EHRs Can Help Identify Patients Who May Benefit From HIV PrEP Medications

MedicalResearch.com Interview with:

Douglas Krakower, MD Infectious Disease Division Beth Israel Deaconess Medical Center Boston, MA,

Dr. Douglas Krakower

Douglas Krakower, MD
Infectious Disease Division
Beth Israel Deaconess Medical Center
Boston, MA,

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: There are 45,000 new HIV infections in the US annually, so effective HIV prevention strategies are needed. HIV pre-exposure prophylaxis (PrEP), whereby a person who is HIV-uninfected uses an HIV treatment medication on a daily basis to protect themselves from becoming infected with HIV, is over 90% effective when taken with high adherence. The Centers for Disease Control and Prevention estimates that there are 1.2 million Americans who are likely to benefit from using PrEP. However, only 80,000 persons have been prescribed PrEP. One of the barriers to implementing PrEP is that clinicians face challenges with identifying persons who are most likely to benefit from PrEP, given infrequent sexual health history assessments during routine clinical care. We thus sought to develop an automated algorithm that uses structured data from electronic health records (EHRs) to identify patients who are most likely to benefit from using PrEP. Our methods included extracting potentially relevant EHR data for patients with incident HIV and without HIV from nearly a decade of EHR data from a large ambulatory practice in Massachusetts. We then used machine learning algorithms to predict HIV infection in those with incident HIV and those without HIV. We found that some algorithms could offer clinically useful predictive power to identify persons who were more likely to become infected with HIV as compared to controls. When we applied these algorithms to the general population and identified a subset of about 1% of the population with risk scores above an inflection point in the total distribution of risk scores; these persons may be appropriate for HIV testing and/or discussions about PrEP.

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Use of Oral Anticoagulation at Time of PCI Surgery Linked To Increase in Adverse Events

MedicalResearch.com Interview with:

Eric A. Secemsky, MD MSc Interventional Cardiology Fellow Massachusetts General Hospital, Harvard Medical School Fellow, Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center

Dr. Eric A. Secemsky

Eric A. Secemsky, MD MSc
Interventional Cardiology Fellow
Massachusetts General Hospital
Harvard Medical School
Fellow, Smith Center for Outcomes Research in Cardiology
Beth Israel Deaconess Medical Center

MedicalResearch.com: What is the background for this study?

Response: Use of oral anticoagulant (OAC) therapy prior to coronary stenting is a significant predictor of post-procedural bleeding events. Previous studies have estimated that the frequency of chronic OAC use among patients undergoing percutaneous coronary intervention (PCI) is between 3% to 7%. Yet many of these analyses examined select patient populations, such as those admitted with acute myocardial infarction or atrial fibrillation, and preceded the market approval of non-vitamin K antagonist oral anticoagulants (NOACs). As such, the contemporary prevalence of OAC use among all-comers undergoing PCI, as well as associated risks of adverse events, are currently unknown.

Therefore, we used PCI data from a large, integrated healthcare system to determine current use of  oral anticoagulant use among all-comers undergoing coronary stenting and the related short- and long-term risks of therapy.

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BMI1 Gene Expression May Predict Response To Lung Cancer Treatment

MedicalResearch.com Interview with:

Dr. Elena Levantini, PhD Beth Israel Deaconess Medical Center Instructor, Medicine, Harvard Medical School Research Associate, Hematology-Oncology Beth Israel Deaconess Medical Center

Dr. Elena Levantini

Dr. Elena Levantini, PhD
Beth Israel Deaconess Medical Center
Instructor, Medicine, Harvard Medical School
Research Associate, Hematology-Oncology
Beth Israel Deaconess Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Lung cancer is one of the deadliest cancers in the world, accounting for 30% of tumor-related deaths. Like many solid tumours, lung cancer is very heterogeneous (consisting of cancer cells which behave and respond differently) and hence there is currently no single efficient drug which is able to treat all patients.

