Opioid Use is Associated with Higher Severity-Adjusted Episode Costs in Patients with Conservatively Managed Degenerative Joint Disease of the Back and Neck.

BACKGROUND: Opioid use and misuse are urgent health issues. Previous studies suggest that opioid use increases healthcare resource use but severity adjustment is lacking. OBJECTIVE: The objective of this study was to evaluate the severity-adjusted cost difference between opioid users and non-users among patients with conservatively managed degenerative joint disease of the spine within a large commercial health plan population in the United States. METHODS: A retrospective observational study was performed using a national commercial database covering 531,819 patients aged 18-64 years with non-surgically managed cervical or lumbar degenerative spine disease during 2015-6. Patients were grouped based on whether there was evidence for an opioid prescription. Costs for the opioids themselves were excluded. Severity adjustment, on an ascending integer scale from 1 to 4, was performed based on member demographics, clinical comorbidities, disease progression indicators, and complications. RESULTS: Median episode costs for patients given opioids were approximately twice that for patients not given opioids after severity adjustment. For patients with episodes in both years and stable severity, patients with new prescriptions for opioids in 2016 doubled their median 2015 costs, and patients who had opioids discontinued in 2016 had a 60% cost reduction. Episode costs showed a nearly linear increase based on the length of time taking opioids, as well as with a higher average daily dose. Cost increases with opioids were broad across service categories even when comparing within the same severity-adjusted episodes of care. CONCLUSIONS: The data suggest a clinically and statistically significant increase in episode costs associated with opioid use for degenerative joint disease of the spine, both within and between patients, and higher costs with a longer duration of opioid use as well as with higher daily dosages. Given the health consequences surrounding the overuse of opioids, concerted efforts to move towards a non-opioid pain control strategy are needed.

Towards a reference model for representing nursing information needs.

Information needs studies in clinical settings often face the problem of integrating and analyzing data collected using different study tools. Generally, a coding taxonomy or a model is developed to capture and code the study data. Significant efforts are required to develop a model that not only captures the study data but is also closer to the clinical domain to draw meaningful real world inferences. Further, a study-specific model limits comparative evaluation of studies across different institutions. In this paper, we propose a reference model for representing nursing information needs. We use an iterative and collaborative approach in representing the concepts in the model. The model consists of 33 information (need) concepts, 29 information sources and 7 categories of nursing tasks which were used to code 228 identified information need instances.

Heuristic evaluation of paper-based Web pages: a simplified inspection usability methodology.

Online medical information, when presented to clinicians, must be well-organized and intuitive to use, so that the clinicians can conduct their daily work efficiently and without error. It is essential to actively seek to produce good user interfaces that are acceptable to the user. This paper describes the methodology used to develop a simplified heuristic evaluation (HE) suitable for the evaluation of screen shots of Web pages, the development of an HE instrument used to conduct the evaluation, and the results of the evaluation of the aforementioned screen shots. In addition, this paper presents examples of the process of categorizing problems identified by the HE and the technological solutions identified to resolve these problems. Four usability experts reviewed 18 paper-based screen shots and made a total of 108 comments. Each expert completed the task in about an hour. We were able to implement solutions to approximately 70% of the violations. Our study found that a heuristic evaluation using paper-based screen shots of a user interface was expeditious, inexpensive, and straightforward to implement.

Practical considerations for exploiting the World Wide Web to create infobuttons.

BACKGROUND: We are studying ways to provide automated, context-specific links (called "infobuttons") between clinical information systems (CIS) and other information resources available on the World Wide Web. As part of this work, we observed the information needs that arose when clinicians used a CIS and we classified those needs into generic questions. We then sought general methods for accessing information resources to answer the questions. METHODS: For each generic question, we identified a satisfactory resource and then developed a method for retrieving from it the information relevant to the question. We then studied these methods to characterize them into general approaches. RESULTS: We identified six general approaches and describe them in detail. These approaches range in complexity from simple, hard-coded links to intelligent agents and calculators. CONCLUSION: Web-based information resources can be exploited using a relatively small number of methods, although the specific methods require custom solutions. Standard methods for accessing Web-based resources would simplify the task of linking to CISs.

The classification of clinicians' information needs while using a clinical information system.

