Translating Comparative TJR Outcomes for Performance Improvement to Guide Surgical Quality Improvement

Background/Purpose: With the CMS decision to publicly report hospital-specific post-operative total joint replacement (TJR) complications and readmissions, orthopedic surgeons need new sources of post-operative outcome data to monitor and improve post-hospital care. The AHRQ funded research program, Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR), developed methods to capture longitudinal patient-reported outcomes (PROs) and comprehensive post-TJR medical and surgical events, and established a web reporting system to return comparative outcome reports to participating surgeons and hospitals in order to monitor and improve quality and outcomes. Methods: This national cohort/registry captures post-TJR measures directly from patients in their homes to assure uniform time, completion, and consistency for data comparisons across hospitals. Quarterly updated web reports deliver hospital- and surgeon-specific TJR outcomes compared with those of their peers and risk-adjusted national benchmarks on PROs as well as on post-operative event rates. Results: Our national cohort enrolled 25,000 patients from 150 diverse orthopedists in 22 US states with varied hospital and surgeon practices. The secure, HIPAA compliant website was established that presents summary and risk-adjusted comparative statistics for primary TJR for all enrolled patients. The website provides a downloadable and printable report and an Executive Summary of key pre-operative patient risk factors, post-operative events, and post-operative PROs enabling the providers to compare their outcomes to the other participating sites. Individual patient reports are available for surgeons with real-time scores and trended outcome data to facilitate patient and surgeon shared treatment decision making. Conclusion/Implications: A secure reporting website was established to disseminate comparative outcome reports to all participating hospitals and surgeons. Returning comparative outcome data to hospitals and surgeons encourages their active participation in this national registry and allows them to undstand their relative performance compared to peers while supporting practice-level quality monitoring and improvement efforts in patient care

Comparative and phylogenomic studies on the mitochondrial genomes of Pentatomomorpha (Insecta: Hemiptera: Heteroptera)

<p>Abstract</p> <p>Background</p> <p>Nucleotide sequences and the gene arrangements of mitochondrial genomes are effective tools for resolving phylogenetic problems. Hemipteroid insects are known to possess highly reorganized mitochondrial genomes, but in the suborder Heteroptera (Insecta: Hemiptera), there was only one complete mitochondrial genome sequenced without gene rearrangement and the phylogeny of infraorder Pentatomomorpha in Heteroptera was still uncertain.</p> <p>Results</p> <p>Fifteen mitochondrial genomes of the suborder Heteroptera were sequenced. Gene rearrangements were found as follows: 1) <it>tRNA-I </it>and <it>tRNA-Q </it>switched positions in Aradidae, 2) <it>tRNA-T </it>and <it>tRNA-P </it>switched positions in Largidae and Pyrrhocoridae. Two recombination events were found in Alydidae and Malcidae. The other mt-genomes were organized in the same way as observed in <it>Drosophila yakuba</it>. The phylogenetic analyses of infraorder Pentatomomorpha based on the nucleotide sequence raised the hypothesis of (Aradoidea + (Pentatomoidea + (Pyrrhocoroidea + (Lygaeoidea + Coreoidea)))). The rearrangement of <it>tRNA-T </it>and <it>tRNA-P </it>also linked Largidae and Pyrrhocoridae together. Furthermore, the conserved sequence block in the unusual intergenic spacers between <it>tRNA-H </it>and <it>ND4 </it>favored the monophyly of Lygaeoidea. Tetranucleotide ATCA was inferred to be the initiation codon of <it>ND2 </it>in Cydnidae. No correlation was found between the rates of nucleotide substitution and gene rearrangement. CG content was significantly correlated with the nucleotide substitution rate of each gene. For ND1, there was a positive correlation (<it>P </it>< 0.01) between amino acids variations and hydrophobicity, but a negative correlation (<it>P </it>< 0.01) for ND6. No conserved sequence was found among the control regions and these regions were not always the most AT-rich region of the mt-genome.</p> <p>Conclusion</p> <p>Heteropteran insects are extremely complex groups worthy of further study because of the unusual tetranucleotide initiation codon and their great mt-genomic diversity, including gene rearrangements and recombinations. The mt-genome is a powerful molecular marker for resolving phylogeny at the level of the superfamily and family. Gene rearrangements were not correlated with nucleotide substitution rates. CG content variation caused the different evolutionary patterns among genes. For ND1, in many polar or nonpolar regions the specific identity of the amino acid residues might be more important than maintaining the polarity of these regions, while the opposite is true for ND6. Most sequences of the control regions did not appear to be important for regulatory functions. Finally, we suggest that the term "AT-rich regions" should not be used.</p

