Publications by authors named "David C Kaelber"

74 Publications

Risk of Herpes Zoster Reactivation After mRNA COVID-19 Vaccination: A Cohort Study.

J Am Acad Dermatol 2021 Nov 23. Epub 2021 Nov 23.

Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California, USA.

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http://dx.doi.org/10.1016/j.jaad.2021.11.025DOI Listing
November 2021

Sex differences in type 2 diabetes mellitus prevalence among persons with HIV: a cross-sectional analysis.

AIDS 2021 Nov 8. Epub 2021 Nov 8.

Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California, USA Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio, USA San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.

Objective: To examine whether type 2 diabetes mellitus (T2DM) is more common among women with HIV (WWH) than men with HIV (MWH).

Design: A cross-sectional analysis of a demographically heterogenous population-based sample of more than 64 million patients in the United States.

Methods: Using the Explorys (IBM) database, compare the prevalence of T2DM among men and women without HIV and influence of HIV on T2DM by sex controlling for confounding factors.

Results: From 19,182,775 persons included in the study, 39,485 were with HIV. Rates of obesity was higher among WWH than MWH (58% vs 35%). Prevalence of T2DM among WWH was 23% compared with 16% among MWH (p < 0.001). In sex-stratified adjusted analysis, WWH had 1.31 (95% confidence interval [CI], 1.24-1.38) times the odds of having T2DM than women without HIV. Women with HIV was associated with T2DM across all demographic subgroups. In contrast, no association between HIV and T2DM was observed among men (OR 1.01; 95% CI 0.98-1.05).

Conclusion: These data suggest that HIV confers a sex-specific increase in odds of T2DM among women, but not men.
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http://dx.doi.org/10.1097/QAD.0000000000003127DOI Listing
November 2021

Irritable bowel syndrome is strongly associated with the primary and idiopathic mast cell disorders.

Neurogastroenterol Motil 2021 Sep 17:e14265. Epub 2021 Sep 17.

University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.

Background: Mounting evidence supports a mechanistic association between irritable bowel syndrome (IBS) symptoms and mast cell hyperactivity. Yet, association between IBS and mast cell disorders (MCDs) has not been studied. We examined this association using two large databases and verified with manual chart review.

Methods: The IBM Watson Health Explorys database (Somers, NY), an aggregate of electronic health record (EHR) data from over two dozen US healthcare systems, and Epic's SlicerDicer tool, a self-service tool containing de-identified data from the Epic EHR, were used to identify patients with IBS and MCDs. Patients with organic gastrointestinal disease or diseases associated with secondary mast cell hyperproliferation were excluded. Results were verified with manual chart review from two academic centers.

Key Results: Up to 4% of IBS patients had a comorbid MCD. IBS was strongly associated with all MCDs. The strongest association was between IBS and mast cell activation syndrome (OR 16.3; 95% CI 13.1-20.3). Odds ratios for IBS+urticaria, IBS+idiopathic urticaria, IBS+non-malignant mastocytosis, and IBS+mast cell malignancy ranged from 4.5 to 9.9. Patients from each of these overlap cohorts were predominantly female, and the overlap occurred with all IBS subtypes. Thorough endoscopic evaluation and comorbid mood disorders and migraines are more common in the overlap cohorts than in IBS alone.

Conclusions/inferences: In a large US database encompassing >53 million patients over >20 years, patients with IBS are at least 4 times more likely to have a MCD than the general population. Further study of mast cell involvement in the pathogenesis of IBS is warranted.
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http://dx.doi.org/10.1111/nmo.14265DOI Listing
September 2021

Improving Timeliness of Antibiotic Administration Using a Provider and Pharmacist Facing Sepsis Early Warning System in the Emergency Department Setting: A Randomized Controlled Quality Improvement Initiative.

Crit Care Med 2021 Aug 20. Epub 2021 Aug 20.

Division of Pulmonary and Critical Care Medicine, MetroHealth Medical Center, Cleveland, OH. Center for Clinical Informatics Research and Education, MetroHealth Medical Center, Cleveland, OH. School of Medicine, Case Western Reserve University, Cleveland, OH. Division of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH. Department of Pharmacy, MetroHealth Medical Center, Cleveland, OH. Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH. Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH. Division of Medicine, MetroHealth Medical Center, Cleveland, OH. Division of Infectious Disease, MetroHealth Medical Center, Cleveland, OH.

Objectives: Results of pre-post intervention studies of sepsis early warning systems have been mixed, and randomized clinical trials showing efficacy in the emergency department setting are lacking. Additionally, early warning systems can be resource-intensive and may cause unintended consequences such as antibiotic or IV fluid overuse. We assessed the impact of a pharmacist and provider facing sepsis early warning systems on timeliness of antibiotic administration and sepsis-related clinical outcomes in our setting.

Design: A randomized, controlled quality improvement initiative.

Setting: The main emergency department of an academic, safety-net healthcare system from August to December 2019.

Patients: Adults presenting to the emergency department.

Intervention: Patients were randomized to standard sepsis care or standard care augmented by the display of a sepsis early warning system-triggered flag in the electronic health record combined with electronic health record-based emergency department pharmacist notification.

Measurements And Main Results: The primary process measure was time to antibiotic administration from arrival. A total of 598 patients were included in the study over a 5-month period (285 in the intervention group and 313 in the standard care group). Time to antibiotic administration from emergency department arrival was shorter in the augmented care group than that in the standard care group (median, 2.3 hr [interquartile range, 1.4-4.7 hr] vs 3.0 hr [interquartile range, 1.6-5.5 hr]; p = 0.039). The hierarchical composite clinical outcome measure of days alive and out of hospital at 28 days was greater in the augmented care group than that in the standard care group (median, 24.1 vs 22.5 d; p = 0.011). Rates of fluid resuscitation and antibiotic utilization did not differ.

Conclusions: In this single-center randomized quality improvement initiative, the display of an electronic health record-based sepsis early warning system-triggered flag combined with electronic health record-based pharmacist notification was associated with shorter time to antibiotic administration without an increase in undesirable or potentially harmful clinical interventions.
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http://dx.doi.org/10.1097/CCM.0000000000005267DOI Listing
August 2021

The Effect of Electronic Health Record Burden on Pediatricians' Work-Life Balance and Career Satisfaction.

