Five United States geographic regions. Region boundaries correspond to...

International electronic health record-derived post-acute sequelae profiles of COVID-19 patients

Article

Full-text available

Jun 2022

The risk profiles of post-acute sequelae of COVID-19 (PASC) have not been well characterized in multi-national settings with appropriate controls. We leveraged electronic health record (EHR) data from 277 international hospitals representing 414,602 patients with COVID-19, 2.3 million control patients without COVID-19 in the inpatient and outpatient settings, and over 221 million diagnosis codes to systematically identify new-onset conditions enriched among patients with COVID-19 during the post-acute period. Compared to inpatient controls, inpatient COVID-19 cases were at significant risk for angina pectoris (RR 1.30, 95% CI 1.09–1.55), heart failure (RR 1.22, 95% CI 1.10–1.35), cognitive dysfunctions (RR 1.18, 95% CI 1.07–1.31), and fatigue (RR 1.18, 95% CI 1.07–1.30). Relative to outpatient controls, outpatient COVID-19 cases were at risk for pulmonary embolism (RR 2.10, 95% CI 1.58–2.76), venous embolism (RR 1.34, 95% CI 1.17–1.54), atrial fibrillation (RR 1.30, 95% CI 1.13–1.50), type 2 diabetes (RR 1.26, 95% CI 1.16–1.36) and vitamin D deficiency (RR 1.19, 95% CI 1.09–1.30). Outpatient COVID-19 cases were also at risk for loss of smell and taste (RR 2.42, 95% CI 1.90–3.06), inflammatory neuropathy (RR 1.66, 95% CI 1.21–2.27), and cognitive dysfunction (RR 1.18, 95% CI 1.04–1.33). The incidence of post-acute cardiovascular and pulmonary conditions decreased across time among inpatient cases while the incidence of cardiovascular, digestive, and metabolic conditions increased among outpatient cases. Our study, based on a federated international network, systematically identified robust conditions associated with PASC compared to control groups, underscoring the multifaceted cardiovascular and neurological phenotype profiles of PASC.

Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review

Article

Full-text available

May 2022
J MED INTERNET RES

Background The adoption of electronic health records (EHRs) and electronic medical records (EMRs) has been slow in the mental health context, partly because of concerns regarding the collection of sensitive information, the standardization of mental health data, and the risk of negatively affecting therapeutic relationships. However, EHRs and EMRs are increasingly viewed as critical to improving information practices such as the documentation, use, and sharing of information and, more broadly, the quality of care provided. Objective This paper aims to undertake a scoping review to explore the impact of EHRs on information practices in mental health contexts and also explore how sensitive information, data standardization, and therapeutic relationships are managed when using EHRs in mental health contexts. Methods We considered a scoping review to be the most appropriate method for this review because of the relatively recent uptake of EHRs in mental health contexts. A comprehensive search of electronic databases was conducted with no date restrictions for articles that described the use of EHRs, EMRs, or associated systems in the mental health context. One of the authors reviewed all full texts, with 2 other authors each screening half of the full-text articles. The fourth author mediated the disagreements. Data regarding study characteristics were charted. A narrative and thematic synthesis approach was taken to analyze the included studies’ results and address the research questions. Results The final review included 40 articles. The included studies were highly heterogeneous with a variety of study designs, objectives, and settings. Several themes and subthemes were identified that explored the impact of EHRs on information practices in the mental health context. EHRs improved the amount of information documented compared with paper. However, mental health–related information was regularly missing from EHRs, especially sensitive information. EHRs introduced more standardized and formalized documentation practices that raised issues because of the focus on narrative information in the mental health context. EHRs were found to disrupt information workflows in the mental health context, especially when they did not include appropriate templates or care plans. Usability issues also contributed to workflow concerns. Managing the documentation of sensitive information in EHRs was problematic; clinicians sometimes watered down sensitive information or chose to keep it in separate records. Concerningly, the included studies rarely involved service user perspectives. Furthermore, many studies provided limited information on the functionality or technical specifications of the EHR being used. Conclusions We identified several areas in which work is needed to ensure that EHRs benefit clinicians and service users in the mental health context. As EHRs are increasingly considered critical for modern health systems, health care decision-makers should consider how EHRs can better reflect the complexity and sensitivity of information practices and workflows in the mental health context.

