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Wu L.,Center for Clinical and Translational Science | Wang Z.,Kern Center for the Science of Health Care Delivery | Zhu J.,University of Minnesota | Murad A.L.,Dan Abraham Healthy Living Center | And 3 more authors.
Nutrition Reviews | Year: 2015

Context: The identification of foods that can decrease the risk of cancer and type 2 diabetes may be helpful in reducing the burden of these diseases. Although nut consumption has been suggested to have a disease-preventive role, current evidence remains inconsistent. Objective: The aim of this systematic review and meta-analysis was to clarify the association between nut consumption and risk of cancer or type 2 diabetes. Data Sources: Six databases were searched for relevant studies from the time of database inception to August 2014. Reference lists of relevant review articles were hand searched, and authors were contacted when data were insufficient. Study Selection: Eligible studies included epidemiological studies (case-control and cohort) or clinical trials that reported an association between nut consumption and the outcome of type 2 diabetes or specific cancers. Data Extraction: Two investigators independently extracted descriptive, quality, and risk data from included studies. Data Synthesis: Random-effects meta-analysis was used to pool relative risks from the included studies. The I2 statistic was used to assess heterogeneity. A total of 36 eligible observational studies, which included 30 708 patients, were identified. The studies had fair methodological quality, and length of follow-up ranged between 4.6 years and 30 years. Comparison of the highest category of nut consumption with the lowest category revealed significant associations between nut consumption and decreased risk of colorectal cancer (3 studies each with separate estimates for males and females, RR 0.76, 95% confidence interval [95%CI] 0.61-0.96), endometrial cancer (2 studies, RR 0.58, 95%CI 0.43-0.79), and pancreatic cancer (1 study, RR 0.68, 95%CI 0.48-0.96). No significant association was found with other cancers or type 2 diabetes. Overall, nut consumption was significantly associated with a reduced risk of cancer incidence (RR 0.85, 95%CI 0.76-0.95). Conclusions: Nut consumption may play a role in reducing cancer risk. Additional studies are needed to more accurately assess the relationship between nut consumption and the prevention of individual types of cancer, given the scarcity of available data. © The Author(s) 2015.

PubMed | Mayo Medical School and Kern Center for the Science of Health Care Delivery
Type: Journal Article | Journal: Mayo Clinic proceedings | Year: 2015

To determine how often unnecessary resting echocardiograms that are not recommended by clinical practice guidelines are performed in patients with stable chest pain and normal resting electrocardiograms (ECGs).We performed a retrospective search of electronic medical records of all outpatients seen at Mayo Clinic Rochester from January 1, 2010, through December 31, 2013, to identify residents of Olmsted County, Minnesota, with stable chest pain and known or suspected coronary artery disease who underwent resting echocardiography and had normal resting ECGs and no other indication for echocardiography.Of the 8280 outpatients from Olmsted County who were evaluated at Mayo Clinic Rochester with chest pain, 590 (7.1%) had resting echocardiograms. Ninety-two of these 590 patients (15.6%) had normal resting ECGs. Thirty-three of these 92 patients (35.9%) had other indications for echocardiography. The remaining 59 patients (10.0% of all echocardiograms and 0.7% of all patients) had normal resting ECGs and no other indication for echocardiography. Fifty-seven of these 59 patients (96.6%) had normal echocardiograms. Thirteen of these 59 echocardiograms (22.0%) were preordered before the provider (physicians, nurses, physician assistants) visit.The overall rate of echocardiography in Olmsted County outpatients with chest pain seen at Mayo Clinic Rochester is low. Only 1 in 10 of these echocardiograms was performed in violation of the class III recommendation in the American College of Cardiology Foundation/American Heart Association guidelines for the management of stable angina. These unnecessary echocardiograms were almost always normal. The rate of unnecessary echocardiograms could be decreased by eliminating preordering.

