Michael H. Kanter

Localization of human BRCA1 and its loss in high-grade, non-inherited breast carcinomas

Although the link between the BRCA1 tumour–suppressor gene and hereditary breast and ovarian cancer is established, the role, if any, of BRCA1 in non–familial cancers is unclear. BRCA1 mutations are rare in sporadic cancers, but loss of BRCA1 resulting from reduced expression or incorrect subcellular localization is postulated to be important in non–familial breast and ovarian cancers. Epigenetic loss, however, has not received general acceptance due to controversy regarding the subcellular localization of BRCA1 proteins, reports of which have ranged from exclusively nuclear, to conditionally nuclear, to the ER/golgi, to cytoplasmic invaginations into the nucleus. In an attempt to resolve this issue, we have comprehensively characterized 19 anti–BRCA1 antibodies. These reagents detect a 220–kD protein localized in discrete nuclear foci in all epithelial cell lines, including those derived from breast malignancies. Immunohistochemical staining of human breast specimens also revealed BRCA1 nuclear foci in benign breast, invasive lobular cancers and low–grade ductal carcinomas. Conversely, BRCA1 expression was reduced or undetectable in the majority of high–grade, ductal carcinomas, suggesting that absence of BRCA1 may contribute to the pathogenesis of a significant percentage of sporadic breast cancers.

Accuracy of statistical methods in TRANSFUSION: a review of articles from July/August 1992 through June 1993

BACKGROUND: Statistical errors have been noted in a large percentage of articles appearing in medical journals. Their incidence in a blood banking journal, however, has not been studied.

Systemic implementation strategies to improve hypertension: the Kaiser Permanente Southern California experience.

The past decade has seen hypertension improving in the United States where control is approximately 50%. Kaiser Permanente has mirrored and exceeded these national advances in control. Integrated models of care such as Kaiser Permanente and the Veterans Administration health systems have demonstrated the greatest hypertension outcomes. We detail the story of Kaiser Permanente Southern California (KPSC) to illustrate the success that can be achieved with an integrated health system model that uses implementation, dissemination, and performance feedback approaches to chronic disease care. KPSC, with a large ethnically diverse population of more than 3.6 million, has used a stepwise approach to achieve control rates greater than 85% in those recognized with hypertension. This was accomplished through systemic implementations of specific strategies: (1) capturing hypertensive members into a hypertension registry; (2) standardization of blood pressure measurements; (3) drafting and disseminating an internal treatment algorithm that is evidence-based and is advocating of combination therapy; and (4) a multidisciplinary approach using medical assistants, nurses, and pharmacists as key stakeholders. The infrastructure, support, and involvement across all levels of the health system with rapid and continuous performance feedback have been pivotal in ensuring the follow-through and maintenance of these strategies. The KPSC hypertension program is continually evolving in these areas. With these high control rates and established infrastructure, they are positioned to take on different innovations and study models. Such potential projects are drafting strategies on resistant hypertension or addressing the concerns about overtreatment of hypertension.

Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program

OBJECTIVE Screening for abdominal aortic aneurysms (AAAs) reduces aneurysm-related mortality and has been recommended by the U.S. Preventive Services Task Force and American Heart Association since 2005. Medicare has covered a one-time screening ultrasound for new male enrollees with a familial or smoking history since 2007. Nevertheless, in the U.S., screening has remained underutilized. Review of patients with ruptured AAA in our system in 2007 showed the majority were undiagnosed, yet met U.S. Preventive Services Task Force and American Heart Association screening guidelines. To reduce the number of preventable AAA ruptures and deaths in our patients, we implemented an AAA screening program using our electronic medical record (EMR). This study describes the design, implementation, and early results of that screening program. METHODS Between March 2012 and June 2013, men aged 65 to 75 years with any history of smoking were targeted for screening. Medical records were reviewed electronically to exclude patients with abdominal imaging studies within 10 years that would have diagnosed an AAA. Best practice alerts (BPA) were created in the EMR so when an appropriate patient is seen, office staff and providers are prompted to order an aortic ultrasound. AAA was defined as aortic diameter ≥3.0 cm or greater, and ultrasound reports contained a standard template providing guidance for patient management when an aneurysm was identified. Newly identified AAAs were triaged for vascular surgery consultation or follow-up with their primary physician. The number of eligible patients, unscreened patients, and AAAs identified were tabulated by our Regional Outpatient Safety Net Program. RESULTS In a population of 3.6 million, 55,610 patients initially met screening criteria, and 26,837 (48.26%) were excluded from the BPA because of prior abdominal imaging studies. After 15 months, there were 68,164 patients who met screening criteria, 54,356 (79.74%) of whom had undergone an abdominal imaging study. Thus, 27,519 patients underwent an imaging study after the BPA was activated. During the study period, 731 new AAAs were diagnosed, 165 over 4.0 cm in diameter. Screening rates have increased at all medical centers where the BPA was activated, and the percentage of unscreened patients has been reduced from 51.74% to 20.26% system-wide. CONCLUSIONS In an integrated health care system using an EMR, AAA screening can be implemented with a dramatic reduction in unscreened patients. Further analysis is required to assess the impact of the screening program on AAA rupture rate and cost-effectiveness in our system.

Evaluating the Psychometric Properties of the CAHPS Patient-Centered Medical Home Survey

OBJECTIVE The goal of this study was to evaluate the reliability and validity of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Patient-Centered Medical Home (PCMH) survey. METHODS We conducted a field test of the CAHPS PCMH survey with 2740 adults. We collected information by mail (n = 1746), telephone (n = 672), and from the Web (n = 322) from 6 sites of care affiliated with a West Coast staff model health maintenance organization. RESULTS An overall response rate of 37% was obtained. Internal consistency reliability estimates for 7 multi-item scales were as follows: access to care, 5 items, α = 0.79; communication with providers, 6 items, α = 0.93; office staff courtesy and respect, 2 items, α = 0.80; shared decision making about medicines, 3 items, α = 0.67; self-management support, 2 items, α = 0.61; attention to mental health issues, 3 items, α = 0.80; and care coordination, 4 items, α = 0.58. The number of responses needed to get reliable information at the site of care level for the composites was generally acceptable (<300 for 0.70 reliability-level) except for self-management support and shared decision making about medicines. Item-scale correlations provided support for distinct composites except for access to care and shared decision making about medicines, which overlapped with the communication with providers scale. Shared decision making and self-management support were significantly, uniquely associated with the global rating of the provider (dependent variable), along with access and communication in a multiple regression model. CONCLUSIONS This study provides further support for the reliability and validity of the CAHPS PCMH survey, but refinement of the self-management support and shared decision-making scales is needed. The survey can be used to provide information about the performance of different health plans on multiple domains of health care, but future efforts to improve some of the survey items is needed.

Effectiveness of a prospective physician self-audit transfusion- monitoring system

BACKGROUND: The purpose of this study was to search for a more effective transfusion‐monitoring system than the existing system of retrospective peer review. STUDY DESIGN AND METHODS: This research used a study‐control, preintervention and postintervention design, to evaluate the effectiveness of a prospective physician self‐audit transfusion‐monitoring system that functioned without the direct involvement of transfusion service physicians. This research also evaluated the effectiveness of issuing to physicians a memo with transfusion guidelines. Three process indicators were used to assess physician behavior at various stages of the blood‐ordering process: 1) the number of crossmatches ordered per admission, 2) the transfusion‐to‐ crossmatch ratio, and 3) the number of blood units returned to the laboratory after physician self‐auditing. The study used two outcome indicators to reflect overall blood utilization: 1) the percentage of patients who received red cell transfusions and 2) the number of blood units transfused per recipient each month. RESULTS: The prospective physician self‐audit system implemented at the study hospital did not reverse physician transfusion decisions, and the process of issuing to physicians a memo with transfusion guidelines at the control hospital failed to reduce blood usage. However, a transient reduction in blood utilization was observed at the study hospital. CONCLUSION: The reduction was hypothesized to be due to a Hawthorne effect, in which observed behavior is affected by the subjects awareness of the research study.

