AHRQ Redesignates ECRI Institute-Penn Medicine as Evidence-based Practice Center
New 5-year contract supports the Agency for Healthcare Research and Quality in its efforts to disseminate scientific research of important healthcare topics
January 30, 2015 — The ECRI Institute-Penn Medicine Evidence-based Practice Center (EPC) was recently redesignated by the Agency for Healthcare Research and Quality (AHRQ) to serve as an EPC through 2019. ECRI Institute has maintained this designation since the inception of the EPC program in 1997. The ECRI Institute-Penn Medicine EPC was established in 2012.
Under the new contract, known as EPC V, the ECRI Institute-Penn Medicine EPC will work with clinicians, policymakers, patients, consumers, and other scientific partners to develop topics and questions for systematic review of the literature, and to promote the synthesis, translation, and dissemination of research evidence. The EPC has reported on a variety of topics, many in the area of cancer, genetic testing, and imaging tests (access free reports).
As part of the new contract, all 13 Evidence-based Practice Centers will be eligible to bid on work to support the U.S. Preventive Services Task Force (USPSTF), an independent, volunteer panel of experts in prevention and evidence-based medicine dedicated to improving the health of Americans.
“Since we began working together, we’ve been able to utilize ECRI Institute’s independent, evidence-based research and Penn Medicine’s clinical and academic leadership to advance research to improve patient care,” says Karen Schoelles, MD, SM, director of the ECRI Institute-Penn Medicine EPC. “This new contract inspires us to build on our previous collaborations and break into new research territory.
”“We look forward to continuing our efforts to transform patient care delivery as we work alongside ECRI Institute and AHRQ,” says Craig A. Umscheid, MD, MSCE, director of the Penn Medicine Center for Evidence-based Practice and senior associate director of the ECRI Institute-Penn Medicine EPC.
The EPC will work with Insight Policy Research, a small woman-owned disadvantaged business.
To learn more about ECRI Institute’s work in evaluating health technologies through the Evidence-based Practice Center, membership in the Health Technology Assessment Information Service, and customized consultation and support for clinical practice guideline development, e-mail email@example.com, or call (610) 825-6000, ext. 5519.
Penn Medicine Experts Urge Expansion of Federal Incentives to Improve Patient Care Quality and Safety
Focusing on structural changes in addition to individual clinical outcomes would bring greater gains
January 13, 2015 — In an invited commentary published online by JAMA Internal Medicine, Patrick J. Brennan, MD, chief medical officer of the University of Pennsylvania Health System, and Craig A. Umscheid, MD, MSCE, director of Penn’s Center for Evidence-based Practice, recommend that the Centers for Medicare and Medicaid Services shift its use of financial incentives from an exclusive focus on preventing specific clinical outcomes toward encouraging the creation of hospital-wide structures that promote the translation of research evidence into clinical practice to improve the quality and safety of patient care.
In 2008, Medicare implemented the Hospital-Acquired Conditions Initiative, a policy denying incremental payment for eight complications of hospital care, also known as “never events.” Another study published in JAMA Internal Medicine led by Teresa Waters, PhD, of the University of Tennessee Health Science Center, found that after the new federal policy was introduced, central line-associated bloodstream infections fell by 11 percent and catheter-associated urinary tract infections fell by ten percent. But there was no significant reduction in hospital-acquired pressure ulcers and serious inpatient falls.
The study authors suggested that the difference in the policy’s effects on infections as compared to falls and pressure ulcers were the result of the evidence available at the time to guide hospitals to improve these outcomes.
But the Penn authors disagreed. Instead, they suggested that the difference in the policy’s effect had more to do with the challenge of improving complex quality outcomes such as pressure ulcers and inpatient falls, when compared to the easier-to-improve outcome of infections. Unlike infection prevention efforts, which often target care providers and involve changes to a limited set of procedures such as catheter insertion and occur in closely monitored settings such as intensive care units, efforts at reducing falls and pressure ulcers are much more complex. They require multidisciplinary, patient-centered collaboration across the entire spectrum of care, not just critical care.
“Incentives are indeed important,” says Brennan. “But they must be the right incentives. There was good-quality evidence available to underpin fall and pressure ulcer prevention efforts when the CMS initiative was launched. Yet neither of these measures has significantly improved. This may be because it’s simply not possible to reduce falls and pressure ulcers by taking a few clear-cut steps, as in the case of reducing infections. Instead, broader and more comprehensive structural changes within hospitals should be considered. Such efforts would reduce an even larger number of never events than by simply tackling them one at a time.”
Hospitals should aim to bridge what’s called the “knowing-doing gap,” Umscheid says. “That’s the disconnect between what we know works based on the best available evidence and what we actually practice. To bridge the gap, we are not advocating abandoning incentives that focus on individual clinical outcomes. Instead we are urging federal regulators to also encourage institution-wide structural changes. We believe these changes can create the necessary conditions for solving difficult problems such as falls and pressure ulcers -- and others as well.”
