Philip J Kroth

Combining Web-Based and Mail Surveys Improves Response Rates: A PBRN Study From PRIME Net

PURPOSE The advent of Web-based survey tools has provided the investigator with an alternative to paper-based survey methods that in many instances may be less expensive to implement than traditional paper-based surveys. Newer technology, however, does not diminish the importance of obtaining an adequate response rate. METHODS We analyzed response rate data obtained from a survey implemented across 3 practice-based research networks (PBRNs) in which the survey was first implemented electronically with 5 rounds of electronic solicitation for an Internet-based questionnaire and then by 2 rounds of a paper-based version mailed only to nonresponders. RESULTS Overall, 24% of the total survey responses received were in the paper mode despite intense promotion of the survey in the electronic phase. CONCLUSIONS Our results suggest there is still an important role for the use of paper-based methods in PBRN survey research. Both hard copy and electronic survey collection methods may be required to enhance clinician response rates in PBRNs.

Undertreatment of osteoporosis in women, based on detection of vertebral compression fractures on chest radiography

BACKGROUND Fractures attributable to ostcoporosis are responsible for preventable suffering and health care costs. Until they experience a fracture, many older adults, particularly women, are unaware that they have osteoporosis. Although radiographs taken for reasons other than evaluating the possibility of osteoporosis may suggest the presence of fracture, such fractures often go undetected and effective treatments are not implemented. OBJECTIVE The goal of this study was to determine the adequacy of treatment of osteoporotic vertebral compression fractures in middle-aged and older women in an internal medicine clinic, as ascertained by reports of chest radiography. The hypothesis was that patients having chest radiographs with observable vertebral compression fractures often did not receive adequate treatment. METHODS This was a retrospective, cross-sectional study conducted at a general internal medicine clinic at a university-affiliated county hospital. The records of an academic internal medicine practice were searched to identify women aged >or=40 years with radiologic evidence of vertebral compression fractures during the period from June 1, 1992, through May 31, 2002. Electronic prescription records were then searched to determine whether patients had received a prescription for a medication for the treatment of osteoporosis. An analysis also was conducted to describe the frequency distribution of various medications for the treatment of osteoporosis. RESULTS One hundred thirteen women were identified who met the study criteria. Their mean (SD) age was 68.1 (21.9) years. Fifty-six (50%) of these women received pharmacologic treatment for osteoporosis. The most commonly prescribed medications were estrogens (35%), calcitonin (16%), and bisphosphonates (12%). CONCLUSIONS No more than half of patients identified as having a vertebral compression fracture on chest radiography received even 1 prescription for the treatment of osteoporosis. Because this study did not examine adherence or long-term medication use, the proportion of women who received adequate osteoporosis therapy was probably much less than half. Physicians should be alert to the possible presence of vertebral compression fractures and take a more aggressive approach to treatment when a fracture is present.

Leveraging Change to Integrate Library and Informatics Competencies into a New CTSC Curriculum: A Program Evaluation

This program evaluation reports on the curricular development and integration of library, biomedical informatics, and scholarly communications (LBS) skills into a required informatics course for a new graduate degree program in the University of New Mexicos Clinical and Translational Sciences Center (CTSC). The course built on the opportunity presented by the new degree program to integrate LBS competencies rarely included in most traditional clinical research training programs. This report tracks the experiences and evaluations of two cohorts of graduate students who have completed the course. This article presents lessons learned on curricular integration and offers thoughts for future work.

Context of Clinical Care: The Case of Hepatitis C in Underserved Communities—A Report from the Primary Care Multiethnic Network (PRIME Net) Consortium

Background: The importance of Hepatitis C (HCV) as a public and individual health concern is well established. However, national groups differ in their recommendations to primary care clinicians about screening people at high risk for HCV. The purpose of this study was to explore the context of care within which primary care clinicians decide to detect and initially manage HCV. Methods: The Primary Care Multiethnic Network conducted a web- and paper-based survey of primary care clinicians who largely practice in low-income, medically underserved communities in 3 regions across the country. Results: A total of 494 clinicians participated, for a response rate of 61%. Most (68%) clinicians view HCV as an important problem; more than half (59%) consider screening for HCV to be important when compared with other conditions they screen for in practice. With regard to reported screening habits for risk factors, 54% of clinicians routinely ask new patients whether they have used intravenous drugs and 28% inquire about blood transfusions before 1992. Sixty-one percent order an alanine aminotransferase test when patients present with other risk factors for HCV. The majority of clinicians (54%) refer 75% or fewer of their patients with HCV for treatment; nearly one-fifth (18%) provide antiviral treatment themselves. Key factors influencing clinician HCV decision making are patient comorbidities (74% reported this as a factor), access to treatment (55% reported this as a factor), and tolerance (44% reported this as a factor) of treatment. Conclusions: In the face of conflicting national guideline recommendations about screening people at high risk for HCV, clinicians have varied views and practice habits influenced by multiple patient, access, and treatment issues.

Inter-Observer Agreement on Subjects' Race and Race- Informative Characteristics

Health and socioeconomic disparities tend to be experienced along racial and ethnic lines, but investigators are not sure how individuals are assigned to groups, or how consistent this process is. To address these issues, 1,919 orthodontic patient records were examined by at least two observers who estimated each individuals race and the characteristics that influenced each estimate. Agreement regarding race is high for African and European Americans, but not as high for Asian, Hispanic, and Native Americans. The indicator observers most often agreed upon as important in estimating group membership is name, especially for Asian and Hispanic Americans. The observers, who were almost all European American, most often agreed that skin color is an important indicator of race only when they also agreed the subject was European American. This suggests that in a diverse community, light skin color is associated with a particular group, while a range of darker shades can be associated with members of any other group. This research supports comparable studies showing that race estimations in medical records are likely reliable for African and European Americans, but are less so for other groups. Further, these results show that skin color is not consistently the primary indicator of an individuals race, but that other characteristics such as facial features add significant information.

