Transcript Automated Patient-Specific Reporting for Chronic Disease Management in the Clinical Laboratory Dr Glenn Edwards MBBS, MD, FRCPA Medical Director, St John of God Pathology Perth, Western.

Automated Patient-Specific Reporting for
Chronic Disease Management in the
Clinical Laboratory
Dr Glenn Edwards
MBBS, MD, FRCPA
Medical Director, St John of God Pathology
Perth, Western Australia
[email protected]
Disclosures
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Former CEO & Medical Director, Pacific Knowledge Systems
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Owns stock in PKS
Cost of Chronic Disease
2007 National Diabetes Fact Sheet
Total: 23.6 million children and adults in the United States (7.8% of
population)
Cost of Diabetes (Direct + Indirect)
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$174 billion: Total costs of diagnosed diabetes in the US in 2007
Including undiagnosed diabetes, pre-diabetes, and gestational diabetes:
$218 billion.
Heart Disease
• The leading cause of death in US. (> 650,000 deaths/yr = 27%)
• Direct + Indirect cost: $475.3 billion in 2009
Chronic Kidney Disease
• 1 in 3 adults at increased risk; 1 in 7 adults have some sign of CKD
• Risk of death from CVD is 20 x need for dialysis or transplantation
• Cost (Medicare): $20.7 billion
Interpretative Reporting
• Testing guidelines improve outcomes and cost
• …but poor compliance and considerable variation
• Physicians want
• higher quality information and advice
• more engagement with laboratory/clinical pathologists
• support for compliance
• Current status
• vast majority of lab tests not interpreted by lab
• most discussion around esoteric testing
• RippleDown shown to support automated commenting in clinical lab
• Current lab role:
• Our goal:
Reactive, Result-focussed
Pro-active, Patient-focussed
Automated support for
pathologist opinions
• LabWizard (RippleDown-based reporting application)
• Interfaced to LabTrak LIS
• Incremental knowledge acquisition based on live cases
• Supports pathologist opinion writing
• Focus on chronic disease
• Common, high volume tests (lipids, glucose, HbA1c, GTT, etc)
• Opinions designed to
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Reinforce management according to guidelines
Detect guideline non-compliance
Identify clinical management priorities & variation
Make specific recommendations to correct non-compliance
• NOT canned comments – must be close match to manual task
Guidelines
• Guidelines for the Assessment of Absolute Cardiovascular Risk
(National Heart Foundation of Australia, 2009)
• Position Statement on Lipid Management (National Heart Foundation
of Australia and Cardiac Society of Australia and New Zealand, 2005)
• Diabetes Management in General Practice, 2009/10 (Diabetes
Australia and Royal Australian College of General Practitioners)
• Chronic Kidney Disease (CKD) Management in General Practice
(Kidney Health Australia, Melbourne, 2007)
• (Local practice)
• (Local opinion)
Key compliance issues
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identifying patients known to be at increased absolute risk for CVD
identifying patients, not known to be at increased risk, who require risk assessment
providing an internet URL as information to doctors
identifying low- and high-risk individuals for CHD
recommending LDL-cholesterol target levels relevant to risk category
identifying non-compliance with LDL-cholesterol targets
recommending statin therapy for patients at increased risk for CHD
identifying patients with various hyperlipidaemias
recommending target levels for triglycerides and HDL-cholesterol
recommending triglyceride-lowering therapy for resistant hypertiglyceridaemia
identifying patients at risk for Familial Hypercholesterolaemia
identifying patients who require testing for secondary causes of hyperlipidaemia
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identifying patients at risk for diabetes
recommending follow up testing for abnormal glucose tests
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Hypothyroidism, Liver disease, Renal disease
On current or previous results
identifying patients who require recurrent follow up (eg impaired glucose tolerance)
recommending timing and selection of appropriate tests for follow up testing
In diabetes, identifying non-compliance and recommending corrective action with:
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annual HbA1c testing for people with diabetes
annual urine microalbumin testing for people with diabetes
annual assessment of lipid profile in people with diabetes
more frequent HbA1c testing in people with poor glycaemic control
annual eGFR testing in people at increased risk for chronic kidney disease
LabWizard case view
Patient-specific report
Patient-specific reports
• Archive: 8,695 total patient reports
• Unique opinions: 2,406
• Opinions given on 5 or fewer occasions: 2,188 (91%)
Specific, low frequency
comments
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Results in diabetic range noted. Absolute Risk for CVD: ASSESS. LDL remains ABOVE target
for high risk individuals. If diabetes not confirmed clinically, suggest glucose tolerance test. Also
suggest check urine microalbumin:creatinine ratio (ACR).
