Temporal variability analysis reveals biases in electronic health records due to hospital process reengineering interventions over seven years

[EN] Objective To evaluate the effects of Process-Reengineering interventions on the Electronic Health Records (EHR) of a hospital over 7 years. Materials and methods Temporal Variability Assessment (TVA) based on probabilistic data quality assessment was applied to the historic monthly-batched admission data of Hospital La Fe Valencia, Spain from 2010 to 2016. Routine healthcare data with a complete EHR was expanded by processed variables such as the Charlson Comorbidity Index. Results Four Process-Reengineering interventions were detected by quantifiable effects on the EHR: (1) the hospital relocation in 2011 involved progressive reduction of admissions during the next four months, (2) the hospital services re-configuration incremented the number of inter-services transfers, (3) the care-services re-distribution led to transfers between facilities (4) the assignment to the hospital of a new area with 80,000 patients in 2015 inspired the discharge to home for follow up and the update of the pre-surgery planned admissions protocol that produced a significant decrease of the patient length of stay. Discussion TVA provides an indicator of the effect of process re-engineering interventions on healthcare practice. Evaluating the effect of facilities¿ relocation and increment of citizens (findings 1, 3¿4), the impact of strategies (findings 2¿3), and gradual changes in protocols (finding 4) may help on the hospital management by optimizing interventions based on their effect on EHRs or on data reuse. Conclusions The effects on hospitals EHR due to process re-engineering interventions can be evaluated using the TVA methodology. Being aware of conditioned variations in EHR is of the utmost importance for the reliable reuse of routine hospitalization data.F.J.P.B, C.S., J.M.G.G. and J.A.C. were funded Universitat Politecnica de Valencia, project "ANALISIS DE LA CALIDAD Y VARIABILIDAD DE DATOS MEDICOS". www.upv.es. J.M.G.G.is also partially supported by: Ministerio de Economia y Competitividad of Spain through MTS4up project (National Plan for Scientific and Technical Research and Innovation 2013-2016, No. DPI2016-80054-R); and European Commission projects H2020-SC1-2016-CNECT Project (No. 727560) and H2020-SC1-BHC-2018-2020 (No. 825750). The funders did not play any role in the study design, data collection and analysis, decision to publish, nor preparation of the manuscript.Perez-Benito, FJ.; Sáez Silvestre, C.; Conejero, JA.; Tortajada, S.; Valdivieso, B.; Garcia-Gomez, JM. (2019). Temporal variability analysis reveals biases in electronic health records due to hospital process reengineering interventions over seven years. PLoS ONE. 14(8):1-19. https://doi.org/10.1371/journal.pone.0220369S119148Aguilar-Savén, R. S. (2004). Business process modelling: Review and framework. International Journal of Production Economics, 90(2), 129-149. doi:10.1016/s0925-5273(03)00102-6Poulymenopoulou, M. (2003). Journal of Medical Systems, 27(4), 325-335. doi:10.1023/a:1023701219563Dadam P, Reichert M, Kuhn K. Clinical Workflows -The Killer Application for Process-oriented Information Systems? Proceedings of the 4th International Conference on Business Information Systems. London: Springer London; 2000. pp. 36–59. doi: https://doi.org/10.1007/978-1-4471-0761-3Lenz, R., & Reichert, M. (2007). IT support for healthcare processes – premises, challenges, perspectives. Data & Knowledge Engineering, 61(1), 39-58. doi:10.1016/j.datak.2006.04.007Rebuge, Á., & Ferreira, D. R. (2012). Business process analysis in healthcare environments: A methodology based on process mining. Information Systems, 37(2), 99-116. doi:10.1016/j.is.2011.01.003Amour EAEH, Ghannouchi SA. Applying Data Mining Techniques to Discover KPIs Relationships in Business Process Context. 2017 18th International Conference on Parallel and Distributed Computing, Applications and Technologies (PDCAT). IEEE; 2017. pp. 230–237. doi: https://doi.org/10.1109/PDCAT.2017.00045Chou, Y.-C., Chen, B.-Y., Tang, Y.-Y., Qiu, Z.-J., Wu, M.-F., Wang, S.-C., … Chuang, W.