Understanding physicians' work via text analytics on EHR inbox messages.

OBJECTIVES: To develop a text analytics methodology to analyze in a refined manner the drivers of primary care physicians' (PCPs') electronic health record (EHR) inbox work. STUDY DESIGN: This study used 1 year (2018) of EHR inbox messages obtained from the Epic system for 184 PCPs from 18 practices. METHODS: An advanced text analytics latent Dirichlet allocation model was trained on physicians' inbox message texts to identify the different work themes managed by physicians and their relative share of workload across physicians and clinics. RESULTS: The text analytics model identified 30 different work themes rolled up into 2 categories of medical and administrative tasks. We found that 50.8% (range across physicians, 34.5%-61.9%) of the messages were concerned with medical issues and 34.1% (range, 23.0%-48.9%) focused on administrative matters. More specifically, 13.6% (range, 7.1%-22.6%) of the messages involved ambiguous diagnosis issues, 13.2% (range, 6.9%-18.8%) involved condition management issues, 6.7% (range, 1.9%-13.4%) involved identified symptoms issues, 9.5% (range, 5.2%-28.9%) involved paperwork issues, and 17.6% (range, 9.3%-27.1%) involved scheduling issues. Additionally, there was significant variability among physicians and practices. CONCLUSIONS: This study demonstrated that advanced text analytics provide a reliable data-driven methodology to understand the individual physician's EHR inbox management work with a significantly greater level of detail than previous approaches. This methodology can inform decision makers on appropriate workflow redesign to eliminate unnecessary workload on PCPs and to improve cost and quality of care, as well as staff work satisfaction.

Understanding Physician Work and Well-being Through Social Network Modeling Using Electronic Health Record Data: a Cohort Study.

BACKGROUND: Understanding association between factors related to clinical work environment and well-being can inform strategies to improve physicians' work experience. OBJECTIVE: To model and quantify what drivers of work composition, team structure, and dynamics are associated with well-being. DESIGN: Utilizing social network modeling, this cohort study of physicians in an academic health center examined inbasket messaging data from 2018 to 2019 to identify work composition, team structure, and dynamics features. Indicators from a survey in 2019 were used as dependent variables to identify factors predictive of well-being. PARTICIPANTS: EHR data available for 188 physicians and their care teams from 18 primary care practices; survey data available for 163/188 physicians. MAIN MEASURES: Area under the receiver operating characteristic curve (AUC) of logistic regression models to predict well-being dependent variables was assessed out-of-sample. KEY RESULTS: The mean AUC of the model for the dependent variables of emotional exhaustion, vigor, and professional fulfillment was, respectively, 0.665 (SD 0.085), 0.700 (SD 0.082), and 0.669 (SD 0.082). Predictors associated with decreased well-being included physician centrality within support team (OR 3.90, 95% CI 1.28-11.97, P=0.01) and share of messages related to scheduling (OR 1.10, 95% CI 1.03-1.17, P=0.003). Predictors associated with increased well-being included higher number of medical assistants within close support team (OR 0.91, 95% CI 0.83-0.99, P=0.05), nurse-centered message writing practices (OR 0.89, 95% CI 0.83-0.95, P=0.001), and share of messages related to ambiguous diagnosis (OR 0.92, 95% CI 0.87-0.98, P=0.01). CONCLUSIONS: Through integration of EHR data with social network modeling, the analysis highlights new characteristics of care team structure and dynamics that are associated with physician well-being. This quantitative methodology can be utilized to assess in a refined data-driven way the impact of organizational changes to improve well-being through optimizing team dynamics and work composition.

E-Cigarette Use, Small Airway Fibrosis, and Constrictive Bronchiolitis.