Levantini and colleagues previously showed that non-small cell lung cancer (NSCLC) tumor cells frequently express too little or none of a transcription factor called C/EBPα, a protein that regulates gene expression and cell proliferation in lung tissues. It’s also known to play a role in a form of leukemia, as well as liver cancer, squamous cell skin carcinomas, squamous cell cancers of the head and neck and other cancers. In their previous work, the scientists suspected that C/EBPα may act as a tumor suppressant in normal cells, but the mechanism by which its absence promoted lung cancer tumors remained unclear.
Dr. Levantini went on to develop a mouse model in which deleting C/EBPα resulted in NSCLC. Analysis of this model led to the discovery that C/EBPα suppressed lung tumor formation by inhibiting the expression of BMI1. Dr Levantini then demonstrated that reducing the levels of BMI1 in her mouse model by genetic means, or by using a drug reducing expression of BMI1, led to inhibition of tumor formation. This study has established an important link between C/EBPα and BMI1 for the first time.

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Women Still Getting CA-125 and CT Testing After Ovarian Cancer, Despite Lack of Clear Benefit

MedicalResearch.com Interview with:

Katharine Mckinley Esselen, M.D. Instructor in Obstetrics, Gynecology and Reproductive Biology Beth Israel Deaconess Medical Center Brigham and Womens Hospital

Dr. Katharine M. Esselen

Katharine Mckinley Esselen, M.D.
Instructor in Obstetrics, Gynecology and Reproductive Biology
Beth Israel Deaconess Medical Center
Brigham and Womens Hospital

MedicalResearch.com: What is the background for this study?

Response: There is no consensus on how to follow a patient in remission from ovarian cancer in order to detect recurrent disease. However, a 2009 randomized clinical trial demonstrated that using CA-125 blood tests for routine surveillance in ovarian cancer increases the use of chemotherapy and decreases patient’s quality of life without improving survival compared with clinical observation. Published guidelines categorize CA-125 tests as optional and discourage the use of radiographic imaging for routine surveillance. Thus, this study aims to examine the use of CA-125 tests and CT scans at 6 Cancer Centers and to estimate the economic impact of this surveillance testing for ovarian cancer.

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Investigational Deutetrabenazine Reduces Chorea in Huntington Disease

MedicalResearch.com Interview with:

Samuel Frank, MD Director of the Huntington’s Disease Society of America Center of Excellence Beth Israel Deaconess Medical Center Boston, MA 02215

Dr. Samuel Frank

Samuel Frank, MD
Director of the Huntington’s Disease Society of America Center of Excellence
Beth Israel Deaconess Medical Center
Boston, MA 02215

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Huntington Disease is a hereditary, progressive neurodegenerative disease characterized by involuntary movements (chorea and dystonia), cognitive dysfunction and psychiatric symptoms. Deutetrabenazine is a novel molecule containing deuterium, which attenuates CYP2D6 metabolism, increases active metabolite half-lives leading to stable systemic exposure. We found that deutetrabenazine significantly reduces chorea. There was also an overall improvement in participants’ condition based on patient and clinician measures and improvement in a quality of life measure. There was no worsening, but also no improvement in balance. The improvements in Huntington Disease were seen with a remarkably good safety and tolerability profile.

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Two New Vaccines Provide Protection Against Zika in Mice

MedicalResearch.com Interview with:

Dan Barouch, M.D., Ph.D. Professor of Medicine Harvard Medical School Ragon Institute of MGH, MIT, and Harvard Director, Center for Virology and Vaccine Research Beth Israel Deaconess Medical Center

Dr. Dan Barouch

Dan Barouch, M.D., Ph.D.
Professor of Medicine
Harvard Medical School
Ragon Institute of MGH, MIT, and Harvard
Director, Center for Virology and Vaccine Research
Beth Israel Deaconess Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We showed that two vaccines, a DNA vaccine and a purified inactivated virus vaccine, both provided complete protection against Zika virus challenge in mice. To the best of our knowledge, this is the first demonstration of Zika vaccine protection in any animal model.

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Only Small Increase in CT Screening for Lung Cancer Despite New Guidelines

MedicalResearch.com Interview with:

Phillip M. Boiselle, MD Professor of Radiology and Associate Dean for Academic and Clinical Affairs Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts

Dr. Phillip Boiselle

Phillip M. Boiselle, MD
Professor of Radiology and Associate Dean for Academic and Clinical Affairs
Harvard Medical School
Beth Israel Deaconess Medical Center
Boston, Massachusetts

Medical Research: What is the background for this study?

Dr. Boiselle: We surveyed leading academic medical centers in 2013 and found considerable variability in their practice patterns as well as a relatively small number of patients being screened for lung cancer at these sites. Considering landmark developments since that time, including favorable policy and payment decisions by USPSTF  and CMS  and development of radiology-specific nodule guidelines by the American College of Radiology, we were curious to see whether there would be greater conformity of practice patterns and increased patient volumes in response to these developments.

