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OBJECTIVE The purpose of this study was to determine whether patients who discuss bariatric surgery with their providers are more likely to undergo the procedure and to lose weight. METHODS A retrospective cohort study of adults with BMI ≥ 35 kg/m2 treated between 2000 and 2015 was conducted to analyze the relationship between a discussion of bariatric surgery in the first year after study entry and weight changes (primary outcome) and receipt of bariatric surgery (secondary outcome) over 2 years after study entry. Natural language processing was used to identify the documentation of bariatric surgery discussion in electronic provider notes. RESULTS Out of 30,560 study patients, a total of 2,659 (8.7%) discussed bariatric surgery with their providers. The BMI of patients who discussed bariatric surgery decreased by 2.18 versus 0.21 for patients who did not (p < 0.001). In a multivariable analysis, patients who discussed bariatric surgery with their providers lost more weight (by 1.43 [change in BMI]; 95% CI: 1.29-1.57) and had greater odds (10.2; 95% CI: 9.0-11.6; p < 0.001) of undergoing bariatric surgery. CONCLUSIONS Clinicians rarely discussed bariatric surgery with their patients. Patients who did have this discussion were more likely to lose weight and to undergo bariatric surgery.

OBJECTIVE To investigate the association between ambulatory medication reconciliation and health care utilization in patients with diabetes. RESEARCH DESIGN AND METHODS In this retrospective cohort analysis, we studied adults taking at least one diabetes medication treated in primary care practices affiliated with two academic medical centers between 2000 and 2014. We assessed the relationship between the fraction of outpatient diabetes medications reconciled over a 6-month period and the composite primary outcome of combined frequency of emergency department (ED) visits and hospitalizations over the subsequent 6 months. RESULTS Among 261,765 reconciliation assessment periods contributed by 31,689 patients, 176,274 (67.3%), 27,775 (10.6%), and 57,716 (22.1%) had all, some, or none of the diabetes medications reconciled, respectively. Patients with all, some, or no diabetes medications reconciled had 0.354, 0.377, and 0.384 primary outcome events per 6 months, respectively (P < 0.0001). In a multivariable analysis adjusted for demographics and comorbidities, having some or all versus no diabetes medications reconciled was associated with a lower risk of the primary outcome (rate ratio 0.94 [95% CI 0.90–0.98; P = 0.0046] vs. 0.92 [0.89–0.95; P < 0.0001], respectively). Introduction of feedback to individual providers was associated with a significant increase in the odds of all diabetes medications being reconciled (2.634 [2.524–2.749]; P < 0.0001). CONCLUSIONS A higher fraction of reconciled outpatient diabetes medications was associated with a lower frequency of ED visits and hospitalizations. Individual performance feedback could help to achieve more comprehensive medication reconciliation.

AIM To determine the relationship between decline of insulin therapy by individuals with type 2 diabetes and subsequent blood glucose control. METHODS We retrospectively studied adults with type 2 diabetes and suboptimal (HbA1c ≥ 53 mmol/mol [7.0%]) glycaemic control followed at two academic hospitals between 2000 and 2014 who were recommended insulin therapy. Decline of insulin therapy recommendations was identified using natural language processing of provider notes. Time to HbA1c < 53 mmol/mol (7.0%) served as the primary outcome. RESULTS Of 5307 study participants, 2267 (42.7%) declined insulin therapy. Median time to HbA1c control in individuals who declined vs. started insulin therapy was 50 vs. 38 months, respectively (P < 0.001). In multivariable analysis, decline of insulin therapy was associated with hazard ratio for HbA1c control of 0.89 (95% CI 0.82 to 0.97; P = 0.008). Participants were more likely to accept insulin therapy recommendations if they had diabetes complications (OR 1.32; 95% CI 1.13 to 1.53; P < 0.001) or a higher HbA1c (OR 1.10; 95% CI 1.07 to 1.13; P < 0.001), and less likely if they were older (OR 0.81; 95% CI 0.76 to 0.86; P < 0.001) or were taking more non-insulin diabetes medications (OR 0.78; 95% CI 0.74 to 0.83; P < 0.001). CONCLUSIONS Individuals with uncontrolled type 2 diabetes who declined insulin therapy subsequently had worse glycaemic control. These findings highlight the need to improve our understanding of the relationship of this common but poorly explored clinical phenomenon to blood glucose control and ultimately diabetes complications.

OBJECTIVE To investigate the relationship between lifestyle counseling in primary care settings and clinical outcomes in patients with diabetes. RESEARCH DESIGN AND METHODS We retrospectively studied hyperglycemic adults with diabetes treated at primary care practices between 2000 and 2014. We analyzed the relationship between frequency of lifestyle counseling (identified using natural language processing of electronic notes) and a composite outcome of death and cardiovascular events during subsequent follow-up. RESULTS Among patients with monthly counseling or more, 10-year cumulative incidence of the primary outcome was 33.0% compared with 38.1% for less than monthly counseling (P = 0.0005). In multivariable analysis, higher frequency of lifestyle counseling was associated with lower incidence of the primary outcome (hazard ratio 0.88 [95% CI 0.82–0.94]; P < 0.001). CONCLUSIONS More frequent lifestyle counseling was associated with a lower incidence of cardiovascular events and death among patients with diabetes.

