Laura A Petersen

Publications of Laura A Petersen

• How variability in the institutional review board review process affects minimal-risk multisite health services research.

  Authors: Laura A Petersen, Kate Simpson, Richard Sorelle, Tracy Urech, Supicha Sookanan Chitwood

  Annals of internal medicine. 05/2012; 156(10):728-35.

  Background: The Department of Health and Human Services recently called for public comment on human subjects research protections. Objective: To assess variability in reviews across institutionalBackground: The Department of Health and Human Services recently called for public comment on human subjects research protections. Objective: To assess variability in reviews across institutional review boards (IRBs) for a multisite, minimal-risk trial of financial incentives for evidence-based hypertension care and to quantify the effect of review determinations on site participation, budget, and timeline. Design: A natural experiment occurring from multiple IRBs reviewing the same protocol for a multicenter trial (May 2005 to October 2007). Participants: 25 Veterans Affairs (VA) medical centers. Measurements: Number of submissions, time to approval, and costs were evaluated; patient complexity, academic affiliation, size, and location (urban or rural) between participating and nonparticipating VA medical centers were compared. Results: Of 25 eligible VA medical centers, 6 did not meet requirements for IRB review and 2 declined to participate. Of 17 applications, 14 were approved. The process required 115 submissions, lasted 27 months, and cost close to $170 000 in staff salaries. One IRB's concern about incentivizing a particular medication recommended by national guidelines prompted a change in our design to broaden our inclusion criteria beyond uncomplicated hypertension. The change required amending the protocol at 14 sites to preserve internal validity. The IRBs that approved the protocol classified it as minimal risk. The 12 sites that ultimately participated in the trial were more likely to be urban and academically affiliated and to care for more complex patients, which limits the external validity of the trial's findings. Limitation: Because data came from a single multisite trial in the VA system that uses a 2-stage review process, generalizability is limited. Conclusion: Complying with IRB requirements for a minimal-risk study required substantial resources and threatened the study's internal and external validity. The current review of regulatory requirements may address some of these problems. Primary Funding Source: Veterans Affairs Health Services Research and Development and the National Heart, Lung, and Blood Institute.

• The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU.

  Authors: Jochen Profit, Jason Etchegaray, Laura A Petersen, J Bryan Sexton, Sylvia J Hysong, Minghua Mei, Eric J Thomas

  Archives of disease in childhood. Fetal and neonatal edition. 03/2012; 97(2):F127-32.

  Neonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unitNeonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unit setting make the SAQ an attractive tool for comparing clinical performance between hospitals. Little information is available on the use of the SAQ for this purpose in the NICU setting. To determine whether the dimensions of safety culture measured by the SAQ give consistent results when used as a NICU performance measure. Cross-sectional survey of caregivers in 12 NICUs, using the six scales of the SAQ: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions. NICUs were ranked by quantifying their contribution to overall risk-adjusted variation across the scales. Spearman rank correlation coefficients were used to test for consistency in scale performance. The authors then examined whether performance in the top four NICUs in one scale predicted top four performance in others. There were 547 respondents in 12 NICUs. Of 15 NICU-level correlations in performance ranking, two were >0.7, seven were between 0.4 and 0.69, and the six remaining were <0.4. The authors found a trend towards significance in comparing the distribution of performance in the top four NICUs across domains with a binomial distribution p=0.051, indicating generally consistent performance across dimensions of safety culture. A culture of safety permeates many aspects of patient care and organisational functioning. The SAQ may be a useful tool for comparative performance assessments among NICUs.

• Treating chronically ill people with diabetes mellitus with limited life expectancy: implications for performance measurement.

  Authors: Lechauncy D Woodard, Cassie R Landrum, Tracy H Urech, Jochen Profit, Salim S Virani, Laura A Petersen

  Journal of the American Geriatrics Society. 02/2012; 60(2):193-201.