The structural changes suggested by Brennan and Umscheid are the fabric of Penn Medicine’s successful quality improvement program. They include:
- establishing unit-based leadership, where physicians, nurses, and quality administrators work together on their local wards or clinics to ensure that quality standards are met
- creating data stores that can provide local evidence for which quality initiatives are effective
- investing in staff education on evidence-based quality improvement, including in-house learning academies
- opening local evidence-based practice centers, where experts can identify and adapt national evidence and best practices to address local problems identified by staff
Penn Medicine's "Sepsis Sniffer" Generates Faster Sepsis Care and Suggests Reduced Mortality: Early identification and intervention lead to better results for hospital inpatients
October 9, 2014 — An automated early warning and response system for sepsis developed by Penn Medicine experts has resulted in a marked increase in sepsis identification and care, transfer to the ICU, and an indication of fewer deaths due to sepsis. A study assessing the tool is published online in the Journal of Hospital Medicine.
Sepsis is a potentially life-threatening complication of an infection; it can severely impair the body’s organs, causing them to fail. There are as many as three million cases of severe sepsis and 750,000 resulting deaths in the United States annually. Early detection and treatment, typically with antibiotics and intravenous fluids, is critical for survival.
The Penn prediction tool, dubbed the “sepsis sniffer,” uses laboratory and vital-sign data (such as body temperature, heart rate, and blood pressure) in the electronic health record of hospital inpatients to identify those at risk for sepsis. When certain data thresholds are detected, the system automatically sends an electronic communication to physicians, nurses, and other members of a rapid response team who quickly perform a bedside evaluation and take action to stabilize or transfer the patient to the intensive care unit if warranted.
The study developed the prediction tool using 4,575 patients admitted to the University of Pennsylvania Health System (UPHS) in October 2011. The study then validated the tool during a pre-implementation period from June to September 2012, when data on admitted patients was evaluated and alerts triggered in a database, but no notifications were sent to providers on the ground. Outcomes in that control period were then compared to a post-implementation period from June to September 2013. The total number of patients included in the pre and post periods was 31,093.
In both the pre- and post-implementation periods, four percent of patient visits triggered the alert. Analysis revealed 90 percent of those patients received bedside evaluations by the care team within 30 minutes of the alert being issued. In addition, the researchers found that the tool resulted in:
• A two to three-fold increase in orders for tests that could help identify the presence of sepsis
• A 1.5 to two-fold increase in the administration of antibiotics and intravenous fluids
• An increase of more than 50 percent in the proportion of patients quickly transferred to the ICU
• A 50 percent increase in documentation of sepsis in the patients’ electronic health record
The study found a lower death rate from sepsis and an increase in the number of patients successfully discharged home, although these findings did not reach statistical significance.
“Our study is the first we’re aware of that was implemented throughout a multihospital health system,” said lead author Craig A. Umscheid, MD, MSCE, director of Penn’s Center for Evidence-based Practice. “Previous studies that have examined the impact of sepsis prediction tools at other institutions have only taken place on a limited number of inpatient wards. The varied patient populations, clinical staffing, practice models, and practice cultures across our health system increases the generalizability of our findings to other health care settings.”
Umscheid also noted that the tool could help triage patients for suitability of ICU transfer. “By better identifying those with sepsis requiring advanced care, the tool can help screen out patients not needing the inevitably limited number of ICU beds.”
In addition to Umscheid, the other Penn co-authors are Joel Betesh, MD; Christine Vanzandbergen, PA, MPH; Asaf Hanish, MPH; Gordon Tait, BS; Mark E. Mikkelsen, MD, MSCE; Benjamin French, PhD; and Barry D. Fuchs, MD, MS.
Dr. Umscheid’s contribution to this project was supported in part by the National Institutes of Health, National Center for Advancing Translational Sciences, grant # UL1TR000003.
Penn Study: Electronic Alerts Significantly Reduce Catheter-Associated Urinary Tract Infections - Design of alerts crucial in achieving benefits for patients
August 22, 2014 — A Penn Medicine team has found that targeted automated alerts in electronic health records significantly reduce urinary tract infections in hospital patients with urinary catheters. In addition, when the design of the alert was simplified, the rate of improvement dramatically increased.
The alerts help physicians decide whether their patients need urinary catheters in the first place and then alert them to reassess the need for catheters that have not been removed within a recommended time period. The electronic alert, developed by medical researchers and technology experts at the Perelman School of Medicine at the University of Pennsylvania, is the subject of a study published in the September issue of Infection Control and Hospital Epidemiology.
