Publications by authors named "Douglas S Bell"

71 Publications

Validation of an Internationally Derived Patient Severity Phenotype to Support COVID-19 Analytics from Electronic Health Record Data.

J Am Med Inform Assoc 2021 Feb 10. Epub 2021 Feb 10.

Department of Neurology, Massachusetts General Hospital; and, Research Information Science and Computing, Mass General Brigham - Boston, United States.

Introduction: The Consortium for Clinical Characterization of COVID-19 by EHR (4CE) is an international collaboration addressing COVID-19 with federated analyses of electronic health record (EHR) data.

Objective: We sought to develop and validate a computable phenotype for COVID-19 severity.

Methods: Twelve 4CE sites participated. First we developed an EHR-based severity phenotype consisting of six code classes, and we validated it on patient hospitalization data from the 12 4CE clinical sites against the outcomes of ICU admission and/or death. We also piloted an alternative machine-learning approach and compared selected predictors of severity to the 4CE phenotype at one site.

Results: The full 4CE severity phenotype had pooled sensitivity of 0.73 and specificity 0.83 for the combined outcome of ICU admission and/or death. The sensitivity of individual code categories for acuity had high variability - up to 0.65 across sites. At one pilot site, the expert-derived phenotype had mean AUC 0.903 (95% CI: 0.886, 0.921), compared to AUC 0.956 (95% CI: 0.952, 0.959) for the machine-learning approach. Billing codes were poor proxies of ICU admission, with as low as 49% precision and recall compared to chart review.

Discussion: We developed a severity phenotype using 6 code classes that proved resilient to coding variability across international institutions. In contrast, machine-learning approaches may overfit hospital-specific orders. Manual chart review revealed discrepancies even in the gold-standard outcomes, possibly due to heterogeneous pandemic conditions.

Conclusion: We developed an EHR-based severity phenotype for COVID-19 in hospitalized patients and validated it at 12 international sites.
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http://dx.doi.org/10.1093/jamia/ocab018DOI Listing
February 2021

International Comparisons of Harmonized Laboratory Value Trajectories to Predict Severe COVID-19: Leveraging the 4CE Collaborative Across 342 Hospitals and 6 Countries: A Retrospective Cohort Study.

medRxiv 2021 Feb 5. Epub 2021 Feb 5.

Objectives: To perform an international comparison of the trajectory of laboratory values among hospitalized patients with COVID-19 who develop severe disease and identify optimal timing of laboratory value collection to predict severity across hospitals and regions.

Design: Retrospective cohort study.

Setting: The Consortium for Clinical Characterization of COVID-19 by EHR (4CE), an international multi-site data-sharing collaborative of 342 hospitals in the US and in Europe.

Participants: Patients hospitalized with COVID-19, admitted before or after PCR-confirmed result for SARS-CoV-2. Primary and secondary outcome measures: Patients were categorized as ″ever-severe″ or ″never-severe″ using the validated 4CE severity criteria. Eighteen laboratory tests associated with poor COVID-19-related outcomes were evaluated for predictive accuracy by area under the curve (AUC), compared between the severity categories. Subgroup analysis was performed to validate a subset of laboratory values as predictive of severity against a published algorithm. A subset of laboratory values (CRP, albumin, LDH, neutrophil count, D-dimer, and procalcitonin) was compared between North American and European sites for severity prediction.

Results: Of 36,447 patients with COVID-19, 19,953 (43.7%) were categorized as ever-severe. Most patients (78.7%) were 50 years of age or older and male (60.5%). Longitudinal trajectories of CRP, albumin, LDH, neutrophil count, D-dimer, and procalcitonin showed association with disease severity. Significant differences of laboratory values at admission were found between the two groups. With the exception of D-dimer, predictive discrimination of laboratory values did not improve after admission. Sub-group analysis using age, D-dimer, CRP, and lymphocyte count as predictive of severity at admission showed similar discrimination to a published algorithm (AUC=0.88 and 0.91, respectively). Both models deteriorated in predictive accuracy as the disease progressed. On average, no difference in severity prediction was found between North American and European sites.

Conclusions: Laboratory test values at admission can be used to predict severity in patients with COVID-19. Prediction models show consistency across international sites highlighting the potential generalizability of these models.
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http://dx.doi.org/10.1101/2020.12.16.20247684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872369PMC
February 2021

Reducing Emergency Room Visits Among Patients With Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams.

Med Care 2021 Jan 7;Publish Ahead of Print. Epub 2021 Jan 7.

Department of Family Medicine Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, CA.

Background: Pharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency room (ER) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care.

Objective: The objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ER and hospital use for patients with diabetes.

Design: This was a quasi-experimental study with a comparator group.

Subjects: The analytic sample included patients with diabetes with uncontrolled cardiovascular risk factors (A1C >9%, blood pressure >140/90 mm Hg, low-density lipoprotein-cholesterol >130 mg/dL) who had 1 or more visits in either a UCMyRx (648 patients, 14 practices) or usual care practice (1944 patients, 14 practices).

Measures: Our outcomes were ER and hospitalization rates as measured before and after the consultations between UCMyRx and usual care. Our predictor variable was the pharmacist consultation. Poisson generalized estimating equations model was used to estimate the adjusted predicted change in utilization before and after the pharmacist consultation. The Average Treatment Effect on the Treated was estimated.

Results: In models adjusted, the adjusted mean predicted number of emergency department visits/month during the year before the consultation was 0.09 among UCMyRx patients. During the year after initiating the care with the pharmacists, this rate decreased to an adjusted mean monthly rate of 0.07, with an Average Treatment Effect on the Treated=0.021 (P=0.035), a predicted reduction of 21% in emergency department visits associated with the clinical pharmacist consults. There was a nonsignificant predicted 3.2% reduction in hospitalizations over time for patients in the UCMyRx program.

Conclusion: Clinical pharmacists are an important addition to clinical care teams in primary care practices and significantly decreased utilization of the ER among patients with poorly controlled diabetes.
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http://dx.doi.org/10.1097/MLR.0000000000001501DOI Listing
January 2021

Accuracy of an Electronic Health Record Patient Linkage Module Evaluated between Neighboring Academic Health Care Centers.

Appl Clin Inform 2020 10 4;11(5):725-732. Epub 2020 Nov 4.

Department of Medicine, University of California Los Angeles, Los Angeles, United States.

Background: Patients often seek medical treatment among different health care organizations, which can lead to redundant tests and treatments. One electronic health record (EHR) platform, Epic Systems, uses a patient linkage tool called Care Everywhere (CE), to match patients across institutions. To the extent that such linkages accurately identify shared patients across organizations, they would hold potential for improving care.

Objective: This study aimed to understand how accurate the CE tool with default settings is to identify identical patients between two neighboring academic health care systems in Southern California, The University of California Los Angeles (UCLA) and Cedars-Sinai Medical Center.

