Medical Record Review Data Research Articles

Clinical outcomes after use of checkpoint inhibitor immunotherapies in people with multiple sclerosis.

Immune checkpoint inhibitors (ICIs) represent a novel class of agents approved for the treatment of several cancers and progressive multifocal leukoencephalopathy (PML). However, due to the risk of autoimmune side effects, their use in people with autoimmune diseases such as multiple sclerosis (MS) has been limited. To characterize outcomes in a cohort of adults with MS who received ICIs. A single-center retrospective review of medical record data was performed for people with MS treated with ICIs. Seven people with MS were identified, with a mean (SD) age at ICI use of 55.4 (13.7) years and a mean MS duration of 18.2 (12.2) years. Six were treated for cancer; 1 was treated for PML. After mean (SD) follow-up of 1.76 (2.15) years after ICI, outcomes are: no evidence of disease (2), residual metastatic disease (1), death due to cancer (1), death due to PML (1), and lost to follow-up (2). Notably, 0 out of 7 patients experienced an MS relapse; two out of six had new asymptomatic demyelinating magnetic resonance imaging lesions. In the three patients with expanded disability status scale (EDSS) scores at baseline and follow-up, EDSS remained stable (mean delta 0.13). In this cohort, no people with MS experienced clinical relapses and one-third experienced asymptomatic radiological activity following ICI treatment.

Prevalence and clinical features of thoracolumbar intervertebral disc-associated epidural hemorrhage in dogs.

BackgroundIntervertebral disc‐associated epidural hemorrhage (EH) in dogs is a poorly understood neurological condition.ObjectiveTo compare the clinical presentation, magnetic resonance imaging (MRI) changes, and clinical outcome of dogs with acute thoracolumbar intervertebral disc herniation (TL‐IVDH) with and without EH.AnimalsOne hundred sixty client‐owned dogs that underwent MRI and hemilaminectomy for acute TL‐IVDH at a private practice in Colorado, including 63 dogs with EH and 97 dogs without EH.MethodsRetrospective review of medical record data from 160 dogs presenting sequentially to a single practice with acute TL‐IVDH that underwent MRI and hemilaminectomy surgery.ResultsSixty‐three of 160 (39%) dogs had confirmed EH. French Bulldogs were significantly overrepresented (23/63; odds ratio [OR]: 4.1; 95% confidence interval [CI]: 1.8‐9.0; P < .001) of the EH cases. Dogs with EH were more likely to present with clinical signs less than 48 hours than were dogs without EH (24‐48 vs 48‐72 hours; OR: 2.4; 95% CI: 1.2‐4.6; P = .02) and were more likely to be nonambulatory on presentation (OR: 2.1; 95% CI: 1.0‐4.1; P = .04). Dogs with EH were more likely to have <50% cross‐sectional spinal cord compression than dogs without EH (OR: 2.3 vs. 0.4; 95% CI: 1.2‐4.4 and 0.2‐0.9, respectively), longer longitudinal spinal cord compression (3 spaces vs 1 space, P < .001), and greater intrinsic spinal cord change (grade 3/severe vs grade 1/mild; P < .001) based on MRI. The location of the intervertebral disc herniation in French Bulldogs with EH was more likely to be thoracolumbar (OR: 10.8; 95% CI: 2.1‐55.7; P = .03).Conclusions and Clinical ImportanceFrench Bulldogs have a high prevalence of intervertebral disc‐associated EH. Dogs with EH have a shorter clinical course and are more likely to be nonambulatory on initial presentation.

Is It Cost Effective to Obtain Fungal and Acid-Fast Bacillus Cultures during Spine Debridement?

