Ted Palen

Association of online patient access to clinicians and medical records with use of clinical services.

CONTEXT Prior studies suggest that providing patients with online access to health records and e-mail communication with physicians may substitute for traditional health care services. OBJECTIVE To assess health care utilization by both users and nonusers of online access to health records before and after initiation of MyHealthManager (MHM), a patient online access system. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of the use of health care services by members (≥18 years old) who were continuously enrolled for at least 24 months during the study period March 2005 through June 2010 in Kaiser Permanente Colorado, a group model, integrated health care delivery system. Propensity scores (using age, sex, utilization frequencies, and chronic illnesses) were used for cohort matching. Unadjusted utilization rates were calculated for both MHM users and nonusers and were the basis for difference-of-differences analyses. We also used generalized estimating equations to compare the adjusted rates of utilization of health care services before and after online access. MAIN OUTCOME MEASURES Rates of office visits, telephone encounters, after-hours clinic visits, emergency department encounters, and hospitalizations between members with and without online access. RESULTS Comparing the unadjusted rates for use of clinical services before and after the index date between the matched cohorts, there was a significant increase in the per-member rates of office visits (0.7 per member per year; 95% CI, 0.6-0.7; P < .001) and telephone encounters (0.3 per member per year; 95% CI, 0.2-0.3; P < .001). There was also a significant increase in per-1000-member rates of after-hours clinic visits (18.7 per 1000 members per year; 95% CI, 12.8-24.3; P < .001), emergency department encounters (11.2 per 1000 members per year; 95% CI, 2.6-19.7; P = .01), and hospitalizations (19.9 per 1000 members per year; 95% CI, 14.6-25.3; P < .001) for MHM users vs nonusers. CONCLUSION Having online access to medical records and clinicians was associated with increased use of clinical services compared with group members who did not have online access.

Comparing virtual consults to traditional consults using an electronic health record: an observational case–control study

BackgroundPatients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing “better, faster, cheaper” processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR.MethodsWe conducted an observational case–control survey study within Kaiser Permanente, Colorado. A sample of patients who had VCs requested by physicians (N = 270) were matched with patients who had TCs requested by physicians (N = 270), by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed.ResultsDuring the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (267 out of 540 patients, 49.4% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p = 0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p < 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs.ConclusionsReferring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient’s perception of care.

Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With Morcellation.

OBJECTIVE: To estimate the incidence of occult uterine sarcoma and leiomyosarcoma in hysterectomies for leiomyomas and the risk associated with their morcellation. METHODS: We conducted a population-based cohort study. All uterine sarcomas from 2006–2013 in an integrated health care system were identified. Age- and race-specific incidences of occult uterine sarcoma were calculated. Kaplan-Meier survival analysis was performed. Crude and adjusted risk ratios of recurrence and death associated with morcellation at 1, 2, and 3 years were estimated using Poisson regression with inverse probability weighting. RESULTS: There were 125 hysterectomies with occult uterine sarcomas identified among 34,728 hysterectomies performed for leiomyomas. The incidence of occult uterine sarcoma and leiomyosarcoma was 1 of 278 or 3.60 (95% confidence interval [CI] 2.97–4.23) and 1 of 429 or 2.33 (95% CI 1.83–2.84) per 1,000 hysterectomies. For stage I leiomyosarcoma (n=111), eight (7.2%) were power and 27 (24.3%) nonpower-morcellated. The unadjusted 3-year probability of disease-free survival for no morcellation, power and nonpower morcellation was 0.54, 0.19, and 0.51, respectively (P=.15); overall survival was 0.64, 0.75, and 0.68, respectively (P=.97). None of the adjusted risk ratios for recurrence or death were significant except for death at 1 year for power and nonpower morcellation groups combined (6/33) compared with no morcellation (4/76) (5.12, 95% CI 1.33–19.76, P=.02). We had inadequate power to infer differences for all other comparisons including 3-year survival and power morcellation. CONCLUSION: Morcellation is associated with decreased early survival of women with occult leiomyosarcomas. We could not accurately assess associations between power morcellation and 3-year survival as a result of small numbers.

Secure e-mailing between physicians and patients: transformational change in ambulatory care.