International Changes in COVID-19 Clinical Trajectories Across 315 Hospitals and 6 Countries: a 4CE Consortium Study (Preprint)

Article

Full-text available

Jun 2021
J MED INTERNET RES

Background: Many countries have experienced two predominant waves of COVID-19-related hospitalizations. Comparing the clinical trajectories of patients hospitalized in separate waves of the pandemic enables further understanding of the evolving epidemiology, pathophysiology, and healthcare dynamics of the COVID-19 pandemic. Objective: In this retrospective cohort study, we analyzed electronic health record (EHR) data from patients with SARS-CoV-2 infections hospitalized in participating healthcare systems representing 315 hospitals across six countries. We compared hospitalization rates, severe COVID-19 risk, and mean laboratory values between patients hospitalized during the first and second waves of the pandemic. Methods: Using a federated approach, each participating healthcare system extracted patient-level clinical data on their first and second wave cohorts and submitted aggregated data to the central site. Data quality control steps were performed at the central site to correct for implausible values and harmonize units. Statistical analyses were performed by computing individual healthcare system effect sizes and synthesizing these using random effects meta-analyses to account for heterogeneity. We focused the laboratory analysis on C-reactive protein (CRP), ferritin, fibrinogen, procalcitonin, D-dimer, and creatinine based on their reported associations with severe COVID-19. Results: Data were available for 79,613 patients, of which 32,467 were hospitalized in the first wave and 47,146 in the second wave. The prevalence of male patients and patients aged 50-69 decreased significantly between the first and second wave. Patients hospitalized in the second wave had a 9.9% reduction in risk of severe COVID-19 compared to patients hospitalized in the first wave (95% CI: 8.5-11.3%). Demographic subgroup analyses indicated that patients aged 26-49 and 50-69; male and female patients; and Black patients had significantly lower risk for severe disease in the second wave compared to the first wave. At admission, the mean values of CRP were significantly lower in the second wave compared to the first. On the seventh hospital day, mean values of CRP, ferritin, fibrinogen, and procalcitonin were significantly lower in the second wave compared to the first. In general, countries exhibited variable changes in laboratory testing rates from the first to the second wave. At admission, there was a significantly higher testing rate for D-dimer in France, Germany, and Spain. Conclusions: Patients hospitalized in the second wave were at significantly lower risk for severe COVID-19. This corresponded to mean laboratory values in the second wave that were more likely to be in typical physiological ranges on the seventh hospital day compared to the first wave. Our federated approach demonstrated the feasibility and power of harmonizing heterogeneous EHR data from multiple international healthcare systems to rapidly conduct large-scale studies to characterize how COVID-19 clinical trajectories evolve. Clinicaltrial:

International Changes in COVID-19 Clinical Trajectories Across 315 Hospitals and 6 Countries: a 4CE Consortium Study (Preprint)