Study DesignRetrospective study.PurposeTo identify the rate of positive acid-fast bacillus (AFB) and fungal cultures during spine debridement, determine whether these infections are more common in certain spine segments, identify comorbidities associated with these infections, and determine whether the universal performance of fungal and AFB cultures during spine debridement is cost effective.Overview of LiteratureSpine infections are associated with significant morbidity and costs. Spine fungal and AFB infections are rare, but their incidence has not been well documented. As such, guidance regarding sample procurement for AFB and fungal cultures is lacking.MethodsA retrospective review of medical record data from patients undergoing spine irrigation and debridement (I&D) at the University of Missouri over a 10-year period was performed.ResultsFor patients undergoing spine I&D, there was a 4% incidence of fungal infection and 0.49% rate of AFB infection. Steroid use was associated with a higher likelihood (odds ratio, 5.62; 95% confidence interval, 1.33–23.75) of positive fungal or AFB cultures. Although not significant, patients undergoing multiple I&D procedures had higher rates of positive fungal cultures during each subsequent I&D. Over a 10-year period, if fungal cultures are obtained for each patient, it would cost our healthcare system $12,151.58. This is compared to an average cost of $177,297.64 per missed fungal infection requiring subsequent treatment.ConclusionsSpine fungal infections occur infrequently at a rate of 4%. Physicians should strongly consider obtaining samples for fungal cultures in patients undergoing spine I&D, especially those using steroids and those undergoing multiple I&Ds. Our AFB culture rates mirror the false positive rates seen in previous orthopedic literature. It is unlikely to be cost effective to send for AFB cultures in areas with low endemic rates of AFB.

Annual and durable HIV retention in care and viral suppression among patients of Peter Ho Clinic, 2013-2017.

To determine rates of annual and durable retention in medical care and viral suppression among patients enrolled in the Peter Ho Clinic, from 2013-2017. This is a retrospective review of medical record data in an urban clinic, located in Newark, New Jersey, a high prevalence area of persons living with HIV. Viral load data were electronically downloaded, in rolling 1-year intervals, in two-month increments, from January 1, 2013 to December 31, 2019. Three teams were established, and every two months, they were provided with an updated list of patients with virologic failure. Retention and viral suppression rates were first calculated for each calendar-year. After patients were determined to be retained/suppressed annually, the proportion of patients with durable retention and viral suppression were calculated in two, three, four, five and six-year periods. Descriptive statistics were used to summarize sample characteristics by retention in care, virologic failure and viral suppression with Pearson Chi-square; p-value <0.05 was statistically significant. Multiple logistic regression models identified patient characteristics associated with retention in medical care, virologic failure and suppression. As of December 31, 2017, 1000 (57%) patients were retained in medical care of whom 870 (87%) were suppressed. Between 2013 and 2016, decreases in annual (85% to 77%) and durable retention in care were noted: two-year (72% to 70%) and three-year (63% to 59%) periods. However, increases were noted for 2017, in annual (89%) and durable retention in the two-year period (79%). In the adjusted model, when compared to current patients, retention in care was less likely among patients reengaging in medical care (adjusted Odds Ratio (aOR): 0.77, 95% CI: 0.61-0.98) but more likely among those newly diagnosed from 2014-2017 (aOR: 1.57, 95% CI: 1.08-2.29), compared to those in care since 2013. A higher proportion of patients re-engaging in medical care had virologic failure than current patients (56% vs. 47%, p < 0.0001). As age decreased, virologic failure was more likely (p<0.0001). Between 2013 and 2017, increases in annual (74% to 87%) and durable viral suppression were noted: two-year (59% to 73%) and three-year (49% to 58%) periods. Viral suppression was more likely among patients retained in medical care up to 2017 versus those who were not (aOR: 5.52, 95% CI: 4.08-7.46). Those less likely to be suppressed were 20-29 vs. 60 years or older (aOR: 0.52, 95% CI: 0.28-0.97), had public vs. private insurance (aOR: 0.29, 95% CI: 0.15-0.55) and public vs. private housing (aOR: 0.59, 95% CI: 0.40-0.87). Restructuring clinical services at this urban clinic was associated with improved viral suppression. However, concurrent interventions to ensure retention in medical care were not implemented. Both retention in care and viral suppression interventions should be implemented in tandem to achieve an end to the epidemic. Retention in care and viral suppression should be measured longitudinally, instead of cross-sectional yearly evaluations, to capture dynamic changes in these indicators.

