Sustainability of an Opt-Out Electronic-Health Record-based Tobacco Treatment Consult Service at a large safety-net hospital: A 6-year Analysis.

INTRODUCTION: Our safety-net hospital implemented a hospital-based tobacco treatment intervention in 2016. We previously showed the intervention, an "opt-out" Electronic Health Record (EHR)-based Best Practice Alert (BPA)+order-set that triggers consultation to an inpatient Tobacco Treatment Consult (TTC) service for all patients who smoke, improves smoking abstinence. We now report on sustainability, 6 years after inception. METHODS: We analyzed data collected between July 2016-June 2022 of patients documented as 'currently smoking' in the EHR. Across the 6 years, we used Pearson's correlation analysis to compare Adoption (clinician acceptance of the BPA+order-set, thus generating consultation to the TTC service); Reach (number of consultations completed by the TTC service); and Effectiveness (receipt of pharmacotherapy orders between patients receiving and not receiving consultations). RESULTS: Among 39,558 adult admissions (July 2016-June 2022) with "currently smoking" status in the EHR for whom the BPA triggered, clinicians accepted the TTC order-set on 50.4% (19,932/39,558), though acceptance varied across services [e.g., Cardiology (71%) and Obstetrics-Gynecology (12%)]. The TTC service consulted on 17% (6779/39,558) of patients due to staffing constraints. Consultations ordered (r=-0.28, p=0.59) and completed (r= 0.45, p=0.37) remained stable over six-years. Compared to patients not receiving consultations, patients receiving consultations were more likely to receive pharmacotherapy orders overall (inpatient: 50.8% vs 35.1%, p<.0001; at discharge: 27.1% vs 10%, p<.0001) and in each year. CONCLUSIONS: The "opt-out" EHR-based TTC service is sustainable, though many did not receive consultations due to resource constraints. Healthcare systems should elevate priority of hospital-based tobacco treatment programs to increase reach to underserved populations. IMPLICATIONS: Our study shows that opt-out approaches that utilize the EHR are a sustainable approach to provide evidence-based tobacco treatment to all hospitalized individuals who smoke, regardless of readiness to stop smoking and clinical condition.

Black Patients Experience Highest Rates of Cancer-associated Venous Thromboembolism.

PURPOSE: Cancer patients are at a higher risk of venous thromboembolism (VTE) than the general population. In the general population, blacks are at a higher risk of VTE compared with whites. The influence of race on cancer-associated VTE remains unexplored. We examined whether black cancer patients are at a higher risk of VTE and whether these differences are present in specific cancer types. DESIGN: A retrospective study was performed in the largest safety net hospital of New England using a cohort of cancer patients characterized by a substantial number of nonwhites. RESULTS: We identified 16,498 subjects with solid organ and hematologic malignancies from 2004 to 2018. Among them, we found 186 unique incident VTE events, of which the majority of the events accrued within the first 2 years of cancer diagnosis. Overall, blacks showed a 3-fold higher incidence of VTE (1.8%) compared with whites (0.6%; P<0.001). This difference was observed in certain cancer types such as lung, gastric and colorectal. In lung cancer, the odds of developing VTE in blacks was 2.77-times greater than those in white patients (confidence interval, 1.33-5.91; P=0.007). Despite the greater incidence of cancer-associated VTE in blacks, their Khorana risk score of VTE was not higher. CONCLUSIONS: In a diverse cancer cohort, we observed a higher incidence of cancer-associated VTE in blacks compared with patients from other races. This study indicates the consideration of race in the risk assessment of cancer-associated VTE. It could also lead to future mechanistic studies aiming at identifying reasons for differential VTE risk depending on cancer type.

Rural Level III centers in an inclusive trauma system reduce the need for interfacility transfer.

BACKGROUND: Development of Level III trauma centers in a regionalized system facilitates early stabilization and prompt transfer to a higher level center. The resources to care for patients at Level III centers could also reduce the burden of interfacility transfers. We hypothesized that the development and designation of Level III centers in an inclusive trauma system resulted in lower rates of transfer, with no increase in morbidity or mortality among the non-transferred patients. METHODS: State trauma registry data from January 2009 through September 2015 were examined from five rural hospitals that transfer patients to our highest (Level II) trauma center and resource hospital. These five rural hospitals began receiving state support in 2010 to develop their trauma programs and were subsequently verified and designated Level III centers (three in 2011, two in 2013). Multivariate logistic regression was used to examine the adjusted odds of patient transfers and adverse outcomes, while controlling for age, gender, penetrating mechanism, presence of a traumatic brain injury, arrival by ambulance, and category of Injury Severity Score. The study period was divided into "Before" Level III center designation (2009-2010) and "After" (2011-2015). RESULTS: 7,481 patient records were reviewed. There was a decrease in the proportion of patients who were transferred After (1,281/5,737) compared to Before (516/1,744) periods (22% vs. 30%, respectively). After controlling for the various covariates, the odds of patient transfer were reduced by 32% (p < 0.0001) during the After period. Among non-transferred patients, there were no significant increases in adjusted odds of mortality, or hospitalizations of seven days or more, Before versus After. CONCLUSIONS: Development of rural Level III trauma centers in a regionalized system can significantly reduce the need for transfer to a remote, higher level trauma center. This may benefit the patient, family, and trauma system, with no adverse effect upon patient outcome. LEVEL OF EVIDENCE: Epidemiological, level III.

Helmet use among motorcycle and moped riders injured in Hawaii: Final medical dispositions from a linked database.