Methods: We studied CE patient linkage queries received at UCLA from Cedars-Sinai between November 1, 2016, and April 30, 2017. We constructed datasets comprised of linkages ("successful" queries), as well as nonlinkages ("unsuccessful" queries) during this time period. To identify false positive linkages, we screened the "successful" linkages for potential errors and then manually reviewed all that screened positive. To identify false-negative linkages, we applied our own patient matching algorithm to the "unsuccessful" queries and then manually reviewed a sample to identify missed patient linkages.

Results: During the 6-month study period, Cedars-Sinai attempted to link 181,567 unique patient identities to records at UCLA. CE made 22,923 "successful" linkages and returned 158,644 "unsuccessful" queries among these patients. Manual review of the screened "successful" linkages between the two institutions determined there were no false positives. Manual review of a sample of the "unsuccessful" queries ( = 623), demonstrated an extrapolated false-negative rate of 2.97% (95% confidence interval [CI]: 1.6-4.4%).

Conclusion: We found that CE provided very reliable patient matching across institutions. The system missed a few linkages, but the false-negative rate was low and there were no false-positive matches over 6 months of use between two nearby institutions.
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http://dx.doi.org/10.1055/s-0040-1718374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641664PMC
October 2020

Privacy-Protecting, Reliable Response Data Discovery Using COVID-19 Patient Observations.

medRxiv 2020 Sep 23. Epub 2020 Sep 23.

There is an urgent need to answer questions related to COVID-19's clinical course and associations with underlying conditions and health outcomes. Multi-center data are necessary to generate reliable answers, but centralizing data in a single repository is not always possible. Using a privacy-protecting strategy, we launched a public Questions & Answers web portal (https://covid19questions.org) with analyses of comorbidities, medications and laboratory tests using data from 202 hospitals (59,074 COVID-19 patients) in the USA and Germany. We find, for example, that 8.6% of hospitalizations in which the patient was not admitted to the ICU resulted in the patient returning to the hospital within seven days from discharge and that, when adjusted for age, mortality for hospitalized patients was not significantly different by gender or ethnicity.
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http://dx.doi.org/10.1101/2020.09.21.20196220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523159PMC
September 2020

International electronic health record-derived COVID-19 clinical course profiles: the 4CE consortium.

NPJ Digit Med 2020 19;3:109. Epub 2020 Aug 19.

Department of Biomedical Informatics, Harvard Medical School, Boston, MA USA.

We leveraged the largely untapped resource of electronic health record data to address critical clinical and epidemiological questions about Coronavirus Disease 2019 (COVID-19). To do this, we formed an international consortium (4CE) of 96 hospitals across five countries (www.covidclinical.net). Contributors utilized the Informatics for Integrating Biology and the Bedside (i2b2) or Observational Medical Outcomes Partnership (OMOP) platforms to map to a common data model. The group focused on temporal changes in key laboratory test values. Harmonized data were analyzed locally and converted to a shared aggregate form for rapid analysis and visualization of regional differences and global commonalities. Data covered 27,584 COVID-19 cases with 187,802 laboratory tests. Case counts and laboratory trajectories were concordant with existing literature. Laboratory tests at the time of diagnosis showed hospital-level differences equivalent to country-level variation across the consortium partners. Despite the limitations of decentralized data generation, we established a framework to capture the trajectory of COVID-19 disease in patients and their response to interventions.
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http://dx.doi.org/10.1038/s41746-020-00308-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438496PMC
August 2020

Impact of a "Chart Closure" Hard Stop Alert on Prescribing for Elevated Blood Pressures Among Patients With Diabetes: Quasi-Experimental Study.

JMIR Med Inform 2020 Apr 17;8(4):e16421. Epub 2020 Apr 17.

Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.

Background: University of California at Los Angeles Health implemented a Best Practice Advisory (BPA) alert for the initiation of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for individuals with diabetes. The BPA alert was configured with a "chart closure" hard stop, which demanded a response before closing the chart.

Objective: The aim of the study was to evaluate whether the implementation of the BPA was associated with changes in ACEI and ARB prescribing during primary care encounters for patients with diabetes.

Methods: We defined ACEI and ARB prescribing opportunities as primary care encounters in which the patient had a diabetes diagnosis, elevated blood pressure in recent encounters, no active ACEI or ARB prescription, and no contraindications. We used a multivariate logistic regression model to compare the change in the probability of an ACEI or ARB prescription during opportunity encounters before and after BPA implementation in primary care sites that did (n=30) and did not (n=31) implement the BPA. In an additional subgroup analysis, we compared ACEI and ARB prescribing in BPA implementation sites that had also implemented a pharmacist-led medication management program.

Results: We identified a total of 2438 opportunity encounters across 61 primary care sites. The predicted probability of an ACEI or ARB prescription increased significantly from 11.46% to 22.17% during opportunity encounters in BPA implementation sites after BPA implementation. However, in the subgroup analysis, we only observed a significant improvement in ACEI and ARB prescribing in BPA implementation sites that had also implemented the pharmacist-led program. Overall, the change in the predicted probability of an ACEI or ARB prescription from before to after BPA implementation was significantly greater in BPA implementation sites compared with nonimplementation sites (difference-in-differences of 11.82; P<.001).

Conclusions: A BPA with a "chart closure" hard stop is a promising tool for the treatment of patients with comorbid diabetes and hypertension with an ACEI or ARB, especially when implemented within the context of team-based care, wherein clinical pharmacists support the work of primary care providers.
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http://dx.doi.org/10.2196/16421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195665PMC
April 2020

Association of a Care Bundle for Early Sepsis Management With Mortality Among Patients With Hospital-Onset or Community-Onset Sepsis.

JAMA Intern Med 2020 05;180(5):707-716

Division of General Internal Medicine, UCLA.

Importance: The Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1) is a quality metric based on a care bundle for early sepsis management. Published evidence on the association of SEP-1 with mortality is mixed and largely excludes cases of hospital-onset sepsis.

Objective: To assess the association of the SEP-1 bundle with mortality and organ dysfunction in cohorts with hospital-onset or community-onset sepsis.

Design, Setting, And Participants: This retrospective cohort study used data from 4 University of California hospitals from October 1, 2014, to October 1, 2017. Adult inpatients with a diagnosis consistent with sepsis or disseminated infection and laboratory or vital signs meeting the Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock) criteria were divided into community-onset sepsis and hospital-onset sepsis cohorts based on whether time 0 of sepsis occurred after arrival in the emergency department or an inpatient area. Data were analyzed from April to October 2019. Additional analyses were performed from December 2019 to January 2020.

