2010 K12 Awardees: Overview of Research Projects

Two UMCCTS Clinical Research Scholars (K awardees) describe their research projects and professional growth as junior faculty: - Sarah Cutrona on Electronic Transmission of Health Information across Networks - Heena Santry on Career Development for an Academic Acute Care Surgeon and Acute Care Surgery Practice Patterns: A Tale of Two Complexitie

Time to Listen More and Talk Less

Submitted as Invited Editorial response to Singh Ospina et. al. Eliciting the Patient’s Agenda – Secondary Analysis of Recorded Clinical Encounters. In 1984, Elliot Mishler published a book called the Discourse of Medicine in which he argued that patients and providers bring different stories to a clinical encounter—the former reflecting the world in which the patient manages their health and illness and the latter reflecting the biomedical definitions of disease and treatment. He showed that providers far too often interrupt the patient stories in favor of a more biomedical version of the person in front of them. It was the beginning of reflections on the need to bridge these two stories in order to foster better communication and patient-centered care

Statin Discontinuation among Nursing Home Residents with Advanced Dementia

Background: Statin use in elderly individuals with life-limiting illness such as advanced dementia is controversial. Objective: To describe factors associated with statin discontinuation and estimate impact of discontinuation on 28-day hospitalizations in nursing home (NH) residents with advanced dementia. Methods: Retrospective cohort study of NH residents ≥ 65 years with recent progression to advanced dementia from 5 large U.S. states drawn from the 2007-2008 Minimum Data Set 2.0. We identified residents using statins. Clinical characteristics and 28-day hospitalization risk were compared for residents discontinuing and continuing statins. Multivariable Cox proportional hazard models identified factors associated with time to statin discontinuation and time to hospitalization. Sensitivity analysis using self-controlled case series examined the role of confounding-by-indication on risk estimation from the cohort approach. Results: Of 10,212 residents with decline to advanced dementia, 16.6% were prescribed statins (n=1,699). Statin users had mean age of 83.1 yrs, 68.9% were female, and mean medication burden was 10.3 (SD 4.8, range 1-31). Over one-third (n=632) discontinued in follow-up. Median time to discontinuation was 36 days after decline to advanced dementia (IQR [25%, 75%]: 12 days, 110 days). After adjustment, factors independently associated with increased hazard of discontinuation included residence in a NH in Florida relative to California, hospitalization in the 30 days prior to decline to advanced dementia, greater medication burden, and having cancer. The 28-day hospitalization risk was higher for residents discontinuing statins compared to continuing (adjusted hazard ratio = 1.78, CI 1.61,2.58). The SCCS estimate for 28-day hospitalization risk following statin discontinuation compared to a 28-day pre-discontinuation control period was lower than the cohort estimate (IRR= 0.79, CI 0.76, 0.83). Conclusion: A significant proportion of nursing home residents with dementia who use statins when they progress to advanced stage disease discontinue use. Hospitalization outcomes following discontinuation differ depending on method of estimation

Theme Trends and Knowledge Structure on Mobile Health Apps: Bibliometric Analysis

BACKGROUND: Due to the widespread and unprecedented popularity of mobile phones, the use of digital medicine and mobile health apps has seen significant growth. Mobile health apps have tremendous potential for monitoring and treating diseases, improving patient care, and promoting health. OBJECTIVE: This paper aims to explore research trends, coauthorship networks, and the research hot spots of mobile health app research. METHODS: Publications related to mobile health apps were retrieved and extracted from the Web of Science database with no language restrictions. Bibliographic Item Co-Occurrence Matrix Builder was employed to extract bibliographic information (publication year and journal source) and perform a descriptive analysis. We then used the VOSviewer (Leiden University) tool to construct and visualize the co-occurrence networks of researchers, research institutions, countries/regions, citations, and keywords. RESULTS: We retrieved 2802 research papers on mobile health apps published from 2000 to 2019. The number of annual publications increased over the past 19 years. JMIR mHealth and uHealth (323/2802, 11.53%), Journal of Medical Internet Research (106/2802, 3.78%), and JMIR Research Protocols (82/2802, 2.93%) were the most common journals for these publications. The United States (1186/2802, 42.33%), England (235/2802, 8.39%), Australia (215/2802, 7.67%), and Canada (112/2802, 4.00%) were the most productive countries of origin. The University of California San Francisco, the University of Washington, and the University of Toronto were the most productive institutions. As for the authors\u27 contributions, Schnall R, Kuhn E, Lopez-Coronado M, and Kim J were the most active researchers. The co-occurrence cluster analysis of the top 100 keywords forms 5 clusters: (1) the technology and system development of mobile health apps; (2) mobile health apps for mental health; (3) mobile health apps in telemedicine, chronic disease, and medication adherence management; (4) mobile health apps in health behavior and health promotion; and (5) mobile health apps in disease prevention via the internet. CONCLUSIONS: We summarize the recent advances in mobile health app research and shed light on their research frontier, trends, and hot topics through bibliometric analysis and network visualization. These findings may provide valuable guidance on future research directions and perspectives in this rapidly developing field