BACKGROUND: Reports regarding helmets in motorcycle crashes have been limited by the lack of data across the spectrum of injury outcomes, generally excluding low-severity injuries that do not require further medical treatment. We hypothesized that the protective effect of helmets may be underestimated in studies that focused only on patients who arrive at a trauma center and that it may differ depending on whether the crash involved a motorcycle or moped. METHODS: The emergency medical service reports of 2,553 crash patients treated from 2007 to 2009 were linked to police crash reports, hospital billing data, death certificates, and the Fatal Analysis Reporting System for a more complete description of the crashes throughout the state. RESULTS: The number of unhelmeted riders (n = 1,674) was nearly double those who were helmeted (n = 879). Multivariate logistic regression models estimated 45% greater odds of a hospital admission (vs. no hospital treatment or a discharge from the emergency department setting) among unhelmeted riders, compared with helmeted riders. Unhelmeted riders also had an adjusted odds of a fatal injury that was more than double that of helmeted riders (odds ratio, 2.71; 95% confidence interval, 1.68-4.46). Stratified analyses showed that these protective associations between helmet use and medical disposition were apparent only among motorcyclists. CONCLUSION: The magnitude of the protective associations between helmets and medical outcomes was generally greater than that reported by other studies. Motorcyclists seem to benefit from helmet use more than moped riders. This data could be used to promote helmet use through education and public policy. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Effect of patient age on outcomes and compliance in women with minimally abnormal pap tests.

OBJECTIVE: To assess follow-up and histologic outcomes by age for an indigent urban cohort of women with minimally abnormal cytology. STUDY DESIGN: Retrospective analysis of Pap tests was performed (January 2, 2002, to June 30, 2005). Adolescents (age < 21) and women with atypical squamous cells of undetermined significance (ASCUS)/high-risk human papillomavirus (HPV) and low-grade squamous intraepithelial lesions (LSIL) Pap results were studied and followed for outcomes at 2 years. The chi2 test was performed to evaluate differences among groups; statistical significance was established as p < or = 0.05. RESULTS: A total of 2,266 women were studied--676 adolescents, 1,063 women aged 21-30 years, and 527 women > 30 years of age. Results included 619 ASCUS/ high-risk HPV and 1,647 LSIL results. Compliance was similar across age-groups; 31% never returned for follow-up. CIN2 was detected in 18.8% of adolescents, 21.6% of women aged 21-30, and 15.7% of women > 30 years (p = 0.53). CIN3 was detected in 8.5% of adolescents, 8.1% of women aged 21-30, and 7.7% of women > 30 years (p = 0.55). CONCLUSION: Adolescents and women had similar rates of loss to follow-up after having a minimally abnormal Pap test. The likelihood of detecting CIN2-3 was similar regardless of age.

Experience of dental care for children with congenital heart disease among Swedish dentists.

This study was conducted in order to examine the experience of and attitudes to dental care for children with congenital heart disease (CHD) among Swedish general dentists. 183 general dentists employed in the Public Dental Health Service in the counties of Västerbotten and Uppsala, and private practitioners listed with dentistry for children in the county of Västerbotten, Sweden, were enrolled in the study. Data were collected with a questionnaire with 18 questions. Eighteen per cent of the dentists stated that they had received special education or information except the graduate training to treat children with CHD. Forty-eight per cent of the dentists had one or more patients with CHD. Seventy-two per cent of these stated that their CHD-patients had a caries problem. Statistically significant differences were displayed between answers on the questions "who in the dental team perform the major part of the dental care for children with CHD" and "what is your opinion on which personal category that should perform the major part of the dental care for this group of children" (p < 0.001). Among dentists whose clinical time mainly was used for dentistry for children, it was more common to treat children with CHD (p < 0.001) than for dentists with a lower degree of dentistry for children. The study showed that the Swedish dental care for children with CHD today mainly is performed by dental nurses, dental hygienists and general dentists. This strongly differs from the dentist's opinion on who should perform the major part of the dental care for this group of children. These findings taken together with the very low number of dentists that had received special education or information except the graduate training to treat children with CHD indicates that the Swedish dentists are unsettled and insecure in the dental treatment of children with heart defects. An early and close cooperation between specialists in pediatric dentistry, dentists with special training and general dentists is strongly desirable to support the dentists and facilitate the dental care for children with CHD.

Overweight and at-risk for overweight among Hawai'i public school students entering kindergarten, 2002-2003.

Recent studies have pointed to an increasing problem of overweight and obesity in children in Hawai'i, but all of these studies have been conducted in specific communities or special population groups. No broad population-based studies have been conducted to document the extent of overweight in the general population of children in Hawai'i. To provide a population based estimate of overweight in Hawai'i's children, this study examined Student Health Records for 10, 199 children entering kindergarten in public schools during 2002-2003. Data on age, gender, height, and weight were used to calculate BMI (body mass index) scores. Because records for all students entering public school kindergarten were available for analysis, the data presented here represents the broadest estimates of overweight and at risk for overweight in Hawai'i's children published to date. The results illustrate that almost one-third of the children aged 4-6 years old entering Hawai'i public schools are either overweight or at risk for overweight. Rates are higher in rural school complexes than urban ones. Compared to a 1984 study that found 'no significant under or over nutrition' in Hawai'i's school children, our results suggest that almost one-third of children aged 4-6 entering Hawai'i public schools are either overweight or at risk for overweight. Physicians should be aware of this growing problem, and seek to implement practices to combat overweight among their pediatric patients and families.