Long-Term Cardiovascular Risk and Management of Patients Recorded in Primary Care With Unattributed Chest Pain: An Electronic Health Record Study.
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SUBMITTER: Jordan KP
PROVIDER: S-EPMC9075433 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:AimsMost adults presenting in primary care with chest pain symptoms will not receive a diagnosis ('unattributed' chest pain) but are at increased risk of cardiovascular events. To assess within patients with unattributed chest pain, risk factors for cardiovascular events and whether those at greatest risk of cardiovascular disease can be ascertained by an existing general population risk prediction model or by development of a new model.Methods and resultsThe study used UK primary care electronic health records from the Clinical Practice Research Datalink linked to admitted hospitalizations. Study population was patients aged 18 plus with recorded unattributed chest pain 2002-2018. Cardiovascular risk prediction models were developed with external validation and comparison of performance to QRISK3, a general population risk prediction model. There were 374 917 patients with unattributed chest pain in the development data set. The strongest risk factors for cardiovascular disease included diabetes, atrial fibrillation, and hypertension. Risk was increased in males, patients of Asian ethnicity, those in more deprived areas, obese patients, and smokers. The final developed model had good predictive performance (external validation c-statistic 0.81, calibration slope 1.02). A model using a subset of key risk factors for cardiovascular disease gave nearly identical performance. QRISK3 underestimated cardiovascular risk.ConclusionPatients presenting with unattributed chest pain are at increased risk of cardiovascular events. It is feasible to accurately estimate individual risk using routinely recorded information in the primary care record, focusing on a small number of risk factors. Patients at highest risk could be targeted for preventative measures.
| S-EPMC10442054 | biostudies-literature
Project description:Objective To ascertain long term cardiovascular outcomes in patients whose chest pain remained undiagnosed six months after first presentation.Design Cohort study.Setting UK electronic health record database (CALIBER) linking primary care, secondary care, coronary registry, and death registry information.Participants 172?180 adults aged ?18 from 223 general practices presenting with a first episode of recorded chest pain, classified from medical records as diagnosed (non-coronary condition or angina) or undiagnosed (cause unattributed) at first consultation between 2002 and 2009 and with no previous record of cardiovascular disease.Main outcome measures Fatal or non-fatal cardiovascular events over 5.5 years' follow-up. Adjustments were made for age, sex, deprivation, body mass index, smoking status, year of index presentation, and previous records of diabetes or hypertension or previous prescriptions for lipid lowering drugs.Results At the index presentation, 72.4% of patients (124?688) did not have a cause attributed for their chest pain; 118?687 (95.2%) of these did not receive any type of cardiovascular diagnosis over the next six months. Only a minority of patients in all three groups (non-coronary 2.0% (769 of 39?232); unattributed 11.7% (14?582 of 124?688); angina 31.5% (2606 of 8260)) had a recorded cardiac diagnostic investigation in the first six months after presentation. The long term incidence of cardiovascular events was higher in those whose chest pain remained unattributed after six months (5126 of 109?628; 4.7%) compared with patients with an initial diagnosis of non-coronary pain (1073 of 36?097; 3.0%) (adjusted hazard ratios for 0.5-1 year after presentation: 1.95, 95% confidence interval 1.66 to 2.31; for 1-3 years: 1.35, 1.23 to 1.48); for 3-5.5 years: 1.21, 1.08 to 1.37). Owing to the larger number of patients in the unattributed group, there were more excess myocardial infarctions in the long term in this group (214 more than expected based on the rate in the non-coronary group) than in the angina group (132 more than expected). Patients who had cardiac diagnostic investigations in the first six months had a higher long term risk of cardiovascular events, regardless of the initial chest pain label. Incidence of unattributed chest pain and angina decreased between 2002 (124 per 10?000 person years and 13 per 10?000 person years, respectively) and 2009 (107 per 10?000 person years and 5 per 10?000 person years, respectively), but the incidence of chest pain attributed to a non-coronary cause remained stable (37-40 per 10?000 person years). Risk of cardiovascular events did not change over time.Conclusions Most patients with first onset chest pain do not have a diagnosis recorded at presentation or in the subsequent six months, including those who undergo cardiac investigations. These patients have an increased risk of cardiovascular events for at least five years. Efforts to better assess and reduce the cardiovascular risk of such patients are warranted.
