Preferred Functions of Personal Health Records in Rural Primary Health Clinics in Canada: Health Care Team Perspectives

Background  Personal health records (PHR) provide opportunities for improved patient engagement, collection of patient-generated data, and overcome health-system inefficiencies. While PHR use is increasing, uptake in rural populations is lower than in urban areas. Objectives  The study aimed to identify priorities for PHR functionality and gain insights into meaning, value, and use of patient-generated data for rural primary care providers. Methods  We performed PHR preimplementation focus groups with rural providers and their health care teams from five primary care clinics in a sparsely populated mountainous region of British Columbia, Canada to obtain their understanding of PHR functionality, needs, and perceived challenges. Results  Eight general practitioners (GP), five medical office assistants, two nurse practitioners (NP), and two registered nurses (14 females and 3 males) participated in focus groups held at their respective clinics. Providers (GPs, NPs, and RNs) had been practicing for a median of 9.5 (range = 1–38) years and had used an electronic medical record for 7.0 (1–20) years. Participants expressed interest in incorporating functionality around two-way communication and appointment scheduling, previsit data gathering, patient and provider data sharing, virtual care including visits using videoconferencing tools, and postvisit sharing of educational materials. Three further themes emerged from the focus groups: (1) the context in which the providers'' practice matters, (2) the need for providing patients and providers with choice (e.g., which data to share, who gets to initiate/respond in communications, and processes around virtual care visits), and (3) perceived risks of system use (e.g., increased complexity for older patients and workload barriers for the health care team). Conclusion  Rural primary care teams perceived PHR opportunities for increased patient engagement and access to patient-generated data, while worries about changes in workflow were the biggest perceived risk. Recommendations for PHR adoption in a rural primary health network include setting provider-patient expectations about response times, ability to share notes selectively, and automatically augmented note-taking from virtual-care visits.     

Direct access from general practice to transvaginal ultrasound for early detection of ovarian cancer: a feasibility study

ObjectiveTo investigate the feasibility of providing general practitioners (GPs) direct and fast referral access to transvaginal ultrasound (TVUS).DesignA prospective cohort study.SettingA total of 232 Danish general practices in parts of the Central Denmark Region.SubjectsWomen aged ≥40 years who consulted their GP for vague and non-specific symptoms (n = 479).Main outcome measuresThe feasibility assessment included the GPs’ referral rate, indications for referral, management of test results, and findings from TVUS.ResultsA total of 479 women were referred to TVUS. The examinations revealed abnormalities in 104 (21.7%) women. Additional investigations were needed in 68 (14.2%) women of whom seven (1.5%) underwent major surgery. No case of ovarian cancer was diagnosed during the study period or the 6-month follow-up. However, three (0.6%) women with an abnormal transvaginal ultrasound were diagnosed with urogynecological cancer; this yielded a PPV of 4.4% (95% confidence interval: 1.5–12.2) and an NPV of 100.0% (95% confidence interval: 96.7–100.0) for urogynecological cancer.ConclusionProviding GPs with direct access to transvaginal ultrasound was feasible; 80% of the investigated women were referred back to the GP, 14% were further investigated, 0.6% were diagnosed with urogynecological cancer, and 1.5% had major procedures performed without complications.ImplicationsDirect access to TVUS could be an important pathway to ensure fast evaluation of women presenting with vague non-specific symptoms of potential ovarian cancer. Future studies should explore the patient experience, cancer outcomes, and health economics issues.

KEY POINTS

•    Current awareness  • GPs have no fast referral option for women presenting with vague non-specific symptoms that could indicate underlying ovarian cancer.   Key findings  • We offered GPs direct and fast referral access to TVUS; 51.7% of practices used the opportunity.  • The GPs referred 479 women to TVUS; 104 had an abnormal TVUS and 68 needed additional investigations.  • Seven women underwent major surgery, leading to three cases of urogynecological cancer. No woman had a false negative TVUS result.

