Quality Improvement Practices in Academic Emergency Medicine: Perspectives from the Chairs

Objective: To assess academic emergency medicine (EM) chairs’ perceptions of quality improvement (QI) training programs.Methods: A voluntary anonymous 20 item survey was distributed to a sample of academic chairs of EM through the Association of Academic Chairs of Emergency Medicine. Data was collected to assess the percentage of academic emergency physicians who had received QI training, the type of training they received, their perception of the impact of this training on behavior, practice and outcomes, and any perceived barriers to implementing QI programs in the emergency department.Results: The response rate to the survey was 69% (N = 59). 59.3% of respondents report that their hospital has a formal QI program for physicians. Chairs received training in a variety of QI programs. The type of QI program used by respondents was perceived as having no impact on goals achieved by QI (χ2 = 12.382; p = 0.260), but there was a statistically significant (χ2 = 14.383; p = 0.006) relationship between whether or not goals were achieved and academic EM chairs’ perceptions about return on investment for QI training. Only 22% of chairs responded that they have already made changes as a result of the QI training. 78.8% of EM chairs responded that quality programs could have a significant positive impact on their practice and the healthcare industry. Chairs perceived that QI programs had the most potential value in the areas of understanding and reducing medical errors and improving patient flow and throughput. Other areas of potential value of QI include improving specific clinical indicators and standardizing physician care.Conclusion: Academic EM chairs perceived that QI programs were an effective way to drive needed improvements. The results suggest that there is a high level of interest in QI but a low level of adoption of training and implementation.[West J Emerg Med. 2010; 11(5):479-485.

Effects of a Community Population Health Initiative on Blood Pressure Control in Latinos.

Background Hypertension remains one of the most important, modifiable cardiovascular risk factors. Yet, the largest minority ethnic group (Hispanics/Latinos) often have different health outcomes and behavior, making hypertension management more difficult. We explored the effects of an American Heart Association-sponsored population health intervention aimed at modifying behavior of Latinos living in Texas. Methods and Results We enrolled 8071 patients, and 5714 (65.7%) completed the 90-day program (58.5 years ±11.7; 59% female) from July 2016 to June 2018. Navigators identified patients with risk factors; initial and final blood pressure ( BP ) readings were performed in the physician\u27s office; and interim home measurements were recorded telephonically. The intervention incorporated home BP monitoring, fitness and nutritional counseling, and regular follow-up. Primary outcomes were change in systolic BP and health-related quality of life. Using a univariate paired-samples pre-post design, we found an average 5.5% (7.6-mm Hg) improvement in systolic BP (139.1 versus 131.5, t=10.32,

Determinants of Potentially Unnecessary Cervical Cancer Screenings in American Women

Objectives To identify factors responsible for potentially clinically unnecessary cervical cancer screenings in women with prior hysterectomy. Methods A retrospective cross-sectional study was conducted using the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS). This study targeted adult women and examined whether they received a both a Papanicolaou (Pap) test and undergone a hysterectomy in the last three years. We conducted multivariate analyses, including weighted proportions and odds ratios (ORs), based on the modified BRFSS weighting method (raking). The inclusion criteria were adult women (>18 years old) who reported having received a Pap test within the last 3 years. Results Of all women (n=252 391), 72 366 had received a Pap test, and 32 935 of those women (45%, or 12.5 million, weighted) had a prior hysterectomy. We found that age, race/ethnicity, marital status, family income, health status, time since last routine checkup, and health insurance coverage were all significant predictors. Black, non-Hispanic women were 2.23 times more likely to receive Pap testing after a hysterectomy than white women (OR, 2.23; 95% confidence interval [CI], 1.99 to 2.50). Similarly, the odds for Hispanic women were 2.34 times higher (OR, 2.34; 95% CI, 1.97 to 2.80). The odds were also higher for those who were married (OR, 1.17; 95% CI, 1.08 to 1.27), healthier (OR, 1.24; 95% CI, 1.14 to 1.35), and had health insurance (OR, 1.54; 95% CI, 1.28 to 1.84), after controlling for confounders. Conclusions We conclude that women may potentially receive Pap tests even if they are not at risk for cervical cancer, and may not be adequately informed about the need for screenings. We recommend strategies to disseminate recommendations and information to patients, their families, and care providers

Barriers and Disparities in Emergency Medical Services 911 Calls for Stroke Symptoms in the United States Adult Population: 2009 BRFSS Survey