Approximately 75 percent of urinary tract infections acquired in the hospital are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. According to the Centers for Disease Control and Prevention, 15 to 25 percent of hospitalized patients receive urinary catheters during their hospital stay. As many as 70 percent of urinary tract infections in these patients may be preventable using infection control measures such as removing no longer needed catheters resulting in up to 380,000 fewer infections and 9,000 fewer deaths each year.
“Our study has two crucial, applicable findings,” said the Penn study’s lead author Charles A. Baillie, MD, an internal medicine specialist and fellow in the Center for Clinical Epidemiology and Biostatistics at Penn Medicine. “First, electronic alerts do result in fewer catheter-associated urinary tract infections. Second, the design of the alerts is very important. By making the alert quicker and easier to use, we saw a dramatic increase in the number of catheters removed in patients who no longer needed them. Fewer catheters means fewer infections, fewer days in the hospital, and even, fewer deaths. Not to mention the dollars saved by the health system in general.”
In the first phase of the study, two percent of urinary catheters were removed after an initial “off-the-shelf” electronic alert was triggered (the stock alert was part of the standard software package for the electronic health record). Hoping to improve on this result in a second phase of the study, Penn experts developed and used a simplified alert based on national guidelines for removing urinary catheters they had previously published with the CDC. Following introduction of the simplified alert, the proportion of catheter removals increased more than seven-fold to 15 percent.
The study also found that catheter associated urinary tract infections decreased from an initial rate of .84 per 1,000 patient days to .70 per 1,000 patient-days following implementation of the first alert and .50 per 1,000 patient days following implementation of the simplified alert. Among other improvements, the simplified alert required two mouse clicks to submit a remove-urinary-catheter order compared to seven mouse clicks required by the original alert.
The study was conducted among 222,475 inpatient admissions in the three hospitals of the University of Pennsylvania Health System between March 2009 and May 2012. In patients’ electronic health records, physicians were prompted to specify the reason (among ten options) for inserting a urinary catheter. On the basis of the reason selected, they were subsequently alerted to reassess the need for the catheter if it had not been removed within the recommended time period based on the reason chosen.
Women’s health units had the highest proportion of alerts that led to a remove-urinary-catheter order and critical care units saw the lowest proportion of alerts leading to a remove order.
“As more hospitals adopt electronic health records, studies such as ours can help point the way toward improved patient care,” said senior author Craig Umscheid, MD, MSCE, assistant professor of Medicine and Epidemiology and director of Penn’s Center for Evidence-based Practice. “Thoughtful development and deployment of technology solutions really can make a difference. In this study, we learned that no two alerts are alike, and that changes to an alert’s usability can dramatically increase its impact.”
Several studies have already shown that reminder systems to limit the use and duration of urinary catheters can lower catheter infection rates. However, the majority of these have used non-computerized reminders, such as written reminders or stickers. The current Penn study is one of the largest to examine the impact of electronically generated alerts. In addition to the size of the study, a second strength is its multi-year duration. Most prior studies relied on a brief study period, and several studies observed an increase in catheter use when the relatively brief intervention had ended.
In addition to Baillie and Umscheid, other Penn Medicine co-authors are Mika Epps, MSN, RN; Asaf Hanish, MPH; Neil O. Fishman, MD; and Benjamin French, PhD.
Link Between Ritual Circumcision Procedure and Herpes Infection in Infants Examined by Penn Medicine AnalysisJuly 24, 2014 — A rare procedure occasionally performed during Jewish circumcisions that involves direct oral suction is a likely source of herpes simplex virus type 1 (HSV-1) transmissions documented in infants between 1988 and 2012, a literature review conducted by Penn Medicine researchers and published online in the Journal of the Pediatric Infectious Diseases Society found. The reviewers, from Penn’s Center for Evidence-based Practice, identified 30 reported cases in New York, Canada and Israel.
The practice—known as metzitzah b’peh—and its link to HSV-1 infections have sparked international debate in recent years, yet no systematic review of the literature has been published in a peer-reviewed journal examining the association and potential risk. During metzitzah b’peh, the mohel, a Jewish person trained to perform circumcisions, orally extracts a small amount of blood from the circumcision wound and discards it.
Lead author Brian F. Leas, MS, MA, a research analyst in the Center for Evidence-based Practice at the University of Pennsylvania Health System, identified six relevant studies for the systematic review. All six studies were descriptive case reports or case series that documented neonatal HSV-1 infections after circumcision with direct oral suction.
“There is sufficient clinical evidence to suggest the practice is a source of infection and therefore a risk exists—though the extent or magnitude of that risk is not well defined and warrants further investigation,” said Leas. All of the studies, the authors report, presented clinical findings consistent with the transmission of infection from mohel to infant, including the location of HSV lesions, timing of symptoms, and HSV type. Two infants died, whereas others experienced mild to severe symptoms of the virus.