     

Leveraging American College of Obstetricians and Gynecologists Guidelines for Point-of-Care Decision Support in Obstetrics

Background  The American College of Obstetricians and Gynecologists (ACOG) provides numerous narrative documents containing formal recommendations and additional narrative guidance within the text. These guidelines are not intended to provide a complete “care pathway” for patient management, but these elements of guidance can be useful for clinical decision support (CDS) in obstetrical and gynecologic care and could be exposed within electronic health records (EHRs). Unfortunately, narrative guidelines do not easily translate into computable CDS guidance. Objective  This study aimed to describe a method of translating ACOG clinical guidance into clear, implementable items associated with specific obstetrical problems for integration into the EHR. Methods  To translate ACOG clinical guidance in Obstetrics into implementable CDS, we followed a set of steps including selection of documents, establishing a problem list, extraction and classification of recommendations, and assigning tasks to those recommendations. Results  Our search through ACOG clinical guidelines produced over 500 unique documents. After exclusions, and counting only sources relevant to obstetrics, we used 245 documents: 38 practice bulletins, 113 committee opinions, 16 endorsed publications, 1 practice advisory, 2 task force and work group reports, 2 patient education, 2 obstetric care consensus, 60 frequently asked questions (FAQ), 1 women''s health care guidelines, 1 Prolog series, and 9 others (non-ACOG). Recommendations were classified as actionable ( n  = 576), informational ( n  = 493), for in-house summary ( n  = 124), education/counseling ( n  = 170), policy/advocacy ( n  = 33), perioperative care ( n  = 4), delivery recommendations ( n  = 50), peripartum care ( n  = 13), and non-ACOG ( n  = 25). Conclusion  We described a methodology of translating ACOG narrative into a semi-structured format that can be more easily applied as CDS in the EHR. We believe this work can contribute to developing a library of information within ACOG that can be continually updated and disseminated to EHR systems for the most optimal decision support. We will continue documenting our process in developing executable code for decision support.     

GPs’ perspectives of the patient encounter – in the context of standardized cancer patient pathways

Objective: We aim to explore how GPs assign meanings and act upon patients’ symptoms in primary care encounters in the context of standardized cancer patient pathways (CPPs).Design, setting and subjects: Thirteen individual interviews were conducted with GPs, at primary healthcare centers (n = 4) in one county in northern Sweden. Interviews were analyzed using grounded theory method. The results were then linked to symbolic interactionism.Main outcome measures: GPs’ perspectives about assigning meanings to patients’ presented symptoms and perception about CPPs.Results: In the encounter, GPs engaged in two simultaneous interactions, one with patients’ symptoms – and the other with CPPs. The core category Disentangling patients’ care trajectory consists of three categories, interpreted as GPs’ strategies developed to assign meaning to symptoms. These strategies are carried out not in a straightforward manner but rather in a conflicting way, illuminating the complexity of GPs’ daily work.Conclusions: Interacting with patients is vital for assigning meaning to presented symptoms. However, nowadays GPs are not only required to interact with patients, they are also required to interact with CPPs. These standardized routines might create pressure and demands on GPs, especially for those experiencing a lack of information about CPPs. Beside of carrying out the challenging patient/person-centered dialogues and interpreting presented symptoms, GPs also need to link the interpreted symptoms to CPPs. Therefore, it is essential that GPs are given opportunities at their workplaces to continuously be informed and be supported in order to practice CPPs and thereby optimize trajectories for patients undergoing cancer diagnostics.

Key points

•  Current awareness:
•  • GPs deliberation about patients’ trajectories is a complex process, often dealing with vague symptoms. How CPPs influence this process within the encounter has not been studied.
•  Main statements:  • GPs in our study were involved in two simultaneous interactions, one with patients’ symptoms in the encounter – and the other with CPPs within the healthcare organization.
•  • Symbolic interactionism helped capture how GPs deliberated about conflicting and paradoxical aspects of the encounter, in terms of balancing two contradictory ways of action that GPs face when providing patient/person-centered care and linking to CPPs.
•  • Based on our results, primary care needs support from healthcare organizations to build capacity about CPPs and how to use them.

