Nutritional assessments for ordinary medical care in patients with chronic liver disease

Aim: In patients with chronic liver disease who are at risk of malnutrition, simple and useful assessments for nutritional status should be established for ordinary medical care. The prognostic nutritional index (PNI) and controlling nutritional status (CONUT) are simple assessments constructed of only two or three laboratory data. We aimed to describe the potential of PNI and CONUT as a nutritional assessment tool in patients with chronic liver disease. Methods: We enrolled 165 patients, aged 18–85 years, with chronic liver disease. These patients were nutritionally assessed by PNI or CONUT, demonstrating the association with the severity of chronic liver disease or anthropometric values. Results: The value of PNI or CONUT was significantly associated with the severity of chronic liver disease (P < 0.001, respectively). In addition, the value of CONUT was significantly associated with all the anthropometric values such as body mass index (BMI, P < 0.05), mid‐arm circumference (AC, P < 0.001), mid‐arm muscle circumference (AMC, P < 0.001), and triceps skinfold thickness (TSF, P < 0.001), whereas the value of PNI was significantly associated with the values of AC (P < 0.01), AMC (P < 0.05) and TSF (P < 0.05). Approximately 80% of cirrhotic patients were assessed by PNI or CONUT to have obvious malnutrition. Conclusion: PNI and CONUT are potential tools for nutritional assessment in patients with chronic liver disease, especially for ordinary medical care, because of their simplicity.     

Mansoor's Self-Report Tool for Cardiovascular Risk Assessment predicts adverse in-hospital events in patients with pulmonary embolism

Background

Pulmonary embolism (PE) is a life-threatening acute disease accompanied by high morbidity and mortality. Regarding hospitalizations of patients with PE, risk stratification of these patients is crucial. Thus, risk stratification tools like risk scores are of key interest.

Methods

The nationwide German inpatient sample of the years 2005–2018 was used for this present analysis. Hospitalized PE patients were stratified according to Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class, and the performance of this score was evaluated to predict adverse in-hospital events.

Results

Overall, 1 174 196 hospitalizations of PE patients (53.5% females; 56.4% ≥70 years) were registered in Germany between 2005 and 2018. According to the Mansoor's self-report tool for cardiovascular risk assessment, 346 126 (29.5%) PE patients were classified as high risk. Higher Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class was predictive for in-hospital death (OR 1.129 [95%CI 1.117–1.141], P < 0.001), shock (OR 1.117 [95%CI 1.095–1.140], P < 0.001), cardiopulmonary resuscitation (OR 1.109 [95%CI 1.092–1.126], P < 0.001), right ventricular dysfunction (OR 1.039 [95%CI 1.030–1.048], P < 0.001), intracerebral bleeding (OR 1.316 [95%CI 1.275–1.358], P < 0.001), and gastro-intestinal bleeding (OR 1.316 [95%CI 1.275–1.358], P < 0.001). Systemic thrombolysis was not associated with lower in-hospital mortality in high-risk class (OR 5.139 [95%CI 4.961–5.323], P < 0.001).

Conclusions

Prognostic performance of the Mansoor's Self-Report Tool for Cardiovascular Risk Assessment for risk stratification of PE patients was poor and not able to identify those PE patients, who might benefit from systemic thrombolysis. However, the Mansoor's Self-Report Tool for Cardiovascular Risk Assessment was moderately helpful to identify PE patients at higher risk for bleeding events.     

Preferences for arthritis interventions: Identifying similarities and differences among African Americans and whites with osteoarthritis

Objective

To determine if there are differences or similarities in arthritis intervention preferences and barriers to participation between African Americans and whites with osteoarthritis (OA).

Methods

Using a needs assessment survey, intervention preferences and barriers to participation in arthritis interventions among African American (n = 60) and white (n = 55) adults with self‐reported doctor‐diagnosed OA were examined. T‐tests, chi‐square tests, and multiple regression analyses adjusting for covariates were examined to determine race effects.

