Sarah J. Crane

Use of an electronic administrative database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: The elders risk assessment index

BackgroundThe prevention of recurrent hospitalizations in the frail elderly requires the implementation of high-intensity interventions such as case management. In order to be practically and financially sustainable, these programs require a method of identifying those patients most at risk for hospitalization, and therefore most likely to benefit from an intervention. The goal of this study is to demonstrate the use of an electronic medical record to create an administrative index which is able to risk-stratify this heterogeneous population.MethodsWe conducted a retrospective cohort study at a single tertiary care facility in Rochester, Minnesota. Patients included all 12,650 community-dwelling adults age 60 and older assigned to a primary care internal medicine provider on January 1, 2005. Patient risk factors over the previous two years, including demographic characteristics, comorbid diseases, and hospitalizations, were evaluated for significance in a logistic regression model. The primary outcome was the total number of emergency room visits and hospitalizations in the subsequent two years. Risk factors were assigned a score based on their regression coefficient estimate and a total risk score created. This score was evaluated for sensitivity and specificity.ResultsThe final model had an AUC of 0.678 for the primary outcome. Patients in the highest 10% of the risk group had a relative risk of 9.5 for either hospitalization or emergency room visits, and a relative risk of 13.3 for hospitalization in the subsequent two year period.ConclusionsIt is possible to create a screening tool which identifies an elderly population at high risk for hospital and emergency room admission using clinical and administrative data readily available within an electronic medical record.

Survival Trends in Patients With Gastric and Esophageal Adenocarcinomas: A Population-Based Study

OBJECTIVE To use a population-based approach to describe survival trends in patients diagnosed as having gastric or esophageal adenocarcinoma. PATIENTS AND METHODS A population-based complete chart review of all inpatient and outpatient records, using the resources of the Rochester Epidemiology Project, was conducted in Olmsted County, Minnesota (population 124,277), a primarily rural county with one large urban area. All residents of Olmsted County who were diagnosed as having gastric or esophageal adenocarcinoma from January 1, 1971, through December 31, 2000, were included in the study. The main outcomes were median survival and 2-year and 5-year survival rates, by decade of diagnosis. RESULTS From 1971 through 2000, median survival for patients with gastric adenocarcinoma (n=121) decreased from 5.5 months to 3.2 months, whereas median survival for patients with esophageal adenocarcinoma (n=65) increased from 8.5 months to 11.7 months. Decade of diagnosis was not significantly associated with patient survival for either gastric or esophageal adenocarcinoma (P>.05). There was no significant shift in stage of disease at diagnosis during the 30-year period for either gastric or esophageal adenocarcinoma (P>.05). CONCLUSION No significant change has occurred in the survival rates of this patient population with gastric or esophageal adenocarcinoma, which is representative of the US white population.

The changing incidence of oesophageal and gastric adenocarcinoma by anatomic sub‐site

The incidence rates of gastric and oesophageal adenocarcinoma are changing significantly, but little is known about specific sub‐sites.

Patient-generated secure messages and eVisits on a patient portal: are patients at risk?

BACKGROUND Patient portals are becoming increasingly common, but the safety of patient messages and eVisits has not been well studied. Unlike patient-to-nurse telephonic communication, patient messages and eVisits involve an asynchronous process that could be hazardous if patients were using it for time-sensitive symptoms such as chest pain or dyspnea. METHODS We retrospectively analyzed 7322 messages (6430 secure messages and 892 eVisits). To assess the overall risk associated with the messages, we looked for deaths within 30 days of the message and hospitalizations and emergency department (ED) visits within 7 days following the message. We also examined message content for symptoms of chest pain, breathing concerns, and other symptoms associated with high risk. RESULTS Two deaths occurred within 30 days of a patient-generated message, but were not related to the message. There were six hospitalizations related to a previous secure message (0.09% of secure messages), and two hospitalizations related to a previous eVisit (0.22% of eVisits). High-risk symptoms were present in 3.5% of messages but a subject line search to identify these high-risk messages had a sensitivity of only 15% and a positive predictive value of 29%. CONCLUSIONS Patients use portal messages 3.5% of the time for potentially high-risk symptoms of chest pain, breathing concerns, abdominal pain, palpitations, lightheadedness, and vomiting. Death, hospitalization, or an ED visit was an infrequent outcome following a secure message or eVisit. Screening the message subject line for high-risk symptoms was not successful in identifying high-risk message content.