     

Impact of Changes in EHR Use during COVID-19 on Physician Trainee Mental Health

Objectives  This article investigates the association between changes in electronic health record (EHR) use during the coronavirus disease 2019 (COVID-19) pandemic on the rate of burnout, stress, posttraumatic stress disorder (PTSD), depression, and anxiety among physician trainees (residents and fellows). Methods  A total of 222 (of 1,375, 16.2%) physician trainees from an academic medical center responded to a Web-based survey. We compared the physician trainees who reported that their EHR use increased versus those whose EHR use stayed the same or decreased on outcomes related to depression, anxiety, stress, PTSD, and burnout using univariable and multivariable models. We examined whether self-reported exposure to COVID-19 patients moderated these relationships. Results  Physician trainees who reported increased use of EHR had higher burnout (adjusted mean, 1.48 [95% confidence interval [CI] 1.24, 1.71] vs. 1.05 [95% CI 0.93, 1.17]; p  = 0.001) and were more likely to exhibit symptoms of PTSD (adjusted mean = 15.09 [95% CI 9.12, 21.05] vs. 9.36 [95% CI 7.38, 11.28]; p  = 0.035). Physician trainees reporting increased EHR use outside of work were more likely to experience depression (adjusted mean, 8.37 [95% CI 5.68, 11.05] vs. 5.50 [95% CI 4.28, 6.72]; p  = 0.035). Among physician trainees with increased EHR use, those exposed to COVID-19 patients had significantly higher burnout (2.04, p  < 0.001) and depression scores (14.13, p  = 0.003). Conclusion  Increased EHR use was associated with higher burnout, depression, and PTSD outcomes among physician trainees. Although preliminary, these findings have implications for creating systemic changes to manage the wellness and well-being of trainees.     

Sexual Orientation Demographic Data in a Clinical Cohort of Transgender Patients

Background  There are specific issues regarding sexual orientation (SO) collection and analysis among transgender and nonbinary patients. A limitation to meaningful SO and gender identity (GI) data collection is their consideration as a fixed trait or demographic data point. Methods  A de-identified patient database from a single electronic health record (EHR) that allows for searching any discrete data point in the EHR was used to query demographic data (sex assigned at birth and current GI) for transgender individuals from January 2011 to March 2020 at a large urban tertiary care academic health center. Results  A cohort of transgender individuals were identified by using EHR data from a two-step demographic question. Almost half of male identified (46.70%, n  = 85) and female identified (47.51%, n  = 86) individuals had “heterosexual/straight” input for SO. Overall, male and female identified (i.e., binary) GI aggregate categories had similar SO responses. Assigned male at birth (AMAB) nonbinary individuals ( n  = 6) had “homosexual/gay” SO data input. Assigned female at birth (AFAB) nonbinary individuals ( n  = 56) had almost half “something else” SO data input (41.67%, n  = 15). Individuals with “choose not to disclose” for GI ( n  = 249) almost all had “choose not to disclose” SO data (96.27%, n  = 232). Conclusion  Current SO categories do not fully capture transgender individuals'' identities and experiences, and limit the clinical and epidemiological utility of collecting this data in the current form. Anatomical assumptions based on SO should be seen as a potential shortcoming in over-reliance on SO as an indicator of screening needs and risk factors.     

Systematic Review of Approaches to Preserve Machine Learning Performance in the Presence of Temporal Dataset Shift in Clinical Medicine

Objective  The change in performance of machine learning models over time as a result of temporal dataset shift is a barrier to machine learning-derived models facilitating decision-making in clinical practice. Our aim was to describe technical procedures used to preserve the performance of machine learning models in the presence of temporal dataset shifts. Methods  Studies were included if they were fully published articles that used machine learning and implemented a procedure to mitigate the effects of temporal dataset shift in a clinical setting. We described how dataset shift was measured, the procedures used to preserve model performance, and their effects. Results  Of 4,457 potentially relevant publications identified, 15 were included. The impact of temporal dataset shift was primarily quantified using changes, usually deterioration, in calibration or discrimination. Calibration deterioration was more common ( n  = 11) than discrimination deterioration ( n  = 3). Mitigation strategies were categorized as model level or feature level. Model-level approaches ( n  = 15) were more common than feature-level approaches ( n  = 2), with the most common approaches being model refitting ( n  = 12), probability calibration ( n  = 7), model updating ( n  = 6), and model selection ( n  = 6). In general, all mitigation strategies were successful at preserving calibration but not uniformly successful in preserving discrimination. Conclusion  There was limited research in preserving the performance of machine learning models in the presence of temporal dataset shift in clinical medicine. Future research could focus on the impact of dataset shift on clinical decision making, benchmark the mitigation strategies on a wider range of datasets and tasks, and identify optimal strategies for specific settings.     

