Automated Chronic Obstructive Pulmonary Disease Phenotyping and Control Assessment in Primary Care: Retrospective Multicenter Study Using the Seleida Model

Background/Objectives: Managing chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) within the Spanish Sistema Nacional de Salud (SNS) presents significant challenges, particularly due to their high prevalence and poor disease control rates-approximately 45.1% for asthma and 63.2% for COPD. This study aims to develop a novel predictive model using electronic health records (EHRs) to estimate the likelihood of poor disease control in these patients, thereby enabling more efficient management in primary care settings. Methods: The Seleida project employed a bioinformatics approach to identify significant clinical variables from EHR data in primary care centers in Seville and Valencia. Statistically significant variables were incorporated into a logistic regression model to predict poor disease control in patients with asthma and COPD patients. Key variables included the number of short-acting β-agonist (SABA) and short-acting muscarinic antagonist (SAMA) canisters, prednisone courses, and antibiotic courses over the past year. Results: The developed model demonstrated high accuracy, sensitivity, and specificity in predicting poorly controlled disease in both asthma and COPD patients. These findings suggest that the model could serve as a valuable tool for the early identification of at-risk patients, allowing healthcare providers to prioritize and optimize resource allocation in primary care settings. Conclusions: Integrating this predictive model into primary care practice could enhance the proactive management of asthma and COPD, potentially improving patient outcomes and reducing the burden on healthcare systems. Further validation in diverse clinical settings is warranted to confirm the model's efficacy and generalizability.

To assess the current state of sex, sexual orientation, and gender identity (SSOGI) data collection options in US electronic health record (EHR) platforms. We utilized an anonymous survey distributed via purposive snowball sampling to assess EHR platforms across the United States. Of 90 surveys started, 41 (45.6%) were completed and used for data analysis. Respondents represented a geographically diverse sample of health care centers across the United States. EPIC was the most used EHR platform (70.7%) followed by Cerner (9.8%). Across reported platforms, a majority utilized structured fields to collect and document patient SSOGI data (n = 25, 61.0%). There was variability across platforms regarding SSOGI data elements collected. No platform collected all recommended SSOGI data elements. Significant variation exists across EHR platforms and across health care settings using the same EHR platform. National standards need to be followed for SSOGI data collection in EHR platforms.

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Background/Objectives: The overuse of short-acting β2-agonists (SABAs) has been associated with increased asthma morbidity and mortality, prompting changes in treatment guidelines. However, the role of frequent short-acting muscarinic antagonists (SAMAs) use remains poorly defined and unaddressed in current recommendations. This study offers the first real-world analysis of SAMA overuse in asthma, quantifying its association with exacerbation risk and healthcare utilization and comparing its predictive value to that of SABAs. Methods: A retrospective multicenter cohort study analyzed electronic health records (EHRs) from 132 adults with asthma in the Spanish National Health System (SNS). Associations between annual SAMA use and clinical outcomes were assessed using negative binomial regression and 5000-sample bootstrap simulations. Interaction and threshold models were applied to explore how SAMA use affected outcomes and identify clinically actionable cutoffs. Results: SAMA use was independently associated with a 19.2% increase in exacerbation frequency per canister and a nearly sixfold increase in the odds of experiencing ≥1 exacerbation (OR = 5.97; 95% CI: 2.43-14.66). An inflection point at 2.5 canisters/year marked the threshold beyond which annual exacerbations exceeded one. Increased SAMA use was also associated with a higher number of respiratory consultations and with more frequent prescriptions of systemic corticosteroids and antibiotics. The risk increased more sharply with SAMAs than with SABAs, and the lack of correlation between them suggests distinct clinical patterns underlying their use. Conclusions: SAMA use emerges as a digitally traceable and clinically meaningful indicator of asthma instability. While the associations observed are robust and consistent across multiple outcomes, they should be considered provisional due to the study's retrospective design and limited sample size. Replication in larger and more diverse cohorts is needed to confirm external validity. These findings support the integration of SAMA tracking into asthma management tools-alongside SABAs-to enable the earlier identification of uncontrolled disease and guide therapeutic adjustment.