BACKGROUND: Vaping, including the use of electronic cigarettes (e-cigarettes), has become increasingly prevalent, yet the associated long-term health risks are largely unknown. Given the prevalence of use, particularly among adolescents early in their lifespan, it is vital to understand the potential chronic pathologic sequelae of vaping. METHODS: We present the cases of four patients with chronic lung disease associated with e-cigarette use characterized by clinical evaluation, with pulmonary function tests (PFTs), chest high-resolution computed tomography (HRCT), endobronchial optical coherence tomography (EB-OCT) imaging, and histopathologic assessment. RESULTS: Each patient presented with shortness of breath and chest pain in association with a 3- to 8-year history of e-cigarette use, with mild progressive airway obstruction on PFTs and/or chest HRCT findings demonstrating evidence of air trapping and bronchial wall thickening. EB-OCT imaging performed in two patients showed small airway-centered fibrosis with bronchiolar narrowing and lumen irregularities. The predominant histopathologic feature on surgical lung biopsy was small airway-centered fibrosis, including constrictive bronchiolitis and MUC5AC overexpression in all patients. Patients who ceased vaping had a partial, but not complete, reversal of disease over 1 to 4 years. CONCLUSIONS: After thorough evaluation for other potential etiologies, vaping was considered to be the most likely common causal etiology for all patients due to the temporal association of symptomatic chronic lung disease with e-cigarette use and partial improvement in symptoms after e-cigarette cessation. In this series, we associate the histopathologic pattern of small airway-centered fibrosis, including constrictive bronchiolitis, with vaping, potentially defining a clinical and pathologic entity associated with e-cigarette use. (Funded in part by the National Institutes of Health.).

A Conserved Distal Lung Regenerative Pathway in Acute Lung Injury.

Improved tools have led to a burgeoning understanding of lung regeneration in mice, but it is not yet known how these insights may be relevant to acute lung injury in humans. We report in detail two cases of fulminant idiopathic acute lung injury requiring extracorporeal membrane oxygenation in previously healthy young adults with acute respiratory distress syndrome, one of whom required lung transplantation. Biopsy specimens showed diffuse alveolar injury with a striking paucity of alveolar epithelial regeneration, rare hyaline membranes, and diffuse contiguous airspace lining by macrophages. This novel constellation was termed diffuse alveolar injury with delayed epithelization. In addition, mirroring data from murine models of lung injury/regeneration, peribronchiolar basaloid pods (previously described as squamous metaplasia) and ciliated bronchiolarization were identified in these patients and in 39% of 57 historical cases with diffuse alveolar damage. These findings demonstrate a common and clinically relevant human disease correlate for murine models of severe acute lung injury. Evidence suggests that peribronchiolar basaloid pods and bronchiolarization are related spatially and temporally and likely represent overlapping sequential stages of the response to severe distal airway injury.

Effects of a New Hospital-Wide Surgical Consultation Protocol in Patients with Clostridium difficile Colitis.

BACKGROUND: Fulminant Clostridium difficile colitis (fCDC) occurs in 2%-8% of patients with CDC and carries a high death rate. Prompt operation may reduce death. Our aim was to determine whether a standardized hospital-wide protocol for surgical referral in CDC would result in earlier surgical consultation, earlier identification of patients who could benefit from surgical therapy, and reduced deaths from fCDC. METHODS: A multidisciplinary team developed consensus criteria for surgical consultation. Compliance was evaluated by prospective review of all inpatient CDC cases. Outcomes of the prospective cohort (POST) were compared to an historic control group (PRE). RESULTS: From November 1, 2010 to October 31, 2012, we identified 1,106 inpatients with CDC; 339 patients matched the consultation criteria, of whom 213 received a surgical consultation, resulting in an overall compliance rate of 62.8%. All those with fCDC received a surgical consultation, with a median time to surgical referral of three hours. Of 46 patients with fCDC, 11 (23.9%) died, compared with 34.8% in the historical control group (p = 0.15). The death rate was 14.7% in the POST group, when excluding patients with limitations of care and those transferred to our institution in a fulminant state. There was a shorter interval between admission and surgical intervention for those who required operation in the POST group-three (1-11) days versus 1.5 (0-3) days, respectively, in the PRE and POST groups (p = 0.018), and a shorter adjusted median hospital length of stay (adjusted difference 9.0, 95% CI 2.2-12.3, p = 0.007) Conclusions: A hospital-wide protocol with established criteria for surgical consultation resulted in faster intervention and a shorter adjusted median hospital length of stay. The overall death rate for fCDC patients without limitations of life-sustaining treatment who presented to our emergency department or in whom fCDC developed while they were admitted to our hospital was 14.7%.

A triad of linezolid toxicity: hypoglycemia, lactic acidosis, and acute pancreatitis.

We present a case of suspected linezolid toxicity in a 34-year-old man with sickle cell disease and line-related vancomycin-resistant enterococcal bacteremia and tricuspid valve endocarditis. The patient developed sudden-onset hypoglycemia, lactic acidosis, and acute pancreatitis 11 days after initiation of linezolid. All adverse effects quickly resolved with drug cessation. The pathophysiology underlying this triad of linezolid toxicity is unclear, but may be related to mitochondrial dysfunction.

