Electronic Health Record Review Research Articles

Prolonged post-operative hydrocodone usage due to psychotropic drug interaction.

To explore pain outcomes in patients prescribed hydrocodone and psychotropic medications with or without CYP2D6 inhibition activity. Patients hospitalized for lower/limited upper extremity injuries who were prescribed hydrocodone alongside a psychotropic medication were considered for this study (n=224). A subset of these patients (n=178) was prescribed a psychotropic medication known to inhibit CYP2D6, while the remainder (n=46) were prescribed psychotropic medications without CYP2D6 inhibition activity. Patient demographics and pain outcomes were collected by electronic health record review and interviews. Patients taking a psychotropic inhibitor of CYP2D6 exhibited longer duration of opioid use post-discharge (median 33days [IQR 10-99]) compared with patients taking a psychotropic non-inhibitor (4days [2-20], p<0.001). No significant differences were observed with in-hospital pain outcomes, including total dose of hydrocodone administered, duration of hydrocodone use, pain index scores, and the occurrence of common mild/moderate/severe hydrocodone side effects. Patients prescribed at least one psychotropic inhibitor of CYP2D6 were more likely to continue using hydrocodone for up to 3months following surgery. Knowledge of these critical drug-drug interactions could enhance clinical practice and improve patient outcomes. This study highlights negative post-operative pain outcomes in patients prescribed hydrocodone alongside a psychotropic inhibitor of CYP2D6. The results of this study indicate that patients taking psychotropic medications that inhibit CYP2D6 are at increased risk for prolonged hydrocodone use following orthopedic surgery.

Sleep difficulties related to psychopathology and neurocognition in people with 22q11.2 deletion syndrome.

The 22q11.2 Deletion Syndrome (22q11.2DS) is a multisystem genetic disorder with prominent sleep disturbances, neuropsychiatric conditions and neurocognitive challenges. Poor sleep can impact cognitive development, psychopathology and daily functioning. An integrative approach in clinical settings can help link these manifestations and suggest interventions. A comprehensive sleep interview was conducted with 100 affected individuals and their parents, complemented with electronic health record review. Independent psychiatric and neurocognitive assessments were conducted in 92 participants, divided into Good Sleeper (score 1-4) and Poor Sleeper (score ≥ 5) groups based on the Pittsburgh Sleep Quality Index (PSQI). Sleep disorders were common, 78% of participants met International Classification of Sleep Disorders criteria. Most prevalent were Insomnia, Sleep Disorder Breathing, Delayed Sleep Phase Disorder and Restless Leg Syndrome. 74% of participants met criteria for at least one current psychiatric disorder. Poor Sleepers had lower Global Assessment of Function (GAF), higher severity of psychosis positive, negative, and general symptoms, and lower performance efficiency on executive, spatial memory, complex cognition and social cognition tests. Mediation models showed that association of psychosis scores and GAF were mediated by PSQI and the association between PSQI and GAF was mediated by psychosis scores. Sleep disorders are prevalent in individuals with 22q11.2DS and impact psychiatric manifestation and neurocognitive performance. Results suggest a possible "vicious cycle " whereby disordered sleep is associated with increased psychosis which, in turn, results in worsening sleep, all affecting GAF. Identification of sleep disorders can facilitate appropriate interventions reducing burden of psychiatric symptoms and improving cognition and functioning.

Centralized Colorectal Cancer Screening Outreach in Federally Qualified Health Centers

