Identification of clinical characteristics of large patient cohorts through analysis of free text physician notes

Thesis (S.M.)--Harvard-MIT Division of Health Sciences and Technology, 2005.Includes bibliographical references (p. 31-33).Background A number of important applications in medicine and biomedical research, including quality of care surveillance and identification of prospective study subjects, require identification of large cohorts of patients with specific clinical characteristics. Currently used conventional techniques are either labor-intensive or imprecise, while natural language processing-based applications are relatively slow and expensive. Specific Aims In this thesis we describe the design and formal evaluation of PACT - a suite of rapid, accurate, and easily portable software tools for identification of patients with specific clinical characteristics through analysis of the text of physician notes in the electronic medical record. Methods PACT algorithm is based on sentence-level semantic analysis. The major steps involve identification of word tags (e.g. name of the disease or medications exclusively used to treat the disease) specific for the clinical characteristics in the sentences of the physician notes. Sentences with word tags and negative qualifiers (e.g. "rule out diabetes") are excluded from consideration. PACT can also identify quantitative (e.g. blood pressure, height, weight) and semi-quantitative (e.g. compliance with medical treatment) clinical characteristics. PACT performance was evaluated against blinded manual chart review (the "gold standard") and currently used computational methods (analysis of billing data). Results Evaluation of PACT demonstrated it to be rapid and highly accurate. PACT processed 6.5 to 8.8x 10⁵ notes/hour (1.0 to 1.4 GB of text / hour).(cont) When compared to the gold standard of manual chart review, PACT sensitivity ranged (depending on the patient characteristic being extracted from the notes) from 74 to 100%, and specificity from 86 to 100%. K statistic for agreement between PACT and manual chart review ranged from 0.67 to 1.0 and in most cases exceeded 0.75, indicating excellent agreement. PACT accuracy substantially exceeded the performance of currently used techniques (billing data analysis). Finally, index of patient non-compliance with physician recommendations computed by PACT was shown to correlate with the frequency of annual Emergency Department visits: patients in the highest quartile for the index of non-compliance had 50% as many annual visits as the patients in the lowest quartile. Conclusion PACT is a rapid, precise and easily portable suite of software tools for extracting focused clinical information out of free text clinical documents. It compares favorably with computation techniques currently available for the purpose (where ones exist). It represents an important advance in the field, and we plan to continue to develop this concept further to improve its performance and functionality.by Alexander Turchin.S.M

One Class of Stochastic Local Search Algorithms

Accelerated probabilistic modeling algorithms, presenting stochastic local search (SLS) technique, are considered. General algorithm scheme and specific combinatorial optimization method, using “golden section” rule (GS-method), are given. Convergence rates using Markov chains are received. An overview of current combinatorial optimization techniques is presented

Lifestyle Counseling in Routine Care and Long-Term Glucose, Blood Pressure, and Cholesterol Control in Patients With Diabetes

OBJECTIVE In clinical trials, diet, exercise, and weight counseling led to short-term improvements in blood glucose, blood pressure, and cholesterol levels in patients with diabetes. However, little is known about the long-term effects of lifestyle counseling on patients with diabetes in routine clinical settings. RESEARCH DESIGN AND METHODS This retrospective cohort study of 30,897 patients with diabetes aimed to determine whether lifestyle counseling is associated with time to A1C, blood pressure, and LDL cholesterol control in patients with diabetes. Patients were included if they had at least 2 years of follow-up with primary care practices affiliated with two teaching hospitals in eastern Massachusetts between 1 January 2000 and 1 January 2010. RESULTS Comparing patients with face-to-face counseling rates of once or more per month versus less than once per 6 months, median time to A1C <7.0% was 3.5 versus 22.7 months, time to blood pressure <130/85 mmHg was 3.7 weeks versus 5.6 months, and time to LDL cholesterol <100 mg/dL was 3.5 versus 24.7 months, respectively (P < 0.0001 for all). In multivariable analysis, one additional monthly face-to-face lifestyle counseling episode was associated with hazard ratios of 1.7 for A1C control (P < 0.0001), 1.3 for blood pressure control (P < 0.0001), and 1.4 for LDL cholesterol control (P = 0.0013). CONCLUSIONS Lifestyle counseling in the primary care setting is strongly associated with faster achievement of A1C, blood pressure, and LDL cholesterol control. These results confirm that the findings of controlled clinical trials are applicable to the routine care setting and provide evidence to support current treatment guidelines

Following the money: copy-paste of lifestyle counseling documentation and provider billing