  To develop an algorithm to identify individuals with limited life expectancy and examine the effect of limited life expectancy on glycemic control and treatment intensification in individuals withTo develop an algorithm to identify individuals with limited life expectancy and examine the effect of limited life expectancy on glycemic control and treatment intensification in individuals with diabetes mellitus. Individuals with diabetes mellitus and coexisting congestive heart failure, chronic obstructive pulmonary disease, dementia, end-stage liver disease, and/or primary or metastatic cancer with limited life expectancy were identified. To validate the algorithm, 5-year mortality was assessed in individuals identified as having limited life expectancy. Rates of meeting performance measures for glycemic control between individuals with and without limited life expectancy were compared. In individuals with uncontrolled glycosylated hemoglobin (HbA(1c) ) levels, the effect of limited life expectancy on treatment intensification within 90 days was examined. One hundred ten Department of Veterans Affairs facilities; October 2006 to September 2007. Eight hundred eighty-eight thousand six hundred twenty-eight individuals with diabetes mellitus. HbA(1c) ; treatment intensification within 90 days of index HbA(1c) reading. Twenty-nine thousand sixteen (3%) participants had limited life expectancy. Adjusting for age, 5-year mortality was five times as high in participants with limited life expectancy than in those without. Participants with limited life expectancy had poorer glycemic control than those without (glycemic control: 77.1% vs 78.1%; odds ratio (OR) = 0.84, 95% confidence interval (CI) = 0.81-0.86) and less-frequent treatment intensification (treatment intensification: 20.9% vs 28.6%; OR = 0.71, 95% CI = 0.67-0.76), even after controlling for patient-level characteristics. Participants with limited life expectancy were less likely than those without to have controlled HbA(1c) levels and to receive treatment intensification, suggesting that providers treat these individuals less aggressively. Quality measurement and performance-based reimbursement systems should acknowledge the different needs of this population.

• Non-high-density lipoprotein cholesterol calculation and goal awareness among physicians-in-training.

  Authors: Smita I Negi, Lynne Steinberg, Venkateshwar R Polsani, Saqib A Gowani, Vijay Nambi, Varinder Kumar, Victor Marinescu, Peter H Jones, Laura A Petersen, Christie M Ballantyne, Salim S Virani

  Journal of clinical lipidology. 01/2012; 6(1):50-7.

  Non-high density lipoprotein cholesterol (non-HDL-C) goal attainment per Adult Treatment Panel III (ATP III) guidelines remains low. To understand gaps in knowledge and practices ofNon-high density lipoprotein cholesterol (non-HDL-C) goal attainment per Adult Treatment Panel III (ATP III) guidelines remains low. To understand gaps in knowledge and practices of physicians-in-training (internal medicine, family medicine, cardiology, endocrinology) towards non-HDL-C. A survey based on a conceptual model to assess the trainee's knowledge, attitudes, and practice regarding non-HDL-C was developed and administered to physicians-in-training (n = 655) at 26 training programs in the United States. Responses of those in internal medicine and family medicine (residents-in-training; n = 418) were compared with those in cardiology and endocrinology (fellows-in-training; n = 124). Response rate was 83.7%. Fifty-three percent of residents and 31% of fellows-in-training had not read the ATP III guidelines (P < .001). Thirty-three percent of the residents and 35% fellows-in-training could not calculate non-HDL-C from a standard lipid panel (P = .7). Sixty-seven percent of the residents and 52% of fellows were not aware of treatment goals for non-HDL-C (P = .004 for comparison between residents and fellows). Both residents and fellows reported infrequent calculation of non-HDL-C levels in patients with elevated triglycerides (≥200 mg/dL; 32.5% vs 35.4%, respectively, P = .6). Lack of familiarity with ATP III guidelines, lack of knowledge regarding importance of non-HDL-C, lack of institutional mandate to calculate non-HDL-C, and lack of emphasis on non-HDL-C by teaching staff were reported as barriers to non-HDL-C use in routine clinical practice. At least one-third of physicians-in-training could not calculate non-HDL-C from a standard lipid panel, and a large number were not aware of ATP III treatment goals pertaining to non-HDL-C. This area represents one for improvement if non-HDL-C is to be retained as a treatment target in the forthcoming ATP-IV guidelines.

• Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol.

  Authors: Laura A Petersen, Tracy Urech, Kate Simpson, Kenneth Pietz, Sylvia J Hysong, Jochen Profit, Douglas Conrad, R Adams Dudley, Meghan Z Lutschg, Robert Petzel, Lechauncy D Woodard

  Implementation science : IS. 10/2011; 6:114.

  ABSTRACT: Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens. ThisABSTRACT: Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens. This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period. We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements. http://www.clinicaltrials.govNCT00302718.

• Frequency and correlates of treatment intensification for elevated cholesterol levels in patients with cardiovascular disease.

  Authors: Salim S Virani, LeChauncy D Woodard, Supicha S Chitwood, Cassie R Landrum, Tracy H Urech, Degang Wang, Jeffrey Murawsky, Christie M Ballantyne, Laura A Petersen

  American heart journal. 10/2011; 162(4):725-732.e1.

  Although current performance measures define low-density-lipoprotein cholesterol (LDL-C) levels <100 mg/dL in patients with cardiovascular disease (CVD) as good quality, they provide a snapshot andAlthough current performance measures define low-density-lipoprotein cholesterol (LDL-C) levels <100 mg/dL in patients with cardiovascular disease (CVD) as good quality, they provide a snapshot and do not address whether treatment intensification was performed to manage elevated LDL-C levels. We determined the proportion of patients with CVD (n = 22,888) with LDL-C <100 mg/dL and the proportion with uncontrolled LDL-C levels (≥100 mg/dL) who received treatment intensification within the 45-day follow-up in a Veterans Affairs Network. We evaluated facility, provider, and patient correlates of treatment intensification. Low-density-lipoprotein cholesterol levels were at goal in 16,350 (71.4%) patients. An additional 2,093 (one third of those eligible for treatment intensification) received treatment intensification. Controlling for clustering between facilities and patient's illness severity: history of diabetes (odds ratio [OR] 1.15, 95% CI 1.01-1.32), hypertension (OR 1.19, 95% CI 1.01-1.42), good medication adherence (OR 2.20, 95% CI 1.91-2.54), and a higher number of lipid panels (OR 1.20, 95% CI 1.14-1.27) were associated with treatment intensification. Patients older than 75 years (OR 0.65, 95% CI 0.56-0.75) and women (OR 0.66, 95% CI 0.43-1.00) were less likely to receive treatment intensification. Teaching status of the facility, physician or specialist primary care provider, and patient's race were not associated with treatment intensification. Only one third of the CVD patients with elevated LDL-C received treatment intensification. Diabetic and hypertensive patients were more likely to receive treatment intensification, whereas, older patients, female patients, and patients with poor medication adherence were less likely to receive treatment intensification. Our findings highlight areas for quality improvement initiatives.

• Passive monitoring versus active assessment of clinical performance: impact on measured quality of care.

  Authors: Sylvia J Hysong, Myrna M Khan, Laura A Petersen

  Medical care. 10/2011; 49(10):883-90.

  Measurement of hospitals' clinical performance is becoming more ubiquitous in an effort to inform patient choices, payer reimbursement decisions, and quality improvement initiatives such asMeasurement of hospitals' clinical performance is becoming more ubiquitous in an effort to inform patient choices, payer reimbursement decisions, and quality improvement initiatives such as pay-for-performance. As more measures are developed, the intensity with which measures are monitored changes. Performance measures are often retired after a period of sustained performance and not monitored as actively as other measures where performance is more variable. The effect of actively versus passively monitoring performance on measured quality of care is not known. We compared the nature and rate of change in hospital outpatient clinical performance as a function of a measure's status (active vs. passive), and examined the mean time to stability of performance after changing status. We hypothesize that performance will be higher when measures are actively monitored than when they are passively monitored. Longitudinal, hierarchical retrospective analyses of outpatient clinical performance measure data from Veterans Health Administration's External Peer Review Program from 2000 to 2008. One hundred thirty-three Veterans Health Administration Medical Centers throughout the United States and its associated territories. Clinical performance on 17 measures covering 5 clinical areas common to ambulatory care: screening, immunization, chronic care after acute myocardial infarction, diabetes mellitus, and hypertension. Contrary to expectations, we found that measure status (whether active or passive) did not significantly impact performance over time; time to stability of performance varied considerably by measure, and did not seem to covary with performance at the stability point (ie, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times). We found no significant "extinction" of performance after measures were retired, suggesting that other features of the health care system, such as organizational policies and procedures or other structural features, may be creating a "strong situation" and sustaining performance. Future research should aim to better understand the effects of monitoring performance using process-of-care measures and creating sustained high performance.