The management and clinical knowledge of headache disorders among general practitioners in Norway: a questionnaire survey

BackgroundGeneral practitioners (GPs) diagnose and manage a majority of headache patients seeking health care. With the aim to understand the potential for clinical improvement and educational needs, we performed a study to investigate Norwegian GPs knowledge about headache and its clinical management.MethodsWe invited GPs from a random sample of 130 Norwegian continuous medical education (CME) groups to respond to an anonymous questionnaire survey.Results367 GPs responded to the survey (73% of invited CME groups, 7.6% of all GPs in Norway). Mean age was 46 (SD 11) years, with an average of 18 (SD 10) years of clinical experience. In general the national treatment recommendations were followed, while the International Classification of Headache Disorders and other international guidelines were rarely used. Overall, 80% (n = 292) of the GPs suggested adequate prophylactic medication for frequent episodic migraine, while 28% (n = 101) suggested adequate prophylactic medication for chronic tension-type headache (CTTH). Half (52%, n = 191)) of the respondents were aware that different types of acute headache medication can lead to medication-overuse headache (MOH), and 59% (n = 217) knew that prophylactic headache medication does not lead to MOH. GPs often used MRI in the diagnostic work-up. GPs reported that lack of good treatment options was a main barrier to more optimized treatment of headache patients.ConclusionThe knowledge of management of CTTH and MOH was moderate compared to migraine among Norwegian GPs.Supplementary InformationThe online version contains supplementary material available at 10.1186/s10194-021-01350-3.     

Comparison of pregnenolone sulfate,pregnanolone and estradiol levels between patients with menstrually-related migraine and controls: an exploratory study

BackgroundNeurosteroids affect the balance between neuroexcitation and neuroinhibition but have been little studied in migraine. We compared the serum levels of pregnenolone sulfate, pregnanolone and estradiol in women with menstrually-related migraine and controls and analysed if a correlation existed between the levels of the three hormones and history of migraine and age.MethodsThirty women (mean age ± SD: 33.5 ± 7.1) with menstrually-related migraine (MM group) and 30 aged- matched controls (mean age ± SD: 30.9 ± 7.9) participated in the exploratory study. Pregnenolone sulfate and pregnanolone serum levels were analysed by liquid chromatography-tandem mass spectrometry, while estradiol levels by enzyme-linked immunosorbent assay.ResultsSerum levels of pregnenolone sulfate and pregnanolone were significantly lower in the MM group than in controls (pregnenolone sulfate: P = 0.0328; pregnanolone: P = 0.0271, Student’s t-test), while estradiol levels were similar. In MM group, pregnenolone sulfate serum levels were negatively correlated with history of migraine (R² = 0.1369; P = 0.0482) and age (R² = 0.2826, P = 0.0025) while pregnenolone sulfate levels were not age-related in the control group (R² = 0.04436, P = 0.4337, linear regression analysis).ConclusionLow levels of both pregnanolone, a positive allosteric modulator of the GABAA receptor, and pregnenolone sulfate, a positive allosteric modulator of the NMDA receptor, involved in memory and learning, could contribute either to headache pain or the cognitive dysfunctions reported in migraine patients. Overall, our results agree with the hypothesis that migraine is a disorder associated with a loss of neurohormonal integrity, thus supporting the therapeutic potential of restoring low neurosteroid levels in migraine treatment.Supplementary InformationThe online version contains supplementary material available at 10.1186/s10194-021-01231-9.     

Continuous venovenous hemofiltration versus extended daily hemofiltration in patients with septic acute kidney injury: a retrospective cohort study

Introduction

Whether continuous venovenous hemofiltration (CVVHF) is superior to extended daily hemofiltration (EDHF) for the treatment of septic AKI is unknown. We compared the effect of CVVHF (greater than 72 hours) with EDHF (8 to 12 hours daily) on renal recovery and mortality in patients with severe sepsis or septic shock and concurrent acute kidney injury (AKI).

Methods

A retrospective analysis of 145 septic AKI patients who underwent renal replacement therapy (RRT) between July 2009 and May 2013 was performed. These patients were treated by CVVHF or EDHF with the same polyacrylonitrile membrane and bicarbonate-based buffer. The primary outcomes measured were occurrence of renal recovery and all-cause mortality by 60 days.

