Terrence J. Adam

Cost analysis of home monitoring in lung transplant recipients

OBJECTIVES The University of Minnesota has maintained a home monitoring program for over 10 years for lung and heart-lung transplant patients. A cost analysis was completed to assess the impact of home monitoring on the cost of post-transplant medical care. METHODS Clinical information gathered with the monitoring system includes spirometry, vital signs, and symptom data. To estimate the impact of this system on medical costs, we completed a retrospective analysis of the effects of home monitoring on the cost of post-lung transplant medical care. The cost analysis used multivariate linear regression with inpatient, outpatient, and total medical care costs as the dependent variables. The independent variables for the regression include home monitoring adherence, underlying disease, ambulatory diagnostic group mapping variables, transplant type, and patient demographics. RESULTS The multivariate regression of the overall cost results predicts a 52.4 percent reduction in total costs with 100 percent patient adherence; this rate includes a 72.24 percent reduction in inpatient costs and a 46.6 percent increase in outpatient costs. The actual first year average patient adherence was 74 percent. CONCLUSIONS Adherence to home monitoring increases outpatient costs and reduces inpatient costs and provides an overall cost savings. The break-even point for patient adherence was 25.28 percent, where the net savings covered the cost of home monitoring. This is well within the actual first year adherence rates (74 percent) for subjects in the lung transplant home monitoring program, providing a net savings with adherence to home monitoring.

Anaemia following initiation of androgen deprivation therapy for metastatic prostate cancer: a retrospective chart review.

Objective. Haemoglobin levels often decline into the anaemic range with androgen deprivation therapy (ADT). We conducted a chart review of patients receiving ADT for metastatic prostate cancer to assess anaemia-related symptoms. Methods. 135 stage IV prostate cancer cases were reviewed for treatment type; haemoglobin values before and after treatment; and symptoms of anaemia. Mean haemoglobin levels before and after for all treatment forms, for leuprolide alone, and for combination leuprolide/bicalutamide were calculated and evaluated for significant differences. The numbers of patients developing symptoms were recorded and the effects of specific therapies evaluated. Results. For all ADT treated patients, mean haemoglobin declined by −1.11 g/dL (p < .0001). Leuprolide-alone treated patients had a mean decline of −1.66 g/dL (p < 0.0001). Leuprolide and bicalutamide combination treatment caused a mean decline of −0.78 g/dL (p = 0.0426). 16 of 43 patients had anemia symptoms. Contingency analysis with Fishers exact test shows patients receiving leuprolide therapy alone versus other forms of ADT were significantly less likely to have symptoms (χ2 = 0.0190). Conclusions. The present study confirms that ADT results in a significant drop in haemoglobin levels into the anaemic range. A number of patients become symptomatic from this change. Practitioners should monitor haemoglobin levels, and treat symptomatic patients.

Usability and clinical efficacy of diabetes mobile applications for adults with type 2 diabetes: A systematic review

OBJECTIVES To assess the usability and clinical effectiveness of diabetes mobile applications (diabetes apps) developed for adults with type 2 diabetes. METHOD A systematic review of the usability and effectiveness of diabetes apps was conducted. Searches were performed using MEDLINE, EMBASE, COMPENDEX, and IEEE XPLORE for articles published from January 1, 2011, to January 17, 2017. Search terms included: diabetes, mobile apps, and mobile health (mHealth). RESULTS The search yielded 723 abstracts of which seven usability studies and ten clinical effectiveness studies met the inclusion criteria from 20 publications. Usability, as measured by satisfaction ratings from experts and patients, ranged from 38% to 80%. Usability problem ratings ranged from moderate to catastrophic. Top usability problems are multi-steps task, limited functionality and interaction, and difficult system navigation. Clinical effectiveness, measured by reductions in HbA1c, ranged from 0.15% to 1.9%. CONCLUSION Despite meager satisfaction ratings and major usability problems, there is some limited evidence supporting the effectiveness of diabetes apps to improve glycemic control for adults with type 2 diabetes. Findings strongly suggest that efforts to improve user satisfaction, incorporate established principles of health behavior change, and match apps to user characteristics will increase the therapeutic impact of diabetes apps.

Interprofessional Collaboration to Improve Discharge from Skilled Nursing Facility to Home: Preliminary Data on Postdischarge Hospitalizations and Emergency Department Visits

