinical information system and by reconstructing the workflow context of a deployed decision-support system for guideline-based care. We discuss the implication of deployment-driven guideline encoding for sharability of executable guidelines.

Multiple cardiovascular complications in a patient with relapsing polychondritis.

Relapsing polychondritis is an uncommon disease of unknown etiology, usually manifested by inflammatory changes of cartilaginous tissues. Cardiovascular complications are rare but have been associated with adverse prognosis. Aortitis, vasculitis of large- and medium-sized arteries with aneurysm formation, valvulitis, pericarditis, and atrioventricular conduction disturbances have been reported as late complications of relapsing polychondritis. We describe a 42-year-old man who developed all the known cardiovascular complications of relapsing polychondritis except for clinically evident pericarditis. This case illustrates the multiple, varied, and potentially fatal cardiovascular complications that can occur with this disorder. Patients with relapsing polychondritis should be monitored closely for development of such complications.

Ultrafast Computed Tomographic Scanning to Assess Patency of Coronary Artery Stents in Bypass Grafts

Anginal chest pain after implantation of coronary stents in bypass grafts is a concern because it suggests the possibility of occlusion. Coronary angiography is the definitive method for determining patency of a stent; however, this procedure is relatively contraindicated in a patient receiving warfarin sodium, who has a therapeutic international normalized ratio. An alternative method for determining patency of a stent is by ultrafast computed tomography. This new, minimally invasive technique shows promise for determining blood flow within the large vessels of the thorax. Herein we describe a case in which a metallic stent placed in a vein graft was noninvasively established to be patent, despite chest pain in the patient. This method may be clinically applicable for determining patency of stents in vein grafts in the setting of patients with chest pain who have undergone complete anticoagulation.

Comparison of the Quality of Patient Referrals From Physicians, Physician Assistants, and Nurse Practitioners

OBJECTIVE To compare the quality of referrals of patients with complex medical problems from nurse practitioners (NPs), physician assistants (PAs), and physicians to general internists. PATIENTS AND METHODS We conducted a retrospective comparison study involving regional referrals to an academic medical center from January 1, 2009, through December 31, 2010. All 160 patients referred by NPs and PAs combined and a random sample of 160 patients referred by physicians were studied. Five experienced physicians blinded to the source of referral used a 7-item instrument to assess the quality of referrals. Internal consistency, interrater reliability, and dimensionality of item scores were determined. Differences between item scores for patients referred by physicians and those for patients referred by NPs and PAs combined were analyzed by using multivariate ordinal logistical regression adjusted for patient age, sex, distance of the referral source from Mayo Clinic, and Charlson Index. RESULTS Factor analysis revealed a 1-dimensional measure of the quality of patient referrals. Interrater reliability (intraclass correlation coefficient for individual items: range, 0.77-0.93; overall, 0.92) and internal consistency for items combined (Cronbach α=0.75) were excellent. Referrals from physicians were scored higher (percentage of agree/strongly agree responses) than were referrals from NPs and PAs for each of the following items: referral question clearly articulated (86.3% vs 76.0%; P=.0007), clinical information provided (72.6% vs 54.1%; P=.003), documented understanding of the patients pathophysiology (51.0% vs 30.3%; P<.0001), appropriate evaluation performed locally (60.3% vs 39.0%; P<.0001), appropriate management performed locally (53.5% vs 24.1%; P<.0001), and confidence returning patient to referring health care professional (67.8% vs 41.4%; P<.0001). Referrals from physicians were also less likely to be evaluated as having been unnecessary (30.1% vs 56.2%; P<.0001). CONCLUSION The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation.

Disease management strategies: managing care giving in managed care.

The rapid rate of change in health care delivery systems has challenged and troubled health care providers. Some new health care delivery systems primarily emphasize the economics of medical care and leave providers with a sense that their profession has strayed from its mission. In addition, there is an increasing demand by payers and the public for public accountability for the quality and expense of clinical services. One response to these changes in health care is the use of disease management strategies. There is a growing body of knowledge regarding disease management strategies and practice guidelines in the literature. This article discusses how a provider group can implement improvement in the clinical process successfully by applying techniques of disease management.