Preprint

Jun 2021

BACKGROUND Many countries have experienced two predominant waves of COVID-19-related hospitalizations. Comparing the clinical trajectories of patients hospitalized in separate waves of the pandemic enables further understanding of the evolving epidemiology, pathophysiology, and healthcare dynamics of the COVID-19 pandemic. OBJECTIVE In this retrospective cohort study, we analyzed electronic health record (EHR) data from patients with SARS-CoV-2 infections hospitalized in participating healthcare systems representing 315 hospitals across six countries. We compared hospitalization rates, severe COVID-19 risk, and mean laboratory values between patients hospitalized during the first and second waves of the pandemic. METHODS Using a federated approach, each participating healthcare system extracted patient-level clinical data on their first and second wave cohorts and submitted aggregated data to the central site. Data quality control steps were performed at the central site to correct for implausible values and harmonize units. Statistical analyses were performed by computing individual healthcare system effect sizes and synthesizing these using random effects meta-analyses to account for heterogeneity. We focused the laboratory analysis on C-reactive protein (CRP), ferritin, fibrinogen, procalcitonin, D-dimer, and creatinine based on their reported associations with severe COVID-19. RESULTS Data were available for 79,487 patients, of which 32,452 were hospitalized in the first wave and 47,035 in the second wave. The prevalence of male patients and patients aged 50–69 decreased significantly between the first and second wave. Patients hospitalized in the second wave had a 9.6% reduction in risk of severe COVID-19 compared to patients hospitalized in the first wave (95% CI: 8.2–11.1%). Demographic subgroup analyses indicated that patients aged 26–49; male and female patients; and Black patients had significantly lower risk for severe disease in the second wave compared to the first wave. At admission, the mean values of CRP were significantly lower in the second wave compared to the first. On the seventh hospital day, mean values of CRP, ferritin, fibrinogen, procalcitonin, and creatinine were significantly lower in the second wave compared to the first. In general, countries exhibited variable changes in laboratory testing rates from the first to the second wave. At admission, there was a significantly higher testing rate for D-dimer in France, Germany, and Spain. CONCLUSIONS Patients hospitalized in the second wave were at significantly lower risk for severe COVID-19. This corresponded to mean laboratory values in the second wave that were more likely to be in typical physiological ranges on the seventh hospital day compared to the first wave. Our federated approach demonstrated the feasibility and power of harmonizing heterogeneous EHR data from multiple international healthcare systems to rapidly conduct large-scale studies to characterize how COVID-19 clinical trajectories evolve.

International changes in COVID-19 clinical trajectories across 315 hospitals and 6 countries: retrospective cohort study

Article

Jan 2021

Background: Many countries have experienced 2 predominant waves of COVID-19–related hospitalizations. Comparing the clinical trajectories of patients hospitalized in separate waves of the pandemic enables further understanding of the evolving epidemiology, pathophysiology, and health care dynamics of the COVID-19 pandemic. Objective: In this retrospective cohort study, we analyzed electronic health record (EHR) data from patients with SARS-CoV-2 infections hospitalized in participating health care systems representing 315 hospitals across 6 countries. We compared hospitalization rates, severe COVID-19 risk, and mean laboratory values between patients hospitalized during the first and second waves of the pandemic. Methods: Using a federated approach, each participating health care system extracted patient-level clinical data on their first and second wave cohorts and submitted aggregated data to the central site. Data quality control steps were adopted at the central site to correct for implausible values and harmonize units. Statistical analyses were performed by computing individual health care system effect sizes and synthesizing these using random effect meta-analyses to account for heterogeneity. We focused the laboratory analysis on C-reactive protein (CRP), ferritin, fibrinogen, procalcitonin, D-dimer, and creatinine based on their reported associations with severe COVID-19. Results: Data were available for 79,613 patients, of which 32,467 were hospitalized in the first wave and 47,146 in the second wave. The prevalence of male patients and patients aged 50 to 69 years decreased significantly between the first and second waves. Patients hospitalized in the second wave had a 9.9% reduction in the risk of severe COVID-19 compared to patients hospitalized in the first wave (95% CI 8.5%-11.3%). Demographic subgroup analyses indicated that patients aged 26 to 49 years and 50 to 69 years; male and female patients; and black patients had significantly lower risk for severe disease in the second wave than in the first wave. At admission, the mean values of CRP were significantly lower in the second wave than in the first wave. On the seventh hospital day, the mean values of CRP, ferritin, fibrinogen, and procalcitonin were significantly lower in the second wave than in the first wave. In general, countries exhibited variable changes in laboratory testing rates from the first to the second wave. At admission, there was a significantly higher testing rate for D-dimer in France, Germany, and Spain. Conclusions: Patients hospitalized in the second wave were at significantly lower risk for severe COVID-19. This corresponded to mean laboratory values in the second wave that were more likely to be in typical physiological ranges on the seventh hospital day compared to the first wave. Our federated approach demonstrated the feasibility and power of harmonizing heterogeneous EHR data from multiple international health care systems to rapidly conduct large-scale studies to characterize how COVID-19 clinical trajectories evolve.