Validation of Acute Myocardial Infarction (AMI) in the FDA’s Mini-Sentinel Distributed Database

The Food and Drug Administration’s (FDA) Mini-Sentinel is a pilot program that aims to conduct active surveillance to detect and refine safety signals that emerge for marketed medical products. The purpose of this Mini-Sentinel AMI Validation project was to: (a) develop and design an abstraction and adjudication process to use when full text medical record review is required to confirm a coded diagnosis; and (b) to test this approach by validating a code algorithm for acute myocardial infarction (AMI)

Improving Rates of Influenza Vaccination Through Electronic Health Record Portal Messages, Interactive Voice Recognition Calls and Patient-Enabled Electronic Health Record Updates: Protocol for a Randomized Controlled Trial

BACKGROUND: Clinical decision support (CDS), including computerized reminders for providers and patients, can improve health outcomes. CDS promoting influenza vaccination, delivered directly to patients via an electronic health record (EHR) patient portal and interactive voice recognition (IVR) calls, offers an innovative approach to improving patient care. OBJECTIVE: To test the effectiveness of an EHR patient portal and IVR outreach to improve rates of influenza vaccination in a large multispecialty group practice in central Massachusetts. METHODS: We describe a nonblinded, randomized controlled trial of EHR patient portal messages and IVR calls designed to promote influenza vaccination. In our preparatory phase, we conducted qualitative interviews with patients, providers, and staff to inform development of EHR portal messages with embedded questionnaires and IVR call scripts. We also provided practice-wide education on influenza vaccines to all physicians and staff members, including information on existing vaccine-specific EHR CDS. Outreach will target adult patients who remain unvaccinated for more than 2 months after the start of the influenza season. Using computer-generated randomization and a factorial design, we will assign 20,000 patients who are active users of electronic patient portals to one of the 4 study arms: (1) receipt of a portal message promoting influenza vaccines and offering online appointment scheduling; (2) receipt of an IVR call with similar content but without appointment facilitation; (3) both (1) and (2); or (4) neither (1) nor (2) (usual care). We will randomize patients without electronic portals (10,000 patients) to (1) receipt of IVR call or (2) usual care. Both portal messages and IVR calls promote influenza vaccine completion. Our primary outcome is percentage of eligible patients with influenza vaccines administered at our group practice during the 2014-15 influenza season. Both outreach methods also solicit patient self-report on influenza vaccinations completed outside the clinic or on barriers to influenza vaccination. Self-reported data from both outreach modes will be uploaded into the EHR to increase accuracy of existing provider-directed EHR CDS (vaccine alerts). RESULTS: With our proposed sample size and using a factorial design, power calculations using baseline vaccination rate estimates indicated that 4286 participants per arm would give 80% power to detect a 3% improvement in influenza vaccination rates between groups (alpha=.05; 2-sided). Intention-to-treat unadjusted chi-square analyses will be performed to assess the impact of portal messages, either alone or in combination with the IVR call, on influenza vaccination rates. The project was funded in January 2014. Patient enrollment for the project described here completed in December 2014. Data analysis is currently under way and first results are expected to be submitted for publication in 2016. CONCLUSIONS: If successful, this study\u27s intervention may be adapted by other large health care organizations to increase vaccination rates among their eligible patients. CLINICALTRIAL: ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277 (Archived by WebCite at http://www.webcitation.org/6fbLviHLH)

Health Links: Who Acts as a Source of Health Information in a Social Network?