Colorectal cancer (CRC) screening is effective but remains underused in federally qualified health centers (FQHCs). To assess the effectiveness of a centralized CRC screening outreach intervention involving mailed fecal immunochemical testing (FIT) outreach and patient navigation to colonoscopy after abnormal results of FIT. A pragmatic randomized clinical trial was conducted, using intention-to-treat analysis. Participants were enrolled from July 6, 2020, to September 17, 2021, and analyses were performed from July 6, 2023, to January 31, 2024. The study was conducted at independent FQHCs comprising 12 clinical delivery sites in North Carolina. The outreach intervention was centralized at an academic cancer center. Active individuals aged 50 to 75 years at average risk for CRC and not current with screening per US Preventive Services Task Force recommendations were included. In addition to usual care, intervention participants received mailed screening outreach materials including an introductory letter, FIT kit packet with instructions and return postage, and 2 reminder letters if needed. Intervention participants with positive results of mailed FIT were offered navigation to facilitate follow-up colonoscopy completion. Control participants received usual care alone. The primary outcome was completion of a US Preventive Services Task Force-recommended CRC screening test within 6 months determined by electronic health record review. Secondary outcomes were colonoscopy completion within 6 months after positive FIT results and detection of advanced colorectal neoplasia, defined as advanced adenoma or CRC. A total of 4002 participants were included (mean [SD] age, 59.6 [6.8] years; 2256 [56.4%] female; 364 (9.1%) Hispanic; 1082 [27.0%] non-Hispanic Black; 2288 [57.2%] non-Hispanic White; 1198 [29.9%] commercially insured; 617 [15.4%] Medicaid; 1227 [30.7%] Medicare; and 960 [24.0%] uninsured), with 2001 randomized to each group. Compared with controls, intervention participants were more likely to complete screening within 6 months of randomization (30.0% vs 9.7%; difference, 20.29 percentage points; 95% CI, 17.85-22.73 percentage points). The intervention was effective in all insurance types. In the intervention arm, 33 of 48 participants with positive FIT results (68.8%) completed follow-up colonoscopy within 6 months compared with 8 of 18 participants (44.4%) in the control arm (difference, 24.3 percentage points; 95% CI, -2.13 to 50.74 percentage points). Advanced colorectal neoplasia was detected in 29 intervention participants (1.4%) and 15 control participants (0.7%) (difference, 0.68 percentage points; 95% CI, 0.05-1.35 percentage points). In this randomized clinical trial of centralized screening outreach intervention in diverse patients served by independent FQHCs, CRC screening completion and advanced colorectal neoplasia detection were substantially increased. Future studies should examine the cost and scalability of this intervention in this context. ClinicalTrials.gov Identifier: NCT04406714.

Electronic Health Record Phenotyping of Pediatric Suicide-Related Emergency Department Visits

Suicide is a leading cause of death among young people. Accurate detection of self-injurious thoughts and behaviors (SITB) underpins equity in youth suicide prevention. To compare methods of detecting SITB using structured electronic health information and measure algorithmic performance across demographics. This cross-sectional study used medical records among youths aged 6 to 17 years with at least 1 mental health-related emergency department (ED) visit in 2017 to 2019 to an academic health system in Southern California serving 787 000 unique individuals each year. Analyses were conducted between January and September 2023. Multiexpert electronic health record review ascertained the presence of SITB using the Columbia Classification Algorithm of Suicide Assessment. Random forest classifiers with nested cross-validation were developed using (1) International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for nonfatal suicide attempt and self-harm and chief concern and (2) all available structured data, including diagnoses, medications, and laboratory tests. Detection performance was assessed overall and stratified by age group, sex, and race and ethnicity. The sample comprised 2702 unique youths with an MH-related ED visit (1384 youths who identified as female [51.2%]; 131 Asian [4.8%], 266 Black [9.8%], 719 Hispanic [26.6%], 1319 White [48.8%], and 233 other race [8.6%]; median [IQR] age, 14 [12-16] years), including 898 children and 1804 adolescents. Approximately half of visits were related to SITB (1286 visits [47.6%]). Sensitivity of SITB detection using only codes and chief concern varied by age group and increased until age 15 years (6-9 years: 59.3% [95% CI, 48.5%-69.5%]; 10-12 years: 69.0% [95% CI, 63.8%-73.9%]; 13-15 years: 88.4% [95% CI, 85.1%-91.2%]; 16-17 years: 83.1% [95% CI, 79.1%-86.6%]), while specificity remained constant. The area under the receiver operating characteristic curve (AUROC) was lower among preadolescents (0.841 [95% CI, 0.815-0.867]) and male (0.869 [95% CI, 0.848-0.890]), Black (0.859 [95% CI, 0.813-0.905]), and Hispanic (0.861 [95% CI, 0.831-0.891]) youths compared with adolescents (0.925 [95% CI, 0.912-0.938]), female youths (0.923 [95% CI, 0.909-0.937]), and youths of other races and ethnicities (eg, White: 0.901 [95% CI, 0.884-0.918]). Augmented classification (ie, using all available structured data) outperformed classification with codes and chief concern alone (AUROC, 0.975 [95% CI, 0.968-0.980] vs 0.894 [95% CI, 0.882-0.905]; P < .001). In this study, diagnostic codes and chief concern underestimated SITB prevalence, particularly among minoritized youths. These results suggest that priority on algorithmic fairness in suicide prevention strategies must extend to accurate detection of youths with suicide-related emergencies.

Desmopressin dosing in children using real-world data and pharmacokinetic/pharmacodynamic model simulations.