Use of AM-PAC “6 Click” Scores to Predict Discharge Location Post-hospitalization in Adults With Cardiovascular Disease: A Retrospective Cohort Study

Purpose: Scores on the Activity Measure for Post-Acute Care (AMPAC) 6-Clicks are used in the hospital setting as functional measures to guide care and discharge recommendations. However, limited evidence exists regarding the accuracy of AMPAC 6-Clicks in predicting discharge location for those with cardiovascular disease (CVD). The purpose of this study was to determine the accuracy of AM-PAC 6-Clicks scores to predict discharge to home/self-care from an acute care hospital in adults with CVD. Methods: A retrospective review of medical record data comprised of AM-PAC 6-Clicks basic mobility or daily activity scores at physical or occupational therapy evaluation and discharge was completed. Logistic regression analyses were performed to determine if 6-Clicks scores could predict discharge to home/self-care while controlling for age, insurance type, and length of stay. Receiver operating characteristic curves were created to determine the 6-Clicks scores with the best sensitivity/specificity to determine discharge to home/self-care. Results: Logistic regression models indicated that the basic mobility score at discharge from physical therapy services accounted for 71% of the variance in predicting discharge to home/self-care after controlling for covariates. The best 6-Clicks non-converted cutoff value for accuracy of discharge to home/self-care was 20.50 for daily activity and 18.5 for basic mobility completed at discharge. Conclusions: Basic mobility scores at discharge are significant predictors of discharge to home/self-care in older adults with CVD. Further inpatient rehabilitation services should be considered for patients who score less than 18.5 (converted = 44.5) on the basic mobility or 20.50 (converted = 43.15) on the daily activity measures.

Protocol for project recovery after cardiac surgery: a single-center cohort study leveraging digital platform to characterise longitudinal patient-reported postoperative recovery patterns

IntroductionImproving postoperative patient recovery after cardiac surgery is a priority, but our current understanding of individual variations in recovery and factors associated with poor recovery is limited. We are using...

MP03-06 ASSOCIATION OF URINARY STONE DISEASE WITH KIDNEY FUNCTION DECLINE

INTRODUCTION AND OBJECTIVE: Prior studies have shown significant differences in glomerular filtration rate (GFR) between stone formers and non-stone formers. There is evidence that nephrolithiasis is a risk factor for chronic kidney disease (CKD). The role of kidney function in kidney stone formation however largely remains unexplored. The objective of this study is to investigate differences in kidney function decline between stone formers and non-stone formers over time. METHODS: A retrospective study was undertaken using de-identified patient data at our tertiary care center. Serum creatinine values of adults (age ≥ 18) were used to calculate GFR using the CKD-EPI creatinine equation. The primary outcome was change in GFR per year using an adjusted linear model. An adjusted cox-model was used to calculate the average risk of stone formation associated with GFR decline in stone formers based on date of initial nephrolithiasis diagnosis. Our secondary outcome was GFR change post stone formation stratified by surgical versus non-surgical intervention. RESULTS: Complete data for analysis was obtained from 3,450 stone formers and 112,072 non-stone formers after review of medical record data between 2010 and 2019. Stone formers had an overall GFR decline of 2.8 cc/min per year (p-value < 0.001) compared to a decline of 0.04 cc/min per year (p-value = 0.38) in non-stone forming patients. A fully adjusted cox-model indicated, on average, each 1 cc/min decline in GFR was associated with an increased risk of stone development in the following 2 years by 3.7%. Stone formers who underwent surgical intervention (PNL, URS, or SWL) had stable GFR post-operatively at 1 year. Patients who did not undergo surgical intervention had GFR decline of 0.82 cc/min CI [-1.56, -0.08] at 1 year (p-value = 0.03). CONCLUSIONS: A decline in GFR is associated with risk of kidney stone presentation up to 2 years prior to a stone event. This suggests that upstream changes in the renal papilla which affect GFR also may be contributing to mineralization. Kidney function decline could be used as a possible predictive tool for risk of stone formation. Additionally, surgical intervention is associated with preservation of GFR within one year after stone event. Clinically, unexplained GFR decline should increase suspicion for nephrolithiasis and appropriate evaluation and treatment should be considered.Source of Funding: none

Prevalence and characteristics of prediabetes in workers in industry.