Sustainment of the TeleSleep program for rural veterans

Article

Full-text available

Nov 2023

Background In fiscal year 2021, the Veterans Health Administration (VHA) provided care for sleep disorders to 599,966 Veterans, including 189,932 rural Veterans. To further improve rural access, the VA Office of Rural Health developed the TeleSleep Enterprise-Wide Initiative (EWI). TeleSleep's telemedicine strategies include tests for sleep apnea at the Veteran's home rather than in a sleep lab; Clinical Video Telehealth applications; and other forms of virtual care. In 2017 and 2020, VHA provided 3-year start-up funding to launch new TeleSleep programs at rural-serving VA medical facilities. Methods In early 2022, we surveyed leaders of 24 sites that received TeleSleep funding to identify successes, failures, facilitators, and barriers relevant to sustaining TeleSleep implementations upon expiration of startup funding. We tabulated frequencies on the multiple choice questions in the survey, and, using the survey's critical incident framework, summarized the responses to open-ended questions. TeleSleep program leaders discussed the responses and synthesized recommendations for improvement. Results 18 sites reported sustainment, while six were “on track.” Sustainment involved medical centers or regional entities incorporating TeleSleep into their budgets. Facilitators included: demonstrating value; aligning with local priorities; and collaborating with spoke sites serving rural Veterans. Barriers included: misalignment with local priorities; and hiring delays. COVID was a facilitator, as it stimulated adoption of telehealth practices; and also a barrier, as it consumed attention and resources. Recommendations included: longer startup funding; dedicated funding for human resources to accelerate hiring; funders communicating with local facility leaders regarding how TeleSleep aligns with organizational priorities; hiring into job classifications aligned with market pay; and obtaining, from finance departments, projections and outcomes for the return on investment in TeleSleep.

The Promise of Query Answering Systems in Sexuality Studies: Current State, Challenges and Limitations

Chapter

Sep 2023

Sexuality is a field of study that attempts to comprehend human behaviour, improve sexual health and understand culture and gender, among others. Recent advances and developments in artificial intelligence, specifically in query answering and natural language processing, can help to study the social relationship between population and sexuality. They are powerful tools to cope with crucial problems in the field, such as subjectivity, social desirability and social opinion biases. In this work, we review the state-of-the-art of AI-based methods in sexuality-related studies. Focusing on the psychological perspective, we analyse the role of query answering in this area of research. We discuss the necessary foundations, challenges, and limitations a query answering system must cover in this specialised and complex field.KeywordsQuery AnsweringNatural Language ProcessingSexualityLarge Language ModelsSexual Health

Association of Prostate-Specific Antigen Screening Rates With Subsequent Metastatic Prostate Cancer Incidence at US Veterans Health Administration Facilities

Article

Oct 2022

Importance There is controversy about the benefit of prostate-specific antigen (PSA) screening. Prostate-specific antigen screening rates have decreased since 2008 in the US, and the incidence of metastatic prostate cancer has increased. However, there is no direct epidemiologic evidence of a correlation between population PSA screening rates and subsequent metastatic prostate cancer rates. Objective To assess whether facility-level variation in PSA screening rates is associated with subsequent facility-level metastatic prostate cancer incidence. Design, Setting, and Participants This retrospective cohort used data for all men aged 40 years or older with an encounter at 128 facilities in the US Veterans Health Administration (VHA) from January 1, 2005, to December 31, 2019. Exposures Yearly facility-level PSA screening rates, defined as the proportion of men aged 40 years or older with a PSA test in each year, and long-term nonscreening rates, defined as the proportion of men aged 40 years or older without a PSA test in the prior 3 years, from January 1, 2005, to December 31, 2014. Main Outcomes and Measures The main outcomes were facility-level yearly counts of incident metastatic prostate cancer diagnoses and age-adjusted yearly metastatic prostate cancer incidence rates (per 100 000 men) 5 years after each PSA screening exposure year. Results The cohort included 4 678 412 men in 2005 and 5 371 701 men in 2019. Prostate-specific antigen screening rates decreased from 47.2% in 2005 to 37.0% in 2019, and metastatic prostate cancer incidence increased from 5.2 per 100 000 men in 2005 to 7.9 per 100 000 men in 2019. Higher facility-level PSA screening rates were associated with lower metastatic prostate cancer incidence 5 years later (incidence rate ratio [IRR], 0.91 per 10% increase in PSA screening rate; 95% CI, 0.87-0.96; P < .001). Higher long-term nonscreening rates were associated with higher metastatic prostate cancer incidence 5 years later (IRR, 1.11 per 10% increase in long-term nonscreening rate; 95% CI, 1.03-1.19; P = .01). Conclusions and Relevance From 2005 to 2019, PSA screening rates decreased in the national VHA system. Facilities with higher PSA screening rates had lower subsequent rates of metastatic prostate cancer. These data may be used to inform shared decision-making about the potential benefits of PSA screening among men who wish to reduce their risk of metastatic prostate cancer.

