Hypertension in older patients, a retrospective cohort study.

BACKGROUND: It is unknown to what extent General Practitioners (GPs) manage hypertension (HT) differently in older patients, as compared to younger age groups. The purpose of our study was to compare HT management in older patients to younger age groups. METHODS: We performed a retrospective cohort study of patients of 159 GP's practices in the Integrated Primary Care Information (IPCI) database. The study period lasted from September 2010 through December 2012. The study population consisted of all patients aged 60 years or older with at least one blood pressure (BP) measurement during the inclusion period, without pre-existent HT, diabetes mellitus (DM) or atherosclerotic cardiovascular disease at time of study start. Study outcomes were a diagnosis of HT within one month after cohort entry and the use of antihypertensive medication within 4 months after cohort entry in HT diagnosed patients. We compared the incidence of outcomes between the age groups, stratified by systolic blood pressure (SBP). Logistic regression analysis was used to assess the influence of age-adjusted SBP Z-scores, age and gender on the outcomes. RESULTS: We included 19,500 patients from 159 GP's practices of whom 1,181 (6.1 %) were newly diagnosed with HT. Corrected for age-adjusted SBP, older patients were less likely to be diagnosed with HT (odds ratio per year age increase 0.98, p < 0.001). Corrected for age-adjusted SBP, no significant effect of age on the probability of treatment in newly diagnosed HT patients was observed (p = 0.82). CONCLUSIONS: This study showed that GPs are less inclined to diagnose HT with increasing patient age, but do not withhold treatment when they diagnose HT in older patients.

Discussion of "Biomedical informatics: we are what we publish".

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Biomedical Informatics: We Are What We Publish", written by Peter L. Elkin, Steven H. Brown, and Graham Wright. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the Elkin et al. paper. In subsequent issues the discussion can continue through letters to the editor.

Treatment of frontal fibrosing alopecia and lichen planopilaris: a systematic review.

Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia with characteristic clinical pattern of progressive frontotemporal hairline recession, perifollicular erythema and hyperkeratosis and symptoms of itch and burning, occurring mainly in post-menopausal women. FFA is considered a subtype of lichen planopilaris (LPP), based on their identical histopathology. Currently, no evidence-based treatment is available for FFA. Our aim was to determine the effectiveness of available treatment options for FFA, and to identify promising treatment options for future studies. For this, literature search was conducted to find all primary studies on the treatment of FFA and LPP. From the primary studies, data were subtracted and analysed. No randomized controlled trials were found, and one controlled trial. Treatment of 114 patients is described in the literature. They received 10 different regimes, of which oral 5-alpha-reductase inhibitors were provided most often, resulting in good clinical response in 45% of them. Hydroxychloroquine resulted in good clinical response in 30% of the 29 treated patients. Topical corticosteroid preparations are ineffective in FFA. The remaining treatments were all reported in less than 10 patients. For the treatment of LPP, topical corticosteroid preparations are the first line of treatment, followed by oral cyclosporine and systemic corticosteroids, although they are characterized by a high relapse rate. Summarizing, there is currently no effective treatment of FFA, the most effective being oral 5-alpha-reductase inhibitors that possibly affect the accompanying androgenetic alopecia. We argue that oral cyclosporine A might be a good candidate for future studies on the treatment of FFA.

An inventory of publications on electronic medical records revisited.

OBJECTIVES: In this short review we provide an update of our earlier inventories of publications indexed in MedLine with the MeSH term 'Medical Records Systems, Computerized'. METHODS: We retrieved and analyzed all references to English articles published before January 1, 2008, and indexed in PubMed with the MeSH term 'Medical Records Systems, Computerized'. RESULTS: We retrieved a total of 11,924 publications, of which 3937 (33%) appeared in a journal with an impact factor. Since 2002 the number of yearly publications, and the number of journals in which those publications appeared, increased. A cluster analysis revealed three clusters: an organizational issues cluster, a technically oriented cluster and a cluster about order-entry and research. CONCLUSIONS: Although our previous inventory in 2003 suggested a constant yearly production of publications on electronic medical records since 1998, the current inventory shows another rise in production since 2002. In addition, many new journals and countries have shown interest during the last five years. In the last 15 years, interest in organizational issues remained fairly constant, order entry and research with systems gained attention, while interest in technical issues relatively decreased.

Mapping the domain of medical informatics.