Introduction: This study examines barriers and disparities in the intentions of American citizens, when dealing with stroke symptoms, to call 911. This study hypothesizes that low socioeconomic populations are less likely to call 911 in response to stroke recognition. Methods: The study is a cross-sectional design analyzing data from the Centers for Disease Control’s 2009 Behavioral Risk Factor Surveillance Survey, collected through a telephone-based survey from 18 states and the District of Columbia. The study identified the 5 most evident stroke-warning symptoms based on those given by the American Stroke Association. We conducted appropriate weighting procedures to account for the complex survey design. Results: A total of 131,988 respondents answered the following question: “If you thought someone was having a heart attack or a stroke, what is the first thing you would do?” A majority of those who said they would call 911 were insured (85.1%), had good health (84.1%), had no stroke history (97.3%), had a primary care physician (PCP) (81.4%), and had no burden of medical costs (84.9%). Those less likely to call 911 were found in the following groups: 65 years or older, men, other race, unmarried, less than or equal to high school degree, less than $25,000 family income, uninsured, no PCP, burden of medical costs, fair/poor health, previous history of strokes, or interaction between burden of medical costs and less than$50,000 family income (p\u3c0.0001 by X2 tests). The only factors significantly associated with “would call 911” were age, sex, race/ethnicity, marital status, and previous history of strokes. Conclusion: Barriers and disparities exist among subpopulations of different socioeconomic statuses. This study suggests that some potential stroke victims could have limited access to EMS services. Greater effort targeting certain populations is needed to motivate citizens to call 911. [West J Emerg Med. 2014;15(2):251–259]

Demographic and Survivorship Disparities in Non–muscle-invasive Bladder Cancer in the United States

Objectives To examine survivorship disparities in demographic factors and risk status for non–muscle-invasive bladder cancer (NMIBC), which accounts for more than 75% of all urinary bladder cancers, but is highly curable with early identification and treatment. Methods We used the US National Cancer Institute’s Surveillance, Epidemiology, and End Results registries over a 19-year period (1988-2006) to examine survivorship disparities in age, sex, race/ethnicity, and marital status of patients and risk status classified by histologic grade, stage, size of tumor, and number of multiple primary tumors among NMIBC patients (n=29 326). We applied Kaplan-Meier (K-M) and Cox proportional hazard methods for survival analysis. Results Among all urinary bladder cancer patients, the majority of NMIBCs were in male (74.1%), non-Latino white (86.7%), married (67.8%), and low-risk (37.6%) to intermediate-risk (44.8%) patients. The mean age was 68 years. Survivorship (in median life years) was highest for non-Latino white (5.4 years), married (5.4 years), and low-risk (5.7 years) patients (K-M analysis, p<0.001). We found significantly lower survivorship for elderly, male (female hazard ratio [HR], 0.96), Latino (HR, 1.20), and unmarried (married HR, 0.93) patients. Conclusions Survivorship disparities were ubiquitous across age, sex, race/ethnicity, and marital status groups. Non-white, unmarried, and elderly patients had significantly shorter survivorship. The implications of these findings include the need for a heightened focus on health policy and more organized efforts to improve access to care in order to increase the chances of survival for all patients

Does Hospital Location Matter? association of Neighborhood Socioeconomic Disadvantage With Hospital Quality in Us Metropolitan Settings

An aspect of a hospital\u27s location, such as its degree of socioeconomic disadvantage, could potentially affect quality ratings of the hospital; yet, few studies have granularly explored this relationship in United States (US) metropolitan areas characterized by a wide breadth of socioeconomic disparities across neighborhoods. An understanding of the effect of neighborhood socioeconomic disadvantage on hospital quality of care is informative for targeting resources in poor neighborhoods. We assessed the association of neighborhood socioeconomic disadvantage with hospital quality of care across several areas of quality (including mortality, readmission, safety, patient experience, effectiveness of care, summary and overall star rating) in US metropolitan areas. Hospitals in the most disadvantaged neighborhoods, compared to hospitals in the least disadvantaged neighborhoods, had worse mortality scores, readmission scores, safety of care scores, patient experience of care scores, effectiveness of care scores, summary scores and overall star rating. Timeliness of care and efficient use of imaging scores were not strongly associated with neighborhood socioeconomic disadvantage; although, future studies are needed to validate this finding. Policymakers could target innovative strategies for improving neighborhood socioeconomic conditions in more disadvantaged areas, as this may improve hospital quality