-C. (2010). Prescription-Filling Process Reengineering of an Outpatient Pharmacy. Journal of Medical Systems, 36(2), 893-902. doi:10.1007/s10916-010-9553-5Leu, J.-D., & Huang, Y.-T. (2009). An Application of Business Process Method to the Clinical Efficiency of Hospital. Journal of Medical Systems, 35(3), 409-421. doi:10.1007/s10916-009-9376-4Gand K. Investigating on Requirements for Business Model Representations: The Case of Information Technology in Healthcare. 2017 IEEE 19th Conference on Business Informatics (CBI). IEEE; 2017. pp. 471–480. doi: https://doi.org/10.1109/CBI.2017.36Ferreira, G. S. A., Silva, U. R., Costa, A. L., & Pádua, S. I. D. de D. (2018). The promotion of BPM and lean in the health sector: main results. Business Process Management Journal, 24(2), 400-424. doi:10.1108/bpmj-06-2016-0115Abdulrahman Jabour RM. Cancer Reporting: Timeliness Analysis and Process. 2016; Available: https://search.proquest.com/openview/4ecf737c5ef6d2d503e948df8031fe54/1?pq-origsite=gscholar&cbl=18750&diss=yHewitt M, Simone J V. Enhancing Data Systems to Improve the Quality of Cancer Care [Internet]. National Academy Press; 2000. Available: http://www.nap.edu/catalog/9970.htmlWeiskopf, N. G., & Weng, C. (2013). Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research. Journal of the American Medical Informatics Association, 20(1), 144-151. doi:10.1136/amiajnl-2011-000681Saez C, Robles M, Garcia-Gomez JM. Comparative study of probability distribution distances to define a metric for the stability of multi-source biomedical research data. Proceedings of the Annual International Conference of the IEEE Engineering in Medicine and Biology Society, EMBS. IEEE; 2013. pp. 3226–3229. doi: https://doi.org/10.1109/EMBC.2013.6610228Sáez, C., Rodrigues, P. P., Gama, J., Robles, M., & García-Gómez, J. M. (2014). Probabilistic change detection and visualization methods for the assessment of temporal stability in biomedical data quality. Data Mining and Knowledge Discovery, 29(4), 950-975. doi:10.1007/s10618-014-0378-6Sáez, C., Zurriaga, O., Pérez-Panadés, J., Melchor, I., Robles, M., & García-Gómez, J. M. (2016). Applying probabilistic temporal and multisite data quality control methods to a public health mortality registry in Spain: a systematic approach to quality control of repositories. Journal of the American Medical Informatics Association, 23(6), 1085-1095. doi:10.1093/jamia/ocw010International Ethical Guidelines for Epidemiological Studies [Internet]. Geneva: Council for International Organizations of Medical Sciences (CIOMS) in collaboration with the World Health Organization; 2009. Available: https://cioms.ch/wp-content/uploads/2017/01/International_Ethical_Guidelines_LR.pdfResearch Ethics Committee of the Universitari i Politècnic La Fe Hospital [Internet]. Available: https://www.iislafe.es/en/research/ethics-committees/Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases, 40(5), 373-383. doi:10.1016/0021-9681(87)90171-8Schneeweiss, S., Wang, P. S., Avorn, J., & Glynn, R. J. (2003). Improved Comorbidity Adjustment for Predicting Mortality in Medicare Populations. Health Services Research, 38(4), 1103-1120. doi:10.1111/1475-6773.00165Quan, H., Sundararajan, V., Halfon, P., Fong, A., Burnand, B., Luthi, J.-C., … Ghali, W. A. (2005). Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative Data. Medical Care, 43(11), 1130-1139. doi:10.1097/01.mlr.0000182534.19832.83Sáez Silvestre C. Probabilistic methods for multi-source and temporal biomedical data quality assessment [Internet]. Thesis. Universitat Politècnica de València. 2016. doi: https://doi.org/10.4995/Thesis/10251/62188Amari S, Nagaoka H. Methods of Information Geometry [Internet]. Amer. Math. Soc. and Oxford Univ. Press. American Mathematical Society; 2000. Available: https://books.google.es/books?hl=es&lr=&id=vc2FWSo7wLUC&oi=fnd&pg=PR7&dq=Methods+of+Information+geometry&ots=4HmyCCY4PX&sig=2-dpCuwMQvEC1iREjxdfIX0yEls#v=onepage&q=MethodsofInformationgeometry&f=falseCsiszár, I., & Shields, P. C. (2004). Information Theory and Statistics: A Tutorial. Foundations and Trends™ in Communications and Information Theory, 1(4), 417-528. doi:10.1561/0100000004Lin, J. (1991). Divergence measures based on the Shannon entropy. IEEE Transactions on Information Theory, 37(1), 145-151. doi:10.1109/18.61115M.Cover T. Elements Of Information Theory Notes [Internet]. 