INTRODUCTION: Information needs are prevalent in clinical practice. They represent a potential source of medical errors. This study seeks to empirically determine the information needs of clinicians while using a clinical information system (CIS), and characterize those needs. In addition this paper will provide the framework necessary for the development of the solutions to these information needs. METHODS: Clinicians were observed while using a CIS. They were recorded on audiotape and the computer screen recorded on videotape. The types of question during these interactions were recorded. A classification of the questions provided the conceptual and architectural basis for the development of context-sensitive links to information resources, called infobuttons. RESULTS: There were 154 information needs. The questions were grouped into seven categories. Within these categories we were able to identify eleven specific repeated question patterns, accounting for 72 or 47% of users' questions. DISCUSSION: These findings are applicable to a number of settings and can be generalized to other institutions. The proposed infobuttons based on six categories, will be navigational ('how-to.' links), cross-reference ('what is the em leader ' links), domain knowledge buttons in the areas of laboratory, pharmacy, diagnosis, and definitions/general information. Using these groups we were able to identity eleven patterns of questions.

Use of online resources while using a clinical information system.

BACKGROUND: Clinical information system (CIS) use is likely to evoke information needs, yet information resources use during CIS use has not been studied. METHODS: We used CIS log files and a survey to characterize clinicians' use of resources and infobuttons (context-sensitive links from a CIS to specific resources) while using a CIS. RESULTS: We examined 38,763 uses of resources and infobuttons by 2,607 users to identify specific sources and contexts (CIS functions) in which they used them. Laboratory results review was the most frequent context and Micromedex was the most popular resource. Differences in resource use were related to context and user type. The survey confirmed that resources and infobuttons were perceived as useful for patient-specific questions while using a CIS. CONCLUSIONS: Understanding context- and user-type-specific information needs can guide the development of infobuttons for use in a CIS.

Clinical information needs in context: an observational study of clinicians while using a clinical information system.

INTRODUCTION: The development of tools to meet the information needs of clinicians requires an understanding of the clinician and the context in which clinical decisions are being made. METHODS: We conducted an observational study of clinicians' information needs via think-aloud protocols during which we observed physicians and nurses as they used the clinical information system. Protocol analysis was then used to identify the information needs events, the types of questions that were asked, the method of meeting that need, the success or failure of meeting the specific information need, and the context in which it arose. RESULTS: Results indicated that a) unmet information needs occur frequently and that b) the predominant feature of these unmet needs is that they are patient-related or domain-specific. Two categories of context: laboratory and medical communication accounted for more than half of the events.

Characterizing information needs and cognitive processes during CIS use.

Medical errors are often associated with inadequate cognitive processing that is based upon impaired access to information.1 Understanding the information needs of nurses and physicians' when using a clinical information system (CIS) is difficult largely because there are few systematic attempts made to do so. We collected 15.5 hours of data of nurses and physicians' CIS interactions in three clinical environments (cardiac ICU, a general medical/surgical nursing, and an ambulatory clinic). We accomplished this through observational, cognitive-based methods (e.g., thinking aloud during interaction) and the video capturing of events with a portable usability laboratory.2 We developed a systematic approach to identify and define in-context clinical information needs while using a CIS, and determine how to categorize and code such events. 3

Fetal growth and cardiovascular risk factors in Jamaican school children

OBJECTIVE-- To determine relationship between school children's blood pressure, glycated haemoglobin level and cholesterol concentration and their anthropometry, socioeconomic status, and birth measurements. DESIGN--Retrospective cohort study. SETTING--27 schools closest to University Hospital of the West Indies, Kingston, Jamaica. SUBJECTS--2337 children aged 6-16 years who were born at University Hospital were recruited, and their birth records were recovered: 1610 had suitable records, 659 had records including birth length, and 610 of these were prepubertal. MAIN OUTCOME MEASURES--Blood pressure, glycated haemoglobin level, serum cholesterol concentration, anthropometry at birth, current anthropometry, and socioeconomic status. RESULTS--Multiple regression analysis showed that children's systolic blood pressure was inversely related to their birth weight (P < 0.0001) and directly related to their currrent weight. Glycated haemoglobin level was higher in children with thicker triceps skinfolds (P < 0.001) and who had been shorter at birth (P = 0.003). Serum cholesterol concentration was inversely related to current height (P = 0.001) and to length at birth (P = 0.09) and was directly related to triceps skinfold thickness and higher socio-economic status (P = 0.001). CONCLUSIONS--Blood pressure in children was inversely related to birth weight and directly to current weight. Glycaemic control and serum cholesterol were related to short length at birth, height deficit in childhood, and childhood obesity (Au).