OBJECTIVES: The domain of medical informatics (MI) is not well defined. It covers a wide range of research topics. Our objective is to characterize the field of MI by means of the scientific literature in this domain. METHODS: We used titles and abstracts from MEDLINE records of papers published between July 1993 and July 2008, and extracted uni-, bi- and trigrams as features. Starting with the ISI category of medical informatics, we applied a semi-automated procedure to identify the set of journals and proceedings pertaining to MI. A clustering algorithm was subsequently applied to the articles from this set of publications. RESULTS: MI literature can be divided into three subdomains: 1) the organization, application, and evaluation of health information systems, 2) medical knowledge representation, and 3) signal and data analysis. Over the last fifteen years, the field has remained relatively stable, although most journals have shifted their focus somewhat. CONCLUSIONS: We identified the scientific literature pertaining to the field of MI, and the main areas of research. We were able to show trends in the field, and the positioning of different journals within this field.

An inventory of publications on computer-based medical records: an update.

OBJECTIVES: In 1998, we reported a steady increase in the number of publications indexed in MedLine with the MeSH term 'Medical Records Systems, Computerized'. No signs indicating an increasing interest of high-impact medical journals to publish on the computer-based patient record could be determined. In this review we provide an update. METHODS: We retrieved and analyzed all English publications indexed before Feb 22, 2002 in PubMed with the MeSH term 'Medical Records Systems, Computerized'. RESULTS: We retrieved a total of 5856 publications, of which 1824 (31%) appeared in a journal with an impact factor in the year of publication. The total impact-score shows an upward trend. CONCLUSIONS: The results show that the earlier observed increase in number of publications did not persist in the second half of the nineteen-nineties. Since the mid-nineties, there has been a steady yearly production of publications indexed with the MeSH term, reflecting a sustained interest in the domain. However, the volume of publications appearing in journals with higher impact factors is increasing. Furthermore, high-impact journals, such as the "British Medical Journal", the "Lancet" and "Annals of Internal Medicine" regularly publish on the subject, reflecting an interest well beyond the medical informatics community.

The methodical collection of ear surgery data as a basis for quality control.

Data relating to daily clinical practice were collected in an otologic database. Over a period of 3 years, information was gathered about 1,000 ear operations. This led to the following conclusions: the collection of data is difficult; the selection of data and the moment it should be fed into the systems are very important; there is a risk of using too many items and therefore reducing surgeon compliance. On the other hand, too few items result in irrelevant overviews. The collection of ear surgery data makes it easier to understand positive and negative outcomes.

Effects of electronic communication between the GP and the pharmacist. The quality of medication data on admission and after discharge.

BACKGROUND: When a patient is admitted to a hospital, the need for information about the medications prescribed is an important issue. OBJECTIVES: Our aim was to assess whether electronic communication between the GP and the pharmacist provides better information regarding current medication when a patient is admitted to the hospital than paper-based communication. METHODS: A prospective study was carried out whereby on the day of admission and 10 days after discharge, three different data collectors independently asked the patient, the GP and the pharmacist details of the patient's current medication. Five GPs and a local pharmacy relying on electronic communication, and five GPs and a local pharmacy relying on paper-based communication were studied. RESULTS: A total of 139 patients were included on the first day of their admission, and 116 on the tenth day after discharge. Of the 275 drugs that the patient, the GP and/or the pharmacist reported on admission in the electronic group, 134 (49%) were reported by the patient, the GP and the pharmacist, and 79 (29%) were not reported by the patient. For the paper group, these figures were 340 drugs on admission, of which 107 (31%) were reported by the patient, the GP and the pharmacist, while 130 (38%) were not reported by the patient. CONCLUSIONS: We conclude that electronic communication between the GP and the community pharmacist results in a better agreement between them with respect to the current medication of the patient than paper-based communication. However, electronic communication does not suffice as a solution to obtain reliable information.

Electronic messaging between primary and secondary care: a four-year case report.