Using LOINC to link 10 terminology standards to one unified standard in a specialized domain

Despite the existence of multiple standards for the coding of biomedical data and the known benefits of doing so, there remain a myriad of biomedical information domain spaces that are essentially un-coded and unstandardized. Perhaps a worse situation is when the same or similar information in a given domain is coded to a variety of different standards. Such is the case with cephalometrics - standardized measurements of angles and distances between specified landmarks on X-ray film used for orthodontic treatment planning and a variety of research applications. We describe how we unified the existing cephalometric definitions from 10 existing cephalometric standards to one unifying terminology set using an existing standard (LOINC). Using our example of an open and web-based orthodontic case file system, we describe how this work benefited our project and discuss how adopting or expanding established standards can benefit other similar projects in specialized domains.

Institutional Repository Access Patterns of Nontraditionally Published Academic Content: What Types of Content Are Accessed the Most?

The authors analyze monthly Internet access to traditionally unpublished academic content in one universitys institutional repository (IR). Content selected for analysis include materials supplementary to peer-reviewed publications, poster images, graduate course research papers, and presentation slides. The content types represent academic output that would not likely be otherwise collected and made freely available were it not for its availability in an IR. The average first-year access rates per month are similar across content types, and evidence of access persists over time, indicating the value of this content to others and the utility of posting nontraditional academic materials in an institutional repository.

The translational sciences: a rare open access opportunity.

Health sciences librarians serve society by making needed health-related information available to our users. The Medical Library Associations (MLAs) slogan, “Professionals providing quality information for improved health”; the 2010 revised MLA Code of Ethics [1]; and the American Library Associations code of ethics [2] all reflect our professions central purpose. One formal research study on the core values of librarians and information professionals also verified that, on the international scale, our profession seeks to provide access to quality information [3].

PS1-50: Implementation and Evaluation of a Health Information Exchange (HIE)

Background/Aims HIEs are secure computer networks that allow sharing of patients’ health records across health care organizations in a standard format to provide more comprehensive information to providers at the point of care. Potential HIE benefits include improved quality (better care coordination, decreased errors) and reduced costs (reduced redundant lab and radiology orders). The New Mexico Health Information Collaborative (NMHIC), the State’s HIE, is implementing pilot clinical use sites in Albuquerque area Emergency Departments (EDs). Here we present the approach evaluating our pilots HIE implementation in the ED setting for its effect on the rate of redundant lab and radiology orders. Methods This is an analysis of the rates of redundant lab and radiology orders before and after installation of an HIE access portal in 2 New Mexico emergency departments. Redundant tests are subsequent tests that provide no more clinically useful data that what is available from the preexisting test. Rates are measured by identifying all ED procedures P and their associated primary diagnosis D. For each first PD pair in the baseline year, count subsequent matching PD pairs as potential duplicates. Filter potential duplicates by evaluating days between pairs and excluding those within clinical guidelines (e.g., >1/month for fractures). Rates are Poisson Sum redundant test type ‘PD’/Sum initial test type ‘PD’ per-member-month. Results For baseline period 1/2009 – 12/2009, we identified 1,464 PD pairs where the procedure was chest x-ray, of which 548 (37%) were potentially redundant, for a rate of 3.1% (2.2–4.2%) per 100,000 member months. We identified 415 PD pairs where the procedure was CT scan, of which 132 (32%)were potentially redundant, for a rate of 7.4% (5.0–10.6%) per 100,000 member months. Rates will be calculated for a similar period following the HIE implementation and compared to baseline rates to assess the impact. Discussion The HIE represents a new tool that can potentially reduce the rates of redundant testing in the ED setting. The process of defining redundant tests is a critical component of this kind of analysis. More work is needed in this area to define, standardize, and validate the “rules” for categorizing tests as redundant.

The electronic elephant in the room: Physicians and the electronic health record

Abstract Objectives Determine the specific aspects of health information and communications technologies (HICT), including electronic health records (EHRs), most associated with physician burnout, and identify effective coping strategies. Materials and methods We performed a qualitative analysis of transcripts from 2 focus groups and a burnout assessment of ambulatory physicians—each at 3 different health care institutions with 3 different EHRs. Results Of the 41 clinicians, 71% were women, 98% were physicians, and 73% worked in primary care for an average of 11 years. Only 22% indicated sufficient time for documentation. Fifty-six percent noted “a great deal of stress” because of their job. Forty-two percent reported “poor” or “marginal” control over workload. Even though 90% reported EHR proficiency, 56% indicated EHR time at home was “excessive” or “moderately high.” Focus group themes included HICT “successes” where all patients’ information is accessible from multiple locations. HICT “stressors” included inefficient user interfaces, unpredictable system response times, poor interoperability between systems and excessive data entry. “Adverse outcomes” included ergonomic problems (eg, eye strain and hand, wrist, and back pain) and decreased attractiveness of primary care. Suggested “organizational changes” included EHR training, improved HICT usability, and scribes. “Personal/resilience” strategies focused on self-care (eg, exercise, maintaining work-life boundaries, and positive thinking). Discussion and conclusion HICT use, while beneficial in many ways for patients and providers, has also increased the burden of ambulatory practice with personal and professional consequences. HICT and clinic architectural and process redesign are likely necessary to make significant overall improvements.