OBJECTIVE To establish quantitative characteristics of lifestyle counseling documentation associated with improved glycemic control in patients with diabetes. RESEARCH DESIGN AND METHODS We retrospectively studied 10,870 hyperglycemic (HbA1c ≥7.0% [53 mmol/mol]) adults with diabetes followed at primary care practices affiliated with two academic hospitals between 2000 and 2010. Documentation intensity was represented by the mean number of characters per note documenting lifestyle counseling. Heterogeneity was calculated as the normalized Levenshtein distance between lifestyle counseling sentences between consecutive notes. Cox proportional hazards model was constructed to assess association of heterogeneity and intensity of lifestyle counseling documentation to time to HbA1c RESULTS Comparing patients in the highest versus lowest tertile by documentation heterogeneity and documentation intensity, median time to HbA1c CONCLUSIONS Higher heterogeneity and intensity of lifestyle counseling documentation in provider notes were associated with better glycemic control. Further studies involving direct observation of patient care are needed to establish the nature of the relationship between documentation characteristics and patient outcomes.

Many patients can tolerate statin therapy after an adverse reaction. However, optimal patient selection criteria and methods of reattempting statin therapy after an adverse reaction are unknown.To identify patient and treatment characteristics associated with a successful statin reattempt after an adverse reaction.We retrospectively studied adults treated in primary care practices affiliated with 2 academic medical centers between 2000 and 2012 who reattempted statin therapy after an adverse reaction. Statin reattempts were considered successful if the patient had at least 2 statin prescriptions after discontinuation of the original statin, and had an active electronic medical record statin record at 2 years after the adverse reaction.Among 6196 patients included in the study, 4536 (73.2%) successfully reattempted statin therapy. In multivariable analysis, history of coronary artery disease, stroke, or diabetes (odds ratio [OR] 1.195; P = .008) and reattempted treatment with a different statin (OR 1.463; P .0001) were associated with greater odds of a successful reattempt. Adverse reaction during the first year after statin initiation (OR 0.721; P .0001) or myalgia or myopathy (OR 0.807; P = .001) as well as history of adverse reactions to nonstatin drugs (OR 0.908; P .0001) were associated with lower odds.Nature and timing of the adverse reaction, patient's medical history and the medication prescribed affected the likelihood of a successful reattempt of statin therapy after an adverse reaction. These findings suggest that a patient-centered approach to restarting statins should be considered for patients at high cardiovascular risk to improve the chances of success.

Background Many patients discontinue statin treatment, often after having a possible adverse reaction. The risks and benefits of continued statin therapy after an adverse reaction are not known. Objective To examine the relationship between continuation of statin therapy (any prescription within 12 months after an adverse reaction) and clinical outcomes. Design Retrospective cohort study. Setting Primary care practices affiliated with 2 academic medical centers. Participants Patients with a presumed adverse reaction to a statin between 2000 and 2011. Measurements Information on adverse reactions to statins was obtained from structured electronic medical record data or natural-language processing of narrative provider notes. The primary composite outcome was time to a cardiovascular event (myocardial infarction or stroke) or death. Results Most (81%) of the adverse reactions to statins were identified from the text of electronic provider notes. Among 28 266 study patients, 19 989 (70.7%) continued receiving statin prescriptions after the adverse reaction. Four years after the presumed adverse event, the cumulative incidence of the composite primary outcome was 12.2% for patients with continued statin prescriptions, compared with 13.9% for those without them (difference, 1.7% [95% CI, 0.8% to 2.7%]; P < 0.001). In a secondary analysis of 7604 patients for whom a different statin was prescribed after the adverse reaction, 2014 (26.5%) had a documented adverse reaction to the second statin, but 1696 (84.2%) of those patients continued receiving statin prescriptions. Limitations The risk for recurrent adverse reactions to statins could not be established for the entire sample. It was also not possible to determine whether patients actually took the statins. Conclusion Continued statin prescriptions after an adverse reaction were associated with a lower incidence of death and cardiovascular events. Primary Funding Source Chinese National Key Program of Clinical Science, National Natural Science Foundation of China, and Young Scientific Research Fund of Peking Union Medical College Hospital.

The programmed self-destruction of infected cells is a powerful antimicrobial strategy in metazoans. For decades, apoptosis represented the dominant mechanism by which the virus-infected cell was thought to undergo programmed cell death. More recently, however, new mechanisms of cell death have been described that are also key to host defense. One such mechanism in vertebrates is programmed necrosis, or "necroptosis", driven by receptor-interacting protein kinase 3 (RIPK3). Once activated by innate immune stimuli, including virus infections, RIPK3 phosphorylates the mixed lineage kinase domain-like protein (MLKL), which then disrupts cellular membranes to effect necroptosis. Emerging evidence demonstrates that RIPK3 can also mediate apoptosis and regulate inflammasomes. Here, we review studies on the mechanisms by which viruses activate RIPK3 and the pathways engaged by RIPK3 that drive cell death.

