Effects of Process Improvement on Guideline-Concordant Cardiac Enzyme Testing.

Easily implemented ordering practices in the electronic health record increased the rate of guideline-concordant testing, decreased cost, and furthered the goal of high-value medical care.

Lung, Breast, and Prostate Cancer Patients with Unknown Ethnicity in US Department of Defense Cancer Registry Data: Comparisons to Patients with Known Ethnicity.

INTRODUCTION: Colorectal cancer (CRC) is one of the leading causes of cancer death for both men and women in the United States. Several factors can increase one's risk of CRC, including a personal or family history of CRC, a diagnosis or family history of a hereditary colon cancer syndrome, or a diagnosis of chronic inflammatory bowel disease. The purpose of this project was to create a colorectal cancer registry (Co-Care) for individuals with a personal or family history of CRC, and those with disorders of the colon or rectum that are associated with an increased risk for developing CRC. METHODS: To be eligible for the registry, patients either had a personal or family history of CRC, a diagnosis or family history of Lynch syndrome, familial adenomatous polyposis, or a diagnosis of Crohn's colitis or ulcerative colitis with dysplasia. Participants were recruited after seeing their gastroenterologist or genetic counselor, or after undergoing a full or partial colectomy at Mount Sinai Hospital in New York City. Eligible patients who agreed to participate were interviewed by a member of the research staff and asked a wide range of questions pertaining to CRC risk. RESULTS: A total of 224 patients were enrolled in the registry. Participants are mostly white, born in the United States, and married, with a bachelor's or graduate degree, reporting an annual household income of $100,000 or more. The largest portion have a family history of CRC (27.2%), and almost half of participants are of Jewish descent (46.2%) and have undergone full or partial colectomy (48.2%). More than half of participants have neither received genetic counseling (54.5%) nor undergone genetic testing (59.7%). Only 3.6% report that they currently smoke cigarettes, and 41.1% consume alcohol at least once per week. Lastly, 18.3%, 10.3%, and 27.7% of participants report that they currently take aspirin, folic acid/folate pills or tablets, or calcium pills/tablets, respectively. CONCLUSIONS: This registry can improve our understanding of CRC and related diseases, and be used to design future interventions related to disease risk, prognosis, and prevention of CRC.

Renal Cancer Patients with Unknown Ethnicity in Cancer Registry Data: Comparisons to Patients with Known Ethnicity.

BACKGROUND: Information on ethnicity is important for health disparity research and health service planning. However, information on ethnicity is often incomplete in large routine databases such as cancer registries. This study aimed to compare survival status and other characteristics between cancer patients with and without information on Hispanic ethnicity in cancer registry data. METHODS: The study included 2,426 patients with clear cell renal cell carcinoma (RCC) diagnosed between 1988 and 2004 and identified from the US Department of Defense (DoD)'s Automated Central Tumor Registry (ACTUR) database. There were 1,353 non-Hispanic patients, 134 Hispanic patients, and 939 patients with unknown ethnicity. Patients were followed through death, date of last contact, or censored on December 31, 2007. RESULTS: Patients with unknown ethnicity exhibited significantly shorter survival than non-Hispanic or Hispanic patients (Log Rank P < .0001). Further analysis showed that compared to patients with known ethnicity, patients with unknown ethnicity were more likely to have advanced tumor stage at diagnosis and more likely to have missing information on tumor grade, size, and some demographic characteristics. After adjustment for demographic, tumor and treatment variables, patients with unknown ethnicity still exhibited significantly higher mortality than non-Hispanic patients (hazard ratio [HR], 1.69; 95% CI, 1.48-1.92), while Hispanic patients were not different from non-Hispanic patients (HR, 0.95; 95% CI, 0.71-1.28). The shorter survival in the unknown ethnicity group was consistently observed in subgroups by age, race, stage, grade, and surgical treatment, suggesting factors other than those investigated in the current study may play a role in the survival differences between patients with and without information on Hispanic ethnicity. IMPLICATIONS: The poor survival of patients with unknown ethnicity in ACTUR warrants further research to elucidate missing mechanisms. Improvement in collection of data by reaching out for more engagement of patients, clinicians and registrars and increasing patient-provider interactions is needed.