• Neonatal intensive care unit safety culture varies widely.

  Authors: Jochen Profit, Jason Etchegaray, Laura A Petersen, J Bryan Sexton, Sylvia J Hysong, Minghua Mei, Eric J Thomas

  Archives of disease in childhood. Fetal and neonatal edition. 09/2011; 97(2):F120-6.

  Background Variation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture. Objective To describe NICU care giverBackground Variation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture. Objective To describe NICU care giver assessments of safety culture, explore variability within and between NICUs on safety culture domains, and test for association with care giver characteristics. Methods NICU care givers in 12 hospitals were surveyed using the Safety Attitudes Questionnaire (SAQ), which has six scales: teamwork climate, safety climate, job satisfaction, stress recognition, perception of management and working conditions. Scale means, SDs and percent positives (percent agreement) were calculated for each NICU. Results There was substantial variation in safety culture domains among NICUs. Composite mean score across the six domains ranged from 56.3 to 77.8 on a 100-point scale and NICUs in the top four NICUs were significantly different from the bottom four (p<0.001). Across the six domains, respondent assessments varied widely, but were least positive on perceptions of management (3%-80% positive; mean 33.3%) and stress recognition (18%-61% positive; mean 41.3%). Comparisons of SAQ scale scores between NICUs and a previously published adult ICU cohort generally revealed higher scores for NICUs. Composite scores for physicians were 8.2 (p=0.04) and 9.5 (p=0.02) points higher than for nurses and ancillary personnel. Conclusion There is significant variation and scope for improvement in safety culture among these NICUs. The NICU variation was similar to variation in adult ICUs, but NICU scores were generally higher. Future studies should validate whether safety culture measured with the SAQ correlates with clinical and operational outcomes in NICUs.

• Exploring situational awareness in diagnostic errors in primary care.

  Authors: Hardeep Singh, Traber Davis Giardina, Laura A Petersen, Michael W Smith, Lindsey Wilson Paul, Key Dismukes, Gayathri Bhagwath, Eric J Thomas

  BMJ quality & safety. 09/2011; 21(1):30-8.

  Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs),Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs), this study explored the use of the situational awareness (SA) framework from aviation human factors research. A mixed-methods study was conducted involving reviews of EHR data followed by semi-structured interviews of selected providers from two institutions in the USA. The study population included 380 consecutive patients with colorectal and lung cancers diagnosed between February 2008 and January 2009. Using a pre-tested data collection instrument, trained physicians identified diagnostic errors, defined as lack of timely action on one or more established indications for diagnostic work-up for lung and colorectal cancers. Twenty-six providers involved in cases with and without errors were interviewed. Interviews probed for providers' lack of SA and how this may have influenced the diagnostic process. Of 254 cases meeting inclusion criteria, errors were found in 30 of 92 (32.6%) lung cancer cases and 56 of 167 (33.5%) colorectal cancer cases. Analysis of interviews related to error cases revealed evidence of lack of one of four levels of SA applicable to primary care practice: information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels. In cases without error, application of the SA framework provided insight into processes involved in attention management. A framework of SA can help analyse and understand diagnostic errors in primary care settings that use EHRs.

• Barriers to non-HDL cholesterol goal attainment by providers.

