Center for Evidence-based Practice | University of Pennsylvania Health System

Penn Study Shows Automated Prediction Alert Helps Identify Patients at Risk for 30-Day Readmission

11/27/2013 An automated prediction tool which identifies newly admitted patients who are at risk for readmission within 30 days of discharge has been successfully incorporated into the electronic health record of the University of Pennsylvania Health System. The tool, developed by researchers at the Perelman School of Medicine, is the subject of a study published in the December issue of the Journal of Hospital Medicine.

The all-Penn team found that having been admitted to the hospital two or more times in the 12 months prior to admission is the best way to predict which patients are at risk for being readmitted in the 30 days after discharge. As a result of this finding, the automated tool is now able to identify patients as being “high risk” for readmission and creates a “flag” in their electronic health record. Upon admission of a high-risk patient, the flag appears next to the patient’s name in a column titled “readmission risk.” The flag can be double-clicked to display detailed information relevant to discharge planning including inpatient and emergency department visits over the previous 12 months, as well as information about the care teams, lengths of stay, and problem(s) associated with those prior admissions.

“The results we’ve seen with this tool show that we can predict, with a good deal of accuracy, patients who are at risk of being readmitted within 30 days of discharge,” said lead author Charles A. Baillie, MD, an internal medicine specialist and fellow in the Center for Clinical Epidemiology and Biostatistics at Penn Medicine. “With this knowledge, care teams have the ability to target these patients, making sure they receive the most intensive interventions necessary to prevent their readmission.”

Interventions proven to help reduce 30-day readmissions include enhanced patient education and medication reconciliation on the day of discharge, increased home services to provide a safe landing, follow up appointments soon after discharge, and follow-up phone calls to ensure an extra level of protection. In the process of medication reconciliation, pharmacists compare a patient's current hospital medication orders to all of the medications that the patient was taking at home prior to their hospital admission. This is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

In support of the study, the Penn Medicine Center for Evidence-based Practice identified in the published literature a number of variables associated with readmission to the hospital, including: prior admissions, visits to the emergency department, previous 30-day readmissions, and the presence of multiple medical disorders.

Using two years of retrospective data, the team examined these variables using their own local data and found that a single variable – prior admission to the hospital two or more times within a span of 12 months – was the best predictor of being readmitted in the future. This marker was integrated into the electronic health record and was studied prospectively for the next year. During that time, patients who triggered the readmission alert were subsequently readmitted 31 percent of the time. When an alert was not triggered, patients were readmitted only 11 percent of the time.

“By automating the process of readmission risk prediction, we were able to provide risk assessment quickly and efficiently in real time, enabling all members of the inpatient team to carry out a coordinated approach to discharge planning, with special attention paid to those identified as being at the highest risk for readmission,” said Craig A Umscheid, MD, MSCE, assistant professor of Medicine and Epidemiology, director of the Penn Medicine Center for Evidence-based Practice, and senior author on the study.

The risk assessment tool is part of a series of steps taken by Penn Medicine to reduce readmissions.

“Readmission rates should improve over time as the risk flag is used more routinely and the interventions necessary to reduce readmission rates for those identified as high risk are implemented,” said Baillie.
In addition to Baillie and Umscheid, other Penn Medicine co-authors include Christine VanZandbergen, Gordon Tait, Asaf Hanish, Brian Leas, Benjamin French, C. William Hanson, and Maryam Behta.

Penn Medicine Review Finds Statin Use Not Linked to a Decline in Cognitive Function

11/18/2013 Based on the largest comprehensive systematic review to date, researchers at the Perelman School of Medicine at the University of Pennsylvania concluded that available evidence does not support an association between statins and memory loss or dementia. The new study, a collaborative effort between faculty in Penn Medicine’s Preventive Cardiovascular Program, the Penn Memory Center, and the Penn Center for Evidence-Based Practice, will be published in Annals of Internal Medicine.

“Statins are prescribed to approximately 30 million people in the United States, and these numbers may increase as a result of the national cholesterol guidelines recently released,” said senior study author Emil deGoma, MD, assistant professor of Medicine and medical director of the Preventive Cardiovascular Program at Penn. “A wealth of data supports a benefit of these cholesterol-lowering medications among individuals at risk for cardiovascular disease in terms of a reduction in the risk of heart attack and stroke; however, potential side effects of statins are less well understood. In February 2012, largely based on anecdotal reports, the U.S. Food and Drug Administration (FDA) issued a safety statement warning patients of possible adverse cognitive effects associated with statin use. Many concerned patients have asked if there is a relationship between statins and memory problems. Their concerns, along with the FDA statement, prompted us to pursue a rigorous analysis of all available evidence to better answer the question – are statins associated with changes in cognition?”