Appl Clin Inform 2021 05 2;12(3):697-707. Epub 2021 Aug 2.

Clinical Informatics Center, UT Southwestern Medical Center, Dallas, Texas, United States.

Objectives: To examine pediatricians' perspectives on administrative tasks including electronic health record (EHR) documentation burden and their effect on work-life balance and life and career satisfaction.

Methods: We analyzed 2018 survey data from the American Academy of Pediatrics (AAP) Pediatrician Life and Career Experience Study (PLACES), a longitudinal cohort study of early and midcareer pediatricians. Cohorts graduated from residency between 2002 and 2004 or 2009 and 2011. Participants were randomly selected from an AAP database (included all pediatricians who completed U.S. pediatric residency programs). Four in 10 pediatricians (1,796 out of 4,677) were enrolled in PLACES in 2012 and considered participants in 2018. Data were weighted to adjust for differences between study participants and the overall population of pediatricians. Chi-square and multivariable logistic regression examined the association of EHR burden on work-life balance (three measures) and satisfaction with work, career, and life (three measures). Responses to an open-ended question on experiences with administrative tasks were reviewed.

Results: A total of 66% of pediatrician participants completed the 2018 surveys (1,192 of 1,796; analytic sample = 1,069). Three-fourths reported EHR documentation as a major or moderate burden. Half reported such burden for billing and insurance and 42.7% for quality and performance measurement. Most pediatricians reported satisfaction with their jobs (86.7%), careers (84.5%), and lives (66.2%). Many reported work-life balance challenges (52.5% reported stress balancing work and personal responsibilities). In multivariable analysis, higher reported EHR burden was associated with lower scores on career and life satisfaction measures and on all three measures of work-life balance. Open-ended responses ( = 467) revealed several themes. Two predominant themes especially supported the quantitative findings-poor EHR functionality and lack of support for administrative burdens.

Conclusion: Most early to midcareer pediatricians experience administrative burdens with EHRs. These experiences are associated with worse work-life balance including more stress in balancing responsibilities and less career and life satisfaction.
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http://dx.doi.org/10.1055/s-0041-1732402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328745PMC
May 2021

Risk of Myocarditis from COVID-19 Infection in People Under Age 20: A Population-Based Analysis.

medRxiv 2021 Jul 27. Epub 2021 Jul 27.

Background: There have been recent reports of myocarditis (including myocarditis, pericarditis or myopericarditis) as a side-effect of mRNA-based COVID-19 vaccines, particularly in young males. Less information is available regarding the risk of myocarditis from COVID-19 infection itself. Such data would be helpful in developing a complete risk-benefit analysis for this population.

Methods: A de-identified, limited data set was created from the TriNetX Research Network, aggregating electronic health records from 48 mostly large U.S. Healthcare Organizations (HCOs). Inclusion criteria were a first COVID-19 diagnosis during the April 1, 2020 - March 31, 2021 time period, with an outpatient visit 1 month to 2 years before, and another 6 months to 2 years before that. Analysis was stratified by sex and age (12-17, 12-15, 16-19). Patients were excluded for any prior cardiovascular condition. Primary outcome was an encounter diagnosis of myocarditis within 90 days following the index date. Rates of COVID-19 cases and myocarditis not identified in the system were estimated and the results adjusted accordingly. Wilson score intervals were used for 95% confidence intervals due to the very low probability outcome.

Results: For the 12-17-year-old male cohort, 6/6,846 (0.09%) patients developed myocarditis overall, with an adjusted rate per million of 876 cases (Wilson score interval 402 - 1,911). For the 12-15 and 16-19 male age groups, the adjusted rates per million were 601 (257 - 1,406) and 561 (240 - 1,313).For 12-17-year-old females, there were 3 (0.04%) cases of myocarditis of 7,361 patients. The adjusted rate was 213 (73 - 627) per million cases. For the 12-15- and 16-19-year-old female cohorts the adjusted rates per million cases were 235 (64 - 857) and 708 (359 - 1,397). The outcomes occurred either within 5 days (40.0%) or from 19-82 days (60.0%).

Conclusions: Myocarditis (or pericarditis or myopericarditis) from primary COVID19 infection occurred at a rate as high as 450 per million in young males. Young males infected with the virus are up 6 times more likely to develop myocarditis as those who have received the vaccine.
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http://dx.doi.org/10.1101/2021.07.23.21260998DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328065PMC
July 2021

Time to integrate oral health screening into medicine? A survey of primary care providers of older adults and an evidence-based rationale for integration.

Gerodontology 2021 May 28. Epub 2021 May 28.

Community Dentistry, Case Western Reserve University School of Dental Medicine, Cleveland, OH, USA.

Objective: Primary care providers were assessed regarding their training and interest to screen oral conditions in patients ≥55 years old.

Background: Oral health (OH) is an essential component of overall health and can affect systemic health. Medical/dental integration in older adults is underdeveloped.

Methods: A brief survey assessed primary care providers' self-reported skills, practices and barriers towards integrating OH screening into adult primary care. Data were collected using Survey Monkey . Respondents were physicians and advanced practice providers (APPs) working at a large mid-western safety-net hospital. Descriptive statistics, T-tests and Chi-squared tests were reported.

Results: Eighty-two of 202 participants (41%) completed the survey. Most respondents were female (75%). A majority were physicians (68%); the remainder APPs. All providers (100%) reported OH was important or extremely important to overall health. More physicians (93%) reported not being well-trained to address adult OH issues and perceived less medical-oral health integration in their practice (16%) compared to APPs (P < .05). Time was more of a barrier with APPs (74%), compared to physicians (51%), to integrate OH screening activities (P < .05). Most providers reported other barriers such as inadequate OH training and insurance coverage. Providers endorsed that OH should be assessed frequently (56%) including providing referrals to dentists (77%) and educating patients on oral-systemic issues (63%). More female than male providers endorsed dental referrals and educating patients (P < .05).

Conclusion: Primary care providers embraced greater medical/dental integration for older adults. Instituting OH activities appears to be supported. Future interventions that are feasible in primary care settings are examined.
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http://dx.doi.org/10.1111/ger.12561DOI Listing
May 2021

Using Large Aggregated De-Identified Electronic Health Record Data to Determine the Prevalence of Common Chronic Diseases in Pediatric Patients Who Visited Primary Care Clinics.