| S-EPMC5482346 | biostudies-literature
Project description:The primary care evaluation of chest pain represents a significant diagnostic challenge.To determine if electronic alerts to physicians can improve the quality and safety of chest pain evaluations.Randomized, controlled trial conducted between November 2008 and January 2010 among 292 primary care clinicians caring for 7,083 adult patients with chest pain and no history of cardiovascular disease.Clinicians received alerts within the electronic health record during office visits for chest pain. One alert recommended performance of an electrocardiogram and administration of aspirin for high risk patients (Framingham Risk Score (FRS)???10%), and a second alert recommended against performance of cardiac stress testing for low risk patients (FRS?<?10%).The primary outcomes included performance of an electrocardiogram and administration of aspirin therapy for high risk patients; and avoidance of cardiac stress testing for low risk patients.The majority (81%) of patients with chest pain were classified as low risk. High risk patients were more likely than low risk patients to be evaluated in the emergency department (11% versus 5%, p?<?0.01) and to be hospitalized (7% versus 3%, p?<?0.01). Acute myocardial infarction occurred among 26 (0.4%) patients, more commonly among high risk compared to low risk patients (1.1% versus 0.2%, p?<?0.01). Among high risk patients, there was no difference between the intervention and control groups in rates of performing electrocardiograms (51% versus 48%, p?=?0.33) or administering aspirin (20% versus 18%, p?=?0.43). Among low risk patients, there was no difference between intervention and control groups in rates of cardiac stress testing (10% versus 9%, p?=?0.40).Primary care management of chest pain is suboptimal for both high and low risk patients. Electronic alerts do not increase risk-appropriate care for these patients.
| S-EPMC3304044 | biostudies-literature
Project description:To be eligible for incentives through the Electronic Health Record (EHR) Incentive Program, many providers using older or locally developed EHRs will be transitioning to new, commercial EHRs. We previously evaluated prescribing errors made by providers in the first year following transition from a locally developed EHR with minimal prescribing clinical decision support (CDS) to a commercial EHR with robust CDS. Following system refinements, we conducted this study to assess the rates and types of errors 2 years after transition and determine the evolution of errors.We conducted a mixed methods cross-sectional case study of 16 physicians at an academic-affiliated ambulatory clinic from April to June 2010. We utilized standardized prescription and chart review to identify errors. Fourteen providers also participated in interviews.We analyzed 1905 prescriptions. The overall prescribing error rate was 3.8 per 100 prescriptions (95% CI 2.8 to 5.1). Error rates were significantly lower 2 years after transition (p<0.001 compared to pre-implementation, 12 weeks and 1 year after transition). Rates of near misses remained unchanged. Providers positively appreciated most system refinements, particularly reduced alert firing.Our study suggests that over time and with system refinements, use of a commercial EHR with advanced CDS can lead to low prescribing error rates, although more serious errors may require targeted interventions to eliminate them. Reducing alert firing frequency appears particularly important. Our results provide support for federal efforts promoting meaningful use of EHRs.Ongoing error monitoring can allow CDS to be optimally tailored and help achieve maximal safety benefits.ClinicalTrials.gov, Identifier: NCT00603070.
| S-EPMC3715358 | biostudies-literature
Project description:BACKGROUND: The use of opioid medications to manage chronic pain is complex and challenging, especially in primary care settings. Medication contracts are increasingly being used to monitor patient adherence, but little is known about the long-term outcomes of such contracts. OBJECTIVE: To describe the long-term outcomes of a medication contract agreement for patients receiving opioid medications in a primary care setting. DESIGN: Retrospective cohort study. SUBJECTS: All patients placed on a contract for opioid medication between 1998 and 2003 in an academic General Internal Medicine teaching clinic. MEASUREMENTS: Demographics, diagnoses, opiates prescribed, urine drug screens, and reasons for contract cancellation were recorded. The association of physician contract cancellation with patient factors and medication types were examined using the Chi-square test and multivariate logistic regression. RESULTS: A total of 330 patients constituting 4% of the clinic population were placed on contracts during the study period. Seventy percent were on indigent care programs. The majority had low back pain (38%) or fibromyalgia (23%). Contracts were discontinued in 37%. Only 17% were cancelled for substance abuse and noncompliance. Twenty percent discontinued contract voluntarily. Urine toxicology screens were obtained in 42% of patients of whom 38% were positive for illicit substances. CONCLUSIONS: Over 60% of patients adhered to the contract agreement for opioids with a median follow-up of 22.5 months. Our experience provides insight into establishing a systematic approach to opioid administration and monitoring in primary care practices. A more structured drug testing strategy is needed to identify nonadherent patients.