More than half of American adults are infected with HSV-1, which frequently presents itself as oral lesions, or cold sores, though many people never or rarely develop symptoms. Newborns infected with HSV-1, on the other hand, can become very sick quickly with high fever and seizures, and it can even cause death. Herpes simplex virus type 2 is a sexually-transmitted disease and is characterized by genital lesions, and is less common, affecting about 16 percent of adults.
The practice of metzitzah b’peh has been used in some ultra-Orthodox Jewish circles; however, the researchers note it is unclear how many metzitzah b’pehs take place in the United States per year.
The New York City Department of Health and Mental Hygiene instituted regulations in the fall of 2012, after a number of babies contracted herpes following the practice. Mohels in New York City are required to obtain written consent from parents before performing metzitzah b’peh. New York City has a relatively higher population of those who identify as ultra-Orthodox compared to the rest of the country.
In a 2012 report, an American Academy of Pediatrics task force concluded that circumcision is safe and provides overall health benefits, including reducing the risk of HIV, but advised against direct oral suction due to risk of infection.
“Neonatal herpes infection can cause severe morbidity and potentially death, so mitigating potential risks for infection is critical,” the authors write. “More research using cohort or case-control designs to fully capture all the relevant data is needed to clarify the real-world risk of HSV-1 infection associated with metzitzah b’peh.”Craig A. Umscheid, MD, MSCE, an assistant professor of Medicine and Epidemiology at the Perelman School of Medicine and Director of Penn Medicine’s Center for Evidence-based Practice, was the senior author on the study.
Major Gaps in Hepatitis C Care Identified As New Drugs and Screening Efforts Emerge, Penn Study Finds.
Less than 10 percent of People Infected with Hepatitis C are Cured
In the largest study of its kind, the team examined data culled from 10 studies between 2003 and 2013 and found that less than 10 percent of people infected with hepatitis C in the United States — 330,000 of nearly 3.5 million people — were cured (achieved viral suppression) with antiviral hepatitis C treatment. The researchers also found that only 50 percent of people were diagnosed and aware of their infection; 43 percent of those with the disease had access to outpatient care; and only 16 percent were prescribed treatment.
“This study puts forth a good baseline of hepatitis C care in the United States over the last 10 years—which will be useful in monitoring the success and impact of new screening efforts and advances in antiviral therapy,” said the study’s first author,Baligh Yehia, MD, MPP, MSHP, an assistant professor of Medicine in Penn’s division of Infectious Diseases. “There are many people who don’t know that they have the infection, don’t have access to hepatitis C care and medications, and who haven’t been treated. With this data, we can see these gaps more clearly. This information will be useful for ensuring better access to hepatitis c care and treatment in the coming years.”
In June, the Centers for Medicare and Medicaid Services began reimbursing for hepatitis C virus screenings for two target populations, including baby boomers (those born between 1945 through 1965) and those at high risk for the infection. Six months prior, the U.S. Food & Drug Administration (FDA) approved sofosbuvir, an oral medication shown to cure most cases of hepatitis C infection, with fewer side effects than the current treatment options. Other drugs — which have shown success in clinical trials, some conducted at Penn Medicine—are expected to gain FDA approval within the year.
“The new regimens will be game changers in the treatment of chronic hepatitis C,” said senior author Vincent Lo Re III, MD, MSCE, assistant professor of Medicine and Epidemiology in the division of Infectious Diseases and department of Biostatistics and Epidemiology at Penn. “Given the high prevalence of this infection, particularly in baby boomers who didn’t know they were infected, having new, highly-effective treatment options to eradicate the virus will be a tremendous benefit to patients that will ultimately help us to reduce liver-related complications and re-infection rates.”
Such advances are expected to increase the number of patients treated for the disease. In the 1990s, HIV treatment turned a monumental corner with the advent of antiretroviral therapy. “It’s a very similar situation that we can learn from,” said Yehia. “With those advances, came challenges with access to and engagement in care. As hepatitis C therapy continues to advance, a focus on improving diagnosis, linkage to care, and insurance coverage will be more critical.”
The team screened close to 10,000 articles before identifying 10 studies that address one or more steps in the cascade of care, ranging from diagnosis to viral suppression. Some of the data came from the National Health and Nutrition Examination Survey and the Chronic Hepatitis B and C Cohort study. The researchers addressed seven key steps along this cascade and estimated the following based off the data analyzed:
- Number of people with chronic hepatitis C infection—3.5 million
- Diagnosed and aware of their infection—1.7 million (50% of those with infection)
- Those with access to outpatient care –1.5 million (43% of those with infection)
- Hepatitis C RNA confirmed—950,000 (27% of those with infection)
- Disease staged by liver biopsy—580,000 (17% of those with infection)
- Prescribed treatment—550,000 (16% of those with infection)
- Achieved sustained virologic response—330,000 (9% of those with infection)
Co-authors of the study, which was funded by the National Institutes of Health, include Craig A. Umscheid, MD, MSCE, and Asher J. Schranz, MD.