Acad Pediatr 2021 08 19;21(6):1084-1093. Epub 2021 May 19.

Center for Internal Medicine and Pediatrics, Center for Clinical Informatics Research and Education, The MetroHealth System (F Ullah, DC Kaelber), Cleveland, Ohio; Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University (DC Kaelber), Cleveland, Ohio.

Objective: We used de-identified clinical data from multiple health care systems using different electronic health records (EHRs) to 1) quantify the prevalence of common pediatric chronic diseases, 2) investigate patent characteristics associated with common pediatric chronic diseases, and 3) compare the results of our methodology to determine chronic disease prevalence with traditional approaches.

Methods: We used a HIPAA-compliant and de-identified web application (Explorys; IBM Watson Health Explorys Inc.) to identify patients 17 years old or younger from multiple health care systems in the US who were seen in primary care clinics between 2016-2018 to determine the most common chronic conditions in this age group. The prevalence of chronic conditions was compared between different age groups, genders, races/ethnicities, and insurance; odds ratios and confidence intervals were calculated and reported.

Results: The top 6 chronic conditions identified by prevalence were: obesity/overweight (36.7%), eczema (15.8%), asthma (12.7%), food allergies (4.7%), attention deficit-hyperactivity disorder (4.09%) and hypertension (4.07%). Chronic conditions were generally more prevalent among relatively older pediatric patients, males, and African-American and multiracial groups.

Conclusions: Approximately 40% of children and adolescents have at least one chronic disease. Obesity/overweight, eczema, and asthma are the most common chronic diseases of childhood, in the US, among those seeking care in health care systems with EHRs. The work compiled herein demonstrates that aggregated, standardized, normalized and de-identified population-level EHR data can provide both sufficient insight and statistical power to calculate the prevalence of chronic diseases and the odds ratio of various risk factors.
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http://dx.doi.org/10.1016/j.acap.2021.05.007DOI Listing
August 2021

The effects of substance use on severe acute respiratory syndrome coronavirus infection risks and outcomes.

Curr Opin Psychiatry 2021 07;34(4):386-392

Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, and the Center for Clinical Informatics Research and Education, Case Western Reserve University/The MetroHealth System, Cleveland, Ohio, USA.

Purpose Of Review: Severe acute respiratory syndrome coronavirus (SARS-CoV2) infection rates are currently occurring at alarmingly accelerated rates. There is also a long-standing and concurrent rise in the prevalence and severity of substance use disorders (SUD). Therefore, the intersection between these two conditions needs to be carefully considered to ensure a more effective delivery of healthcare.

Recent Findings: Generally, those with SUDs are more likely to have higher risk social determinants of health factors. Therefore, these patients are more likely to have barriers that can create difficulties in following appropriate infection control measures which in turn increases the risk of exposure to SARS-CoV2. In addition, these individuals have higher rates of medical comorbidities which increases the risk of all adverse outcomes, including mortality, from SARS-CoV2 infection.

Summary: Individuals with SUDs are at increased risk of both contracting SARS-CoV2 infection and suffering from worse outcomes afterwards. Though these risks of adverse outcomes are specific of SARS-CoV2 infection, the risk of exposure to other infectious diseases is increased in this population too. Healthcare providers and policymakers should then consider how to better protect this at-risk population and alleviate this increased disease burden.
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http://dx.doi.org/10.1097/YCO.0000000000000711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183241PMC
July 2021

A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support.

BMC Fam Pract 2021 05 4;22(1):85. Epub 2021 May 4.

Population Health Research Institute, MetroHealth System, OH, Cleveland, USA.

Introduction: This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP training in a health system that implemented an Ask-Advise-Connect (AAC) systems-based approach.

Methods: A stepped wedge cluster randomized trial included eight community health centers. Training involved a web module and onsite skill development with standardized patients and coaching. Main outcome measures included contact and enrollment in cessation services among patients referred for counseling, prescription of cessation medications and quit attempts.

Results: Forty-four of 60 eligible clinicians received the TMCP training. Among TMCP-trained clinicians 68% used a TMCP approach (documented by flowsheet use) one or more times, with the median number of uses being 15 (IQR 2-33). Overall, the TMCP was used in 661 out of 8198 visits by smokers (8%). There was no improvement in any of the tobacco cessation assistance outcomes for the AAC + TMCP vs. the AAC only period. Visits where clinicians used the TMCP approach were associated with increased ordering of tobacco cessation medications, (OR = 2.6; 95% CI = 1.9, 3.5) and providing advice to quit OR 3.2 (95% CI 2.2, 4.7).

Conclusions: Despite high fidelity to the training, uptake of the TMCP approach in routine practice was poor, making it difficult to evaluate the impact on patient outcomes. When the TMCP approach was used, ordering tobacco cessation medications increased.

Implications: Tobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient. The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach.

Trial Registration: clinicaltrials.gov #NCT02764385 , registration date 06/05/2016.
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http://dx.doi.org/10.1186/s12875-021-01423-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097804PMC
May 2021

Drug Alert Experience and Salience during Medical Residency at Two Healthcare Institutions.

Appl Clin Inform 2021 03 28;12(2):355-361. Epub 2021 Apr 28.

Department of Pediatrics, MetroHealth System, Case Western Reserve University, Cleveland, Ohio, United States.

Background: Drug alerts are clinical decision support tools intended to prevent medication misadministration. In teaching hospitals, residents encounter the majority of the drug alerts while learning under variable workloads and responsibilities that may have an impact on drug-alert response rates.

Objectives: This study was aimed to explore drug-alert experience and salience among postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2), and postgraduate year 3 (PGY-3) internal medicine resident physicians at two different institutions.

Methods: Drug-alert information was queried from the electronic health record (EHR) for 47 internal medicine residents at the University of Pennsylvania Medical Center (UPMC) Pinnacle in Pennsylvania, and 79 internal medicine residents at the MetroHealth System (MHS) in Ohio from December 2018 through February 2019. Salience was defined as the percentage of drug alerts resulting in removal or modification of the triggering order. Comparisons were made across institutions, residency training year, and alert burden.