To examine the prevalence of work stress and prediabetes in computer technology company employees; to analyse the relationships among stress, work stress, and prediabetes; and to explore the potential mediating effects sleep on the relationship between work stress and prediabetes. A descriptive, cross-sectional design was used. A convenience sample included employees from a large computer technology company in central Texas. Data collection during March-October 2015 included: retrospective electronic medical record review and online surveys. Electronic medical record review data included: height, weight, waist circumference, blood pressure, high-density lipids, triglycerides, and fasting glucose. Online surveys collected demographic, global stress, diet, exercise, coping, sleep and work stress data from participants. Spearman rho calculations analyzed associations between demographic, socio-cultural factors, health behaviours, work stress, and prediabetes variables. Logistic regression analyses identified probability variables. A structural equation model examined mediating variables. Prediabetes prevalence was lower and prevalence of work stress was higher in the participant sample than in the USA population. Findings suggested that low job imbalance increases the probability for prediabetes. Job imbalance was inversely related to prediabetes. Three variables increased the probability prediabetes: alcohol, job imbalance, and sleep. Sleep potentially modified the relationship between job imbalance and prediabetes. Participants were college-educated males working in white-collar, technical jobs. Participants had high rates of work stress. Job imbalance was inversely related to prediabetes, which challenges previous empirical data. Future research should continue to explore the relationship between work stress and prediabetes in this population. This study explored the relationship between work stress and prediabetes in a white-collar worker population in technical industry. Findings suggested that workers in industry have a unique type of stress. Nurses who learn to recognize the non-traditional risk factors for prediabetes can improve screening for prediabetes by including work stress and poor sleep questions.

A primary care learning collaborative to improve office systems and clinical management of pediatric asthma

Objective Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled. Methods The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven. Results This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures. Conclusions A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.

Characteristics and outcomes of patient presentations made by police to an Australian emergency department.

To describe and compare characteristics and outcomes of patient presentations brought in by police (BIBP) with those not BIBP (NBIBP) to one Australian ED. A retrospective observational study. All patient presentations to a tertiary hospital ED made during the period 8 October 2012 to 7 April 2013 were included. Routinely collected ED information data and medical record review data were used. ED care delivery for people BIBP from the watch house (WH) or other location was compared. Univariate comparison and multivariate logistic regression analyses were performed to identify the different characteristics and ED outcomes between BIBP and NBIBP groups. A total of 35 127 ED presentations occurred within the 6 month period; 392 (1.1%) were BIBP. Compared with those NBIBP, those BIBP were diagnosed with 'psychiatric' and 'toxicology-related' illnesses in higher proportions. Overlap in health conditions (primarily for physical health reasons) between those BIBP and NBIBP existed. Presentations BIBP from the WH reflected 'physical health emergencies' whereas presentations BIBP from other locations reflected 'behavioural emergencies'. Compared to those NBIBP, those BIBP had a longer wait to be seen (by about 5 min), longer ED length of stay (LOS) if not admitted (by about 20 min) but shorter ED LOS if admitted (by about 59 min). When adjusted for sex, age group and diagnosis, ED LOS (if admitted) and admission rate were statistically significant. For those BIBP, mental health related orders and alcohol breath tests were common. Patients BIBP were different to those NBIBP. Despite comprising a small proportion of overall ED attendances, they are a group where mental health and drug and alcohol issues are over-represented. Differences in ED care delivery for those BIBP highlights potential opportunities for pre-hospital healthcare interventions.

Improving Adolescent Depression Screening in Pediatric Primary Care

ObjectiveDepression among adolescents is a leading public health problem. Although screening for adolescent depression in primary care is strongly recommended, screening rates remain low. Effective quality improvement (QI) initiatives can facilitate change. This study aims to assess the impact of a QI learning collaborative on adolescent depression screening and initial plans of care in primary care. MethodsSeventeen pediatric-serving practices in Vermont participated in a QI learning collaborative aimed at improving practitioner knowledge and office systems around adolescent depression screening. Monthly medical record reviews provided monitoring of adolescent depression screening and initial plans of care over 7 months for QI. Randomly sampled annual medical record review data allowed comparison of screening and initial plans of care after the QI learning collaborative between participating and 21 control practices. ResultsAs practices improved their office systems around adolescent depression screening and initial plans of care, data showed marked improvement in depression screening at all 17 practices, from 34% to 97% over 7 months. Adolescents at participating practices had 3.5 times greater odds (95% confidence interval [CI], 1.14–10.98, P = .03) of being screened for depression and 37.5 times greater odds (95% CI, 7.67–183.48, P < .0005) of being screened with a validated tool than adolescents at control practices, accounting for patient characteristics. ConclusionsThere were significant within practice increases in adolescent depression screening after a QI learning collaborative, as well as in comparison with control practices 1 year later.