Chronic obstructive pulmonary disease (COPD), is associated with an increased risk of myocardial infarction (MI), and additionally, cardiovascular disease is responsible for up to 1/3 of deaths in people with COPD. This may be attributable to the fact people with COPD are managed differently and have higher mortality after MI compared to people without COPD. One reason for the differences in management may be that prognostic risk scores after MI do not perform well in those with COPD. Another reason may be that acute exacerbations of COPD (AECOPD) are thought to be associated with a transiently increased risk of MI. The aims of this thesis are to: 1)systematically review the evidence for an increased risk of MI associated with COPD and AECOPD, and increased risk of death following MI for those with COPD; 2) investigate the potential contribution of differences in management after MI on differences in mortality; 3) investigate the performance of prognostic risk scores after MI for those with COPD; 4) validate the recording of AECOPD in UK electronic healthcare records (EHR); 5) investigate the recording of hospitalisations for AECOPD in UK primary and secondary care EHR; and 6) to conduct a self-controlled case series to investigate the risk of MI associated with AECOPD. This work showed an increased risk of MI associated with COPD independent of smoking, and evidence for an increased risk of death following hospital discharge for people with compared to those without COPD. This work demonstrated that differences in recognition and management of MI for those with COPD may explain some of the higher risk of death for COPD patients following MI. Additionally, the GRACE score (commonly used for risk stratification following MI) does not perform as well for COPD patients and may explain some of the differences in management. A validated algorithm was developed for identifying AECOPD both in primary care and resulting in hospital admission in electronic health records. Finally, using a self-controlled case series analysis, data showed that AECOPD is associated with increased risk of MI for approximately four weeks following AECOPD onset, and that the risk is modified by important patient characteristics.

No More Equivalence Trials for Antibiotics in Exacerbations of COPD, Please

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. 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. 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. 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. 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.

Bioactive lipids in emphysema. Decoding fat to reveal COPD phenotypes.

IntroductionReal-world evidence and comparison among commonly seen chronic obstructive pulmonary disease (COPD) phenotypes, i.e., asthma–COPD overlap (ACO), bronchiectasis–COPD overlap (BCO), and their coexistence (ABCO) have not been fully depicted, especially in Chinese patients.MethodsData were retrieved from an ongoing nationwide registry in hospitalized patients due to acute exacerbation of COPD in China (ACURE).ResultsOf the eligible 4,813 patients with COPD, 338 (7.02%), 492 (10.22%), and 63 (1.31%) were identified as ACO, BCO, and ABCO phenotypes, respectively. Relatively, the ABCO phenotype had a younger age with a median of 62.99 years [interquartile range (IQR): 55.93–69.48] and the COPD phenotype had an older age with a median of 70.15 years (IQR: 64.37–76.82). The BCO and COPD phenotypes were similar in body mass index with a median of 21.79 kg/m2 (IQR: 19.47–23.97) and 21.79 kg/m2 (IQR: 19.49–24.22), respectively. The COPD phenotype had more male gender (79.90%) and smokers (71.12%) with a longer history of smoking (median: 32.45 years, IQR: 0.00–43.91). The ACO and ABCO phenotypes suffered more prior allergic episodes with a proportion of 18.05 and 19.05%, respectively. The ACO phenotype exhibited a higher level of eosinophil and better lung reversibility. Moreover, the four phenotypes showed no significant difference neither in all-cause mortality, intensive care unit admission, length of hospital stay, and COPD Assessment Test score change during the index hospitalization, and nor in the day 30 outcomes, i.e., all-cause mortality, recurrence of exacerbation, all-cause, and exacerbation-related readmission.ConclusionsThe ACO, BCO, ABCO, and COPD phenotypes exhibited distinct clinical features but had no varied short-term prognoses. Further validation in a larger sample is warranted.