Results: A total of 126 residents were exposed to 52,624 alerts over a 3-month period. UPMC Pinnacle had 15,574 alerts with 47 residents and MHS had 37,050 alerts with 79 residents. At MHS, salience was 8.6% which was lower than UPMC Pinnacle with 15%. The relatively lower salience (42% lower) at MHS corresponded to a greater number of alerts-per-resident (41% higher) compared with UPMC Pinnacle. Overall, salience was 11.6% for PGY-1, 10.5% for PGY-2, and 8.9% for PGY-3 residents.

Conclusion: Our results are suggestive of long-term drug-alert desensitization during progressive residency training. A higher number of alerts-per-resident correlating with a lower salience suggests alert fatigue; however, other factors should also be considered including differences in workload and culture.
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http://dx.doi.org/10.1055/s-0041-1729167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081588PMC
March 2021

Bone Mineral Density Screening Among People With HIV: A Population-Based Analysis in the United States.

Open Forum Infect Dis 2021 Mar 18;8(3):ofab081. Epub 2021 Feb 18.

Department of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California, USA.

HIV infection is associated with premature bone loss. The potential impact of recently updated osteoporosis screening guidelines is unknown. In a population-based cohort, we found low adherence and sex differences among eligible people with HIV.
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http://dx.doi.org/10.1093/ofid/ofab081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990062PMC
March 2021

A randomized, open-label, pragmatic study to assess reliever-triggered inhaled corticosteroid in African American/Black and Hispanic/Latinx adults with asthma: Design and methods of the PREPARE trial.

Contemp Clin Trials 2021 02 11;101:106246. Epub 2020 Dec 11.

Division of Critical Care/Pulmonary, Baystate Health, Tolosky Center, 3300 Main Street, Suite 2B, Springfield, MA, United States of America. Electronic address:

Background: Asthma prevalence, morbidity, and mortality disproportionately impact African American/Black (AA/B) and Hispanic/Latinx (H/L) communities. Adherence to daily inhaled corticosteroid (ICS), recommended by asthma guidelines in all but the mildest cases of asthma, is generally poor. As-needed ICS has shown promise as a patient-empowering asthma management strategy, but it has not been rigorously studied in AA/B or H/L patients or in a real-world setting. Design and Aim The PeRson EmPowered Asthma RElief (PREPARE) Study is a randomized, open-label, pragmatic study which aims to assess whether a patient-guided, reliever-triggered ICS strategy called PARTICS (Patient-Activated Reliever-Triggered Inhaled CorticoSteroid) can improve asthma outcomes in AA/B and H/L adult patient populations. In designing and implementing the study, the PREPARE research team has relied heavily on advice from AA/B and H/L Patient Partners and other stakeholders. Methods PREPARE is enrolling 1200 adult participants (600 AA/Bs, 600H/Ls) with asthma. Participants are randomized to PARTICS + Usual Care (intervention) versus Usual Care (control). Following a single in-person enrollment visit, participants complete monthly questionnaires for 15 months. The primary endpoint is annualized asthma exacerbation rate. Secondary endpoints include asthma control; preference-based quality of life; and days lost from work, school, or usual activities. Discussion The PREPARE study features a pragmatic design allowing for the real-world assessment of a patient-centered, reliever-triggered ICS strategy in AA/B and H/L patients. Outcomes of this study have the potential to offer powerful evidence supporting PARTICS as an effective asthma management strategy in patient populations that suffer disproportionately from asthma morbidity and mortality.
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http://dx.doi.org/10.1016/j.cct.2020.106246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130188PMC
February 2021

Assessing Different Approaches to Leveraging Historical Smoking Exposure Data to Better Select Lung Cancer Screening Candidates: A Retrospective Validation Study.

Nicotine Tob Res 2021 08;23(8):1334-1340

Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH.

Introduction: There is mounting interest in the use of risk prediction models to guide lung cancer screening. Electronic health records (EHRs) could facilitate such an approach, but smoking exposure documentation is notoriously inaccurate. While the negative impact of inaccurate EHR data on screening practices reliant on dichotomized age and smoking exposure-based criteria has been demonstrated, less is known regarding its impact on the performance of model-based screening.

Aims And Methods: Data were collected from a cohort of 37 422 ever-smokers between the ages of 55 and 74, seen at an academic safety-net healthcare system between 1999 and 2018. The National Lung Cancer Screening Trial (NLST) criteria, PLCOM2012 and LCRAT lung cancer risk prediction models were validated against time to lung cancer diagnosis. Discrimination (area under the receiver operator curve [AUC]) and calibration were assessed. The effect of substituting the last documented smoking variables with differentially retrieved "history conscious" measures was also determined.

Results: The PLCOM2012 and LCRAT models had AUCs of 0.71 (95% CI, 0.69 to 0.73) and 0.72 (95% CI, 0.70 to 0.74), respectively. Compared with the NLST criteria, PLCOM2012 had a significantly greater time-dependent sensitivity (69.9% vs. 64.5%, p < .01) and specificity (58.3% vs. 56.4%, p < .001). Unlike the NLST criteria, the performances of the PLCOM2012 and LCRAT models were not prone to historical variability in smoking exposure documentation.

Conclusions: Despite the inaccuracies of EHR-documented smoking histories, leveraging model-based lung cancer risk estimation may be a reasonable strategy for screening, and is of greater value compared with using NLST criteria in the same setting.

Implications: EHRs are potentially well suited to aid in the risk-based selection of lung cancer screening candidates, but healthcare providers and systems may elect not to leverage EHR data due to prior work that has shown limitations in structured smoking exposure data quality. Our findings suggest that despite potential inaccuracies in the underlying EHR data, screening approaches that use multivariable models may perform significantly better than approaches that rely on simpler age and exposure-based criteria. These results should encourage providers to consider using pre-existing smoking exposure data with a model-based approach to guide lung cancer screening practices.
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http://dx.doi.org/10.1093/ntr/ntaa192DOI Listing
August 2021

Colorectal Cancer, Age, and Obesity-Related Comorbidities: A Large Database Study.

Dig Dis Sci 2021 09 21;66(9):3156-3163. Epub 2020 Sep 21.

