Publications by authors named "Cindy Y Chang"

12 Publications

  • Page 1 of 1

Prescription and Prescriber Specialty Characteristics of Initial Opioid Prescriptions Associated with Chronic Use.

Pain Med 2020 12;21(12):3669-3678

Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: This study evaluated the characteristics of opioid prescriptions, including prescriber specialty, given to opioid-naïve patients and their association with chronic use.

Design: Cross-sectional analysis of the Ohio prescription drug monitoring program from January 2010 to November 2017.

Setting: Ohio, USA.

Subjects: Patients who had no opioid prescriptions from 2010 to 2012 and a first-time prescription from January 2013 to November 2016.

Methods: Chronic use was defined as at least six opioid prescriptions in one year and either one or more years between the first and last prescription or an average of ≤30 days not covered by an opioid during that year.

Results: A total of 4,252,809 opioid-naïve patients received their first opioid prescription between 2013 and 2016; 364,947 (8.6%) met the definition for chronic use. Those who developed chronic use were older (51.7 vs 45.6 years) and more likely to be female (53.6% vs 52.8%), and their first prescription had higher pill quantities (44.9 vs 30.2), higher morphine milligram equivalents (MME; 355.3 vs 200.0), and was more likely to be an extended-release formulation (2.9% vs 0.7%, all P < 0.001). When compared with internal medicine, the adjusted odds of chronic use were highest with anesthesiology (odds ratio [OR] = 1.46) and neurology (OR = 1.43) and lowest with ophthalmology (OR = 0.33) and gynecology (OR = 0.37).

Conclusions: Eight point six percent of opioid-naïve individuals who received an opioid prescription developed chronic use. This rate varied depending on the specialty of the provider who wrote the prescription. The risk of chronic use increased with higher MME content of the initial prescription and use of extended-release opioids.
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December 2020

Association Between Emergency Physician Length of Stay Rankings and Patient Characteristics.

Acad Emerg Med 2020 10 17;27(10):1002-1012. Epub 2020 Jul 17.

From the, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.

Objective: Emergency physicians are commonly compared by their patients' length of stay (LOS). We test the hypothesis that LOS is associated with patient characteristics and that accounting for these features impacts physician LOS rankings.

Methods: This was a retrospective observational study of all encounters at an emergency department in 2010 to 2015. We compared the characteristics of patients seen by physicians in different quartiles of LOS. Primary outcome was variation in patient characteristics at time of physician assignment (age, sex, comorbidities, Emergency Severity Index [ESI], and chief complaint) across LOS quartiles. We also quantified the change in LOS rankings after accounting for difference in characteristics of patients seen by different physicians.

Results: A total of 264,776 encounters seen by 62 attending physicians met inclusion criteria. Physicians in the longest LOS quartile saw patients who were older (age = 49.1 vs 48.6 years, difference = +0.5 years, 95% confidence interval [CI] = 0.3 to 0.7) with more comorbidities (Gagne score = 1.3 vs. 0.9, difference = +0.4, 95% CI = 0.4 to 0.4) and higher acuity (ESI = 2.8 vs. 2.9, difference = -0.1, 95% CI = 0.1 to 0.1) than physicians in the shortest LOS quartile. The odds ratio (OR) of physicians in the longest LOS quartile seeing patients over age 50 compared to the shortest LOS quartile was 1.1 (95% CI = 1.0 to 1.1); the OR of physicians in the longest LOS quartile seeing patients with ESI of 1 or 2 was also 1.1 (95% CI = 1.0 to 1.1). Accounting for variation in patient characteristics seen by different physicians resulted in substantial reordering of physician LOS rankings: 62.9% (39/62) of physicians reclassified into a different quartile with mean absolute percentile change of 25.8 (95% CI = 20.3 to 31.3). A total of 62.5% (10/16) of physicians in the shortest LOS quartile and 56.3% (9/16) in the longest LOS quartile moved into a different quartile after accounting for variation in patient characteristics.

Conclusions: Length of stay was significantly associated with patient characteristics, and accounting for variation in patient characteristics resulted in substantial reordering of relative physician rankings by LOS. Comparisons of emergency physicians by LOS that do not account for patient characteristics should be reconsidered.
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October 2020

Association of Clinical Characteristics With Variation in Emergency Physician Preferences for Patients.

JAMA Netw Open 2020 01 3;3(1):e1919607. Epub 2020 Jan 3.

Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Importance: Much of the wide variation in health care has been associated with practice variation among physicians. Physicians choosing to see patients with more (or fewer) care needs could also produce variations in care observed across physicians.