OBJECTIVE Studies have shown that patients without a consistent primary care provider have inferior outcomes. However, little is known about the mechanisms for these effects. This study aims to determine whether primary care physicians (PCPs) provide more frequent medication intensification, lifestyle counseling, and patient encounters than other providers in the primary care setting. RESEARCH DESIGN AND METHODS This retrospective cohort study included 584,587 encounters for 27,225 patients with diabetes and elevated A1C, blood pressure, and/or LDL cholesterol monitored for at least 2 years. Encounters occurred at primary care practices affiliated with two teaching hospitals in eastern Massachusetts. RESULTS Of the encounters documented, 83% were with PCPs, 13% were with covering physicians, and 5% were with midlevel providers. In multivariable analysis, the odds of medication intensification were 49% (P < 0.0001) and 26% (P < 0.0001) higher for PCPs than for covering physicians and midlevel providers, respectively, whereas the odds of lifestyle counseling were 91% (P < 0.0001) and 21% (P = 0.0015) higher. During visits with acute complaints, covering physicians were even less likely, by a further 52% (P < 0.0001), to intensify medications, and midlevel providers were even less likely, by a further 41% (P < 0.0001), to provide lifestyle counseling. Compared with PCPs, the hazard ratios for time to the next encounter after a visit without acute complaints were 1.11 for covering physicians and 1.19 for midlevel providers (P < 0.0001 for both). CONCLUSIONS PCPs provide better care through higher rates of medication intensification and lifestyle counseling. Covering physicians and midlevel providers may enable more frequent encounters when PCP resources are constrained.

Patients with both diabetes and coronary artery disease (CAD) have exceedingly high cardiovascular risk. Nevertheless, little is known about prevalence of statin therapy in this population and reasons why some patients may not be receiving this potentially life-saving treatment.To investigate prevalence and predictors of statin therapy in patients with combined diabetes and CAD.We conducted a retrospective cohort study of primary care patients with diabetes and CAD followed at 2 academic medical centers between 2000 and 2011. We used multivariable logistic regression to identify patient and provider characteristics associated with (1) statin initiation (any history of statin therapy) and (2) statin persistence (active statin prescription at the study end).Of 8488 study patients, 7427 (87.5%) ever received statins and 6212 (73.2%) had persistent statin therapy. Younger age (odds ratio [OR], 1.26 per decade), smoking (OR, 1.49) and cardiologist evaluation (OR, 2.26) were associated with statin initiation (P .0001 for all). Younger age (OR, 1.17), family history of CAD (OR, 1.39), no adverse reactions to statins (OR, 1.40; P .0001 for all), female sex (OR, 1.22; P = .005), history of smoking (OR, 1.22; P = .003), cardiologist evaluation (OR, 1.23; P = .002), and lower HbA1c (OR, 1.04; P = 0.003) were associated with persistent statin therapy. Only 362 (29.8%) of the 1215 patients without persistent statin therapy had tried at least 2 statins, and 58 (4.8%) tried 3 statins.Many patients with combined CAD and diabetes are not treated with statins, although in this very high-risk group, even moderate-intensity statins result in meaningful reductions in cardiovascular events. Higher cardiovascular risk and cardiologist evaluation were associated with higher prevalence of statin therapy.

OBJECTIVE In clinical trials, diet, exercise, and weight counseling led to short-term improvements in blood glucose, blood pressure, and cholesterol levels in patients with diabetes. However, little is known about the long-term effects of lifestyle counseling on patients with diabetes in routine clinical settings. RESEARCH DESIGN AND METHODS This retrospective cohort study of 30,897 patients with diabetes aimed to determine whether lifestyle counseling is associated with time to A1C, blood pressure, and LDL cholesterol control in patients with diabetes. Patients were included if they had at least 2 years of follow-up with primary care practices affiliated with two teaching hospitals in eastern Massachusetts between 1 January 2000 and 1 January 2010. RESULTS Comparing patients with face-to-face counseling rates of once or more per month versus less than once per 6 months, median time to A1C CONCLUSIONS Lifestyle counseling in the primary care setting is strongly associated with faster achievement of A1C, blood pressure, and LDL cholesterol control. These results confirm that the findings of controlled clinical trials are applicable to the routine care setting and provide evidence to support current treatment guidelines.

Medical applications frequently contain a wide range of functionalities. Users are often unaware of all of the functionalities available. More effective ways of delivering information about available functionalities to the users are needed. We conducted a pseudo-randomized controlled trial to determine whether interruptive alerts will increase utilization of several functionalities by the users of the Pre-Admission Medication List (PAML) Builder application at two academic medical centers. In a log-linear model, alerts increased total utilization of the promoted functionalities per PAML built by 70% compared to the controls at the site level (p

Many e-prescribing systems allow for both structured and free-text fields in prescriptions, making possible internal discrepancies. This study reviewed 2914 electronic prescriptions that contained free-text fields. Internal discrepancies were found in 16.1% of the prescriptions. Most (83.8%) of the discrepancies could potentially lead to adverse events and many (16.8%) to severe adverse events, involving a hospital admission or death. Discrepancies in doses, routes or complex regimens were most likely to have a potential for a severe event (p=0.0001). Discrepancies between structured and free-text fields in electronic prescriptions are common and can cause patient harm. Improvements in electronic medical record design are necessary to minimize the risk of discrepancies and resulting adverse events.

