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Stephen D Persell

Publications and source records attributed to Stephen D Persell.

10 recordsLinked to original sources
PubMed2006

Assessing the validity of national quality measures for coronary artery disease using an electronic health record.

BACKGROUND: Nationally endorsed, clinical performance measures are available that allow for quality reporting using electronic health records (EHRs). To our knowledge, how well they reflect actual quality of care has not been studied. We sought to evaluate the validity of performance measures for coronary artery disease (CAD) using an ambulatory EHR. METHODS: We performed a retrospective electronic medical chart review comparing automated measurement with a 2-step process of automated measurement supplemented by review of free-text notes for apparent quality failures for all patients with CAD from a large internal medicine practice using a commercial EHR. The 7 performance measures included the following: antiplatelet drug, lipid-lowering drug, beta-blocker following myocardial infarction, blood pressure measurement, lipid measurement, low-density lipoprotein cholesterol control, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for patients with diabetes mellitus or left ventricular systolic dysfunction. RESULTS: Performance varied from 81.6% for lipid measurement to 97.6% for blood pressure measurement based on automated measurement. A review of free-text notes for cases failing an automated measure revealed that misclassification was common and that 15% to 81% of apparent quality failures either satisfied the performance measure or met valid exclusion criteria. After including free-text data, the adherence rate ranged from 87.5% for lipid measurement and low-density lipoprotein cholesterol control to 99.2% for blood pressure measurement. CONCLUSIONS: Profiling the quality of outpatient CAD care using data from an EHR has significant limitations. Changes in how data are routinely recorded in an EHR are needed to improve the accuracy of this type of quality measurement. Validity testing in different settings is required.

Ambulatory Care↗
PubMed2006

National Cholesterol Education Program risk assessment and potential for risk misclassification.

BACKGROUND: The National Cholesterol Education Program Adult Treatment Panel report from 2001 (ATP III) recommends clinicians calculate 10-year coronary risk using multivariable methods only for adults with 2 or more risk factors. We aimed to determine who would be falsely classified as low risk using this approach. METHODS: We studied 4097 adults aged 20 to 79 years without diagnosed cardiovascular disease or diabetes from the National Health and Nutrition Examination Survey from 1999 to 2002. We determined the proportion with fewer than 2 risk factors who nonetheless had estimated 10-year risk of cardiac death or myocardial infarction > or =10% using multivariable methods. RESULTS: Among persons with fewer than 2 risk factors, 5.3% (95% confidence interval 4.7 to 6.1%), had a 10-year risk > or =10% using the Framingham Risk Score and would be misclassified using the risk factor counting method (this corresponds to approximately 5,640,000 U.S. adults). Compared to individuals whose classification was unchanged, those misclassified as low risk were older (P<0.001) and more likely male (85.5% vs. 41.2%, P<0.001). CONCLUSIONS: Relying on the ATP III risk factor counting method rather than determining risk using multivariable methods in all patients resulted in misclassifiying as low risk over 5 million adults with at least moderately high risk of coronary heart disease, most of whom are middle-aged and older men.

Adult↗
PubMed2005

Implications of changing national cholesterol education program goals for the treatment and control of hypercholesterolemia.

BACKGROUND: Modifications to the National Cholesterol Education Program (NCEP) guidelines lowered optional low-density lipoprotein cholesterol (LDL-C) treatment goals. OBJECTIVE: We evaluated the implications of widely adopting these optional goals in clinical practice. DESIGN AND PARTICIPANTS: We performed a cross-sectional study using 1999 to 2002 data from 3,281 U.S. adults aged 20 to 79 years participating the National Health and Nutrition Examination Survey. MEASUREMENTS: The primary outcomes were the proportions of adults whose fasting LDL-C levels exceeded NCEP recommended and optional targets from 2001 and 2004. We used survey weights to estimate the size of the U.S. population exceeding targets. We examined outcomes for 4 coronary disease risk subgroups described by the NCEP. RESULTS: Low-density lipoprotein cholesterol values exceeded 2001 NCEP goals for 30.0% of adults, and 35.8% had levels above optional 2004 goals. An estimated 24,900,000 individuals (14.2%) exceeded 2001 thresholds for drug therapy, 46,200,000 (26.3%) exceeded optional 2001 thresholds for drug therapy, and 56,500,000 (32.2%) were above the optional 2004 thresholds for drug therapy. For lower, moderate, moderately high, and high-risk groups, 13.4%, 44.2%, 58.8%, and 71.8%, respectively, exceeded 2001 NCEP goals; 13.4%, 15.7%, 87.4%, and 96.0% of these groups exceeded optional 2004 thresholds for drug therapy. CONCLUSIONS: In 1999 to 2002, LDL-C levels commonly exceeded 2001 NCEP goals, especially for moderately high and high-risk individuals, and cholesterol-lowering medications were underused. Optional goals promulgated by the NCEP in 2001 and 2004 moderately increased the number of adults with LDL-C above their goal, and greatly increased the number of low, moderately high, and high-risk adults who exceeded LDL-C thresholds, for cholesterol-lowering medication.

Adult↗
PubMed2005

Ambulatory hypercholesterolemia management in patients with atherosclerosis. Gender and race differences in processes and outcomes.