Predictors of outpatient resource utilization following ventral and incisional hernia repair.

Little is known about the predictors of increased ambulatory costs following open ventral and incisional hernia repair (VIHR); however, postoperative complications would be expected to be associated with an increased burden on outpatient resources. The purpose of this study is to evaluate the impact of perioperative factors on outpatient resource utilization following VIHR. With IRB approval, the surgery scheduling system was queried to identify all cases of VIHR done at our institution over 3years. Cases with other procedures done at time of VIHR were excluded. National Surgical Quality Improvement Program clinical data, physician billing data which included market and payor across cases, and medical record review data were combined and evaluated in order to quantify care and predictors of usage during the 6months postoperatively. Data were analyzed for 308 patients. Median patient age was 52years (SD=13.3), and over half were female. The number of outpatient visits to the surgical office varied from 0 to 18 [median=2; interquartile range (IQR)=1-3]. CDC Wound Class >1 was associated with increase of mean 1.4 visits (IQR: 0.5-2.3); p=0.003. Component separation, longer duration of operation, and increased mesh size were also predictive of increased number of office visits (p<0.01). Postoperative infected seroma/seroma requiring drainage added a mean 2.3 visits (IQR: 1.3-3.3), (p<0.001); and deep wound infection added a mean 3.9 visits (IQR: 1.9-5.9) (p<0.001). Postoperative complications confer a significant burden for patients and to the outpatient surgical office. In an era in which improved quality and cost-efficiency has become imperative, measures to decrease risk of postoperative complications particularly for more complex VIHR would be expected to decrease resource utilization and increase value of care.

Axitinib treatment among patients with mRCC in a U.S. community oncology setting: A retrospective study of 135 patients.

569 Background: We have previously reported differences in a variety of outcome measures between clinical trial and real world use of several therapies for advanced renal cell carcinoma (RCC) (Vogelzang NJ, et al. Clin Genitourin Cancer, 2015, Hutson TE et al. Lancet Oncol, 2013, Motzer RJ, et al. NEJM, 2013). In an attempt to better understand the real-world use of axitinib in patients (pts) with metastatic RCC (mRCC) after one prior systemic therapy, a retrospective study was conducted using the US Oncology’s (USON) iKnowMed electronic health records database and medical record review data. Methods: Eligibility criteria were: pts with mRCC ≥ 18 years of age at first diagnosis, treated with VEGFR-TKIs or immunotherapy including IL-2 and IFN as first line of therapy (LOT), received second or third line axitinib between 1/1/2012 and 10/31/2014, with ≥ 2 visits within the USON. LOT was defined based on treatment sequence. Dosing analysis included duration of therapy, dose change, and reasons for discontinuation. Results: 135 pts met eligibility criteria. The most common prior therapies were sunitinib (48.5%) and pazopanib (48.5%) for pts with axitinib as 2nd LOT (n=68), and everolimus (55.2%), temsirolimus (19.4%), and pazopanib (14.9%) for pts with axitinib as 3rdLOT (n=67). 80.7% (109) of pts started axitinib at 5mg BID, and 68.9% remained at this dose. 17.8% had a dose increase mainly due to physician’s choice and 13.3% a dose decrease mainly due to toxicity. The median duration of therapy was 4.57 months (mean 6.32, SD 5.91, range 0.03-35.49). Axitinib was discontinued in 91 (67.4%) pts, and the most common reasons for discontinuation were disease progression (39.3%) and toxicity (17.0%). Conclusions: In the community oncology setting, axitinib was commonly used in the 2nd and 3rd line setting for pts with mRCC. The usage pattern appears to be consistent with published NCCN guideline recommendations. Surprisingly and in contrast to our experience with other agents for RCC, dose changes were less common and duration of therapy was consistent with the pivotal clinical trial results. These findings suggest ease of use among community oncologists and patient tolerance are key features of axitinib.