OBJECTIVE Hypoglycemia is associated with adverse outcomes in mixed populations of patients in intensive care units. It is not known whether the same risks exist for diabetic patients who are less severely ill. In this study, we aimed to determine whether hypoglycemic episodes are associated with higher mortality in diabetic patients hospitalized in the general ward. RESEARCH DESIGN AND METHODS This retrospective cohort study analyzed 4,368 admissions of 2,582 patients with diabetes hospitalized in the general ward of a teaching hospital between January 2003 and August 2004. The associations between the number and severity of hypoglycemic (≤50 mg/dl) episodes and inpatient mortality, length of stay (LOS), and mortality within 1 year after discharge were evaluated. RESULTS Hypoglycemia was observed in 7.7% of admissions. In multivariable analysis, each additional day with hypoglycemia was associated with an increase of 85.3% in the odds of inpatient death (P = 0.009) and 65.8% (P = 0.0003) in the odds of death within 1 year from discharge. The odds of inpatient death also rose threefold for every 10 mg/dl decrease in the lowest blood glucose during hospitalization (P = 0.0058). LOS increased by 2.5 days for each day with hypoglycemia (P < 0.0001). CONCLUSIONS Hypoglycemia is common in diabetic patients hospitalized in the general ward. Patients with hypoglycemia have increased LOS and higher mortality both during and after admission. Measures should be undertaken to decrease the frequency of hypoglycemia in this high-risk patient population.

To characterize the relationship between body mass index (BMI) and all-cause mortality among adults with hypertension.We conducted a retrospective cohort study of adults with hypertension from The Health Improvement Network primary care research database in the United Kingdom. Mortality rates within each BMI category were compared after adjustment for age, sex, pre existing medical conditions, smoking, alcohol use, and socioeconomic status.During a median follow-up period of 8.0 years, 34,354 deaths occurred (8.8%) among the 388,724 study patients. In multivariable analysis that included interaction terms between smoking, heavy alcohol use, preexisting cardiovascular disease and chronic obstructive pulmonary disease (COPD), and BMI category to account for these conditions' association with increased mortality at lower BMI levels, a U-shaped relationship was observed between BMI and mortality, with no difference in mortality in overweight (25.0-29.9 kg/m(2) ) versus normal (18.5-24.9 kg/m(2) ) BMI (risk ratio 1.00, 95% confidence interval 0.95 to 1.04, P = 0.80). In multivariable analysis that used narrower BMI categories, lowest mortality was observed between BMI of 23.0 and 26.9 kg/m(2) .Patients with hypertension who have no history of smoking, heavy alcohol use, cardiovascular disease, or COPD have lowest mortality between BMI of 23.0 and 26.9 kg/m(2) .

Background Systematic data on discontinuation of statins in routine practice of medicine are limited. Objective To investigate the reasons for statin discontinuation and the role of statin-related events (clinical events or symptoms believed to have been caused by statins) in routine care settings. Design A retrospective cohort study. Setting Practices affiliated with Brigham and Women's Hospital and Massachusetts General Hospital in Boston. Patients Adults who received a statin prescription between 1 January 2000 and 31 December 2008. Measurements Information on reasons for statin discontinuations was obtained from a combination of structured electronic medical record entries and analysis of electronic provider notes by validated software. Results Statins were discontinued at least temporarily for 57 292 of 107 835 patients. Statin-related events were documented for 18 778 (17.4%) patients. Of these, 11 124 had statins discontinued at least temporarily; 6579 were rechallenged with a statin over the subsequent 12 months. Most patients who were rechallenged (92.2%) were still taking a statin 12 months after the statin-related event. Among the 2721 patients who were rechallenged with the same statin to which they had a statin-related event, 1295 were receiving the same statin 12 months later, and 996 of them were receiving the same or a higher dose. Limitations Statin discontinuations and statin-related events were assessed in practices affiliated with 2 academic medical centers. Utilization of secondary data could have led to missing or misinterpreted data. Natural-language-processing tools used to compensate for the low (30%) proportion of reasons for statin discontinuation documented in structured electronic medical record fields are not perfectly accurate. Conclusion Statin-related events are commonly reported and often lead to statin discontinuation. However, most patients who are rechallenged can tolerate statins long-term. This suggests that many of the statin-related events may have other causes, are tolerable, or may be specific to individual statins rather than the entire drug class. Primary funding source National Library of Medicine, Diabetes Action Research and Education Foundation, and Chinese National Key Program of Clinical Science.

Background Evidence suggests that copy-pasted components of electronic notes may not reliably reflect the care delivered. Federal agencies have raised concerns that such components may be used to justify inappropriately inflated claims for reimbursement. It is not known whether copied information is used to justify higher evaluation and management (E&M) charges. Methods This retrospective cohort study aimed to assess the relationship between the level of evaluation and management (E&M) charges and the method of documentation (none, distinct or copied) of lifestyle counseling (diet, exercise and weight loss) for patients with diabetes mellitus. To determine the association, an ordered multinomial logistic regression model that corrected for clustering within individual providers and patients and adjusted for patient and encounter characteristics was utilized. E&M charge level served as the primary outcome variable. Patients were included if they were followed by primary care physicians affiliated with two academic hospitals for a minimum of two years between 01/01/2000 and 12/13/2009. Results Lifestyle counseling was documented in 65.4% of 155,168 primary care encounters of 16,164 patients. Copied counseling was identified in 12,527 encounters. In multivariable analysis higher E&M charges were associated with older patient age, longer notes, treatment with insulin, medication changes and acute complaints. However, copied lifestyle counseling was associated with a decrease of 70.5% in the odds of higher E&M charge levels when time spent on counseling (required to justify higher charges based on counseling) was recorded (p Conclusion There is no evidence that copied documentation of lifestyle counseling is used to justify higher evaluation and management charges. Higher charges were generally associated with indicators of complexity of care.