Phylogenetic analysis of the true water bugs (Insecta: Hemiptera: Heteroptera: Nepomorpha): evidence from mitochondrial genomes

<p>Abstract</p> <p>Background</p> <p>The true water bugs are grouped in infraorder Nepomorpha (Insecta: Hemiptera: Heteroptera) and are of great economic importance. The phylogenetic relationships within Nepomorpha and the taxonomic hierarchies of Pleoidea and Aphelocheiroidea are uncertain. Most of the previous studies were based on morphological characters without algorithmic assessment. In the latest study, the molecular markers employed in phylogenetic analyses were partial sequences of 16S rDNA and 18S rDNA with a total length about 1 kb. Up to now, no mitochondrial genome of the true water bugs has been sequenced, which is one of the largest data sets that could be compared across animal taxa. In this study we analyzed the unresolved problems in Nepomorpha using evidence from mitochondrial genomes.</p> <p>Results</p> <p>Nine mitochondrial genomes of Nepomorpha and five of other hemipterans were sequenced. These mitochondrial genomes contain the commonly found 37 genes without gene rearrangements. Based on the nucleotide sequences of mt-genomes, Pleoidea is not a member of the Nepomorpha and Aphelocheiroidea should be grouped back into Naucoroidea. Phylogenetic relationships among the superfamilies of Nepomorpha were resolved robustly.</p> <p>Conclusion</p> <p>The mt-genome is an effective data source for resolving intraordinal phylogenetic problems at the superfamily level within Heteroptera. The mitochondrial genomes of the true water bugs are typical insect mt-genomes. Based on the nucleotide sequences of the mt-genomes, we propose the Pleoidea to be a separate heteropteran infraorder. The infraorder Nepomorpha consists of five superfamilies with the relationships (Corixoidea + ((Naucoroidea + Notonectoidea) + (Ochteroidea + Nepoidea))).</p

Sharing Patient Disease Data with Privacy Preservation

When patient data are shared for studying a specific disease, a privacy disclosure occurs as long as an individual is known to be in the shared data. Individuals in such specific disease data are thus subject to higher disclosure risk than those in datasets with different diseases. This problem has been overlooked in privacy research and practice. In this study, we analyze disclosure risks for this problem and identify appropriate risk measures. An efficient algorithm is developed for anonymizing the data. An experimental study is conducted to demonstrate the effectiveness of the proposed approach

Healthy Food Accessibility in Grocery Stores in Central Massachusetts

BACKGROUND. Accessibility to healthy food is one of the most influential community-level factors affecting obesity and chronic disease. The Community Nutrition Environment Evaluation Data System (C-NEEDS) is a set of instruments for objectively assessing availability and quality of 61 major healthy and unhealthy food items in foods stores in the Northeast region. METHODS. The C-NEEDS was developed considering seasonal variations, cultural relevance and utility to cardiovascular health research. Both inter- and intra-rater reliability tests showed a high degree of agreement. Using the instruments, we conducted four rounds of longitudinal surveys of 107 grocery stores in Worcester County, Massachusetts between 2007 and 2010. A healthy food availability index (HFAI, 0-37 points) was calculated for each store, a higher score indicating a greater availability and better quality of healthy foods. Using linear regression models, we examined variations in HFAI in relation to community household income and housing density. RESULTS. Store-level HFAI did not vary significantly by tertile of community median income, but did vary by housing density. High-density communities (upper tertile) had the greatest percentage of stores in the top HFAI tertile (34-37 points). Middle-density communities had the greatest percentage of stores in the low HFAI tertile (0-17 points). A majority of the stores located in low-density communities had middle range of HFAI (18-33 points). The mean HFAI increased with each successive round of grocery store surveys (β=2.02/round [95% confidence interval 0.74-3.31]). CONCLUSION. Access to healthy foods improved slightly over time, however, notable disparities still existed in Central Massachusetts during the study period. Better access was associated with community housing density but not median household income. Further studies on the causes of the disparities may inform public health organizations about necessary community actions to reduce these disparities

A Web-Based Treatment Decision Support Tool for Patients With Advanced Knee Arthritis: Evaluation of User Interface and Content Design

