Background The diagnosis of chronic kidney disease (CKD) is based on laboratory results easily extracted from electronic health records; therefore, CKD identification and management is an ideal area for targeted electronic decision support efforts. Early CKD management frequently occurs in primary care settings where primary care providers (PCPs) may not implement all the best practices to prevent CKD-related complications. Few previous studies have employed randomized trials to assess a CKD electronic clinical decision support system (eCDSS) that provided recommendations to PCPs tailored to each patient based on laboratory results. Objective The aim of this study was to report the trial design and implementation experience of a CKD eCDSS in primary care. Methods This was a 3-arm pragmatic cluster-randomized trial at an academic general internal medicine practice. Eligible patients had 2 previous estimated-glomerular-filtration-rates by serum creatinine (eGFR Cr ) <60 mL/min/1.73m 2 at least 90 days apart. Randomization occurred at the PCP level. For patients of PCPs in either of the 2 intervention arms, the research team ordered triple-marker testing (serum creatinine, serum cystatin-c, and urine albumin-creatinine-ratio) at the beginning of the study period, to be completed when acquiring labs for regular clinical care. The eCDSS launched for PCPs and patients in the intervention arms during a regular PCP visit subsequent to completing the triple-marker testing. The eCDSS delivered individualized guidance on cardiovascular risk-reduction, potassium and proteinuria management, and patient education. Patients in the eCDSS+ arm also received a pharmacist phone call to reinforce CKD-related education. The primary clinical outcome is blood pressure change from baseline at 6 months after the end of the trial, and the main secondary outcome is provider awareness of CKD diagnosis. We also collected process, patient-centered, and implementation outcomes. Results A multidisciplinary team (primary care internist, nephrologists, pharmacist, and informaticist) designed the eCDSS to integrate into the current clinical workflow. All 81 PCPs contacted agreed to participate and were randomized. Of 995 patients initially eligible by eGFR Cr , 413 were excluded per protocol and 58 opted out or withdrew, resulting in 524 patient participants (188 usual care; 165 eCDSS; and 171 eCDSS+). During the 12-month intervention period, 53.0% (178/336) of intervention patient participants completed triple-marker labs. Among these, 138/178 (77.5%) had a PCP appointment after the triple-marker labs resulted; the eCDSS was opened for 73.9% (102/138), with orders or education signed for 81.4% (83/102). Conclusions Successful integration of an eCDSS into primary care workflows and high eCDSS utilization rates at eligible visits suggest ...
Most adults with chronic kidney disease (CKD) in the United States are cared for by primary care providers (PCPs). We evaluated the feasibility and preliminary effectiveness of an electronic clinical decision support system (eCDSS) within the electronic health record with or without pharmacist follow-up to improve the management of CKD in primary care. Study Design: Pragmatic cluster-randomized trial. Setting & Participants: 524 adults with confirmed creatinine-based estimated glomerular filtration rates of 30 to 59 mL/min/1.73 m 2 cared for by 80 PCPs at the University of California San Francisco. Electronic health record data were used for patient identification, intervention deployment, and outcomes ascertainment. Interventions: Each PCP's eligible patients were randomly assigned as a group into 1 of 3 treatment arms: (1) usual care; (2) eCDSS: testing of creatinine, cystatin C, and urinary albumincreatinine ratio with individually tailored guidance for PCPs on blood pressure, potassium, and proteinuria management, cardiovascular risk reduction, and patient education; or (3) eCDSS plus pharmacist counseling (eCDSS-PLUS). Outcomes: The primary clinical outcome was change in blood pressure over 12 months. Secondary outcomes were PCP awareness of CKD and use of angiotensin-converting enzyme inhibitor/ angiotensin receptor blocker and statin therapy. Results: All 80 eligible PCPs participated. Mean patient age was 70 years, 47% were nonwhite, and mean estimated glomerular filtration rate was 56 ± 0.6 mL/min/1.73 m 2. Among patients receiving eCDSS with or without pharmacist counseling (n = 336), 178 (53%) completed laboratory measurements and 138 (41%) had laboratory measurements followed by a PCP visit with eCDSS deployment. eCDSS was opened by the PCP for 102 (74%) patients, with at least 1 suggested order signed for 83 of these 102 (81%). Changes in systolic blood pressure were −2.1 ± 1.5 mm Hg with usual care, −2.8 ± 1.8 mm Hg with eCDSS, and −1.1 ± 1.1 with eCDSS-PLUS (P = 0.7). PCP awareness of CKD was 16% with usual care, 26% with eCDSS, and 32% for eCDSS-PLUS (P = 0.09). In as-treated analyses, PCP awareness of CKD was significantly greater with eCDSS and eCDSS-PLUS (73% and 69%) versus usual care (47%; P = 0.002). Limitations: Recruitment of smaller than intended sample size and limited uptake of the testing component of the intervention. Editorial, p. 613 Complete author and article information provided before references.