PubMed | Center for Health Information and Communication, Patient-Centered Outcomes Research Institute, Kern Center for the Science of Health Care Delivery, U.S. National Institutes of Health and Center for Health Services Research in Primary Care
Type: Journal Article | Journal: Cancer | Year: 2016

The current study was performed to determine whether patient characteristics, including race/ethnicity, were associated with patient-reported care coordination for patients with colorectal cancer (CRC) who were treated in the Veterans Affairs (VA) health care system, with the goal of better understanding potential goals of quality improvement efforts aimed at improving coordination.The nationwide Cancer Care Assessment and Responsive Evaluation Studies survey involved VA patients with CRC who were diagnosed in 2008 (response rate, 67%). The survey included a 4-item scale of patient-reported frequency (never, sometimes, usually, and always) of care coordination activities (scale score range, 1-4). Among 913 patients with CRC who provided information regarding care coordination, demographics, and symptoms, multivariable logistic regression was used to examine odds of patients reporting optimal care coordination.VA patients with CRC were found to report high levels of care coordination (mean scale score, 3.50 [standard deviation, 0.61]). Approximately 85% of patients reported a high level of coordination, including the 43% reporting optimal/highest-level coordination. There was no difference observed in the odds of reporting optimal coordination by race/ethnicity. Patients with early-stage disease (odds ratio [OR], 0.60; 95% confidence interval [95% CI], 0.45-0.81), greater pain (OR, 0.97 for a 1-point increase in pain scale; 95% CI, 0.96-0.99), and greater levels of depression (OR, 0.97 for a 1-point increase in depression scale; 95% CI, 0.96-0.99) were less likely to report optimal coordination.Patients with CRC in the VA reported high levels of care coordination. Unlike what has been reported in settings outside the VA, there appears to be no racial/ethnic disparity in reported coordination. However, challenges remain in ensuring coordination of care for patients with less advanced disease and a high symptom burden. Cancer 2015;121:2207-2213. 2015 American Cancer Society.

PubMed | Center for Individualized Medicine, Mayo Medical School, Kern Center for the Science of Health Care Delivery, Office of Information and Knowledge Management and Molecular Therapeutics
Type: | Journal: Genetics in medicine : official journal of the American College of Medical Genetics | Year: 2016

Despite potential clinical benefits, implementation of pharmacogenomics (PGx) faces many technical and clinical challenges. These challenges can be overcome with a comprehensive and systematic implementation model.The development and implementation of PGx were organized into eight interdependent components addressing resources, governance, clinical practice, education, testing, knowledge translation, clinical decision support (CDS), and maintenance. Several aspects of implementation were assessed, including adherence to the model, production of PGx-CDS interventions, and access to educational resources.Between August 2012 and June 2015, 21 specific drug-gene interactions were reviewed and 18 of them were implemented in the electronic medical record as PGx-CDS interventions. There was complete adherence to the model with variable production time (98-392 days) and delay time (0-148 days). The implementation impacted approximately 1,247 unique providers and 3,788 unique patients. A total of 11 educational resources complementary to the drug-gene interactions and 5 modules specific for pharmacists were developed and implemented.A comprehensive operational model can support PGx implementation in routine prescribing. Institutions can use this model as a roadmap to support similar efforts. However, we also identified challenges that will require major multidisciplinary and multi-institutional efforts to make PGx a universal reality.Genet Med advance online publication 22 September 2016Genetics in Medicine (2016); doi:10.1038/gim.2016.120.