Subsite-specific risk factors for esophageal and gastric adenocarcinoma.

BACKGROUND:The incidence rates of adenocarcinoma involving specific gastric and esophageal subsites are changing significantly, but the risk factors associated with those subsite changes remain controversial. We aimed to describe the site-specific risk factors associated with adenocarcinoma of the stomach and esophagus.METHODS:Using the Rochester Epidemiology Project, all cases of gastric and esophageal adenocarcinoma among Olmsted County, Minnesota, residents first diagnosed between 1971 and 2000 were identified. Complete inpatient and outpatient records were reviewed and specific subsites defined. Risk factors were assessed in cases, and age- and sex-matched controls.RESULTS:A total of 186 incident cases of gastric or esophageal adenocarcinoma were identified between 1971 and 2000, in Olmsted County. Gastroesophageal reflux disease (GERD) was a significant risk factor for both esophageal (OR 5.5, 95% CI 1.2–25) and esophagogastric junction adenocarcinoma (OR 13.0, 95% CI 1.7–99), but not for either proximal or distal gastric cancer. Smoking (OR 2.8, 95% CI 1.0–7.8) was associated with distal gastric cancer. Proton pump inhibitor (PPI) exposure was limited and was not a significant risk factor at any subsite.CONCLUSIONS:This identification of distinct risk factors by subsite supports the concept that esophageal and gastric adenocarcinomas are two different diseases. Adenocarcinoma of the junction is probably a form of esophageal cancer and should not be coded with gastric neoplasms.

Patient portal doldrums: does an exam room promotional video during an office visit increase patient portal registrations and portal use?

The patient portal is a web service which allows patients to view their electronic health record, communicate online with their care teams, and manage healthcare appointments and medications. Despite advantages of the patient portal, registrations for portal use have often been slow. Using a secure video system on our existing exam room electronic health record displays during regular office visits, the authors showed patients a video which promoted use of the patient portal. The authors compared portal registrations and portal use following the video to providing a paper instruction sheet and to a control (no additional portal promotion). From the 12,050 office appointments examined, portal registrations within 45 days of the appointment were 11.7%, 7.1%, and 2.5% for video, paper instructions, and control respectively (p<0.0001). Within 6 months following the interventions, 3.5% in the video cohort, 1.2% in the paper, and 0.75% of the control patients demonstrated portal use by initiating portal messages to their providers (p<0.0001).

Use of the elderly risk assessment (ERA) index to predict 2-year mortality and nursing home placement among community dwelling older adults

The objective was to determine the relationship between a high score on the ERA index and 2-year mortality and nursing home placement. As of January 1, 2005, 12,650 community-dwelling patients over 60 years of age were impaneled with a primary care practice at the Mayo Clinic in Rochester, MN. This was a retrospective cohort study utilizing an administrative risk score, the ERA score. Primary outcomes were 2-year mortality and 2-year nursing home placement. The predictor variable was ERA score. Relative risk estimates were used to describe the association between the ERA index and mortality and nursing home placement. The relative risk of 2-year mortality was 51.4 (95% confidence interval=CI=28.0-94.4) in patients in the highest risk group compared to the lowest group. The relative risk of nursing home placement was 113.2 (95% CI=76.1-168.4). Patients with high ERA scores are at high risk for 2-year mortality and 2-year nursing home placement. These findings suggest that the utilization of an electronic risk score can help identify patients at risk for death or nursing home placement. Clinically, the identification of high risk individuals may be useful for utilization of clinical case management.