2006. Available: http://books.google.fr/books?id=VWq5GG6ycxMC&printsec=frontcover&dq=intitle:Elements+of+Information+Theory&hl=&cd=1&source=gbs_api%5Cnpapers2://publication/uuid/BAF426F8-5A4F-44A4-8333-FA8187160D9BBrandes, U., & Pich, C. (s. f.). Eigensolver Methods for Progressive Multidimensional Scaling of Large Data. Lecture Notes in Computer Science, 42-53. doi:10.1007/978-3-540-70904-6_6Liaw, S. T., Rahimi, A., Ray, P., Taggart, J., Dennis, S., de Lusignan, S., … Talaei-Khoei, A. (2013). Towards an ontology for data quality in integrated chronic disease management: A realist review of the literature. International Journal of Medical Informatics, 82(1), 10-24. doi:10.1016/j.ijmedinf.2012.10.001Arts, D. G. T. (2002). Defining and Improving Data Quality in Medical Registries: A Literature Review, Case Study, and Generic Framework. Journal of the American Medical Informatics Association, 9(6), 600-611. doi:10.1197/jamia.m1087Bray, F., & Parkin, D. M. (2009). Evaluation of data quality in the cancer registry: Principles and methods. Part I: Comparability, validity and timeliness. European Journal of Cancer, 45(5), 747-755. doi:10.1016/j.ejca.2008.11.032Parkin, D. M., & Bray, F. (2009). Evaluation of data quality in the cancer registry: Principles and methods Part II. Completeness. European Journal of Cancer, 45(5), 756-764. doi:10.1016/j.ejca.2008.11.033Fernandez-Llatas, C., Ibanez-Sanchez, G., Celda, A., Mandingorra, J., Aparici-Tortajada, L., Martinez-Millana, A., … Traver, V. (2019). Analyzing Medical Emergency Processes with Process Mining: The Stroke Case. Lecture Notes in Business Information Processing, 214-225. doi:10.1007/978-3-030-11641-5_17Fernandez-Llatas, C., Lizondo, A., Monton, E., Benedi, J.-M., & Traver, V. (2015). Process Mining Methodology for Health Process Tracking Using Real-Time Indoor Location Systems. Sensors, 15(12), 29821-29840. doi:10.3390/s151229769Van der Aalst, W., Weijters, T., & Maruster, L. (2004). Workflow mining: discovering process models from event logs. IEEE Transactions on Knowledge and Data Engineering, 16(9), 1128-1142. doi:10.1109/tkde.2004.47Weijters AJMM, Van Der Aalst WMP, Alves De Medeiros AK. Process Mining with the HeuristicsMiner Algorithm [Internet]. Available: https://pdfs.semanticscholar.org/1cc3/d62e27365b8d7ed6ce93b41c193d0559d086.pdfShim, S. J., & Kumar, A. (2010). Simulation for emergency care process reengineering in hospitals. Business Process Management Journal, 16(5), 795-805. doi:10.1108/14637151011076476Svolba, G., & Bauer, P. (1999). Statistical Quality Control in Clinical Trials. Controlled Clinical Trials, 20(6), 519-530. doi:10.1016/s0197-2456(99)00029-xKahn, M. G., Raebel, M. A., Glanz, J. M., Riedlinger, K., & Steiner, J. F. (2012). A Pragmatic Framework for Single-site and Multisite Data Quality Assessment in Electronic Health Record-based Clinical Research. Medical Care, 50, S21-S29. doi:10.1097/mlr.0b013e318257dd67Batini, C., Cappiello, C., Francalanci, C., & Maurino, A. (2009). Methodologies for data quality assessment and improvement. ACM Computing Surveys, 41(3), 1-52. doi:10.1145/1541880.1541883Heinrich, B., Klier, M., & Kaiser, M. (2009). A Procedure to Develop Metrics for Currency and its Application in CRM. Journal of Data and Information Quality, 1(1), 1-28. doi:10.1145/1515693.1515697Sirgo, G., Esteban, F., Gómez, J., Moreno, G., Rodríguez, A., Blanch, L., … Bodí, M. (2018). Validation of the ICU-DaMa tool for automatically extracting variables for minimum dataset and quality indicators: The importance of data quality assessment. International Journal of Medical Informatics, 112, 166-172. doi:10.1016/j.ijmedinf.2018.02.007Hinton, G. E., & Salakhutdinov, R. R. (2006). Reducing the Dimensionality of Data with Neural Networks. Science, 313(5786), 504-507. doi:10.1126/science.1127647Kohn LT, Corrigan JM. To err is human: building a safer health system. A report of the Committee on Quality of Health Care in America. 2000. p. 287. National Academies Press