It is not known whether narrative medical text directly reflects clinical reality. We have tested the hypothesis that the pattern of distribution of lexical concept of medication intensification in narrative provider notes correlates with clinical practice as reflected in electronic medication records. Over 29,000 medication intensifications identified in narrative provider notes and 444,000 electronic medication records for 82 anti-hypertensive, anti-hyperlipidemic and anti-hyperglycemic medications were analyzed. Pearson correlation coefficient between the fraction of dose increases among all medication intensifications and therapeutic range calculated from EMR medication records was 0.39 (p = 0.0003). Correlations with therapeutic ranges obtained from two medication dictionaries, used as a negative control, were not significant. These findings provide evidence that narrative medical documents directly reflect clinical practice and constitute a valid source of medical data.

BACKGROUND:Women are less likely to be prescribed statins than men. Existing reports explain only a fraction of this difference. We conducted a study to identify factors that account for sex differences in statin therapy among patients with coronary artery disease (CAD). METHODS AND RESULTS:We retrospectively studied 24,338 patients with CAD who were followed for at least a year between 2000 and 2011 at two academic medical centers. Women (9,006 / 37% of study patients) were less likely to either have initiated statin therapy (81.9% women vs. 87.7% men) or to have persistent statin therapy at the end of follow-up (67.0% women vs. 71.4% men). Women were older (72.9 vs. 68.4 years), less likely to have ever smoked (49.8% vs. 65.6%), less likely to have been evaluated by a cardiologist (57.5% vs. 64.5%) and more likely to have reported an adverse reaction to a statin (27.1% vs. 21.7%) (p < 0.0001 for all). In multivariable analysis, patients with history of smoking (OR 1.094; p 0.017), younger age (OR 1.013 / year), cardiologist evaluation (OR 1.337) and no reported adverse reactions to statins (OR 1.410) were more likely (p < 0.0001 for all) to have persistent statin therapy. Together, these four factors accounted for 90.4% of the sex disparity in persistent statin therapy. CONCLUSIONS:Several specific factors appear to underlie divergent statin therapy in women vs. men. Identifying such drivers may facilitate programmatic interventions and stimulate further research to overcome sex differences in applying proven interventions for cardiovascular risk reduction.

Patient death is an important clinical outcome. It is typically ascertained by matching database records with external death indices. Accuracy of the matching algorithms is imperfect.We have investigated whether clinical records made1 month after the date of death accurately identify false positive matches to the Death Master File. Positive predictive value (PPV) varied from 74.7% (notes) to 95.9% (labs) and sensitivity from 57.4% (adverse medication reactions) to 94.9% (notes). Presence of any two out of four (billing data, labs, vital signs and medications) data elements had sensitivity of 83.0% and PPV of 98.3%. Area under the ROC curve for a multivariable logistic model that included the number of these four data elements recorded1 month after death was 0.987.Clinical data recorded after the date of death can help identify false positive matches to death indices and could be utilized to improve existing record linkage algorithms.

Background Home blood pressure (BP) is closely linked to patient outcomes. However, the prevalence of its documentation has not been examined. The objective of this study was to analyze the prevalence and factors affecting documentation of home BP in routine clinical care. Methods A retrospective study of 142,973 encounters of 9,840 hypertensive patients with diabetes from 2000 to 2005 was performed. The prevalence of recorded home BP and the factors associated with its documentation were analyzed. We assessed validity of home BP information by comparing the difference between home and office BP to previously published prospective studies. Results Home BP was documented in narrative notes for 2.08% of encounters where any blood pressure was recorded and negligibly in structured data (EMR flowsheets). Systolic and diastolic home BP in narrative notes were lower than office BP readings by 9.6 and 2.5 mm Hg, respectively (p < 0.0001 for both), consistent with prospective data. Probability of home BP documentation increased by 23.0% for each 10 mm Hg of office systolic BP (p < 0.0001), by 6.2% for each $10,000 in median income of zip code (p = 0.0055), and by 17.7% for each decade in the patient's age (p < 0.0001). Conclusions Home BP readings provide a valid representation of the patient's condition, yet are seldom documented despite their potential utility in both patient care and research. Strong association between higher patient income and home BP documentation suggests that the cost of the monitors may be a limiting factor; reimbursement of home BP monitoring expenses should be pursued.