ROCHESTER, Minn. -- Using a shared decision-making aid to involve patients more in their own care decisions can prevent unnecessary hospitalization or advanced cardiac tests for patients reporting low-risk chest pain -- for the cost of about 1 minute of time. So says a study from Mayo Clinic researchers, published online today in The BMJ. MULTIMEDIA ALERT: Video and audio are available for download on the Mayo Clinic News Network. According to the Centers for Disease Control and Prevention, the second highest cause of emergency department visits is chest pain. "Chest pain can be caused by a wide variety of problems," says Erik Hess, M.D., study lead author and emergency medicine physician at Mayo Clinic. "While we recommend that people seek immediate medical help when experiencing chest pain, the next steps can vary - and be unnecessarily costly." Patients at low risk for acute coronary syndrome - a range of conditions that includes a heart attack and is associated with sudden, reduced blood flow to the heart - are frequently admitted for observation and cardiac testing. Dr. Hess and his colleagues say this is because, "Given the potential for missing a diagnosis of acute coronary syndrome, clinicians have a very low risk threshold to admit patients for observation and advanced cardiac testing." "Despite little possibility that these low-risk patients are experiencing acute coronary syndrome, emergency physicians are more likely to default to admission for observation and additional testing," says Dr. Hess. "This presents a substantial unnecessary burden and cost to the patient and the health care system." The research team felt that introducing a shared decision-making approach might not only increase patients' understanding of their symptoms and risks, but also allow them to participate more actively in deciding whether hospital admission and advanced cardiac testing were necessary. Using the Chest Pain Choice decision aid, emergency department physicians and patients with low-risk chest pain can estimate the risk for acute coronary syndrome within the next 45 days. Based on that risk, they can then have a joint discussion on whether hospital admission and advanced cardiac testing is warranted, or whether a follow-up appointment with primary care or cardiology is a more appropriate step. In a randomized clinical trial across six emergency departments in five states, the researchers compared usual care for 447 patients to 451 patients receiving the Chest Pain Choice decision aid intervention. The primary outcome, selected by patient and caregiver representatives, was patient knowledge. Secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30-day rate of major adverse cardiac events. The team showed that using the decision aid resulted in: Both patients and physicians were satisfied with the decision aid and its use, which, according to the study authors, "took an average of one additional minute of clinician time." Shared decision-making resulted in significantly less overuse of hospitalization and advanced cardiac testing, thereby reducing the overall burden on the health care system, as well as potential costs for patients. "When patients are involved with their care decisions, it is more likely they will get the right care for their concerns," says Dr. Hess. "We believe that the Chest Pain Choice decision aid will make it easier for patients and physicians to have a thoughtful discussion and make an individualized care plan that is less likely to overuse unnecessary services." Dr. Hess first presented the Chest Pain Choice decision aid at the American College of Cardiology's 65th Annual Scientific Session (Read news release.). The study was funded by the Patient-Centered Outcomes Research Institute and the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. It was conducted in collaboration with the Knowledge and Evaluation Research Unit. This unit focuses much of its efforts on developing and validating shared decision aids across health care. Mayo Clinic is a nonprofit organization committed to clinical practice, education and research, providing expert, whole-person care to everyone who needs healing. For more information, visit mayoclinic.org/about-mayo-clinic and newsnetwork.mayoclinic.org.