Results

While there were many similarities, African Americans were more likely to report cost (P < 0.01), lack of trust (P = 0.04), fear of being the only person of their race (P < 0.001), lack of recommendation from their doctor (P = 0.04), and lack of recommendation of a family member or friend (P = 0.02) as barriers to participating in a community‐based self‐management arthritis intervention. After adjusting for covariates, African Americans preferred interventions that provide information on arthritis‐related internet sources (P = 0.04), solving arthritis‐related problems (P = 0.04), and talking to family and friends about their condition (P = 0.02) in comparison to whites. African Americans also preferred an intervention with child care services provided (P < 0.01), with instructors and participants of the same race (P < 0.01 and P < 0.001, respectively) or sex (P < 0.001 and P = 0.03, respectively), that allows a friend (P = 0.001) or family member (P = 0.02) to attend, that is offered at a local church (P = 0.01) or clinic (P < 0.01), or that is mailed (P < 0.01).

Conclusion

Findings suggest that similar interventions are preferred across racial groups, but some practical adaptations could be made to existing arthritis interventions to minimize barriers, increase cultural sensitivity, and offer programs that would be appealing to African Americans and whites with arthritis.     

Emergency room visit: a red‐flag indicator for poor diabetes care

Aim To determine the association between emergency room (ER) admission and quality of diabetes care in the community. Methods In a nested case–control study of patients with Type 2 diabetes mellitus (DM) within a large health maintenance organization (HMO) in Israel, 919 patients who were admitted to one of West Jerusalem’s ERs between 1 May and 30 June 2004 were compared with 1952 control subjects not admitted. Data on study covariates were retrieved from the HMO’s computerized database and a subset of the study population was interviewed. Logistic regressions were conducted to estimate the odds ratios of being admitted according to different measures of quality of care, controlling for socio‐demographic variables, co‐morbidities and type of DM treatment. Results The main indices of quality of primary care that were inversely associated with visiting an ER during the study period included performance of a cholesterol test in the year prior to the index date [adjusted odds ratio (OR) 0.23, 95% confidence interval (CI) 0.19–0.29, P < 0.001], performance of glycated haemoglobin test (OR 0.26, 95% CI 0.24–0.29, P < 0.001), visiting an ophthalmologist (OR 0.47, 95% CI 0.32–0.68, P = 0.001), and recommendations to stop smoking (OR 0.10, 95% CI 0.05–0.21, P < 0.001). Conclusions Admission to the ER can be used as an indicator for poor quality of diabetes care. There is an association between ER admission and poor quality of diabetes care.     

Factors associated with specialist assessment and treatment for hepatitis C virus infection in New South Wales,Australia

Summary. Assessment and treatment for hepatitis C virus (HCV) in the community remains low. We evaluated factors associated with HCV specialist assessment and treatment in a cross‐sectional study to evaluate treatment considerations in a sample of 634 participants with self‐reported HCV infection in New South Wales, Australia. Participants having received HCV specialist assessment (n = 294, 46%) were more likely to be have been older (vs <35 years; 35–44 OR 1.64, P = 0.117; 45–54 OR 2.00, P = 0.024; ≥55 OR 5.43, P = 0.002), have greater social support (vs low; medium OR 3.07, P = 0.004; high OR 4.31, P < 0.001), HCV‐related/attributed symptoms (vs none; 1–10 OR 3.89, P = 0.032; 10–21 OR 5.01, P = 0.010), a diagnosis of cirrhosis (OR 2.40, P = 0.030), have asked for treatment information (OR 1.91, P = 0.020), have greater HCV knowledge (OR 2.49, P = 0.001), have been told by a doctor to go onto treatment (OR 3.00, P < 0.001), and less likely to be receiving opiate substitution therapy (OR 0.10, P < 0.001) and never to have seen a general practitioner (OR 0.24, P < 0.001). Participants having received HCV treatment (n = 154, 24%) were more likely to have greater fibrosis (vs no biopsy; none/minimal OR 3.45, P = 0.001; moderate OR 11.47, P < 0.001; severe, OR 19.51, P < 0.001), greater HCV knowledge (OR 2.57; P = 0.004), know someone who has died from HCV (OR 2.57, P = 0.004), been told by a doctor to go onto treatment (OR 3.49, P < 0.001), were less likely to have been female (OR 0.39, P = 0.002), have recently injected (OR 0.42, P = 0.002) and be receiving opiate substitution therapy (OR 0.22, P < 0.001). These data identify modifiable patient‐, provider‐ and systems‐level barriers associated with HCV assessment and treatment in the community that could be addressed by targeted interventions.     