  Authors: Salim S Virani, Lynne Steinberg, Tyler Murray, Smita Negi, Vijay Nambi, LeChauncy D Woodard, Biykem Bozkurt, Laura A Petersen, Christie M Ballantyne

  The American journal of medicine. 09/2011; 124(9):876-80.e2.

  Despite improvements in low-density lipoprotein cholesterol goal attainment, non-high-density lipoprotein cholesterol (non-HDL-C) goal attainment remains poor. This study assessed providers'Despite improvements in low-density lipoprotein cholesterol goal attainment, non-high-density lipoprotein cholesterol (non-HDL-C) goal attainment remains poor. This study assessed providers' knowledge of, attitude toward, and practice regarding non-HDL-C. Based on a conceptual model, we designed a questionnaire that was administered to internal medicine, family practice, cardiology, and endocrinology providers attending continuous medical education conferences. Responses were compared with those of providers attending a clinical lipidology conference. The response rate was 33.3% (354/1063). Among providers attending nonlipidology conferences, only 26% knew that non-HDL-C was a secondary treatment target, 34% knew non-HDL-C treatment goals, 56% could calculate non-HDL-C levels, and 66% knew that non-HDL-C levels could be calculated from a standard lipid panel. Compared with providers attending the lipidology conference, the other providers were less likely (P≤.01) to have read the Adult Treatment Panel III guidelines (46% vs 98%) or to use non-HDL-C (36% vs 91%). No differences were found between primary care and specialty providers. Lack of familiarity with Adult Treatment Panel III guidelines (34%) and of knowledge regarding non-HDL-C importance (21%) and calculation (22.7%) were the most common barriers identified. Major gaps remain in providers' awareness regarding non-HDL-C definition, calculation, and goals. System-level interventions are needed across specialties to address these gaps.

• Institutional, provider, and patient correlates of low-density lipoprotein and non-high-density lipoprotein cholesterol goal attainment according to the Adult Treatment Panel III guidelines.

  Authors: Salim S Virani, Lechauncy D Woodard, Cassie R Landrum, Kenneth Pietz, Degang Wang, Christie M Ballantyne, Laura A Petersen

  American heart journal. 06/2011; 161(6):1140-6.

  The aim of this analysis was to identify the proportion of coronary heart disease (CHD) patients achieving guideline-recommended low-density lipoprotein cholesterol (LDL-C) and non-high-densityThe aim of this analysis was to identify the proportion of coronary heart disease (CHD) patients achieving guideline-recommended low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) goals and to identify correlates of dual goal attainment. We analyzed patient, provider, and facility characteristics for 21,801 CHD patients in one Veterans Affairs Hospitals Network. Low-density lipoprotein cholesterol goal attainment was 80%, but optional LDL-C goal attainment was 41%. Of patients with triglycerides ≥200 mg/dL, 51% attained both LDL-C and non-HDL-C goals. Correlates of higher dual goal attainment included older age (65-74 years: odds ratio [OR] 1.47, 95% CI 1.28-1.69), diabetes (OR 1.33, 95% CI 1.16-1.53), obesity (OR 1.25, 95% CI 1.04-1.50), a higher number of primary care visits (OR 1.04, 95% CI 1.04-1.05), and mild increase in illness severity of patients in provider's panel (OR 1.20, 95% CI 1.0008-1.46), whereas African American patients were less likely to achieve dual lipid goals (OR 0.63, 95% CI 0.48-0.82). Receipt of care from physician (vs nonphysician) or specialist (vs primary care) provider, number of patients in provider's panel, and percentage of patients in provider's panel with diagnosis of hyperlipidemia were not associated with dual goal attainment. A large proportion of CHD patients attained LDL-C goal, but optional LDL-C goal attainment was low. Patients with elevated triglycerides had poor attainment of dual LDL-C and non-HDL-C goals, suggesting a treatment gap. Factors associated with dual goal attainment may identify interventions needed to improve future guideline adherence.

• Impact of comorbidity type on measures of quality for diabetes care.

