Sara L. Jackson

Predictors of urinary incontinence in a prospective cohort of postmenopausal women.

OBJECTIVE: To prospectively assess risk factors associated with occurrence of urinary incontinence among postmenopausal women. METHODS: We followed up 1,017 postmenopausal health maintenance organization enrollees, aged 55 to 75 years, for 2 years. The primary outcome measures were any urinary incontinence and severe incontinence reported at 12- or 24-month follow-up visits. RESULTS: Baseline prevalence of any amount or frequency of urinary incontinence in the past year was 66%. Among the 345 women without incontinence at baseline, 65 (19%) at 1 year and 66 (19%) at 2 years reported any incontinence. Ninety-two of 672 (14%) and 96 of 672 (14%) women with incontinence at baseline reported no incontinence at years 1 and 2. In an adjusted multiple logistic regression model, independent predictors of any incontinence included white race (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1–2.6), vaginal estrogen cream (OR 2.0, CI 1.1–3.7), vaginal dryness (OR 1.6, CI 1.2–2.2), vaginal discharge (OR 1.5, CI 1.0–2.2), 6 or more lifetime urinary tract infections (OR 1.8, CI 1.2–2.6), and diabetic peripheral neuropathy (OR 1.7, CI 1.0–3.1). In adjusted models, predictors of severe incontinence were history of hysterectomy (OR 1.8, CI 1.1–2.7) and any vaginal symptom (OR 1.7, CI 1.0–2.8). CONCLUSION: A substantial proportion of incontinence-free postmenopausal women developed urinary incontinence during 2 years of follow-up. Because vaginal symptoms are associated with urinary incontinence, their relationship with other risk factors, including vaginal Escherichia coli colonization and vaginal estrogen cream use, warrant additional study. Similarly, diabetic peripheral neuropathy and hysterectomy associations suggest areas for future investigation. LEVEL OF EVIDENCE: II-2

Diabetes Mellitus and Urinary Tract Infection: Epidemiology, Pathogenesis and Proposed Studies in Animal Models

PURPOSE We reviewed the current state of knowledge about urinary tract infection in patients with diabetes from the clinical and basic science perspectives. We identified key knowledge gaps and areas for further research. MATERIALS AND METHODS We performed a focused literature search on certain topics, including clinical studies related to etiology and pathophysiology of urinary tract infection in patients with diabetes, urinary tract infection studies in animal models of diabetes and basic science studies of the molecular mechanisms of urinary tract infection. RESULTS Individuals with diabetes are at higher risk for urinary tract infection. Increased susceptibility in patients with diabetes is positively associated with increased duration and severity of diabetes. Clinical epidemiological data identifying mechanisms of increased urinary tract infection susceptibility in patients with diabetes are generally lacking and indicate only that urinary tract infections in women with and without diabetes are qualitatively similar in bacterial etiology and morbid sequelae. Existing animal models for diabetes have not been well characterized for urinary tract infection research. The increased incidence, prevalence and severity of urinary tract infection in patients with diabetes argue for aggressive antibacterial chemotherapy but novel therapies resulting from urinary tract infection research in nondiabetic animal models are still not available. CONCLUSIONS Future clinical investigations of urinary tract infection in patients with diabetes should focus on how the disease differs from that in patients without diabetes, notably on the role of glycosuria and urinary tract infection risk. Basic science research priorities for urinary tract infection in patients with diabetes should emphasize further development of diabetic animal models for urinary tract infection research and clinical translation of known important virulence determinants into new therapies.

Urinary incontinence and urinary tract infection: temporal relationships in postmenopausal women.

OBJECTIVE: To estimate the temporal relationship between self-reported urine loss and incident, symptomatic, microbiologically confirmed urinary tract infection (UTI). METHODS: We used daily diaries to collect information on incontinent episodes during a 2-year prospective study of incident UTI among 913 healthy postmenopausal health maintenance organization enrollees. We calculated the monthly rate of urine loss to assess for association with incident UTI. We also estimated the basal rate of urinary incontinence among women who experienced a UTI (excluding the 14-day time period pre- and post-UTI) and compared this to urine loss during the 3-day time period after UTI, to evaluate changes after infection. RESULTS: Sixty percent of women reported urinary incontinence, at a mean rate of 4.7 times per month. The monthly mean rate of urine loss was 2.64 times per month among women who did not experience a UTI compared with 4.60 times per among women who developed a UTI (P=.04). Among women who developed a UTI (n=78), the rate of urine loss during the 3 days after UTI onset was 1.5 times higher than the basal rate (0.23 compared with 0.15 reports per day, P=.26). CONCLUSION: After eliminating episodes of incontinence surrounding a UTI, the basal rate of urine loss was higher among women who experienced UTIs compared with those who did not. Additionally, among women who experienced a UTI, an increase in urine loss occurred in the immediate 3-day time period post-UTI, compared with infection-free periods. Urinary incontinence characterizes women who experience UTIs, both intercurrently and during an acute episode. LEVEL OF EVIDENCE: III