Exposures: Administration of SEP-1 and 4 individual bundle components (serum lactate level testing, blood culture, broad-spectrum intravenous antibiotic treatment, and intravenous fluid treatment).

Main Outcomes And Measures: The primary outcome was in-hospital mortality. The secondary outcome was days requiring vasopressor support, measured as vasopressor days.

Results: Among the 6404 patient encounters identified (3535 men [55.2%]; mean [SD] age, 64.0 [18.2] years), 2296 patients (35.9%) had hospital-onset sepsis. Among 4108 patients (64.1%) with community-onset sepsis, serum lactate level testing within 3 hours of time 0 was associated with reduced mortality (absolute difference, -7.61%; 95% CI, -14.70% to -0.54%). Blood culture (absolute difference, -1.10 days; 95% CI, -1.85 to -0.34 days) and broad-spectrum intravenous antibiotic treatment (absolute difference, -0.62 days; 95% CI, -1.02 to -0.22 days) were associated with fewer vasopressor days. Among patients with hospital-onset sepsis, broad-spectrum intravenous antibiotic treatment was the only bundle component significantly associated with any improved outcome (mortality difference, -5.20%; 95% CI, -9.84% to -0.56%). Care that was adherent to the complete SEP-1 bundle was associated with increased vasopressor days in patients with community-onset sepsis (absolute difference, 0.31 days; 95% CI, 0.11-0.51 days) but was not significantly associated with reduced mortality in either cohort (absolute difference, -0.07%; 95% CI, -3.02% to 2.88% in community-onset; absolute difference, -0.42%; 95% CI, -6.77% to 5.93% in hospital-onset).

Conclusions And Relevance: SEP-1-adherent care was not associated with improved outcomes of sepsis. Although multiple components of SEP-1 were associated with reduced mortality or decreased days of vasopressor therapy for patients who presented with sepsis in the emergency department, only broad-spectrum intravenous antibiotic treatment was associated with reduced mortality when time 0 occurred in an inpatient unit. Current sepsis quality metrics may need refinement.
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http://dx.doi.org/10.1001/jamainternmed.2020.0183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136852PMC
May 2020

The Impact of Resident Holdover Admissions on Length of Hospital Stay and Risk of Transfer to an Intensive Care Unit.

J Patient Saf 2020 Mar 24. Epub 2020 Mar 24.

General Internal Medicine, University of California, Los Angeles, Los Angeles, California.

Objective: Implementation of residency duty hour standards has led to adoption of different staffing models, such as the "holdover" model, whereby nighttime teams admit patients and transfer their care to daytime teams who provide ongoing care. In contrast, nonholdover teams at our institution are responsible for both admitting patients and providing ongoing care. We sought to determine whether patients admitted by holdover teams experience worse outcomes than those admitted by nonholdover teams.

Methods: This is a retrospective cohort study of patients admitted to the internal medicine hospital service at a quaternary care hospital from July 2013 to June 2015. Primary outcomes included hospital length of stay (LOS) and transfer to an intensive care unit within 72 hours of admission. Secondary outcomes were any transfer to an intensive care unit, in-hospital mortality, discharge to home (versus discharge to postacute care facility), and readmission to the health system within 30 days of discharge.

Results: We analyzed 5518 encounters, 64% of which were admitted by a holdover team. Outcomes were similar between study groups, except the LOS, which was 5.5 hours longer for holdover encounters in unadjusted analyses (5.18 versus 4.95 days, P = 0.04) but not significantly different in adjusted analyses. The mean discharge time was 4:00 P.M. for both groups, whereas the mean admission times were 12:00 A.M. and 4:00 P.M. for holdover and nonholdover encounters, respectively.

Conclusions: Holdover encounters at our institution were not associated with worse patient safety outcomes. A small increase in LOS may have been attributable to holdover patients having earlier admission and identical discharge times.
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http://dx.doi.org/10.1097/PTS.0000000000000662DOI Listing
March 2020

An Effectiveness Evaluation of a Primary Care-Embedded Clinical Pharmacist-Led Intervention Among Blacks with Diabetes.

J Gen Intern Med 2020 09 6;35(9):2569-2575. Epub 2020 Mar 6.

Department of Medicine, Division of General Internal Medicine and Health Services Research (GIM/HSR), University of California, Los Angeles, Los Angeles, CA, 90024, USA.

Background: Black individuals with type 2 diabetes suffer disproportionate morbidity and mortality relative to whites with type 2 diabetes, irrespective of health insurance coverage.

Objective: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on cardiovascular risk factor control among blacks with type 2 diabetes in a large healthcare system.

Design: We used data extracted from the electronic health records (EHR) system and a difference-in-differences study design with a propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure (SBP) among black patients with type 2 diabetes, relative to usual care.

Participants: Individuals with type 2 diabetes identified as either black or African American in the EHR that were ≥ 18 years of age that had the following observations during the study window (03/02/2013-12/31/18: (1) HbA1C ≥ 8%, at least once, anywhere between 365 days before and 14 days after the UCMyRx visit and a follow-up HbA1c measure within 120 to 365 days after the visit and/or (2) SBP ≥ 140 mmHg at least once between 365 days before and 14 days after the UCMyRx visit that had a follow-up SBP measure within 120 to 450 days after the visit.

Intervention: UCMyRx pharmacists review labs and vital signs, perform medication reconciliation, use a standardized survey to assess barriers to medication adherence, and develop tailored interventions to improve medication adherence.

Main Measures: Change in HbA1c and change in SBP from before to after the first UCMyRx visit.

Key Results: Having at least one visit with a UCMyRx clinical pharmacist was associated with a significant reduction in HbA1c (- 0.4%, p value = .01); however, there was no significant impact on SBP (- .051 mmHg, p value = 0.74).

Conclusions: The UCMyRx intervention is a useful strategy for improving HbA1c control among blacks with type 2 diabetes.
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http://dx.doi.org/10.1007/s11606-020-05750-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458955PMC
September 2020

Clinical Characteristics of and Risk Factors for Chronic Kidney Disease Among Adults and Children: An Analysis of the CURE-CKD Registry.

JAMA Netw Open 2019 12 2;2(12):e1918169. Epub 2019 Dec 2.

Division of Nephrology, University of California, Los Angeles.

Importance: Chronic kidney disease (CKD) is serious and common, yet recognition and public health responses are limited.

Objective: To describe clinical features of, prevalence of, major risk factors for, and care for CKD among patients treated in 2 large US health care systems.

Design, Setting, And Participants: This cohort study collected data from the Center for Kidney Disease Research, Education, and Hope (CURE-CKD) registry, an electronic health record-based registry jointly curated and sponsored by Providence St Joseph Health and the University of California, Los Angeles. Patients were adults and children with CKD (excluding end-stage kidney disease) and adults at risk of CKD (ie, with diabetes, hypertension, or prediabetes) identified by laboratory values, vital signs, prescriptions, and administrative codes. Data were collected from January 2006 through December 2017, with analyses performed from March 2019 through November 2019.