Variability in pediatric dosing of desmopressin (ddAVP) in AVP-deficiency (AVP-D) is well-documented but dosing recommendations are limited. This study evaluates and optimizes ddAVP dosing regimens in children with AVP-D using pharmacokinetic and pharmacodynamic (PK/PD) simulations. Retrospective electronic health record review was done to identify children (<18 years) with AVP-D on ddAVP evaluated in the outpatient setting using ICD 9 and 10 codes. A previously developed PK/PD model from Michelet et al was used to simulate ddAVP concentrations and urine rates based on a child's age and ddAVP dose. The effects of demographic characteristics (age, weight, etc.) on dose and urine rate were investigated through simulations to optimize doses of ddAVP for children who were wet overnight. A total of 276 dosing records were identified among 53 children with AVP-D. Simulations indicated that in children under 5 years of age who were wet overnight, increasing the outpatient dose to 50 mcg was predicted to decrease urine rate to a pattern similar to those who remained dry. An initial outpatient dose of at least 50 mcg for children between 1 and 5 years of age would improve efficacy of ddAVP. 50 mcg is likely a safe initial outpatient dose of oral desmopressin tablet for young children 1-5 yrs of age with central Diabetes Insipidus/AVP-Deficiency. We confirmed that desmopressin doses vary greatly in children with central Diabetes Insipidus/AVP-deficiency. Real-world clinical data can be leveraged to improve medication dosing in rare diseases.

Cardiovascular Precision Medicine and Remote Intervention Trial Rationale and Design

Background: It has recently been shown that excessive fluctuation in blood pressure readings for an individual over time is closely associated with poor outcomes, including increased risk of cardiovascular mortality, coronary heart disease and stroke. Fluctuations may be associated with inconsistent adherence to medical recommendations. This new marker of risk has not yet been incorporated into a monitoring and intervention strategy that seeks to reduce cardiovascular risk by identifying patients through an algorithm tied to their electronic health record (EHR). Methods: We describe the methods used in an innovative “proof of concept” trial using CP&amp;R (Cardiovascular Precision Medicine and Remote Intervention). A blood pressure variability index is calculated for clinic patients via an EHR review. Consenting patients with excessive variability are offered a remote intervention aimed at improving adherence to medical recommendations. The outcomes include the ability to identify and engage the identified patients and the effects of the intervention on blood pressure variability using a pre–post comparison design without parallel controls. Conclusions: Our innovative approach uses a recently identified marker based on reviewing and manipulating EHR data tied to a remote intervention. This design reduces patient burden and supports equitable and targeted resource allocation, utilizing an objective criterion for behavioral risk. This study is registered under ClinicalTrials.gov Identifier: NCT05814562.

Characterization of Oral Ketamine Use: A Retrospective Review

Ketamine is an N-methyl D-aspartate (NMDA) receptor antagonist used to treat pain at subanesthetic doses. Ketamine is beneficial for pain control in patients who have a high tolerance to opioids and are experiencing opioid-induced hyperalgesia. This study characterizes oral ketamine use for analgesia at a large academic hospital and reports safety outcomes for hospitalized patients. This study was a retrospective electronic health record (EHR) review of patients ≥ 18 years or older receiving oral ketamine. The primary endpoint was median ketamine starting dose and maximum dose (mg/kg/day) during treatment duration. Secondary outcomes included oral Morphine Milligram Equivalents (MMEs), buprenorphine dose, minimum and maximum pain scores on the first and last day of therapy. Safety endpoints were reported. The median starting dose was 1 mg/kg/day, and the median maximum dose was 1.6 mg/kg/day. Median MMEs decreased from the first day to the last day of oral ketamine therapy. The study population experienced a low incidence of safety events overall. Oral ketamine was administered safely for analgesia, with patients receiving ketamine doses that were on the lower end of the established therapeutic range. Evaluation of the efficacy and safety of oral ketamine use for analgesia should be further studied.

Dizziness and Imbalance Across the Lifespan: Findings of a Pediatric and Adult Vestibular Clinic.

To evaluate diagnostic trends in pediatric and adult patients presenting for multidisciplinary subspecialty evaluation of dizziness and imbalance across the lifespan. Retrospective chart review. Single pediatric and single adult academic tertiary care hospital. Retrospective review of electronic health record for patients presenting to an adult or pediatric multidisciplinary vestibular clinic from 2017 to 2020, including clinical data, physical therapy evaluation, and audiovestibular testing. A total of 1934 patients aged 1 to 95 were evaluated. Most patients were female (n = 1188, 61%); the largest cohort was in the fifth decade of life (n = 321, 17%). Seventy-six percent of patients (n = 1470) were assigned a pathologic diagnosis. Central causes of dizziness were most common in children and young adults, comprising 38% to 54% of all diagnoses in ages 1 to 30. The proportion of peripheral vestibular disorders increased with age, peaking at 32% in ages 61 to70. Vestibular migraine was the most common pathologic diagnosis in ages 6 to 20 (n = 110, 39%) and 31 and 50 (n = 69, 17%) regardless of gender, but was more prevalent in females (21% vs 14%; P < .0001). The prevalence of benign paroxysmal positional vertigo (BPPV) increased throughout the lifespan, peaking at age 71 to 80. Meniere's disease (MD) did not occur within the first decade of life, but increased thereafter, peaking at ages 51 to 60. Multidisciplinary vestibular evaluation resulted in a diagnosis for the majority of patients. Vestibular diagnoses vary across the lifespan however among most age groups, central disorders, including migraine disorders, outnumber peripheral vestibulopathies. The prevalence of peripheral vestibular disorders such as BPPV and MD increased with age. Level IV.