Results

Sixty-five and eighty patients were treated with CVVHF and EDHF, respectively. Patients in the CVVHF group had significantly higher recovery of renal function (50.77% of CVVHF group versus 32.50% in the EDHF group, P = 0.026). Median time to renal recovery was 17.26 days for CVVHF patients and 25.46 days for EDHF patients (P = 0.039). Sixty-day all-cause mortality was similar between CVVHF and EDHF groups (44.62%, and 46.25%, respectively; P = 0.844). 55.38% of patients on CVVHF and 28.75% on EDHF developed hypophosphatemia (P = 0.001). The other adverse events related to RRT did not differ between groups. On multivariate analysis, including physiologically clinical relevant variables, CVVHF therapy was significantly associated with recovery of renal function (HR 3.74; 95% CI 1.82 to 7.68; P < 0.001), but not with mortality (HR 0.69; 95% CI 0.34 to 1.41; P = 0.312).

Conclusions

Patients undergoing CVVHF therapy had significantly improved renal recovery independent of clinically relevant variables. The patients with septic AKI had similar 60-day all-cause mortality rates, regardless of type of RRT.     

Development and Evaluation of an Intravenous Infusion Sequence Annotation System

Objectives  The sequence of intravenous infusions may impact the efficacy, safety, and cost of intravenous medications. The study describes and assesses a computerized clinical decision support annotation system capable of analyzing the sequence of intravenous infusions. Methods  All intravenous medications on the hospital formulary were analyzed based on factors that impact intravenous infusion sequence. Eight pharmacy infusion knowledge databases were constructed based on Hospital Infusion Standards. These databases were incorporated into the computerized sequence annotation module within the electronic health record system. The annotation process was changed from pharmacists'' manual annotation (phase 1) to computer-aided pharmacist manual annotation (phase 2) to automated computer annotation (phase 3). Results  Comparing phase 2 to phase 1, there were significant differences in sequence annotation with regards to the percentage of hospital wards annotated (100% vs. 4.65%, chi-square  = 180.95, p  < 0.001), percentage of patients annotated (64.18% vs. 0.52%, chi-square = 90.46, p  < 0.001), percentage of intravenous orders annotated (75.67% vs. 0.77%, chi-square = 118.78, p  < 0.001), and the number of tubing flushes per ward per day (118.51 vs. 2,115.00, p  < 0.001). Compared with phase 1, there were significant cost savings in tubing flushes in phase 2 and phase 3. Compared with phase 1, there was significant difference in the time nurses spent on tubing flushes in phase 2 and phase 3 (1,244.94 vs. 21,684.8 minutes, p  < 0.001; 1,369.51 vs. 21,684.8 minutes, p  < 0.001). Compared with phase 1, significantly less time was required for pharmacist annotation in phase 2 and phase 3 (90.6 vs. 4,753.57 minutes, p  < 0.001; 0.05 vs. 4,753.57 minutes, p  < 0.001). Conclusion  A computerized infusion annotation system is efficient in sequence annotation and significant savings in tubing flushes can be achieved as a result.     

The Effect of WeChat on Parental Care Burden,Anxiety, and Depression in Children after CHD Surgery during COVID-19 Pandemic

Objectives  This study aimed to explore the effect of applying WeChat in the follow-up and health education of children after congenital heart disease (CHD) surgery during the coronavirus disease 2019 (COVID-19) epidemic. Methods  Data from 135 children were retrospectively analyzed. The care burden, anxiety, depression, and satisfaction of the parents of patients at home were analyzed and compared. Results  One month after discharge, the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Zarit Burden Interview (ZBI), and Patient Satisfaction Questionnaire-18 scores of the WeChat follow-up group were significantly better than those of the outpatient follow-up group ( p  < 0.05). Compared with the discharge time, the SAS, SDS, and ZBI scores were significantly improved in the WeChat follow-up group but not in the outpatient follow-up group ( p  < 0.05). Conclusion  During the COVID-19 epidemic, the application of WeChat to the follow-up management of children after CHD surgery can effectively reduce care burden and relieve anxiety and depression in parents at home. It can also improve the satisfaction of parents with medical treatment.     