Division of Gastroenterology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Wearn 244, Cleveland, OH, 44106-5066, USA.

Background And Aims: The association between obesity and colorectal cancer (CRC) is well established in older individuals, but evidence is limited in the younger population. The study aims to analyze the relationship of obesity and its related comorbidities in early-onset CRC (E-CRC) and compare it to late-onset CRC (L-CRC).

Methods: A retrospective, cross-sectional study was performed on average-risk individuals ≥ 20 years who were active patients in the commercial database, IBM Watson Health Explorys in the last 5 years. Individuals with CRC were compared to those without CRC across different age groups (20-39, 40-49, and 50-74 years). Individuals with CRC diagnosed < 50 years (E-CRC) were compared to those with CRC between 50 and 74 years (L-CRC). Variables included sex, smoking, obese BMI, diabetes mellitus type 2 (DM2), hypertension (HTN), and hyperlipidemia (HLD). Since Explorys aggregates population-level, de-identified data, approval from institutional review board was not required.

Results: Among 37,483,140 individuals, 162,150 cases of sporadic CRC were identified. Compared to the general population, obesity and HLD were independent risk factors for CRC across all age groups; DM2, HTN, and smoking were independent risk factors for CRC in men of all age groups and women with L-CRC. Compared to L-CRC, individuals with E-CRC had lower percentages of obesity-related comorbidities.

Conclusion: In E-CRC, obesity, DM2, HTN, HLD, and smoking are independent risk factors for CRC among men; obesity and HLD are independent risk factors for CRC in women. These subgroups may benefit from a personalized screening approach to detect early-onset CRC.
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http://dx.doi.org/10.1007/s10620-020-06602-xDOI Listing
September 2021

Persistent Hypertension in Children and Adolescents: A 6-Year Cohort Study.

Pediatrics 2020 10 18;146(4). Epub 2020 Sep 18.

Comparative Effectiveness Research through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois.

Objectives: To determine the natural history of pediatric hypertension.

Methods: We conducted a 72-month retrospective cohort study among 165 primary care sites. Blood pressure measurements from two consecutive 36 month periods were compared.

Results: Among 398 079 primary care pediatric patients ages 3 to 18, 89 347 had ≥3 blood pressure levels recorded during a 36-month period, and 43 825 children had ≥3 blood pressure levels for 2 consecutive 36-month periods. Among these 43 825 children, 4.3% (1881) met criteria for hypertension (3.5% [1515] stage 1, 0.8% [366] stage 2) and 4.9% (2144) met criteria for elevated blood pressure in the first 36 months. During the second 36 months, 50% (933) of hypertensive patients had no abnormal blood pressure levels, 22% (406) had elevated blood pressure levels or <3 hypertensive blood pressure levels, and 29% (542) had ≥3 hypertensive blood pressure levels. Of 2144 patients with elevated blood pressure in the first 36 months, 70% (1492) had no abnormal blood pressure levels, 18% (378) had persistent elevated blood pressure levels, and 13% (274) developed hypertension in the second 36-months. Among the 7775 patients with abnormal blood pressure levels in the first 36-months, only 52% (4025) had ≥3 blood pressure levels recorded during the second 36-months.

Conclusions: In a primary care cohort, most children initially meeting criteria for hypertension or elevated blood pressure had subsequent normal blood pressure levels or did not receive recommended follow-up measurements. These results highlight the need for more nuanced initial blood pressure assessment and systems to promote follow-up of abnormal results.
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http://dx.doi.org/10.1542/peds.2019-3778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786824PMC
October 2020

COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States.

Mol Psychiatry 2021 01 14;26(1):30-39. Epub 2020 Sep 14.

National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA.

The global pandemic of COVID-19 is colliding with the epidemic of opioid use disorders (OUD) and other substance use disorders (SUD) in the United States (US). Currently, there is limited data on risks, disparity, and outcomes for COVID-19 in individuals suffering from SUD. This is a retrospective case-control study of electronic health records (EHRs) data of 73,099,850 unique patients, of whom 12,030 had a diagnosis of COVID-19. Patients with a recent diagnosis of SUD (within past year) were at significantly increased risk for COVID-19 (adjusted odds ratio or AOR = 8.699 [8.411-8.997], P < 10), an effect that was strongest for individuals with OUD (AOR = 10.244 [9.107-11.524], P < 10), followed by individuals with tobacco use disorder (TUD) (AOR = 8.222 ([7.925-8.530], P < 10). Compared to patients without SUD, patients with SUD had significantly higher prevalence of chronic kidney, liver, lung diseases, cardiovascular diseases, type 2 diabetes, obesity and cancer. Among patients with recent diagnosis of SUD, African Americans had significantly higher risk of COVID-19 than Caucasians (AOR = 2.173 [2.01-2.349], P < 10), with strongest effect for OUD (AOR = 4.162 [3.13-5.533], P < 10). COVID-19 patients with SUD had significantly worse outcomes (death: 9.6%, hospitalization: 41.0%) than general COVID-19 patients (death: 6.6%, hospitalization: 30.1%) and African Americans with COVID-19 and SUD had worse outcomes (death: 13.0%, hospitalization: 50.7%) than Caucasians (death: 8.6%, hospitalization: 35.2%). These findings identify individuals with SUD, especially individuals with OUD and African Americans, as having increased risk for COVID-19 and its adverse outcomes, highlighting the need to screen and treat individuals with SUD as part of the strategy to control the pandemic while ensuring no disparities in access to healthcare support.
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http://dx.doi.org/10.1038/s41380-020-00880-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488216PMC
January 2021

Disparities in Colorectal Cancer Screening Practices in a Midwest Urban Safety-Net Healthcare System.

Dig Dis Sci 2021 08 20;66(8):2585-2594. Epub 2020 Aug 20.

MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.

Aims: Although colorectal cancer screening (CRC) using stool-based test is well-studied, evidence on fecal immunochemical test (FIT) patterns in a safety-net healthcare system utilizing opportunistic screening is limited. We studied the FIT completion rates and adenoma detection rate (ADR) of positive FIT-colonoscopy (FIT-C) in an urban safety-net system.