Racing to disaster: A 10-year retrospective analysis of pediatric competitive motocross injuries.

In competitive motocross, children as young as 4 years old race in groups on motorized off-road bikes on uneven terrain. We aimed to describe pediatric injuries occurring during an annual week-long certified amateur motocross competition between 2011 and 2021. Secondarily, we compared injury characteristics and medical evaluation by age. This retrospective analysis of injuries sustained by children during an annual motocross competition included children<18 years who received care for an event-related injury within either of the two large regional hospital systems between 2011 and 2021. Data were collected through electronic health record review and analyzed with descriptive statistics. We used chi-square and Fisher exact tests to compare findings by age (young child less than 12 years vs. adolescent 12 years or older). Over the 10-week study period (1week per year for each of 10 years), 286 encounters were made by 278 children. Nearly all children (280/286, 98%) underwent imaging; most had at least one traumatic finding (71.7% of x-rays, 62.4% of computed tomography [CT] scans). Ninety-three children (32.5% of 286) sustained multisystem injuries. Emergency department procedures included one endotracheal intubation, one thoracostomy, 46 closed reductions, and 37 procedural sedations. Twenty-eight children (9.8% of 286) required operative intervention. Overall, 25.5% of children (73/286) were hospitalized and one adolescent died. Adolescents were more likely than young children to undergo CT imaging (40.1%vs. 26.8%, p=0.042) and have multisystem injuries (36.3%vs. 23.2%, p=0.045). There was no difference in hospitalization or operative intervention by age. This comprehensive assessment of injuries sustained by children during competitive motocross demonstrates significant morbidity and mortality. Findings have implications for families who consider participation and health systems in regions where competitions occur.

(302) THE PREVALENCE OF PHOSPHODIESTERASE-5 INHIBITOR USAGE IN MEN WITH RETROGRADE EJACULATION

Abstract Introduction Retrograde ejaculation (RE) represents a disruption and reversal in the normal antegrade seminal pathway, frequently resulting in sexual dissatisfaction and potential subfertility among men. Established etiologies of RE include alpha-adrenergic blockers used for benign prostatic hyperplasia (BPH) and certain psychotropic medications; however, the exact mechanism of action is not yet understood. Phosphodiesterase-5 inhibitors (PDE5Is), which like alpha-adrenergic blockers similarly result in vasodilation, are commonly administered for lower urinary tract symptoms, including erectile dysfunction and BPH. Despite their widespread use, there is limited literature exploring the association between PDE5I administration and the onset of retrograde ejaculation. Objective The purpose of this study is to elucidate if a relationship exists between PDE5I usage and retrograde ejaculation. Methods An IRB-approved retrospective review at a tertiary referral center identified men with a diagnosis of retrograde ejaculation via ICD-9 or ICD-10 codes and through retrograde semen analysis. Exclusion criteria included men without retrograde ejaculation based on semen analysis or electronic health record review. Baseline demographics included comorbidities, medications, and PDE5I usage. Data were analyzed using descriptive statistics and chi-square tests. Results Search criteria resulted in 98 male patients with a diagnosis of retrograde ejaculation (93 via ICD-9 or 10 code, 5 confirmed via semen analysis with post-ejaculatory urinalysis) with a mean age of 51.68 ± 15.99 years. 19 of these patients (19.4%) had recorded use of PDE5I at the time of RE diagnosis. 26 of the resulting patients (26.5%) were previously exposed to PDE5Is at the time of RE diagnosis. Men who were previously prescribed PDE5Is were more likely on average to be older at time of diagnosis (58.19 ± 13.31 years, p = 0.016). There were no statistically significant differences in BMI, race, ethnicity, smoking status, or presence of diabetes between men with previous PDE5I usage versus those without (p &amp;gt; 0.062). Of the men exposed to PDE5Is at any point, 34.6% were on sildenafil, 30.8% were on tadalafil, and 34.6% were on a combination of the two. There was no significant difference between concomitant alpha blocker use or use of psychotropic medications in men who had a history of PDE5Is usage compared to those who had not (p &amp;gt; 0.086). Conclusions In our findings, 19.4% patients had noted concurrent PDE5I use at the time of diagnosis of retrograde ejaculation. The use of PDE5I therapy is not uncommon in men with retrograde ejaculation. Further prospective studies to navigate this association are warranted. Disclosure No.

