Diabetes and hypertension quality measurement in four safety-net sites: lessons learned after implementation of the same commercial electronic health record.

BACKGROUND: In this new era after the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the literature on lessons learned with electronic health record (EHR) implementation needs to be revisited. OBJECTIVES: Our objective was to describe what implementation of a commercially available EHR with built-in quality query algorithms showed us about our care for diabetes and hypertension populations in four safety net clinics, specifically feasibility of data retrieval, measurements over time, quality of data, and how our teams used this data. METHODS: A cross-sectional study was conducted from October 2008 to October 2012 in four safety-net clinics located in the Midwest and Western United States. A data warehouse that stores data from across the U.S was utilized for data extraction from patients with diabetes or hypertension diagnoses and at least two office visits per year. Standard quality measures were collected over a period of two to four years. All sites were engaged in a partnership model with the IT staff and a shared learning process to enhance the use of the quality metrics. RESULTS: While use of the algorithms was feasible across sites, challenges occurred when attempting to use the query results for research purposes. There was wide variation of both process and outcome results by individual centers. Composite calculations balanced out the differences seen in the individual measures. Despite using consistent quality definitions, the differences across centers had an impact on numerators and denominators. All sites agreed to a partnership model of EHR implementation, and each center utilized the available resources of the partnership for Center-specific quality initiatives. CONCLUSIONS: Utilizing a shared EHR, a Regional Extension Center-like partnership model, and similar quality query algorithms allowed safety-net clinics to benchmark and improve the quality of care across differing patient populations and health care delivery models.

Hypertension outcomes in an urban nurse-managed center.

PURPOSE: To assess the quality of hypertension (HTN) care in an urban nurse-managed center (NMC) by chart audits of insured and uninsured (N = 52) African Americans who were managed by nurse practitioners. DATA SOURCES: A chart audit form was developed by the authors that merged Health Plan Employer Data and Information Set (HEDIS) criteria with the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria. CONCLUSIONS: There was near comparable hypertension control among the two groups. No difference was found in systolic blood pressure (BP) control; however, the uninsured group had a slightly greater average diastolic BP compared with the insured group. There was no significant difference in the number of HTN medications or the number of risk factors. A significant difference was found in the number of NP visits per year between the two groups; the uninsured group averaged 3.2 more visits per year. IMPLICATIONS FOR PRACTICE: Nurse practitioners in this NMC were able to manage HTN in a high-risk population despite a lack of insurance coverage for anti-hypertensive prescriptions. The finding that the uninsured group had more clinic visits per year than the insured group is significant in that it increases the cost of providing care for these patients and the health care system. The patient cost in time, transportation and burden needs further assessment.

Electrorotation of isolated generative and vegetative cells, and of intact pollen grains of Lilium longiflorum.

The dielectric structure of mature pollen of the angiosperm Lilium longiflorum was studied by means of single-cell electrorotation. The use of a microstructured four-electrode chamber allowed the measurements to be performed over a wide range of medium conductivity from 3 to 500 mS m-1. The rotation spectra of hydrated pollen grains exhibited at least three well-resolved peaks in the kHz-MHz frequency range, which obviously arise due to the multilayered structure of pollen grains. The three-shell model can explain the complex rotational behavior of pollen grains in terms of conductivities, permittivities and thicknesses of the following compartments: the exine and intine of the pollen grain wall as well as the membrane and cytoplasm of the vegetative cell. However, the number of unknown parameters (more than 8) was too large to allow unambiguous values to be assigned to any of them. Therefore, to facilitate the evaluation of the pollen grain parameters, additional rotational measurements were made on isolated vegetative and generative cells. The rotation spectra of these cells could be fitted very accurately on the basis of the single-shell model by assuming a dispersion of the cytoplasm. The data on the membrane and cytoplasmic properties of isolated vegetative cells were then used for modeling the rotation spectra of pollen grains. This greatly facilitated the fitting of the theoretical model to the experimental data and allowed the dielectric properties of the major structural units to be determined. The dielectric characterization of pollen is of enormous interest for plant biotechnology, where pollen and isolated germ cells are successfully used for production of transgenic crop and drug plants of economic importance by means of electromanipulation techniques.

Treatment of complicated pleural fluid collections with image-guided drainage and intracavitary urokinase.

STUDY OBJECTIVE: We report the results of image-guided catheter drainage with adjunctive enzymatic pleural debridement in the treatment of empyemas and other complicated pleural fluid collections. DESIGN: Retrospective review. PATIENTS: One hundred eighteen patients with complicated pleural fluid collections were treated with image-guided drainage. There were 79 empyemas, 27 sterile loculated parapneumonic effusions, 10 sterile hemothoraces, and 2 sterile postoperative exudative effusions. Forty-one patients had failed prior large-bore thoracostomy drainage. The estimated age of the effusions at the time of image-guided drainage ranged from 1 to 175 days with a mean estimated age of 13 days. INTERVENTIONS: Patients were treated with image-guided placement of one or more 12F to 16F chest drains. Adjunctive urokinase instillation was used in 98 cases. Urokinase (100,000 to 250,000 U/mL) was instilled in 20 to 240-mL aliquots and reaspirated in 1 to 4 h. One to four instillations were performed per day until drainage was complete. MEASUREMENTS AND RESULTS: Drainage was successful in 111 cases (94%). Two patients died of sepsis with incomplete drainage. Five patients underwent decortication (three recovered and two died postoperatively). Fifty-three patients (45%) required placement of more than one drain. The mean duration of drainage was 6.3 days. Patients treated with pleurolysis required a mean of five instillations of urokinase. The mean total dose of urokinase used per case was 466,000 U. There were no complications. CONCLUSION: Image-guided drainage with adjunctive pleural urokinase therapy is a safe and effective method of closed thoracostomy drainage of complicated pleural fluid collections and can obviate surgery in most cases.

Quantitative NMR microscopy on intact plants.

Quantitative high resolution images on intact young maize plants were acquired by using magnetization-prepared NMR microscopy. Although the spatial resolution is low compared with that of light microscopy, the calculated spin density and T1 maps exhibit contrasts that are in excellent agreement with photomicrographic images. The T2 map gives image contrasts that are not visible in a usual light microscopic image. The diffusion images show an anisotropic behavior of the water self-diffusion coefficient in the vascular bundles, which can be understood by the cell morphology in this plant section. This work demonstrates that quantitative imaging on intact plant systems is possible and that long total acquisition times are no obstacle. Furthermore, the different single parameter maps give a better insight into the morphology of plants under in vivo conditions.

Factors associated with nightly variability in sleep-disordered breathing in the elderly.

The purpose of this study was to evaluate factors associated with nightly variability in sleep-disordered breathing. In this study, variability in sleep-disordered breathing over two consecutive laboratory nights was evaluated in 71 aged volunteers with varying levels of sleep apnea. High variability (n = 13) and low variability (n = 58) groups were formed on the basis of an absolute two-night apnea/hypopnea index difference of a minimum ten events per hour. Results indicate high variability was related to longer soft palate measurements and the presence of nasal obstruction on physical examination. Within the high variability group, variation in sleep-disordered breathing occurred within identical gross body position over the two nights. The results suggest that local, anatomic factors affecting airway patency may not be constant from night to night.