OBJECTIVE: To observe how electronic messaging between a hospital consultant and general practitioners (GPs) in 15 practices about patients suffering from diabetes evolved over a 3-year period after an initial 1-year study. DESIGN: Case report. Electronic messages between a hospital consultant and GPs were counted. The authors determined whether a message sent by the consultant was integrated into the receiving GP's electronic medical record system. After the observation period, the GPs answered a questionnaire. MEASUREMENTS: The number of electronic messages and the percentage of messages integrated into the electronic medical record. RESULTS: The volume of messages was maintained during the 3 years after the original study. In the original study, the percentage of the messages integrated by the GPs increased during the year. After that study, however, seven GPs stopped integrating data from messages. The extent to which received messages were integrated varied widely among practices. CONCLUSION: The authors conclude that extrapolation of the results of the original study would have led to incorrect conclusions. Although the volume of messages remained stable after the original study, GPs changed their method of handling messages. Initially, all GPs used the opportunity to copy data from the messages into their own records. At the end of the observation period (that is, the 3 years after completion of the original study), more than 50 percent of GPs had ceased copying data from the messages into their own records. The majority of GPs, however, wanted to expand the use of electronic messaging.

Effects of electronic communication in general practice.

OBJECTIVE: To obtain insight into the effects of electronic communication on GPs by studying those publications in literature describing the effects of structured electronic clinical communication in general practice. METHODS: We retrieved all publications in the English language indexed in MEDLINE under the MESH term 'Computer Communication Networks' AND having either 'family practice' or 'primary health care' as MESH term OR 'GP', or 'GPs' as text word. RESULTS: A total of 176 publications were retrieved of which 30 publications met the criteria. In 28 of these 30 publications potential effects were described; one described claimed effects, three described demonstrated effects with subjective data and five described demonstrated effects with objective data. The studies documented, furthermore, effects on the speed of communication, the content of information and records, a change of processes involved in the communication, quality of care, costs, workload of physicians, appreciation of physicians, confidentiality, and adherence. CONCLUSIONS: We conclude that only a few studies evaluated electronic communication versus paper communication. Of these studies, only a few report improvement. Our final conclusion is that, so far, literature has not shown that the positive effects can be explained by electronic communication as such.

Shared care for diabetes: supporting communication between primary and secondary care.

OBJECTIVE: To assess the effects on information exchange of electronic communication between physicians co-treating diabetic patients. DESIGN: Comparison of traditional paper-based communication for reporting and electronic communication. SETTING: General practitioners and an internal medicine outpatient clinic of an urban public hospital. SUBJECTS: A total of 275 diabetic patients, and the 32 general practitioners and one internal medicine consultant who cared for them. INTERVENTION: An electronic communication network, linking up the computer-based patient records of the physicians, thus enabling electronic data interchange. MAIN OUTCOME MEASURES: Number of letters sent and received per year by the general practitioners, the number of diabetes-related parameters (e.g. results of laboratory tests) in the patient records, and HBA1C levels. RESULTS: INTERVENTION GPs received more messages per year (1.6 per patient) than control GPs (0.5 per patient, P<0.05). Significant higher availability (P<0.05) was achieved for data on HBA1C levels, fructosamine levels, blood pressure measurements, cholesterol levels, triglyceride levels and weight measurements. INTERVENTION patients showed a slight but significant decrease of HBA1C levels in the second semester of 1994 (from 7.0 to 6.8, P = 0.03), control patients also showed a slightly decreased group mean, but this change was not significant (from 6.6 to 6.5, P = 0.52). The magnitudes of these mean differences, however, were not significantly different (intervention group: 0.21; control group: 0.12, P = 0.68). CONCLUSIONS: The electronic communication network for exchanging consultation outcomes significantly increased frequency of communication and the availability of data to the general practitioner on diagnostic procedures performed in the hospital, thus providing more complete information about the care that patients are receiving. A large-scale experiment over a longer period of time is needed to assess the effects of improved communication on quality of care.

An inventory of publications on electronic patient records.

This study describes an analysis of 1832 papers dealing with electronic patient records, and indexed in NLM's MEDLINE. Of each retrieved publication the country of origin and the journal in which it was published was determined. Furthermore, insight into the subjects of the publication was obtained by analysing the MeSH terms by which it was indexed. Since 1990 the number of publications on electronic patient records has increased. Publications originated from 43 different countries representing all continents. However, 75% stemmed from only 4 countries. The publications appeared in 379 different journals, of which 26 journals had 10 or more publications. Of all publications, 5.3% had appeared in journals with an impact factor of at least 4.5. The topics most often dealt with were: Hospital Information Systems, Computer Communication Networks, User-Computer Interface, Confidentiality and Computer Security. No obvious trends, other than an increased interest in confidentiality and computer security, were observed.

An analysis of 5 years of medical informatics publications.