Incidence and predictors of late total occlusion following coronary stenting

To determine the incidence and predictors of total occlusion in‐stent restenosis, we reviewed three randomized stent vs. stent trials and one stent registry, which provided 955 coronary artery lesions with 6‐month angiographic follow‐up. Fifteen (1.6%) of the 955 stented lesions were totally occluded at 6‐month follow‐up. Most patients with total occlusion presented with recurrent angina at the time of repeat angiography (60.0%) while no patient presented with an acute ST segment elevation myocardial infarction. The univariate predictors of total occlusion following elective coronary stenting included stenting for restenosis after a previous percutaneous intervention (P = 0.001), longer stent length (P < 0.001), longer lesion length (P < 0.001), smaller reference vessel diameter (P = 0.022), smaller preprocedure minimum lumen diameter (MLD; P = 0.004), and smaller postprocedure MLD (P = 0.036). Stepwise multiple logistic regression analysis demonstrated that stenting for restenotic lesions (P = 0.004), longer stent length (P < 0.001), and smaller preprocedure MLD (P = 0.012) were independent predictors of total occlusion following coronary stenting. Catheter Cardiovasc Interv 2003;60:344‐351. © 2003 Wiley‐Liss, Inc.     

Hepatitis C virus coinfection and the risk of cardiovascular disease among HIV‐infected patients

Background

Among HIV‐infected patients, hepatitis C virus (HCV) coinfection is associated with lower cholesterol levels, but it remains unclear how it affects cardiovascular outcomes.

Methods

We performed logistic regression to evaluate acute myocardial infarction (AMI) and cerebrovascular disease (CVD) events by HCV status among HIV‐infected US veterans in the highly active antiretroviral therapy (HAART) era (1996–2004). We then performed survival analyses to evaluate incident AMI and CVD, exploring antiretroviral therapy (ART) as a time‐dependent variable.

Results

A total of 19 424 HIV‐infected patients [31.6% of whom were HCV‐coinfected (HIV/HCV)] contributed 76 376 patient‐years of follow‐up. HCV coinfection was associated with lower rates of hypercholesterolaemia (18.0% in HIV/HCV vs. 30.7% in HIV‐only patients; P<0.001), but higher rates of hypertension (43.8%vs. 35.6%; P<0.0001), type 2 diabetes mellitus (16.2%vs. 11.1%; P<0.0001) and smoking (36.7%vs. 24.7%; P=0.009). Rates of AMI and CVD were significantly higher among HIV/HCV than HIV‐only patients: 4.19 vs. 3.36 events/1000 patient‐years, respectively (P<0.001), for AMI; and 12.47 vs. 11.12 events/1000 patient‐years, respectively (P<0.001), for CVD. When analyses were controlled for diabetes mellitus, hypertension, age and duration of ART, hazard ratios (HRs) among those with HIV/HCV (vs. HIV only) were 1.25 [95% confidence interval (CI) 0.98–1.61; P=0.072] for AMI and 1.20 (CI 1.04–1.38; P=0.013) for CVD. Hypertension (HR 2.05; P<0.001), greater age (HR 1.79; P<0.001) and longer duration (cumulative years) of antiretroviral use (HR 1.12; P=0.0411) were also associated with increased risk of AMI in the adjusted model.

Conclusions

In the HAART era, HCV coinfection was associated with a significantly increased risk of CVD and a trend towards an increased risk of AMI among HIV‐infected patients.     