Medical Research: What are the main findings?

Dr. Boiselle: First, our finding of greater conformity of lung cancer screening practices at present compared to 2013 confirmed our hypothesis that the development of radiology-specific guidelines by ACR would contribute to greater uniformity.

Second, we were surprised by the very modest level of increase in patient volumes for CT screening over time despite the favorable USPSTF and CMS decisions. We emphasize, however, that the timing of our survey occurred too early to determine the full impact of CMS coverage on patient volumes

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Some Hemorrhagic Strokes Can Have Transient Symptoms

Sandeep Kumar, MD Assistant Professor of Neurology Harvard Medical School Director, Inpatient Stroke Service Department of Neurology, Stroke Division Beth Israel Deaconess Medical Center Boston, MA 02215

Dr. Sandeep Kumar

MedicalResearch.com Interview with:
Sandeep Kumar, MD

Assistant Professor of Neurology
Harvard Medical School
Director, Inpatient Stroke Service
Department of Neurology, Stroke Division
Beth Israel Deaconess Medical Center
Boston, MA 02215

Medical Research: What is the background for this study? What are the main findings?

Dr. Kumar: Transient deficits that start suddenly and typically last for a few minutes to a few hours are the hallmark of a transient ischemic attack (TIA) or a minor ischemic stroke. In this single-center observational study, we have reported similar clinical presentation in some patients with intracerebral hemorrhage (ICH) that are difficult to distinguish from cerebral ischemia based only on clinical signs and symptoms.

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Some Nodules on CT Scans More Likely to Be Lung Cancer In Women

Phillip Boiselle, M.D. Staff, Cardiothoracic Imaging Beth Israel Deaconess Medical Center Associate Dean for Academic and Clinical Affairs Professor of Radiology, Harvard Medical School Boston, Mass

Dr. Boiselle

MedicalResearch.com Interview with:
Phillip Boiselle, M.D.
Staff, Cardiothoracic Imaging
Beth Israel Deaconess Medical Center
Associate Dean for Academic and Clinical Affairs
Professor of Radiology, Harvard Medical School
Boston, Mass

Medical Research: What is the background for this study? What are the main findings?

Dr. Boiselle: Previous studies have shown that women have a greater mortality benefit from lung cancer screening then men, and that this test (CT screening) is more cost-effective for women than men. Our purpose was to determine whether the relative risk of lung cancer for women and men differed depending on the specific type of lung nodule that was discovered at screening. Such differences could potentially help to influence a more personalized approach to patient management in lung cancer screening.

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New HCV Treatment Improves Hepatitis C Cirrhosis

Dr. Michael P. Curry, MD Medical Director for Liver Transplantation Harvard Medical Faculty Physicians Beth Israel Deaconess Medical Center

Dr. Curry

MedicalResearch.com Interview with:
Dr. Michael P. Curry, MD
Medical Director for Liver Transplantation
Harvard Medical Faculty Physicians
Beth Israel Deaconess Medical Center

Medical Research: What is the background for this study? What are the main findings

Dr. Curry: As the population that is infected with the hepatitis C virus (HCV) ages, the number of patients with decompensated cirrhosis is expected to increase. For many years, the only treatment option for these patients was liver transplantation. Recently, however, clinical trials of newly approved direct-acting antiviral agents (DAAs) have shown that it is possible to treat HCV infection safely and effectively in patients with decompensated cirrhosis. We conducted this Phase 3, open-label trial to assess the efficacy and safety of a fixed dose combination of sofosbuvir/velpatasvir with or without ribavirin for 12 weeks or sofosbuvir/velpatasvir for 24 weeks in patients infected with hepatitis C virus genotypes 1 through 6 and with decompensated cirrhosis. We found that treatment with sofosbuvir/velpatasvir resulted in high rates of sustained virologic response (SVR) and early improvements in hepatic function in this patient population. SVR rates were 83 percent  in patients who received sofosbuvir/velpatasvir for 12 weeks, 94 percent among those who received sofosbuvir/velpatasvir plus ribavirin, and 86 percent among those who received sofosbuvir/velpatasvir for 24 weeks.

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3D Printers Make Accurate Low Cost Bronchoscopes for Education

Dr. George Cheng MD Beth Israel Deaconess Medical Center

Dr. George Cheng

MedicalResearch.com Interview with:
Dr. George Cheng MD
Beth Israel Deaconess Medical Center 

Medical Research: What is the background for this study? What are the main findings?