Comparison of chronic disease prevalence between U.S. Navy ships without medical doctors and a similar shore-based population.

OBJECTIVE: Most U.S. Navy ships operate without embarked physicians, employing Independent Duty Corpsmen to provide primary and emergency medical care to crewmembers. We sought to characterize the burden of chronic disease faced by Independent Duty Corpsmen aboard Navy ships and compare it to that of a similar shore-based population. METHODS: We conducted cross-sectional analyses of shipboard and shore-based samples using 1,305 records from Norfolk, Virginia-based U.S. Navy ships without doctors between March and May 2007, and records for Norfolk shore-based sailors from the same time frame matched 3:1 on age, sex, and race against the shipboard sample. RESULTS: Asthma prevalence was 2.0% and 5.9% for the shipboard and shore-based samples, respectively (p < 0.0001). Cervical dysplasia among women was 16.2% and 23.1% (p = 0.3687). Depression was 4.6% and 8.4% (p < 0.0001). Diabetes was 1.0% and 2.3% (p = 0.0096). Hyperlipidemia was 20.6% and 21.4% (p = 0.5597). Hypertension was 25.5% and 36.1% (p < 0.0001). Total prevalence for any of the above conditions was 42.5% and 50.9% (p = 0.0001). CONCLUSION: Over 42% of shipboard sailors have one or more chronic health conditions. Even though the studied conditions were significantly less prevalent aboard ship than in the comparable shore-based sample, nonphysician practitioners aboard ships must be prepared to diagnose and treat chronic diseases.

Predictors of tool usage in the military health system's electronic health record, the Armed Forces Health Longitudinal Technology Application.

OBJECTIVE: To assess the association between key predictor variables and use of advanced features for the Armed Forces Health Longitudinal Technology Application (AHLTA), the electronic health record (EHR) for the Military Health System (MHS). METHODS: Secondary analysis of a web-based volunteer survey of 520 Navy AHLTA users. chi2 and logistic regression methods were used to assess the strength of relationship between three predictor variables and the use of several advanced AHLTA features. RESULTS: Adequacy of initial training was associated with increased use of the template management module (adjusted OR = 2.34, 95% CI 1.64-3.61) and order sets (adjusted OR = 1.64, 95% CI 1.07-2.51). Duration of AHLTA usage was associated with use of all advanced features (adjusted OR = 1.69-6.12, p < or = 0.001-0.045). Physicians use most of the advanced features more than nonphysicians (adjusted OR = 1.95-7.07, p < or = 0.001-0.030). Seventy percent of users cited a slow screen refresh rate as a problem. CONCLUSIONS: Training, duration of usage, and provider role are associated with use of advanced features.

Increasing differential mortality by educational attainment in adults in the United States.

Economic inequality has increased substantially in the United States since the early 1970s. Inequality in mortality increased from 1960 to 1986. To assess the trend in inequality in mortality the authors calculate age-adjusted mortality rates by educational attainment for 2000 and compare them with rates from 1960 and 1986, using relative and absolute indexes of inequality. Rates are calculated for non-Hispanic white and black adults aged 25 to 64 years, using mortality data from U.S. Vital Statistics and population estimates from the Census Public Use Microdata Sample. The trend toward increasing inequality in mortality between 1960 and 1986 accelerated from 1986 to 2000. Improvements in mortality went disproportionately to those with the most education. Mortality rates for whites with low education, which declined from 1960 to 1986, actually rose from 1986 to 2000. The relative change was greatest for those with only a high school education. This change, however, is largely explained by shifts in the distribution of education, which left those with a high school education in a lower position. The increase in inequality was particularly strong in whites and stronger in men than in women. For black men there was a small decline in absolute inequality between 1986 and 2000.