Patient-Reported Geriatric Symptoms as Risk Factors for Hospitalization and Emergency Department Visits

There is an urgent need to identify predictors of adverse outcomes and increased health care utilization in the elderly. The Mayo Ambulatory Geriatric Evaluation (MAGE) is a symptom questionnaire that was completed by patients aged 65 years and older during office visits to Primary Care Internal Medicine at Mayo Clinic in Rochester, MN. It was introduced to improve screening for geriatric conditions. We conducted this study to explore the relationship between self-reported geriatric symptoms and hospitalization and emergency department (ED) visits within 1 year of completing the survey. This was a retrospective cohort study of patients who completed the MAGE from April 2008 to December 2010. The primary outcome was an ED visit or hospitalization within 1 year. Predictors included responses to individual questions in the MAGE. Data were obtained from the electronic medical record and administrative records. Logistic regression analyses were performed from significant univariate factors to determine predictors in a multivariable setting. A weighted scoring system was created based upon the odds ratios derived from a bootstrap process. The sensitivity, specificity, and AUC were calculated using this scoring system. The MAGE survey was completed by 7738 patients. The average age was 76.2 ± 7.68 years and 57% were women. Advanced age, a self-report of worse health, history of 2 or more falls, weight loss, and depressed mood were significantly associated with hospitalization or ED visits within 1 year. A score equal to or greater than 2 had a sensitivity of 0.74 and specificity of 0.45. The calculated AUC was 0.60. The MAGE questionnaire, which was completed by patients at an outpatient visit to screen for common geriatric issues, could also be used to assess risk for ED visits and hospitalization within 1 year.

Telemedicine barriers associated with regional quality Measures

Telemedicine practitioners are familiar with multiple barriers to delivering care at a distance. Licensing and reimbursement barriers are well known and are being addressed at national and state levels by the American Telemedicine Association. Another telemedicine barrier comes in the form of quality measures for diabetes. Minnesota medical practices are currently being compared on the proportion of their patients with diabetes who have attained goals for blood pressure, low-density lipoprotein cholesterol, and hemoglobin A1C. The quality measure for blood pressure specifically excludes measurements taken by the patient, thus precluding blood pressure telemonitoring as a way to meet the blood pressure goal. To counter this barrier, advocacy in telemedicine is needed so that telemonitoring as a data collection tool is included in quality measures.

Effect of integrated community neurology on utilization, diagnostic testing, and access

Background: The primary care medical home (PCMH) aims to promote delivery of high-value health care. However, growing demand for specialists due to increasingly older adults with complicated and chronic disease necessitates development of novel care models that efficiently incorporate specialty expertise while maintaining coordination and continuity with the PCMH. We describe the effect of a model of integrated community neurology (ICN) on health care utilization, diagnostic testing, and access. Methods: This is a retrospective, matched case-control comparison of patients referred to ICN for a face-to-face consultation over a 12-month period. The control group consisted of propensity score–matched patients referred to a non-colocated neurology practice during the study period. Administrative data were used to assess for diagnostic testing, visit utilization, and patient time to appointment. Results: From October 1, 2014, to September 30, 2015, we identified 459 patients evaluated by ICN for a face-to-face visit and 459 matched controls evaluated by the non-colocated neurology practice. The majority of patients were Caucasian and female. ICN patients had lower odds of EMGs ordered (adjusted odds ratio [OR] 0.64; 95% confidence interval [CI] 0.46–0.89; p = 0.009), MRI brain (adjusted OR 0.60; 95% CI 0.45–0.79; p = 0.0004), or subsequent referral to outpatient neurology (adjusted OR 0.62; 95% CI 0.47–0.83; p = 0.001). ICN was not associated with an increase in emergency department visits, hospitalizations, or appointment wait time. Conclusions: The ICN model in a PCMH has the potential to reduce diagnostic testing and utilization.