Person: Platt, Richard
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Platt
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Platt, Richard
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Publication Improving Public Reporting and Data Validation for Complex Surgical Site Infections After Coronary Artery Bypass Graft Surgery and Hip Arthroplasty(Oxford University Press, 2014) Calderwood, Michael S.; Kleinman, Kenneth Paul; Murphy, Michael; Platt, Richard; Huang, Susan S.Background: Deep and organ/space surgical site infections (D/OS SSI) cause significant morbidity, mortality, and costs. Rates are publicly reported and increasingly used as quality metrics affecting hospital payment. Lack of standardized surveillance methods threaten the accuracy of reported data and decrease confidence in comparisons based upon these data. Methods: We analyzed data from national validation studies that used Medicare claims to trigger chart review for SSI confirmation after coronary artery bypass graft surgery (CABG) and hip arthroplasty. We evaluated code performance (sensitivity and positive predictive value) to select diagnosis codes that best identified D/OS SSI. Codes were analyzed individually and in combination. Results: Analysis included 143 patients with D/OS SSI after CABG and 175 patients with D/OS SSI after hip arthroplasty. For CABG, 9 International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes identified 92% of D/OS SSI, with 1 D/OS SSI identified for every 4 cases with a diagnosis code. For hip arthroplasty, 6 ICD-9 diagnosis codes identified 99% of D/OS SSI, with 1 D/OS SSI identified for every 2 cases with a diagnosis code. Conclusions: This standardized and efficient approach for identifying D/OS SSI can be used by hospitals to improve case detection and public reporting. This method can also be used to identify potential D/OS SSI cases for review during hospital audits for data validation.Publication Improving documentation and coding for acute organ dysfunction biases estimates of changing sepsis severity and burden: a retrospective study(BioMed Central, 2015) Rhee, Chanu; Murphy, Michael; Li, Lingling; Platt, Richard; Klompas, MichaelIntroduction: Claims-based analyses report that the incidence of sepsis-associated organ dysfunction is increasing. We examined whether coding practices for acute organ dysfunction are changing over time and if so, whether this is biasing estimates of rising severe sepsis incidence and severity. Methods: We assessed trends from 2005 to 2013 in the annual sensitivity and incidence of discharge ICD-9-CM codes for organ dysfunction (shock, respiratory failure, acute kidney failure, acidosis, hepatitis, coagulopathy, and thrombocytopenia) relative to standardized clinical criteria (use of vasopressors/inotropes, mechanical ventilation for ≥2 consecutive days, rise in baseline creatinine, low pH, elevated transaminases or bilirubin, abnormal international normalized ratio or low fibrinogen, and decline in platelets). We studied all adult patients with suspected infection (defined by ≥1 blood culture order) at two US academic hospitals. Results: Acute organ dysfunction codes were present in 57,273 of 191,695 (29.9 %) hospitalizations with suspected infection, most commonly acute kidney failure (60.2 % of cases) and respiratory failure (28.9 %). The sensitivity of all organ dysfunction codes except thrombocytopenia increased significantly over time. This was most pronounced for acute kidney failure codes, which increased in sensitivity from 59.3 % in 2005 to 87.5 % in 2013 relative to a fixed definition for changes in creatinine (p = 0.019 for linear trend). Acute kidney failure codes were increasingly assigned to patients with smaller creatinine changes: the average peak creatinine change associated with a code was 1.99 mg/dL in 2005 versus 1.49 mg/dL in 2013 (p <0.001 for linear decline). The mean number of dysfunctional organs in patients with suspected infection increased from 0.32 to 0.59 using discharge codes versus 0.69 to 0.79 using clinical criteria (p <0.001 for both trends and comparison of the two trends). The annual incidence of hospitalizations with suspected infection and any dysfunctional organ rose an average of 5.9 % per year (95 % CI 4.3, 7.4 %) using discharge codes versus only 1.1 % (95 % CI 0.1, 2.0 %) using clinical criteria. Conclusions: Coding for acute organ dysfunction is becoming increasingly sensitive and the clinical threshold to code patients for certain kinds of organ dysfunction is decreasing. This accounts for much of the apparent rise in severe sepsis incidence and severity imputed from claims.Publication Pragmatic clinical trials embedded in healthcare systems: generalizable lessons from the NIH Collaboratory(BioMed Central, 2017) Weinfurt, Kevin P.; Hernandez, Adrian F.; Coronado, Gloria D.; DeBar, Lynn L.; Dember, Laura M.; Green, Beverly B.; Heagerty, Patrick J.; Huang, Susan S.; James, Kathryn T.; Jarvik, Jeffrey G.; Larson, Eric B.; Mor, Vincent; Platt, Richard; Rosenthal, Gary E.; Septimus, Edward J.; Simon, Gregory E.; Staman, Karen L.; Sugarman, Jeremy; Vazquez, Miguel; Zatzick, Douglas; Curtis, Lesley H.Background: The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. Methods: To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. Results: In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. Conclusion: A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.Publication 1236The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative(Oxford University Press, 2014) Klompas, Michael; Anderson, Deverick; Trick, William; Babcock, Hilary M.; Sinkowitz-Cochran, Ronda; Ely, E. Wesley; Jernigan, John; Magill, Shelley S.; Lyles, Rosie D.; Neil, Caroline O'; Balas, Michele; Murphy, Michael; Cox, Christopher; Lautenbach, Ebbing; Sexton, Daniel J.; Fraser, Victoria J.; Weinstein, Robert A.; Platt, RichardPublication 915Is a hospital's surgical site infection rate among Medicare-insured patients a good indicator of outcome for commercially-insured patients?(Oxford University Press, 2014) Calderwood, Michael S.; Kleinman, Kenneth Paul; Murphy, Michael; Yokoe, Deborah; Platt, Richard; Huang, Susan S.Publication 1288Rapid Dissemination of Universal Decolonization in Adult Intensive Care Units (ICUs) Reduces Healthcare-Associated (HA) Central Line Associated Bloodstream Infections (CLABSI) in over 100 Community Hospitals in a Single Healthcare System(Oxford University Press, 2014) Hickok, Jason; Moody, Julia; Kleinman, Kenneth Paul; Avery, Taliser; Huang, Susan S.; Bienvenu, Sara; Perlin, Jonathan; Platt, Richard; Septimus, EdwardPublication Confounding by indication affects antimicrobial risk factors for methicillin-resistant Staphylococcus aureus but not vancomycin-resistant enterococci acquisition(BioMed Central, 2014) Datta, Rupak; Kleinman, Kenneth Paul; Rifas-Shiman, Sheryl; Placzek, Hilary; Lankiewicz, Julie; Platt, Richard; Huang, Susan SBackground: Observational studies rarely account for confounding by indication, whereby empiric antibiotics initiated for signs and symptoms of infection prior to the diagnosis of infection are then viewed as risk factors for infection. We evaluated whether confounding by indication impacts antimicrobial risk factors for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) acquisition. Findings: We previously reported several predictors of MRSA and VRE acquisition in 967 intensive care unit (ICU) patients with no prior history of MRSA or VRE who had an initial negative screening culture followed by either a subsequent negative screening culture (controls) or positive screening or clinical culture (cases). Within and prior to this acquisition interval, we collected demographic, comorbidity, daily device and antibiotic utilization data. We now re-evaluate all antibiotics by medical record review for evidence of treatment for signs and symptoms ultimately attributable to MRSA or VRE. Generalized linear mixed models are used to assess variables associated with MRSA or VRE acquisition, accounting for clustering by ward. We find that exclusion of empiric antibiotics given for suspected infection affects 17% (113/661) of antibiotic prescriptions in 25% (60/244) of MRSA-positive patients but only 1% (5/491) of antibiotic prescriptions in 1% (3/227) of VRE-positive patients. In multivariate testing, fluoroquinolones are no longer associated with MRSA acquisition, and aminoglycosides are significantly protective (OR = 0.3, CI:0.1-0.7). Conclusions: Neglecting treatment indication may cause common empiric antibiotics to appear spuriously associated with MRSA acquisition. This effect is absent for VRE, likely because empiric therapy is infrequent given the low prevalence of VRE.Publication Launching PCORnet, a national patient-centered clinical research network(BMJ Publishing Group, 2014) Fleurence, Rachael L; Curtis, Lesley H; Califf, Robert M; Platt, Richard; Selby, Joe V; Brown, JeffreyThe Patient-Centered Outcomes Research Institute (PCORI) has launched PCORnet, a major initiative to support an effective, sustainable national research infrastructure that will advance the use of electronic health data in comparative effectiveness research (CER) and other types of research. In December 2013, PCORI's board of governors funded 11 clinical data research networks (CDRNs) and 18 patient-powered research networks (PPRNs) for a period of 18 months. CDRNs are based on the electronic health