Diabetes Mellitus Coding Training for Family Practice Residents.

Although physicians regularly use numeric coding systems such as the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to describe patient encounters, coding errors are common. One of the most complicated diagnoses to code is diabetes mellitus. The ICD-9-CM currently has 39 separate codes for diabetes mellitus; this number will be expanded to more than 50 with the introduction of ICD-10-CM in October 2015. To assess the effect of a 1-hour focused presentation on ICD-9-CM codes on diabetes mellitus coding. A 1-hour focused lecture on the correct use of diabetes mellitus codes for patient visits was presented to family practice residents at Doctors Hospital Family Practice in Columbus, Ohio. To assess resident knowledge of the topic, a pretest and posttest were given to residents before and after the lecture, respectively. Medical records of all patients with diabetes mellitus who were cared for at the hospital 6 weeks before and 6 weeks after the lecture were reviewed and compared for the use of diabetes mellitus ICD-9 codes. Eighteen residents attended the lecture and completed the pretest and posttest. The mean (SD) percentage of correct answers was 72.8% (17.1%) for the pretest and 84.4% (14.6%) for the posttest, for an improvement of 11.6 percentage points (P≤.035). The percentage of total available codes used did not substantially change from before to after the lecture, but the use of the generic ICD-9-CM code for diabetes mellitus type II controlled (250.00) declined (58 of 176 [33%] to 102 of 393 [26%]) and the use of other codes increased, indicating a greater variety in codes used after the focused lecture. After a focused lecture on diabetes mellitus coding, resident coding knowledge improved. Review of medical record data did not reveal an overall change in the number of diabetic codes used after the lecture but did reveal a greater variety in the codes used.

Potential for Deceased Donation Not Optimally Exploited

Most countries today promote living donation as an alternative to challenge the organ shortage from deceased donors. This seems justifiable provided the potential for deceased donation is optimally exploited. We used the Donor Action (DA) Medical Record Review (MRR) methodology in six countries, to measure whether the potential for heart-beating (HB) deceased donors was adequately converted to donation. Medical record review data were collected from 52,383 patients who died in 605 critical care units in 227 hospitals between January 2007 and December 2009. On a total of 17,903 ventilated patients aged younger than 76 years and without contraindications to HB donation, 4,855 cases met criteria for brain death (BD) diagnosis and were considered potential HB donors. On average, 24.8±15.9% was not identified as potential donor, 21.9% of identified cases was not referred as such to a procurement team, and in 11.3% of identified cases, no approached was offered with the option to donate. Average consent rates/family approaches or registry consultation was 69.1±14.5%, and average conversion of potential into actual donors was 42.1±7.3%. Over 57% of deceased potential donors in the study cohort were missed along the donation pathway because of nonidentification, no referral, no approach of relatives, or objections to donate. In countries with lower donation rates, expectedly more potential donors are missed proportionally. Efforts to increase the organ pool should therefore focus on optimizing clinical practices in deceased organ donation in addition to promoting living organ donation.

Abstract P270: Automating Processes to Expedite Medical Record Review in Research

Problem. Heart failure (HF) clinical trials often use medical record review data to determine HF related hospital events, such as emergency room visits and readmissions. However, reviewing medical records for each hospital event can be daunting. The purpose of this project was to expedite medical record review processes using an automated method for identifying potential HF related hospital events. Methods. A stepwise procedure was developed for obtaining electronic information of all consented HF clinical trial participants' hospital events. First, an electronic list of all study participants was generated from a study data base and electronically sent to the Medical Records department each month. Next, a list of all emergency room visits and hospitalizations, including admission and discharge dates, discharge disposition, and diagnosis and procedure codes was electronically generated by the Medical Records department. A trained cardiovascular research nurse reviewed the abstracted coding and billing data for each hospital event and identified specific codes potentially related to HF. Last, hospital events identified as meeting specific criteria were included in the medical record review. Results. Using the automated system, a total of 294 hospital events for 125 subjects were obtained from the Medical Records department during the initial 2 years of the clinical trial. Of these, 85 (29%) hospital events were identified as needing to undergo chart review. Thirty-three (39%) of the 85 charts that underwent blinded review were identified as being HF related hospital events. Conclusions. Automating procedures for obtaining hospital event information expedited both the systematic data review and chart review processes. In this study, combined use of automated processes for obtaining hospital event data and nurse review reduced the number of charts requiring blinded review by nearly 60%.