The My Diabetes Care Patient Portal Intervention: Usability and Pre-Post Assessment

Background  My Diabetes Care (MDC) is a novel, multifaceted patient portal intervention designed to help patients better understand their diabetes health data and support self-management. MDC uses infographics to visualize and summarize patients'' diabetes health data, incorporates motivational strategies, and provides literacy level–appropriate educational resources. Objectives  We aimed to assess the usability, acceptability, perceptions, and potential impact of MDC. Methods  We recruited 69 participants from four clinics affiliated with Vanderbilt University Medical Center. Participants were given 1 month of access to MDC and completed pre- and post-questionnaires including validated measures of usability and patient activation, and questions about user experience. Results  Sixty participants completed the study. Participants'' mean age was 58, 55% were females, 68% were Caucasians, and 48% had limited health literacy (HL). Most participants (80%) visited MDC three or more times and 50% spent a total of ≥15 minutes on MDC. Participants'' median System Usability Scale (SUS) score was 78.8 [Q1, Q3: 72.5, 87.5] and significantly greater than the threshold value of 68 indicative of “above average” usability ( p  < 0.001). The median SUS score of patients with limited HL was similar to those with adequate HL (77.5 [72.5, 85.0] vs. 82.5 [72.5, 92.5]; p  = 0.41). Participants most commonly reported the literacy level–appropriate educational links and health data infographics as features that helped them better understand their diabetes health data (65%). All participants (100%) intended to continue to use MDC. Median Patient Activation Measure® scores increased postintervention (64.3 [55.6, 72.5] vs. 67.8 [60.6, 75.0]; p  = 0.01). Conclusion  Participants, including those with limited HL, rated the usability of MDC above average, anticipated continued use, and identified key features that improved their understanding of diabetes health data. Patient activation improved over the study period. Our findings suggest MDC may be a beneficial addition to existing patient portals.     

Clinical Decision Support System with Renal Dose Adjustment Did Not Improve Subsequent Renal and Hepatic Function among Inpatients: The Japan Adverse Drug Event Study

Background  Medication dose adjustment is crucial for patients with renal dysfunction (RD). The assessment of renal function is generally mandatory; however, the renal function may change during the hospital stay and the manual assessment is sometimes challenging. Objective  We developed the clinical decision support system (CDSS) that provided a recommended dose based on automated calculated renal function. Methods  We conducted a prospective cohort study in a single teaching hospital in Japan. All hospitalized patients were included except for obstetrics/gynecology and pediatric wards between September 2013 and February 2015. The CDSS was implemented on December 2013. Renal and hepatic dysfunction (HD) were defined as changes in the estimated glomerular filtration rate (eGFR) and alanine aminotransferase or alkaline phosphatase levels based on these measurements during hospital stay. These measurements were obtained before (phase I), after (phase II), and 1 year after (phase III) the CDSS implementation. Results  We included 6,767 patients (phase I: 2,205; phase II: 2,279; phase III: 2,283). The patients'' characteristics were similar among phases. Changes in eGFR were similar among phases, but the incidence of RD increased in phase III (phase I: 228 [10.3%]; phase II: 260 [11.4%]; phase III: 296 [13.0%], p  = 0.02). However, the differences in incidences of RD were not statistically significant after adjusting for eGFR at baseline and age. The incidences of HD were also similar among phases (phase I: 175 [13.2%]; phase II: 171 [12.9%]; phase III: 167 [12.2%], p  = 0.72). Conclusion  The CDSS implementation did not affect the incidence of renal and HD and changes in renal and hepatic function among hospitalized patients. The effectiveness of the CDSS with renal-guided doses should be investigated with respect to other endpoints.     

Comparison of shock index-based risk indices for predicting in-hospital outcomes in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

ObjectiveWe aimed to determine whether the prognostic value of the shock index (SI) and its derivatives is better than that of the Thrombolysis In Myocardial Infarction risk index (TRI) for predicting adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).MethodsA total of 257 patients with STEMI undergoing primary PCI from January 2018 to June 2019 were analyzed in a retrospective cohort study. The SI, modified shock index (MSI), age SI (age × the SI), age MSI (age × the MSI), and TRI at admission were calculated. Clinical endpoints were in-hospital complications, including all-cause mortality, acute heart failure, cardiac shock, mechanical complications, re-infarction, and life-threatening arrhythmia.ResultsMultivariate analyses showed that a high SI, MSI, age SI, age MSI, and TRI at admission were associated with a significantly higher rate of in-hospital complications. The predictive value of the age SI and age MSI was comparable with that of the TRI (area under the receiver operating characteristic curve: z = 1.313 and z = 0.882, respectively) for predicting in-hospital complications.ConclusionsThe age SI and age MSI appear to be similar to the TRI for predicting in-hospital complications in patients with STEMI undergoing primary PCI.     