Validity of the Developed Arabic Multidimensional Health Assessment Questionnaire for use in standard clinical care of patients with rheumatic diseases

Objective: To assess the validity, reliability and comprehensibility of the Developed Arabic Multidimensional Health Assessment Questionnaire (Arabic‐MDHAQ) for use in standard clinical care of patients with rheumatic diseases. Methods: The multidimensional questionnaire was developed on a one‐page sheet. One side includes 10 activities of daily living (Arabic HAQII), four items to assess psychological distress, duration of morning stiffness as well as visual analogue scales for pain, global status, and fatigue. The other side includes review of the systems, falls and cardiovascular risk assessment, the rheumatology attitudes index to assess the psychological construct of helplessness and self‐report of joint counts. The questionnaire was completed by consecutive patients with various rheumatic diseases including 85 with rheumatoid arthritis, 57 with fibromyalgia, 57 with osteoarthritis, 18 with psoriatic arthritis and 11 with ulcerative colitis. Results: The test was reliable as demonstrated by a high standardized alpha‐value and minimal changes recorded in the second from the first test. The Developed Arabic‐MDHAQ correlated significantly with clinical parameters of disease activity as well as inflammatory markers. Changes in both functional and psychological assessment scores showed variation with diseases. The Arabic health assessment questionnaire II (functional disability) was significantly correlated with the original Arabic‐HAQ. The psychological assessment items in the Arabic‐MDHAQ were significantly correlated with depression as well as anxiety scores as demonstrated by Hamilton scales for depression and anxiety (P < 0.001). The Arabic‐MDHAQ showed also a high degree of comprehensibility (92.9%). Conclusion: The Developed Arabic‐MDHAQ is a reliable and valid instrument for assessment of Arabic patients suffering from rheumatic diseases. Being short, rapid and comprehensive, this adds more to its applicability. The data support the value of completion of the simple 2‐page patient questionnaire, which provides a quantitative written documented record by the patient, at each visit to a rheumatologist.     

Efficacy and safety of tanezumab administered as a fixed dosing regimen in patients with knee or hip osteoarthritis: a meta-analysis of randomized controlled phase III trials

This study aims to evaluate the efficacy and safety of tanezumab administered as a fixed dosing regimen in patients with knee or hip osteoarthritis. Randomized controlled phase III trials (RCTs) that evaluated the efficacy and safety associated with tanezumab for knee or hip OA were systematically identified by searching electronic databases, including Cochrane Library, PubMed, and Embase, for 30 years from December 1990 up to July 2020. Ten relevant studies were included in our meta-analysis. The research was reported based on the preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure the reliability and verity of results. Our study showed that the tanezumab groups were more effective than the placebo groups in terms of mean change from the baseline in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (P < .00001), WOMAC physical functional (P < .00001), and patient’s global assessment (PGA) (P < .00001). Discontinued due to adverse events (AEs) (P < .00001), serious AEs (P = .02), abnormal peripheral sensations (both P < .00001), and peripheral neuropathy (P < .002) in tanezumab groups were significantly higher than that in control groups. Compared with placebo, tanezumab can effectively relieve pain and improve WOMAC physical function and patient’s global assessment (PGA) in knee and hip osteoarthritis. Meanwhile, adverse events are transient in nature and generally well-tolerated. However, we still need large-sample, high-quality studies to investigate the long-term safety of tanezumab to give the conclusion.

     

Patients with acute myocardial infarction using ambulance or private transport to reach definitive care: which mode is quicker?