Exposures: Diabetes, hypertension, and prediabetes.

Main Outcomes And Measures: Clinical and demographic characteristics, prevalence, and prescribed medications.

Results: Of 2 625 963 adults and children in the sample, 606 064 adults (23.1%) with CKD had a median (interquartile range [IQR]) age of 70 (59-81) years, with 338 785 women (55.9%) and 434 474 non-Latino white individuals (71.7%). A total of 12 591 children (0.4%) with CKD had a median (IQR) age of 6 (1-13) years, with 7079 girls (56.2%) and 6653 non-Latino white children (52.8%). Median (IQR) estimated glomerular filtration rate was 53 (41-61) mL/min/1.73 m2 among adults and 70 (50-95) mL/min/1.73 m2 in children. Prevalence rates for CKD in adults were 4.8% overall (606 064 of 12 669 700) with 1.6% (93 644 of 6 011 129) during 2006 to 2009, 5.7% (393 455 of 6 903 084) during 2010 to 2013, and 8.4% (683 574 of 8 179 860) during 2014 to 2017 (P < .001). A total of 226 693 patients (37.4%) had category 3a CKD; 100 239 (16.5%), category 3b CKD; 39 125 (6.5%), category 4 CKD; and 20 328 (3.4%), category 5 CKD. Among adults with CKD, albuminuria and proteinuria assessments were available in 52 551 (8.7%) and 25 035 (4.1%) patients, respectively. A renin-angiotensin system inhibitor was prescribed to 124 575 patients (20.6%), and 204 307 (33.7%) received nonsteroidal anti-inflammatory drugs or proton pump inhibitors. Of 1 973 258 adults (75.1%) at risk, one-quarter had diabetes or prediabetes (512 299 [26.0%]), nearly half had hypertension (955 812 [48.4%]), and one-quarter had both hypertension and diabetes or prediabetes (505 147 [25.6%]).

Conclusions And Relevance: This registry-based cohort study revealed a burgeoning number of patients with CKD and its major risk factors. Rates of identification and use of kidney protective agents were low, while potential nephrotoxin use was widespread, underscoring the pressing need for practice-based improvements in CKD prevention, recognition, and treatment.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.18169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991307PMC
December 2019

Rationale and design of a multicenter Chronic Kidney Disease (CKD) and at-risk for CKD electronic health records-based registry: CURE-CKD.

BMC Nephrol 2019 11 20;20(1):416. Epub 2019 Nov 20.

Providence St. Joseph Health, Providence Medical Research Center, Spokane, Washington, USA.

Background: Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function.

Methods: We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data.

Results: The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials.

Discussion: CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.
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http://dx.doi.org/10.1186/s12882-019-1558-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868861PMC
November 2019

Sustainability considerations for clinical and translational research informatics infrastructure.

J Clin Transl Sci 2018 Oct 5;2(5):267-275. Epub 2018 Dec 5.

Department of Preventive Medicine, Division of Health and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

A robust biomedical informatics infrastructure is essential for academic health centers engaged in translational research. There are no templates for what such an infrastructure encompasses or how it is funded. An informatics workgroup within the Clinical and Translational Science Awards network conducted an analysis to identify the scope, governance, and funding of this infrastructure. After we identified the essential components of an informatics infrastructure, we surveyed informatics leaders at network institutions about the governance and sustainability of the different components. Results from 42 survey respondents showed significant variations in governance and sustainability; however, some trends also emerged. Core informatics components such as electronic data capture systems, electronic health records data repositories, and related tools had mixed models of funding including, fee-for-service, extramural grants, and institutional support. Several key components such as regulatory systems (e.g., electronic Institutional Review Board [IRB] systems, grants, and contracts), security systems, data warehouses, and clinical trials management systems were overwhelmingly supported as institutional infrastructure. The findings highlighted in this report are worth noting for academic health centers and funding agencies involved in planning current and future informatics infrastructure, which provides the foundation for a robust, data-driven clinical and translational research program.
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http://dx.doi.org/10.1017/cts.2018.332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6390401PMC
October 2018

Characteristics of the National Applicant Pool for Clinical Informatics Fellowships (2016-2017).

AMIA Annu Symp Proc 2018 5;2018:225-231. Epub 2018 Dec 5.

David Geffen School of Medicine at UCLA, Los Angeles, CA.

We conducted a national study to assess the numbers and diversity of applicants for 2016 and 2017 clinical informatics fellowship positions. In each year, we collected data on the number of applications that programs received from candidates who were ultimately successful vs. unsuccessful. In 2017, we also conducted an anonymous applicant survey. Successful candidates applied to an average of 4.2 and 5.5 programs for 2016 and 2017, respectively. In the survey, unsuccessful candidates reported applying to fewer programs. Assuming unsuccessful candidates submitted between 2-5 applications each, the total applicant pool numbered 42-69 for 2016 (competing for 24 positions) and 52-85 for 2017 (competing for 30 positions). Among survey respondents (n=33), 24% were female, 1 was black and none were Hispanic. We conclude that greater efforts are needed to enhance interest in clinical informatics among medical students and residents, particularly among women and members of underrepresented minority groups.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371309PMC
September 2019

Depression in Nonclassical Hypogonadism in Young Men.

J Endocr Soc 2018 Nov 21;2(11):1306-1313. Epub 2018 Sep 21.

Department of Medicine, David Geffen School of Medicine at UCLA and the UCLA Clinical and Translational Science Institute, Los Angeles, California.

The specific objective of this study was to test the clinically derived hypothesis associating a high prevalence of depression in young men with nonclassical hypogonadism. We studied the entire population of men aged 18 to 40 years who had an outpatient visit at an academic health system in the years 2013 to 2015. The study group comprised 186 patients with a diagnosis of eugonadotropic hypogonadism and a testosterone value below 10.4 nmol/L with no apparent cause. We compared their demographic factors, other diagnoses, and treatments with those of (i) the entire population, (ii) a matched population of 930 controls, and (iii) 404 controls with normal testosterone determinations, and no hypogonadism diagnosis. Depression, defined as either an () diagnosis or treatment with an antidepressant medication, was found in 22.6% of cases vs 6.6% of population controls [ < 0.001; OR: 1.13 (1.09 to 1.17); 95% CI]. Obesity was also higher in the cases ( < 0.001). The matched controls had a depression rate of 13.4% compared with the case rate of 22.6% [ < 0.002; OR 1.14 (1.08 to 1.17)]. Controls with normal testosterone determinations had a depression rate of 16.8% [ = 0.121; OR: 1.04 (0.96 to 1.12)], suggesting that clinicians may have ordered a testosterone determination because of symptoms consistent with both depression and hypogonadism. The high incidence of depression in nonclassical hypogonadism in young men, although only associative, supports a depression evaluation and treatment as appropriate as well as investigation of the proximate causes of this form of hypogonadism.
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http://dx.doi.org/10.1210/js.2018-00137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223247PMC
November 2018

Escalating Opioid Dose Is Associated With Mortality: A Comparison of Patients With and Without Opioid Use Disorder.