The Jamaican childhood cardiovascular risk status study; blood pressure in Jamaican school children, relationship to body size and composition - abstract

Hypertension is one of the most prevalent chronic cardiovascular diseases and is the leading cause of death in the Caribbean as well as in the developed countries. Childhood blood pressure is predictive of hypertension in adulthood. Risk factors for hypertension, including body composition, are often present in childhood when they may be modified in order to contribute to primary prevention of hypertension. As part of a study of risk factors for cardiovascular disease, we measured blood pressure (BP) and anthropometry in Jamaican schoolchildren. Anthropometric and demographic variables were analysed to explain the variance of blood pressure in the children. A total of 2332 children (1046 males; 1286 females) were studied. Their ages ranged from 6 to 16 years. Boys and girls were similar in age. Mean diastolic and systolic blood pressures were similar in boys and girls' pulse rate was significantly higher than in boys. Boys had significantly greater Waist-Hip Ratio (0.82 vs 0.76; p<0.0001) and Lean Body Mass (34.2 vs 33.20 kg; p=0.006). Girls had significantly greater weight (42.3 vs 39.5; p<0.0001); Height (150.6 vs 148.9; p=0.005); BMI (18.2 vs 17.3; p<0.0001); MUAC (21.5 vs 20.8; p<0.0001); Hip Circumference (79.5 vs 73.9; p<0.0001); Triceps Skinfold (11.6 vs 8.3; p<0.0001); Per cent Body Fat (19.5 vs 11.6; p<0.0001); Fat Weight (9.1 vs 5.2; p<0.0001). Systolic BP increased steadily with age from 101 ñ 9.9 mm Hg at 6 years to 112 ñ 8.5 mm Hg at 16 years. Systolic BP was significantly correlated with weight, height, BMI, MUAC, WH Ratio, fat mass and lean body mass on univariate analysis but only weight and lean body mass were independently correlated (p<0.0001 for both variables). There was a significant age-sex interaction on Systolic BP (p<0.0001) but only at age 15 years were the mean BPs significantly different (boys vs girls = 119 ñ 15.2 vs 107.8 ñ 10.8; p<0.001). Diastolic BP increased less steeply with age. Significant predictors were MUAC and hip circumference (p<0.0001 and p<0.002, respectively). The data reveal significant correlation between anthropometric variables and blood pressure. This could provide an opportunity for intervention and primary prevention of hypertension (AU)

The Jamaican childhood cardiovascular risk status study: serum total cholesterol concentration in Jamaican schoolchildren - abstract

The pathogenesis of atherosclerosis occurs over decades and begins in childhood. Hypertension, elevated serum cholesterol levels and obesity are major risk factors for the development of cardiovascular disease. In population-based studies, the presence of these two risk factors in childhood has been shown to be predictive of hypertension and hypercholesterolaemia in adulthood and ultimately of coronary heart disease mortality rates. There is evidence that much of the risk of developing hypercholesterolaemia is due to exposure to an unfavourable environment. Therefore it should be possible to reduce or eliminate this risk. In this study of 2337 Jamaican school children aged 6 to 16 years, girls were found to have higher cholesterol levels than boys (4.2ñ0.82vs4.1ñ0.83mM;p<0.003). At all ages (except 11), the cholesterol concentration in girls was higher than in boys, and girls had significantly more body fat. Cholesterol levels were found to be associated with socio-economic status (SES), 4.0mM in children from the lowest SES and 4.4mM in those from the highest (p<0.0000). Multiple regression analysis revealed signigicant correlation between cholesterol, weight, body fat and SES. This result for SES is different from studies in the developed world which report an inverse relationship between cholesterol and SES. In our population there was also correlation between SES and height and weight. Obesity and weight are important contributors to the risk of developing hypercholesterolaemia. Differences in dietary intake and levels of activity between the SES groups may contribute to this difference. The greater adiposity evident from the first decade of life is also worthy of note. Combined with the higher serum total of cholesterol levels, this may be an important indicator of the likelihood of future cardiovascular disease in this group (AU)