Background: One of the main reasons cited by patients with acute myocardial infarction (AMI) for not using an ambulance was quickness of private transport. Aims: To examine differences in transport times for patients with AMI who used ambulance compared with patients who used private transportation to reach definitive care in Beijing. Methods: Data were prospectively collected from the 498 patients with ST‐elevation myocardial infarction admitted within 12 h of symptom onset to 19 hospitals in Beijing between 1 November 2005 and 31 December 2006. Elapsed time to definitive care was examined through the use of (i) decision to seek care to hospital arrival (private transport group) versus emergency medical service (EMS) arrival on scene (ambulance transport group), (ii) decision to seek care to hospital arrival, (iii) decision to seek care to reperfusion therapy and (iv) symptom onset to reperfusion therapy for both groups. Results: Private transportation resulted in faster hospital arrival than using ambulance (median, 35 vs 50 min, P < 0.001). However, if one considers EMS treatment to be initial definitive care, using ambulance resulted in much quicker care than patients using private transportation to the hospital (median, 15 vs 35 min, P < 0.001). In addition, using ambulance resulted in shorter decision‐to‐balloon (173 vs 193 min, P = 0.049) and symptom onset‐to‐balloon (medians, 223 vs 300 min, P < 0.001) times compared with patients using private transportation. Conclusion: Although private transportation results in a faster trip to the hospital, quicker definitive care is obtained with the use of ambulance.     

Glucosylsphingosine is a key biomarker of Gaucher disease

Gaucher disease (GD) involves the accumulation of glucosylceramide (GL1) and its deacylated lysolipid, glucosylsphingosine (lyso‐GL1) which is implicated in mediating immune dysregulation and skeletal disease. The aim of our study was to assess plasma Lyso‐GL1 as a biomarker of GD and its response to therapy. Plasma lyso‐GL1 in 169 patients with GD type 1 (GD1) was measured by LC‐MS/MS. Significant predictors of plasma LGL1 were assessed by Pearson's correlation coefficient, Wilcoxon Mann Whitney test and multiple linear regression. Propensity scores were used to match patients on treatment mode: Enzyme Replacement Therapy (ERT) vs. Eliglustat Tartrate SRT (ELI‐SRT). Plasma Lyso‐GL1 levels in healthy controls averaged 1.5 ng/ml (1.3–1.7; 95% CI). In untreated GD patients, the levels were massively elevated (180.9 ng/ml: 95% CI, 145.4–216.5) and imiglucerase ERT resulted in marked reduction (89 ng/ml: 95% CI, 69.2–129.4) (P < 0.001). Lyso‐GL1 correlated with chitotriosidase (r = 0.59 P < 0.001), CCL18 (r = 0.62 P <0.001), hepatomegaly (r = 0.28 P < 0.001), splenomegaly (r = 0.27 P = 0.003), splenectomy (P = 0.01) and treatment mode (P < 0.001). By multiple linear regression, the strongest predictors of lyso‐GL1 were age (P < 0.001), splenectomy (P = 0.02), Chitotriosidase (P < 0.001) and CCL18 levels (P = 0.001). After propensity score matching to obtain comparable groups of patients on ERT vs ELI‐SRT, lyso‐GL1 levels were lower among patients receiving ELI‐SRT by 113 ng/ml (95% CI: 136–90.3 ng/ml P < 0.001). Plasma lyso‐GL1 is a key biomarker of GD. ERT reduced lyso‐GL1 levels. By propensity scoring, ELI‐SRT resulted in greater reduction of lyso‐GL1 than ERT. Am. J. Hematol. 91:1082–1089, 2016. © 2016 Wiley Periodicals, Inc.     

PCI versus CABG for multivessel coronary disease in diabetics

Objectives: To explore the clinical performance of a strategy of revascularization by percutaneous coronary intervention (PCI) with drug‐eluting stent (DES) in diabetic patients with multivessel disease (MVD) compared with coronary artery bypass graft (CABG), when it is based on clinical judgment. Background: Diabetes mellitus (DM) is a major risk factor for poor outcome after PCI. However, PCI may result in better outcome if the choice of revascularization (PCI versus CABG) is based on the physician decision, rather than randomization. Limited experiences have compared revascularization by DES‐PCI versus CABG in DM patients with MVD. Methods: From August 2004 to August 2005, 220 consecutive DM patients with MVD underwent DES‐PCI (93) or CABG (127) at our Institution. The type of revascularization was dependent on patient and/or physician choice. Major adverse cardiac and cerebrovascular events (MACCE) included death, myocardial infarction, repeat coronary revascularization, and stroke. Results: Compared with PCI patients, CABG patients had higher prevalence of 3‐vessel disease (P < 0.001), significant LAD involvement (P < 0.001), presence of total occlusions (P = 0.04), collateral circulation (P < 0.001). At 2‐year follow‐up, MACCE were not different between CABG group and DES‐PCI group (OR 1.2; P = 0.6) and, only when the clinical judgment on the revascularization choice was excluded at propensity analysis, DES‐PCI increased the risk of 24‐month MACCE in total population (OR 1.8; P = 0.04). Conclusions: For patients with DM and MVD, a clinical judgment‐based revascularization by DES‐PCI is not associated with worse 2‐year outcome compared with CABG. © 2008 Wiley‐Liss, Inc.     

