Vikrant Deshmukh

Value Driven Outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes

Objective To develop expeditiously a pragmatic, modular, and extensible software framework for understanding and improving healthcare value (costs relative to outcomes). Materials and methods In 2012, a multidisciplinary team was assembled by the leadership of the University of Utah Health Sciences Center and charged with rapidly developing a pragmatic and actionable analytics framework for understanding and enhancing healthcare value. Based on an analysis of relevant prior work, a value analytics framework known as Value Driven Outcomes (VDO) was developed using an agile methodology. Evaluation consisted of measurement against project objectives, including implementation timeliness, system performance, completeness, accuracy, extensibility, adoption, satisfaction, and the ability to support value improvement. Results A modular, extensible framework was developed to allocate clinical care costs to individual patient encounters. For example, labor costs in a hospital unit are allocated to patients based on the hours they spent in the unit; actual medication acquisition costs are allocated to patients based on utilization; and radiology costs are allocated based on the minutes required for study performance. Relevant process and outcome measures are also available. A visualization layer facilitates the identification of value improvement opportunities, such as high-volume, high-cost case types with high variability in costs across providers. Initial implementation was completed within 6 months, and all project objectives were fulfilled. The framework has been improved iteratively and is now a foundational tool for delivering high-value care. Conclusions The framework described can be expeditiously implemented to provide a pragmatic, modular, and extensible approach to understanding and improving healthcare value.

Evaluating the informatics for integrating biology and the bedside system for clinical research

BackgroundSelecting patient cohorts is a critical, iterative, and often time-consuming aspect of studies involving human subjects; informatics tools for helping streamline the process have been identified as important infrastructure components for enabling clinical and translational research. We describe the evaluation of a free and open source cohort selection tool from the Informatics for Integrating Biology and the Bedside (i2b2) group: the i2b2 hive.MethodsOur evaluation included the usability and functionality of the i2b2 hive using several real world examples of research data requests received electronically at the University of Utah Health Sciences Center between 2006 - 2008. The hive server component and the visual query tool application were evaluated for their suitability as a cohort selection tool on the basis of the types of data elements requested, as well as the effort required to fulfill each research data request using the i2b2 hive alone.ResultsWe found the i2b2 hive to be suitable for obtaining estimates of cohort sizes and generating research cohorts based on simple inclusion/exclusion criteria, which consisted of about 44% of the clinical research data requests sampled at our institution. Data requests that relied on post-coordinated clinical concepts, aggregate values of clinical findings, or temporal conditions in their inclusion/exclusion criteria could not be fulfilled using the i2b2 hive alone, and required one or more intermediate data steps in the form of pre- or post-processing, modifications to the hive metadata, etc.ConclusionThe i2b2 hive was found to be a useful cohort-selection tool for fulfilling common types of requests for research data, and especially in the estimation of initial cohort sizes. For another institution that might want to use the i2b2 hive for clinical research, we recommend that the institution would need to have structured, coded clinical data and metadata available that can be transformed to fit the logical data models of the i2b2 hive, strategies for extracting relevant clinical data from source systems, and the ability to perform substantial pre- and post-processing of these data.

Efficiency of CYP2C9 Genetic Test Representation for Automated Pharmacogenetic Decision Support

OBJECTIVES We investigated the suitability of representing discrete genetic test results in the electronic health record (EHR) as individual single nucleotide polymorphisms (SNPs) and as alleles, using the CYP2C9 gene and its polymorphic states, as part of a pilot study. The purpose of our investigation was to determine the appropriate level of data abstraction when reporting genetic test results in the EHR that would allow meaningful interpretation and clinical decision support based on current knowledge, while retaining sufficient information in order to enable reinterpretation of the results in the context of future discoveries. METHODS Based on the SNP & allele models, we designed two separate lab panels within the laboratory information system, one containing SNPs and the other containing alleles, built separate rules in the clinical decision support system based on each model, and evaluated the performance of these rules in an EHR simulation environment using real-world scenarios. RESULTS Although decision-support rules based on allele model required significantly less computational time than rules based on SNP model, no difference was observed on the total time taken to chart medication orders between rules based on these two models. CONCLUSIONS Both, SNP- and allele-based models, can be used effectively for representing genetic test results in the EHR without impacting clinical decision support systems. While storing and reporting genetic test results as alleles allow for the construction of simpler decision-support rules, and make it easier to present these results to clinicians, SNP-based model can retain a greater amount of information that could be useful for future reinterpretation.