Discovering disease-disease associations using electronic health records in The Guideline Advantage (TGA) dataset

Certain diseases have strong comorbidity and co-occurrence with others. Understanding disease-disease associations can potentially increase awareness among healthcare providers of co-occurring conditions and facilitate earlier diagnosis, prevention and treatment of patients. In this study, we utilized the valuable and large The Guideline Advantage (TGA) longitudinal electronic health record dataset from 70 outpatient clinics across the United States to investigate potential disease-disease associations. Specifically, the most prevalent 50 disease diagnoses were manually identified from 165,732 unique patients. To investigate the co-occurrence or dependency associations among the 50 diseases, the categorical disease terms were first mapped into numerical vectors based on disease co-occurrence frequency in individual patients using the Word2Vec approach. Then the novel and interesting disease association clusters were identified using correlation and clustering analyses in the numerical space. Moreover, the distribution of time delay (Δt) between pair-wise strongly associated diseases (correlation coefficients ≥ 0.5) were calculated to show the dependency among the diseases. The results can indicate the risk of disease comorbidity and complications, and facilitate disease prevention and optimal treatment decision-making

Women and ethnoracial minorities with poor cardiovascular health measures associated with a higher risk of developing mood disorder

BACKGROUND: Mood disorders (MDS) are a type of mental health illness that effects millions of people in the United States. Early prediction of MDS can give providers greater opportunity to treat these disorders. We hypothesized that longitudinal cardiovascular health (CVH) measurements would be informative for MDS prediction. METHODS: To test this hypothesis, the American Heart Association\u27s Guideline Advantage (TGA) dataset was used, which contained longitudinal EHR from 70 outpatient clinics. The statistical analysis and machine learning models were employed to identify the associations of the MDS and the longitudinal CVH metrics and other confounding factors. RESULTS: Patients diagnosed with MDS consistently had a higher proportion of poor CVH compared to patients without MDS, with the largest difference between groups for Body mass index (BMI) and Smoking. Race and gender were associated with status of CVH metrics. Approximate 46% female patients with MDS had a poor hemoglobin A1C compared to 44% of those without MDS; 62% of those with MDS had poor BMI compared to 47% of those without MDS; 59% of those with MDS had poor blood pressure (BP) compared to 43% of those without MDS; and 43% of those with MDS were current smokers compared to 17% of those without MDS. CONCLUSIONS: Women and ethnoracial minorities with poor cardiovascular health measures were associated with a higher risk of development of MDS, which indicated the high utility for using routine medical records data collected in care to improve detection and treatment for MDS among patients with poor CVH

Time-series cardiovascular risk factors and receipt of screening for breast, cervical, and colon cancer: The Guideline Advantage

BACKGROUND: Cancer is the second leading cause of death in the United States. Cancer screenings can detect precancerous cells and allow for earlier diagnosis and treatment. Our purpose was to better understand risk factors for cancer screenings and assess the effect of cancer screenings on changes of Cardiovascular health (CVH) measures before and after cancer screenings among patients. METHODS: We used The Guideline Advantage (TGA)-American Heart Association ambulatory quality clinical data registry of electronic health record data (n = 362,533 patients) to investigate associations between time-series CVH measures and receipt of breast, cervical, and colon cancer screenings. Long short-term memory (LSTM) neural networks was employed to predict receipt of cancer screenings. We also compared the distributions of CVH factors between patients who received cancer screenings and those who did not. Finally, we examined and quantified changes in CVH measures among the screened and non-screened groups. RESULTS: Model performance was evaluated by the area under the receiver operator curve (AUROC): the average AUROC of 10 curves was 0.63 for breast, 0.70 for cervical, and 0.61 for colon cancer screening. Distribution comparison found that screened patients had a higher prevalence of poor CVH categories. CVH submetrics were improved for patients after cancer screenings. CONCLUSION: Deep learning algorithm could be used to investigate the associations between time-series CVH measures and cancer screenings in an ambulatory population. Patients with more adverse CVH profiles tend to be screened for cancers, and cancer screening may also prompt favorable changes in CVH. Cancer screenings may increase patient CVH health, thus potentially decreasing burden of disease and costs for the health system (e.g., cardiovascular diseases and cancers)

The diffusion of operators research in management decision making : An analysis of U.S. Healthcare organisations

EThOS - Electronic Theses Online ServiceGBUnited Kingdo