Maternal adiposity as an independent risk factor for pre‐eclampsia: a meta‐analysis of prospective cohort studies

Studies investigating the association between maternal adiposity and risk of pre‐eclampsia showed contradictory results. Therefore, we performed a meta‐analysis of prospective cohort studies to estimate the effect of maternal adiposity on pre‐eclampsia. We reviewed 1,286 abstracts and finally included 29 prospective cohort studies with 1,980,761 participants and 67,075 pre‐eclampsia events. We pooled data with a random‐effects model, and obtained risk estimates for five predetermined bodyweight groups: low, normal‐weight (reference), overweight, obese and severely obese. In the cohort studies that unadjusted for pre‐eclampsia risk factors, the pooled unadjusted relative risks (RR) with 95% confidence intervals (95%CI) for pre‐eclampsia of overweight, obese and severely obese women were 1.58 (95% CI 1.44–1.72, P < 0.001), 2.68 (95% CI 2.39–3.01, P < 0.001) and 3.12 (95% CI 2.24–4.36, P < 0.001), respectively. In those cohorts that adjusted for pre‐eclampsia risk factors, the pooled unadjusted RRs for pre‐eclampsia of overweight, obese and severely obese women were 1.70 (95% CI 1.60–1.81, P < 0.001), 2.93 (95% CI 2.58–3.33, P < 0.001) and 4.14 (95% CI 3.61–4.75, P < 0.001), respectively. Sensitivity analysis showed maternal adiposity was associated with increased risk of pre‐eclampsia in both nulliparous and multiparas women. In conclusion, overweight or obese pregnant women have a substantially increased risk of pre‐eclampsia, and maternal adiposity is an independent risk factor of pre‐eclampsia.     

A systematic model improves hepatitis C virus birth cohort screening in hospital‐based primary care

Despite national and local governing board recommendations in the United States of America to perform an HCV screening test in baby boomers, screening rates remain low. Our goal was to study the impact of an HCV screening and link‐to‐care programme with patient navigation in two New York City primary care practices. This was a 2‐year prospective study of patients born between 1945‐1965 (“baby boomers”) with encounters at two primary care practices at the Mount Sinai Hospital between November 1, 2013 and November 30, 2015. Baseline HCV screening rates were collected for four months. A multifaceted intervention was sequentially implemented involving electronic alerts, housestaff education, data feedback and patient navigation. HCV screening rates and link to care, defined as attending an appointment with a viral hepatitis specialist, were compared before and after these interventions. There were 14 642 primary care baby boomer patients of which 4419 (30.2%) were newly screened during the study. There was a significant increase in HCV screening rates from 55% to 75% (P<.01) with an HCV seropositive rate of 3.3%. Factors associated with being HCV seropositive included older age (P<.01), male sex (P<.01), African American race (P<.01) and receiving care in the housestaff practice (P<.01). With patient navigation, 78 of 84 (93%) newly diagnosed HCV‐infected persons were referred to a specialist and 60 (77%) attended their first appointment. A structured, multifaceted HCV screening programme using well‐studied principles identifies a large number of undiagnosed baby boomers within hospital‐based primary care and improves access to specialty providers in a timely manner.     