Dr. Cheng: Since the introduction of flexible bronchoscope in late 1960s, flexible bronchoscopy has gained wide popularity and with over 500,000 procedures being performed in the USA annually.  Bronchoscopy training has been undergoing rapid advancement in recent years.  Virtual bronchoscopy, either web-based training or VR bronchoscopic simulators, were used to teach and to improve performance in bronchoscopy.  However, virtual reality simulators often cost over $100,000 dollars.  Given the prohibitive high cost, recent CHEST expert panel recommended that high fidelity simulators be offered only in regional simulation centers.  Therefore, low cost realistic bronchoscopy training models are an area of need.

Recent development in 3D printing and 3D medical modeling has allowed clinicians to utilize CT scans to create physical models.  This approach can be used to create affordable 3D printed, anatomically accurate bronchoscopy training models.  However, the 3D printed tracheobronchial model has never been evaluated as a bronchoscopy simulation tool.  We aimed to address this question with our study.

The 3D printed bronchoscopy model was generated from flexible nylon material and stained to match the airway mucosa coloration.  Participants of varies training levels performed bronchoscopy on both standard and 3D printed bronchoscopy model, graded each on a sliding scale from 0-100.  Overall, clinicians preferred the 3D printed model regardless of their level of training.

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Comparison of Surgical Techniques For Abdominal Aortic Aneurysm Repair

Dr. Marc Schermerhorn, MD Chief of Vascular and Endovascular Surgery Beth Israel Deaconess MedicalMedicalResearch.com Interview with:
Dr. Marc Schermerhorn, MD
Chief of Vascular and Endovascular Surgery
Beth Israel Deaconess Medical

Medical Research: What is the background for this study?

Dr. Schermerhorn: Abdominal Aortic Aneurysm is common, about 4% of men over 60 and 1% of women will have AAA, higher in smokers and those with family members with AAA.

Medical Research: What are the main findings?

Dr. Schermerhorn: Endovascular repair has substantially lower operative mortality and complications and patients leave the hospital earlier and are more likely to go home rather than rehab or a nursing home.

The early survival advantage with endovascular repair fades over time and late survival is similar.  After endovascular repair more re-interventions to maintain the Abdominal Aortic Aneurysm repair are needed while after open repair there are more complications related to the abdominal incision.

Importantly, late Abdominal Aortic Aneurysm rupture is more common after endovascular repair.  This highlights the need for more research to prevent late rupture and highlights the need for patients to continue to undergo routine surveillance to detect problems that can potentially be fixed with a minimally invasive treatment.

Finally, endovascular results are improving over time.

Citation:

Marc L. Schermerhorn, M.D., Dominique B. Buck, M.D., A. James O’Malley, Ph.D., Thomas Curran, M.D., John C. McCallum, M.D., Jeremy Darling, B.A., and Bruce E. Landon, M.D., M.B.A.

N Engl J Med 2015; 373:328-338
July 23, 2015

DOI: 10.1056/NEJMoa1405778

Dr. Marc Schermerhorn, MD (2015). Comparison of Surgical Techniques For Abdominal Aortic Aneurysm Repair 

Evaluating Liver Fat On Cardiac CT Helps Predict Risk vs Benefit of Statin Therapy

MedicalResearch.com Interview with:
Venkatesh L. Murthy, MD, PhD, FACC, FASNC University of Michigan
Venkatesh L. Murthy, MD, PhD, FACC, FASNC

University of Michigan

Dr. Ravi Shah MD Beth Israel Deaconess Medical Centerand Dr. Ravi Shah MD
Beth Israel Deaconess Medical Center

 


MedicalResearch: What is the background for this study?

Response: Recent changes recommend statin therapy for cardiovascular risk reduction in an increasingly large number of Americans. Conversely, a number of studies have identified an increased risk of diabetes with statin treatment. Thus, there is increasing need for tools to target statin therapy to those with a favorable risk-benefit profile.

MedicalResearch: What are the main findings?

