Wednesday, May 29, 2013

Patient Safety MOOC

There is a MOOC (Massive On-line Open Course) focused on patient safety
taught by Peter Pronovost and colleagues-it is free.
https://www.coursera.org/#course/healthcaresafety

Tuesday, May 28, 2013

Clinical Research Oriented Workshop (CROW) Meeting: May 23, 2013



Present:  Abby Crocker, Kairn Kelley, Rodger Kessler, Ben Littenberg, Connie van Eeghen
1.                  Start Up: Ben’s dad is turning 89 – hooray!

2.                  Journal Article Review Kairn: Discussion of binomial model in 1978 journal article by Thornton Raffin “Speech Discrim Scores Modeled As Binomial Variable”
a.       Article focuses on a specific test: W22; Kairn uses a similar test (single syllable words): NU6
b.      One part of the article is focused on adjusting the confidence limits of this use of a binomial distribution.  There are several ways to do this transformation; the various methods aren’t in complete agreement with each other but they’re close.
c.       The article does not use a standard binomial distribution; it uses a transformation to account for distributions that can’t be normally shaped because their means are close to extreme values (i.e. close to 0 or 100).  Per Abby, the appendix does a good job illustrating how the transformation variable theta is derived. 
d.      These adjusted confidence intervals estimate a range of uncertainty but don’t indicate whether 2 scores are different.  To figure this out, we need to know the proportions of the two scores (# right/total), the difference between them, and the standard deviation of the difference.  Abby explained this as the combined, pooled estimate, which is described here as the square root of the sum of each “pooled” proportion complement, each divided by sample size.  Or, SQRT((PQ/N1)+(PQ/N2)) as an Excel formula. 
e.       We tested this out manually and then validated with a chi square and Fisher’s Exact on Stata.  It worked!  The point of the article, though, was that the binomial distribution needs to be adjusted for test results at the extreme (when a tester gets all or none of the responses right).  In these cases, the distribution is skewed because the number of wrong responses can’t be less than 0 or greater or 100.
f.       Abby went on to show us the shape of the binomial distribution and how it changes using our proportion estimates, mirroring the distribution we had been working on.  The distribution will look like a normal model for probabilities that are not close to the extreme ends of the scale. 
g.      Abby pointed out that when the small proportions are very small (i.e. the denominator is very large or incalculable), the preference is to use the Poisson distribution, rather than a very skewed binomial distribution. 
h.      The reason this discussion is important is because many audiologists don’t have a strong understanding of probability and it could be possible to interpret changes in test scores incorrectly.  This work can both help develop strong research methods and help develop a method for communicating the results clearly to audiologists.  Use the chi square for the difference between two results and use a transformation (a table or sin arc formula) to the normal model to create confidence intervals.

3.                  Next Workshop Meeting(s): Thursday, 2:00 p.m. – 3:30 p.m., at Given Courtyard South Level 4. 
a.       Thursday, May 30:  (no Abby) LAST THURSDAY MEETING Ben: Journal article by Feldman, 2013, “Impact of Providing Fee Data on Laboratory Test Ordering, JAMA
b.      Wednesday, June 5: NOTE: New summer schedule will start: Wednesdays, 11:30 – 1:00.  Abby: Journal article (no Connie)
c.       Wednesday, June 12: Marianne: Feedback on ideas for web site that will help CTS students (faculty, and fellows too)  find/know /access, evaluate/apply content and literature they need for courses and research
d.      Thursday, June 13: 2:00 – 3:30 Wilson Pace, Director & Dave West from the largest practice based research networks from American Academy of Family Physicians; access to Medicaid data base.  Kairn, Abby, Charlie can all make it. 
e.       Wednesday, June 19:
f.       June 26:
g.      July 3:
h.      July 10: Marianne: Review of literature review
i.        July 17:
j.        July 24:
k.      July 31:
l.        August 7
m.    August 14
n.      August 21
o.      August 28
p.      Future agenda to consider:
                                                  i.      Abby and Charlie: data analysis of Exploration of analytical plan for Natural History of Acute Opioid Use
                                                ii.      Peter Callas or other faculty on multi-level modeling
                                              iii.      Charlie MacLean: demonstration of Tableau; or Rodger’s examples of Prezi
                                              iv.      Journal article: Gomes, 2013, Opioid Dose and MVA in Canada (Charlie)
                                                v.      Ben: Tukey chapter reading assignments, or other book of general interest
                                              vi.      Summer plan: each week, one person will send out an article or prezi ahead for review or discussion by all.  Alternatively, if a participant is working on a key document for their professional development, this is also welcome (e.g. K awards, F awards, etc.)

Recorder: Connie van Eeghen

Tuesday, May 21, 2013

Clinical Research Oriented Workshop (CROW) Meeting: May 16, 2013



Present:  Marianne Burke, Abby Crocker, Kairn Kelley, Rodger Kessler, Ben Littenberg, Charlie MacLean, Connie van Eeghen
1.                  Start Up: Project review for GIM-Research – to be posted on SharePoint, when we set up a new site.