The relationship between encounter frequency (average number of provider-patient encounters over a period of time) and blood pressure for hypertensive patients is unknown. We tested the hypothesis that shorter encounter intervals are associated with faster blood pressure normalization. We performed a retrospective cohort study of 5042 hypertensive patients with diabetes mellitus treated at primary care practices affiliated with 2 academic hospitals between 2000 and 2005. Distinct periods of continuously elevated blood pressure (≥130/85 mm Hg) were studied. We evaluated the association of the average encounter interval with time to blood pressure normalization and rate of blood pressure decrease. Blood pressure of the patients with the average interval between encounters ≤1 month normalized after a median of 1.5 months at the rate of 28.7 mm Hg/month compared with 12.2 months at 2.6 mm Hg/month for the encounter interval >1 month ( P P P

Objective: To compare information obtained from narrative and structured electronic sources using anti-hypertensive medication intensification as an example clinical issue of interest. Design: A retrospective cohort study of 5,634 hypertensive patients with diabetes from 2000 to 2005. Measurements: The authors determined the fraction of medication intensification events documented in both narrative and structured data in the electronic medical record. The authors analyzed the relationship between provider characteristics and concordance between intensifications in narrative and structured data. As there is no gold standard data source for medication information, the authors clinically validated medication intensification information by assessing the relationship between documented medication intensification and the patients' blood pressure in univariate and multivariate models. Results: Overall, 5,627 (30.9%) of 18,185 medication intensification events were documented in both sources. For a medication intensification event documented in narrative notes the probability of a concordant entry in structured records increased by 11% for each study year (p 0.0001) and decreased by 19% for each decade of provider age (p 0.035). In a multivariate model that adjusted for patient demographics and intraphysician correlations, an increase of one medication intensification per month documented in either narrative or structured data were associated with a 5-8 mm Hg monthly decrease in systolic and 1.5-4 mm Hg decrease in diastolic blood pressure (p 0.0001 for all). Conclusion: Narrative and structured electronic data sources provide complementary information on anti- hypertensive medication intensification. Clinical validity of information in both sources was demonstrated by correlation with changes in blood pressure.

To correlate wheeze detection in the pediatric intensive care unit among staff members (a physician, nurses, and respiratory therapists [RTs]) and digital recordings from a computerized respiratory sound monitor (PulmoTrack).We prospectively studied 11 patients in the pediatric intensive care unit. A physician, nurses, and RTs auscultated the patients and recorded their opinions about the presence of wheeze at baseline and then every hour for 6 hours. The clinician auscultated while the PulmoTrack recorded the lung sounds. The data were analyzed by a technician trained in interpretation of acoustic data and by a panel of experts blinded to the source of the recorded data, who scored all tracks for the presence or absence of wheeze. The degree of correlation among the expert panel, the staff, and the PulmoTrack was evaluated with the Kappa coefficient and McNemar's test. The determinations of the expert panel were taken as the true state (accepted standard).The PulmoTrack and expert panel were in agreement on detection of wheeze during inspiration, expiration, and the whole breath cycle; in all cases the Kappa coefficients were 0.54, 0.42, and 0.50 respectively. The PulmoTrack was significantly more sensitive than the physician (P = .002), nurses (P.001), or RTs (P = .001). However, the specificity of the PulmoTrack was not significantly different from that of the physician, nurses, or RTs.Between the physician, RTs, and nurses there was agreement about the presence of wheeze in critically ill patients in the pediatric intensive care unit. Compared to the objective acoustic measurements from the PulmoTrack, the intensive care unit staff was similar in their ability to detect the absence of wheeze. The PulmoTrack was better than the staff in detecting wheeze.

Background—Regular recertification is mandatory to maintain board certification status in all specialties. However, the evidence that physicians’ performance decreases with time since initial certification is limited. We therefore carried out a study to determine whether the frequency of antihypertensive treatment intensification for diabetic patients changes with time since their physicians’ last board certification.Methods and Results—In this retrospective cohort study, we analyzed treatment of 8127 hypertensive patients with diabetes mellitus treated by 301 internists at primary care practices affiliated with 2 large academic hospitals. Patient visits with documented blood pressure ≥130/85 mm Hg between January 1, 2000, and August 31, 2005, were studied. The association between the number of years since the physician’s last board certification and the probability of pharmacological antihypertensive treatment intensification at a given visit was analyzed. Frequency of treatment intensification decreased from 26.7% for physicians who were board certified the previous year to 6.9% for physicians who were board certified 31 years before the visit. Treatment intensification rate was 22.5% for physicians certified ≤10 years ago versus 16.9% for physicians last certified >10 years ago (PP=0.0097).Conclusion—Physician intensification of pharmacological therapy for blood pressure levels above the recommended treatment goals decreases with time since the last board certification. This finding supports the current policy of mandatory recertification.

Medication records in clinical information systems (CIS) are frequently inaccurate, leading to potentially incorrect clinical decisions and preventing valid decision support interventions. It is not known what characteristics of electronic medication records are predictive of their validity. We studied a dataset of 136,351 electronic medication records of patients admitted to two academic hospitals that were individually validated by admitting providers using novel medication reconciliation software. We analyzed the relationship between characteristics of individual medication records and the probability of record validation using a multivariable linear regression model. Electronic medication records were less likely to be validated if more time had passed since their last update (14.6% for every 6 months), if they represented an antiinfective (61.6%) or a prn (50.9%) medication, or if they were in an outpatient CIS rather than on an inpatient discharge medication list (18.1%); p0.0001 for all. Several characteristics of electronic medication records are strongly associated with their validity. These findings could be incorporated in the design of CIS software to alert providers to medication records less likely to be accurate.