| S-EPMC1829426 | biostudies-other
Project description:ImportanceCardiovascular disease is the leading cause of death in the United States. To improve cardiovascular outcomes, primary care must have valid methods of assessing performance on cardiovascular clinical quality measures, including aspirin use (aspirin measure), blood pressure control (BP measure), and smoking cessation counseling and intervention (smoking measure).ObjectiveTo compare observed performance scores measured using 2 imperfect reference standard data sources (medical record abstraction [MRA] and electronic health record [EHR]-generated reports) with misclassification-adjusted performance scores obtained using bayesian latent class analysis.Design, setting, and participantsThis cross-sectional study used a subset of the 2016 aspirin, BP, and smoking performance data from the Healthy Hearts for Oklahoma Project. Each clinical quality measure was calculated for a subset of a practice's patient population who can benefit from recommended care (ie, the eligible population). A random sample of 380 eligible patients were included for the aspirin measure; 126, for the BP measure; and 115, for the smoking measure. Data were collected from 21 primary care practices belonging to a single large health care system from January 1 to December 31, 2018, and analyzed from February 21 to April 17, 2019.Main outcomes and measuresThe main outcomes include performance scores for the aspirin, BP, and smoking measures using imperfect MRA and EHRs and estimated through bayesian latent class models.ResultsA total of 621 eligible patients were included in the analysis. Based on MRA and EHR data, observed aspirin performance scores were 76.0% (95% bayesian credible interval [BCI], 71.5%-80.1%) and 74.9% (95% BCI, 70.4%-79.1%), respectively; observed BP performance scores, 80.6% (95% BCI, 73.2%-86.9%) and 75.1% (95% BCI, 67.2%-82.1%), respectively; and observed smoking performance scores, 85.7% (95% BCI, 78.6%-91.2%) and 75.4% (95% BCI, 67.0%-82.6%), respectively. Misclassification-adjusted estimates were 74.9% (95% BCI, 70.5%-79.1%) for the aspirin performance score, 75.0% (95% BCI, 66.6%-82.5%) for the BP performance score, and 83.0% (95% BCI, 74.4%-89.8%) for the smoking performance score.Conclusions and relevanceEnsuring valid performance measurement is critical for value-based payment models and quality improvement activities in primary care. This study found that extracting information for the same individuals using different data sources generated different performance score estimates. Further research is required to identify the sources of these differences.
| S-EPMC7388024 | biostudies-literature
Project description:ObjectivesThe Health Information Technology for Economic and Clinical Health (HITECH) Act created incentives for adopting electronic health records (EHRs) for some healthcare organisations, but long-term care (LTC) facilities are excluded from those incentives. There are realisable benefits of EHR adoption in LTC facilities; however, there is limited research about this topic. The purpose of this systematic literature review is to identify EHR adoption factors for LTC facilities that are ineligible for the HITECH Act incentives.SettingWe conducted systematic searches of Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete via Ebson B. Stephens Company (EBSCO Host), Google Scholar and the university library search engine to collect data about EHR adoption factors in LTC facilities since 2009.ParticipantsSearch results were filtered by date range, full text, English language and academic journals (n=22).InterventionsMultiple members of the research team read each article to confirm applicability and study conclusions.Primary and secondary outcome measuresResearchers identified common themes across the literature: specifically facilitators and barriers to adoption of the EHR in LTC.ResultsResults identify facilitators and barriers associated with EHR adoption in LTC facilities. The most common facilitators include access to information and error reduction. The most prevalent barriers include initial costs, user perceptions and implementation problems.ConclusionsSimilarities span the system selection phases and implementation process; of those, cost was the most common mentioned. These commonalities should help leaders in LTC facilities align strategic decisions to EHR adoption. This review may be useful for decision-makers attempting successful EHR adoption, policymakers trying to increase adoption rates without expanding incentives and vendors that produce EHRs.