records and other electronic sources of very large populations receiving healthcare within integrated or networked delivery systems. PPRNs are built primarily by communities of motivated patients, forming partnerships with researchers. These patients intend to participate in clinical research, by generating questions, sharing data, volunteering for interventional trials, and interpreting and disseminating results. Rapidly building a new national resource to facilitate a large-scale, patient-centered CER is associated with a number of technical, regulatory, and organizational challenges, which are described here.Publication The Impact of Prescribing Safety Alerts for Elderly Persons in an Electronic Medical Record(American Medical Association (AMA), 2006) Smith, David H.; Perrin, Nancy; Feldstein, Adrianne; Yang, Xiuhai; Kuang, Daniel; Simon, Steven; Sittig, Dean F.; Platt, Richard; Soumerai, StephenBackground Considerable effort and attention have focused on medication safety in elderly persons; one approach that has been understudied in the outpatient environment is the use of computerized provider order entry with clinical decision support. The objective of this study was to examine the effects of computerized provider order entry with clinical decision support in reducing the use of potentially contraindicated agents in elderly persons. Methods With data from a 39-month period of a natural experiment, we evaluated changes in medication dispensing using interrupted time series analysis to estimate changes, controlling for prealert prescribing trends. The setting was a large health maintenance organization in the Pacific Northwest. All adult enrollees of the health plan participated. The intervention was computerized alerts cautioning against using certain medications in elderly persons. The main outcome measure was dispensing per 10 000 members per month. Results Following the implementation of the drug-specific alerts, a large and persistent reduction (5.1 prescriptions per 10 000, P=.004), a 22% relative decrease from the month before alert implementation, in the exposure of elderly patients to nonpreferred medications was observed. We found no evidence of a decrease in use of nonpreferred agents for nonelderly patients. The reduction seen in use of nonpreferred agents for elderly persons was driven primarily by decreases in dispensing for tertiary tricyclic agents. Conclusions We found that alerts in an outpatient electronic medical record aimed at decreasing prescribing of medication use in elderly persons may be an effective method of reducing prescribing of contraindicated medications. The effect of the alerts on patient outcomes is less certain and deserves further investigation.Publication Distributed Health Data Networks(Ovid Technologies (Wolters Kluwer Health), 2010) Brown, Jeffrey; Holmes, John H.; Shah, Kiran; Hall, Ken; Lazarus, Ross; Platt, RichardBackground: Comparative effectiveness research, medical product safety evaluation, and quality measurement will require the ability to use electronic health data held by multiple organizations. There is no consensus about whether to create regional or national combined (eg, “all payer”) databases for these purposes, or distributed data networks that leave most Protected Health Information and proprietary data in the possession of the original data holders. Objectives: Demonstrate functions of a distributed research network that supports research needs and also address data holders concerns about participation. Key design functions included strong local control of data uses and a centralized web-based querying interface. Research Design: We implemented a pilot distributed research network and evaluated the design considerations, utility for research, and the acceptability to data holders of methods for menu-driven querying. We developed and tested a central, web-based interface with supporting network software. Specific functions assessed include query formation and distribution, query execution and review, and aggregation of results. Results: This pilot successfully evaluated temporal trends in medication use and diagnoses at 5 separate sites, demonstrating some of the possibilities of using a distributed research network. The pilot demonstrated the potential utility of the design, which addressed the major concerns of both users and data holders. No serious obstacles were identified that would prevent development of a fully functional, scalable network. Conclusions: Distributed networks are capable of addressing nearly all anticipated uses of routinely collected electronic healthcare data. Distributed networks would obviate the need for centralized databases, thus avoiding numerous obstacles.