Inefficient electronic health record (EHR) usage increases the documentation burden on physicians and other providers, which increases cognitive load and contributes to provider burnout. Studies show that EHR efficiency sessions, optimization sprints, reduce burnout using a resource-intense five-person team. We implemented sprint-inspired one-on-one post-go-live efficiency training sessions (mini-sprints) as a more economical training option directed at providers. We evaluated a post-go-live mini-sprint intervention to assess provider satisfaction and efficiency. NorthShore University HealthSystem implemented one-on-one provider-to-provider mini-sprint sessions to optimize provider workflow within the EHR platform. The physician informaticist completed a 9-point checklist of efficiency tips with physician trainees covering schedule organization, chart review, speed buttons, billing, note personalization/optimization, preference lists, quick actions, and quick tips. We collected postsession survey data assessing for net promoter score (NPS) and open-ended feedback. We conducted financial analysis of pre- and post-mini-sprint efficiency levels and financial data. Seventy-six sessions were conducted with 32 primary care physicians, 28 specialty physicians, and 16 nonphysician providers within primary care and other areas. Thirty-seven physicians completed the postsession survey. The average NPS for the completed mini-sprint sessions was 97. The proficiency score had a median of 6.12 (Interquartile range (IQR): 4.71-7.64) before training, and a median of 7.10 (IQR: 6.25-8.49) after training. Financial data analysis indicates that higher level billing codes were used at a greater frequency post-mini-sprint. The revenue increase 12 months post-mini-sprint was $213,234, leading to a return of $75,559.50 for 40 providers, or $1,888.98 per provider in a 12-month period. Our data show that mini-sprint sessions were effective in optimizing efficiency within the EHR platform. Financial analysis demonstrates that this type of training program is sustainable and pays for itself. There was high satisfaction with the mini-sprint training modality, and feedback indicated an interest in further mini-sprint training sessions for physicians and nonphysician staff.

Background: Exacerbations of chronic obstructive pulmonary disease (COPD) are heterogeneous and different phenotypes were established. Less is known about exacerbations phenotypes in occupational COPD. Objective: To evaluate exacerbations phenotypes in COPD related to different occupational factors. Methods: Data on COPD exacerbations were collected during a 5-year period from 167 COPD subjects of whom 42 exposed to aromatic hydrocarbons 55 to dust and 70 tobacco smokers. Evaluation included hospitalizations, symptoms, lung function, induced sputum cytology. Pathogens in sputum were assessed by PCR and standard routine culture. Logistic regression and ANCOVA were used to explore the relationships. Results: COPD due to chemicals was associated negatively with all exacerbations OR, 0.2; 95% CI, 0.1-0.5 but positively with exacerbations requiring hospitalizations OR, 3.8; 95% CI, 1.7-8.4. Most of exacerbations in this group were eosinophilic (55%) or paucigranulocytic (31%) with greater FEV1 decline (151±10.2ml) and increase in mMRC score (1±0.5). COPD due to dust was associated negatively with exacerbations requiring hospitalizations OR, 0.3; 95% CI, 0.1-0.8. Most of exacerbations in COPD due to dust were paucigranulocytic (49%) or eosinophilic (31%) with less FEV1 decline (124±14.3 ml). Percentage of exacerbations caused by infection was 58% in COPD due to chemicals 71% in COPD due to dust and 85% in COPD due to tobacco smoke. Haemophilus influenza was more common for COPD due to tobacco smoke and Streptococcus pneumoniae for occupational COPD. Conclusions: Exacerbations of occupational COPD due to chemicals and due to dust have the potential of being distinct phenotypes.

Objective: To explore the role of pulmonary arterial pressure in chronic obstructive pulmonary disease (COPD) phenotypes based on cluster analysis and its prognostic value. Methods: Three hundred and nineteen patients admitted to Beijing Chaoyang Hospital and Xuanwu Hospital from April 2013 to April 2016 were recruited in the study. All the patients were older than 40 years old and in stable COPD. One-year follow-up was performed and the endpoint was acute exacerbation of COPD or all-cause mortality. Age, body mass index (BMI), smoking index, history of exacerbation, modified British medical research council (mMRC), forced expiratory volume in first second (FEV(1)), pulmonary arterial pressure and right ventricular transverse diameter measured by echocardiography were selected as cluster indicators to classify patients, survival analysis was performed. Results: Eight cluster indexes were converted into four independent principal components by principal component analysis (PCA), with a cumulative contribution rate of 70.1%. The extracted principal components were used for cluster analysis. Patients were divided into four categories, each contained different GOLD grades and had statistically significant differences in age, symptoms, degree of pulmonary function impairment and pulmonary arterial pressure (all P<0.001). The four categories were: class 1: young, pulmonary function damage was medium, lower pulmonary arterial pressure, good prognosis; class 2: elderly, pulmonary function damage was mild, higher pulmonary arterial pressure, poor prognosis; class 3: young, pulmonary function damage was serious, normal pulmonary arterial pressure, the best prognosis; class 4: elderly, pulmonary function damage was medium, pulmonary arterial pressure increased significantly, the worst prognosis. Conclusion: Cluster analysis based on pulmonary artery pressure can be used to identify COPD patients with different risk of acute exacerbation or death, suggesting that pulmonary hypertension as a COPD phenotype plays a role in prognostic assessment.