The research team conducted a systematic review of the published literature and identified 57 statin studies reporting measures of cognitive function. Dr. deGoma and colleagues found no evidence of an increased risk of dementia with statin therapy. In fact, in cohort studies, statin users had a 13 percent lower risk of dementia, a 21 percent lower risk of Alzheimer’s disease, and a 34 percent lower risk of mild cognitive impairment compared to people who did not take statins.

Most importantly, cognitive test scores were not adversely affected by statin treatment in randomized controlled trials. In these trials, roughly half of the study participants received statins and the other half received placebo. All study participants underwent formal testing of memory and other cognitive domains through tests such as the ability to recall a set of numbers. The analysis of 155 cognitive tests spanning eight categories of cognitive function, including 26 tests of memory, revealed no differences between study participants treated with statins and those provided placebo.

The research team additionally performed an analysis of the FDA post-marketing surveillance databases and found no difference in the frequency of cognitive adverse event reports between statins and two commonly prescribed cardiovascular medications that have not been associated with cognitive impairment, namely, clopidogrel and losartan.

“Overall, these findings are quite reassuring. I wouldn’t let concerns about adverse effects on cognition influence the decision to start a statin in patients suffering from atherosclerotic disease or at risk for cardiovascular disease. I also wouldn’t jump to the conclusion that statins are the culprit when an individual who is taking a statin describes forgetfulness. We may be doing more harm than good if we withhold or stop statins – medications proven to reduce the risk of heart attack and stroke – due to fears that statins might possibly cause memory loss,” said Dr. deGoma.

The team acknowledges that while their analysis is reassuring, large, high-quality randomized controlled trials are needed to confirm their findings.

“For many of the cognitive outcomes that we examined, the identified studies were small, were at risk for bias, used varying diagnostic tests to assess cognitive domains, and did not include patients on high-dose statins, which is important given the increasing use of high-dose statins for secondary prevention,” noted study co-author Craig Umscheid, MD, MSCE, assistant professor of Medicine and Epidemiology and director of the Penn Center for Evidence-based Practice. “Thus, additional trials addressing these limitations would strengthen our conclusions. Despite this, the totality of the evidence does reassure us that there’s unlikely to be a significant link between statins and cognitive impairment.”
Additional Penn authors include Marisa Schoen, BA, Benjamin French, PhD, Matthew D. Mitchell, PhD, Steven E. Arnold, MD, and Daniel J. Rader, MD.

UPHS Team Awarded for Using Information Technology to Reduce Catheter—Associated Urinary Tract Infections

12/04/2012 A Penn Medicine team led by Craig Umscheid, MD, MSCE, FACP, assistant professor of medicine and epidemiology and director of the Center for Evidence-based Practice has won the first place 2012 Health Care Improvement Foundation's (HCIF) "Patient Safety and Quality Award” for its work leveraging information technology to decrease catheter-associated urinary tract infections (CAUTIs).

Established in 2002, the annual honor recognizes "innovative contributions in advancing patient care" and comes with a $5,000 grant to support future efforts in patient safety research. The award was announced at yesterday's annual meeting of the Delaware Valley Healthcare Council of the Hospital & Healthsystem Association of Pennsylvania.

CAUTIs are the most common type of healthcare-associated infection. As much as 70 percent of CAUTIs may be preventable with recommended infection control measures; resulting in as many as 380,000 fewer infections and preventing as many as 9,000 deaths each year. To help eliminate these infections, the Penn Medicine Center for Evidence-based Practice (CEP) worked with the Centers for Disease Control and Prevention to revise the national guidelines on preventing CAUTIs. Then, leaders from Nursing, Infection Control, Quality and Safety, and Information Technology at Penn Medicine collaborated with CEP to integrate the guidelines into computerized clinical decision support to reduce CAUTIs locally.

Over about a year of using this system, the group found that the intervention helped physicians decide whether their patients needed urinary catheters, and alerted physicians when catheters needed to be removed (reducing the days they were used overall).