Hyperglycemia is common among diabetic inpatients, and has been linked to adverse outcomes. However, antihyperglycemic treatment is seldom intensified in noncritical care patients, and the relationship between intensification frequency and glucose control is poorly understood. We evaluated the relationship between treatment intensification and changes in blood glucose in hospitalized diabetic patients.We retrospectively analyzed 3,613 hospitalized diabetic patients who were admitted to the hospital between January 2003 and August 2004, were not hospitalized in an ICU, were not prescribed IV insulin or total parenteral nutrition (TPN), had a length of stay of at least 3 days, and had at least one point-of-care blood glucose measurement. A linear model was used to assess the relationship between intensification of antihyperglycemic medications and the average daily change in point-of-care glucose measurements.Hyperglycemia (180 mg/dL) was documented at least once for 82.5% of patient admissions. Antihyperglycemic treatment was intensified for 22.0% of days with hyperglycemia. Intensifications of scheduled and sliding scale insulin, but not oral medications, were associated with a 11.1 mg/dL (p0.0001) and 12.2 mg/dL (p0.0001) reduction in the average daily glucose, respectively. Hypoglycemia (50 mg/dL) was documented on 2.2% of days after antihyperglycemic treatment intensification.In this cohort, lack of treatment intensification in response to inpatient hyperglycemia was common. Antihyperglycemic treatment intensification was strongly associated with decrease in average daily glucose, while hypoglycemia was uncommon. This suggests that increasing the frequency of treatment intensifications could lead to improved glycemic control in inpatients with diabetes.

Misspellings are common in medical documents and can be an obstacle to information retrieval. We evaluated an algorithm to identify misspelled words through analysis of their prevalence in a representative body of text. We evaluated the algorithm's accuracy of identifying misspellings of 200 anti-hypertensive medication names on 2,000 potentially misspelled words randomly selected from narrative medical documents. Prevalence ratios (the frequency of the potentially misspelled word divided by the frequency of the non-misspelled word) in physician notes were computed by the software for each of the words. The software results were compared to the manual assessment by an independent reviewer. Area under the ROC curve for identification of misspelled words was 0.96. Sensitivity, specificity, and positive predictive value were 99.25%, 89.72% and 82.9% for the prevalence ratio threshold (0.32768) with the highest F-measure (0.903). Prevalence analysis can be used to identify and correct misspellings with high accuracy.

OBJECTIVE—The volume of patients cared for by an individual physician (physician volume) has been linked to improved outcomes for a number of conditions. It is not known whether a similar association exists for treatment of diabetes. In this study we aimed to determine whether physician volume is associated with improved process measures and outcomes in diabetes care. RESEARCH DESIGN AND METHODS—This retrospective cohort study analyzed electronic medical records data for 7,120 patients with diabetes treated by 368 primary care physicians at practices affiliated with two large academic hospitals. The associations between physician volume of diabetic patients (diabetes volume) and annual A1C and LDL testing, as well as blood pressure, A1C, and LDL levels, were evaluated. RESULTS—In multivariable analysis, absolute diabetes volume was linked to decreased odds of A1C testing (4% less for each additional patient seen; P = 0.05), and relative diabetes volume (fraction of the total patients seen who had diabetes) was associated with decreased odds of both A1C (25% less for every 10% increase in the number of diabetic patients seen annually; P = 0.03) and LDL testing (20% less for every 10% increase in the number of diabetic patients; P < 0.001). Physician volume was not significantly associated with the odds of blood pressure, A1C, or LDL control at the end of the study. CONCLUSIONS—Higher physician volume in care of diabetic patients is associated with decreased adherence to surveillance guidelines and no measurable difference in treatment outcomes.

To investigate the optimal systolic blood pressure goal above which new antihypertensive medications should be added or doses of existing medications increased ("systolic intensification threshold") and to determine the relation between delays in medication intensification and follow-up and the risk of cardiovascular events or death.Retrospective cohort study.Primary care practices in the United Kingdom, 1986-2010.88 756 adults with hypertension from The Health Improvement Network nationwide primary care research database.Rates of acute cardiovascular events or death from any cause for patients with different hypertension treatment strategies (defined by systolic intensification threshold, time to intensification, and time to follow-up over the course of a 10 year treatment strategy assessment period) after adjustment for age, sex, smoking status, socioeconomic deprivation, history of diabetes, cardiovascular disease or chronic kidney disease, Charlson comorbidity index, body mass index, medication possession ratio, and baseline blood pressure.During a median follow-up of 37.4 months after the treatment strategy assessment period, 9985 (11.3%) participants had an acute cardiovascular event or died. No difference in risk of the outcome was seen between systolic intensification thresholds of 130-150 mm Hg, whereas systolic intensification thresholds greater than 150 mm Hg were associated with progressively greater risk (hazard ratio 1.21, 95% confidence interval 1.13 to 1.30; P0.001 for intensification threshold of 160 mm Hg). Outcome risk increased progressively from the lowest (0-1.4 months) to the highest fifth of time to medication intensification (hazard ratio 1.12, 1.05 to 1.20; P=0.009 for intensification between 1.4 and 4.7 months after detection of elevated blood pressure). The highest fifth of time to follow-up (2.7 months) was also associated with increased outcome risk (hazard ratio 1.18, 1.11 to 1.25; P0.001).Systolic intensification thresholds higher than 150 mm Hg, delays of greater than 1.4 months before medication intensification after systolic blood pressure elevation, and delays of greater than 2.7 months before blood pressure follow-up after antihypertensive medication intensification were associated with increased risk of an acute cardiovascular event or death. These findings support the importance of timely medical management and follow-up in the treatment of patients with hypertension.