Secure e-mailing between Kaiser Permanente physicians and patients is widespread; primary care providers receive an average of 5 e-mails from patients each workday. However, on average, secure e-mailing with patients has not substantially impacted primary care provider workloads. Secure e-mail has been associated with increased member retention and improved quality of care. Separate studies associated patient portal and secure e-mail use with both decreased and increased use of other health care services, such as office visits, telephone encounters, emergency department visits, and hospitalizations. Directions for future research include more granular analysis of associations between patient-physician secure e-mail and health care utilization.

Association between secure patient–clinician email and clinical services utilisation in a US integrated health system: a retrospective cohort study

Objective To assess associations between secure patient–clinician email use and clinical services utilisation over time. Design Retrospective cohort study between July 2010 and December 2013. Controlling for a utilisation surge around first secure email use, we analysed difference of differences between propensity score-matched groups of secure patient–clinician email users and non-users for utilisation 1–12 months before and 7–18 months after first email (users) or a randomly assigned index date (non-users). Setting US integrated healthcare delivery system. Participants 9345 adults with first secure email use between July 2011 and July 2012 and continuous enrolment for ≥30 months and 9345 adults without secure email use between July 2010 and July 2012 matched to users on demographics, health status, and baseline utilisation. Primary Outcome Measures Rates of office visits, patient-initiated phone calls, scheduled telephone visits, after-hours clinic visits, emergency department visits, and hospitalisations. Results After controlling for multiple factors, no statistically significant differences in utilisation between secure email users and non-users occurred. Utilisation transiently increased by 88–237% around first email use. Annual rates of patient-initiated phone calls decreased among secure email users, 0.2 fewer calls per person (95% CI −0.3 to −0.1), from a mean of 4.1 calls per person 1–12 months before first use to a mean of 3.8 calls per person 7–18 months after first use. Rates of patient-initiated phone calls also decreased among non-users, 0.1 fewer calls per person (95% CI −0.2 to 0.0), from a mean of 4.2 calls per person 1–12 months before the index date to mean of 4.1 calls per person 7–18 months after the index date. Conclusions Compared with non-users, patient use of secure email with clinicians was not associated with statistically significant differences in clinical services utilisation 7–18 months after first use.

Adjuvant gemcitabine-docetaxel chemotherapy for stage I uterine leiomyosarcoma: Trends and survival outcomes

OBJECTIVE To assess recent trends of administering adjuvant gemcitabine-docetaxel (GD) chemotherapy for Stage I uterine leiomyosarcoma, and to compare disease-free and overall survival between women who received and did not receive adjuvant GD chemotherapy. METHODS All patients diagnosed with Stage I uterine leiomyosarcoma in a California-Colorado population-based health plan inclusive of 2006-2013 were included in a retrospective cohort. Adjuvant GD chemotherapy rates, clinico-pathologic characteristics and survival estimates were assessed. RESULTS Of 111 women with Stage I uterine leiomyosarcoma, 33 received adjuvant GD (median 4cycles), 77 received no chemotherapy, and 1 patient excluded for non-GD chemotherapy. GD-chemotherapy and no-chemotherapy groups were similar with respect to age, stage (IA/IB), uterine weight, mitotic index, body mass index, and Charlson comorbidity score. Non-Hispanic white women were twice as likely to receive adjuvant chemotherapy as non-white or Hispanic women (37.7 vs. 17.1%, P=0.02). The proportion of women receiving adjuvant GD chemotherapy increased from 6.5% in 2006-2008 to 46.9% in 2009-2013 (P<0.001). There was no significance difference in unadjusted Kaplan-Meyer estimated disease-free (P=0.95) or overall survival (P=0.43) between GD-chemotherapy and no-chemotherapy cohorts. Corresponding adjusted Cox proportional hazard ratios for adjuvant GD chemotherapy compared to no chemotherapy were 1.01 (95% confidence interval [CI] 0.57-1.80, P=0.97) for recurrence and 1.28 (95% CI 0.69-2.36, P-0.48) for mortality. CONCLUSIONS Use of adjuvant GD chemotherapy for Stage I uterine leiomyosarcoma has increased significantly in the last decade, despite unclear benefit. Compared to no chemotherapy, 4-6cycles of adjuvant GD chemotherapy does not appear to alter survival outcomes.