The life-saving technology, together with other health system interventions, reduced CAUTIs by about 50 percent over about one year. Estimates suggest this effort also led to an estimated financial savings of approximately $140,000 annually.

HCIF is an independent, nonprofit corporation that fosters healthcare initiatives aimed at improving the safety, outcomes, and care experiences in health care facilities across the five-county Philadelphia region.

Penn Medicine Partners with ECRI to Win Evidence-Based Practice Center Designation from the Agency for Healthcare Research and Quality

9/18/2012 The University of Pennsylvania Health System’s Center for Evidence-based Practice, in partnership with the ECRI Institute, a nonprofit organization dedicated to researching approaches to improve patient care, has been selected by the Agency for Healthcare Research and Quality (AHRQ) as one of its 11 Evidence-based Practice Centers (EPCs). This new EPC designation will allow ECRI Institute and Penn Medicine clinicians and researchers to bid for projects through AHRQ to review and synthesize literature on preventive, therapeutic and diagnostic interventions to assess which are most beneficial to patients. The work informs clinical practice guidelines for physicians and educational materials for patients, as well as health-care-related decisions by the federal government, states, and national medical societies, such as those related to the development of new measures of clinical effectiveness and quality.

“We are extremely excited to partner with ECRI on the synthesis of those research findings most important to our patients’ health,” says Craig A. Umscheid, MD, MS, a hospitalist at the Hospital of the University of Pennsylvania, director of the Penn Medicine Center for Evidence-based Practice, and Senior Associate Director of the newly formed ECRI Institute-Penn Medicine EPC. “ECRI’s objectivity and methodologic soundness set the standard for the field of research synthesis. Combined with the breadth and depth of our faculty’s clinical and research expertise, and our Center’s local experience in supporting patient care through research synthesis and dissemination, we’ll be positioned to make a real difference.”

There are no specific dollar amounts that are guaranteed from winning this designation, but the designation itself allows the ECRI-Penn EPC as well as the other 10 AHRQ EPCs to compete for up to $50 million worth of contracts from AHRQ in the next five years.

“We are pleased and honored to hold the trust of AHRQ and the healthcare system more broadly in advancing the science of systematic review to assess the effectiveness of healthcare interventions and practices based on outcomes that matter to patients,” says Karen Schoelles, MD, SM, director of the ECRI Institute-Penn Medicine EPC.

Associate Clinical Informatics Officer - Office of the Chief Medical Information Officer
University of Pennsylvania Health System

The Office of the Chief Medical Officer (CMO) is accountable for patient care quality and safety, and has established the Blueprint for Quality and Patient Safety to guide these efforts. The Chief Medical Information Officer (CMIO) is responsible for ensuring that clinical information technology initiatives align with the Blueprint. The Associate Clinical Informatics Officer will support clinical decision support activities (CDS) and clinical IT initiatives throughout Penn Medicine including staffing the system-wide CDS Workgroup. The mission of the CDS program at Penn is to facilitate evidence-based clinical decision making consistent with the goals of the Blueprint so as to provide patients with the highest quality, safest and highest value care. The Penn Medicine CDS Workgroup is established within the Center for Evidence-based Practice (CEP) to advance the goals of the CDS program. The Workgroup is led by the Director of CEP, who functions as the Medical Director of CDS and reports on CDS activities to the CMIO and CMO. The Associate Clinical Informatics Officer will partner with the Medical Director of CDS to advance the goals of the CDS program. For more information and to apply, see the link below:

Healthcare Technology Assessment Analyst - Center for Evidence-Based Practice
University of Pennsylvania Health System

The mission of the University of Pennsylvania Health System (UPHS) Center for Evidence-Based Practice (CEP) is to support the quality, safety and value of patient care at UPHS through evidence-based practice. The CEP Analyst position is at the core of these translational activities, and is accountable for preparing evidence reviews to inform high impact clinical policy at UPHS. Secondary accountabilities include the dissemination and implementation of findings from the review process. Applicants should have experience in performing systematic reviews and meta-analyses, computer skills including expertise with Microsoft Office, statistical software and bibliographic management software, and a Masters degree or doctorate in clinical epidemiology or related fields, or a background in health technology assessment. Individuals with clinical proficiency are particularly encouraged to apply.

Interested candidates should contact Craig A Umscheid, MD, MSCE, Assistant Professor of Medicine and Epidemiology and Director of the UPHS Center for Evidence-based Practice for more information.