A data extraction algorithm for assessment of contraceptive counseling and provision.

BACKGROUND: Contraception counseling and provision is an essential preventative service. Real-time assessment of these services is critical for quality improvement and comparative study. Direct observation is not feasible on a large scale, so indirect measures (such as chart review) have been determined to be acceptable tools for this assessment. Computer-aided chart review has significant benefits over manual chart review as far as greater efficiency and ease of repeated measurements. The wide use of electronic medical records provides an opportunity to create a data extraction algorithm for computer-aided chart review that is sharable among institutions. We provide a useful schema for others who use electronic medical record systems and are interested in real-time assessment of contraception counseling and provision for the purposes of baseline assessment of services and quality improvement. OBJECTIVE: The purpose of this study was to create a comprehensive and accurate data extraction algorithm that is useful in the assessment of contraception counseling and provision rates in the outpatient setting. STUDY DESIGN: We included all visits between August 2015 and May 2016 at 8 outpatient clinics that are affiliated with a large, urban academic medical center in which nonpregnant women who were 14-45 years old were seen by a nurse practitioner, physician's assistant, or physician. Contraception-related prescriptions, International Classification of Diseases codes, current procedural terminology codes, and search-term capture were extracted with the use of structured query language from electronic medical record data that were stored in a relational database. The algorithm's hierarchy was designed to query prescription data first, followed by International Classification of Diseases and current procedural terminology codes, and finally search-term capture. Visits were censored when the first positive evidence of contraceptive service was obtained. Search terms were selected based on group discussion of investigators and providers. This algorithm was then compared with manual chart review and refined 3 times until high sensitivity and specificity, when compared with manual chart review, were achieved. RESULTS: There were 22,134 visits of reproductive-aged women who our inclusion criteria. Electronic medical record evidence of contraception counseling or provision was found in 56.9% of these visits. Of these, 21.3% were captured by prescriptions; 8.9% were captured by International Classification of Diseases codes, and 69.7% were captured by search-term capture with the use of our algorithm. Among visits with evidence of contraception counseling without provision, 15.7% were captured by diagnosis codes and 84.3% were captured by search-term capture. When compared with manual chart review, sensitivity and specificity improved from 0.79 and 0.85 to 0.99 and 0.98, respectively, over the 3 rounds of testing and revision. CONCLUSION: Data extraction algorithms can be used effectively for computer-aided chart review of contraception counseling and provision measures, but testing and refinement are extremely important. Search-term capture from unstructured data is a critical component of a comprehensive algorithm, especially for the capture of instances of contraception counseling without provision. The algorithm that we developed here could be used by others with an electronic medical record system who are interested in real-time assessment, quality improvement, and comparative study of the delivery of contraceptive services. The ease of execution of this algorithm also allows for its repeated use for ongoing assessments over time.

Performance of implementing guideline-driven cervical cancer screening measures in an inner-city hospital system.

OBJECTIVE: : In 2006, the American Society for Colposcopy and Cervical Pathology updated evidence-based guidelines recommending screening intervals for women with abnormal cervical cytology diagnosis. In our low-income inner-city population, we sought to improve performance by uniformly applying the guidelines to all patients. We report the prospective performance of a comprehensive tracking, evidence-based algorithmically driven call back, and appointment scheduling system for cervical cancer screening in a resource-limited inner-city population. MATERIALS AND METHODS: : Outreach efforts were formalized with algorithm-based protocols for triage to colposcopy, with universal adherence to evidence-based guidelines. During implementation from August 2006 to July 2008, we prospectively tracked performance using the electronic medical record with administrative and pathology reports to determine performance variables such as the total number of Pap tests, colposcopy visits, and the distribution of abnormal cytology and histology results, including all cervical intraepithelial neoplasia 2, 3 diagnoses. RESULTS: : A total of 86,257 gynecologic visits and 41,527 Pap tests were performed system-wide during this period of widespread and uniform implementation of standard cervical cancer screening guidelines. The number of Pap tests performed per month varied little. The incidence of CIN 1 significantly decreased from 117 (68.4%) of 171 during the first tracked month to 52 (54.7%) of 95 during the last tracked month (p = 0.04). The monthly incidence rate of CIN 2, 3, including incident cervical cancers, did not change. The total number of colposcopy visits declined, resulting in a 50% decrease in costs related to colposcopy services and approximately a 12% decrease in costs related to excisional biopsies. CONCLUSIONS: : Adherence to cervical cancer screening guidelines reduced the number of unnecessary colposcopies without increasing numbers of potentially missed CIN 2, 3 lesions, including cervical cancer. Uniform implementation of administrative-based performance initiatives for cervical cancer screening minimizes differences in provider practices and maximizes performance of screening while containing cervical cancer screening costs.

Outcomes after an excisional procedure for cervical intraepithelial neoplasia in HIV-infected women.

OBJECTIVE: To determine predictors of treatment failure and recurrence after surgical excisional procedures for CIN in HIV-infected women. METHODS: A retrospective cohort study was conducted in which 136 eligible HIV-infected women treated for CIN between 1999 and 2005 were included. Data were abstracted from charts and computer databases. Treatment failures were defined as the presence of CIN 1+ at initial follow-up. Recurrences were defined as the presence of CIN 1+ subsequent to initial normal follow-up. RESULTS: Treatment failure at initial follow-up was common, occurring in 51% of CIN 1 and 55% of CIN 2+. Most lesions detected at treatment failure were high grade (>70%), regardless of the grade of initial lesion. Significant risk factors for treatment failure were loop electrosurgical excision procedure (LEEP) compared to cold knife conization (RR=1.76; 95% CI: 1.15-2.64), and low CD4+ count (p=0.04). Among those with an initial normal clinical evaluation, 55% eventually recurred. As with treatment failure, most lesions detected at recurrence were high grade. Risk factors for recurrence included use of LEEP (hazard ratio [HR]=3.38; 95% CI: 1.55-7.39), higher HIV RNA level, and the presence of positive margins at treatment (HR=6.12; 95% CI: 1.90-19.73). CONCLUSIONS: Most CIN treatment of HIV-infected women studied either failed or resulted in recurrence. Of particular concern, many of these subsequent lesions were high grade. Conization, however, was associated with significantly less failure/recurrence than LEEP. Clinicians treating CIN in HIV-infected women should avoid raising expectations of cure and instead focus on the achievable goal of cancer prevention until there are better therapies for this patient population.