PS3-28: Telemedicine Specialty Consultation in a Medically Underserved Community

Background and Aims: During the current national health care reform discussions, health information technologies (HIT) are receiving a lot of attention as means of lowering health care costs, improving access to health care, reducing errors during the delivery of healthcare, and improving health outcomes. Patients in rural or medically underserved areas find it difficult to obtain and maintain adequate access to health care. Telemedicine (TM) services can exchange video and audio information between healthcare providers and patients in different locations. For individuals in rural communities TM may improve access to care through the use of novel care delivery models. We are conducting a proof of concept (POC) study to evaluate the use of TM consultation between a primary care clinic in a medically underserved region of southern Colorado and a specialty care (endocrinology) clinic in Denver. Methods: This is a prospective health services POC study. We are taking advantage of a “natural experiment,” the expansion of primary care services into a medically underserved area of southern Colorado, to examine the requirements for establishing TM services between a rural primary care clinic and metropolitan based specialists. Results: Technical requirements included establishing network capabilities (512 kbps ISDN, H.320), 2 Mbps IP (H.323 or SIP), wirelss LAN connection, encryption embedded transmissions (H.235 and IEEE 802.1 x authentication); and remote monitoring equipment (exam camera, ENT/otoscope, electronic digital audio stethoscope (frequency: 40 Hz–2000 Hz, response: 45 Hz–1.6 KHz). Legal requirements involved the review of both federal and state statutes governing the use of TM for patient care and geographical/population requirements. Billing and regulatory requirements entail ensuring the use of the correct CPT and modifiers codes for TM and making sure these are operational within the medical record. Establishing criteria to ensure patients are appropriate for TM, the contents for TM informed consent, rules governing the use of TM for Medicare/Medicaid and non-Medicare/Medicaid patients. Establish clinical workflows for TM between the primary care and specialty care clinics. Conclusions: Invovle legal counsel early to review state statutes and develop TM patient/provider consent forms. Coordinate services with IT department. Coordinate documentation requirements with the billing and coding department. Work with clinic staff to incorporate TM into the clinic and admnistrative workflow. Define roles and responsibilites. Early planning and inter-department coordination is essential for a successful TM project.

Using a Handheld Device for Patient Data Collection: A Pilot for Medical Countermeasures Surveillance.

Medical countermeasures (MCMs) are medical products used during public health emergencies. This study, conducted within the Mini-Sentinel Initiative, sought to develop the patient identification and matching processes necessary to assess safety outcomes for MCMs. A handheld device was used to collect identifying information (e.g., name, birthdate, and sex) from the drivers licenses of 421 individuals presenting for routine care at their primary care medical office. Overall, 374 individuals (88.8%) could be linked to their electronic health data using drivers license information. The device was also pilot-tested at a seasonal influenza immunization clinic: detailed vaccine information (e.g., lot number and manufacturer) was captured with a high degree of accuracy. This investigation demonstrated that a handheld device is a feasible means of collecting patient identity and medical product receipt data. This capacity should be useful for safety surveillance of MCMs, particularly when dispensed in settings outside the traditional health-care delivery system.

Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With Morcellation

Uterine leiomyomas are the most common indication for hysterectomy in the United States. Leiomyomas may be indistinguishable from malignant uterine sarcomas, which occur rarely and have a poor prognosis. Although the use of laparoscopic hysterectomy and power morcellation has substantially reduced morbidity of surgery for uterine leiomyomas, there has been increasing concern over peritoneal dissemination of occult uterine sarcomas for which there was no preoperative or operative suspicion. To address these concerns, the US Food and Drug Administration issued a warning in November 2014 against use of power morcellators in most women undergoing hysterectomy for uterine leiomyomas. Estimates of the incidence of uterine sarcoma among women undergoing hysterectomy for leiomyomas have been obtained primarily from single-center studies or studies conducted in tertiary-based practices. These articles include a broad range of publication dates (1990–2012) and small numbers of patients. Interpretation of data from these studies is challenging because of small numbers of sarcomas and morcellation procedures per study as well as flawed methodology. This population-based cohort study was performed to estimate the incidence of occult uterine sarcoma and leiomyosarcoma in hysterectomies for leiomyomas and the risk associated with their morcellation. Data were abstracted for all uterine sarcomas identified after surgery from 2006 to 2013 in an integrated health care system. Ageand race-specific incidence rates for occult uterine sarcoma were calculated. Kaplan-Meier survival analysis was performed to estimate the unadjusted cumulative 3-year disease-free and overall survival probabilities. Poisson regression with inverse probability weighting was used to estimate crude and adjusted risk ratios (aRRs) of recurrence and death associated with morcellation at 1, 2, and 3 years. Hysterectomies were categorized as 3 groups: no morcellation, power morcellation, and nonpower morcellation. Among 34,728 hysterectomies performed for leiomyomas, 125 were identified with occult uterine sarcomas. The incidence of occult uterine sarcoma and leiomyosarcoma in women with hysterectomy for leiomyomas was 1 of 278 or 3.60 (95% confidence interval [CI], 2.97–4.23) per 1,000 and 1 of 429 or 2.33 (95% CI, 1.83–2.84) per 1,000 hysterectomies. There were 111 stage I leiomyosarcomas. Among these, power and nonpower morcellation occurred in only a small number (8 [7.2%] and 27 [24.3%]). For stage I leiomyosarcomas, the unadjusted probability of disease-free 3-year survival with no morcellation, power morcellation, and nonpower morcellation was 0.54, 0.19, and 0.51, respectively (P = 0.15); overall 3-year survival was 0.64, 0.75, and 0.68, respectively (P = 0.97). With the adjusted data, none of the aRRs for recurrence or death were significant except for death at 1 year for power and nonpower morcellation groups combined (6/33) compared with no morcellation (4/76); the aRR was 5.12, with a 95% CI of 1.33 to19.76; P = 0.02). Differences for all other comparisons including 3-year survival and power morcellation could not be estimated because of the small number of events and inadequate power. These data demonstrate association of morcellation with decreased early survival for women with occult leiomyosarcomas. Associations between power morcellation and 3-year survival could not be accurately assessed as a result of small numbers. www.obgynsurvey.com | 214 Copyright

B1-1: Predictive Modeling to Identify Patients at Risk for Index Hospitalization

Background/Aims Preventable hospital readmissions are the focus of many performance metrics. However, little attention has been given to preventing index admissions. The likelihood of hospitalization (LOH) is a statistical model (Verisk Analytics®) which uses patient historical clinical data and logistic regression to predict the likelihood of admission in the next six months. One of our goals was to test the accuracy of the LOH model to predict hospitalizations. The second goal was to identify possible common intervenable causes for the hospitalization. Methods We obtained the list of patients with LOH scores in the top 1% calculated as of July 1, 2012. We then retrospectively identified which of these patients had hospitalizations in the following 6 months. We censored patients who had hospitalizations related to trauma and pregnancy. We performed chart reviews on a subset of the hospitalized patients and classified reasons for the admission into intervenable or non-intervenable causes. Results Of the patients in the top 1% of LOH (N = 1460; mean LOH = 0.47), 412 (28.2%) were hospitalized within 6 months of the LOH calculation date. The average age and percent female for hospitalized and non-hospitalized patients was 74.1 years, 57.8% and 73.4 years, 60.0%, respectively (not significant). 324 of the hospitalized patients had no emergency department visits in the prior 6 months. Fifty percent of hospitalizations occurred within 33 days of the LOH calculation date. We performed chart reviews on 134 (32.5%) of the hospitalized patients. Twenty-eight patients (20.9%) were classified with intervenable causes for the admission, 19 (67.9%) of which were related to system issues such as inadequate follow-up after procedures or medication adjustments. Conclusions Identifying patients with intervenable causes for hospitalizations may significantly decrease unnecessary admissions. Risking algorithms may have utility in developing strategies to identify these patients. Risk of Hospitalization (RHO2) uses near real-time clinical data from the electronic medical to calculate risk scores. Future studies will compare the performance characteristics of LOH to RHO2 to identify overlapping cohorts of patients. If RHO2 performs as well as LOH, we will use the near-real time clinical data in RHO2 to flag patients with intervenable causes of hospitalization at the point-of-care.