Penn Experts Urge Focus on Reducing Preventable Hospital Readmissions, Estimated to Constitute Just 25 Percent of All Readmissions.
Current efforts may hinder quality improvement and unfairly penalize hospitals
Under the Affordable Care Act, hospitals must report readmission rates for heart attack, heart failure, and pneumonia to CMS. CMS then imposes financial penalties on institutions having an excessive number of readmissions that take place within 30 days following patient discharge. Additional medical conditions will be added in 2015. Many patients with these conditions suffer from additional illnesses that are complex and come with many co-morbid conditions.
“Reducing hospital readmissions is clearly important on many levels,” says lead author Julia G. Lavenberg, PhD, RN, a research analyst at Penn’s Center for Evidence-based Practice. “Patients prefer to remain at home, payers save money, and hospitals avoid financial penalties for having high readmission rates. But while current policy assumes that a significant proportion of readmissions are preventable, research tells us that this is simply not so. Moreover, there is no consensus in the medical and policy communities on how to define preventable readmissions, which is essential for taking action to reduce them.”
Other payers, such as private insurers, are likely to follow the federal lead and withhold funding for high readmission rates. As a result, hospitals and health systems nationwide are devoting significant time, effort, and money to reducing readmissions. Steps include increasing patient education before discharge, introducing or expanding home health visits, and working more closely with nursing homes and rehabilitation centers.
“Current research tells us that only about 25 percent of hospital readmissions are preventable,” says senior author Sunil Kripalani, MD, MSc, chief of the Section of Hospital Medicine at Vanderbilt University. “We urge a focus on preventing these readmissions, so that hospitals can enhance efforts in areas where it will have the greatest effect as well as ensure fair and equitable reporting of hospital performance.”
Until a validated measure of preventability is developed, the authors recommend several steps. First, the readmission time horizon should be reduced from the current 30 days to seven or 15 days, as research suggests that early readmissions – those within seven to 15 days of discharge -- are more likely preventable than those occurring later. Second, policymakers should take the socioeconomic status of patients into account by only comparing hospitals serving similar patient communities when determining penalties for excess readmission rates. Finally, adjusting for other community factors such as practice patterns and access to care is necessary to more accurately reflect factors under a hospital’s control.
“We’re encouraging a major shift in perspective,” adds co-author Craig A Umscheid, MD, MSCE, a hospitalist and Director of the Center for Evidence-based Practice at Penn. “We want policymakers to acknowledge that hospitals should not be penalized for factors beyond their control which may play an important role in readmissions, such as inadequate community health resources or severity of the patient’s illness.”
Such a shift would require agreement among healthcare researchers and policymakers on how to identify and measure preventable or potentially preventable readmissions. While there are existing methods for doing so, there is no consensus on which is best. Furthermore, some of these methods are proprietary and thus unavailable for evaluation by others. These methods use such techniques as identifying readmission for conditions closely related to the original diagnosis or complications arising from the original admission.
To rectify this gap, the authors urge healthcare researchers and policymakers to come to agreement on a transparent, universal method for defining preventable or potentially preventable readmissions. This could include algorithms -- based on insurance claims data -- that recognize patterned relationships between original and readmission diagnoses for a variety of medical conditions. Then, clinicians at individual hospitals could use these standards to evaluate whether individual readmissions were potentially preventable or not. In time, researchers could codify these individual decisions into best-practice standards to serve as guides for subsequent assessments.
In addition to Lavenberg and Umscheid, Penn co-authors include Brian Leas; Kendal Williams, MD; and David R. Goldmann, MD.
Dr. Umscheid was supported in part by the National Center for Research Resources and the National Center for Advancing Translational Sciences (UL1TR000003). Dr. Kripalani receives funding from the National Heart, Lung and Blood Institute (R01HL109388), and from CMS (1C1CMS331006-01 and 1C1CMS330979-01).
Penn Study Shows Automated Prediction Alert Helps Identify Patients at Risk for 30-Day Readmission11/27/2013 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.