Changes in Oral Anticoagulant Treatment Rates in Atrial Fibrillation before and after the Introduction of Direct Oral Anticoagulants

Background: Direct oral anticoagulants (DOACs) have the potential to improve stroke prevention among atrial fibrillation (AF) patients. We sought to determine if oral anticoagulation (OAC) treatment rates have increased since the approval of DOACs. Methods: We identified 6,688 patients with AF at an academic medical center from January 2008 to June 2015. We examined OAC prescription rates over time and according to CHA2DS2VASc score using multivariable Poisson regression models, with an interaction term between risk score and year of AF diagnosis. Results: Among 6,688 AF patients, 78% had CHA2DS2VASc scores ≥2, 51.6% of whom received an OAC prescription within 90 days of diagnosis. The OAC prescription rate was 47.8% in the pre-DOAC era and peaked at 56.4% in 2014. Relative to the pre-DOAC era, prescription rates increased in 2012 and leveled off thereafter. The prescription rate for the highest risk group was 58.5%, compared with 45.0% in patients with a CHA2DS2VASc score of 2 (p < 0.01). In the adjusted analysis, prescription rates were higher for the higher risk group (adjusted relative risk 1.24 for CHA2DS2VASc score 7-9 vs. 2, 95% CI 1.09-1.40). Conclusions: OAC treatment rates have increased since DOAC introduction, but substantial treatment gaps remain, specifically among the higher risk patients.

Integrating historical clinical and financial data for pharmacological research.

BackgroundRetrospective research requires longitudinal data, and repositories derived from electronic health records (EHR) can be sources of such data. With Health Information Technology for Economic and Clinical Health (HITECH) Act meaningful use provisions, many institutions are expected to adopt EHRs, but may be left with large amounts of financial and historical clinical data, which can differ significantly from data obtained from newer systems, due to lack or inconsistent use of controlled medical terminologies (CMT) in older systems. We examined different approaches for semantic enrichment of financial data with CMT, and integration of clinical data from disparate historical and current sources for research.MethodsSnapshots of financial data from 1999, 2004 and 2009 were mapped automatically to the current inpatient pharmacy catalog, and enriched with RxNorm. Administrative metadata from financial and dispensing systems, RxNorm and two commercial pharmacy vocabularies were used to integrate data from current and historical inpatient pharmacy modules, and the outpatient EHR. Data integration approaches were compared using percentages of automated matches, and effects on cohort size of a retrospective study.ResultsDuring 1999-2009, 71.52%-90.08% of items in use from the financial catalog were enriched using RxNorm; 64.95%-70.37% of items in use from the historical inpatient system were integrated using RxNorm, 85.96%-91.67% using a commercial vocabulary, 87.19%-94.23% using financial metadata, and 77.20%-94.68% using dispensing metadata. During 1999-2009, 48.01%-30.72% of items in use from the outpatient catalog were integrated using RxNorm, and 79.27%-48.60% using a commercial vocabulary. In a cohort of 16304 inpatients obtained from clinical systems, 4172 (25.58%) were found exclusively through integration of historical clinical data, while 15978 (98%) could be identified using semantically enriched financial data.ConclusionsData integration using metadata from financial/dispensing systems and pharmacy vocabularies were comparable. Given the current state of EHR adoption, semantic enrichment of financial data and integration of historical clinical data would allow the repurposing of these data for research. With the push for HITECH meaningful use, institutions that are transitioning to newer EHRs will be able to use their older financial and clinical data for research using these methods.

