Silvana Figar

Implementation of a clinical decision support system using a service model: results of a feasibility study.

Numerous studies have shown that the quality of health care is inadequate, and healthcare organizations are increasingly turning to clinical decision support systems (CDSS) to address this problem. In implementing CDSS, a highly promising architectural approach is the use of decision support services. However, there are few reported examples of successful implementations of operational CDSS using this approach. Here, we describe how Hospital Italiano de Buenos Aires evaluated the feasibility of using the SEBASTIAN clinical decision support Web service to implement a CDSS integrated with its electronic medical record system. The feasibility study consisted of three stages: first, end-user acceptability testing of the proposed CDSS through focus groups; second, the design and implementation of the system through integration of SEBASTIAN and the authoring of new rules; and finally, validation of system performance and accuracy. Through this study, we found that it is feasible to implement CDSS using a service-based approach. The CDSS is now under evaluation in a randomized controlled trial. The processes and lessons learned from this initiative are discussed.

Mortality in an elderly type 2 diabetic patients' cohort who attended a self-management educational workshop

AIMS To compare the all-cause mortality rate in elderly type 2 diabetic patients who attended self-management educational workshops compared with those who did not. METHODS Retrospective cohort study in a Health Maintenance Organization in Buenos Aires, Argentina. Patients older than 64 years with type 2 diabetes before December 2003 conformed the cohort followed from January 01, 2001 until death, censored date or December 31, 2007. All-cause mortality rate was ascertained from vital status reports and assessed according to educational workshops attendance. Results were adjusted for baseline variables, co-morbidities and A1C levels using Cox proportional hazards model. RESULTS 1730 elderly diabetic patients were included, yielding 8685 person/years of observation. Educated and non-educated groups were similar regarding sex, co morbidities, diabetes duration, prevalent cases, insulin treatment, tobacco use, clinical and laboratory measures. All-cause mortality rate was 5.53 (4.04-5.07) per 100 person/years for non-attendants and 3.06 (2.39-3.91) for attendants. Crude hazard ratio for exposure to workshops was 0.68 (0.52-0.88); p = 0.004. After adjustment, attendance to diabetic workshops decreased its effect from 33% to 18% (HR 0.82; 95%CI: 0.61-1.08). CONCLUSIONS Workshop attendants had 33% lower all-cause crude mortality rate at 6 years of follow-up. More research is needed to explore whether these findings are explained by education itself, behavioural or personal characteristics of workshop attendants, the intensified participation in an integral diabetes programme, or a combination of them.

Healthcare Information Systems to Assess Influenza Outbreaks: An analysis of the 2009 H1N1 Epidemic in Buenos Aires

OBJECTIVE To determine whether a private HIS could have detected the influenza epidemic outbreaks earlier through changes in morbidity and mortality patterns. METHODS Data Source included a health information system (HIS) from an academic tertiary health care center integrating administrative and clinical applications. It used a local interface terminology server which provides support through data autocoding of clinical documentation. Specific data subsets were created to compare the burden of influenza during the epidemiological week (EW) 21 to 26 for years 2007 to 2009 among 150,000 Health Maintenance Organization members in Argentina. The threshold for identifying an epidemic was considered met when the weekly influenza-like illness (ILI) rate exceeded 200 per 100,000 visits. Case fatality rates and mortality rates of severe acute respiratory infection (SARI) from 2007 to 2009 were retrospectively compared. Case fatality rates and mortality rates for A/H1N1 influenza 2009 also were estimated. RESULTS The HIS detected the outbreak in EW 23 while the government Ministry of Health (MoH) gave a national epidemic alert during EW 25. The number of visits for ILI increased more than fourfold when comparing 2009 to the period 2007-2008. The SARI mortality rate in 2009 was higher than in 2008 (RR 2.8; 95%CI 1.18-6.63) and similar to that of 2007 (RR 1.05; 95%CI 0.56-1.49). 2009 was the first year with mortalities younger than 65 years attributable to SARI. The estimated A/H1N1 case fatality rate for SARI was 6.2% (95%CI 2.5 to 15.5) and A/H1N1 mortality rate was 6 per 100,000 (95%CI 0 to 11.6). CONCLUSION Our HIS detected the outbreak two weeks before than the MoH gave a national alert. The information system was useful in assessing morbidity and mortality during the 2009 influenza epidemic H1N1 outbreak suggesting that with a private-public integration a more real-time outbreak and disease surveillance system could be implemented.

Prevención de eventos cardiovasculares en hipertensos mayores de 65 años bajo el cuidado de un programa de control: Estudio de cohorte

Introduction: We started on year 2000 a Complex Intervention Program addressed at hypertension control among our patients. Aim: To compare the risk of cardiovascular events and of dying in hypertensive patients under Program care. Method: We started follow-up of a cohort of 1922 patients over 65 years in August 2000. Hipertension diagnosis was ascertained if patient reported to be hypertensive, or was under anti hypertensive treatment or if he/she had two blood pressure measurements ≥ 140/90 mm Hg. Cardiovascular events were considered to be admissions due to coronary disease, cardiac insufficiency or stroke. Incidence is reported by 100 person years follow-up. Relative risks between hypertensive and normotensive patients were calculated and Cox regresidn was used to adjust for potential confounders. We compared time to first cardiovascular event and to death with Log Rank Test. Results: Fourty eight point three percent of patients were hypertensive and differed from normotensive patients as to age (79 (5) years vs. 77 (5) p < 0.001), proportion of diabetic patients (16.1% vs. 7.6% p < 0.001). Mean follow-up time was 28 months. Mortality RR was 1.04 (95% CI 0.69-1.58). As to incidence of cardiovascular events it was 1.86 in normotensive vs. 3.02 (RR 1.62 95% CI 1.09-2.42). When adjusted by age, sex, smoking, dislipemia and diabetes, OR was 1.3 (95% CI 0.86-1.98) Conclusions: Hypertension did not increase the risk in cardiovascular events among our hypertensive patients at 2.3 years follow-up.