CEP Abstract Wins First Place in National Evidence-Based Quality Improvement Conference
7/20/2012 Julia Lavenberg, PhD, RN, a research analyst at the Penn Medicine Center for Evidence-based Practice, won First Place at the 2012 Summer Institutes on Evidence-Based Quality Improvement conference for her abstract submission entitled “Evidence-based QI: The first six years of a hospital-based HTA center.” The abstract received the highest score out of 120 abstracts submitted. It focused on CEP’s model of integrating evidence into clinical practice across a multi-hospital academic health system. The national conference is an annual one that is offered jointly by the Academic Center for Evidence-Based Practice (ACE) and the Improvement Science Research Network (ISRN) at the University of Texas Health Science Center in San Antonio, Texas. There were 600 registrants for the conference, and attendees included nurses, advance practice nurses, clinicians, researchers, educators, physicians, pharmacists, librarians, and administrators. For more information about Dr. Lavenberg’s abstract, see the Penn Media release here: http://www.uphs.upenn.edu/news/News_Releases/2012/09/lavenberg/. For more information about the conference, click here: http://www.acestar.uthscsa.edu/
Poster Presented at IHI Meeting in Orlando
12/26/2012 Joel Betesh, M.D., F.A.C.P., the Pennsylvania Hospital liaison to the Penn Medicine Center for Evidence-based Practice, presented a poster at the 24th Annual Institute for Healthcare Improvement National Forum in Orlando in December 2012. The poster was entitled “An Evidence Based Practice Center in an Academic Medical Center Supports Continuous Quality Improvement. .” It focused on CEP’s model of integrating evidence into clinical practice across a multi-hospital academic health system, and described the recent collaboartion between CEP and the ECRI Institute as one of eleven AHRQ Evidence-based Practice Centers. The poster highlighted two evidence reviews that were used as the basis for major informatics projects within the health system: the blood transfusion order set and the early warning system for sepsis. The IHI national conference is an annual event. There were 5500 registrants for the conference, and attendees included physicians, nurses, advance practice nurses, researchers, educators, and administrators.
For more information about the conference, click the link below:
Cost/ Benefit Analysis
07/06/2012 Matthew Mitchell and Craig Umscheid of the Center for Evidence-based Practice at Penn Medicine have studied different cardiac stenting locations based on effectiveness, safety and cost.
CEP Work Recognized in Two UPHS Quality and Patient Safety Awards for 2011
01/31/2012 Contributions by the Penn Center for Evidence- based Practice were recognized in two UPHS Quality and Safety Awards for 2011. These awards are designed to acknowledge faculty and staff of UPHS departments who have exhibited leadership and innovation in activities that ensure high quality clinical outcomes, patient satisfaction, patient safety and cost efficiency. CEP team members Terese Kornet, Ingi Lee, Neil Fishman and Craig Umscheid were recognized for their contributions to the submission that was the "Overall Winner" for the UPHS Quality and Patient Safety Award. The submission was titled “The Impact of Computerized Decision Support on Indwelling Urinary Catheter Use at UPHS”. CEP Directors Craig Umscheid and Kendal Williams were also part of a team that received the "Operational Award" for the UPHS Quality and Patient Safety Award. The submission was entitled “Standardizing Identification Of Patients’ Covering Provider Throughout UPHS Hospitals To Improve Communication And Patient Safety”. The list of all of those who collaborated on each project as well as all of the project submissions and award winners is included in the link below.
CEP Introduces a New Product to Communicate Our Most Clinically Relevant Reports to Penn Providers
10/06/2011 - CEP introduces a new format to communicate our most clinically relevant evidence reviews to Penn providers. The synopses are called Penn Reviews Of Valid Evidence – or PROVE. The first of these reviews will address gastrointestinal bleeding prophylaxis for high risk critical care patients, and will include a “bottom line”, results table, commentary by a clinician and an analyst, and a link to the full report.
09/30/2011 - The Center for Evidence-based Practice recently co-authored with the Centers for Disease Control and Prevention (CDC) a guideline for the prevention of norovirus gastroenteritis outbreaks in health care settings. The guideline can be found on the CDC website at http://www.cdc.gov/hicpac/index.html
09/29/2010 Contributions by the Penn Center for Evidence- based Practice were recognized in two UPHS Quality and Safety Awards for 2010. These awards are designed to acknowledge faculty and staff of UPHS departments who have exhibited leadership and innovation in activities that ensure high quality clinical outcomes, patient satisfaction, patient safety and cost efficiency. CEP team members David Goldmann and Brian Leas were recognized for their contributions to the submission that was the "CPUP Overall Winner" for the UPHS Quality and Patient Safety Award. The submission was titled “Introducing best practices for reducing aberrant behavior in patients prescribed opiates for non-cancer pain”. CEP Directors Craig Umscheid and Kendal Williams received "Honorable Mention" for the UPHS Quality and Patient Safety Award for their submission detailing the results of their updated VTE prophylaxis computerized clinical decision support. The submission was entitled “The Impact of an Updated Computerized Clinical Decision Support on Venous Thromboembolism Prophylaxis at UPHS”. The list of all of those who collaborated on each project as well as all of the project submissions and award winners is included in the link below.