Variability of interpretive accuracy among diagnostic mammography facilities

BACKGROUND Interpretive performance of screening mammography varies substantially by facility, but performance of diagnostic interpretation has not been studied. METHODS Facilities performing diagnostic mammography within three registries of the Breast Cancer Surveillance Consortium were surveyed about their structure, organization, and interpretive processes. Performance measurements (false-positive rate, sensitivity, and likelihood of cancer among women referred for biopsy [positive predictive value of biopsy recommendation {PPV2}]) from January 1, 1998, through December 31, 2005, were prospectively measured. Logistic regression and receiver operating characteristic (ROC) curve analyses, adjusted for patient and radiologist characteristics, were used to assess the association between facility characteristics and interpretive performance. All statistical tests were two-sided. RESULTS Forty-five of the 53 facilities completed a facility survey (85% response rate), and 32 of the 45 facilities performed diagnostic mammography. The analyses included 28 100 diagnostic mammograms performed as an evaluation of a breast problem, and data were available for 118 radiologists who interpreted diagnostic mammograms at the facilities. Performance measurements demonstrated statistically significant interpretive variability among facilities (sensitivity, P = .006; false-positive rate, P < .001; and PPV2, P < .001) in unadjusted analyses. However, after adjustment for patient and radiologist characteristics, only false-positive rate variation remained statistically significant and facility traits associated with performance measures changed (false-positive rate = 6.5%, 95% confidence interval [CI] = 5.5% to 7.4%; sensitivity = 73.5%, 95% CI = 67.1% to 79.9%; and PPV2 = 33.8%, 95% CI = 29.1% to 38.5%). Facilities reporting that concern about malpractice had moderately or greatly increased diagnostic examination recommendations at the facility had a higher false-positive rate (odds ratio [OR] = 1.48, 95% CI = 1.09 to 2.01) and a non-statistically significantly higher sensitivity (OR = 1.74, 95% CI = 0.94 to 3.23). Facilities offering specialized interventional services had a non-statistically significantly higher false-positive rate (OR = 1.97, 95% CI = 0.94 to 4.1). No characteristics were associated with overall accuracy by ROC curve analyses. CONCLUSIONS Variation in diagnostic mammography interpretation exists across facilities. Failure to adjust for patient characteristics when comparing facility performance could lead to erroneous conclusions. Malpractice concerns are associated with interpretive performance.

Patients who share transparent visit notes with others: characteristics, risks, and benefits.

Background Inviting patients to read their primary care visit notes may improve communication and help them engage more actively in their health care. Little is known about how patients will use the opportunity to share their visit notes with family members or caregivers, or what the benefits might be. Objective Our goal was to evaluate the characteristics of patients who reported sharing their visit notes during the course of the study, including their views on associated benefits and risks. Methods The OpenNotes study invited patients to access their primary care providers’ visit notes in Massachusetts, Pennsylvania, and Washington. Pre- and post-intervention surveys assessed patient demographics, standardized measures of patient-doctor communication, sharing of visit notes with others during the study, and specific health behaviors reflecting the potential benefits and risks of offering patients easy access to their visit notes. Results More than half (55.43%, 2503/4516) of the participants who reported viewing at least one visit note would like the option of letting family members or friends have their own Web access to their visit notes, and 21.70% (980/4516) reported sharing their visit notes with someone during the study year. Men, and those retired or unable to work, were significantly more likely to share visit notes, and those sharing were neither more nor less concerned about their privacy than were non-sharers. Compared to participants who did not share clinic notes, those who shared were more likely to report taking better care of themselves and taking their medications as prescribed, after adjustment for age, gender, employment status, and study site. Conclusions One in five OpenNotes patients shared a visit note with someone, and those sharing Web access to their visit notes reported better adherence to self-care and medications. As health information technology systems increase patients’ ability to access their medical records, facilitating access to caregivers may improve perceived health behaviors and outcomes.

A collaborative care team to integrate behavioral health care and treatment of poorly-controlled type 2 diabetes in an urban safety net primary care clinic

OBJECTIVE Demonstrate the feasibility of implementing a collaborative care program for poorly-controlled type 2 diabetes and complex behavioral health disorders in an urban academically-affiliated safety net primary care clinic. METHODS This retrospective cohort study evaluates multidisciplinary team care approach to diabetes in a safety net clinic, and included 634 primary care clinic patients with hemoglobin A1c (HbA1c)>9%. HbA1c, blood pressure, and depression severity were assessed at the initial visit and at the end of treatment, and compared to those of patients who were not referred to the team. RESULTS The 151 patients referred to the program between March 2013 and November 2014 had a higher initial mean HbA1c: 10.6% vs. 9.4%, and were more likely to have depression (p=0.006), anxiety (p=0.04), and bipolar disorder (p=0.03), compared to the 483 patients who were not referred. During the 18-month study period, there was a mean decrease in HbA1c of 0.9 (10.6 to 9.4) among those referred to the team, compared to a mean decrease of 0.2 (9.4 to 9.2) among those not referred. This was a significantly greater percent change in HbA1c (p=0.008). CONCLUSION The integration of behavioral healthcare into chronic care management of patients with diabetes is a promising strategy to improve outcomes among the high risk population in safety net settings.

Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.

Objective To evaluate the potential effect of second opinions on improving the accuracy of diagnostic interpretation of breast histopathology. Design Simulation study. Setting 12 different strategies for acquiring independent second opinions. Participants Interpretations of 240 breast biopsy specimens by 115 pathologists, one slide for each case, compared with reference diagnoses derived by expert consensus. Main outcome measures Misclassification rates for individual pathologists and for 12 simulated strategies for second opinions. Simulations compared accuracy of diagnoses from single pathologists with that of diagnoses based on pairing interpretations from first and second independent pathologists, where resolution of disagreements was by an independent third pathologist. 12 strategies were evaluated in which acquisition of second opinions depended on initial diagnoses, assessment of case difficulty or borderline characteristics, pathologists’ clinical volumes, or whether a second opinion was required by policy or desired by the pathologists. The 240 cases included benign without atypia (10% non-proliferative, 20% proliferative without atypia), atypia (30%), ductal carcinoma in situ (DCIS, 30%), and invasive cancer (10%). Overall misclassification rates and agreement statistics depended on the composition of the test set, which included a higher prevalence of difficult cases than in typical practice. Results Misclassification rates significantly decreased (P<0.001) with all second opinion strategies except for the strategy limiting second opinions only to cases of invasive cancer. The overall misclassification rate decreased from 24.7% to 18.1% when all cases received second opinions (P<0.001). Obtaining both first and second opinions from pathologists with a high volume (≥10 breast biopsy specimens weekly) resulted in the lowest misclassification rate in this test set (14.3%, 95% confidence interval 10.9% to 18.0%). Obtaining second opinions only for cases with initial interpretations of atypia, DCIS, or invasive cancer decreased the over-interpretation of benign cases without atypia from 12.9% to 6.0%. Atypia cases had the highest misclassification rate after single interpretation (52.2%), remaining at more than 34% in all second opinion scenarios. Conclusion Second opinions can statistically significantly improve diagnostic agreement for pathologists’ interpretations of breast biopsy specimens; however, variability in diagnosis will not be completely eliminated, especially for breast specimens with atypia.

Patient Access to Online Visit Notes: Perceptions of Doctors and Patients at an Urban HIV/AIDS Clinic

Patients living with HIV/AIDS face large societal and medical challenges. Inviting patients to read their doctors’ visit notes via secure electronic portals may empower patients and improve health. We investigated whether utilization and perceptions about access to doctors’ notes differed among doctors and patients in an HIV/AIDS clinic versus primary care setting. We analyzed pre- and 1-year postintervention data from 99 doctors and 3819 patients. HIV clinic patients did not report differences in perceived risks and benefits compared to primary care clinic patients, however, they were more likely to share notes with friends (33% versus 9%, P = .002), other health professionals (24% versus 8%, P = .03), or another doctor (38% versus 9%, P < .0001). HIV clinic doctors were less likely than primary care doctors to change the level of candor in visit notes (P < .04). Our findings suggest that HIV clinic patients and doctors are ready to share visit notes online.

Characteristics of Patients Who Report Confusion After Reading Their Primary Care Clinic Notes Online

ABSTRACT Patient access to online electronic medical records (EMRs) is increasing and may offer benefits to patients. However, the inherent complexity of medicine may cause confusion. We elucidate characteristics and health behaviors of patients who report confusion after reading their doctors’ notes online. We analyzed data from 4,528 patients in Boston, MA, central Pennsylvania, and Seattle, WA, who were granted online access to their primary care doctors’ clinic notes and who viewed at least one note during the 1-year intervention. Three percent of patients reported confusion after reading their visit notes. These patients were more likely to be at least 70 years of age (p < .0001), have fewer years of education (p < .0017), be unemployed (p < .0001), have lower levels of self-reported health (p < .0043), and worry more after reading visit notes (relative risk [RR] 4.83; confidence interval [CI] 3.17, 7.36) compared to patients who were not confused. In adjusted analyses, they were less likely to report feeling more in control of their health (RR 0.42; CI 0.25, 0.71), remembering their care plan (RR 0.26; CI 0.17, 0.42), and understanding their medical conditions (RR 0.32; CI 0.19, 0.54) as a result of reading their doctors’ notes compared to patients who were not confused. Patients who were confused by reading their doctors’ notes were less likely to report benefits in health behaviors. Understanding this small subset of patients is a critical step in reducing gaps in provider–patient communication and in efforts to tailor educational approaches for patients.

Patients Typing Their Own Visit Agendas Into an Electronic Medical Record: Pilot in a Safety-Net Clinic

Collaborative visit agenda setting between patient and doctor is recommended. We assessed the feasibility, acceptability, and utility of patients attending a large primary care safety-net clinic typing their agendas into the electronic visit note before seeing their clinicians. One hundred and one patients and their 28 clinicians completed post-visit surveys. Patients and clinicians agreed that the agendas improved patient-clinician communication (patients 79%, clinician 74%), and wanted to continue having patients type agendas in the future (73%, 82%). Enabling patients to type visit agendas may enhance care by engaging patients and giving clinicians an efficient way to prioritize patients’ concerns.