Methods: We performed a retrospective cross-sectional chart review on individuals ≥ 50 years who underwent CRC screening using FIT or screening colonoscopy, 09/01/2017-08/30/2018. Demographic differences in FIT completion were studied; ADR of FIT-C was compared to that of screening colonoscopy.

Results: Among 13,427 individuals with FIT ordered, 7248 (54%) completed the stool test and 230 (48%) followed up a positive FIT with colonoscopy. Increasing age (OR 1.01, CI 1.01-1.02), non-Hispanic Blacks (OR 0.87, CI 0.80-0.95, p = 0.002), current smokers (OR 0.84, CI 0.77-0.92, p < 0.0001), those with Medicaid (OR 0.86, CI 0.77-0.96, p = 0.006), commercial insurance (OR 0.85, CI 0.78-0.94, p = 0.002), CCI score ≥ 3 (OR 0.82, CI 0.74-0.91, p < 0.0001), orders by family medicine providers (OR 0.87, CI 0.81-0.94, p < 0.0001) were associated with lower completion of stool test. Individuals from low median household income cities had lower follow-up of positive FIT, OR 0.43, CI 0.21-0.86, p = 0.017. ADR of FIT-C was higher than that of screening colonoscopy.

Conclusion: Adherence to CRC screening is low in safety-net systems employing opportunistic screening. Understanding demographic differences may allow providers to formulate targeted strategies in high-risk vulnerable groups.
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http://dx.doi.org/10.1007/s10620-020-06545-3DOI Listing
August 2021

Increased Morbidity and Mortality in Hypertensive Patients With Substance Use Disorders: Electronic Health Record Findings.

J Stud Alcohol Drugs 2020 07;81(4):471-478

Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio.

Objective: Substance use disorder (SUD) management by medical providers may be important for patients with comorbid health conditions exacerbated by SUD. This study evaluated potential associations of SUD with morbidity and mortality in a large sample of hypertensive patients.

Method: Analysis of a limited data set was obtained through IBM Watson Health Explorys, a platform integrating data from electronic health records. Matched controls were defined for each of five SUDs: tobacco use disorder (TUD), alcohol use disorder (AUD), cocaine use disorder (COUD), opioid use disorder (OUD), and cannabis use disorder (CUD) using Mahalanobis distance within propensity score calipers. All patients were from The MetroHealth System (Cleveland, OH) and had diagnosed hypertension. SUD group participants had diagnosed abuse/dependence for the substance of interest. Controls for each SUD group had no diagnosis code related to the substance of interest and were selected to match the SUD patients on several factors. Total sample sizes for each SUD-control comparison ranged from 3,176 (CUD) to 49,696 (TUD); proportions of female patients ranged from 31.7% (AUD) to 51.2% (TUD). Outcomes were diagnosis (yes/no) of the following: cerebrovascular accident, myocardial infarction, renal failure, and all-cause mortality.

Results: Logistic regressions revealed that SUD was significantly associated with cerebrovascular accident (odds ratios [ORs]: TUD = 2.23; AUD = 1.68; COUD = 2.53; OUD = 1.87; CUD = 2.20), renal failure (ORs: TUD = 1.46; COUD = 2.09; OUD = 1.77), myocardial infarction (ORs: TUD = 2.96; AUD = 1.92; COUD = 3.00), and mortality (ORs: TUD = 1.34; AUD = 1.60; COUD = 1.83; OUD = 1.35; CUD = 1.39).

Conclusions: Among patients with hypertension, those with SUDs appear to have significantly greater risk for morbidity and mortality, suggesting the importance of managing SUD in hypertensive patients.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437550PMC
July 2020

Hydroxychloroquine ineffective for COVID-19 prophylaxis in lupus and rheumatoid arthritis.

Ann Rheum Dis 2020 Aug 5. Epub 2020 Aug 5.

Internal Medicine and Rheumatology, Case Western Reserve University at The MetroHealth System, Cleveland, Ohio, USA.

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http://dx.doi.org/10.1136/annrheumdis-2020-218500DOI Listing
August 2020

The association between regular cocaine use, with and without tobacco co-use, and adverse cardiovascular and respiratory outcomes.

Drug Alcohol Depend 2020 09 27;214:108136. Epub 2020 Jun 27.

Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA.

Background: Understanding the potential impact of cocaine use on health is increasingly important as cocaine use rises in the U.S.

Objectives: This study evaluated the associations of regular cocaine use, with and without tobacco co-use, with cardiovascular and respiratory outcomes.

Methods: Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls were defined for: 1) cocaine-using patients (n = 8244; 44 % female); and subgroups of cocaine-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4706); and 3) without a TUD diagnosis (non-TUD; n = 3538). Patients had at least one documented medical evaluation in the MetroHealth System (Cleveland, Ohio). Cocaine-using patients had an encounter diagnosis of cocaine abuse/dependence and/or ≥2 cocaine-positive drug screens. Control patients, with no documented cocaine-use, were matched to the cocaine-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident, heart arrhythmia, myocardial infarction, subarachnoid hemorrhage, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and all-cause mortality.

Results: TUD-patients had the greatest prevalence of cardiovascular and respiratory disease, regardless of cocaine-use indication. In the total sample, TUD, and non-TUD subgroups, regular cocaine use was significantly associated with greater risk for cerebrovascular accident, arrhythmia, myocardial infarction, asthma, COPD, pneumonia and mortality.

Conclusions: Cocaine use is associated with significantly greater risk of adverse cardiovascular and respiratory diagnoses and all-cause mortality.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7423623PMC
September 2020

Tumor Necrosis Factor (TNF) blocking agents are associated with lower risk for Alzheimer's disease in patients with rheumatoid arthritis and psoriasis.

PLoS One 2020 23;15(3):e0229819. Epub 2020 Mar 23.

Tetra Therapeutics, Grand Rapids, MI, United States of America.