ROCHESTER, Minn.­ -- A common way of scheduling surgeries to expand patient access to care and improve hospital efficiency, known as "overlapping surgeries," is as safe and provides the same outcomes for patients as non-overlapping surgeries, a Mayo Clinic study has found. Spacing operations so a surgeon has two patients in operating rooms at the same time is a common practice in surgery at Mayo and other leading medical institutions. It gives patients greater access to qualified surgeons, allows more efficient use of operating rooms, and avoids unnecessary downtime for surgeons. A Mayo Clinic study compared the outcomes of thousands of such overlapping surgeries with non-overlapping operations at its Rochester campus and found no difference in the rates of postoperative complications or deaths within a month after surgery between the two groups. The findings are published in the Annals of Surgery. The researchers used Mayo Clinic data from the University HealthSystem Consortium, an alliance of academic medical centers whose members include Mayo Clinic, to match 10,614 overlapping surgeries to 16,111 non-overlapping procedures performed at Mayo in Rochester. An additional sample using more than 10,000 operations including over 3,000 with overlap, matched by surgeon, was analyzed using data from Mayo Clinic's Rochester campus in the American College of Surgeons-National Surgical Quality Improvement Program. That analysis also found no differences in outcomes. "Our data shows that overlapping surgery as practiced here is safe," says co-author Robert Cima, M.D., a colorectal surgeon and chair of surgical quality at Mayo Clinic's Rochester campus. "We think it provides value to our patients because it allows more patients timely access to surgery and care by expert teams." In medical parlance, overlapping surgery differs from concurrent surgery. In overlapping surgeries, operations are staggered so the key parts, called the "critical portions," do not occur at the same time; the surgeon is present for the critical portions of each operation and immediately available for non-critical portions such as closing the wound. In concurrent surgery, a surgeon also has two patients in operating rooms at the same time, but the critical portions of the surgeries overlap. Concurrent surgery is rare and is not allowed by Medicare. Mayo Clinic has long studied its surgical outcomes to improve quality and refine operating room scheduling and other surgical systems and procedures to improve patients' experience, patient access and hospital efficiency. Key findings over the years include the importance of scheduling surgeries early in the day when possible, rather than at night, when data shows complications are likelier. Planning cases to overlap during the day helps avoid needless night surgeries. Teams with multiple surgeons are common at Mayo, which has the skill and surgical infrastructure to perform complex operations that involve two or more surgical specialties; cases also may overlap to make surgeons available when needed in multi-surgeon procedures. Dr. Cima is medical director of surgical outcomes research at the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. The study's senior author is Elizabeth Habermann, Ph.D., scientific director of surgical outcomes research. The first author is Joseph Hyder, M.D., Ph.D., an anesthesiologist and associate medical director of surgical outcomes research. Dr. Hyder received research support from the Anesthesia Patient Safety Foundation and the Anesthesia Quality Institute. Co-author Daryl Kor, M.D., a Mayo Clinic anesthesiologist and medical director of the Center for the Science of Health Care Delivery's health care systems engineering program, received funding from National Institutes of Health grants U01-HL108712 and R01-HL121232. Mayo Clinic is a nonprofit organization committed to clinical practice, education and research, providing expert, whole-person care to everyone who needs healing. For more information, visit mayoclinic.org/about-mayo-clinic or newsnetwork.mayoclinic.org.

Hyder J.A.,Kern Center for the Science of Health Care Delivery | Hebl J.R.,Mayo Medical School
Anesthesiology Clinics | Year: 2015

Anesthesiologists are obligated to demonstrate the value of the care they provide. The Centers for Medicare and Medicaid Services has multiple performance-based payment programs to drive high-value care and motivate integrated care for surgical patients and hospitalized patients. These programs rely on diverse arrays of performance measures and complex reporting rules. Among all specialties, anesthesiology has tremendous potential to effect wide-ranging change on diverse measures. Performance measures deserve scrutiny by anesthesiologists as tools to improve care, the means by which payment is determined, and as a means to demonstrate the value of care to surgeons, hospitals, and patients. © 2015 Elsevier Inc.

PubMed | Mayo Medical School and Kern Center for the Science of Health Care Delivery
Type: Journal Article | Journal: Journal of medical systems | Year: 2015

Sociometers are wearable sensors that continuously measure body movements, interactions, and speech. The purpose of this study is to test sociometers in a smart environment in a live clinical setting, to assess their reliability in capturing and quantifying data. The long-term goal of this work is to create an intelligent emergency department that captures real-time human interactions using sociometers to sense current system dynamics, predict future state, and continuously learn to enable the highest levels of emergency care delivery. Ten actors wore the devices during five simulated scenarios in the emergency care wards at a large non-profit medical institution. For each scenario, actors recited prewritten or structured dialogue while independent variables, e.g., distance, angle, obstructions, speech behavior, were independently controlled. Data streams from the sociometers were compared to gold standard video and audio data captured by two ward and hallway cameras. Sociometers distinguished body movement differences in mean angular velocity between individuals sitting, standing, walking intermittently, and walking continuously. Face-to-face (F2F) interactions were not detected when individuals were offset by 30, 60, and 180 angles. Under ideal F2F conditions, interactions were detected 50 % of the time (4/8 actor pairs). Proximity between individuals was detected for 13/15 actor pairs. Devices underestimated the mean duration of speech by 30-44 s, but were effective at distinguishing the dominant speaker. The results inform engineers to refine sociometers and provide health system researchers a tool for quantifying the dynamics and behaviors in complex and unpredictable healthcare environments such as emergency care.