Objective: To quantify emergency physician preferences by measuring nonrandom variations in patients they choose to see.

Design, Setting, And Participants: This cross-sectional study used a large, detailed clinical data set from an electronic health record system of a single academic hospital. The data set included all emergency department (ED) encounters of adult patients from January 1, 2010, to May 31, 2015, as well as ED visits information. Data were analyzed from September 1, 2018, to March 31, 2019.

Exposure: Patient assignment to a particular emergency physician.

Main Outcomes And Measures: Variation in patient characteristics (age, sex, acuity [Emergency Severity Index score], and comorbidities) seen by emergency physicians before patient selection, adjusted for temporal factors (seasonal, weekly, and hourly variation in patient mix).

Results: This study analyzed 294 915 visits to the ED seen by 62 attending physicians. Of the 294 915 patients seen, the mean (SD) age was 48.6 (19.8) years and 176 690 patients (59.9%) were women. Many patient characteristics, such as age (F = 2.2; P < .001), comorbidities (F = 1.7; P < .001), and acuity (F = 4.7; P < .001), varied statistically significantly. Compared with the lowest-quintile physicians for each respective characteristic, the highest-quintile physicians saw patients who were older (mean age, 47.9 [95% CI, 47.8-48.1] vs 49.7 [95% CI, 49.5-49.9] years, respectively; difference, +1.8 years; 95% CI, 1.5-2.0 years) and sicker (mean comorbidity score: 0.4 [95% CI, 0.3-0.5] vs 1.8 [95% CI, 1.7-1.8], respectively; difference, +1.3; 95% CI, 1.2-1.4). These differences were absent or highly attenuated during overnight shifts, when only 1 physician was on duty and there was limited room for patient selection. Compared with earlier in the shift, the same physician later in the shift saw patients who were younger (mean age, 49.7 [95% CI, 49.4-49.7] vs 44.6 [95 % CI, 44.3-44.9] years, respectively; difference, -5.1 years; 95% CI, 4.8-5.5) and less sick (mean comorbidity score: 0.7 [95% CI, 0.7-0.8] vs 1.1 [95% CI, 1.1-1.1], respectively; difference, -0.4; 95% CI, 0.4-0.4). Accounting for preference variation resulted in substantial reordering of physician ranking by care intensity, as measured by ED charges, with 48 of 62 physicians (77%) being reclassified into a different quintile and 9 of 12 physicians (75%) in the highest care intensity quintile moving into a lower quintile. A regression model demonstrated that 22% of reported ED charges were associated with physician preference.

Conclusions And Relevance: This study found preference variation across physicians and within physicians during the course of a shift. These findings suggest that current efforts to reduce practice variation may not affect the variation associated with physician preferences, which reflect underlying differences in patient needs and not physician practice.
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January 2020

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

Circ Heart Fail 2019 11 29;12(11):e006214. Epub 2019 Oct 29.

Division of Cardiovascular Medicine, and Department of Medicine (E.F..L.), Brigham and Women's Hospital, Boston, MA.

Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
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November 2019

Developing metrics for emergency care research in low- and middle-income countries.

Afr J Emerg Med 2016 Sep 12;6(3):116-124. Epub 2016 Aug 12.

Department of Emergency Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.

Introduction: There is little research on emergency care delivery in low- and middle-income countries (LMICs). To facilitate future research, we aimed to assess the set of key metrics currently used by researchers in these settings and to propose a set of standard metrics to facilitate future research.

Methods: Systematic literature review of 43,109 published reports on general emergency care from 139 LMICs. Studies describing care for subsets of emergency conditions, subsets of populations, and data aggregated across multiple facilities were excluded. All facility- and patient-level statistics reported in these studies were recorded and the most commonly used metrics were identified.

Results: We identified 195 studies on emergency care delivery in LMICs. There was little uniformity in either patient- or facility-level metrics reported. Patient demographics were inconsistently reported: only 33% noted average age and 63% the gender breakdown. The upper age boundary used for paediatric data varied widely, from 5 to 20 years of age. Emergency centre capacity was reported using a variety of metrics including annual patient volume ( = 175, 90%); bed count ( = 60, 31%), number of rooms ( = 48, 25%); frequently none of these metrics were reported ( = 16, 8%). Many characteristics essential to describe capabilities and performance of emergency care were not reported, including use and type of triage; level of provider training; admission rate; time to evaluation; and length of EC stay.

Conclusion: We found considerable heterogeneity in reporting practices for studies of emergency care in LMICs. Standardised metrics could facilitate future analysis and interpretation of such studies, and expand the ability to generalise and compare findings across emergency care settings.
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September 2016

Burden of emergency conditions and emergency care usage: new estimates from 40 countries.