J Addict Med 2019 Jan/Feb;13(1):41-46

University of California, Los Angeles, CA (YIH, LJM, KM, YZ, CKY, DH, DSB); Veterans Affairs Puget Sound Health Care System, Seattle, WA (AJS); University of California, San Diego, CA (DL).

Objective: Prescription Drug Monitoring Programs (PDMPs) are intended to help reduce prescription drug misuse and opioid overdose, yet little is known about the longitudinal patterns of opioid prescribing that may be associated with mortality. This study investigated longitudinal opioid prescribing patterns among patients with opioid use disorder (OUD) and without OUD in relation to mortality using PDMP data.

Methods: Growth modeling was used to examine opioid prescription data from the California PDMP for a 4-year period before death or a comparable period ending in 2014 for those remaining from a sample of 7728 patients (2576 with OUD, and 5152 matched non-OUD controls) treated in a large healthcare system.

Results: Compared to controls, individuals with OUD (alive and deceased) had received significantly more opioid prescriptions, greater number of days' supply, and steeper increases of opioid dosages over time. For morphine equivalents (ME, in grams), the interaction of OUD and mortality was significant at both intercept (β = 10.4, SE = 4.4, P < 0.05) and slope (β = 6.0, SE = 1.1, P < 0.001); deceased OUD patients demonstrated the sharpest increase (ie, an average yearly increment of 7.84 grams over alive patients without OUD) and ended with the highest level of opioids prescribed before they died (ie, 20.2 grams higher). Older age, public health insurance, cancer, and chronic pain were associated with higher number and dose of opioid prescriptions.

Conclusions: Besides the amount of prescriptions, clinicians must be alert to patterns of opioid prescription such as escalating dosage as critical warning signals for heightened mortality risks, particularly among patients with OUD.
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http://dx.doi.org/10.1097/ADM.0000000000000458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6349485PMC
March 2020

Primary care provider adherence to an alert for intensification of diabetes blood pressure medications before and after the addition of a "chart closure" hard stop.

J Am Med Inform Assoc 2018 09;25(9):1167-1174

Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA.

Objective: To evaluate provider responses to a narrowly targeted "Best Practice Advisory" (BPA) alert for the intensification of blood pressure medications for persons with diabetes before and after implementation of a "chart closure" hard stop, which is non-interruptive but demands an action or dismissal before the chart can be closed.

Materials And Methods: We designed a BPA that fired alerts within an electronic health record (EHR) system during outpatient encounters for patients with diabetes when they had elevated blood pressures and were not on angiotensin receptor blocking medications. The BPA alerts were implemented in eight primary care practices within UCLA Health. We compared data on provider responses to the alerts before and after implementing a "chart closure" hard stop, and we conducted chart reviews to adjudicate each alert's appropriateness.

Results: Providers responded to alerts more often after the "chart closure" hard stop was implemented (P < .001). Among 284 alert firings over 16 months, we judged 107 (37.7%) to be clinically unnecessary or inappropriate based on chart review. Among the remainder, which represent clear opportunities for treatment, providers ordered the indicated medication more often (41% vs 75%) after the "chart closure" hard stop was implemented (P = .001).

Discussion: The BPA alerts for diabetes and blood pressure control achieved relatively high specificity. The "chart closure" hard stop improved provider attention to the alerts and was effective at getting patients treated when they needed it.

Conclusion: Targeting specific omitted medication classes can produce relatively specific alerts that may reduce alert fatigue, and using a "chart closure" hard stop may prompt providers to take action without excessively disrupting their workflow.
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http://dx.doi.org/10.1093/jamia/ocy073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118864PMC
September 2018

Implementation of informatics for integrating biology and the bedside (i2b2) platform as Docker containers.

BMC Med Inform Decis Mak 2018 07 16;18(1):66. Epub 2018 Jul 16.

Massachusetts General Hospital, Boston, MA, USA.

Background: Informatics for Integrating Biology and the Bedside (i2b2) is an open source clinical data analytics platform used at over 200 healthcare institutions for querying patient data. The i2b2 platform has several components with numerous dependencies and configuration parameters, which renders the task of installing or upgrading i2b2 a challenging one. Even with the availability of extensive documentation and tutorials, new users often require several weeks to correctly install a functional i2b2 platform. The goal of this work is to simplify the installation and upgrade process for i2b2. Specifically, we have containerized the core components of the platform, and evaluated the containers for ease of installation.

Results: We developed three Docker container images: WildFly, database, and web, to encapsulate the three major deployment components of i2b2. These containers isolate the core functionalities of the i2b2 platform, and work in unison to provide its functionalities. Our evaluations indicate that i2b2 containers function successfully on the Linux platform. Our results demonstrate that the containerized components work out-of-the-box, with minimal configuration.

Conclusions: Containerization offers the potential to package the i2b2 platform components into standalone executable packages that are agnostic to the underlying host operating system. By releasing i2b2 as a Docker container, we anticipate that users will be able to create a working i2b2 hive installation without the need to download, compile, and configure individual components that constitute the i2b2 cells, thus making this platform accessible to a greater number of institutions.
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http://dx.doi.org/10.1186/s12911-018-0646-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6048900PMC
July 2018

Automating Installation of the Integrating Biology and the Bedside (i2b2) Platform.

Biomed Inform Insights 2018 4;10:1178222618777749. Epub 2018 Jun 4.

Massachusetts General Hospital, Boston, MA, USA.

Informatics for Integrating Biology and the Bedside (i2b2) is an open source clinical data analytics platform used at more than 150 institutions for querying patient data. An i2b2 installation (called hive) comprises several i2b2 cells that provide different functionalities. Given the complex architecture of i2b2 installation, creating a working installation of the platform is challenging for new users. This is despite the availability of extensive documentation for i2b2 and access to a large and active mailing list community of i2b2 users. To address this problem, we have created an automated installation package, called i2b2-quickstart, which automatically downloads the latest i2b2 source code and dependencies, and compiles and configures the i2b2 cells to create a functional i2b2 hive installation. This package will serve as a convenient starting point and reference implementation that will facilitate researchers in the installation and exploration of the i2b2 platform.
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http://dx.doi.org/10.1177/1178222618777749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5989048PMC
June 2018

Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial.

BMJ Qual Saf 2018 07 6;27(7):512-520. Epub 2017 Oct 6.