Drug delivery to the peritoneum is hampered by rapid clearance, and could be improved by application of controlled release technology. We investigated the suitability for peritoneal use of micro- and nanoparticles of poly(lactic-co-glycolic) acid (PLGA), a biodegradable polymer with generally excellent biocompatibility commonly used for controlled drug release. We injected 90 kDa PLGA microparticles, 5-250 microm in diameter, into the murine peritoneum, in dosages of 10-100 mg (n=3-5 per group). We found a high incidence of polymeric residue and adhesions 2 weeks after injection (e.g., 50 mg of 5-microm microparticles caused adhesions in 83% of animals). Histology revealed chronic inflammation, with foreign body giant cells prominent with particles>5 microm in diameter. Five micrometer microspheres made from 54, 57, and 10 kDa PLGA (gamma irradiated) caused fewer adhesions (16.7%) with a similar incidence of residue. Nanoparticles (265 nm) of 90 kDa PLGA also caused much fewer adhesions (6.3% of animals), possibly because they were cleared from the peritoneum within 2 days, and sequestered in the spleen and liver, where foamy macrophages were noted. The effect of sterilization technique on the incidence of adhesion formation is also studied.

More frequent patient-provider encounters may lead to faster control of hemoglobin A1c level, blood pressure (BP), and low-density lipoprotein (LDL) cholesterol (LDL-C) level (hereafter referred to as hemoglobin A1c, BP, and LDL-C) and improve outcomes, but no guidelines exist for how frequently patients with diabetes mellitus (DM) should be seen.This retrospective cohort study analyzed 26,496 patients with diabetes and elevated hemoglobin A1c, BP, and/or LDL-C treated by primary care physicians at 2 teaching hospitals between January 1, 2000, and January 1, 2009. The relationship between provider encounter (defined as a note in the medical record) frequency and time to hemoglobin A1c, BP, and LDL-C control was assessed.Comparing patients who had encounters with their physicians between 1 to 2 weeks vs 3 to 6 months, median time to hemoglobin A1c less than 7.0% was 4.4 vs 24.9 months (not receiving insulin) and 10.1 vs 52.8 months (receiving insulin); median time to BP lower than 130/85 mm Hg was 1.3 vs 13.9 months; and median time to LDL-C less than 100 mg/dL was 5.1 vs 32.8 months, respectively (P.001 for all). In multivariable analysis, doubling the time between physician encounters led to an increase in median time to hemoglobin A1c (not receiving [35%] and receiving [17%] insulin), BP (87%), and LDL-C (27%) targets (P.001 for all). Time to control decreased progressively as encounter frequency increased up to once every 2 weeks for most targets, consistent with the pharmacodynamics of the respective medication classes.Primary care provider encounters every 2 weeks are associated with fastest achievement of hemoglobin A1c, BP, and LDL-C targets for patients with diabetes mellitus.

Electronic medical records (EMRs) can improve many aspects of patient care(1). Utilization of electronic medical records is increasing and is particularly encouraged by recent federal legislation(2). However EMRs are not always used optimally. Concerns have been raised about inappropriate copying and pasting of information between provider notes(3, 4). Up to 50% of the content of progress notes may be copied from older documents(5, 6) and copying frequently leads to errors in documentation(6). However, whether copied text generally reflects the care delivered is not known. Lifestyle counseling improves outcomes in patients with diabetes and is recommended by treatment guidelines(7). Narrative provider notes are the primary source of information on whether lifestyle counseling was provided. However, if copying and pasting of note fragments does not reflect treatment, the information contained in narrative electronic documents may not be reliable. We therefore performed a retrospective study of over 5,000 patients with diabetes to determine the relationship between copied lifestyle counseling and glucose control.

Study objective The potential of infectious disease spread in diseases such as tuberculosis, infectious disease epidemic such as avian flu and the threat of terrorism with agents capable of airborne transmission have focused attention on the need for increased surge capacity for patient isolation. Total negative pressure isolation using portable bioisolation tents may provide a solution. The study assesses the ability of health care workers to perform emergency procedures in this environment. Methods Physician performance in completing predetermined critical actions in 5 emergency care scenarios inside and outside of a bioisolation tent ("setting") was studied in an advanced medical simulation laboratory. By design, no pretraining of subjects about total negative pressure isolation use occurred. Impact of setting on time to completion of predetermined critical actions was the primary outcome measured. Secondary variables studied included impact of study groups, scenarios, and run order (inside or outside of the tent first). Subjective assessments were obtained through questionnaires. Results Four teams of 3 physicians completed 5 emergency patient care scenarios during 2 4-hour sessions. Mean time to completion of critical actions was for tent/no tent 298 seconds/284 seconds (P=.69, one way ANOVA), respectively. Mean time to completion for first versus second performance of a scenario in the crossover design was 338 versus 243 (P=.01). The mean score for self-assessed performance did not differ according to setting. Conclusion The ability of physicians naive to the total negative pressure isolation environment to perform emergency medical critical actions was not significantly degraded by a simulated bioisolation tent patient care environment.