| S-EPMC4316426 | biostudies-literature
Project description:BackgroundNumerous studies have reported that losing as little as 5% of one's total body weight (TBW) can improve health, but no studies have used electronic health record data to examine long-term changes in weight, particularly for adults with severe obesity [body mass index (BMI) ≥35 kg/m].ObjectiveTo measure long-term weight changes and examine their predictors for adults in a large academic health care system.Research designObservational study.SubjectsWe included 59,816 patients aged 18-70 years who had at least 2 BMI measurements 5 years apart. Patients who were underweight, pregnant, diagnosed with cancer, or had undergone bariatric surgery were excluded.MeasuresOver a 5-year period: (1) ≥5% TBW loss; (2) weight loss into a nonobese BMI category (BMI <30 kg/m); and (3) predictors of %TBW change via quantile regression.ResultsOf those with class 2 or 3 obesity, 24.2% and 27.8%, respectively, lost at least 5% TBW. Only 3.2% and 0.2% of patients with class 2 and 3 obesity, respectively, lost enough weight to attain a BMI <30 kg/m. In quantile regression, the median weight change for the population was a net gain of 2.5% TBW.ConclusionsAlthough adults with severe obesity were more likely to lose at least 5% TBW compared with overweight patients and patients with class 1 obesity, sufficient weight loss to attain a nonobese weight class was very uncommon. The pattern of ongoing weight gain found in our study population requires solutions at societal and health systems levels.
| S-EPMC7218679 | biostudies-literature
Project description:To characterize patterns of electronic medical record (EMR) use at pediatric primary care acute visits.Direct observational study of 529 acute visits with 27 experienced pediatric clinician users.For each 20 s interval and at each stage of the visit according to the Davis Observation Code, we recorded whether the physician was communicating with the family only, using the computer while communicating, or using the computer without communication. Regression models assessed the impact of clinician, patient and visit characteristics on overall visit length, time spent interacting with families, and time spent using the computer while interacting.The mean overall visit length was 11:30 (min:sec) with 9:06 spent in the exam room. Clinicians used the EMR during 27% of exam room time and at all stages of the visit (interacting, chatting, and building rapport; history taking; formulation of the diagnosis and treatment plan; and discussing prevention) except the physical exam. Communication with the family accompanied 70% of EMR use. In regression models, computer documentation outside the exam room was associated with visits that were 11% longer (p=0.001), and female clinicians spent more time using the computer while communicating (p=0.003).The 12 study practices shared one EMR.Among pediatric clinicians with EMR experience, conversation accompanies most EMR use. Our results suggest that efforts to improve EMR usability and clinician EMR training should focus on use in the context of doctor-patient communication. Further study of the impact of documentation inside versus outside the exam room on productivity is warranted.
| S-EPMC3005866 | biostudies-other
Project description:Background This project uses electronic medical record (EMR) data to assess performance by family physicians (FPs) in the screening for, diagnosis, and management of cardiovascular disease (CVD) and risk factors against national harmonized guidelines by the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE). Methods A retrospective cohort study using the Electronic Medical Record Administrative Data Linked Database (EMRALD) was conducted. A set of quality indicators (QIs) were developed on the basis of the 2014 C-CHANGE guidelines. Twenty-three readily measurable QIs were used to measure performance in the screening for and management of CVD, and to identify gaps in performance. Results Our study population consisted of 324 Ontario FPs and 284,959 patients. We assessed 23 of the 74 recommendations. There was variance in rates of adherence to QIs related to screening rates for CVD. Highest adherence to C-CHANGE guidelines was related to laboratory testing for patients with hypertension and prescription of antihypertensive therapies (? 91.4%). Lowest adherence to the guidelines was seen in administration of oral glucose tolerance tests for assessing prediabetic patients (4.4%). Conclusions FP EMR data can be used to measure adherence to one-third of the C-CHANGE recommendations. There are varying levels of adherence among the measurable C-CHANGE recommendations, and there is room for improvement in quality of primary care management of CVD in Ontario. There is potential to use EMR data to assess changes to CVD management in FP practice using guidelines if recommendations are quantifiable and measurable.
| S-EPMC7063608 | biostudies-literature