Barriers to expanding primary care roles for chiropractors: the role of chiropractic as primary care gatekeeper

As our population ages and the burden of chronic illness rises, there is increasing need to implement quality metrics that measure and benchmark care of the seriously ill, including the delivery of both primary care and specialty palliative care. Such metrics can be used to drive quality improvement, value-based payment, and accountability for population-based outcomes. In this article, we examine use of the electronic health record (EHR) as a tool to assess quality of serious illness care through narrative review and description of a palliative care quality metrics program in a large healthcare system. In the search for feasible, reliable, and valid palliative care quality metrics, the EHR is an attractive option for collecting quality data on large numbers of seriously ill patients. However, important challenges to using EHR data for quality improvement and accountability exist, including understanding the validity, reliability, and completeness of the data, as well as acknowledging the difference between care documented and care delivered. Challenges also include developing achievable metrics that are clearly linked to patient and family outcomes and addressing data interoperability across sites as well as EHR platforms and vendors. This article summarizes the strengths and weakness of the EHR as a data source for accountability of community- and population-based programs for serious illness, describes the implementation of EHR data in the palliative care quality metrics program at the University of Washington, and, based on that experience, discusses opportunities and challenges. Our palliative care metrics program was designed to serve as a resource for other healthcare systems. Although the EHR offers great promise for enhancing quality of care provided for the seriously ill, significant challenges remain to operationalizing this promise on a national scale and using EHR data for population-based quality and accountability.

Intimate partner violence (IPV) is a significant public health issue, with a 25% lifetime prevalence. Screening for IPV in primary care is a recommended practice whose effectiveness is debated. To assess the effect of an electronic health record (EHR)-based multifactorial intervention screening on the detection of IPV risk in primary care practice. This cluster randomized clinical trial used a stepped-wedge design to assign 15 family medicine primary care clinics in the Medical University of South Carolina Health System in the Charleston region to 3 matched blocks from October 6, 2020, to March 31, 2023. All women aged 18 to 49 years who were seen in these clinics participated in this study. A noninterruptive EHR alert combined with confidential screening by computer questionnaire using the EHR platform followed by risk assessment and a decision support template. The main outcomes were the rate at which patients were screened for IPV across the clinics and the rate at which patients at risk for IPV were detected by screening procedures. The study clinics cared for 8895 unique patients (mean [SD] age, 34.6 [8.7] years; 1270 [14.3%] with Medicaid or Medicare and 7625 [85.7%] with private, military, or other insurance) over the study period eligible for the screening intervention. The intervention had significant effects on the overall rate of screening for IPV, increasing the rate of screening from 45.2% (10 268 of 22 730 patient visits) to 65.3% (22 303 of 34 157 patient visits) when the noninterruptive alert was active (relative risk, 1.46 [95% CI, 1.44-1.49]; P < .001). The confidential screening process was more effective than baseline nurse-led oral screening at identifying patients reporting past-year IPV (130 of 8895 patients [1.5%] vs 9 of 17 433 patients [0.1%]). The intervention was largely effective in increasing screening adherence and the positive detection rate of IPV in primary care. A highly private approach to screening for IPV in primary care may be necessary to achieve adequate detection rates while addressing potential safety issues of patients experiencing IPV. ClinicalTrials.gov Identifier: NCT06284148.