An interprofessional collaborative practice model was established at Hennepin County Medical Center to improve discharge management from the transitional care unit of the skilled nursing facility (SNF) to home. The practice model involves a geriatrician, nurse practitioner, and pharmacist who care for individuals at a community‐based SNF. Before SNF discharge, the pharmacist conducts a chart and in‐person medication review and collaborates with the nurse practitioner to determine the discharge medication regimen. The pharmacists review focuses on assessing the indication, safety, effectiveness, and convenience of medications. The pharmacist provides follow‐up in‐home or over the telephone 1 week after SNF discharge, focusing on reviewing medications and assessing adherence. Hospitalizations and emergency department (ED) visits 30 days after SNF discharge of individuals who received care from this model was compared with those of individuals who received usual care from a nurse practitioner and geriatrician. From October 2012 through December 2013, the intervention was delivered to 87 individuals, with 189 individuals serving as the control group. After adjusting for age, sex, race, and payor, those receiving the intervention had a lower risk of ED visits (odds ratio (OR) = 0.46, 95% confidence interval (CI) = 0.22–0.97), although there was no significant difference in hospitalizations (OR = 0.47, 95% CI = 0.21–1.08). The study suggests that an interprofessional approach involving a pharmacist may be beneficial in reducing ED visits 30 days after SNF discharge.

Drug Therapy Problems Identified by Pharmacists Through Comprehensive Medication Management Following Hospital Discharge

Background: Pharmacists influence health care outcomes through the identification and resolution of drug therapy problems (DTPs). Objective: The objectives of this study were to describe number, type, and severity of DTPs based on clinical significance and likelihood of harm in patients transitioning from hospital to home as assessed during a comprehensive medication management (CMM) visit with a pharmacist. Secondary objectives were to assess intrarater reliability in severity ratings and assess likelihood of harm for adverse drug reactions (ADR) by drug classes. Methods: Retrospective review of 408 patients having a face-to-face, telephonic, or virtual CMM visit within the Fairview Health System. Teams of 3 investigators reviewed each DTP from the electronic medical record for each of the 408 patients and assigned a severity score (0-10) for clinical significance and likelihood of harm. Main Results: The highest severity DTP classes were adherence and ADR. The lowest severity DTP class was unnecessary drug therapy. An average of 2.5 DTPs was found per patient at the index CMM visit following hospital discharge. The most common DTP classes were needs additional therapy and dose too low. There were statistically significant differences in DTP severity scoring between reviewer types, though differences were <5%. Drug classes with the highest severity ADR included diabetes, cardiovascular, and anticoagulant/antiplatelet agents. Conclusions: The DTP severity ratings indicated that reviewers found ADR and adherence DTPs were potentially the most severe. There were differences in DTP ratings between reviewer types, though clinical significance of these differences is unclear.

Launching: university partnership for health informatics

The University Partnership for Health Informatics (UP-HI) is a private-public partnership between the University of Minnesota and the College of St. Scholastica that builds on 11 existing health information technology (HIT) certificates and degrees. It is a newly funded University-Based Training Program enabled by the ARRA HITECH Act. The overall goals and objectives of this partnership are to: 1) rapidly train students to serve in all six HIT professional roles identified by the Office of the National Coordinator for HIT requiring university-level training, including: a) Clinical/Public Health Leaders; b) Health Information Management/Exchange Specialists; c) Health Information Privacy/Security Specialists; d) Research and Development Specialists; e) Programmers/Software Engineers; and f) Health Information Technology Sub-Specialists; and 2) enhance existing HIT certificates and degrees with unique features, including: program access, communication, and asset management through a shared web portal; improved alignment of course content and assignments with role-specific competencies; enhanced online delivery of courses, and enhanced training/mentoring through work context immersion and a journal club. This paper reports on the innovative features of this newly-launched program.

Big Data Cohort Extraction to Facilitate Machine Learning to Improve Statin Treatment

Health care Big Data studies hold substantial promise for improving clinical practice. Among analytic tools, machine learning (ML) is an important approach that has been widely used by many industries for data-driven decision support. In Big Data, thousands of variables and millions of patient records are commonly encountered, but most data elements cannot be directly used to support decision making. Although many feature-selection tools can help identify relevant data, these tools are typically insufficient to determine a patient data cohort to support learning. Therefore, domain experts with nursing or clinic knowledge play critical roles in determining value criteria or the type of variables that should be included in the patient cohort to maximize project success. We demonstrate this process by extracting a patient cohort (37,506 individuals) to support our ML work (i.e., the production of a proactive strategy to prevent statin adverse events) from 130 million de-identified lives in the OptumLabs™ Data Warehouse.

Drug Therapy Problem Severity Following Hospitalization and Association With 30-Day Clinical Outcomes

