Electronic Documentation of Lifestyle Counseling and Glycemic Control in Patients with Diabetes

Transcription

1 Electronic Documentation of Lifestyle Counseling and Glycemic Control in Patients with Diabetes Naoshi Hosomura, DDS, DMSc 1, Saveli I Goldberg, PhD 2, Mary Zhang, MA 1, Maria Shubina, ScD 1, Alexander Turchin, MD, MS, FACMI 1,3,4 1 Brigham and Women s Hospital, 2 Massachusetts General Hospital 3 Harvard Medical School, 4 Harvard Clinical Research Institute June 16, 2015

2 Background netproces.pl

3 Background The Meaningful Use incentive of electronic medical record (EMR) technology has introduced a wide array of electronic measures (emeasures) of quality of care. Most studies on EMR use and quality of care focused on structured EMR data. Very little is known about how characteristics of narrative electronic documentation may reflect the quality of care.

4 Background Lifestyle counseling has been shown to be strongly associated with faster achievement of HbA1c control in patients with diabetes (e.g. Morrison et al., 2012). Most of the proposed emeasures of lifestyle counseling focus on the presence or absence of counseling rather than counseling quality or effectiveness.

5 Objectives To establish quantitative characteristics of lifestyle counseling documentation that are associated with improved glycemic control in patients with diabetes

6 Context Copy-paste documentation of lifestyle counseling, unlike original records, is not associated with faster achievement of target A1c level (Turchin et al., 2011). Hypothesis More heterogeneous documentation of lifestyle counseling is associated with faster achievement of HbA1c control.

7 Context More intensive lifestyle counseling where patients are given detailed instructions on diet and exercise is more effective than less intensive methods (e.g. Greaves et al., 2011). Hypothesis More intensive documentation of lifestyle counseling is associated with faster achievement of HbA1c control.

8 Approach We developed two metrics of narrative documentation: documentation heterogeneity and documentation intensity. We utilized Natural Language Processing (NLP) system to abstract sentences documenting lifestyle counseling from narrative provider notes.

9 Materials & Methods

10 Study Design Retrospective cohort study Study Cohort Adult patients with diabetes: Materials and Methods a. followed for 2+ years at the primary care practices affiliated with BWH/MGH between b. at least one annual encounter with a PCP during the hyperglycemic period (defined on the next slide)

11 Unit of Analysis Materials and Methods Hyperglycemic period a single period of continuous HgbA1c > target A1c End of study Target Time Outcome variable Hyperglycemic Period 1 Hyperglycemic Period 2 Time to A1c < 7.0% = length of the hyperglycemic period

12 Exclusion criteria No Zip code information (to adjust for median household income) 2+ encounters with an endocrinologist No medication records Materials and Methods Suspected HbA1c measurement errors (rate of HbA1c change >3SD from the mean) Transient elevations of HbA1c (a single elevated measurement followed by a fall below the target at the next measurement with no interceding medication intensification)

13 Confounder variables Materials and Methods Age Gender Race/ethnicity Primary language Income Health insurance On insulin vs. not on insulin Obesity (BMI > 30) Charlson comorbidity index Starting HbA1c level Frequency of HbA1c testing Frequency of documented lifestyle counseling Frequency of anti-hyperglycemic medication intensification

14 Predictor Variables 1. Documentation Heterogeneity

15 Documentation Levenshtein Heterogeneity Distance Documentation heterogeneity: the normalized Levenshtein distance between lifestyle counsling sentences between consecutive notes. The Levenshtein distance between two strings is the minimum number of editing operations needed to transform one into the other. Insertion of a character Deletion of a character Substitution of a character by another character

16 Example 1 Levenshtein Distance = 5 Example 2 Levenshtein Distance = 9

17 Normalized Levenshtein Distance The Levenshtein distance divided by the length of the longer string 11 characters 8 characters Levenshtein distance = 5 Normalized Levenshtein distance = 5/11 = 0.45

18 Additional Exclusion Criteria Sentence length threshold 100 characters per sentence; to exclude sentences composed of multiple sentences without separating punctuations Documentation heterogeneity calculability Only 1 note with documented lifestyle counseling (i.e. documentation heterogeneity incalculable) Copy/paste notes Lifestyle counseling documentation consisted entirely of copied/duplicate sentences (zero documentation heterogeneity).

