Showing papers by "Michael Klompas published in 2011"

Multicenter evaluation of a novel surveillance paradigm for complications of mechanical ventilation.

Abstract: Background Ventilator-associated pneumonia (VAP) surveillance is time consuming, subjective, inaccurate, and inconsistently predicts outcomes. Shifting surveillance from pneumonia in particular to complications in general might circumvent the VAP definition's subjectivity and inaccuracy, facilitate electronic assessment, make interfacility comparisons more meaningful, and encourage broader prevention strategies. We therefore evaluated a novel surveillance paradigm for ventilator-associated complications (VAC) defined by sustained increases in patients' ventilator settings after a period of stable or decreasing support. Methods We assessed 600 mechanically ventilated medical and surgical patients from three hospitals. Each hospital contributed 100 randomly selected patients ventilated 2–7 days and 100 patients ventilated >7 days. All patients were independently assessed for VAP and for VAC. We compared incidence-density, duration of mechanical ventilation, intensive care and hospital lengths of stay, hospital mortality, and time required for surveillance for VAP and for VAC. A subset of patients with VAP and VAC were independently reviewed by a physician to determine possible etiology. Results Of 597 evaluable patients, 9.3% had VAP (8.8 per 1,000 ventilator days) and 23% had VAC (21.2 per 1,000 ventilator days). Compared to matched controls, both VAP and VAC prolonged days to extubation (5.8, 95% CI 4.2–8.0 and 6.0, 95% CI 5.1–7.1 respectively), days to intensive care discharge (5.7, 95% CI 4.2–7.7 and 5.0, 95% CI 4.1–5.9), and days to hospital discharge (4.7, 95% CI 2.6–7.5 and 3.0, 95% CI 2.1–4.0). VAC was associated with increased mortality (OR 2.0, 95% CI 1.3–3.2) but VAP was not (OR 1.1, 95% CI 0.5–2.4). VAC assessment was faster (mean 1.8 versus 39 minutes per patient). Both VAP and VAC events were predominantly attributable to pneumonia, pulmonary edema, ARDS, and atelectasis. Conclusions Screening ventilator settings for VAC captures a similar set of complications to traditional VAP surveillance but is faster, more objective, and a superior predictor of outcomes.

Herpes Zoster and Postherpetic Neuralgia Surveillance Using Structured Electronic Data

Abstract: OBJECTIVE To develop electronic algorithms for rapid, automated surveillance for herpes zoster and postherpetic neuralgia (PHN) using codified electronic health data. PATIENTS AND METHODS We attempted to identify every case of herpes zoster and PHN arising between January 1 and December 31, 2008, within the electronic medical record of a 560,000-patient ambulatory practice using an array of diagnosis codes; intervals between herpes zoster encounters; and prescriptions for analgesics, anticonvulsants, and antidepressants. We assessed the sensitivity and positive predictive value (PPV) of each screening criterion by medical record review and then integrated multiple criteria into combination algorithms to optimize sensitivity and PPV. We applied the optimized algorithms to the practice's historical data spanning January 1, 1996, to December 31, 2008, to assess for changes in the annual incidence of PHN. RESULTS The International Classification of Diseases, Ninth Revision, code 053 detected herpes zoster with 98% sensitivity and 93% PPV. A combination algorithm including diagnosis codes, visit intervals, and prescriptions detected PHN with 86% sensitivity and 78% PPV. Between 1996 and 2008, the age- and sex-adjusted annual incidence of PHN rose from 0.18 to 0.47 cases per 1000 patients, and the proportion of herpes zoster patients progressing to PHN rose from 5.4% to 17.6%. CONCLUSION Novel algorithms incorporating multiple streams of electronic health data can reasonably detect herpes zoster and PHN. These algorithms could facilitate meaningful public health surveillance using electronic health data. The incidence of PHN may be increasing.

Harnessing Electronic Health Records for Public Health Surveillance

Abstract: Electronic medical record (EMR) systems are a rich potential source for detailed, timely, and efficient surveillance of large populations. We created the Electronic medical record Support for Public Health (ESP) system to facilitate and demonstrate the potential advantages of harnessing EMRs for public health surveillance. ESP organizes and analyzes EMR data for events of public health interest and transmits electronic case reports or aggregate population summaries to public health agencies as appropriate. It is designed to be compatible with any EMR system and can be customized to different states’ messaging requirements. All ESP code is open source and freely available. ESP currently has modules for notifiable disease, influenza-like illness syndrome, and diabetes surveillance. An intelligent presentation system for ESP called the RiskScape is under development. The RiskScape displays surveillance data in an accessible and intelligible format by automatically mapping results by zip code, stratifying outcomes by demographic and clinical parameters, and enabling users to specify custom queries and stratifications. The goal of RiskScape is to provide public health practitioners with rich, up-to-date views of health measures that facilitate timely identification of health disparities and opportunities for targeted interventions. ESP installations are currently operational in Massachusetts and Ohio, providing live, automated surveillance on over 1 million patients. Additional installations are underway at two more large practices in Massachusetts.