Background: Improved understanding of how drug therapy problems (DTPs) contribute to rehospitalization is needed. Objective: The primary objectives were to assess the association of DTP likelihood of harm (LoH) severity score, as measured by comprehensive medication management (CMM) pharmacist after hospital discharge, with 30-day risk of hospital readmission, observation visit, or emergency department visit, and to determine whether resolution of DTPs reduces 30-day risk. Secondary objectives were to determine if any eventswere associated with DTPs and preventability of events. Methods: Data were collected for 365 patients who received CMM following hospitalization and had at least 1 DTP identified. Retrospective chart reviews were completed for 80 patients with subsequent events to assess associationg with a DTP and its preventability. Results: For each 1-point increment in maximum LoH score, there was 10% higher risk of the composite end point (hazard ratio [HR]=1.10; 95% CI:0.97-1.26; P=0.13). When DTPs were resolved by the CMM pharmacist, the association was attenuated, with a HR of 1.15 (95% CI:0.96-1.38; P=0.12) when the DTP was unresolved and HR of 1.09 (95% CI:0.96-1.25; P=0.52) when resolved; for hospital readmission alone, the corresponding HRs were 1.23 (95% CI:1.00-1.53; P=0.05) and 1.05 (95% CI:0.87-1.27; P=0.60). Of 80 subsequent events, 44 were associated with a medication; 22 were considered preventable. Conclusion and Relevance: The LoH severity score was associated with risk of 30-day events. The strength of association was attenuated when DTPs were resolved by the CMM pharmacist. However, because of statistical uncertainty, larger studies are needed to confirm these patterns.

Reply to: Impact of Post discharge Contact by Health care Team

We thank Iraqi and Hughes for their thoughtful comments regarding our article. In our study, there were 64 emergency department (ED) visits in control group (n = 189) and 21 in the intervention group (n = 88). After adjusting for age, sex, ethnicity, payor, and clinical comorbidities, those receiving care from the collaborative interprofessional model were less likely to have an ED visit within 30 days after skilled nursing facility (SNF) discharge (odds ratio = 0.46, 95% confidence interval = 0.22–0.97). Our pilot study data lacked granularity to determine whether ED visits that occurred were related to the individuals’ current conditions. Our methodology did not examine causes of ED visits, so it is unknown whether ED visits were medication related. There is not a clear and convenient mechanism in the literature to determine a medication-related ED visit. The Naranjo algorithm is a standardized mechanism to determine causality of adverse drug reactions (ADRs), but ADRs may not encompass all medication-related ED visits. For example, a person may present to the ED with a heart failure exacerbation because his diuretic is dosed subtherapeutically. This instance may not be identified as an ADR but could be considered a medication-related ED visit. Other studies that have identified medication-related hospitalizations have relied on clinician review of medical charts and used variable and subjective criteria. Future research should use the Naranjo algorithm with clinician chart review to determine whether a collaborative interprofessional practice model affects the rate of medication-related ED visits and hospitalizations. We did not see a significant difference in the number of medication-related problems identified after SNF discharge in intervention group participants. The average number of medication-related problems was 2.1 per person before discharge and 1.8 after discharge. In those individuals, there were no associations between aggregate number or type of medication-related problem and clinical outcomes. Future analysis should examine whether certain types of medication-related problems put people at greatest risk of ED visits or whether certain drugs have a greater risk. Findings of our study must be applied with caution. The pharmacist follow-up is one part of our model, but it is delivered in collaboration with nurse practitioners and geriatricians while the individual is in the SNF. Our invention has two parts, and we cannot conclude that the pharmacist home visit is the key component of the intervention. Although pharmacists are well equipped to identify and resolve medication-related problems, future iterations of this model may be needed to test alternative methods of follow-up. Shannon L. Reidt, PharmD, MPH College of Pharmacy, University of Minnesota, Minneapolis, Minnesota Hennepin County Medical Center, Minneapolis, Minnesota

Usability Evaluation of Electronic Health Record System around Clinical Notes Usage–An Ethnographic Study

Background A substantial gap exists between current Electronic Health Record (EHR) usability and potential optimal usability. One of the fundamental reasons for this discrepancy is poor incorporation of a User-Centered Design (UCD) approach during the Graphical User Interface (GUI) development process. Objective To evaluate usability strengths and weaknesses of two widely implemented EHR GUIs for critical clinical notes usage tasks. Methods Twelve Internal Medicine resident physicians interacting with one of the two EHR systems (System-1 at Location-A and System-2 at Location-B) were observed by two usability evaluators employing an ethnographic approach. User comments and observer findings were analyzed for two critical tasks: (1) clinical notes entry and (2) related information-seeking tasks. Data were analyzed from two standpoints: (1) usability references categorized by usability evaluators as positive, negative, or equivocal and (2) usability impact of each feature measured through a 7-point severity rating scale. Findings were also validated by user responses to a post observation questionnaire. Results For clinical notes entry, System-1 surpassed System-2 with more positive (26% vs. 12%) than negative (12% vs. 34%) usability references. Greatest impact features on EHR usability (severity score pertaining to each feature) for clinical notes entry were: autopopulation (6), screen options (5.5), communication (5), copy pasting (4.5), error prevention (4.5), edit ability (4), and dictation and transcription (3.5). Both systems performed equally well on information-seeking tasks and features with greatest impacts on EHR usability were navigation for notes (7) and others (e.g., looking for ancillary data; 5.5). Ethnographic observations were supported by follow-up questionnaire responses. Conclusion This study provides usability-specific insights to inform future, improved, EHR interface that is better aligned with UCD approach.