Background: Evidence suggests that copy-pasted components of electronic notes may not reliably reflect the care delivered. Federal agencies have raised concerns that such components may be used to justify inappropriately inflated claims for reimbursement. It is not known whether copied information is used to justify higher evaluation and management (E&M) charges. Methods: This retrospective cohort study aimed to assess the relationship between the level of evaluation and management (E&M) charges and the method of documentation (none, distinct or copied) of lifestyle counseling (diet, exercise and weight loss) for patients with diabetes mellitus. To determine the association, an ordered multinomial logistic regression model that corrected for clustering within individual providers and patients and adjusted for patient and encounter characteristics was utilized. E&M charge level served as the primary outcome variable. Patients were included if they were followed by primary care physicians affiliated with two academic hospitals for a minimum of two years between 01/01/2000 and 12/13/2009. Results: Lifestyle counseling was documented in 65.4% of 155,168 primary care encounters of 16,164 patients. Copied counseling was identified in 12,527 encounters. In multivariable analysis higher E&M charges were associated with older patient age, longer notes, treatment with insulin, medication changes and acute complaints. However, copied lifestyle counseling was associated with a decrease of 70.5% in the odds of higher E&M charge levels when time spent on counseling (required to justify higher charges based on counseling) was recorded (p<0.0001). This finding is opposite to what would have been expected if the impetus for copied documentation of lifestyle counseling was an increase in submitted E&M charges. Conclusion: There is no evidence that copied documentation of lifestyle counseling is used to justify higher evaluation and management charges. Higher charges were generally associated with indicators of complexity of care

Hypoglycemia, With or Without Insulin Therapy, Is Associated With Increased Mortality Among Hospitalized Patients

OBJECTIVE Hypoglycemia is associated with increased mortality in hospitalized patients. We investigated the relationship between spontaneous hypoglycemia versus insulin-associated hypoglycemia and mortality in hospitalized patients. RESEARCH DESIGN AND METHODS Data for this retrospective cohort study were obtained from electronic databases of patients admitted between 1 April 2008 and 30 November 2010. Patients with one or more blood glucose values ≤50 mg/dL on point-of-care glucose testing were considered hypoglycemic. Patients treated with insulin were assumed to have insulin-associated hypoglycemia. Age-, sex-, and race-matched patients with all blood glucose values >70 mg/dL were selected as controls. The Charlson comorbidity index (CCI) was used to control for severity of illness. RESULTS There were four groups: 1) noninsulin-treated hypoglycemia (NTH) (n = 135), 2) insulin-treated hypoglycemia (ITH) (n = 961), 3) noninsulin-treated control (NTC) (n = 1,058), and 4) insulin-treated control (ITC) (n = 736). Mortality was higher in the ITH group compared with the ITC group (20.3 vs. 4.5%, P < 0.0001), with a relatively higher CCI (1.8 vs. 1.5%, P < 0.0001), but much higher in the NTH group compared with the NTC group (34.5 vs. 1.1%, P < 0.0001), with much higher CCI (2.4 vs. 1.1%, P < 0.0001). Mortality was higher in the NTH group compared with the ITH group (P < 0.0001) but lower in the NTC group compared with the ITC group (P < 0.0001). After controlling for age, sex, CCI, and admission to the intensive care unit, insulin treatment was associated with a lower mortality among the hypoglycemic patients; hazard ratio of death in the ITH group relative to the NTH group was 0.34 (95% CI 0.25–0.47, P < 0.0001). CONCLUSIONS Insulin-associated and spontaneous hypoglycemia are associated with increased mortality among hospitalized patients

Performance of Primary Care Physicians and Other Providers on Key Process Measures in the Treatment of Diabetes

OBJECTIVE Studies have shown that patients without a consistent primary care provider have inferior outcomes. However, little is known about the mechanisms for these effects. This study aims to determine whether primary care physicians (PCPs) provide more frequent medication intensification, lifestyle counseling, and patient encounters than other providers in the primary care setting. RESEARCH DESIGN AND METHODS This retrospective cohort study included 584,587 encounters for 27,225 patients with diabetes and elevated A1C, blood pressure, and/or LDL cholesterol monitored for at least 2 years. Encounters occurred at primary care practices affiliated with two teaching hospitals in eastern Massachusetts. RESULTS Of the encounters documented, 83% were with PCPs, 13% were with covering physicians, and 5% were with midlevel providers. In multivariable analysis, the odds of medication intensification were 49% (P < 0.0001) and 26% (P < 0.0001) higher for PCPs than for covering physicians and midlevel providers, respectively, whereas the odds of lifestyle counseling were 91% (P < 0.0001) and 21% (P = 0.0015) higher. During visits with acute complaints, covering physicians were even less likely, by a further 52% (P < 0.0001), to intensify medications, and midlevel providers were even less likely, by a further 41% (P < 0.0001), to provide lifestyle counseling. Compared with PCPs, the hazard ratios for time to the next encounter after a visit without acute complaints were 1.11 for covering physicians and 1.19 for midlevel providers (P < 0.0001 for both). CONCLUSIONS PCPs provide better care through higher rates of medication intensification and lifestyle counseling. Covering physicians and midlevel providers may enable more frequent encounters when PCP resources are constrained

Documentation of body mass index and control of associated risk factors in a large primary care network