2346 Modified hospital frailty risk score (mHFRS) as a tool to identify frail hospitalised older adults

Abstract Introduction Frailty is common in hospitalised older adults. This study compared efficacy of a modified Hospital Frailty Risk Score (mHFRS) to standard HFRS and Clinical Frailty Scale (CFS) to determine whether mHFRS can be used to identify frail hospitalised patients. Methods Anonymised retrospective review of Electronic Health Records was undertaken in patients = &amp;gt; 65 years old attending the Emergency Department (ED) and admitted to hospital 1st July 2022 to 31st March 2023. mHFRS utilises 2 prior emergency admissions within 2 years to generate a frailty risk score, whereas HFRS requires an index admission plus 2 prior emergency admissions. Hospitalisation outcomes and predictive models were evaluated with correlation and measures of agreement between CFS and HFRS, CFS and mHFRS using Spearman’s rank correlation and Cohen’s kappa. Results Of 3042 patients, CFS categorised 1635 patients as non-frail (CFS 1–4) and 1407 as frail (CFS 5–9). Using mHFRS, only 1623 patients could be categorised and of these, 608 were deemed low, 657 intermediate and 358 high risk of frailty. Frail patients were older (81.8 years, SD 8.41 vs 75.3 years, SD 7.20, p = &amp;lt;.001), had significantly longer LOS (52.5% % vs 31.5%, p = &amp;lt;0.001), higher 30-day unplanned hospital readmissions (18.5% vs 9.9%, p = &amp;lt;0.001), and higher in-patient (6.1% vs 2.0%, p &amp;lt; 0.001), 30-day (9.1% vs 2.3%, p &amp;lt; 0.001), and 90-day (15.8% vs 5.1%, p &amp;lt; 0.001) mortality. mHFRS achieved comparable association with hospitalisation outcomes compared to CFS &amp; HFRS. Cohens’s kappa, showed fair agreement across HFRS and mHFRS, κ of 0.235 0.243 respectively. mHFRS was less sensitive at identifying frail patients but had better specificity to identify non frail patients. Conclusion mHFRS is a comparable frailty screening tool that doesn’t require clinical assessment but is standardised and easy to use in those who can be scored.

Quality of Care in the Last Two Years of Life for Children With Complex Chronic Conditions

ContextLimited data exists about care received by children with complex chronic conditions (CCCs) in the final years of their disease and end-of-life (EOL). ObjectiveTo examine hospital performance on EOL quality measures and to describe healthcare services during the last two years of life for children with CCCs who died in-hospital. MethodsRetrospective automated electronic health record review of children with ≥1 CCC ICD-10 diagnosis code, who died inpatient between October 2020 and March 2023 at a single quaternary U.S. children's hospital. Quality was assessed based on performance on 15 measures across five domains: healthcare utilization, interprofessional supports, medical intensity, symptom management, and communication. Quality EOL care and healthcare services in the last two years of life were determined overall by age group and per patient. Descriptive statistics were used to evaluate demographic differences by age. Results266 children with CCCs died in the study timeframe; 45% were infants (n = 120), 52% (n = 137) were male, 42% (n = 113) were white, 64% (n = 170) were non-Hispanic, and 59% (n=156) had public insurance. Children had a median of three CCCs (IQR 2.4; range 1–8). On average, children met 69% (SD 13%) of EOL quality measures for which they were eligible. In the two years prior to death, 98% (n = 261) had an ICU admission, 75% (n = 200) had a procedure requiring sedation, and 29% (n = 79) had received cardiopulmonary resuscitation. 86% (n = 229) died in the ICU. ConclusionIn this study, children with CCCs met 69% of quality measures and received high-intensity healthcare in the last two years of life.