Background: Members of a social network can influence the preventive health choices and cancer screening behaviors of other network members. Study Design: We conducted in-person interviews with 438 insured adults ages 40-70 in Massachusetts, Hawaii, and Georgia. We gathered information on social network communication regarding routine health topics and cancer screening. Participants reported whether family members and friends ask them for information or advice on health topics. Characteristics of each respondent’s social network were explored, including number of people with whom the participant has discussed colorectal cancer (CRC) screening. Participants were asked whether communication with social network members had ever led them to seek cancer screening. Principal Findings:80% of respondents in our group described themselves as a source of health information or advice for others in their social network (89% of women vs. 68% of men, p Conclusions: People who identified themselves as a source of health information within their social network were more likely to have discussed CRC screening with others and communicated with more people. Further study is necessary to understand the roles played by these individuals. As “health information ambassadors,” they may be effective targets for interventions that promote preventive screening

Networks Fighting Nicotine: Will Visitors to a Tobacco Cessation Website Engage in an Online Support Community?

Background: Online tobacco cessation social networks may influence effectiveness of Web-Assisted Tobacco Interventions (WATIs). Purpose: To understand characteristics and quit rates of WATI participants navigating to BecomeAnEx.org, an online cessation network. Methods: We recruited 759 smokers to a WATI (decide2quit.org), through in-person primary care and dental office referrals and Google ads. We used online surveys to gather data on sociodemographics, tobacco use, and readiness to quit. Smokers were able to navigate online from the WATI to an online social network supporting cessation (BecomeAnEx.org). We identified visitors to and registrants with BecomeAnEx.org, examining associations between BecomeAnEx.org use and sociodemographic characteristics, patterns of WATI use and likelihood of tobacco cessation. Results: One-quarter (26.0%) of WATI users visited BecomeAnEx.org ; 7.5% registered. BecomeAnEx.org visitors were more likely than nonvisitors to be female (73.0% vs. 62.6% p\u3c0.01) and more likely to have visited a smoking cessation website before (43.9% vs 17.4%, p\u3c.01). Registrants were more likely to engage in other WATI tools including e-mails to trained tobacco specialists (68.4% vs 28.8). No significant association was found between BecomeAnEx.org use (visiting or registration) and tobacco cessation. Conclusions: BecomeAnEx.org navigation from our WATI was limited, attracting those already inclined toward online cessation tools. Future studies must explore whether online cessation social networks may have additional benefits if designed to attract larger audiences

Health Information Seeking on Behalf of Others: Characteristics of ‘Surrogate Seekers’

Understanding the health information seeking behaviors of surrogate seekers (those who seek health information for others) may guide efforts to reach disadvantaged populations. We used 2011-2012 data from the Health Information National Trends Survey to describe the behaviors of online surrogate seekers. Respondents were asked about their use of the Internet for surrogate seeking over the prior 12 months. Data were weighted to calculate population estimates. Compared to those who sought health information online for only themselves, surrogate seekers were more likely to live in households with others (weighted percent 89.4% vs. 82.5% of self-seekers; p \u3c 0.05); no significant differences in gender, race, income or education were observed. Surrogate seekers were more likely to report: visits to social networking sites to read and share about medical topics; participation in online health support groups and downloading of health information to electronic devices. On multivariate analysis, those who had looked online for a healthcare provider were more likely to be surrogate seekers (OR 1.67, 95% CI 1.08-2.59). Our results offer insight for leveraging health communication efforts to reach populations who rely upon surrogate seekers for health information

Collective-Intelligence Recommender Systems: Advancing Computer Tailoring for Health Behavior Change Into the 21st Century

BACKGROUND: What is the next frontier for computer-tailored health communication (CTHC) research? In current CTHC systems, study designers who have expertise in behavioral theory and mapping theory into CTHC systems select the variables and develop the rules that specify how the content should be tailored, based on their knowledge of the targeted population, the literature, and health behavior theories. In collective-intelligence recommender systems (hereafter recommender systems) used by Web 2.0 companies (eg, Netflix and Amazon), machine learning algorithms combine user profiles and continuous feedback ratings of content (from themselves and other users) to empirically tailor content. Augmenting current theory-based CTHC with empirical recommender systems could be evaluated as the next frontier for CTHC. OBJECTIVE: The objective of our study was to uncover barriers and challenges to using recommender systems in health promotion. METHODS: We conducted a focused literature review, interviewed subject experts (n=8), and synthesized the results. RESULTS: We describe (1) limitations of current CTHC systems, (2) advantages of incorporating recommender systems to move CTHC forward, and (3) challenges to incorporating recommender systems into CTHC. Based on the evidence presented, we propose a future research agenda for CTHC systems. CONCLUSIONS: We promote discussion of ways to move CTHC into the 21st century by incorporation of recommender systems