Disparities in Telemedicine Access: A Cross-Sectional Study of a Newly Established Infrastructure during the COVID-19 Pandemic

Background  The COVID-19 pandemic led to dramatic increases in telemedicine use to provide outpatient care without in-person contact risks. Telemedicine increases options for health care access, but a “digital divide” of disparate access may prevent certain populations from realizing the benefits of telemedicine. Objectives  The study aimed to understand telemedicine utilization patterns after a widespread deployment to identify potential disparities exacerbated by expanded telemedicine usage. Methods  We performed a cross-sectional retrospective analysis of adults who scheduled outpatient visits between June 1, 2020 and August 31, 2020 at a single-integrated academic health system encompassing a broad range of subspecialties and a large geographic region in the Upper Midwest, during a period of time after the initial surge of COVID-19 when most standard clinical services had resumed. At the beginning of this study period, approximately 72% of provider visits were telemedicine visits. The primary study outcome was whether a patient had one or more video-based visits, compared with audio-only (telephone) visits or in-person visits only. The secondary outcome was whether a patient had any telemedicine visits (video-based or audio-only), compared with in-person visits only. Results  A total of 197,076 individuals were eligible (average age = 46 years, 56% females). Increasing age, rural status, Asian or Black/African American race, Hispanic ethnicity, and self-pay/uninsured status were significantly negatively associated with having a video visit. Digital literacy, measured by patient portal activation status, was significantly positively associated with having a video visit, as were Medicaid or Medicare as payer and American Indian/Alaskan Native race. Conclusion  Our findings reinforce previous evidence that older age, rural status, lower socioeconomic status, Asian race, Black/African American race, and Hispanic/Latino ethnicity are associated with lower rates of video-based telemedicine use. Health systems and policies should seek to mitigate such barriers to telemedicine when possible, with efforts such as digital literacy outreach and equitable distribution of telemedicine infrastructure.     

Prognostic value of GRACE and CHA2DS2-VASc score among patients with atrial fibrillation undergoing percutaneous coronary intervention

AimsThe GRACE and CHA2DS2-VASc risk score are developed for risk stratification in patients with acute coronary syndrome and AF, respectively. We aimed to assess the predictive performance of the GRACE score and CHA2DS2-VASc score among patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsConsecutive patients with a diagnosis of AF admitted to our hospital for PCI between January 2016 and December 2018 were included and followed up for at least 1 year. The primary endpoint was a composite of major adverse cardiac events (MACEs) including all-cause mortality, repeat revascularization, myocardial infarction, or ischaemic stroke.ResultsA total of 1452 patients were identified. Cox regression demonstrated that the GRACE (HR 1.014, 95% CI 1.008–1.020, p < 0.001) but not the CHA2DS2-VASc score was associated with the risk of MACEs. Both GRACE and CHA2DS2-VASc scores were predictive of all-cause mortality with HR of 1.028 (95% CI 1.020–1.037, p < 0.001) and 1.334 (95% CI 1.107–1.632, p = 0.003). Receiver operating characteristic analyses showed both scores had similar discrimination capacity for all-cause mortality (C-statistic: 0.708 for GRACE vs. 0.661 for CHA2DS2-VASc, p = 0.299). High GRACE score was also significantly associated with increased risk of ischaemic stroke (HR 1.018, 95% CI 1.005–1.031, p = 0.006) and major bleeding (HR 1.012, 95% CI 1.001–1.024, p = 0.039), whereas high CHA2DS2-VASc score was not.ConclusionsHigh GRACE score but not CHA2DS2-VASc score were both associated with an increased risk of MACEs after PCI in patients with AF. The GRACE and CHA2DS2-VASc scores have similar predictive performance for predicting all-cause mortality.

Key messages:

• In patients with AF undergoing PCI, increasing GRACE but not CHA2DS2-VASc scores was independently associated high risk of MACEs.
• The GRACE score could also help identify patients at higher risk of stroke and major bleeding.
• Both GRACE and CHA2DS2-VASc scores showed good ability in the prediction of all-cause mortality.

