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Limited data exist on asthma and chronic obstructive pulmonary disease (COPD) management-major drivers of healthcare resource utilization (HCRU) in the USA. We describe prevalence and exacerbation rates, therapeutic interventions, and HCRU for asthma and/or COPD within a large, integrated healthcare system. Patients with asthma, COPD, and asthma + COPD were identified from retrospective electronic health record data (2016-2018) of >1.7 million patients. Descriptive analysis of disease prevalence and exacerbation frequencies, pharmacotherapies, and HCRU was performed. Time-to-event analysis of time to first exacerbation was performed in patients with asthma and/or COPD. Exacerbation rates, pharmacotherapies, and HCRU were examined by exploratory analysis in an outpatient subset. Overall, 149,086 unique patients (8.6%) had encounters for asthma, COPD, or asthma + COPD. Acute care utilization was high, including emergency department visits (asthma, 52.9%; COPD, 35.1%) and hospitalizations (asthma, 26.7%; COPD, 65.7%). Many patients were prescribed short-acting therapies (asthma, 45.3%; COPD, 40.0%; asthma + COPD, 54.7%). Prescription rates for maintenance therapies were low (17.1%, 20.8%, 31.7%) and annual exacerbation rates were 0.65, 0.80, and 1.33. This analysis showed a substantive prevalence of pulmonary disease, variability between documented prescriptions and pharmacotherapy guidelines, and high HCRU. Appropriate tailoring of pharmacotherapies and management of asthma and COPD over a continuum are opportunities to improve patient care., (Copyright © 2022 Baylor University Medical Center.) more...

Objective: Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence-based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non-valvular AF (EDAFMP) on hospital use and care process measures., Methods: We deployed a voluntary-use EDAFMP in 4 EDs (1 tertiary hospital, 1 cardiac hospital, 2 community hospitals) of an integrated delivery organization using a multifaceted implementation approach. We compared outcomes between patients with AF treated using the EDAFMP and historical and contemporaneous "usual care" controls, using a propensity-score adjusted generalized estimating equation. Patients with an index ED encounter for a primary visit reason of non-valvular AF (and no excluding concurrent diagnoses) were eligible for inclusion., Results: Preimplementation (January 1, 2016-December 31, 2016), 628 AF patients were eligible; postimplementation (September 1, 2017-June 30, 2019), 1296, including 271 (20.9%) treated with the EDAFMP, were eligible. EDAFMP patients were less likely to be admitted than both historical (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.45, 0.29-0.71) and contemporaneous controls (aOR, 95%CI: 0.63, 0.46-0.86). ED visits and hospital readmissions over 90 days subsequent to index ED encounters were similar between postimplementation EDAFMP and usual care groups. EDAFMP patients were more likely to be prescribed anticoagulation (38% v. 5%, P  < 0.001) and be referred to a cardiologist (93% vs 29%, P  < 0.001) versus the comparator group., Conclusion: EDAFMP use is associated with decreased hospital admission during an index ED encounter for non-valvular AF, and improved delivery of AF care processes., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.) more...

Context: Collaborative networks support the goals of a learning health system by sharing, aggregating, and analyzing data to facilitate identification of best practices care across delivery organizations. This case study describes the infrastructure and process developed by an integrated health delivery system to successfully prepare and submit a complex data set to a large national collaborative network., Case Description: We submitted four years of data for a diverse population of patients in specific clinical areas: diabetes, chronic heart failure, sepsis, and hip, knee, and spine. The most recent submission included 19 tables, more than 376,000 unique patients, and almost 5 million patient encounters. Data was extracted from multiple clinical and administrative systems., Lessons Learned: We found that a structured process with documentation was key to maintaining communication, timelines, and quality in a large-scale data submission to a national collaborative network. The three key components of this process were the experienced project team, documentation, and communication. We used a formal QA and feedback process to track and review data. Overall, the data submission was resource intensive and required an incremental approach to data quality., Conclusion: Participation in collaborative networks can be time and resource intense, however it can serve as a catalyst to increase the technical data available to the learning health system. more...