Shared Decision-Making in Colorectal Cancer Screening for Older Adults

Decisions about whether to stop colorectal cancer (CRC) screening tests in older adults can be difficult and may benefit from shared decision-making (SDM). To evaluate the effect of physician training in SDM and electronic previsit reminders (intervention) vs reminders only (comparator) on receipt of the patient-preferred approach to CRC screening and on overall CRC screening rates of older adults at 12 months. This was a secondary analysis of the Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED) cluster randomized clinical trial. In the PRIMED trial, primary care physicians (PCPs) from 36 primary care practices in Massachusetts and Maine were enrolled between May 1 and August 30, 2019, and were randomized to the intervention group or the comparator group. Patients aged 76 to 85 years who were overdue for CRC screening and did not have a prior diagnosis of CRC enrolled between October 21, 2019, and April 8, 2021. Data analysis was performed between May 24, 2022, and May 10, 2023. Primary care physicians in the intervention group completed an SDM training course and received previsit reminders of patients eligible for CRC testing discussion, whereas PCPs in the comparator group received reminders only. The primary outcome was concordance, or the percentage of patients who received their preferred screening approach. Postvisit surveys were administered to assess patient preference for testing, and electronic health record review was used to assess CRC testing at 12 months. Heterogeneity of treatment effect analyses examined interaction between study groups and different factors on concordance rates. This study included 59 physicians and 466 older adults. Physicians had a mean (SD) age of 52.7 (9.4) years and a mean (SD) of 21.6 (10.2) years in practice; 30 (50.8%) were women and 16 (27.1%) reported prior training in SDM. Patients had a mean (SD) age of 80.3 (2.8) years; 249 (53.4%) were women and 238 (51.1%) reported excellent or very good overall health. Patients preferred stool-based tests (161 [34.5%]), followed by colonoscopy (116 [24.8%]) or no further screening (97 [20.8%]); 75 (16.1%) were not sure. The distribution of patient preferences was similar across groups (P = .36). At 12 months, test uptake was also similar for both the intervention group (29 [12.3%] for colonoscopy, 62 [26.3%] for stool-based tests, and 145 [61.4%] for no testing) and the comparator group (32 [13.9%] for colonoscopy, 35 [15.2%] for stool-based tests, and 163 [70.9%] for no testing; P = .08). Approximately half of patients in the intervention group received their preferred approach vs the comparator group (115 of 226 [50.9%] vs 103 of 223 [46.2%]; P = .47). Heterogeneity of treatment effect analyses found significantly higher rates with the intervention vs the comparator for patients with a strong intention to follow through with the preferred approach (adjusted odds ratio [AOR], 1.79 [95% CI, 1.11-2.89]; P = .02, P = .05 for interaction) and for patients who reported more than 5 minutes (AOR, 3.27 [95% CI, 1.25-8.59]; P = .02, P = .05 for interaction) of discussion with their PCP regarding screening. Higher rates were also observed among patients who reported 2 to 5 minutes of discussion with their PCP, although this finding was not significant (AOR, 1.89 [95% CI, 0.93-3.84]; P = .08, P = .05 for interaction). In this secondary analysis of a cluster randomized clinical trial, approximately half of older patients received their preferred approach to CRC screening. Physician training in SDM did not result in higher concordance rates overall but may have benefitted some subgroups. Future work to refine and evaluate clinical decision support (in the form of an electronic advisory or reminder) as well as focused SDM skills training for PCPs may promote high-quality, preference-concordant decisions about CRC testing for older adults. ClinicalTrials.gov Identifier: NCT03959696.

Examining inequities associated with incarceration among breast cancer patients.

Breast cancer treatment patterns and quality of care among patients experiencing incarceration are underexplored. This study examined associations between incarceration and breast cancer disease and treatment characteristics. This retrospective analysis was conducted at a tertiary center in the Southeastern United States that serves as the state's safety-net hospital and primary referral site for the state's prisons. All patients ≥18 years diagnosed with breast cancer between 4/14/2014-12/30/2020 were included. Incarceration status was determined through electronic health record review. Linear regression was used to estimate the association of incarceration with time to treatment. Unadjusted overall survival (OS) was estimated using the Kaplan-Meier method with log-rank tests to compare groups. Of the 4329 patients included, 30 (0.7%) were incarcerated at the time of diagnosis or treatment (DI) and 4299 (99.3%) had no incarceration history (NI). Compared to patients who were NI, patients who were DI were younger (p < 0.001), more likely to be unmarried (p < 0.001), and more likely to have family history of breast cancer (p = 0.02). Patients who were DI had an increased time from diagnosis to neoadjuvant chemotherapy (+47.2 days on average, 95% CI 3.9-90.5, p = 0.03) and from diagnosis to surgery (+20 days on average, 95% CI 6.5-33.5, p = 0.02) compared to NI patients. No difference in OS was observed (log-rank p = 0.70). Patients who are incarcerated experienced significant delays in breast cancer care. While no differences in mortality were appreciated, these findings are concerning, as they indicate poorer care coordination for patients who are incarcerated. Further research is necessary to understand the full scope of these disparities and elucidate factors that contribute to them.

Decreasing Intraoperative Skin Damage in Prone-Position Surgeries.