Emerg Med J 2016 Nov 22;33(11):794-800. Epub 2016 Jun 22.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: To estimate the global and national burden of emergency conditions, and compare them to emergency care usage rates.

Methods: We coded all 291 Global Burden of Disease 2010 conditions into three categories to estimate emergency burden: conditions that, if not addressed within hours to days of onset, commonly lead to serious disability or death; conditions with common acute decompensations that lead to serious disability or death; and non-emergencies. Emergency care usage rates were obtained from a systematic literature review on emergency care facilities in low-income and middle-income countries (LMICs), supplemented by national health system reports.

Findings: All 15 leading causes of death and disability-adjusted life years (DALYs) globally were conditions with potential emergent manifestations. We identified 41 facility-based reports in 23 countries, 12 of which were in LMICs; data for 17 additional countries were obtained from national or regional reports on emergency usage. Burden of emergency conditions was the highest in low-income countries, with median DALYs of 47 728 per 100 000 population (IQR 45 253-50 085) in low-income, 25 186 (IQR 21 982-40 480) in middle-income and 15 691 (IQR 14 649-16 382) in high-income countries. Patterns were similar using deaths to measure burden and excluding acute decompensations from the definition of emergency conditions. Conversely, emergency usage rates were the lowest in low-income countries, with median 8 visits per 1000 population (IQR 6-10), 78 (IQR 25-197) in middle-income and 264 (IQR 177-341) in high-income countries.

Conclusions: Despite higher burden of emergency conditions, emergency usage rates are substantially lower in LMICs, likely due to limited access to emergency care.
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November 2016

Children successfully treated for moderate acute malnutrition remain at risk for malnutrition and death in the subsequent year after recovery.

J Nutr 2013 Feb 19;143(2):215-20. Epub 2012 Dec 19.

Department of Pediatrics, Washington University, St. Louis, MO, USA.

Moderate acute malnutrition (MAM) affects 11% of children <5 y old worldwide and increases their risk for morbidity and mortality. It is assumed that successful treatment of MAM reduces these risks. A total of 1967 children aged 6-59 mo successfully treated for MAM in rural Malawi following randomized treatment with corn-soy blend plus milk and oil (CSB++), soy ready-to-use supplementary food (RUSF), or soy/whey RUSF were followed for 12 mo. The initial supplementary food was given until the child reached a weight-for-height Z-score (WHZ) >-2. The median duration of feeding was 2 wk, with a maximum of 12 wk. The hypothesis tested was that children treated with either RUSF would be more likely to remain well-nourished than those treated with CSB++. The primary outcome, remaining well-nourished, was defined as mid-upper arm circumference ≥12.5 cm or WHZ ≥-2 for the entire duration of follow-up. During the 12-mo follow-up period, only 1230 (63%) children remained well-nourished, 334 (17%) relapsed to MAM, 190 (10%) developed severe acute malnutrition, 74 (4%) died, and 139 (7%) were lost to follow-up. Children who were treated with soy/whey RUSF were more likely to remain well-nourished (67%) than those treated with CSB++ (62%) or soy RUSF (59%) (P = 0.01). A seasonal pattern of food insecurity and adverse clinical outcomes was observed. This study demonstrates that children successfully treated for MAM with soy/whey RUSF are more likely to remain well-nourished; however, all children successfully treated for MAM remain vulnerable.
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February 2013

Densely interconnected transcriptional circuits control cell states in human hematopoiesis.

Cell 2011 Jan;144(2):296-309

Broad Institute, Cambridge, MA 02142, USA.

Though many individual transcription factors are known to regulate hematopoietic differentiation, major aspects of the global architecture of hematopoiesis remain unknown. Here, we profiled gene expression in 38 distinct purified populations of human hematopoietic cells and used probabilistic models of gene expression and analysis of cis-elements in gene promoters to decipher the general organization of their regulatory circuitry. We identified modules of highly coexpressed genes, some of which are restricted to a single lineage but most of which are expressed at variable levels across multiple lineages. We found densely interconnected cis-regulatory circuits and a large number of transcription factors that are differentially expressed across hematopoietic states. These findings suggest a more complex regulatory system for hematopoiesis than previously assumed.
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January 2011

Chemical genetic strategy identifies histone deacetylase 1 (HDAC1) and HDAC2 as therapeutic targets in sickle cell disease.

Proc Natl Acad Sci U S A 2010 Jul 28;107(28):12617-22. Epub 2010 Jun 28.