OBJECTIVE: To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control. DESIGN: Retrospective cohort study. SETTING: Primary care clinics affiliated with an academic medical center. PARTICIPANTS: Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)>130 mg/dl. MEASUREMENTS AND MAIN RESULTS: The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P=.01), and 37.3% of black and 31.7% of white patients' visits (P=.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C <130 mg/dl occurred less often for women than men (41% vs 61%; P=.003), black than white patients (39% vs 58%; P=.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P=.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C <130 mg/dl and gender. CONCLUSIONS: In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients.

Academic Medical Centers↗
PubMed2004

Understanding of drug indications by ambulatory care patients.

PURPOSE: Patients' knowledge of the indications of their prescription medications was studied and those medications that were most likely to be taken without patients understanding the correct indication were identified. METHODS: Adult patients who received care at four primary care practices were surveyed. Patients were eligible to participate if they were over 18 years old and had received a prescription from a participating physician at a clinic visit. Patients were telephoned and asked to retrieve the bottles of all medications they were currently taking, identify their medications, and state the reason they took each medicine. The primary outcome was absent or incorrect knowledge of a drug's indication. RESULTS: A total of 2340 prescription medications were used by the 616 patients whose data were analyzed. Eighty-three patients (13.5%) lacked knowledge of the indication for at least one of their prescription medications. They did not know the indication for 148 medications (6.3%). After multivariable adjustment, lack of knowledge was more common for cardiovascular drugs (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.03-2.19) and less common for diabetes medications (OR, 0.37; 95% CI, 0.16-0.84) and analgesics (OR, 0.23; 95% CI, 0.05-1.01) compared with all other medications, and more common if the patient taking these medications was older, black, or had a high school education or less. CONCLUSION: More than 13% of patients in primary care practices did not know the indication of at least one of their prescription medications. Lack of knowledge was most prevalent for cardiovascular medications.

Age Factors↗
PubMed2004

Relationship of diabetes-specific knowledge to self-management activities, ambulatory preventive care, and metabolic outcomes.

BACKGROUND: Educational interventions increase diabetes patients' knowledge and self-care activities, but their impact on the use of health services to prevent diabetes complications is unclear. We sought to determine the relationship of patients' diabetes-specific knowledge with self-management behaviors, use of ambulatory preventive care, and metabolic outcomes. METHODS: We surveyed 670 adults with diabetes from three managed care plans to assess diabetes knowledge (using an eight-item scale) and self-management activities. With chart review, we assessed five processes of care--retinal and foot examinations, low-density lipoprotein cholesterol (LDL-C) testing, hemoglobin A1c (HbA1c) testing, and urine microalbumin testing--and three metabolic outcomes--HbA1c < or = 9.5%, LDL-C <130 mg/dL (3.36 mmol/L), and last blood pressure <140/90 mm Hg. RESULTS: In adjusted analyses, a one-point increase on the knowledge scale was associated with following a diabetes diet (OR 1.23, 95% CI 1.10-1.38), blood glucose self-measurement (OR 1.29, 95% CI 1.13-1.48), and regular exercise (OR 1.15, 95% CI 1.03-1.28) but not with processes of care or metabolic outcomes. CONCLUSIONS: Knowledgeable patients were more likely to perform self-management activities but not to receive recommended ambulatory care or reach metabolic outcome goals. Providing patient education about diabetes care processes should be tested as a means of increasing ambulatory care to prevent diabetes complications.

Adult↗
PubMedDate not supplied

Aspirin use among adults with diabetes: recent trends and emerging sex disparities.

BACKGROUND: Despite high cardiovascular risk among adults with diabetes mellitus, aspirin use has been low. METHODS: To assess recent self-reported regular aspirin use among adults 35 years or older with diabetes, we used statewide telephone surveys conducted in 7 states in 1997 and 20 states in 1999 and 2001 including 875, 3205, and 4272 subjects in 1997, 1999, and 2001, respectively. RESULTS: Aspirin use increased from 37.5% in 1997 to 48.7% in 2001. In 2001, 74.2% (95% confidence interval [CI], 70.9%-77.5%) of diabetic adults with cardiovascular disease, but only 37.9% (95% CI, 35.1%-40.7%) of those without cardiovascular disease, used aspirin regularly, including less than 40% with diagnosed hypertension or hypercholesterolemia or who smoked. After adjusting for cardiac risk factors and socioeconomic characteristics, among those without cardiovascular disease, aspirin use was less common in women aged 35 to 49 years (adjusted rate ratio [RR], 0.35; 95% CI, 0.24-0.51) and 50 to 64 years (RR, 0.69; 95% CI, 0.53-0.88) and in men aged 35 to 49 years (RR, 0.62; 95% CI, 0.43-0.85) compared with men 65 years and older. For those with diagnosed cardiovascular disease, aspirin use was lower among women (RR, 0.81 compared with men; 95% CI, 0.70-0.90) and adults younger than 50 years (RR compared with those >/=65 years, 0.81; 95% CI, 0.61-0.98). The disparity in aspirin use between men and women appeared between 1997 and 2001. CONCLUSIONS: Aspirin use among adults with diabetes has increased. However, many high-risk individuals, especially women and those younger than 50 years, do not use this effective and inexpensive therapy.

Adult↗