To determine if subepidermal moisture (SEM) measures help detect and prevent intraoperative acquired pressure injuries (IAPIs) for prone-position surgery. In this clinical trial of patients (n = 39 preintervention, n = 48 intervention, 100 historical control) undergoing prone-position surgery, researchers examined the use of multidimensionally flexible silicone foam (MFSF) dressings applied preoperatively to patients' face, chest, and iliac crests. Visual skin assessments and SEM measures were obtained preoperatively, postoperatively, and daily for up to 5 days or until discharge. Electronic health record review included demographic, medical, and surgery data. Of the 187 total participants, 76 (41%) were women. Participants' mean age was 61.0 ± 15.0 years, and 9.6% were Hispanic (n = 18), 9.6% were Asian (n = 18), 6.9% were Black or African American (n = 13), and 73.8% were White (n = 138). Participants had a mean Scott-Triggers IAPI risk score of 1.5 ± 1.1. Among those with no erythema preoperatively, fewer intervention participants exhibited postoperative erythema on their face and chest than did preintervention participants. Further, fewer intervention participants had SEM-defined IAPIs at all locations in comparison with preintervention participants. The MFSF dressings overcame IAPI risk factors of surgery length, skin tone, and body mass index with fewer IAPIs in intervention participants. Patients undergoing prone-position surgeries developed fewer IAPIs, and SEM measures indicated no damage when MFSF dressings were applied to sites preoperatively. The SEM measures detected more damage than visual assessment.

Factors Associated With Nonprescription of Oseltamivir for Infant Influenza Over 9 Seasons.

The Centers for Disease Control and Prevention (CDC) recommends oseltamivir phosphate for children <2 years old with confirmed or suspected influenza as they are at high risk for complications. We analyzed infant characteristics associated with nonprescription of oseltamivir over 9 years. We conducted a retrospective electronic health record (EHR) review of infants <12 months old born between January 1, 2012 and December 31, 2019 within the University of Pittsburgh Medical Center health system in Southwestern Pennsylvania who had >2 well-child visits during their first year. Infants with a confirmed positive test for influenza were included in the analysis. Factors associated with infant oseltamivir nonprescription were assessed using multivariable logistic regression. Of 457 infants with confirmed influenza, 86% were prescribed oseltamivir. The proportion of infants prescribed oseltamivir increased from an average of 64.6% during the 2012-2016 influenza seasons to 90.4% during the 2016-2020 influenza seasons. Infants were more likely to not be prescribed oseltamivir if they experienced >2 days of influenza symptoms (odds ratio (OR): 9.4, 95% CI: 4.8, 18.7, P < .001), were diagnosed during the 2012-2016 influenza seasons (OR: 4.2, 95% CI: 1.8, 9.5, P < .001), tested positive for influenza via a multiplex/reverse transcriptase polymerase chain reaction test (OR: 6.7, 95% CI: 2.7, 16.3, P < .001; OR: 2.7, 95% CI: 1.1, 7.1; P = .04), or did not have a fever at point-of-care (OR: 2.3, 95% CI: 1.2, 4.6, P = .01). Adherence to CDC influenza antiviral treatment guidelines for infants is high and improved over time. However, the provision of targeted education to providers may further improve oseltamivir prescribing practices for high-risk children <12 months of age.

Evaluation of synthetic electronic health records: A systematic review and experimental assessment

Recent studies have shown how synthetic data generation methods can be applied to electronic health records (EHRs) to obtain synthetic versions that do not violate privacy rules. This growing body of research has resulted in the emergence of numerous methods for evaluating the quality of generated data, with new publications often introducing novel evaluation methods. This work presents a detailed review of synthetic EHRs, focusing on the various evaluation methods used to assess the quality of the generated EHRs. We discuss the existing evaluation methods, offering insights into their use as well as providing an interpretation of the evaluation metrics from the perspectives of achieving fidelity, utility and privacy. Furthermore, we highlight the key factors influencing the selection of evaluation methods, such as the type of data (e.g., categorical, continuous, or discrete) and the mode of application (e.g., patient level, cohort level, and feature level). To assess the effectiveness of current evaluation measures, we conduct a series of experiments to shed light on the potential limitations of these measures. The findings from these experiments reveal notable shortcomings, including the need for meticulous application of methods to the data to reduce inconsistent evaluations, the qualitative nature of some assessments subject to individual judgment, the need for clinical validations, and the absence of techniques to evaluate temporal dependencies within the data. This highlights the need to place greater emphasis on evaluation measures, their application, and the development of comprehensive evaluation frameworks as it is crucial for advancing progress in this field.