Descriptive analysis of emergency department oxygen use in acute exacerbation of chronic obstructive pulmonary disease

Background: Inconsistencies in oxygen therapy recommendations in acute exacerbation of chronic obstructive pulmonary disease (COPD) may result in variability in emergency department (ED) oxygen management of patients with COPD. The aim of this study was to describe oxygen management in the first 4 h of ED care for patients with exacerbation of COPD. Methods: A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were 273 adult ED patients with COPD presenting with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were physiological data, including oxygen saturation (SpO₂), oxygen delivery devices and flow rates on ED arrival, 1 and 4 h. Results: Oxygen was used in 82.0% of patients. Patients who required oxygen had higher incidence of ambulance transport (P < 0.001), triage category 2 (P= 0.006), home oxygen use (P < 0.001), and increased work of breathing on ED arrival (P < 0.001), and higher median respiratory rate (P < 0.001) and heart rate (P= 0.001). SpO₂ > 90% occurred in the majority of patients (87.5%; 96.4%; 95.6%); however, a considerable number of patients with SpO₂ < 90% were not given oxygen (61.8%; 30%; 45.5%). Conclusions: A number of patients with documented hypoxaemia were not given oxygen and there may be variables other than oxygen saturation that may influence oxygen use. Future research should focus on increasing the evidence‐based supporting oxygen use and better understanding of clinicians' oxygen decision‐making in patients with COPD.     

Predictive factors for not undergoing RNA testing in patients found to have hepatitis C serology and impact of an automatic alert

The process of diagnosis and linkage to care in cases of hepatitis C virus (HCV) infection remains an obstacle to disease control. The aims of this study were to evaluate predictive factors for not undergoing RNA testing among patients with positive HCV serology and impact of incorporating an automated electronic alert with recommendations in clinical practice. We collected HCV antibody tests requested from October 2011 to September 2014 to evaluate the rate of RNA testing and predictive factors for not undergoing RNA testing. Since October 2014, an automated alert notification has been implemented to remind physicians for testing RNA after a positive HCV test and referral to specialist care. 41 403 HCV antibody tests were requested from 34 073 patients. 870 (2.55%) patients tested positive. After a median of follow‐up of 57.0 months (range 45.6‐82.1), 37.6% did not have RNA testing. The independent predictors for not undergoing RNA testing were primary care serology requests (P < 0.001), no history of drug use (P = 0.005) and a lack of social support (P = 0.015). The intervention impact was evaluated in a pre‐alert cohort (October 2011‐September 2014) and a post‐alert cohort (October 2014‐September 2015). After the incorporation of the alert, the rate of RNA testing increased from 62.4% to 77.7% (P < 0.001). Incomplete assessment of HCV infection is a challenge in primary care. The implementation of an automated alert for recommending RNA testing after a positive HCV antibody test is feasible in clinical practice and increases the rate of patients with RNA testing.     

Influence of patient and provider characteristics on quality of care for the myelodysplastic syndromes

Little is known about quality of care for patients with myelodysplastic syndromes (MDS), or patient and provider factors that influence quality. We identified Medicare enrollees diagnosed with MDS between 2006 and 2011, and analysed linked claims for performance on two widely‐accepted quality measures: diagnostic bone marrow cytogenetic testing (diagnostic quality) and pre‐treatment iron assessment for patients receiving an erythropoiesis‐stimulating agent (ESA; treatment quality). A total of 4575 patients met the criteria for diagnostic quality measurement, and 3379 for treatment quality measurement. In the diagnostic cohort, 74% had a claim for marrow cytogenetic testing 3 months before to 3 months after diagnosis. In multivariate models, younger age (P < 0·001), treatment at a higher‐volume MDS centre (P < 0·001), and claims for pancytopenia (P < 0·001) were all associated with higher levels of testing. A borderline result was observed for diagnostic year, with improvement over time (P = 0·06). In the treatment cohort, 56% had evidence of pre‐ESA iron assessment, with higher rates for later years of diagnosis (P < 0·001), higher household income (P = 0·03), and those treated at higher‐volume centres (P = 0·01). In this large cohort of patients with MDS, quality of care was suboptimal overall, but worse in several specific subgroups. These data suggest that targeted educational and/or process‐focused interventions are warranted.