General Internal Medicine and Health Services Research, UCLA, Los Angeles, California, USA.

Background: Admission medication history (AMH) errors frequently cause medication order errors and patient harm.

Objective: To quantify AMH error reduction achieved when pharmacy staff obtain AMHs before admission medication orders (AMO) are placed.

Methods: This was a three-arm randomised controlled trial of 306 inpatients. In one intervention arm, pharmacists, and in the second intervention arm, pharmacy technicians, obtained initial AMHs prior to admission. They obtained and reconciled medication information from multiple sources. All arms, including the control arm, received usual AMH care, which included variation in several common processes. The primary outcome was severity-weighted mean AMH error score. To detect AMH errors, all patients received reference standard AMHs, which were compared with intervention and control group AMHs. AMH errors and resultant AMO errors were independently identified and rated by ≥2 investigators as significant, serious or life threatening. Each error was assigned 1, 4 or 9 points, respectively, to calculate severity-weighted AMH and AMO error scores for each patient.

Results: Patient characteristics were similar across arms (mean±SD age 72±16 years, number of medications 15±7). Analysis was limited to 278 patients (91%) with reference standard AMHs. Mean±SD AMH errors per patient in the usual care, pharmacist and technician arms were 8.0±5.6, 1.4±1.9 and 1.5±2.1, respectively (p<0.0001). Mean±SD severity-weighted AMH error scores were 23.0±16.1, 4.1±6.8 and 4.1±7.0 per patient, respectively (p<0.0001). These AMH errors led to a mean±SD of 3.2±2.9, 0.6±1.1 and 0.6±1.1 AMO errors per patient, and mean severity-weighted AMO error scores of 6.9±7.2, 1.5±2.9 and 1.2±2.5 per patient, respectively (both p<0.0001).

Conclusions: Pharmacists and technicians reduced AMH errors and resultant AMO errors by over 80%. Future research should examine other sites and patient-centred outcomes.

Trial Registration Number: NCT02026453.
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http://dx.doi.org/10.1136/bmjqs-2017-006761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5912995PMC
July 2018

Physician experiences with clinical pharmacists in primary care teams.

J Am Pharm Assoc (2003) 2017 Nov - Dec;57(6):686-691. Epub 2017 Aug 12.

Background: Improving medication management is an important component of comprehensive care coordination for health systems. The Managing Your Medication for Education and Daily Support (MyMeds) medication management program at the University of California Los Angeles addresses medication management issues by embedding trained clinical pharmacists in primary care practice teams.

Objectives: The aim of this work was to examine and explore physician opinions about the clinical pharmacist program and identify common themes among physician experiences as well as barriers to integration of clinical pharmacists into primary care practice teams.

Methods: We conducted a mixed quantitative-qualitative methods study consisting of a cross-sectional physician survey (n = 69) as well as semistructured one-on-one physician interviews (n = 13). Descriptive statistics were used to summarize survey responses, and standard qualitative content-analysis methods were used to identify major themes from the interviews.

Results: The survey response rate was 61%; 13 interviews were conducted. Ninety percent of survey respondents agreed or strongly agreed that having the pharmacist in the office makes management of the patient's medication more efficient, 93% agreed or strongly agreed that pharmacist recommendations are clinically helpful, 71% agreed or strongly agreed that having access to a pharmacist has increased their knowledge about medications they prescribe, and 75% agreed or strongly agreed that having a pharmacist as part of the primary care team has made their job easier. Qualitative interviews corroborated survey findings, and physicians highlighted the value of the clinical pharmacist's communication, team care and expanded roles, and medication management.

Conclusion: Primary care physicians valued the integrated pharmacy program highly, particularly its features of strong communication, expanded roles, and medication management. Pharmacists were viewed as integral members of the health care team.
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http://dx.doi.org/10.1016/j.japh.2017.06.018DOI Listing
June 2018

Chronic pain among patients with opioid use disorder: Results from electronic health records data.

J Subst Abuse Treat 2017 06 9;77:26-30. Epub 2017 Mar 9.

University of California, Los Angeles, United States.

Purpose: To examine the prevalence of comorbid chronic pain among patients with opioid use disorder (OUD) and to compare other comorbidities (substance use disorder (SUD), mental health disorders, health/disease conditions) among patients in four categories: no chronic pain (No Pain), OUD prior to pain (OUD First), OUD and pain at the same time (Same Time), or pain condition prior to OUD (Pain First).

Methods: Using an electronic health record (EHR) database from 2006-2015, the study assessed 5307 adult patients with OUD in a large healthcare system; 35.6% were No Pain, 9.7% were OUD First, 14.9% were Same Time, and 39.8% were Pain First.

Results: Most OUD patients (64.4%) had chronic pain conditions, and among them 61.8% had chronic pain before their first OUD diagnosis. Other SUDs occurred more frequently among OUD First patients than among other groups in terms of alcohol (33.4% vs. 25.4% for No Pain, 20.7% for Same Time, and 20.3% for Pain First), cocaine (19.0%, vs. 13.8%, 9.4%, 7.1%), and alcohol or drug-induced disorders. OUD First patients also had the highest rates of HIV (4.7%) and hepatitis C virus (HCV; 28.2%) among the four groups. Pain First patients had the highest rates of mental disorder (81.7%), heart disease (72.0%), respiratory disease (68.4%), sleep disorder (41.8%), cancer (23.4%), and diabetes (19.3%).

Conclusions: The alarming high rates of chronic pain conditions occurring before OUD and the associated severe mental health and physical health conditions require better models of assessment and coordinated care plans to address these complex medical conditions.
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http://dx.doi.org/10.1016/j.jsat.2017.03.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5424616PMC
June 2017

High Mortality Among Patients With Opioid Use Disorder in a Large Healthcare System.

J Addict Med 2017 Jul/Aug;11(4):315-319

University of California, Los Angeles, CA (Y-IH, LJM, KM, DSB, YZ, DL, DH); Veterans Affairs Puget Sound Health Care System, Seattle, WA (AJS).

Objectives: Elevated mortality has been observed among individuals with opioid use disorder (OUD) treated in addiction specialty clinics or programs. Information about OUD patients in general healthcare settings is needed in light of the current effort to integrate addiction services into primary healthcare systems. This study examined mortality rates, causes of death, and associated risk factors among patients with OUD in a large general healthcare system.

Methods: Mortality data were linked with electronic health records of 2576 OUD patients cared for in a large university health system from 2006 to 2014.