Role of [18F]FDG PET/CT in the differential diagnosis of a supraclavicular lump: neurofibromatosis disease

We report a 31-year-old male with a history of left forearm neuroma surgically removed, consulting for a supraclavicular bultoma congruent with the supradiaphragmatic lymphoproliferative syndrome in computed tomography (CT) scan. [18F]FDG PET/CT images helped to establish the most diagnostic yield lesion for the biopsy, and allowed an accurate staging of the neurofibromatosis (NF) disease, leading to the most appropriate therapeutic option for the patient

¿Cambia mucho el tamaño de grano obtenido mediante tamizado manual frente al mecánico?

Los procesos erosivos en el litoral, junto con la importancia económica del turismo (Houston, 2008), hacen que las realimentaciones periódicas de nuestras playas sean sumamente frecuentes. Y el tamaño de la arena es uno de los más importantes parámetros a la hora proyectar este tipo de obras. La media o la desviación típica del tamaño de grano son imprescindibles para comprobar si la arena de préstamo (terrestre o sumergida) es adecuada para sustituir a la transportada previamente por el mar (Pranzini et al., 2018). Además, el conocimiento de la distribución granulométrica del sedimento hace posible prever la reacción del perfil transversal ante una tormenta (Larson y Kraus, 1991), o calcular la cantidad necesaria de arena para abordar una regeneración (USACE, 2002). Por otra parte, a la hora de tomar decisiones sobre la zona de vertido de una cántara llena de arena, el gestor precisa conocer los parámetros antes mencionados de manera casi inmediata. Eso significa que los análisis del sedimento deben efectuarse a bordo de la draga, mientras se desplaza de la zona de préstamo hacia la costa a regenerar. Sin embargo, debido a la habitual escasez de espacio, a la ausencia de un laboratorio adecuado y al no siempre fiable suministro eléctrico, los tamizados deben hacerse a mano. Ya se ha estudiado la influencia del tiempo de tamizado a la hora de analizar la distribución granulométrica de una arena de playa o de duna (Roman-Sierra et al., 2013). Sin embargo, hasta este momento no se ha analizado la posible diferencia en la media y la desviación típica de una arena tamizada de manera manual a bordo de una draga frente a una tamizadora mecánica en un laboratorio en tierra. Asímismo, para ahorrar espacio y esfuerzo físico, a bordo de la draga suelen usarse tamices de 10 cm de diámetro frente a los más habituales de 20 cm en laboratorio. Para dar respuesta a estas preguntas, se aprovechó una regeneración efectuada en Cádiz en el año 2017 para efectuar una serie de pruebas a bordo de la draga Njord. Los extrapolables y más que útiles resultados, así como la influencia y consecuencias que tienen las diferencias observadas en la dirección de obras de regeneración de playas, se expondrán durante la presentación oral

Towards optimal cut-off trough levels of adalimumab and etanercept for a good therapeutic response in rheumatoid arthritis. Results of the INMUNOREMAR study

Article en format correspondènciaWe read with great interest the paper by Chen et al1 analysing the relationship between therapeutic response to adalimumab and etanercept and serum drug trough levels in 70 patients with rheumatoid arthritis (RA). ..

Mindfulness skills and experiential avoidance as therapeutic mechanisms for treatment-resistant depression through mindfulness-based cognitive therapy and lifestyle modification

Background/objective: The COVID-19 pandemic and consequent physical distancing has made it difficult to provide care for those with Treatment-Resistant Depression (TRD). As a secondary analysis of a clinical trial, the aim of this study was to explore potential mechanisms through which three online-delivered approaches, added to treatment as usual, improve depressive symptoms in TRD patients. Methods: The three approaches included (a) Minimal Lifestyle Intervention (MLI), (b) Mindfulness-Based Cognitive Therapy (MBCT), and (c) Lifestyle Modification Program (LMP). Sixty-six participants with TRD completed assessments pre-post intervention (mindfulness skills [FFMQ]; self-compassion [SCS]; and experiential avoidance [AAQ-II]) and pre-intervention to follow-up (depressive symptoms [BDI-II]). Data were analyzed using within-subjects regression models to test mediation. Results: Mindfulness skills mediated the effect of MBCT on depressive symptoms (ab = −4.69, 95% CI = −12.93 to−0.32), whereas the lack of experiential avoidance mediated the effect of LMP on depressive symptoms (ab = −3.22, 95% CI = −7.03 to−0.14). Conclusion: Strengthening mindfulness skills and decreasing experiential avoidance may promote recovery in patients with TRD, MBCT, and LMP have demonstrated that they may help increase mindfulness skills and decrease experiential avoidance, respectively. Future work will need to unpick the components of these interventions to help isolate active ingredients and increase optimization