Aging-Related Disease Risks among Young Thyroid Cancer Survivors

Background: Thyroid cancer is the most rapidly increasing cancer in the United States, affects a young population, has high survival, and is one of the most common cancers in people under age 40. The aim of this study was to examine the risks of aging-related diseases in a statewide sample of thyroid cancer survivors who were diagnosed <40 years compared with those diagnosed ≥40 and a cancer-free sample. Methods: Thyroid cancer survivors diagnosed 1997 to 2012 were matched to up to 5 cancer-free individuals on birth year, sex, birth state, using the statewide Utah Population Database. Medical records were used to identify disease diagnoses stratified over three time periods: 1 to 5, >5 to 10, and 10+ years after cancer diagnosis. Cox proportional hazards models were used to estimate hazard ratios with adjustment on matching factors, race, body mass index, and Charlson Comorbidity Index. Results: There were 3,706 thyroid cancer survivors and 15,587 matched cancer-free individuals (1,365 cases diagnosed <40 years old). Both age groups had increased risks for multiple circulatory health conditions 1 to 5 years after cancer diagnosis compared with cancer-free individuals. Survivors <40 had a higher risk of hypertension, cardiomyopathy, and nutritional deficiencies. Conclusions: Increased risks for diseases associated with aging were observed for both age groups, with younger thyroid cancer survivors having higher risks for select diseases. Impact: As thyroid cancer survivors in this study were found to have increased risks for aging-related diseases, future studies are needed to assess what can be done to reduce the increased risks of these long-term health effects. Cancer Epidemiol Biomarkers Prev; 26(12); 1695–704. ©2017 AACR.

Risk Factors for Cardiovascular Disease among Thyroid Cancer Survivors: Findings from the Utah Cancer Survivors Study.

Context Thyroid cancer survivors are at high risk of developing multiple cardiac and vascular conditions as consequence of cancer diagnosis and treatment. However, it is still unclear how the baseline and prognostic factors, as well as cancer treatments, play a role in increasing cardiac and vascular disease risk among thyroid cancer survivors. Objective To investigate the association between potential risk factors, treatment effects, and cardiovascular disease (CVD) outcomes in thyroid cancer survivors. Design, Setting, Patients Primary thyroid cancer survivors, diagnosed from 1997 to 2012 (n = 3822), were identified using the statewide Utah Population Database. The medical records were used to ascertain information on risk factors and CVD outcomes. Cox proportional hazards models were used to assess the risk of CVD with baseline demographic data and clinical factors. Results Among thyroid cancer survivors, age and year at cancer diagnosis, cancer stage, sex, baseline body mass index, baseline comorbidities, and TSH suppression therapy were significantly associated with CVD risk 1 to 5 years after cancer diagnosis. Patients who were male, overweight or obese, older at cancer diagnosis, and diagnosed with cancer since 2005 had an increased risk of CVD compared with patients who were female, had a normal body mass index, were younger at cancer diagnosis, and diagnosed with cancer from 1997 to 1999. Administration of TSH suppression therapy, distant metastases at cancer diagnosis, and a higher Charlson comorbidity index score were associated with an increased CVD risk among thyroid cancer survivors. Conclusions Our findings suggest that examining the effect of thyroid cancer diagnosis, cancer treatment, and demographic characteristics on the risk of CVD is critical.

Long-term Cardiovascular Outcomes Among Endometrial Cancer Survivors in a Large, Population-Based Cohort Study