  Authors: Lechauncy D Woodard, Tracy Urech, Cassie R Landrum, Degang Wang, Laura A Petersen

  Medical care. 03/2011; 49(6):605-10.

  Studies provide conflicting results about the impact of comorbid conditions on the quality of chronic illness care. We assessed the effect of comorbidity type (concordant, discordant, or both) on theStudies provide conflicting results about the impact of comorbid conditions on the quality of chronic illness care. We assessed the effect of comorbidity type (concordant, discordant, or both) on the receipt of guideline-recommended care among patients with diabetes. Patients were assigned to 1 of 4 condition groups: diabetes-concordant (hypertension, ischemic heart disease, hyperlipidemia), and/or diabetes-discordant (arthritis, depression, chronic obstructive pulmonary disease) conditions, or neither. We evaluated hemoglobin A1c, blood pressure, and low-density lipoprotein cholesterol readings at index and measured overall good quality of diabetes care, including a 6-month follow-up interval. We assessed the effect of condition group on overall good quality of care with logistic regression and generalized ordered logistic regression. We assigned 35,872 patients to the diabetes comorbid condition groups, ranging from 2.0% in the discordant-only group to 58.0% in the concordant-only group. Patients with both types of conditions were more likely than those with no comorbidities to receive overall good quality for glycemic [odds ratio (OR), 2.13; 95% confidence interval (CI), 1.86-2.41], blood pressure (OR, 1.62; 95% CI, 1.40-1.84), and low-density lipoprotein cholesterol (OR, 3.57; 95% CI, 3.08-4.05) control within 6 months of an index visit. They were also more likely to receive overall good quality for all 3 quality measures combined (OR, 2.17; 95% CI, 1.96-2.39). Patients with the greatest clinical complexity were more likely than less complex patients to receive high quality diabetes care, suggesting that increased complexity does not necessarily predispose chronically ill patients to receiving poorer care. However, caution should be used in treating certain patient groups, such as the elderly, for whom adherence to multiple condition-specific guidelines may lack benefit or cause harm.

• Follow-up actions on electronic referral communication in a multispecialty outpatient setting.

  Authors: Hardeep Singh, Adol Esquivel, Dean F Sittig, Daniel Murphy, Himabindu Kadiyala, Rachel Schiesser, Donna Espadas, Laura A Petersen

  Journal of general internal medicine. 01/2011; 26(1):64-9.

  Electronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronicElectronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility. We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information. Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up. Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.

• Importance of patient, provider, and facility predictors of hepatitis C virus treatment in veterans: a national study.

  Authors: Jennifer R Kramer, Fasiha Kanwal, Peter Richardson, Thomas P Giordano, Laura A Petersen, Hashem B El-Serag

  The American journal of gastroenterology. 11/2010; 106(3):483-91.

  Several patient characteristics are known to impact hepatitis C virus (HCV) antiviral treatment rates. However, it is unclear whether, and to what extent, health-care providers or facilitySeveral patient characteristics are known to impact hepatitis C virus (HCV) antiviral treatment rates. However, it is unclear whether, and to what extent, health-care providers or facility characteristics impact HCV treatment rates. Using national data obtained from the Department of Veterans Affairs (VA) HCV Clinical Case Registry, we conducted a retrospective cohort study of patients with active HCV viremia, who were diagnosed between 2003 and 2004. We evaluated patient-, provider-, and facility-level predictors of receipt of HCV treatment with hierarchical logistic regression. The overall HCV treatment rate in 29,695 patients was 14.2%. The strongest independent predictor for receipt of treatment was consultation with an HCV specialist (odds ratio=9.34; 8.03-10.87). Patients were less likely to receive HCV treatment if they were Black, older, male, current users of alcohol or drugs, had HCV genotype 1 or 4, had higher creatinine levels, or had severe anxiety/post-traumatic stress disorder or depression. Patients with high hemoglobin levels, cirrhosis, and persistently high liver enzyme levels were more likely to receive treatment. Patient, provider, and facility factors explained 15, 4, and 4%, respectively, of the variation in treatment rates. Treatment rates for HCV are low in the VA. In addition to several important patient-level characteristics, a specialist consultant has a vital role in determining whether a patient should receive HCV treatment. These findings support the development of patient-level interventions targeted at identifying and managing comorbidities and contraindications and fostering greater involvement of specialists in the care of HCV.