Response: In our study, we analyzed data from 3,153 individuals from the Multi-Ethnic Study of Atherosclerosis who underwent CT scanning at baseline for assessment of calcium score. The CT scans were analyzed to assess liver attenuation as a measure of the amount of liver fat. We demonstrated that high liver fat doubled the risk of diabetes over a median of 9 years of follow-up. Importantly, statin therapy also doubled the risk of diabetes. The two together had an additive effect, even after adjusting for BMI, age, gender, family history of diabetes, waist circumference, lipids, hsCRP and exercise habits. As in prior studies, the risk of cardiovascular disease (CVD) events increased with increasing calcium score, as has previously been shown in MESA and in other studies.

We then divided the cohort into six groups based on calcium score (0, 1-100 and >100) and liver fat (low/high). Using published data from meta-analyses of statin trials, we computed the number needed to treat to prevent one hard CVD event for statin therapy. Using data from our study, we computed the number needed to harm to cause one additional case of diabetes from statin therapy. The numbers needed to treat with ranged from 29-40 for calcium score of >100 to 218-252 for calcium score of 0. Conversely, the numbers needed to harm were approximately 63-68 for those with low liver fat versus 22-24 for those with high liver fat. Thus the combination of calcium score and liver fat assessment, from a single standard calcium score scan, allows for physicians to provide better assessment of risk and benefit of statins in discussion with their patients. Continue reading

Type 2 Diabetes Linked to Decreased Brain Blood Flow and Cognitive Ability

Vera Novak, MD PhD Associate Professor of Neurology Dept. of Neurology, Stroke Division Director Syncope and Falls in the Elderly Laboratory Beth Israel Deaconess Medical Center Boston, MAMedicalResearch.com Interview with:
Vera Novak, MD PhD
Associate Professor of Neurology
Dept. of Neurology, Stroke Division
Director Syncope and Falls in the Elderly Laboratory
Beth Israel Deaconess Medical Center
Boston, MA

MedicalResearch: What is the background for this study?

Dr. Novak: Diabetes mellitus (DM) is a major contributor to morbidity and mortality.
Type 2 diabetes mellitus affects more than 44 million people in the U.S., and its numbers are growing rapidly, affecting up to 27% of older adults. Diabetes mellitus accelerates brain aging by about 5 years1, manifests as a widespread generalized atrophy2, and promotes earlier onset of vascular dementia and Alzheimer’s disease (AD).3,4 Diabetes mellitus -related atrophy manifests as worse cognitive function, memory, and gait, especially during a dual task, 5,6 and even a tight glycemic control did not improve cognitive function in participants of the large clinical trials 7.

MedicalResearch: What are the main findings?

Dr. Novak: Sixty-five participants (aged 66± 9.2 years) 35 with T2DM and 30 non-diabetic controls participated in this study. After 2 years of follow-up, participants with T2 Diabetes mellitus had diminished vascular reactivity in the brain (an ability to increase blood flow in responses to a task or metabolic demands) and performed worse on multiple cognitive tasks (in particular verbal learning and memory). In T2DM group, lower cerebral vasoreactivity correlated with worse performance on daily living activities. Specifically, the lower vasodilatation (ability to increase blood flow) was associated with worse mental functions. In addition, those with higher markers of inflammation had greater decline in vascular function in the brain.

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Your Smartphone May Help You Control Your Blood Pressure

MedicalResearch.com Interview with:
Neetika Garg, MD
Fellow in Nephrology
Beth Israel Deaconess Medical Center
Division of Nephrology, Department of Medicine
Boston, MA 02215

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Garg: One in every three Americans suffers from hypertension. Since high blood pressure (BP) frequently does not cause any symptoms, self-blood pressure monitoring at home and patient education are critical components of patient management. With more than 58% of the US adults owning a smartphone, mobile-based health technologies (most commonly in the form of applications or “apps”) can serve as useful adjuncts in diagnosis and management of hypertension. At the same time, several smartphone-based applications are advertised as having blood pressure measurement functionality, which have not been validated against a gold standard. In this cross-sectional study, we analyzed the top 107 hypertension related apps available on the most popular smartphone platforms (Google Android and Apple iPhone) to analyze the functional characteristics and consumer interaction metrics of various hypertension related apps.

Nearly three-quarters of the apps record and track blood pressure, heart rate, salt intake, caloric intake and weight/body mass index. These app features can facilitate patient participation in hypertension management, medication adherence and patient-physician communication. However, it was concerning to find that 6.5% of the apps analyzed could transform the smartphone into a cuffless BP measuring device. None of these had any documentations of validation against a gold standard. Furthermore, number of downloads and favorable user ratings were significantly higher for these apps compared to apps without blood pressure measurement function. This highlights the need for greater oversight and regulation in medical device development.