<p>Abstract</p> <p>Background</p> <p>Body mass index (BMI) will be a reportable health measure in the United States (US) through implementation of Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. We evaluated current documentation of BMI, and documentation and control of associated risk factors by BMI category, based on electronic health records from a 12-clinic primary care network.</p> <p>Methods</p> <p>We conducted a cross-sectional analysis of 79,947 active network patients greater than 18 years of age seen between 7/05 - 12/06. We defined BMI category as normal weight (NW, 18-24.9 kg/m²), overweight (OW, 25-29.9), and obese (OB, ≥ 30). We measured documentation (yes/no) and control (above/below) of the following three risk factors: blood pressure (BP) ≤130/≤85 mmHg, low-density lipoprotein (LDL) ≤130 mg/dL (3.367 mmol/L), and fasting glucose <100 mg/dL (5.55 mmol/L) or casual glucose <200 mg/dL (11.1 mmol/L).</p> <p>Results</p> <p>BMI was documented in 48,376 patients (61%, range 34-94%), distributed as 30% OB, 34% OW, and 36% NW. Documentation of all three risk factors was higher in obesity (OB = 58%, OW = 54%, NW = 41%, p for trend <0.0001), but control of all three was lower (OB = 44%, OW = 49%, NW = 62%, p = 0.0001). The presence of cardiovascular disease (CVD) or diabetes modified some associations with obesity, and OB patients with CVD or diabetes had low rates of control of all three risk factors (CVD: OB = 49%, OW = 50%, NW = 56%; diabetes: OB = 42%, OW = 47%, NW = 48%, p < 0.0001 for adiposity-CVD or diabetes interaction).</p> <p>Conclusions</p> <p>In a large primary care network BMI documentation has been incomplete and for patients with BMI measured, risk factor control has been poorer in obese patients compared with NW, even in those with obesity and CVD or diabetes. Better knowledge of BMI could provide an opportunity for improved quality in obesity care.</p

"Summary Page": a novel tool that reduces omitted data in research databases

<p>Abstract</p> <p>Background</p> <p>Data entry errors are common in clinical research databases. Omitted data are of particular concern because they are more common than erroneously inserted data and therefore could potentially affect research findings. However, few affordable strategies for their prevention are available.</p> <p>Methods</p> <p>We have conducted a prospective observational study of the effect of a novel tool called "<it>Summary Page</it>" on the frequency of correction of omitted data errors in a radiation oncology research database between July 2008 and March 2009. "<it>Summary Page</it>" was implemented as an optionally accessed screen in the database that visually integrates key fields in the record. We assessed the frequency of omitted data on the example of the <it>Date of Relapse </it>field. We considered the data in this field to be omitted for all records that had empty <it>Date of Relapse </it>field and evidence of relapse elsewhere in the record.</p> <p>Results</p> <p>A total of 1,156 records were updated and 200 new records were entered in the database over the study period. "<it>Summary Page</it>" was accessed for 44% of all updated records and for 69% of newly entered records. Frequency of correction of the omitted date of cancer relapse was six-fold higher in records for which "<it>Summary Page</it>" was accessed (p = 0.0003).</p> <p>Conclusions</p> <p>"<it>Summary Page</it>" was strongly associated with an increased frequency of correction of omitted data errors. Further, controlled, studies are needed to confirm this finding and elucidate its mechanism of action.</p

Prevalence and factors affecting home blood pressure documentation in routine clinical care: a retrospective study

<p>Abstract</p> <p>Background</p> <p>Home blood pressure (BP) is closely linked to patient outcomes. However, the prevalence of its documentation has not been examined. The objective of this study was to analyze the prevalence and factors affecting documentation of home BP in routine clinical care.</p> <p>Methods</p> <p>A retrospective study of 142,973 encounters of 9,840 hypertensive patients with diabetes from 2000 to 2005 was performed. The prevalence of recorded home BP and the factors associated with its documentation were analyzed. We assessed validity of home BP information by comparing the difference between home and office BP to previously published prospective studies.</p> <p>Results</p> <p>Home BP was documented in narrative notes for 2.08% of encounters where any blood pressure was recorded and negligibly in structured data (EMR flowsheets). Systolic and diastolic home BP in narrative notes were lower than office BP readings by 9.6 and 2.5 mm Hg, respectively (p < 0.0001 for both), consistent with prospective data. Probability of home BP documentation increased by 23.0% for each 10 mm Hg of office systolic BP (p < 0.0001), by 6.2% for each $10,000 in median income of zip code (p = 0.0055), and by 17.7% for each decade in the patient's age (p < 0.0001).</p> <p>Conclusions</p> <p>Home BP readings provide a valid representation of the patient's condition, yet are seldom documented despite their potential utility in both patient care and research. Strong association between higher patient income and home BP documentation suggests that the cost of the monitors may be a limiting factor; reimbursement of home BP monitoring expenses should be pursued.</p