This study describes an analysis of 1520 papers that were published in six medical informatics journals from 1992 through 1996, and indexed in NLM's MEDLINE. Of retrieved publications the countries of origin were determined, and insight in the subject of the publication was obtained by analysing the used MeSH terms. The main conclusion is that despite the fact that publications in medical informatics stem from a wide international community, scientific recognition can still not be demonstrated by high impact factors of journals.

Self-contained patient data in ORCA to cope with an evolving vocabulary.

Because of the benefits of standardization in healthcare data for research, decision support, and quality assessment, much research effort focuses on collection of structured patient data. Many strategies to obtain such data are based on controlled vocabularies to guide data entry in a far more flexible way than a fixed-form approach. Medical controlled vocabularies evolve, but change is difficult to reconcile with standardization. Retrieval of data, collected with different versions of vocabularies, is not straightforward and has consequences for patient care and research. There are several strategies to cope with these problems: keep each version, keep a record of changes, or conversion of previously collected data. Each of these strategies has pros and cons regarding storage consumption, performance during patient care, and research. The approach in ORCA (Open Record for Care) is based on self-contained patient data and combines the strengths of these strategies.

A multi-strategy approach for medical records of specialists.

Despite a number of well recognized shortcomings of paper medical records, the use of a Computer Patient Record (CPR) is not widespread among specialists. The complexity of specialized care combined with the diversity of their domains of expertise, make it a challenge to design a CPR that satisfies the needs of a specialist. Ideally, CPRs are tailored to the specific tasks of each user, and yet general enough to permit exchange and sharing of information. The basic philosophy behind our CPR is a 'mother' record, which is extended with specialized sub-records. Two different types of subrecords are discussed: one to accommodate standardized data entry in the context of a specialty or research protocol, and another for structured recording of accidental findings outside one's own domain of expertise. The CPR supports the entry of free text and does not impose structured data entry on the physician, but stimulates him to do so by confronting him with the benefits of a structured CPR.

Descriptive features of gastric ulcers: do endoscopists agree on what they see?

BACKGROUND: Little is known about the interobserver variation between endoscopists on descriptive morphologic features. METHODS: This study describes the agreement among 10 endoscopists on their description of 12 morphologic features, using 10 photographs of gastric ulcers, and on their eventual interpretation. The endoscopists used a form with predefined options for description. RESULTS: Kappa value was on average 0.36 for descriptive features and 0.31 for interpretation. The proportion of endoscopists agreeing on descriptive features was on average 84%, and 81% on interpretations. The chance of an endoscopist describing all 12 morphologic features of an ulcer on a photograph exactly the same as a colleague ranged from 4% to 46% (average 15%). A positive correlation between agreement in description and interpretation (0.75, p < 0.05) was found. CONCLUSIONS: These results indicate a poor agreement between endoscopists in their translation of visual observations into descriptive terms. The positive correlation between agreement in description and interpretation suggests disagreement in description as an important cause for disagreement in interpretation. We believe that the use of more explicit descriptive terms will improve agreement in description and in subsequent interpretation.

Evaluation of reporting based on descriptional knowledge.

OBJECTIVE: In an attempt to enhance the completeness and clarity of clinical narratives, the authors developed a general formalism for the entry of structured data. The objective of this study was to gain insight into the expressive power of the formalism through its use for reporting in endoscopy. DESIGN: Each of ten endoscopists reported twice about eight endoscopy videotapes. They produced free-text reports first, and then structured reports using this formalism. Statements in the resulting reports were compared. RESULTS: In total, 6.8% of the endoscopists' statements could not be expressed in structured options. Most of these statements were not due to limitations of the formalism itself. Topics mentioned in the free-text reports were described more frequently in the structured reports and, in addition, the structured reports included a greater variety of topics. Overall, increases of 83% for topics not related to abnormal findings (366 in free-text reports and 671 in structured reports) and 45% for features of abnormal findings (406 in free-text reports and 586 in structured reports) were observed. Although there was an overall information gain, features of abnormal findings were, on average, described by only half of the endoscopists. CONCLUSION: The expressive power of this formalism is promising, but general, multipurpose usage of the acquired data requires that topics be described by a larger percentage of physicians. Since this formalism led to more complete and more uniform data, additional research is justified to study how spontaneous reporting can be augmented further. The few subjects that occurred less often in structured reports suggest a possible negligence effect of structured reporting.