Results: There were 465 deaths confirmed (18.1% of the study participants), corresponding to a crude mortality rate of 48.6 per 1000 person-years and standardized mortality ratio of 10.3 (95% confidence interval [CI] 9.4-11.3). Drug overdose and disorder (19.8%), cardiovascular diseases (17.4%), cancer (16.8%), and infectious diseases (13.5%, including 12% hepatitis C virus [HCV]) were the leading causes of death. HCV (hazard ratio [HR] 1.99, 95% CI 1.62-2.46) and alcohol use disorder (HR 1.27, 95% CI 1.05-1.55) were 2 clinically important indicators of overall mortality risk. Tobacco use disorder (adjusted HR [AHR] 2.58, 95% CI 1.60-4.17) was associated with increased risk of cardiovascular death, HCV infection (AHR 2.55, 95% CI 1.52-4.26) with cancer mortality risk, and HCV (AHR 1.92, 95% CI 1.03-3.60) and alcohol use disorder (AHR 5.44, 95% CI 2.95-10.05) with liver-related mortality risk.

Conclusions: Patients with OUD in a general healthcare system demonstrated alarmingly high morbidity and mortality, which challenges healthcare systems to find innovative ways to identify and treat patients with substance use disorder.
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http://dx.doi.org/10.1097/ADM.0000000000000312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5930020PMC
April 2017

Effects of a Laboratory Health Information Exchange Intervention on Antiretroviral Therapy Use, Viral Suppression, and Racial/Ethnic Disparities.

J Acquir Immune Defic Syndr 2017 07;75(3):290-298

*Division of General Internal Medicine and Health Services Research, Department of Medicine, School of Medicine, University of California, Los Angeles, CA; Departments of †Health Policy and Management; ‡Community Health Sciences, School of Public Health, University of California, Los Angeles, CA; and §St. Mary's Medical Center, Long Beach, CA.

Background: Although antiretroviral therapy (ART) is available to treat HIV+ persons and prevent transmission, ineffective delivery of care may delay ART use, impede viral suppression (VS), and contribute to racial/ethnic disparities along the continuum of care. This study tested the effects of a bi-directional laboratory health information exchange (LHIE) intervention on each of these outcomes.

Methods: We used a quasi-experimental, interrupted time-series design to examine whether the LHIE intervention improved ART use and VS, and reduced racial/ethnic disparities in these outcomes among HIV+ patients (N = 1181) in a comprehensive HIV/AIDS clinic in Southern California. Main outcome measures were ART pharmacy fill and HIV viral load laboratory data extracted from the medical records over 3 years. Race/ethnicity and an indicator for the intervention (after vs. before) were the main predictors. The analysis involved 3-stage, multivariable logistic regression with generalized estimating equations.

Results: Overall, the intervention predicted greater odds of ART use (odds ratio [OR] = 2.50; 95% confidence interval: 2.29 to 2.73; P < 0.001) and VS (OR = 1.12; 95% confidence interval: 1.04 to 1.21; P < 0.05) in the final models that included sociodemographic, behavioral, and clinical covariates. Before the intervention, there were significant black/white disparities in ART use OR = 0.75 (0.58-0.98; P = 0.04) and VS OR = 0.75 (0.61-0.92; P = 0.001). After the intervention, the black/white disparities decreased after adjusting for sociodemographics and the number of HIV care visits, and Latinos had greater odds than whites of ART use and VS, adjusting for covariates.

Conclusions: The intervention improved overall ART treatment and VS, and reduced black/white disparities. LHIE interventions may hold promise if implemented among similar patients.
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http://dx.doi.org/10.1097/QAI.0000000000001385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478385PMC
July 2017

A Time and Motion Study of Pharmacists and Pharmacy Technicians Obtaining Admission Medication Histories.

J Hosp Med 2017 03;12(3):180-183

Department of Medicine, Division of General Internal Medicine, Cedars-Sinai Health System, Los Angeles, CA USA.

Pharmacists' admission medication histories (AMHs) are known to reduce adverse drug events (ADEs). Pharmacist-supervised pharmacy technicians (PSPTs) have also been used in this role. Nonetheless, few studies estimate the costs of utilizing PSPTs to obtain AMHs. We used time and motion methodology to study the time and cost required for pharmacists and PSPTs to obtain AMHs for patients at high risk for ADEs. Pharmacists and PSPTs required 58.5 (95% confidence interval [CI], 46.9-70.1) and 79.4 (95% CI, 59.1-99.8) minutes per patient, respectively (P = 0.14). PSPT-obtained AMHs also required 26.0 (95% CI, 14.9-37.1) minutes of pharmacist supervision per patient. Based on 2015 US Bureau of Labor Statistics wage data, we estimated the cost of having pharmacists and PSPTs obtain AMHs to be $55.91 (95% CI, 44.9-67.0) and $45.00 (95% CI, 29.7-60.4), respectively, which included pharmacist supervisory cost, per patient (P = 0.32). Thus, we found no statistically significant difference in time or cost between the two provider types. Journal of Hospital Medicine 2017;12:180-183.
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http://dx.doi.org/10.12788/jhm.2702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866092PMC
March 2017

Implementing Community Engagement as a Mission at the David Geffen School of Medicine at the University of California, Los Angeles.

J Health Care Poor Underserved 2016 ;27(1):8-21

This manuscript describes the development and implementation of community engagement as a mission at UCLA's David Geffen School of Medicine (DGSOM) and UCLA Health System, and summarizes survey results documenting existing community-engaged projects and interest between 2010 to 2013.
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http://dx.doi.org/10.1353/hpu.2016.0009DOI Listing
April 2018

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors.

J Am Med Inform Assoc 2016 09 17;23(5):942-50. Epub 2016 Jan 17.

Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA, USA Institute for Clinical Evaluative Sciences, Toronto, Canada Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA University Health Network, Toronto, Canada.

Objective: We sought to assess the potential of a widely available source of electronic medication data to prevent medication history errors and resultant inpatient order errors.

Methods: We used admission medication history (AMH) data from a recent clinical trial that identified 1017 AMH errors and 419 resultant inpatient order errors among 194 hospital admissions of predominantly older adult patients on complex medication regimens. Among the subset of patients for whom we could access current Surescripts electronic pharmacy claims data (SEPCD), two pharmacists independently assessed error severity and our main outcome, which was whether SEPCD (1) was unrelated to the medication error; (2) probably would not have prevented the error; (3) might have prevented the error; or (4) probably would have prevented the error.

Results: Seventy patients had both AMH errors and current, accessible SEPCD. SEPCD probably would have prevented 110 (35%) of 315 AMH errors and 46 (31%) of 147 resultant inpatient order errors. When we excluded the least severe medication errors, SEPCD probably would have prevented 99 (47%) of 209 AMH errors and 37 (61%) of 61 resultant inpatient order errors. SEPCD probably would have prevented at least one AMH error in 42 (60%) of 70 patients.