19 Predictor Variables 2. Documentation Intensity hqwall.net

20 Calculation of Documentation Intensity Assessment NOTE 1/ Plan: Assessment NOTE 2/ Plan: 1. Diabetes Assessment NOTE 3/ Plan: A1c remains elevated 1. Diabetes: Assessment NOTE 4/ Plan: - advised the patient to avoid - A1c food remains with high elevated. 1. Diabetes glycemic index (>40) - advised weight loss A1c remains elevated 1. Diabetes: - encouraged the patient -to explained lower fat importance content in - increase of replacing metformin regular from - A1c 500 remains to 1000 elevated. mg daily their diet sodas with diet sodas -for patient glucose was control encouraged - increased to get regular metformin exercise from 1000 to 1500 mg - recommended a low fat -diet, recommended portion/calorie monitoring - reviewed carbohydrate with the patient intake dailythe importance of a controlled meal such as Jenny using experience-based Craig low estimation fat diet - strongly encouraged the patient to follow a low - discussed a referral -to recommended the diabetic education a higher fat, consumption carbohydrate of restricted fruits, diet 2. Hypercholesterolemia center for advice on diet vegetables, fiber, and lean - discussed meats a referral to the diabetic education center for advice on diet LDL-C 125 mg/dl - increase simvastatin from 2. Hypercholesterolemia 20 to 40 mg daily 2. Hypertension LDL-C on target Under good control 2. Hypertension John Jones, MD - continue simvastatin -40 continue mg daily current management Under good control - continue current management John Jones, MD John Jones, MD John Jones, MD 153 characters 182 characters 141 characters 120 characters Documentation Intensity: the mean number of characters per note dedicated to documenting lifestyle counseling 1 4 ( ) = 149

21 Sample Data Hyperglycemic Period 1 NoteID Sentence 0001 Extensive counseling on DASH diet, diabetes, and exercise interventions 0001 Counseled on diet and need for more vigorous daily exercise and caloric restriction 0002 DASH diet reviewed again 0003 Ongoing struggle father reports with dietary compliance 0003 Extensive counseling regarding diabetes mellitus including diet 0003 Recommended referral to nutritionist based on post visit labs Hyperglycemic Period 2 NoteID Sentence 0004 pt advised about weight loss 0005 pt advised about weight loss 0006 Has gained about 5 lbs since last visit 0006 pt advised about weight loss Documentation Heterogeneity* Documentation Intensity (characters/note) Hyperglycemic Period Hyperglycemic Period *Documentation heterogeneity represented by the normalized Levenshtein distance.

22 Statistical Analyses Log-rank test to compare Kaplan-Meier curves for time to HbA1c target between tertiles by documentation heterogeneity and intensity. Marginal Cox proportional hazards models to estimate the association between time to HbA1c control and documentation characteristics while adjusting for covariates and accounting for clustering within individual patients P values adjusted for multiple hypothesis testing using the Simes- Hochberg method

23 Results

24 Results 13,594 hyperglycemic periods included in the analyses. 10,870 patients contributed to the hyperglycemic periods. The NLP software identified 183,611 sentences from 92,671 provider notes.

25 Patient Characteristics

26 Hyperglycemic Period Characteristics

27 Documentation heterogeneity and time to HbA1c control Documentation heterogeneity* Median time to HbA1c control months months < months *Documentation heterogeneity represented by the normalized Levenshtein distance.

28 Documentation intensity and time to HbA1c control Documentation intensity 100 Median time to HbA1c control 24 months months < months Number of characters per note

29 Hazard ratios for associations between documentation characteristics and time to HbA1c control Values are hazard ratios for reaching a HbA1c < 7.0%. b P values <0.001 are significant after Simes-Hochberg correction.

30 Discussion & Conclusions

31 Discussion In this large, long-term retrospective study, we identified novel quantitative characteristics of electronic documentation of lifestyle counseling associated with improved glycemic control. This is the first study to describe an association between metrics of documentation characteristics and patient outcomes.

32 Discussion Documentation intensity may reflect the extent of the counseling provided. e.g. More time spent on counseling, more detailed instructions Documentation heterogeneity may reflect the variety of advice or the amount of new information content. e.g. Trying a different diet or exercise approach after the previous one did not work

33 Limitations Excluded ~ 1/2 of the patients meeting the initial inclusion criteria Documentation heterogeneity not applicable when <2 notes Type 1 vs. type 2 diabetes Notes by PCPs vs. notes by non-physician clinicians. The accuracy of the NLP software Retrospective study

34 Conclusions Higher heterogeneity and higher intensity of lifestyle counseling documentation in narrative provider notes are associated with better glycemic control in patients with diabetes. Further studies involving direct observation of patient care are needed to establish the nature of the relationship between documentation characteristics and patient outcomes.

35 Acknowledgments Dr. Anna Rumshisky, PhD Assistant Professor of Computer Science, UMass Lowell

36 Questions? Naoshi Hosomura, DDS, DMSc