Augmenting communication and decision making in the intensive care unit with a cardiopulmonary resuscitation video decision support tool: a temporal intervention study.

OBJECTIVE: Effective communication between intensive care unit (ICU) providers and families is crucial given the complexity of decisions made regarding goals of therapy. Using video images to supplement medical discussions is an innovative process to standardize and improve communication. In this six-month, quasi-experimental, pre-post intervention study we investigated the impact of a cardiopulmonary resuscitation (CPR) video decision support tool upon knowledge about CPR among surrogate decision makers for critically ill adults. METHODS: We interviewed surrogate decision makers for patients aged 50 and over, using a structured questionnaire that included a four-question CPR knowledge assessment similar to those used in previous studies. Surrogates in the post-intervention arm viewed a three-minute video decision support tool about CPR before completing the knowledge assessment and completed questions about perceived value of the video. RESULTS: We recruited 23 surrogates during the first three months (pre-intervention arm) and 27 surrogates during the latter three months of the study (post-intervention arm). Surrogates viewing the video had more knowledge about CPR (p=0.008); average scores were 2.0 (SD 1.1) and 2.9 (SD 1.2) (out of a total of 4) in pre-intervention and post-intervention arms. Surrogates who viewed the video were comfortable with its content (81% very) and 81% would recommend the video. CPR preferences for patients at the time of ICU discharge/death were distributed as follows: pre-intervention: full code 78%, DNR 22%; post-intervention: full code 59%, DNR 41% (p=0.23).

Variant alveolar lipoproteinosis: a syndrome with distinct clinical and pathological features.

Pulmonary alveolar proteinosis (PAP) is a rare condition in which pulmonary macrophages fail to clear surfactant, resulting in the alveolar accumulation of lipoproteinaceous debris. The histopathology of PAP is typified by diffuse filling of terminal airways with eosinophilic, PAS/diastase (PAS/D)-positive acellular material. We present five patients who showed histopathological changes in the lungs consistent with mild PAP. However, these cases were notable for the abundance of degenerating alveolar macrophages, weak PAS staining of lipoproteinaceous material and paucity of lamellated bodies on ultrastructural examination. Only one patient showed the CT finding of mosaiform 'crazy-paving' and the opalescent bronchoalveolar lavage fluid characteristic of PAP. In one case, therapeutic lung lavage based on a presumptive diagnosis of PAP exacerbated respiratory distress. Three patients showed partial or near-complete resolution of disease in response to high-dose corticosteroid therapy, a treatment approach that is generally ineffective in PAP. We conclude that distinguishing 'variant alveolar lipoproteinosis' from classical PAP is clinically important. Despite the otherwise typical appearance of lipoproteinaceous alveolar material in lung biopsies, the presence of degenerating foamy macrophages and atypical histochemical, ultrastructural and radiographic features suggest a steroid-responsive form of proteinosis that is likely pathogenetically distinct and may not be amenable to whole-lung lavage.

An administrative claims model for profiling hospital 30-day mortality rates for pneumonia patients.

BACKGROUND: Outcome measures for patients hospitalized with pneumonia may complement process measures in characterizing quality of care. We sought to develop and validate a hierarchical regression model using Medicare claims data that produces hospital-level, risk-standardized 30-day mortality rates useful for public reporting for patients hospitalized with pneumonia. METHODOLOGY/PRINCIPAL FINDINGS: Retrospective study of fee-for-service Medicare beneficiaries age 66 years and older with a principal discharge diagnosis of pneumonia. Candidate risk-adjustment variables included patient demographics, administrative diagnosis codes from the index hospitalization, and all inpatient and outpatient encounters from the year before admission. The model derivation cohort included 224,608 pneumonia cases admitted to 4,664 hospitals in 2000, and validation cohorts included cases from each of years 1998-2003. We compared model-derived state-level standardized mortality estimates with medical record-derived state-level standardized mortality estimates using data from the Medicare National Pneumonia Project on 50,858 patients hospitalized from 1998-2001. The final model included 31 variables and had an area under the Receiver Operating Characteristic curve of 0.72. In each administrative claims validation cohort, model fit was similar to the derivation cohort. The distribution of standardized mortality rates among hospitals ranged from 13.0% to 23.7%, with 25(th), 50(th), and 75(th) percentiles of 16.5%, 17.4%, and 18.3%, respectively. Comparing model-derived risk-standardized state mortality rates with medical record-derived estimates, the correlation coefficient was 0.86 (Standard Error = 0.032). CONCLUSIONS/SIGNIFICANCE: An administrative claims-based model for profiling hospitals for pneumonia mortality performs consistently over several years and produces hospital estimates close to those using a medical record model.