Broad Institute of Harvard and Massachusetts Institute Technology, Cambridge, MA 02142, USA.

The worldwide burden of sickle cell disease is enormous, with over 200,000 infants born with the disease each year in Africa alone. Induction of fetal hemoglobin is a validated strategy to improve symptoms and complications of this disease. The development of targeted therapies has been limited by the absence of discrete druggable targets. We developed a unique bead-based strategy for the identification of inducers of fetal hemoglobin transcripts in primary human erythroid cells. A small-molecule screen of bioactive compounds identified remarkable class-associated activity among histone deacetylase (HDAC) inhibitors. Using a chemical genetic strategy combining focused libraries of biased chemical probes and reverse genetics by RNA interference, we have identified HDAC1 and HDAC2 as molecular targets mediating fetal hemoglobin induction. Our findings suggest the potential of isoform-selective inhibitors of HDAC1 and HDAC2 for the treatment of sickle cell disease.
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July 2010

Identification of RPS14 as a 5q- syndrome gene by RNA interference screen.

Nature 2008 Jan;451(7176):335-9

Broad Institute of MIT and Harvard, Cambridge, Massachusetts 02142, USA.

Somatic chromosomal deletions in cancer are thought to indicate the location of tumour suppressor genes, by which a complete loss of gene function occurs through biallelic deletion, point mutation or epigenetic silencing, thus fulfilling Knudson's two-hit hypothesis. In many recurrent deletions, however, such biallelic inactivation has not been found. One prominent example is the 5q- syndrome, a subtype of myelodysplastic syndrome characterized by a defect in erythroid differentiation. Here we describe an RNA-mediated interference (RNAi)-based approach to discovery of the 5q- disease gene. We found that partial loss of function of the ribosomal subunit protein RPS14 phenocopies the disease in normal haematopoietic progenitor cells, and also that forced expression of RPS14 rescues the disease phenotype in patient-derived bone marrow cells. In addition, we identified a block in the processing of pre-ribosomal RNA in RPS14-deficient cells that is functionally equivalent to the defect in Diamond-Blackfan anaemia, linking the molecular pathophysiology of the 5q- syndrome to a congenital syndrome causing bone marrow failure. These results indicate that the 5q- syndrome is caused by a defect in ribosomal protein function and suggest that RNAi screening is an effective strategy for identifying causal haploinsufficiency disease genes.
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January 2008

Cytologic features and diagnostic pitfalls of primary ampullary tumors by endoscopic ultrasound-guided fine-needle aspiration biopsy.

Cancer 2005 Oct;105(5):289-97

Department of Pathology, University of California Irvine Medical Center, Orange, California 92868, USA.

Background: Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-guided FNAB) is highly sensitive and specific in cytologic diagnosis and clinical staging of malignant neoplasms of the gastrointestinal tract, pancreas, liver, and lymph nodes. However, no study has been performed to evaluate its accuracy, sensitivity, specificity, and the cytomorphologic features of suspected primary ampullary tumors.

Methods: All EUS-guided FNABs of suspected primary ampullary lesions at the University of California Irvine Medical Center (Orange, CA) from January 1998 to September 2004 were retrospectively retrieved. The number of passes necessary to arrive at a preliminary diagnosis during adequacy assessment was documented. The cytologic features were analyzed with endosonographic correlation. Follow-up information was also collected.

Results: Thirty-five patients were found, 17 men and 18 women. The mean age of the patients was 68.9 years (range, 34-87 yrs). Adenocarcinoma was diagnosed in 13 patients. Atypical cells were found in six patients, four of which were suspicious for adenocarcinoma and two of which were consistent with reactive atypia. Adenoma was diagnosed in two patients and carcinoid tumor in one. Thirteen patients had a diagnosis that was negative for malignant cells. The average number of aspiration passes was 2.4 (range, 1-6 passes). Follow-up information was available in 27 patients. There were three false-negative results and no false-positive results. The sensitivity, specificity, and the positive and the negative predictive values were 82.4%, 100%, 100%, and 76.9%, respectively. The diagnostic accuracy was 88.8%. The consistent cytologic features in specimens that were positive or suspicious for adenocarcinoma included high cellularity, single cells, 3-dimensional cell balls, high nuclear-to-cytoplasmic ratio, prominent nucleoli, coarse/uneven distribution of chromatin, and necrosis.

Conclusions: EUS-guided FNAB was accurate, sensitive, and specific in the assessment of suspected primary ampullary masses. Adenoma presented a diagnostic challenge and endosonographic correlation was instrumental to increase the diagnostic accuracy.
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October 2005