This large, retrospective case-control study of electronic health records from 56 million unique adult patients examined whether or not treatment with a Tumor Necrosis Factor (TNF) blocking agent is associated with lower risk for Alzheimer's disease (AD) in patients with rheumatoid arthritis (RA), psoriasis, and other inflammatory diseases which are mediated in part by TNF and for which a TNF blocker is an approved treatment. The analysis compared the diagnosis of AD as an outcome measure in patients receiving at least one prescription for a TNF blocking agent (etanercept, adalimumab, and infliximab) or for methotrexate. Adjusted odds ratios (AORs) were estimated using the Cochran-Mantel-Haenszel (CMH) method and presented with 95% confidence intervals (CIs) and p-values. RA was associated with a higher risk for AD (Adjusted Odds Ratio (AOR) = 2.06, 95% Confidence Interval: (2.02-2.10), P-value <0.0001) as did psoriasis (AOR = 1.37 (1.31-1.42), P <0.0001), ankylosing spondylitis (AOR = 1.57 (1.39-1.77), P <0.0001), inflammatory bowel disease (AOR = 2.46 (2.33-2.59), P < 0.0001), ulcerative colitis (AOR = 1.82 (1.74-1.91), P <0.0001), and Crohn's disease (AOR = 2.33 (2.22-2.43), P <0.0001). The risk for AD in patients with RA was lower among patients treated with etanercept (AOR = 0.34 (0.25-0.47), P <0.0001), adalimumab (AOR = 0.28 (0.19-0.39), P < 0.0001), or infliximab (AOR = 0.52 (0.39-0.69), P <0.0001). Methotrexate was also associated with a lower risk for AD (AOR = 0.64 (0.61-0.68), P <0.0001), while lower risk was found in patients with a prescription history for both a TNF blocker and methotrexate. Etanercept and adalimumab also were associated with lower risk for AD in patients with psoriasis: AOR = 0.47 (0.30-0.73 and 0.41 (0.20-0.76), respectively. There was no effect of gender or race, while younger patients showed greater benefit from a TNF blocker than did older patients. This study identifies a subset of patients in whom systemic inflammation contributes to risk for AD through a pathological mechanism involving TNF and who therefore may benefit from treatment with a TNF blocking agent.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229819PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7089534PMC
July 2020

Doubling Hepatitis C Virus Screening in Primary Care Using Advanced Electronic Health Record Tools-A Non-Randomized Controlled Trial.

J Gen Intern Med 2020 02 2;35(2):498-504. Epub 2019 Dec 2.

Department of Medicine, The MetroHealth System, Case Western Reserve University, Cleveland, OH, USA.

Background: Hepatitis C virus (HCV) infection is a major public health burden, affecting over 4 million people. The Centers for Disease Control and Prevention and the US Preventive Services Task Force guidelines recommend screening everyone born between 1945 and 1965, but screening rates remain low.

Objective: To determine whether bulk ordering and electronic messaging to patients improves guideline-based HCV screening rates.

Design: A non-randomized controlled trial of 1024 adults from November 2016 to March 2017.

Participants: Patients due for HCV screening with at least one primary care office visit in one of three primary care clinics and enrolled in the healthcare system's tethered personal health record (tPHR).

Interventions: Control patients received normal care for HCV screening, consisting of passive HCV reminders to providers during face-to-face visits and passive HCV screening notification through the patient's tPHR. Intervention patients received normal care and also had HCV antibody tests ordered for them and customized messages sent through their tPHR inviting them to go directly to the lab for HCV screening over a 12-week period.

Main Measures: Percentage/number of patients receiving HCV antibody tests during the intervention period. Percentage/number of intervention group patients receiving HCV screening with other blood work.

Key Results: In the intervention group, 33% (168 of 514) completed HCV testing, compared with 19% (97 of 510) of controls (OR 1.7, 95% CI 1.2-2.1). Bulk lab ordering appeared to have a large impact while bulk messaging appeared to have a less significant role.

Conclusions: Leveraging population analytics and bulk ordering in an electronic health record with bulk messaging to a tPHR directly engages patients in blood screening tests and can significantly improve completion. This methodology has a broad range of applications including many recommended screening or disease-specific testing. This bulk ordering and direct-to-patient messaging approach improves patient screening while decreasing provider/staff work.

Trial Registration: MetroHealth IRB16-00776 (ClinicalTrials.gov).
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http://dx.doi.org/10.1007/s11606-019-05536-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7018893PMC
February 2020

The association between regular cannabis use, with and without tobacco co-use, and adverse cardiovascular outcomes: cannabis may have a greater impact in non-tobacco smokers.

Am J Drug Alcohol Abuse 2020 07 19;46(4):454-461. Epub 2019 Nov 19.

Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine , Cincinnati, OH, USA.

Background: Understanding the potential impact of cannabis use on cardiovascular health is increasingly important as cannabis use rises in the U.S. Objectives: This study evaluated the associations between regular cannabis use, with and without tobacco co-use, and cardiovascular outcomes.

Methods: Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8,944; 43% female); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4,682); and 3) without a TUD diagnosis (non-TUD; n = 4,262). Patients had ≥1 blood pressure measurement and blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens. Control patients, with no cannabis-use-documentation, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident (CVA), heart arrhythmia, myocardial infarction, subarachnoid hemorrhage (SAH), and all-cause mortality.

Results: TUD-patients had the greatest prevalence of cardiovascular disease, regardless of cannabis-use indication. In the total sample and non-TUD subgroup, regular cannabis use was significantly associated with greater risk for CVA, arrhythmia, SAH, and mortality. In the TUD subgroup, regular cannabis use was significantly associated with greater risk for arrhythmia and SAH.

Conclusions: Cannabis use is associated with significantly greater risk of adverse cardiovascular diagnoses and overall death, particularly in non-tobacco users.
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http://dx.doi.org/10.1080/00952990.2019.1676433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7702298PMC
July 2020

Designing for Sustainability: An Approach to Integrating Staff Role Changes and Electronic Health Record Functionality Within Safety-Net Clinics to Address Provision of Tobacco Cessation Care.

Jt Comm J Qual Patient Saf 2019 12 21;45(12):798-807. Epub 2019 Oct 21.

Background: Guidelines urge primary care practices to routinely provide tobacco cessation care, but quality indicators for the provision of advice and assistance to quit smoking lag. This study evaluated the implementation of a systems-based strategy to improve performance of tobacco cessation care in primary care clinics.