Comparative effectiveness research (CER) studies involving multiple institutions with diverse electronic health records (EHRs) depend on high quality data. To ensure uniformity of data derived from different EHR systems and implementations, the CER Hub informatics platform developed a quality assurance (QA) process using tools and data formats available through the CER Hub. The QA process, implemented here in a study of smoking cessation services in primary care, used the 'emrAdapter' tool programmed with a set of quality checks to query large samples of primary care encounter records extracted in accord with the CER Hub common data framework. The tool, deployed to each study site, generated error reports indicating data problems to be fixed locally and aggregate data sharable with the central site for quality review. Across the CER Hub network of six health systems, data completeness and correctness issues were prevalent in the first iteration and were considerably improved after three iterations of the QA process. A common issue encountered was incomplete mapping of local EHR data values to those defined by the common data framework. A highly automated and distributed QA process helped to ensure the correctness and completeness of patient care data extracted from EHRs for a multi-institution CER study in smoking cessation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.) more...

Objective: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system., Study Setting: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed., Study Design: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems., Data Collection: Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs)., Principal Findings: Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs., Conclusions: AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems., (© Health Research and Educational Trust.) more...

Evidence-based management guidelines have been shown to improve patient outcomes, yet their utilization by trauma centers remains unknown. This study measured adoption of practice management guidelines or protocols by trauma centers. A survey of 228 trauma centers was conducted over 1 year; 55 completed the survey. Centers were classified into three groups: noncompliant, partially compliant, and compliant with adoption of management protocols. Characteristics of compliant centers were compared with those of the other two groups. Most centers were Level I (58%) not-for-profit (67%) teaching hospitals (84%) with a surgical residency (74%). One-third of centers had an accredited fellowship in surgical critical care (37%). Only one center was compliant with all 32 management protocols. Half of the centers were compliant with 14 of 32 protocols studied (range, 4 to 32). Of the 21 trauma center characteristics studied, only two were independently associated with compliant centers: use of physician extenders and daily attending rounds (both P < .0001). Adoption of management guidelines by trauma centers is inconsistent, with wide variations in practices across centers. more...

We have examined rates of hospitalization for respiratory diseases in relation to residences in zip codes with hazardous waste sites, as well as socio-economic status. Chronic bronchitis and chronic airway obstruction were elevated in persons who live in zip codes containing persistent organic pollutants (POPs) (PCBs and persistent pesticides) as compared to "clean" zip codes without hazardous waste sites or zip codes with hazardous waste sites containing other kinds of wastes, but the differences could be due to socio-economic status and behavioral risk factors since these are also important risk factors for respiratory diseases. Therefore, we investigated rates of hospitalization for individuals living in zip codes along the Hudson River, because here the average per capita income is higher than in the rest of the state, and there is less smoking, better diet and more exercise. We found a similar elevation of chronic bronchitis and chronic airway obstruction along the Hudson. These observations are consistent with the possibility that living near a POPs-contaminated site poses a risk of exposure and increased risk of chronic respiratory disease, probably secondary to suppression of the immune system. more...

Previous investigations have shown that women exposed to polychlorinated biphenyls (PCBs) are at increased risk of giving birth to an infant with low birth weight (< 2,500 g), and that this relationship is stronger for male than for female infants. We have tested the hypothesis that residents in a zip code that contains a PCB hazardous waste site or abuts a body of water contaminated with PCBs are at increased risk of giving birth to a low-birth-weight baby. We used the birth registry of the New York State Vital Statistics to identify all births between 1994 and 2000 in New York State except for New York City. This registry provides information on the infant, mother, and father together with the zip code of the mother's residence. The 865 state Superfund sites, the 86 National Priority List sites, and the six Areas of Concern in New York were characterized regarding whether or not they contain PCBs as a major contaminant. We identified 187 zip codes containing or abutting PCB-contaminated sites, and these zip codes were the residences of 24.5% of the 945,077 births. The birth weight in the PCB zip codes was on average 21.6 g less than in other zip codes (p < 0.001). Because there are many other risk factors for low birth weight, we have adjusted for these using a logistic regression model for these confounders. After adjusting for sex of the infant, mother's age, race, weight, height, education, income, marital status, and smoking, there was still a statistically significant 6% increased risk of giving birth to a male infant of low birth weight. These observations support the hypothesis that living in a zip code near a PCB-contaminated site poses a risk of exposure and giving birth to an infant of low birth weight. more...