• The reply.

  Authors: Hardeep Singh, Laura A Petersen, Eric J Thomas, Lindsey Wilson, Dean F Sittig

  The American journal of medicine. 10/2010; 123(10):e21.

• Reducing referral delays in colorectal cancer diagnosis: is it about how you ask?

  Authors: Hardeep Singh, Laura A Petersen, Kuang Daci, Clyde Collins, Myrna Khan, Hashem B El-Serag

  Quality & safety in health care. 10/2010; 19(5):e27.

  Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. The authors tested whether certain details of information transmitted through computerised providerDelays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. The authors tested whether certain details of information transmitted through computerised provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed CRC. The authors studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees and other specialists. From the colonoscopy referral preceding CRC diagnosis, the authors determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. The authors compared distributions of proportions of diagnostic clues between patients with a lag of >60 and ≤60 day, and examined predictors of lag time. Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had a lag of >60 days. Referrals associated with longer lag times included those with 'positive faecal occult blood test' (92 days, p<0.0001), 'haematochesia' (75 days, p=0.02), 'history of polyps' (221 days, p=0.0006) and when 'screening' (vs specific symptoms) was given as the reason for diagnostic colonoscopy (203 days, p=0.002). Independent predictors of shorter wait times included three diagnostic clues, notation of urgency and documentation of verbal contact. Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.

• Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans.

  Authors: Laura A Petersen, Margaret M Byrne, Christina N Daw, Jennifer Hasche, Brian Reis, Kenneth Pietz

  Health services research. 06/2010; 45(3):762-91.

  To determine how reliance on Veterans Affairs (VA) for medical care among veterans enrolled in Medicare is affected by medical conditions, access, and patient characteristics. Department of VeteransTo determine how reliance on Veterans Affairs (VA) for medical care among veterans enrolled in Medicare is affected by medical conditions, access, and patient characteristics. Department of Veterans Affairs. We examined reliance on the VA for inpatient, outpatient, and overall medical care among all VA users in fiscal years 2003 and 2004 who were also enrolled in Medicare. We calculated the marginal effects of patient factors on VA reliance using fractional logistic regression; we also analyzed overall VA reliance separately for under-65 and age-65+ groups. The primary focus of this analysis was the relationship between aggregated condition categories (ACCs), which represent medical conditions, and reliance on the VA. Mean VA reliance was significantly higher in the under-65 population than in the age-65+ group (0.800 versus 0.531). Lower differential distance to the VA, and higher VA-determined priority for health care, predicted higher VA reliance. Most individual ACCs were negatively associated with VA reliance, though substance abuse and mental health disorders were significantly associated with increased reliance on VA care. Conditions of the eyes and ears/nose/throat had positive marginal effect on VA reliance for the under 65, while diabetes was positive for age 65+. Among inpatients, veterans with ACCs for mental health conditions, eye conditions, amputations, or infectious and parasitic conditions had higher likelihood of a VA hospitalization than inpatients without these conditions. Many dually enrolled Veterans use both Medicare and VA health care. Age, accessibility, and priority level for VA services have a clear relationship with VA reliance. Because dual use is common, coordination of care among health care settings for such patients should be a policy priority.

• Preoperative statin therapy decreases risk of postoperative renal insufficiency.

  Authors: Salim S Virani, Vijay Nambi, Venkateshwar R Polsani, Vei-Vei Lee, MacArthur Elayda, Shun Kohsaka, Wei Pan, Ross M Reul, James M Wilson, Laura A Petersen, James T Willerson, Christie M Ballantyne

  Cardiovascular therapeutics. 04/2010; 28(2):80-6.