1/1/10 - The Center for Evidence-based Practice recently partnered with the Healthcare Infection Control Practices Advisory Committee (HICPAC) to update their guideline methodology and publish new guidelines. HICPAC is a federal advisory committee made up of 14 external infection control experts who provide advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (HHS) regarding the practice of health care infection control, strategies for surveillance and prevention and control of health care associated infections in United States health care facilities.
CEP was instrumental in updating their guideline methodology and publishing the first guideline using these new methods: "The 2009 Guideline for Prevention of Catheter-associated Urinary Tract Infections". Links to the Methodology Update and the UTI guideline can be found at HICPAC's website.
6/12/09 - Congratulations to Jalpa Doshi, PhD on winning the 2009 Department of Medicine Austrian Award for Health Evaluation Research. Dr. Doshi, Director of CEP's Economic Evaluations Unit, presented a poster titled "Assessing the Financial Impact of a Unit Based Clinical Leadership Model at a University Hospital: A Case Study of Reductions in Central Line-Associated Bloodstream Infections ." The poster estimated the impact of the University of Pennsylvania Health System's Unit Based Clinical Leadership quality infrastructure on catheter associated blood stream infections at Penn. The study was performed by Dr. Doshi along with colleagues in the Center for Evidence-based Practice and the Department of Medicine, and was recently presented as an oral abstract by CEP Co-Director Dr. Craig Umscheid at the Annual Society for Healthcare Epidemiology in America Meeting in San Diego. Besides finding reductions in blood stream infections and costs savings resulting from the novel quality infrastructure, the study also provides an example of the challenges faced and approaches used while evaluating healthcare interventions in the presence of multifaceted quality improvement processes in real-world hospital settings.
6/8/08 - CEP hosted a multidisciplinary forum entitled "Improving the Quality, Safety and Value of Patient Care through Evidence-based Practice" on the Penn campus in Houston Hall's hall of Flags. The purpose was to explore how payors, providers, researchers, policymakers and the biomedical industry can work together to improve the quality, safety and value of patient care in the Philadelphia region through evidence-based practice. Highlights included a keynote address by Brent James, MD, Executive Director, Institute for Healthcare Delivery Research, Intermountain Health Care on collaborative opportunities for applying evidence. Other presenters included:
- Carolyn Clancy, MD, Director, Agency for Healthcare Research and Quality
- L. Gregory Pawlson, MD, MPH, Executive Vice President, National Committee for Quality Assurance
- Donald F. Schwarz, MD, MPH, MBA, Deputy Mayor of Health and Opportunity and Health Commissioner for the City of Philadelphia
- Harold C. Sox, MD, Editor, Annals of Internal Medicine
- I. Steven Udvarhelyi, MD, Senior Vice President and Chief Medical Officer, Independence Blue Cross
- Newell McElwee, PharmD, MSPH, Senior Director, Pfizer
- Steven Teutsch, MD, MPH, Executive Director, Outcomes Research and Management, Merck
.For more information and a link to a full video of Conference proceedings, please visit our Conferences section.
5/23/08 - Congratulations to Dr. Jeff Miller on winning the 2008 Edward W. Holmes Research Award for Residents and Students in Evaluative Research. Dr. Miller, a third year resident in the Department of Medicine, presented a poster titled "Chlorhexidine versus Povidone-Iodine in Skin Antisepsis: A Systematic Review and Cost Analyses to Inform Initiatives to Reduce Hospital Acquired Infections." It describes the work he performed during his resident elective with Dr. Rajender Agarwal at the Center for Evidence-based Practice. Drs. Miller and Agarwal found that chlorhexidine was more cost-effective than betadine at reducing surgical site infections. Their work informed purchasing decisions and policy changes in UPHS operating rooms.
CEP has a new office location...
3/12/08 - Formerly located on 1 Founders in the Hospital of the University of Pennsylvania at 3400 Spruce Street, the Center for Evidence-based Practice has moved to:
3535 Market Street
CEP Sponsors Evidence-based Medicine Resource for UPHS Clinicians
11/1/07 - Beginning November 1, 2007, the UPHS Center for Evidence-based Practice began sponsoring the emailing of InfoPOEMs® to primary care physicians at UPHS, including CPUP and CCA clinicians in Internal Medicine, Gynecology, Family Medicine, and Emergency Medicine. InfoPOEMs® are published by Wiley InterScience®, and are concise daily email summaries of the latest most clinically relevant published peer-reviewed research. After an InfoPOEM® is emailed, it is accessible at all times using the search engine InfoRetriever®. InfoRetriever® also allows you to search other resources like clinical calculators, ICD-9 codes, and abstracts of Cochrane Systematic Reviews. These products were purchased with the hope that the concise, clinically relevant and evidence based information they provide will help UPHS clinicians meet the continual challenge of keeping up to date with the latest study findings that matter most to their patients. The product should also improve accessibility to these findings at and beyond the point of care.