Improving Blood Pressure Control in a Large Multiethnic California Population Through Changes in Health Care Delivery, 2004–2012

The Kaiser Permanente Southern California (Kaiser) health care system succeeded in improving hypertension control in a multiethnic population by adopting a series of changes in health care delivery. Data from the Healthcare Effectiveness Data and Information Set (HEDIS) was used to assess blood pressure control from 2004 through 2012. Hypertension control increased overall from 54% to 86% during that period, and 80% or more in every subgroup, regardless of race/ethnicity, preferred language, or type of health insurance plan. Health care delivery changes improved hypertension control across a large multiethnic population, which indicates that health care systems can achieve a clinical target goal of 70% for hypertension control in their populations.

The Transfusion Audit as a Tool to Improve Transfusion Practice: a Critical Appraisal

Transfusion audits have a long history and they are required by many regulatory agencies. These audits have been touted as effective in reducing unnecessary transfusions as evidenced by many published articles on the subject. Most of these studies, however, have one or more flaws in their design including the use of historical controls, disregard of the Hawthorne effect, use of multiple interventions, and publication bias. Studies differ in the baseline rate of inappropriate transfusions and have different methods of measuring these rates. There is also little data on how long the effect of implementing a transfusion audit system may last. Transfusion audits appear most successful when there is a high baseline rate of inappropriate transfusions and interventions other than the audit itself are performed. Individual institutions should critically evaluate whether or not their current system of transfusion audits is useful.

Stepping toward discharge: Level of ambulation in hospitalized patients.

Little information is available on how active adult patients are during their hospitalization. The purpose of this study is to describe the level of ambulation in hospitalized patients. This was a cohort study of ambulatory patients from 3 hospital medical-surgical units conducted March 2014 through July 2014. Patients wore an accelerometer upon admission to the unit until discharge to home. Sensor placement and data review were performed as part of routine care. Step counts were merged with administrative and clinical data for analysis. Data were available on 777 patients who had at least 24 hours of monitoring prior to discharge. The sample included 57% females, and 55% were nonwhite. The median total step count over 24 hours was 1158 (interquartile range: 636-2238). Patients who were older accrued fewer steps compared to younger patients (962 vs 1294, P < 0.0001). For patients who had at least 48 hours of monitoring (n = 378), there was an increase from 811 steps in the first 24 hours to 1188 steps in the final 24 hours prior to discharge. More frequent documentation was associated with higher step counts (P ≤ 0.001). We found that a diverse sample of hospitalized adult patients accrued over 1000 steps in the 24 hours prior to discharge home.

Electronic Clinical Surveillance to Improve Outpatient Care: Diverse Applications within an Integrated Delivery System

Efforts to improve patient safety have largely focused on inpatient or emergency settings, but the importance of patient safety in ambulatory care is increasingly being recognized as a key component of overall health care quality. Care gaps in outpatient settings may include missed diagnoses, medication errors, or insufficient monitoring of patients with chronic conditions or on certain medications. Further, care gaps may occur across a wide range of clinical conditions. We report here an innovative approach to improve patient safety in ambulatory settings – the Kaiser Permanente Southern California (KPSC) Outpatient Safety Net Program – which leverages electronic health information to efficiently identify and address a variety of potential care gaps across different clinical conditions. Between 2006 and 2012, the KPSC Outpatient Safety Net Program implemented 24 distinct electronic clinical surveillance programs, which routinely scan the electronic health record to identify patients with a particular condition or event. For example, electronic clinical surveillance may be used to scan for harmful medication interactions or potentially missed diagnoses (e.g., abnormal test results without evidence of subsequent care). Keys to the success of the program include strong leadership support, a proactive clinical culture, the blame-free nature of the program, and the availability of electronic health information. The Outpatient Safety Net Program framework may be adopted by other organizations, including those who have electronic health information but not an electronic health record. In the future, the creation of a forum to share electronic clinical surveillance programs across organizations may facilitate more rapid improvements in outpatient safety.