Conclusion: When current SEPCD was available for older adult patients on complex medication regimens, it had substantial potential to prevent AMH errors and resultant inpatient order errors, with greater potential to prevent more severe errors. Further study is needed to measure the benefit of SEPCD in actual use at hospital admission.
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http://dx.doi.org/10.1093/jamia/ocv171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997032PMC
September 2016

Effectiveness of a smartphone application for weight loss compared with usual care in overweight primary care patients: a randomized, controlled trial.

Ann Intern Med 2014 Nov;161(10 Suppl):S5-12

Background: Many smartphone applications (apps) for weight loss are available, but little is known about their effectiveness.

Objective: To evaluate the effect of introducing primary care patients to a free smartphone app for weight loss.

Design: Randomized, controlled trial. (ClinicalTrials.gov: NCT01650337).

Setting: 2 academic primary care clinics.

Patients: 212 primary care patients with body mass index of 25 kg/m2 or greater.

Intervention: 6 months of usual care without (n = 107) or with (n = 105) assistance in downloading the MyFitnessPal app (MyFitnessPal).

Measurements: Weight loss at 6 months (primary outcome) and changes in systolic blood pressure and behaviors, frequency of app use, and satisfaction (secondary outcomes).

Results: After 6 months, weight change was minimal, with no difference between groups (mean between-group difference, -0.30 kg [95% CI, -1.50 to 0.95 kg]; P = 0.63). Change in systolic blood pressure also did not differ between groups (mean between-group difference, -1.7 mm Hg [CI, -7.1 to 3.8 mm Hg]; P = 0.55). Compared with patients in the control group, those in the intervention group increased use of a personal calorie goal (mean between-group difference, 2.0 d/wk [CI, 1.1 to 2.9 d/wk]; P < 0.001), although other self-reported behaviors did not differ between groups. Most users reported high satisfaction with MyFitnessPal, but logins decreased sharply after the first month.

Limitations: Despite being blinded to the name of the app, 14 control group participants (13%) used MyFitnessPal. In addition, 32% of intervention group participants and 19% of control group participants were lost to follow-up at 6 months. The app was given to patients by research assistants, not by physicians.

Conclusion: Smartphone apps for weight loss may be useful for persons who are ready to self-monitor calories, but introducing a smartphone app is unlikely to produce substantial weight change for most patients.

Primary Funding Source: Robert Wood Johnson Foundation Clinical Scholars Program, National Institutes of Health/National Center for Advancing Translational Sciences for the UCLA Clinical and Translational Science Institute, and the Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly under the National Institutes of Health/National Institute on Aging.
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http://dx.doi.org/10.7326/M13-3005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422872PMC
November 2014

Local public health department adoption and use of electronic health records.

J Public Health Manag Pract 2015 Jan-Feb;21(1):E20-8

School for the Science of Health Care Delivery, College of Health Solutions, Arizona State University, Phoenix (Dr McCullough); Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles (Dr Zimmerman); General Internal Medicine, Geffen School of Medicine, University of California, Los Angeles (Dr Bell); and Division of Health Policy & Management, School of Public Health, University of California, Berkeley, Berkeley, California (Dr Rodriguez).

Context: Electronic health records (EHRs) may help local health departments (LHDs) to improve services and thereby promote and protect population health. Yet, little is known about nationwide trends and correlates of EHR use by LHDs.

Objective: We examine relative contributions of LHD finances, leadership, and governance to EHR adoption and use from 2010 to 2013. The impact of LHD service provision and meaningful use factors on EHR use is explored in depth.

Design: Combining data from the National Association of County & City Health Officials Profile survey and the Area Health Resource File, logistic regression models were used to examine EHR use in 2013. Multinomial logistic models examined EHR adoption, use, or discontinuation from 2010 to 2013.

Participants: EHR usage data were available for 514 and 488 LHDs in 2010 and 2013, respectively. A total of 117 LHDs had data for both 2010 and 2013.

Main Outcome Measures: Outcomes included dichotomized measures of LHD self-reported use of EHRs in 2010 and 2013. For LHDs with 2 years of data, a 4-category variable measuring self-reported EHR use, nonuse, adoption, or discontinuation was analyzed.

Results: Overall LHD EHR use did not increase significantly between 2010 (19.3%) and 2013 (22.0%). While 15% of LHDs reported adopting EHRs from 2010 to 2013, another 8.5% reported discontinuing use of EHRs during this time. Likelihood of EHR use was strongly associated with LHD clinical service characteristics, per capita expenditures, and state governance structure.

Conclusions: EHRs do not appear to be rapidly diffusing across LHDs, and retention of current systems may be a concern. Given trends away from clinical service provision and other pressing demands for LHD resources, the benefits of EHR adoption are unclear.
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http://dx.doi.org/10.1097/PHH.0000000000000143DOI Listing
November 2016

Electronic health information exchange in underserved settings: examining initiatives in small physician practices & community health centers.

BMC Health Serv Res 2014 Sep 21;14:415. Epub 2014 Sep 21.

School for the Science of Health Care Delivery, College of Health Solutions, Arizona State University, Phoenix, AZ, USA.

Background: Health information exchange (HIE) is an important tool for improving efficiency and quality and is required for providers to meet Meaningful Use certification from the United States Centers for Medicare and Medicaid Services. However widespread adoption and use of HIE has been difficult to achieve, especially in settings such as smaller-sized physician practices and federally qualified health centers (FQHCs). We assess electronic data exchange activities and identify barriers and benefits to HIE participation in two underserved settings.

Methods: We conducted key-informant interviews with stakeholders at physician practices and health centers. Interviews were recorded, transcribed, and then coded in two waves: first using an open-coding approach and second using selective coding to identify themes that emerged across interviews, including barriers and facilitators to HIE adoption and use.

Results: We interviewed 24 providers, administrators and office staff from 16 locations in two states. They identified barriers to HIE use at three levels-regional (e.g., lack of area-level exchanges; partner organizations), inter-organizational (e.g., strong relationships with exchange partners; achieving a critical mass of users), and intra-organizational (e.g., type of electronic medical record used; integration into organization's workflow). A major perceived benefit of HIE use was the improved care-coordination clinicians could provide to patients as a direct result of the HIE information. Utilization and perceived benefit of the exchange systems differed based on several practice- and clinic-level factors.

Conclusions: The adoption and use of HIE in underserved settings appears to be impeded by regional, inter-organizational, and intra-organizational factors and facilitated by perceived benefits largely at the intra-organizational level. Stakeholders should consider factors both internal and external to their organization, focusing efforts in changing modifiable factors and tailoring HIE efforts based on all three categories of factors. Collective action between organizations may be needed to address inter-organizational and regional barriers. In the interest of facilitating HIE adoption and use, the impact of interventions at various levels on improving the use of electronic health data exchange should be tested.
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http://dx.doi.org/10.1186/1472-6963-14-415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181433PMC
September 2014