PubMed | University of Minnesota, Mayo Medical School and Kern Center for the Science of Health Care Delivery
Type: | Journal: Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation | Year: 2017

Efficient management of fibromyalgia (FM) requires precise measurement of FM-specific symptoms. Our objective was to assess the measurement properties of the Patient-Reported Outcome Measurement Information System (PROMIS) fatigue item bank (FIB) in people with FM.We applied classical psychometric and item response theory methods to cross-sectional PROMIS-FIB data from two samples. Data on the clinical FM sample were obtained at a tertiary medical center. Data for the U.S. general population sample were obtained from the PROMIS network. The full 95-item bank was administered to both samples. We investigated dimensionality of the item bank in both samples by separately fitting a bifactor model with two group factors; experience and impact. We assessed measurement invariance between samples, and we explored an alternate factor structure with the normative sample and subsequently confirmed that structure in the clinical sample. Finally, we assessed whether reporting FM subdomain scores added value over reporting a single total score.The item bank was dominated by a general fatigue factor. The fit of the initial bifactor model and evidence of measurement invariance indicated that the same constructs were measured across the samples. An alternative bifactor model with three group factors demonstrated slightly improved fit. Subdomain scores add value over a total score.We demonstrated that the PROMIS-FIB is appropriate for measuring fatigue in clinical samples of FM patients. The construct can be presented by a single score; however, subdomain scores for the three group factors identified in the alternative model may also be reported.

ROCHESTER, Minn. - People diagnosed with multiple myeloma are more likely to live longer if they are treated at a medical center that sees many patients with this blood cancer. Mayo Clinic researchers published these findings today in the Journal of Clinical Oncology. Multiple myeloma is a rare form of blood cancer that attacks plasma cells -- white blood cells that normally produce antibodies to fight infection. The study measures the difference in life expectancy for patients treated by doctors with varying degrees of experience with the disease. "Studies on cancer surgery have shown the more experience the center or practitioner has, the better the outcome," states study author Ronald Go, M.D., a hematologist and health care delivery researcher at Mayo Clinic. "It is very difficult to be proficient when doctors are seeing only one or two new cases of multiple myeloma per year. We wanted to see if volume matters when it comes to nonsurgical treatment of rare cancers such as multiple myeloma." The new research shows multiple myeloma patients benefit from treatment at more experienced centers. For example, patients treated at centers seeing 10 new patients per year had a 20 percent higher risk of death than those treated at centers seeing 40 new patients per year. Most cancer treatment centers in the United States see fewer than 10 new multiple myeloma patients per year. The researchers used the National Cancer Database, examining outcomes for 94,722 multiple myeloma patients at 1,333 centers. These findings previously were presented at the American Society of Hematology Annual Meeting in December 2015. This study was made possible by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. The center's goal is to uses data-driven science to improve the quality, safety and value of health care, and create better patient experiences. Dr. Go is a Kern Health Care Delivery Scholar in the center. Additional support came from the Eagles Cancer Research Fund Pilot Grant, Mayo Clinic Cancer Center, and the Division of Hematology. Mayo Clinic is a nonprofit organization committed to clinical practice, education and research, providing expert, whole-person care to everyone who needs healing. For more information, visit mayoclinic.org/about-mayo-clinic or newsnetwork.mayoclinic.org.

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