73-Year-Old Woman With Fever and Mental Status Changes

A 73-year-old right-handed woman from Wisconsin presented to her local hospital in early March with sharp central chest pain, epigastric discomfort, and painful swallowing. Findings on a work-up for intra-abdominal pathology and cardiac ischemia (including extensive blood work, serial electrocardiograms, and a computed tomographic [CT] scan of the abdomen and pelvis were unremarkable, and the patient was given a presumptive diagnosis of gastroesophageal reflux disease. Before discharge, however, the patient developed recurrent fevers ranging as high as 39.4oC and had difficulty with speaking. Over the next day, her mental status and speech continued to worsen, prompting transfer to Mayo Clinic in Rochester, Minn. The patient’s medical history was notable for nonischemic dilated cardiomyopathy with frequent ventricular ectopy, polymyalgia, and hypothyroidism. Her surgical history included excision of 2 parathyroid glands for hyperparathyroidism. She had traveled only within the upper Midwest. Her medications were all oral and included 81 mg/d of aspirin, 12.5 mg of carvedilol twice daily, 50 mg/d of losartan, 40 mg/d of furosemide, 400 mg/d of amiodarone, 20 mg/d of prednisone (as part of a slow taper after an initial dosage of 30 mg/d started 4 months earlier), and 125 μg/d of levothyroxine. On physical examination, the patient had a temperature of 38.4°C, a heart rate of 92 beats/min, a regular blood pressure of 140/60 mm Hg, a respiratory rate of 24/min, and an oxygen saturation rate of 94% while breathing room air. Her mucous membranes were dry, and 2 shallow bleeding ulcers were noted on her upper palate and tongue. Findings on examination of the lungs, abdomen, extremities, and skin were normal. However, cardiac examination revealed a grade 2/6 systolic ejection murmur. Neurologic examination revealed that the patient was somnolent, opening her eyes and maintaining arousal only when verbally stimulated. She was unable to follow even simple 1-step commands and answered “yes” to most questions. Her speech was otherwise unintelligible. The patient was able to track with her eyes and blinked to threat bilaterally. Her optic discs were flat, and her face was symmetric. She had strong spontaneous movements of the upper and lower extremities and localized to pain throughout. Reflexes on the right were slightly stronger than those on the left. The right plantar response was extensor, whereas the left was flexor. No nuchal rigidity was observed.

Inclusion of short-term care patients affects the perceived performance of specialists: a retrospective cohort study

BackgroundCurrent publicly reported quality performance measures directly compare primary care to specialty care. Specialists see short-term patients referred due to poor control of their disease who then return to their local provider. Our study looked to determine if outcomes measured in short-term care patients differed from those in long-term care patients and what impact those differences may have on quality performance profiles for specialists.MethodsRetrospective cohort from a large academic medical Center. Performance was measured as “Optimal Care” - all or none attainment of goals. Patients with short-term care (<90 days contact) versus long-term care (>90 days contact) were evaluated for both specialty and primary care practices during the year 2008.ResultsPatients with short-term care had significantly lower “Optimal Care”: 7.2% vs. 19.7% for optimal diabetes care in endocrinology and 41.3% vs. 53.1% for optimal ischemic vascular disease care in cardiology (p < 0.001). Combining short and long term care patients lowered overall perceived performance for the specialty practice.ConclusionsFactors other than quality affect the perceived performance of the specialty practice. Extending current primary care quality measurement to short-term specialty care patients without adjustment produces misleading results.

46-Year-Old Man With Fatigue and Brown Urine

A 46-year-old man presented for evaluation of a 3-day history of progressive fatigue, malaise, brown urine, and spontaneous ecchymosis of the right arm associated with anorexia and bilious emesis. He denied any traumatic injury, recent illness, fever, weight loss, night sweats, abdominal pain, or sick contacts.

74-Year-Old Woman With New-Onset Myoclonus

A 74-year-old female nursing home resident with Alzheimer disease was admitted to the hospital with a 5-month history of aggressive behavior, including physically striking other nursing home residents. She had been treated with quetiapine with mild improvement; however, she became tremulous while receiving this medication and so was switched to 0.125 mg/d of risperidone orally. Unfortunately, the patient continued to act aggressively and was brought to the emergency department, where she was unable to follow commands or answer questions appropriately. Laboratory blood tests revealed an elevated serum creatinine level of 1.2 mg/dL (0.6-1.1 mg/dL), compared with a baseline of 0.8 mg/dL. Urine studies showed the presence of gram-negative bacilli and 10 to 20 white blood cells per high-power field, indicating a possible urinary tract infection (UTI). Results for all other diagnostic tests were unremarkable. The patient was treated empirically with a 10-day course of sulfamethoxazole-trimethoprim (SMX-TMP) for a presumed UTI and admitted to the psychiatry unit for behavioral dyscontrol.