6/25/07 - The Center for Evidence-based Practice recently received an award from the University Research Foundation of the University of Pennsylvania to support our upcoming conference entitled “Improving the Quality, Safety and Value of Patient Care through Evidence-based Practice: A Multidisciplinary Regional Forum”. The conference is being scheduled for Summer 2008. Please check back for more details on the conference.
The Center for Evidence-Based Practice Announces its New Resident Evidence-based Medicine (EBM) Elective
3/1/07 - The Center for Evidence-based Practice recently introduced its Resident Evidence-based Medicine (EBM) elective to the Graduate Medical Education Committee. Created by co-directors Kendal Williams and Craig Umscheid in collaboration with the Biomedical Library, the curriculum applies EBM precepts to real world problems facing the health system. It is open to residents from all services, and will give practical experience in conducting systematic reviews and meta-analyses. Through the elective, participants have the opportunity to take part in one of CEP’s ongoing reviews of healthcare technologies at the University of Pennsylvania Health System, including evaluations of medical and surgical drugs, devices and processes of care. To learn more about the CEP Resident EBM elective, please click here.
Penn Announces New, Unique “Center for Evidence-Based Practice” To Answer Important Clinical Questions by Examining the Evidence
Center to Offer Evidence-Based Guidelines to Health System to Support Healthcare Quality
7/1/06 - The University of Pennsylvania Health System (UPHS) is launching a new “Center for Evidence-Based Practice” in July 2006. Its purpose is to provide, throughout the entire health system, recommendations -- based on scientific methodology -- on clinical practices and policies. The center will evaluate drugs, as well as non-drug technologies like medical devices and equipment, and processes of care by examining research findings and drawing on the expertise of clinicians and industry experts.
“We wanted to create a forum to develop clinical practices and policies that would span the whole health system. The ultimate goal with this new center is to significantly improve patient safety and clinical outcomes and to reduce occurrences,” states P.J. Brennan, MD, Chief Medical Officer at UPHS, who will ultimately oversee the new center. “We want to take a proactive approach to evaluate new drugs on the market and the processes we use -- to have the evidence to support its use. We will methodically examine the data using scientific standards of analysis, and allow a rigorous review, to bring us to a logical conclusion.”
Once a specific medical issue is identified, the center will form a task force consisting of clinician experts from within UPHS to work alongside the center to examine the issue. The review process may last up to a few months for each issue, with multiple reviews occurring simultaneously. The process of review will start with a comprehensive search and evaluation of the world’s medical literature on the issue at hand. Then, the task force will obtain further input from thought leaders, institutional experts, and industry as appropriate.
When all of the evidence is analyzed, the task force will develop a set of recommended guidelines, which will be disseminated to each hospital’s chief medical officer for further review and application. This effort includes all of UPHS: the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center and Pennsylvania Hospital, all in Philadelphia.
Brennan adds, “The recommendations these task forces make will stem from a language and process that the medical community at Penn knows and respects. The intention here is to create a center that gathers, examines, and analyzes evidence and then brings clinical experts and industry into the process for their input. It’s a way to honestly analyze what we’re using and doing here at Penn. I know of no other center like this in existence at an academic medical center. We will directly apply evidence to clinical practice.”
Kendal Williams, MD, MPH and Craig Umscheid, MD, both Assistant Professors in the Department of Medicine with formal training in public health and epidemiology respectively, will serve as the center’s co-directors.
“Our main mission is to apply the best research findings from around the globe to our patient population. Penn has the ability to do this well,” comments Williams. "With this new center, we’re also tackling the important issue of clinician-industry relations and quality of care. Often many ‘special interests’ involved in patient care are in-line with our goals as healthcare professionals, but not always. It is the responsibility of a health system to promote the health and protect the safety of its patients. The health system leadership is showing, through this new center, that they take this duty very seriously."
In fact, Williams views the new center as a positive way to create a proactive, collaborative, patient-centered relationship between the health system and the pharmaceutical and medical device industry, based on science.
“This will encourage more scientific dialogue with industry rather than marketing dialogue,” adds Umscheid. “We want to be a resource to help our physicians to make decisions and practice medicine based on findings from valid clinical studies. The topic of our first review is the use of aprotinin, a drug used by anesthesiologists during cardiac surgery to reduce blood loss. Recently, its safety has come into question. We assembled a group of clinical experts from within Penn to help us conduct a clinically relevant, systematic review of the pertinent studies on the topic and we hope to recommend guidelines for its use within the next month.”
Also, the new center is in the process of developing a website to post its recommended guidelines so that they can serve as a resource beyond Penn, to the public and to other healthcare professionals who may be dealing with the same issues in similar patient populations.