  Although current guidelines recommend withholding statins in perioperative patients, little information is available on whether perioperative statin use increases risk for postoperative renalAlthough current guidelines recommend withholding statins in perioperative patients, little information is available on whether perioperative statin use increases risk for postoperative renal failure. We examined the relation between preoperative statin therapy and postoperative risk for renal insufficiency in patients undergoing cardiac surgery. Retrospective cohort review from the Texas Heart Institute research database was performed. Patients were divided into two groups: those who received preoperative statins and those who did not. Primary outcome was the development of postoperative renal insufficiency (requiring dialysis or not). Outcomes were assessed in the entire cohort and in subgroups undergoing isolated coronary artery bypass grafting (CABG), isolated valve surgery, or combined CABG and valve surgery. Of 3001 patients, 56% received preoperative statins. In multivariate logistic regression analysis, preoperative statins were associated with significant reductions in risk for postoperative renal insufficiency in the entire cohort (odds ratio [OR]= 0.60, 95% confidence interval [CI] 0.38-0.95) and in patients undergoing isolated CABG (OR = 0.34, 95% CI 0.17-0.68). In patients undergoing isolated valve surgery (OR = 1.35, 95% CI 0.61-2.96) or combined CABG and valve surgery (OR = 1.39, 95% CI 0.48-3.99), preoperative statins were not associated with decreased incidence of postoperative renal insufficiency. Age >65 years, preoperative renal insufficiency, history of congestive heart failure, preoperative intra-aortic balloon pump insertion, and total cardiopulmonary bypass time >80 min were also independent predictors associated with increased risk for postoperative renal insufficiency. Preoperative statin therapy was associated with decreased incidence of postoperative renal insufficiency in patients undergoing cardiac surgeries, particularly in patients undergoing isolated CABG.

• Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

  Authors: Hardeep Singh, Eric J Thomas, Dean F Sittig, Lindsey Wilson, Donna Espadas, Myrna M Khan, Laura A Petersen

  The American journal of medicine. 03/2010; 123(3):238-44.

  Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examinedFollow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. We studied 4 alerts: hemoglobin A1c > or =15%, positive hepatitis C antibody, prostate-specific antigen > or =15 ng/mL, and thyroid-stimulating hormone > or =15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84). Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

• Children with chronic illness return to their baseline functional status after organ dysfunction on the first day of admission in the pediatric intensive care unit.

  Authors: Katri V Typpo, Nancy J Petersen, Laura A Petersen, M Michele Mariscalco

  The Journal of pediatrics. 03/2010; 157(1):108-113.e1.

  To determine chronic illness outcomes after admission with multiple organ dysfunction syndrome (MODS) for patients in the pediatric intensive care unit (PICU). We evaluated consecutive PICUTo determine chronic illness outcomes after admission with multiple organ dysfunction syndrome (MODS) for patients in the pediatric intensive care unit (PICU). We evaluated consecutive PICU admissions from 35 US children's hospitals from January 2004-December 2005 in the virtual PICU Performance System database. We excluded hospitals with >10% missing values for MODS variables and patients<1 month or>18 years of age. MODS was identified by laboratory and vital sign values from day of admission with International Pediatric Sepsis Consensus Conference criteria. Chronic illness was identified by secondary diagnoses, classified by modified Delphi method. We evaluated functional outcomes with pediatric overall performance category and pediatric cerebral performance category scores from PICU admission and discharge. Of 44 693 admissions, 52.1% had a chronic diagnosis. Chronic diagnoses increased MODS at PICU admission (24.6% vs 12.0%, P<.001) and mortality rates (3.7% vs 1.9%, P<.001). Patients with a chronic diagnosis had similar changes in pediatric overall performance category and pediatric cerebral performance category scores from PICU admission to discharge as previously healthy children. However, outcome in different chronic diagnosis categories was variable. Chronic illness increased MODS incidence at PICU admission and impacted all-cause PICU mortality rates. Although, in aggregate, children who survive return to baseline functional status, this varies by chronic illness category.