Trends in blood pressure diagnosis, treatment, and control among VA nursing home residents, 2007–2018

Article

May 2022
J AM GERIATR SOC

Background: Inadequate treatment of high blood pressure (BP) can lead to preventable adverse events in nursing home residents, while excessive treatment can lead to associated harms. Methods: Data were extracted from the VA electronic health record and Bar Code Medication Administration system on 40,079 long-term care residents aged ≥65 years from October 2006 through September 2018 (FY2007-2018). Hypertension prevalence at admission was identified by ICD code(s) in the year prior, and antihypertensive medication use was defined as administration ≥50% of days. BP measures were averaged over 2-year epochs. Results: The age-standardized prevalence of hypertension diagnosis at admission increased from 75.2% in FY2007-2008 to 85.1% in FY2017-2018 (p-value for trend <0.001). Rates of BP treatment and control among residents with hypertension at admission declined slightly over time (p-values for trend <0.001) but remained high (80.3% treated in FY2017-2018, 80.1% with average BP <140/90 mmHg). The age-adjusted prevalence of chronic low BP (average <90/60 mmHg) also declined from 11.1% in FY2007-2008 to 4.7% in FY2017-2018 (p-value for trend <0.001). Persons identified as Black race or Hispanic ethnicity and those with a history of diabetes, stroke, and renal disease were less likely to have an average BP <140/90 mmHg. Conclusions: Hypertension is well controlled in VA nursing homes, and recent trends of less intensive BP control were accompanied by a lower prevalence of chronic low BP. Nonetheless, some high-risk populations have average BP levels >140/90 mmHg. Future research is needed to better understand the benefits and harms of BP control in nursing home residents.

Extracting Social Determinants of Health from Electronic Health Records using Natural Language Processing: A Systematic Review

Article

Full-text available

Aug 2021
J AM MED INFORM ASSN

Objective: Social determinants of health (SDoH) are non-clinical dispositions that impact patient health risks and clinical outcomes. Leveraging SDoH in clinical decision making can potentially improve diagnosis, treatment planning, and patient outcomes. Despite increased interest in capturing SDoH in electronic health records (EHRs), such information is typically locked in unstructured clinical notes. Natural language processing (NLP) is the key technology to extract SDoH information from clinical text and expand its utility in patient care and research. This article presents a systematic review of the state-of-the-art NLP approaches and tools that focus on identifying and extracting SDoH data from unstructured clinical text in EHRs. Methods: A broad literature search was conducted in February 2021 using three scholarly databases (ACL Anthology, PubMed, and Scopus) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 6402 publications were initially identified; and after applying study inclusion criteria, 82 publications were selected for the study. Results: Smoking status (n=27), substance use (n=21), homelessness (n=20), and alcohol use (n=15) are the most frequently studied SDoH categories. Homelessness (n=7) and other less studied SDoH are mostly identified using rule-based approaches. In contrast, machine learning approaches are popular for identifying smoking status (n=13), substance use (n=9), and alcohol use (n=9). Conclusion: NLP offers significant potential to extract SDoH data from narrative clinical notes, which in turn can aid in the development of screening tools, risk prediction models, and clinical decision support systems.

Five United States geographic regions. Region boundaries correspond to Veterans Affairs Integrated Service Network (VISN) catchment areas. Green circles indicate Veterans Affairs medical center locations.

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