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Pop-Up Screen On Electronic Medical Records May Reduce Some Unnecessary Testing

Elliot B Tapper, M.D. Clinical Fellow in Medicine (EXT) Beth Israel Deaconess Medical Center Boston MA 02215MedicalResearch.com Interview with:
Elliot B Tapper, M.D.
Clinical Fellow in Medicine (EXT)
Beth Israel Deaconess Medical Center
Boston MA 02215

Medical Research: What is the background for this study? What are the main findings?

Dr. Tapper: Elevation of liver enzymes is a common problem, affecting 7.9% of Americans. It is usually related to typical conditions such as fatty liver disease or viral hepatitis. Oftentimes, clinicians test patients with elevated liver enzymes for a multitude of possible causes including very rare genetic diseases, for example, a disease called Wilson Disease. This pattern of evaluation is called non-directed testing. It is a specific form of over-testing that is common in many fields and can be expensive or generate false positives. Wilson Disease, an inborn error of copper metabolism associated with liver injury, is rare (prevalence 0.003%) and there are guidelines available to suggest who should be tested, usually with a blood test called ceruloplasmin. These guidelines suggest excluding common liver diseases before testing for Wilson Disease and testing in younger patients (< 55 years old) because it is very rare to present after age 55.

We created a ‘pop-up’ screen in our provider ordering system to present clinicians who were choosing to order ceruloplasmin with the guidelines as well as its test characteristics, while still allowing them to order the test if they wanted. We studied the 7 months before and after the implementation of this intervention. We found a 51% reduction in ceruloplasmin orders. More importantly, we found that simultaneous testing for common liver diseases like viral hepatitis declined by 54% and the number of patients over the age of 55 who were tested declined by 61%. Incidentally, all positive tests were false positives.

First, we show that adherence to guidelines can be achieved when the ordering system interrupts clinician workflow to provide concrete data and advice. Second, we feel that there is considerable benefit to be obtained from similar interventions via reduced costs and fewer false positives given how common non-directed testing is in medical practice. Other areas that could benefit include, for example, antibody tests for rheumatogic or infectious diseases and daily blood tests for stable inpatients.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Tapper: Future research should pursue two questions. First, interventions to reduce over testing should include an assessment of patient outcomes both in terms of the burden of false positives or the possibility of missed diagnoses.

Second, studies should assess whether a directed strategy of testing is cost-effective compared to the seemingly more convenient all-at-once non-directed strategy.

Citation:

Tapper EB, Sengupta N, Lai M, Horowitz G. A Decision Support Tool to Reduce Overtesting for Ceruloplasmin and Improve Adherence With Clinical Guidelines. JAMA Intern Med. Published online June 01, 2015. doi:10.1001/jamainternmed.2015.2062.

 

Elliot B Tapper, M.D., Clinical Fellow in Medicine (EXT), Beth Israel Deaconess Medical Center, & Boston MA 02215 (2015). Pop-Up Screen On Electronic Medical Records May Reduce Some Unnecessary Testing 

Late Hospital Readmissions Linked To Chronic Health and Social Problems

MedicalResearch.com Interview with:
Kelly L. Graham, MD, MPH

Instructor in Medicine
Harvard Medical School Division of General Medicine and Primary Care
Beth Israel Deaconess Medical Center

Medical Research: What is the background for this study? What are the main findings?

Dr. Graham: 30-day readmissions have become a standard quality metric used to represent inpatient quality of care and unnecessary healthcare utilization.  Effective 10/1/2009, hospitals with excess 30-day readmissions have been faced with financial penalties.  Experts have questioned the validity of this metric, and have raised concerns about the potential unintended consequence of creating health disparities, as critical access hospitals caring for the most socioeconomically burdened patients have faced the highest penalties. We were interested to see if factors associated with readmissions in the early part of the 30 day window (0-7 days post-discharge) differed from those associated with the later window (8-30 days post-discharge), ultimately attempting to better understand the “pathophysiology” of a readmission.

Our findings suggest that early readmissions are associated with many factors, including those related to the index admission (acute illness burden and suboptimal discharge timing), and factors that are not related to the index hospitalization, such as chronic illness burden and social determinants of health.  In contrast, late readmissions were only associated with chronic illness burden and social determinants of health.
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