Alternativas al Trabajo Fin de Master: el juego de empresas. Proyecto de Innovación y Mejora de la Calidad Docente Convocatoria 2014. Nº 279

El business game o juego de empresas es una actividad que cumple los objetivos que se señalan para un Trabajo Fin de Master y que, en opinión del grupo de trabajo de este proyecto, aporta más valor formativo para el alumno que un TFM convencional y a facilitar la finalización de la titulación dentro del curso académico

Reducing residual thrombotic risk in patients with peripheral artery disease : impact of the COMPASS trial

Altres ajuts: Writing and editorial assistance was funded by Bayer Hispania.Patients with peripheral artery disease (PAD) are at a high risk not only for the classical cardiovascular (CV) outcomes (major adverse cardiovascular events; MACE) but also for vascular limb events (major adverse limb events; MALE). Therefore, a comprehensive approach for these patients should include both goals. However, the traditional antithrombotic approach with only antiplatelet agents (single or dual antiplatelet therapy) does not sufficiently reduce the risk of recurrent thrombotic events. Importantly, the underlying cause of atherosclerosis in patients with PAD implies both platelet activation and the initiation and promotion of coagulation cascade, in which Factor Xa plays a key role. Therefore, to reduce residual vascular risk, it is necessary to address both targets. In the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial that included patients with stable atherosclerotic vascular disease, the rivaroxaban plus aspirin strategy (versus aspirin) markedly reduced the risk of both CV and limb outcomes, and related complications, with a good safety profile. In fact, the net clinical benefit outcome composed of MACE; MALE, including major amputation, and fatal or critical organ bleeding was significantly reduced by 28% with the COMPASS strategy, (hazard ratio: 0.72; 95% confidence interval: 0.59-0.87). Therefore, the rivaroxaban plus aspirin approach provides comprehensive protection and should be considered for most patients with PAD at high risk of such events

Análise da utilização da escala Nursing Activities Score em duas UCIS Espanholas

The aim of this study was to analyze the discourse of health managers on aspects related to delay in tuberculosis diagnosis. This was a qualitative research study, conducted with 16 Family Health Unit managers. The empirical data were obtained through semi-structured interviews. The analysis was based on the theoretical framework of the French school of discourse analysis. According to the managers’ statements, the delay in tuberculosis diagnosis is related to patient and health service aspects. As for patient aspects, managers report fear, prejudice and lack of information as factors that may promote a delayed diagnosis. Regarding health service aspects, structural problems and lack of professional skills were reported. The discourse of managers should be considered to qualify tuberculosis control actions and to prevent delays in diagnosis.Estudio prospectivo cuyo objetivo fue analizar las diferencias en el llenado de la escala Nursing Activities Score (NAS) en dos UCIs polivalentes de dos hospitales españoles. Datos relacionados a la carga de trabajo se recogieron diariamente, mediante la escala para los pacientes internados en las unidades durante el periodo de octubre a noviembre del 2011. Se recogieron datos de 103 pacientes obteniéndose un total de 941 medidas de la escala NAS. Diferencias significativas se encontraron en los ítems: monitorización, procedimientos de higiene, movilización y posición, tareas administrativas y monitorización de la aurícula izquierda (p < 0.001). Se concluyó que el empleo de instrumentos estandarizados es fundamental para poder comparar la carga de trabajo en diferentes unidades. La escala presenta ítems con un componente de valoración subjetiva, siendo importante la unificación de criterios para poder comparar los resultados entre las distintas unidades.Estudo prospetivo cujo objetivo foi analisar as diferenças no preenchimento da escala Nursing Activities Score (NAS) em duas UTI polivalentes de dois hospitais espanhóis. Dados relativos internados nas unidades durante o período de outubro a novembro de 2011. Os dados recolhidos de 103 pacientes produziram 941 medições na escala NAS. Diferenças significativas foram encontradas nos itens: monitoramento, procedimentos de higiene, mobilização e posicionamento, atividades administrativas e monitoramento auricular à esquerda (p < 0,001). Conclui-se que o uso de instrumentos padronizados é essencial quando se compara a carga de trabalho em unidades diferentes. A escala apresenta itens com uma componente de avaliação subjetiva, sendo por isso importante a unificação de critérios para a comparação de resultados entre diferentes unidades