     

Lessons Learned for Identifying and Annotating Permissions in Clinical Consent Forms

Background  The lack of machine-interpretable representations of consent permissions precludes development of tools that act upon permissions across information ecosystems, at scale. Objectives  To report the process, results, and lessons learned while annotating permissions in clinical consent forms. Methods  We conducted a retrospective analysis of clinical consent forms. We developed an annotation scheme following the MAMA (Model-Annotate-Model-Annotate) cycle and evaluated interannotator agreement (IAA) using observed agreement ( A _o ), weighted kappa ( κ _w ), and Krippendorff''s α . Results  The final dataset included 6,399 sentences from 134 clinical consent forms. Complete agreement was achieved for 5,871 sentences, including 211 positively identified and 5,660 negatively identified as permission-sentences across all three annotators ( A _o  = 0.944, Krippendorff''s α  = 0.599). These values reflect moderate to substantial IAA. Although permission-sentences contain a set of common words and structure, disagreements between annotators are largely explained by lexical variability and ambiguity in sentence meaning. Conclusion  Our findings point to the complexity of identifying permission-sentences within the clinical consent forms. We present our results in light of lessons learned, which may serve as a launching point for developing tools for automated permission extraction.     

eHealth Literacy of Medical and Health Science Students and Factors Affecting eHealth Literacy in an Ethiopian University: A Cross-Sectional Study

Background  eHealth literacy is individual''s ability to look for, understand, and evaluate health information from electronic sources. Integrating eHealth literacy to the health system could help lower health care costs and ensure health equity. Despite its importance, the eHealth literacy level in Ethiopia has not been studied on medical and health science students, who are important parties in the health system. Understanding their level of eHealth literacy augments practice of health care, efficiency in education, and use of eHealth technologies. Objective  This research study aims to determine eHealth literacy level and identify its associated factors among medical and health science students in University of Gondar (UoG). Methods  An institution-based cross-sectional study was conducted from March to May 2019 among undergraduate medical and health science students in the UoG. Stratified multistage sampling was used. The eHealth literacy scale was used to measure eHealth literacy. A binary logistic regression model was fitted to measure association between eHealth literacy and the independent variables. Results  A total of 801 students participated in this study with a 94.6% of response rate. The majority (60%) were male and previously lived-in urban areas (68%). The mean eHealth literacy score was 28.7 and 60% of the participants possessed high eHealth literacy. Using health-specific Web sites (adjusted odds ratio [AOR] = 2.84, 95% confidence interval [CI]: 1.86–4.33), having higher Internet efficacy (AOR = 2.26, 95% CI: 1.56–3.26), perceived usefulness of the Internet (AOR = 3.33, 95% CI: 1.95–5.69), medical app use (AOR = 1.70, 95% CI: 1.13–2.55), being female (AOR = 1.55, 95% CI: 1.08–2.22), and being health informatics student (AOR = 2.02, 95% CI: 1.149–3.148) affect a high eHealth literacy level. Conclusion  The level of eHealth literacy in this study was moderate. Using specific reputable health Web sites, using smartphone medical applications, and Internet efficacy determine eHealth literacy significantly.     

Cognitive processing of cluster headache patients: evidence from event-related potentials

Background

The peripheral and central origins of pain in cluster headache (CH) have been a matter of much debate. The development and application of functional imaging techniques have provided more evidence supporting the hypothesis that CH is not a disorder exclusively peripheral in origin, and in fact central regions might be more important. Event-related potentials confer advantages in the functional evaluation of the cortex, but few studies thus far have employed this method in cluster headache.

Methods

Seventeen cluster patients (15 males; mean age = 35.4 years) and 15 age-matched healthy participants (13 males; mean age = 34.6 years) were recruited. A visual oddball paradigm was employed to analyze target processing using event-related potentials. We investigated the P3/P3d components in the experiment.

Results

P3/P3d amplitudes were decreased in CH patients (P3, 3.82 μV; P3d, 5.8 μV) compared with controls (P3, 7.28 μV; P3d, 8.95 μV), F(1,30) = 4.919, p < 0.05, η2 = 0.141 for P3 and F(1,30) = 8.514, p < 0.05, η2 = 0.221 for P3d, respectively). Moreover, the amplitudes of P3/P3d were no significantl difference in the side of pain as compared to contralateral one (p > 0.05).

Conclusions

These results provide evidence of dysfunction in the cognitive processing of CH patients, which may also contribute to the pathophysiology of CH.