Background Endometrial cancer is the second most common cancer among female cancer survivors in the United States. Cardiovascular disease is the leading cause of death among endometrial cancer survivors. Studies that examine long-term cardiovascular outcomes among endometrial cancer survivors are critical. Methods Cohorts of 2648 endometrial cancer survivors diagnosed between 1997 and 2012 and 10 503 age-matched women from the general population were identified. Cardiovascular disease diagnoses were identified from electronic medical records and statewide ambulatory surgery and statewide inpatient data. Cox regression models were used to estimate hazard ratios (HRs) at one to five years, more than five to 10 years, and more than 10 years after cancer diagnosis. Results Between one and five years after diagnosis, increased cardiovascular risks among endometrial cancer survivors were observed for phlebitis, thrombophlebitis, and thromboembolism (HR = 2.07, 99% confidence interval [CI] = 1.57 to 2.72), pulmonary heart disease (HR = 1.74, 99% CI = 1.26 to 2.40), and atrial fibrillation (HR = 1.50, 99% CI = 1.07 to 2.11). At more than five to 10 years, some elevated risk persisted for cardiovascular diseases. Compared with patients who had surgery, patients who additionally had radiation therapy and/or chemotherapy were at increased risk for heart and circulatory system disorders between one and five years after cancer diagnosis. Older age and obesity were also risk factors for hypertension and heart disease among endometrial cancer survivors. Conclusions Endometrial cancer survivors are at higher risk for various adverse long-term cardiovascular outcomes compared with women from the general population. This study suggests that increased monitoring for cardiovascular diseases may be necessary for endometrial cancer patients for 10 years after cancer diagnosis.

Rural-metropolitan disparities in ovarian cancer survival: a statewide population-based study

PURPOSE To investigate rural-metropolitan disparities in ovarian cancer survival, we assessed ovarian cancer mortality and differences in prognostic factors by rural-metropolitan residence. METHODS The Utah Population Database was used to identify ovarian cancer cases diagnosed between 1997 and 2012. Residential location information at the time of cancer diagnosis was used to stratify rural-metropolitan residence. All-cause death and ovarian cancer death risks were estimated using Cox proportional hazard regression models. RESULTS Among 1661 patients diagnosed with ovarian cancer, 11.8% were living in rural counties of Utah. Although ovarian cancer patients residing in rural counties had different characteristics compared with metropolitan residents, we did not observe an association between rural residence and risk of all-cause nor ovarian cancer-specific death after adjusting for confounders. However, among rural residents, ovarian cancer mortality risk was very high in older age at diagnosis and for mucinous carcinoma, and low in overweight at baseline. CONCLUSIONS Rural residence was not significantly associated with the risk of ovarian cancer death. Nevertheless, patients residing in rural-metropolitan areas had different factors affecting the risk of all-cause mortality and cancer-specific death. Further research is needed to quantify how mortality risk can differ by residential location accounting for degree of health care access and lifestyle-related factors.

Long-term, adverse genitourinary outcomes among endometrial cancer survivors in a large, population-based cohort study

OBJECTIVE With the increasing incidence of endometrial cancer, the high survival rate, and the large number of endometrial cancer survivors, investigations of long-term genitourinary outcomes are important for the management of these outcomes among endometrial cancer survivors. METHODS Cohorts of 2648 endometrial cancer survivors diagnosed in the state of Utah between 1997 and 2012 and 10,503 general population women were identified. All ICD-9 diagnosis codes were collected from the states two largest healthcare systems and statewide databases. Multivariate Cox regression models were used to estimate hazard ratios at 1-5years and >5-10years after endometrial cancer diagnosis for genitourinary outcomes. RESULTS Endometrial cancer survivors were at elevated risk for urinary system disorders between 1 and 5years (HR: 1.64, 95% CI: 1.50-1.78) and >5-10years (HR: 1.40, 95% CI: 1.26-1.56) and genital organ disorders between 1 and 5years (HR: 1.71, 95% CI: 1.58-2.03) and >5-10years (HR: 1.33, 95% CI: 1.19-1.49). Significantly elevated risk was observed among endometrial cancer survivors for renal failure, chronic kidney disease, urinary tract infections, and nonmalignant breast conditions, persisting between >5-10years. Between 1 and 5years after cancer diagnosis, those with higher stage, higher grade, older age and treated with radiation or chemotherapy were at higher risk for urinary disorders. CONCLUSIONS Endometrial cancer survivors were at higher risk for many genitourinary outcomes compared to women from the general population. This study presents evidence suggesting the necessity of increased monitoring and counseling for genitourinary disorders for endometrial cancer patients both immediately after treatment cessation and for years afterwards.