EVALPAX: Evaluation of a pharmacist-driven protocol for nirmatrelvir/ritonavir prescribing in a community hospital system.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The purpose of this study was to evaluate pharmacist prescribing of nirmatrelvir/ritonavir to ensure this method of increasing access to treatment is safe and effective. This multicenter, retrospective observational study included patients receiving a prescription for nirmatrelvir/ritonavir by a physician, nurse practitioner (NP), physician assistant (PA), or pharmacist at an Indiana University (IU) Health West Central Region site over a 3-month period. Patients were divided into two groups: those who received nirmatrelvir/ritonavir prescribed by a pharmacist (the pharmacist prescribed group) and those who received nirmatrelvir/ritonavir prescribed by other providers (the physician/NP/PA prescribed group). Electronic health record (EHR) reviews were performed to assess the appropriateness of prescriptions based on the presence of risk factors and symptoms, day of symptom onset, and dosing. The primary endpoint was the overall appropriateness of nirmatrelvir/ritonavir prescriptions in the two study groups based on emergency use authorization inclusion and exclusion requirements. Secondary endpoints included appropriateness of nirmatrelvir/ritonavir dosing and medically attended visits or mortality within 30 days. Statistical analysis of the endpoints occurred post hoc utilizing the Fisher's exact test. A total of 259 patients were included in the pharmacist prescribed group and 265 patients in the physician/NP/PA prescribed group. Overall appropriate nirmatrelvir/ritonavir prescribing occurred in 258 patients (99.6%) and 232 patients (87.5%) in the pharmacist and physician/NP/PA prescribed groups, respectively (P < 0.0001). Nirmatrelvir/ritonavir dosing was appropriate in 256 patients (98.8%) and 240 patients (90.6%) in the pharmacist and physician/NP/PA prescribed groups, respectively (P < 0.0001). The 30-day rates of medically attended visits were similar between groups. No patients died within 30 days of treatment in either group. Pharmacist prescribing of nirmatrelvir/ritonavir may result in a higher likelihood of prescriptions meeting overall appropriateness criteria. Pharmacists represent an important healthcare professional resource to improve nirmatrelvir/ritonavir prescribing and utilization.

Effect of digital tools to promote hospital quality and safety on adverse events after discharge.

Post-discharge adverse events (AEs) are common and heralded by new and worsening symptoms (NWS). We evaluated the effect of electronic health record (EHR)-integrated digital tools designed to promote quality and safety in hospitalized patients on NWS and AEs after discharge. Adult general medicine patients at a community hospital were enrolled. We implemented a dashboard which clinicians used to assess safety risks during interdisciplinary rounds. Post-implementation patients were randomized to complete a discharge checklist whose responses were incorporated into the dashboard. Outcomes were assessed using EHR review and 30-day call data adjudicated by 2 clinicians and analyzed using Poisson regression. We conducted comparisons of each exposure on post-discharge outcomes and used selected variables and NWS as independent predictors to model post-discharge AEs using multivariable logistic regression. A total of 260 patients (122 pre, 71 post [dashboard], 67 post [dashboard plus discharge checklist]) enrolled. The adjusted incidence rate ratios (aIRR) for NWS and AEs were unchanged in the post- compared to pre-implementation period. For patient-reported NWS, aIRR was non-significantly higher for dashboard plus discharge checklist compared to dashboard participants (1.23 [0.97,1.56], P = .08). For post-implementation patients with an AE, aIRR for duration of injury (>1 week) was significantly lower for dashboard plus discharge checklist compared to dashboard participants (0 [0,0.53], P < .01). In multivariable models, certain patient-reported NWS were associated with AEs (3.76 [1.89,7.82], P < .01). While significant reductions in post-discharge AEs were not observed, checklist participants experiencing a post-discharge AE were more likely to report NWS and had a shorter duration of injury. Interventions designed to prompt patients to report NWS may facilitate earlier detection of AEs after discharge. NCT05232656.

Patient Satisfaction and Clinical Experience With the Tandem t:slim X2 With Control-IQ Technology Advanced Hybrid Closed-Loop Insulin Delivery System.

The purpose of this study was to assess patient satisfaction and clinical experience with the t:slim X2 with Control-IQ Technology automated insulin delivery system. This descriptive study used a retrospective electronic health record review of all individuals trained on the Control-IQ system between December 2019 and April 2022 in one adult endocrinology practice. A total of 99 patients using the Control-IQ system for at least 3 months completed the glucose monitoring satisfaction survey (GMSS). The primary outcome was overall satisfaction with the system as measured by the GMSS. Secondary outcomes included changes in A1C from baseline at 3, 6, and 12 months; the association between GMSS scores and A1C levels; and the use of the system's sleep activity feature to achieve lower A1C levels. The overall satisfaction score for patients using the system was 4.0 ± 0.6 (possible score range 1-5). A1C decreased by 0.6% 3 months, 0.7% at 6 months, and 0.8% at 12 months. Participants with A1C levels ≤7% did not experience greater satisfaction compared to those with higher A1C levels. Participants using the Control-IQ system reported a high rate of overall satisfaction and experienced significant reductions from baseline A1C at 3, 6, and 12 months.