Methods: Changes to the electronic health record (EHR) facilitated staff to document when they ask about tobacco use, advise the patient to quit, offer to connect the patient to a quitline (QL) counselor, and refer interested patients to receive a call from a QL. Medical assistants (MAs) were trained to use the new sections of the EHR, and their roles were expanded to include the provision of brief cessation advice and activation of the QL referral. Primary outcomes were change in tobacco cessation processes preimplementation vs. one, three, and six months postimplementation of the strategy.

Results: The increase in performance of tobacco cessation care was significant and sustained at six months postimplementation for assessing smoking status (50.9% vs. 76.3%; odds ratio [OR] = 3.04; 95% confidence interval [CI] = 2.80-3.31), providing advice (15.1% vs. 92.7%; OR = 69.3; 95% CI = 51.88-92.60), assessing readiness to quit (22.8% vs. 76.6%; OR = 10.80; 95% CI = 8.92-13.08), and accepting a referral to the QL (1.3% vs. 21.7%; OR = 20.31; 95% CI = 4.91-84.05).

Conclusion: Key stakeholder engagement informed a system change intervention that includes an EHR-supported role expansion of MAs for QL referrals; these changes substantially increased the provision of tobacco cessation care.
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http://dx.doi.org/10.1016/j.jcjq.2019.09.003DOI Listing
December 2019

Differences, Opportunities, and Strategies in Drug Alert Optimization-Experiences of Two Different Integrated Health Care Systems.

Appl Clin Inform 2019 10 16;10(5):777-782. Epub 2019 Oct 16.

The Center for Clinical Informatics Research and Education, The MetroHealth System, Case Western Reserve University, Cleveland, Ohio, United States.

Background: Concerns about the number of automated medication alerts issued within the electronic health record (EHR), and the subsequent potential for alarm fatigue, led us to examine strategies and methods to optimize the configuration of our drug alerts.

Objectives: This article reports on comprehensive drug alerting rates and develops strategies across two different health care systems to reduce the number of drug alerts.

Methods: Standardized reports compared drug alert rates between the two systems, among 13 categories of drug alerts. Both health care systems made modifications to the out-of-box alerts available from their EHR and drug information vendors, focusing on system-wide approaches, when relevant, while performing more drug-specific changes when necessary.

Results: Drug alerting rates even after initial optimization were 38 alerts and 51 alerts per 100 drug orders, respectively. Eight principles were identified and developed to reflect the themes in the implementation and optimization of drug alerting.

Conclusion: A team-based, systematic approach to optimizing drug-alerting strategies can reduce the number of drug alerts, but alert rates still remain high. In addition to strategic principles, additional tactical guidelines and recommendations need to be developed to enhance out-of-the-box clinical decision support for drug alerts.
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http://dx.doi.org/10.1055/s-0039-1697596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6795529PMC
October 2019

A step closer to nationwide electronic health record-based chronic disease surveillance: characterizing asthma prevalence and emergency department utilization from 100 million patient records through a novel multisite collaboration.

J Am Med Inform Assoc 2020 01;27(1):127-135

Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio, USA.

Objective: The study sought to assess the feasibility of nationwide chronic disease surveillance using data aggregated through a multisite collaboration of customers of the same electronic health record (EHR) platform across the United States.

Materials And Methods: An independent confederation of customers of the same EHR platform proposed and guided the development of a program that leverages native EHR features to allow customers to securely contribute de-identified data regarding the prevalence of asthma and rate of asthma-associated emergency department visits to a vendor-managed repository. Data were stratified by state, age, sex, race, and ethnicity. Results were qualitatively compared with national survey-based estimates.

Results: The program accumulated information from 100 million health records from over 130 healthcare systems in the United States over its first 14 months. All states were represented, with a median coverage of 22.88% of an estimated state's population (interquartile range, 12.05%-42.24%). The mean monthly prevalence of asthma was 5.27 ± 0.11%. The rate of asthma-associated emergency department visits was 1.39 ± 0.08%. Both measures mirrored national survey-based estimates.

Discussion: By organizing the program around native features of a shared EHR platform, we were able to rapidly accumulate population level measures from a sizeable cohort of health records, with representation from every state. The resulting data allowed estimates of asthma prevalence that were comparable to data from traditional epidemiologic surveys at both geographic and demographic levels.

Conclusions: Our initiative demonstrates the potential of intravendor customer collaboration and highlights an organizational approach that complements other data aggregation efforts seeking to achieve nationwide EHR-based chronic disease surveillance.
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http://dx.doi.org/10.1093/jamia/ocz172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647242PMC
January 2020

Regular cannabis use, with and without tobacco co-use, is associated with respiratory disease.

Drug Alcohol Depend 2019 11 16;204:107557. Epub 2019 Sep 16.

Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA.

Background: Cannabis use is a potential risk factor for respiratory disease but its role apart from tobacco use is unclear. We evaluated the association between regular cannabis use, with and without tobacco co-use, and onset of asthma, chronic obstructive pulmonary disease (COPD), and pneumonia.

Methods: Analysis of a limited data set obtained through IBM Watson Health Explorys, an electronic-health-record-integration platform. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8932); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4678); and 3) without a TUD diagnosis (non-TUD; n = 4254). Patients had at least: one recorded blood pressure measurement and one blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens (UDSs). Control patients, not having cannabis-related diagnoses or cannabis-positive UDSs, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status.

Results: Regular cannabis use was significantly associated with greater risk for asthma (odds ratio (OR) = 1.44; adjusted odds ratio (aOR) = 1.50; OR = 1.32), COPD (OR = 1.56; aOR = 1.44; OR = 2.17), and pneumonia (OR = 1.80; OR = 1.84; OR = 2.13) in the total sample and TUD and non-TUD subgroups, respectively. TUD-patients had the greatest prevalence of respiratory disease, regardless of cannabis-use indication.

Conclusions: Regular cannabis use is associated with significantly greater risk of respiratory disease regardless of TUD status. Future research to understand the impact of cannabis use on respiratory health is warranted.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.107557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6878136PMC
November 2019

Aligning Adult and Pediatric Blood Pressure Guidelines.

Hypertension 2019 05;73(5):938-943

University of Maryland School of Medicine, Baltimore (C.B.-S.).

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http://dx.doi.org/10.1161/HYPERTENSIONAHA.119.12653DOI Listing
May 2019
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