Since the introduction of e-cigarettes into the U.S. market, the number and variety of vaping products have proliferated. E-hookahs are long, pen-like vaping devices that debuted in U.S. markets in 2014. By applying the Host, Agent, Vector, Environment (HAVE) model, the objective of this exploratory study was to assess differences between e-cigarettes and e-hookahs to help inform tobacco regulatory science and practice. In June–August 2014, a total of 54 unique manufactured e-cigarette and e-hookah products were identified at point of sales (POS) around three college campuses in Southeast U.S. Documented characteristics included brand name, disposable, rechargeable, nicotine containing, packaging, and flavor type. Descriptive analyses were conducted October to November 2014 to assess frequency and percent of product type across POS and specific characteristics. Among 54 products, 70.4% was e-cigarettes and 29.6% was e-hookahs. Across POS, drug stores and grocery stores carried e-cigarettes exclusively, while gas stations carried the greatest proportion of e-hookahs. Compared to e-hookahs, a greater proportion of e-cigarettes were non-disposable and contained nicotine; a greater proportion of e-hookahs came in fruit and other types of flavors compared to e-cigarettes. The present study suggests that e-cigarettes and e-hookahs differ by specific product characteristics and by places where they are sold. Despite these differences, the products are used for similar purposes warranting careful monitoring of industry manufacturing and marketing, because the safety of both products is still undetermined. Additional research is needed to understand the uptake and continued use of these products.
Participants completed a cross-sectional survey about their use of the after visit summary (AVS) at a previous primary care visit. Of 355 participants, 294 (82.8%) recalled receiving it, 67.4% consulted it, 45.9% consulted it more than once, and 31.6% shared the AVS. In multivariable analysis, higher education and older age were associated with AVS consultation. Among the subset of 133 patients recalling personalized free-text instructions, 96% found them easy to understand and 94.4% found them useful. Our findings suggest that the AVS is a useful communication tool and improvement efforts should emphasize clarity for those most vulnerable to communication errors.
Background Racial disparities in the uptake of cancer genetic services are well documented among African American (AA) women. Understanding the multiple social and psychological factors that can influence the uptake of genetic testing among AA women is needed. Methods Data came from 270 AA women diagnosed with ovarian cancer and participating in a population‐based, case‐control study of ovarian cancer who were asked about genetic testing. Logistic regression analyses tested the associations of predisposing, enabling, and need factors with reported genetic testing uptake. Results One‐third of the sample (35%) reported having had genetic testing. In the multivariable model, AA women with higher incomes had more than double the odds of being tested than those with the lowest income (odds ratio [OR] for $25,000‐$74,999, 2.04; 95% confidence interval [CI], 1.06‐3.99; OR for ≥$75,000, 2.32; 95% CI, 0.92‐5.94). AA women who reported employment discrimination were significantly less likely to report genetic testing than those who did not report job discrimination (OR, 0.39; 95% CI, 0.14‐0.95). Marital status, Medicaid versus other insurance, prayer frequency, and perceived social support were significantly associated with genetic testing uptake in bivariate analyses but were not significant contributors in multivariable analyses. Conclusions Consistent with other studies of AA women, a minority of African American Cancer Epidemiology Study participants had undergone genetic testing. Having a lower income and experiencing job discrimination decreased the likelihood of testing. These results provide foundational evidence supporting the need for interventions to improve the uptake of genetic testing among AA women by reducing cost barriers and providing credible assurances that genetic results will be kept private and not affect social factors such as employability.
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