BACKGROUND: Data-driven surgical decisions will ensure proper use and timing of surgical care. We developed a Web-based patient-centered treatment decision and assessment tool to guide treatment decisions among patients with advanced knee osteoarthritis who are considering total knee replacement surgery. OBJECTIVE: The aim of this study was to examine user experience and acceptance of the Web-based treatment decision support tool among older adults. METHODS: User-centered formative and summative evaluations were conducted for the tool. A sample of 28 patients who were considering total knee replacement participated in the study. Participants\u27 responses to the user interface design, the clarity of information, as well as usefulness, satisfaction, and acceptance of the tool were collected through qualitative (ie, individual patient interviews) and quantitative (ie, standardized Computer System Usability Questionnaire) methods. RESULTS: Participants were older adults with a mean age of 63 (SD 11) years. Three-quarters of them had no technical questions using the tool. User interface design recommendations included larger fonts, bigger buttons, less colors, simpler navigation without extra next page click, less mouse movement, and clearer illustrations with simple graphs. Color-coded bar charts and outcome-specific graphs with positive action were easiest for them to understand the outcomes data. Questionnaire data revealed high satisfaction with the tool usefulness and interface quality, and also showed ease of use of the tool, regardless of age or educational status. CONCLUSIONS: We evaluated the usability of a patient-centered decision support tool designed for advanced knee arthritis patients to facilitate their knee osteoarthritis treatment decision making. The lessons learned can inform other decision support tools to improve interface and content design for older patients\u27 use

Assessing Availability of Healthy Options in Food Stores to Guide Community Transformation Grant Activities in Massachusetts

INTRODUCTION. Availability of healthy options in food stores is important to preventing obesity. The Mass in Motion Initiative and two Community Transformation Grant (CTG) projects are conducting statewide longitudinal surveys on availability of major healthy and unhealthy food items in foods stores in Massachusetts (MA). METHODS. The Community Nutrition Environment Evaluation Data System (C-NEEDS) was developed for food environment surveillance. C-NEEDS takes into account seasonal and geographic variations in food supplies, cultural relevance, and USDA dietary recommendations. Between summer 2012 and winter 2013, 567 food stores in 34 municipalities were surveyed and analyzed. Healthy food availability index (HFAI) was calculated for each store. HFAI has a possible range of 0 to 56, with a higher score indicating a greater availability of healthy food items. Community-level variations in HFAI were analyzed in relation to median household income and housing density. RESULTS. The HFAI scores had good to excellent inter- and intra-rater reliabilities. Store-level HFAI scores had a bimodal distribution, with over 70% of the stores having a score DISCUSSION. The majority of the surveyed stores were low in healthy food availability, indicating the need of community interventions. Analysis of store- and community-level variations in availability is useful for CTG programs to formulate and prioritize interventions. Future longitudinal surveys of food stores in the intervention and control communities will help evaluate the effectiveness of CTG intervention

Comprehensive Data Management System for National Patient-Centered Outcomes Research for Comparative Effectiveness in Total Joint Replacement

Introduction: The Agency for Healthcare Research and Quality (AHRQ) funded research program, Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR), is a national patient-centered outcomes research registry. To serve such multi-center longitudinal patient-reported outcomes research, we designed an innovative system to support systematic data collection, management and quality monitoring for long-term outcome evaluation of care. Methods: The system structure design explicitly considered the continuum of study procedures, including patient enrollment, patient-reported baseline and follow-up surveys, joint implant components, and ambulatory record review for future potential adverse events. Patient enrollment process is recorded through a web-based data capture system. Patient-reported outcomes are completed by patients via scannable paper or web-based standardized surveys before and after surgery. Patient risk factors and implant components are collected from community-based orthopedic practices and hospital operating rooms. All data from the different sources are combined into a centralized database. Quality checks and monitoring processes are routinely conducted for each source of data. De-identified data are cleaned and scored for research analysis and surgeon quality reporting. Results: This system for the registry program was initiated in 2011. As of Feburary 2014, over 16,000 patients have been enrolled from more than 130 surgeons in 22 states. The centralized database integrating data from patients, surgeons and hospitals is updated weekly. Cleaned, scored data are provided quaterly for all surgeons to review their site- and individual-surgeon-specific outcomes through web reports. Discussion: This comprehensive data management system is expected to enhance future uses of multi-source data to guide surgeon decisions and drive quality improvement. We anticipate that this system will facilitate translation of data integration to broad clinical research to inform best practices in TJR