2.                  Presentation: Connie: Feedback on poster presentation on “Quick Turns in Tight Places: Implementing Change in Small Practices,” to be presented at Academy Health at the end of June in Baltimore.  Comments:
a.       Focus on the audience: predominately researchers rather than clinicians.  They will be more interested in the method of implementation than in the practice strategies for managing opioid prescriptions.
b.      Organize the poster to visually support this: the process flow steps go top and center, not the strategies.  Shrink the strategies, remove the “universal” part of the title as this is not self-explanatory to this group and does not add to the discussion.
c.       Change the color scheme in the process flow: using yellow on the one least used step makes it look like the most important step. 
d.      Add an “Intervention” section to highlight the process flow; remove this language from Methods
e.       Modify the objectives to match this focus.
f.       Streamline the discussion to focus on the points about the intervention.
g.      Adjust the title to reflect all of the above.  Yes, it’s been accepted under the current title, but as long as the first five words stay the same, it won’t confuse the audience. Add the department name.
h.      (Took a half hour – Efficiency is Us!)

3.                  Manuscript Review: Connie: Introduction and Methods sections of manuscript with working title: “Integrating Behavioral Health using Workflow (Lean)”
a.       As with the above poster, it is important to emphasize the key purpose of the study.  In this case, with submission planned for JGIM, the readers are clinicians with a keen interested in the topic of integrating behavioral health (BH), with less interest/prior understanding of Lean.  So this is a story about integration, its impact, and what the participants (providers and staff) thought about the method of integration, which happens to be Lean.
b.      Lots of helpful rewording, with clearer language; not listed here.
c.       Discussion of whether we should add 18 months of data and re-analyze: the P value is about as good as it can get, so more data are not needed to improve power.  And in the 3-4 months it would take to re-do, we likely wouldn’t have gained much.  Keep as is.
d.      Debated identifying the practice.  At this point, no.
e.       Next step: rewrite, with Results & Discussion, and ask for more comments.  Thank you!

4.                  Next Workshop Meeting(s): Thursday, 2:00 p.m. – 3:30 p.m., at Given Courtyard South Level 4. 
a.       May 23: Kairn: Discussion of binomial model in 1978 journal article by Thornton Raffin “Speech Discrim Scores Modeled As Binomial Variable” (no Marianne)
b.      May 30:  (no Abby)
c.       June 5: NOTE: New summer schedule will start: Wednesdays, 11:30 – 1:00.  Abby: Shared learning on the NAMCS, DAWN, NHANES and KID databases?
d.      June 12: Marianne: Feedback on ideas for web site that will help CTS students (faculty, and fellows too)  find/know /access, evaluate/apply content and literature they need for courses and research
e.       June 19:
f.       June 26:
g.      July 3:
h.      July 10: Marianne: Review of literature review
i.        July 17:
j.        July 24:
k.      July 31:
l.        4 Wednesdays in August
m.    Future agenda to consider:
                                                  i.      Abby and Charlie: data analysis of Exploration of analytical plan for Natural History of Acute Opioid Use
                                                ii.      Peter Callas or other faculty on multi-level modeling
                                              iii.      Charlie MacLean: demonstration of Tableau
                                              iv.      Journal article: Gomes, 2013, Opioid Dose and MVA in Canada (Charlie)

Recorder: Connie van Eeghen

Wednesday, May 15, 2013

Clinical Research Oriented Workshop (CROW) Meeting: May 9, 2013



Present:  Marianne Burke, Abby Crocker, Kairn Kelley, Amanda Kennedy, Ben Littenberg, Charlie MacLean, Connie van Eeghen
1.                  Start Up: Connie reported back from a poster presentation in Denver; great opportunity to meet new colleagues