Given : 5
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Total cholesterol > 7.5 mmol/L. Absolute Risk for CVD: INCREASED. LDL is ABOVE target for
high risk individuals. Consider statin therapy. Aim for LDL < 2.5 mmol/L. Consider possible
Familial Hypercholesterolaemia when LDL > 4.9 mmol/L. Suggest review for clinical stigmata of
FH (eg tendon xanthomata, corneal arcus), review family history, and repeat full lipid profile.
Also suggest check TSH to exclude sub-clinical hypothyroidism. Given : 5
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Absolute Risk for CVD: ASSESS IF INDICATED (www.heartfoundation.org.au). LDL is now
WITHIN target for high risk individuals. Given : 4
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Absolute Risk for CVD: ASSESS. LDL is WITHIN target for high risk individuals. Dyslipidaemic
pattern, with raised triglycerides and low HDL. Aim for triglycerides < 1.5 mmol/L and HDL > 1.0
mmol/L. Suggest check fasting glucose. Given : 4
27/04/2010
13/04/2010
30/03/2010
16/03/2010
2/03/2010
16/02/2010
2/02/2010
19/01/2010
5/01/2010
22/12/2009
8/12/2009
24/11/2009
10/11/2009
27/10/2009
13/10/2009
Incremental Knowledge
Acquisition
Rules built per day
60
50
40
30
20
10
0
Auto-validation control
2/
11
/2
4/ 0 0
11 9
/2
6/ 0 0
11 9
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8/ 20 0
11 9
10 /20
/1 09
1
12 /2 0
/1 09
1
14 /2 0
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1
16 /2 0
/1 09
1
18 /2 0
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1
20 /2 0
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22 /2 0
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24 /2 0
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26 /2 0
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28 /2 0
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30 /2 0
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1/
2
2/ 00
12 9
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4/ 0 0
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6/ 0 0
12 9
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9
%AV
Auto-validation
Auto-validation rate
90.00
80.00
70.00
60.00
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40.00
30.00
20.00
10.00
0.00
Ambiguous data
Key findings
• Acceptance by pathologist group
• Patient specific
• Addressed entire patient record
• Doctor specific
• Modified for diabetes specialists, cardiologists and nephrologists
• Guideline concordance
• Near-natural language
• Opinions closely match to pathologists level of uncertainty
• Ambiguous or missing data
• Customise commentary
• Manual validation of relevant cases
• Filtered by clinical relevance, rather than “abnormal” values
• AV customised according to need
• Minimal impact on TAT
Conclusions
• Rippledown-based expert systems facilitate comprehensive provision
of pathologist opinions
• Applicable to all areas of clinical pathology
• Support best clinical practice in chronic disease
• Not only “esoteric” tests
• Focus of clinical interpretation
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Trends
Guideline/best practice compliance
Therapy
Care planning
… not just diagnosis
• Restores clinical dialogue for lab/clinical pathologist
Automated Patient-Specific Reporting for
Chronic Disease Management in the
Clinical Laboratory
Dr Glenn Edwards
MBBS, MD, FRCPA
St John of God Pathology
Perth, Western Australia
[email protected]
Conclusions
The myriad guidelines….
> 15% Absolute Risk of CVD in 5 years
• Diabetes and age > 60yrs
• Diabetes with microalbuminuria
• Males :
• Females :
ACR > 2.5 mg/mmol
ACR > 3.5 mg/mmol
• Moderate or severe CKD
• eGFR < 45 mL/min/1.73m2
• Known diagnosis of Familial Hypercholesterolaemia
• Hypertension
• SBP >= 180 mmHg
• DBP >= 110 mmHg
• Serum total cholesterol > 7.5 mmol/L
Rules by type
Rule additions by type
160
140
120
Report
100
Format
80
Building Blocks
60
Silent
40
20
0
1
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Fortnight
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Non-compliance with guidelines in
chronic disease
Impact of education campaign
Compliance
Before
After
Annual HbA1c
60%
85%
HbA1c < 7%
38%
50%
Annual eye clinic
65%
75%
Annual microalbumin
27%
37%
Stern E. et al Int J Clin Pract. 2005 Oct;59(10):1126-30
“Non-compliance”
Total DMs
292 (13%)
% of DMs
HbA1c overdue
27.00
9.25
ACR overdue
Total pts with
overdue
88.00
30.14
90.00
30.82