Evaluating the impact of patients' online access to doctors' visit notes: designing and executing the OpenNotes project

Background: Providers and policymakers are pursuing strategies to increase patient engagement in health care. Increasingly, online sections of medical records are viewable by patients though seldom are clinicians' visit notes included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes would not lead to significant disruptions to doctors' practices. Methods/Design: Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3 sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs were given access to their PCPs' visit notes for one year. PCPs who declined participation in the intervention and their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and post-intervention surveys for online administration addressing attitudes and experiences based on interviews and focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the intervention. Results: PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000 patient surveys. Discussion: Many primary care physicians were willing to participate in this "real world" experiment testing the impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety, and improving the quality of care

Sex differences in circumstances and consequences of outdoor and indoor falls in older adults in the MOBILIZE Boston cohort study

Background: Despite extensive research on risk factors associated with falling in older adults, and current fall prevention interventions focusing on modifiable risk factors, there is a lack of detailed accounts of sex differences in risk factors, circumstances and consequences of falls in the literature. We examined the circumstances, consequences and resulting injuries of indoor and outdoor falls according to sex in a population study of older adults. Methods: Men and women 65 years and older (N = 743) were followed for fall events from the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston prospective cohort study. Baseline measurements were collected by comprehensive clinical assessments, home visits and questionnaires. During the follow-up (median = 2.9 years), participants recorded daily fall occurrences on a monthly calendar, and fall circumstances were determined by a telephone interview. Falls were categorized by activity and place of falling. Circumstance-specific annualized fall rates were calculated and compared between men and women using negative binomial regression models. Results: Women had lower rates of outdoor falls overall (Crude Rate Ratio (RR): 0.72, 95% Confidence Interval (CI): 0.56-0.92), in locations of recreation (RR: 0.34, 95% CI: 0.17-0.70), during vigorous activity (RR: 0.38, 95% CI: 0.18-0.81) and on snowy or icy surfaces (RR: 0.55, 95% CI: 0.36-0.86) compared to men. Women and men did not differ significantly in their rates of falls outdoors on sidewalks, streets, and curbs, and during walking. Compared to men, women had greater fall rates in the kitchen (RR: 1.88, 95% CI: 1.04-3.40) and while performing household activities (RR: 3.68, 95% CI: 1.50-8.98). The injurious outdoor fall rates were equivalent in both sexes. Women’s overall rate of injurious indoor falls was nearly twice that of men’s (RR: 1.98, 95% CI: 1.44-2.72), especially in the kitchen (RR: 6.83, 95% CI: 2.05-22.79), their own home (RR: 1.84, 95% CI: 1.30-2.59) and another residential home (RR: 4.65, 95% CI: 1.05-20.66) or other buildings (RR: 2.29, 95% CI: 1.18-4.44). Conclusions: Significant sex differences exist in the circumstances and injury potential when older adults fall indoors and outdoors, highlighting a need for focused prevention strategies for men and women

Jarosite in Gale Crater, Mars: The Importance of Temporal and Spatial Variability and Implications for Habitiability

The Curiosity rover has recently found evidence for small amounts of jarosite, a ferric sulfate, in the Pahrump Hills region at the base of Aeolis Mons (Mount Sharp), Gale crater. While jarosite has been described previously at other locations on Mars, including several sites at Meridiani Planum (explored by the Opportunity rover; and Mawrth Vallis (by remote MRO-CRISM observations; this is the first identification in Gale. Jarosite is interpreted to be a mineral indicator of acidic conditions (pH less than 4; on Earth, it is most commonly found in acid rock-drainage or acid sulfate soil environments. However, jarosite has also been described from a number of terrestrial environments where widespread acidic conditions are not prevalent. As a case study, we describe here an occurrence of sedimentary pyrite nodules that have been variably oxidized in situ to gypsum, schwertmannite, K-/Na-jarosite and iron oxides in a polar desert environment on Devon Island, Nunavut, Canada. Remarkably, these nodules occur in loosely consolidated carbonate sediments, which would have required a higher pH environment at their time of formation and deposition. Thus, acidic conditions may only exist at a small (sub-cm) scale or in a restricted temporal window in an otherwise well-buffered environment. On Devon Island, the jarosite occurs in the most oxidized nodules and is never associated directly with pyrite. Schwertmannite, a metastable iron oxyhydroxysulfate that can form at pH higher than that required for jarosite, occurs in association with partially oxidized pyrite. The paragenetic sequence observed here suggests initial formation of schwertmannite and late-stage precipitation of jarosite in restricted micro-environments, possibly forming via transformation of an amorphous schwertmannite-like phase. While the carbonate environment on Devon Island differs significantly from that of Gale crater, i.e., where we find predominantly basaltic sedimentary rocks, this terrestrial analog provides insight into the significance of jarosite with respect to habitability. For example, the variable abundance of jarosite on Mars and possibly in Gale crater points to potentially localized conditions favorable for jarosite formation. Interestingly, small amounts of sulfide minerals have also been detected by Curiosity at Yellowknife Bay; oxidation of sulfide minerals at Pahrump could explain the presence of small amounts of jarosite. The iron-rich rocks at Pahrump may also represent relatively altered basaltic sediments, or they could be sediments that were altered further by a fluid with a distinct, possibly more acidic, composition. In addition, the abundance of iron-rich amorphous material in Gale rocks allows for the possibility that pre-cursor, iron-bearing phases transform to jarosite post-depositionally. Thus, the occurrence of jarosite at Pahrump could reflect changing paleoenvironmental conditions, though continuing study of its context and textural relationships should provide a fuller understanding of the significance of this mineral to past fluid compositions and past habitability at Gale crater