2.                  Presentation: Charlie MacLean: Exploration of analytical plan for Natural History of Acute Opioid Use
a.       Key points from the 2009 Boudreau article that Amanda found in her lit review: Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain (CNCP)
                                                  i.      CONSORT study of adults enrolled in two health plans serving > 1% of US population (4m)
                                                ii.      Automated health plan data to construct episodes of opioid use 1997-2005; incidence & prevalence; rates of change
                                              iii.      Long term episode: >90 days with 120+ days’ supply or 10+ opioid rx in one year
                                              iv.      Results: incident long term use increased from 8.5 to 12.1/1000 (Group Health) with 6% annual change (PCA) and 6.3 to 8.6/1000 (Kaiser Permanente) with 5.5 PCA
1.      Small increases observed in overall use of opioids: 2.2 PCA and 0.83 PCA
2.      Prevalent long term use almost doubled: 8.1 PCA and 8.6 PCA
3.      Incident long term use lasted > 1 year for 75% of episodes
                                                v.      Non-Schedule II opioids most common and increased in long term use
1.      MEq dose was stable for incident long term opioid users
                                              vi.      Regular users of sedative hypnotics: 28.6% (GH) and 30.2% (KPNC)
                                            vii.      Conclusion: increasing prevalence; need to study benefits and risks.  Need to study concurrent use of opioids and sedative-hypnotics, which were unexpectedly common
b.      Amanda provide a draft introduction and her search strategy.
                                                  i.      Target population: adults getting their first dose of opioids with the intention of short term management.
c.       Research Question: what proportion of opioid na├»ve adult patients started on an opioid become long term users?  What are the characteristics of use?  What are the predictors of long term use?
                                                  i.      Previous study (Boudreau, above) provides definitions for “long term,” although we may not be able to determine “days’ supply.”  Can be estimated and evaluated with a sensitivity analysis.  We can look only at first to last claim, not scripts.
                                                ii.      Can be constructed as a survival analysis, with the “survivors” being those who continue to generate additional claims. 
d.      Ben & Abby sketched out statistical analyses
                                                  i.      Kaplan-Meier survival analysis
                                                ii.      Logistic regression based on whether or not patient became long term/chronic, with variables of interest:
1.      Should cancer-related opioid use be included?  Literature is separate.  We cannot easily determine patients considered terminally ill and long term consequences of opioid use for this population is not a great concern. May be identifiable by provider or treatments.  Retain the data and examine: does the inclusion of cancer patients make a difference? Plan to stratify on cancer patients.
2.      Eliminate non-opioid patients.
3.      Eliminate non-opioid medications as inclusion criteria; keep as covariates.  Include all opioids, including non-Schedule II.
4.      Classify each episode as acute or chronic.
5.      Collect predictive data: age, sex, nearness of provider (zip code), prior episodes, prior rx, prior chronic episodes, recent diagnoses (low back pain, headache), other med use, prescriber (specialty: PCP, ED, other; buprenorphine prescribers; methadone prescribers; chronicity index-preference for prescribing opioids), length of days of dose, dosage, insurer, co-morbid mental health conditions (anti-depressant use, diagnosis within past six months… but keep benzo’s separate), history of substance use disorder (previous SA claims), zip code linked to median income and education; out-of-state pharmacy (mail or picked up) based on pharmacy zip code
6.      Drug index: was the initial drug a long or short acting formulation? 
7.      Hospital initiation: Will not see hospital prescriptions but will include hospital claims.  96 hours post-hospital filled rx is likely to be a hospital-initiated drug.
                                              iii.      Charlie: how do the prescribers cluster in prescribing patterns or preferences
e.       Specification for data report
                                                  i.      One record for each claim, linking medication data and patient data: Charlie and Abby over the next two weeks (on May 17th)
1.      Steve Kappel this morning released a 5 gig data base for Charlie to review: all prescriptions from all prescribers; not the other claims: Charlie will import and clean
                                                ii.      Test data for face validity BEFORE excluding any claims from the study
1.      Clean in STATA: Abby and Charlie
2.      Run descriptive analyses – in CROW: Abby and Charlie
                                              iii.      Meet with Neil S on validation plan (Abby to join biweekly Tuesday meetings)
1.      Request IRB permission for validation process
2.      Validation process needed to confirm that patient identifiers are unique (not shared with other patients ) and not duplicated (only one per patient).  May need to cross-validate with other data sources, under supervision by the IRB.
a.       Use four years of data to build predication model; test model on data from year 5 – or hold out 20% of data, to avoid problems with a time trend – or both
b.      One time related issue is the policy decision to avoid prescribing NSAIDs to elderly (over 65) in order to avoid stomach and kidney problems, resulting in greater use of opioids
                                              iv.      Analysis – CROW session TBD

3.                  Summer sessions: consider Wed 11:30 – 1:00 starting June 5.  Will ask Sylvie for help in figuring this out.

4.                  Next Workshop Meeting(s): Thursday, 2:00 p.m. – 3:30 p.m., at Given Courtyard South Level 4. 
a.       May 16: Connie: Feedback on poster presentation on “Quick Turns in Tight Places: Implementing Change in Small Practices” and the Introduction and Methods sections of manuscript with working title: “Integrating Behavioral Health using Workflow (Lean)”
b.      May 23:
c.       May 30:  
d.      June 5: New summer schedule will start
e.       Future agenda to consider:
                                                  i.      Christina Cruz, 3rd year FM resident with questionnaire for mild serotonin withdrawal syndrome?
                                                ii.      Peter Callas or other faculty on multi-level modeling
                                              iii.      Charlie MacLean: demonstration of Tableau
                                              iv.      Journal article: Gomes, 2013, Opioid Dose and MVA in Canada (Charlie)

Recorder: Connie van Eeghen