Evaluating the Efficacy of Lay Health Advisors for Increasing Risk-Appropriate Pap Test Screening: A Randomized Controlled Trial among Ohio Appalachian Women

Cervical cancer is a significant health disparity among women in Ohio Appalachia. The goal of this study was to evaluate the efficacy of a lay health advisor (LHA) intervention for improving Papanicolaou (Pap) testing rates, to reduce cervical cancer, among women in need of screening. Women from 14 Ohio Appalachian clinics in need of a Pap test were randomized to receive either usual care or an LHA intervention over a 10-month period. The intervention consisted of two in-person visits with an LHA, two phone calls, and four postcards. Both self-report and medical record review (MRR) data (primary outcome) were analyzed. Of the 286 women, 145 and 141 were randomized to intervention and usual care arms, respectively. According to MRR, more women in the LHA arm had a Pap test by the end of the study compared with those randomized to usual care (51.1% vs. 42.0%; OR = 1.44, 95% CI: 0.89-2.33; P = 0.135). Results of self-report were more pronounced (71.3% vs. 54.2%; OR = 2.10, 95% CI: 1.22-3.61; P = 0.008). An LHA intervention showed some improvement in the receipt of Pap tests among Ohio Appalachian women in need of screening. Although biases inherent in using self-reports of screening are well known, this study also identified biases in using MRR data in clinics located in underserved areas. LHA interventions show promise for improving screening behaviors among nonadherent women from underserved populations.

Medical Record Review Conduction Model for Improving Interrater Reliability of Abstracting Medical-Related Information

Medical record review (MRR) is often used in clinical research and evaluation, yet there is limited literature regarding best practices in conducting a MRR, and there are few studies reporting interrater reliability (IRR) from MRR data. The aim of this research was twofold: (a) to develop a MRR abstraction tool and standardize the MRR process and (b) to examine the IRR from MRR data. This study introduces the MRR-Conduction Model, which was used to implement a MRR, and examines the IRR between two abstractors who collected preinjury medical and psychiatric, incident-related medical and postinjury head symptom information from the medical records of 47 neurologically injured workers. Results showed that the percentage agreement was > or =85% and the unweighted kappa statistic was > or =.60 for most variables, indicating substantial IRR. An effective and reliable MRR to abstract medical-related information requires planning and time. The MRR-Conduction Model is proposed to guide the process of creating a MRR.

Triply-diagnosed patients in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study: patterns of home care use

Although AIDS is a chronic illness, little is known about the patterns and correlates of long-term care use among triply diagnosed HIV patients. We examined nursing and home care use among 1,045 participants in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site study of HIV-positive patients with at least one mental health and one substance disorder. Patient interviews and medical record review data were used to examine the average monthly cost of nursing home, formal home and informal home care. Multinomial logit and two-part regression models were used to identify correlates of the use of formal and informal home care and the number of informal home care hours used. During the three months prior to baseline, 2, 7 and 23% of participants used nursing home, formal home and informal home care, respectively. Patients who were better-educated, had higher incomes, had Medicaid insurance (with or without Medicare coverage) and whose transmission mode was homosexual sex had higher regression-adjusted probabilities of receiving any formal home care; Latinos and physically healthier patients had lower probabilities. Women and patients who abused drugs or alcohol (but not both) were more likely to receive informal care only. Overall, patients who were female, better-educated, physically or mentally sicker or single-substance abusers were more likely to receive any home care (either formal or informal), while those contracting HIV through heterosexual sex were less likely. Women received 28 more monthly hours of informal care than men and married patients received 31 more hours than unmarried patients. We conclude that at least one mutable policy factor (Medicaid insurance) is strongly associated with formal home care use among triply diagnosed patients. Further research is needed to explore possible implications for access among this vulnerable subpopulation.

Accuracy of Healthcare Worker Recall and Medical Record Review for Identifying Infectious Exposures to Hospitalized Patients

To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting. Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall. A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario. Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts. Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient-HCW pairs were not recorded in patients' medical records. Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.