Role of the Mechanisms of Detection in the Increased Risk of Thyroid Cancer: A Retrospective Cohort Study in an HMO in Buenos Aires

Background Two hypotheses attempt to explain the increase of thyroid cancer (TC) incidence: overdetection by excessive diagnostic scrutiny and a true increase in new cases brought about by environmental factors. Changes in the mechanism of detection and the risk of incidentally diagnosed TC could result in an increase of TC incidence. Methods Retrospective cohort study. We identified incident cases of TC from the pathological reports of patients in a HMO and review of clinical records. The results were analyzed in two periods: 2003-2007 and 2008-2012. Incidence rates expressed per 100,000 person-years (with 95% CI) and relative risk of incidence rates of incidental and nonincidental TC were estimated. Results The relative risk of incidentally detecting a thyroid cancer in 2008-2012 compared to 2003-2007 was 6.06 (95%CI 1.84-20.04). Clinical evaluations detected 31 (75.6%) cancers in the period 2003-2007 and 70 (51.8%) cancers in the period 2008-2012 (p<0.007). Although tumor median size was significantly lower in the period 2008-2012 (10 vs. 14 mm, p<0.03), tumors greater than 40 mm (4.3%) were only present in 2008-2012. The female/male ratio decreased between analyzed periods from 8 (3-21) to 4 (3-7). Conclusions Our findings partially support the hypothesis of increased incidence due to overdetection but do not explain the changes in the increase of larger tumors and decrease in the female/male ratio, which could be secondary to the influence of unidentified environmental factors.

P1-423 Assessment of influenza outbreaks using a private healthcare information system: an analysis of the 2009 H1N1 epidemic in Buenos Aires

Introduction This study aims to determine if the A/H1N1 influenza outbreak could have been earlier detected through changes in morbidity and mortality patterns analysed from a health information system (HIS). Methods Specific data subsets were created to compare the burden of influenza during the epidemiological week (EW) 21 to 26 for years 2007 to 2009 among 150 000 Health Maintenance Organization members in Buenos Aires. The threshold for identifying an epidemic was considered met when the weekly influenza-like illness (ILI) rate exceeded 200 per 100 visits. Mortality rates of severe acute respiratory infection (SARI) from 2007 to 2009 were compared. Case fatality and mortality rates for A/H1N1 influenza 2009 also were estimated. Results The HIS detected the outbreak in EW 23 while the government Ministry of Health (MoH) gave a national epidemic alert during EW 25. The number of visits for ILI increased more than fourfold when comparing 2009 to the 2007–2008. SARI mortality rate in 2009 was higher than in 2008 (RR 2.8; 95% CI 1.18 to 6.63) and similar to that of 2007 (RR 1.05; 95% CI 0.56 to 1.49). 2009 was the first year with mortalities younger than 65 years attributable to SARI. The estimated A/H1N1 case fatality rate for SARI was 6.2% (95% CI 2.5 to 15.5). The estimated A/H1N1 mortality rate was 6 per 100 000 (95% CI 0 to 11.6). Conclusions the outbreak was detected 2 weeks before than the MoH gave a national alert suggesting that with a private-public integration a more real-time outbreak and disease surveillance system could be implemented.

P2-7 Mortality and cardiovascular events in patients under treatment with clopidogrel and omeprazole

Introduction In 2009, it was announced that clopidogrel should not be taken with proton pump inhibitors. Omeprazole possibly reduces antiplatelet effect of clopidogrel. We compared mortality and cardiovascular rates between patients that had been treated with clopidogrel alone and those with both clopidogrel and omeprazole. Methods A retrospective dynamic cohort study using secondary data of a health information system from a Health Maintenance Organization in Buenos Aires was analysed. Patients older than 17 years with purchase record of clopidogrel were followed for all-cause mortality and cardiovascular events (CE) from 1 January 2004 to 31 December 2008. Rates and 95% CIs are expressed per 1000 persons-year. Cox regression was used to obtain adjusted HRs for the risk of all-cause mortality and CE in groups exposed and unexposed concomitant to omeprazole at baseline. Results Mean follow-up 13 months, 2518 patients received clopidogrel from whom 17.31% also received omeprazole. Exposed and unexposed to omeprazole were similar in sex (male 60%), age (mean 68) and comorbidities. The CE rate was 32.4 (95% CI 27.3 to 38.4) and 26.1 (95% CI 24.1 to 28.4) for each group respectively (RR 1.23 (p=0.026) and adjusted RR 1.15 (p=0.137)). The all-cause mortality rate was 2.5 (95% CI 1.4 to 4.5) and 1.23 (95% CI 0.8 to 1.7) for each group respectively (RR 2.06 (p=0.034) and adjusted RR 1.76 (p=0.109)). Conclusion Patients treated with clopidogrel and omeprazole had not increase risk for all-cause mortality and for CE after adjusting for comorbidities.