Fall Risk is Not Black and White

Objective: To determine whether previously reported racial differences in fall rates between White and Black/African American is explained by differences in health status and neighborhood characteristics. Design: Prospective cohort Setting: Community Participants: The study included 550 White and 116 Black older adults in the Greater Boston area (mean age: 78 years; 36% men) who were English-speaking, able to walk across a room, and without severe cognitive impairment. Measurements: Falls were prospectively reported using monthly fall calendars. The location of each fall and fall-related injuries were asked during telephone interviews. At baseline, we assessed risk factors for falls, including sociodemographic characteristics, physiologic risk factors, physical activity, and community-level characteristics. Results: Over the mean follow-up of 1,048 days, 1,539 falls occurred (incidence: 806/1,000 person-years). Whites were more likely than Blacks to experience any falls (867 versus 504 falls per 1,000 person-years; RR [95% CI]: 1.77 [1.33, 2.36]), outdoor falls (418 versus 178 falls per 1,000 person-years; 1.78 [1.08, 2.92]), indoor falls (434 versus 320 falls per 1,000 person-years; 1.44 [1.02, 2.05]), and injurious falls (367 versus 205 falls per 1,000 person-years; 1.79 [1.30, 2.46]). With exception of injurious falls, higher fall rates in Whites than Blacks were substantially attenuated with adjustment for risk factors and community-level characteristics: any fall (1.24 [0.81, 1.89]), outdoor fall (1.57 [0.86, 2.88]), indoor fall (1.08 [0.64, 1.81]), and injurious fall (1.77 [1.14, 2.74]). Conclusion: Our findings suggest that the racial differences in fall rates may be largely due to confounding by individual-level and community-level characteristics

Rare B Decays with a HyperCP Particle of Spin One

In light of recent experimental information from the CLEO, BaBar, KTeV, and Belle collaborations, we investigate some consequences of the possibility that a light spin-one particle is responsible for the three Sigma^+ -> p mu^+ mu^- events observed by the HyperCP experiment. In particular, allowing the new particle to have both vector and axial-vector couplings to ordinary fermions, we systematically study its contributions to various processes involving b-flavored mesons, including B-Bbar mixing as well as leptonic, inclusive, and exclusive B decays. Using the latest experimental data, we extract bounds on its couplings and subsequently estimate upper limits for the branching ratios of a number of B decays with the new particle. This can serve to guide experimental searches for the particle in order to help confirm or refute its existence.Comment: 17 pages, 3 figures; discussion on spin-0 case modified, few errors corrected, main conclusions unchange

Yet Another Extension of the Standard Model: Oases in the Desert?

We have searched for conceptually simple extensions of the standard model, and describe here a candidate model which we find attractive. Our starting point is the assumption that off-diagonal CKM mixing matrix elements are directly related by lowest order perturbation theory to the quark mass matrices. This appears to be most easily and naturally implemented by assuming that all off-diagonal elements reside in the down-quark mass matrix. This assumption is in turn naturally realized by introducing three generations of heavy, electroweak-singlet down quarks which couple to the Higgs sector diagonally in flavor, while mass-mixing off-diagonally with the light down-quarks. Anomaly cancellation then naturally leads to inclusion of electroweak vector-doublet leptons. It is then only a short step to completing the extension to three generations of fundamental representations of E(6). Assuming only that the third generation B couples to the Higgs sector at least as strongly as does the top quark, the mass of the B is roughly estimated to lie between 1.7 TeV and 10 TeV, with lower-generation quarks no heavier. The corresponding guess for the new leptons is a factor two lower. Within the validity of the model, flavor and CP violation are ``infrared'' in nature, induced by semi-soft mass mixing terms, not Yukawa couplings. If the Higgs couplings of the new quarks are flavor symmetric, then there necessarily must be at least one ``oasis'' in the desert, induced by new radiative corrections to the top quark and Higgs coupling constants, and roughly at 1000 TeV.Comment: LaTex, 40 page

Methodological Challenges in Estimating Trends and Burden of Cardiovascular Disease in Sub-Saharan Africa

Background. Although 80% of the burden of cardiovascular disease (CVD) is in developing countries, the 2010 global burden of disease (GBD) estimates have been cited to support a premise that sub-Saharan Africa (SSA) is exempt from the CVD epidemic sweeping across developing countries. The widely publicized perspective influences research priorities and resource allocation at a time when secular trends indicate a rapid increase in prevalence of CVD in SSA by 2030. Purpose. To explore methodological challenges in estimating trends and burden of CVD in SSA via appraisal of the current CVD statistics and literature. Methods. This review was guided by the Critical review methodology described by Grant and Booth. The review traces the origins and evolution of GBD metrics and then explores the methodological limitations inherent in the current GBD statistics. Articles were included based on their conceptual contribution to the existing body of knowledge on the burden of CVD in SSA. Results/Conclusion. Cognizant of the methodological challenges discussed, we caution against extrapolation of the global burden of CVD statistics in a way that underrates the actual but uncertain impact of CVD in SSA. We conclude by making a case for optimal but cost-effective surveillance and prevention of CVD in SSA

Don't Stop Thinking About Leptoquarks: Constructing New Models

We discuss the general framework for the construction of new models containing a single, fermion number zero scalar leptoquark of mass $\simeq 200-220$ GeV which can both satisfy the D0/CDF search constraints as well as low energy data, and can lead to both neutral and charged current-like final states at HERA. The class of models of this kind necessarily contain new vector-like fermions with masses at the TeV scale which mix with those of the Standard Model after symmetry breaking. In this paper we classify all models of this type and examine their phenomenological implications as well as their potential embedding into SUSY and non-SUSY GUT scenarios. The general coupling parameter space allowed by low energy as well as collider data for these models is described and requires no fine-tuning of the parameters.Comment: Modified text, added table, and updated reference