Development, validation, and results of a measure of 30-day readmission following hospitalization for pneumonia.

BACKGROUND: Readmission following hospital discharge has become an important target of quality improvement. OBJECTIVE: To describe the development, validation, and results of a risk-standardized measure of hospital readmission rates among elderly patients with pneumonia employed in federal quality measurement and efficiency initiatives. DESIGN: A retrospective cohort study using hospital and outpatient Medicare claims from 2005 and 2006. SETTING: A total of 4675 hospitals in the United States. PATIENTS: Medicare beneficiaries aged >65 years with a principal discharge diagnosis of pneumonia. INTERVENTION: None. MEASUREMENTS: Hospital-specific, risk-standardized 30-day readmission rates calculated as the ratio of predicted-to-expected readmissions, multiplied by the national unadjusted rate. Comparison of the areas under the receiver operating curve (ROC) and measurement of correlation coefficient in development and validation samples. RESULTS: The development sample consisted of 226,545 hospitalizations at 4675 hospitals, with an overall unadjusted 30-day readmission rate of 17.4%. The median risk-standardized hospital readmission rate was 17.3%, and the odds of readmission for a hospital one standard deviation above average was 1.4 times that of a hospital one standard deviation below average. Performance of the medical record and administrative models was similar (areas under the ROC curve 0.59 and 0.63, respectively) and the correlation coefficient of estimated state-specific standardized readmission rates from the administrative and medical record models was 0.96. CONCLUSIONS: Rehospitalization within 30 days of treatment for pneumonia is common, and rates vary across hospitals. A risk-standardized measure of hospital readmission rates derived from administrative claims has similar performance characteristics to one based on medical record review.

Imaging features of sarcoidosis on MDCT, FDG PET, and PET/CT.

OBJECTIVE: The objectives of this article are to discuss the epidemiology and natural history of sarcoidosis; to review the classic imaging features of sarcoidosis on radiography, CT, and 67Ga nuclear medicine scans; and to present clinical examples of sarcoidosis as seen on PET and PET/CT in the chest, abdomen and pelvis, and bones. CONCLUSION: The imaging features of sarcoidosis are diverse and can be seen on a variety of imaging techniques. It is important for radiologists and nuclear medicine physicians to recognize the common imaging features and patterns of sarcoidosis in order to raise the possibility in the appropriate clinical setting.

The effect of a teaching hospital's financial crisis and reorganization on a group of residents.

PURPOSE: Allegheny General Hospital (AGH) in Pittsburgh, Pennsylvania, was part of a statewide health care system that underwent a financial crisis and operational reorganization between 1998 and 2000. This study assessed internal medicine (IM) residents' perceptions of the effects of AGH's financial crisis on their residencies METHOD: A confidential, program-based questionnaire was distributed to 75 IM residents at AGH in spring 2000 and included questions on demographic information, inpatient and outpatient medical education, and the hospital's financial crisis. Residents were asked to assess the effects of the financial crisis on their residencies, personal experiences, and attitudes toward health care systems. Outcomes included consideration of transfer, recommendation of the program to a medical student, concerns about fellowship opportunities, opinions about large health care systems, and medicine as a career recommendation. RESULTS: A total of 71 residents (95%) responded to the questionnaire. Fifty-five (79%) had experienced effects on their residencies due to the financial crisis, but perceptions differed widely. Eighteen (25%) considered transferring from the program, but 44 of 59 (75%) would have recommended the program to a medical student. Because of the financial crisis, respondents reported significant changes in concerns about fellowship opportunities (p <.001), opinions about large health care systems (p <.001), and opinions about recommending medicine as a career (p <.001). CONCLUSION: This study highlights the fact that residents serve as program ambassadors and their experiences may influence recruitment and retention. Thus, programs should consider ways to assess and address residents' concerns during any system crisis or reorganization.