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Studies Published Using CLG

CLG has demonstrated its value in improving both operational and clinical quality in medical centers. It gives these enterprises new abilities to analyze patient and operational information in an endless combination of ways. New uses of the tool continually result in peer-reviewed publications in the most highly-regarded journals. As new studies are published, they will be posted here.

This Article summarizes core principles, philosophy, and actual use of Clinical Looking Glass in its first five years in production at the Montefiore Medical Center.

This summary provides a listing of all peer reviewed articles that have employed CLG as a part of their study.  It is organized by Clinical Department.

The objective of this study was to compare the polysomnography findings and cardiometabolic function among adolescent girls with polycystic ovary syndrome (PCOS) and matched female and male controls. A retrospective chart review of electronic medical records of 28 girls with PCOS (age:16.8 ± 1.9 years, body mass index (BMI) Z-score 2.4 ± 0.4), 28 control females (age: 17.1 ± 1.8, BMI Z-score 2.4 ± 0.3) and 28 control males (age: 16.6 ± 1.6, BMI Z-score 2.5 ± 0.5) in a tertiary care centre was performed.  We report a higher prevalence of OSA and metabolic dysfunction in a selected group of obese girls with PCOS referred with sleep-related complaints compared to BMI-matched control girls without PCOS. We also report higher prevalence of cardiometabolic dysfunction in girls with PCOS and OSA compared to girls with PCOS without OSA.

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The purpose of this study was to characterize cumulative radiation exposure from diagnostic imaging (CEDI) in pediatric patients and to investigate its relationship to patients' socioeconomic status and comorbid medical conditions. A retrospective cohort study of_19,000 pediatric patients seen within the outpatient clinic system of an academic tertiary care urban medical center during the month of January 2006 was conducted to estimate CEDI from all procedures performed within 3 years of the index visit (until January 2009). Socioeconomic status was estimated from census tract geocoding. Comorbid medical conditions were identified from the electronic medical record. Patients living in areas of greater poverty were exposed over time to more radiation from diagnostic testing than those living in areas with lower percentages of residents living in poverty. This association was explained almost entirely by the presence of disease burden. No direct association was found between socioeconomic status and CEDI.

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Discharge against medical advice is associated with increased risk for mortality and readmission.  In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting the increased risks associated with discharge against medical advice are attributable to premature discharge.

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Coincident with increasing CT scan use to diagnose pulmonary emboli has been a significant increase in the diagnosis.  In this study, individual short term fatality rates of pulmonary emboli patients  diagnosed with CT were compared to those diagnosed with Ventillation:Perfusion scanning.  Controlling for comorbidities CT diagnosed patients had a lower short term fatality rate raising the possibility that pulmonary emboli detected on CT represent overdiagnosis or a different spectrum of disease with potential implications for appropriate intervention strategies.

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Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEs/ARBs) have proven benefit for patients with myocardial infarction and heart failure; their use is a core measure of hospital quality for the Centers for Medicare and Medicaid Services. The authors’ urban medical center has lower-than-average performance on this measure. The authors used published best practices to design and implement a comprehensive strategy to improve ACE/ARB performance with existing decision support and human resources. Chart reminders were targeted to providers of patients eligible for ACEs/ARBs but not receiving them. ACE/ARB performance increased 8.5% in postintervention patients compared with historical controls. The increase was 20.7% among patients not on ACEs/ARBs on admission (P =.03). Chronic kidney disease (CKD) was inversely associated with the effectiveness of the intervention. A comprehensive strategy can be effective in narrowing the performance gap even for populations with a high prevalence of CKD. However, future work is needed to improve performance among patients whose ACEs/ARBs are withheld during hospitalization.

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Objective:  To determine whether dementia status and medical burden were independent predictors of emergency department (ED) visits and hospitalizations in older patients from an urban geriatric practice participating in a primary care based cognitive screening program.  Dementia status and medical burden were independent predcitors of ED visits.  Conclusion: Dementia status and medical burden were independent predictors of ED visits and death in patients with clinically diagnosed dementia followed from the early stage of disease.

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For Hospital admissions age greater than or equal to 18  between January 1, 2000 and December 31, 2009, Black race and non-O groups have increased venous thromboembolism risk when stratified for age and controlling for comorbid conditions.

Previous studies suggested that patients taking statin drugs at the time of their bacteremia had a lower mortality rate than those not on statins at baseline. The anti-inflamatory nature of statin drugs provided the biologic rational for the presumed reduced damage experienced by patients during bacteremia.  The authors utilized Clinical Looking Glass to identify patients who were bacteremic during a hospital admission and to determine statin use in both the outpatient and inpatient period pior to documented bacteremia.  A careful propensity matched analysis refuted previous studies suggesting statin utility in mortality or length of stay reduction.

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It is not understood whether high levels of antiphospholipid antibodies constitute an additional risk factor for thrombosis in individuals without autoimmune disease.  This study did not find an association between antiphospholipid/LAC positivity and the presence of traditional cardiovascular or thrombosis risk factors in individuals wthout automimmune diseases who were admitted to hospital with DVT, PE, or CVA.  Statin use was associated with increased odds ofantiphospholipid/LAC positivity, even after adjusting for age, ethnicity, and gender.  If statins serve as a proxy for history of hyperlipidemia, it is possible that long standing hyperlipidemia, which triggers statin use in clinical practice, may be associated with highter antiphospholipid levels.

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A cohort of systemic lupus erythematosis (SLE) patients with endstage renal failure were studied to evaluate whether continuing rheumatology follow up visits and immunosuppressive therapy after starting renal replacement were associated with increased survival.  Patients with SLE followed frequently after starting dialysis had significantly higher four year survival rates compared with patientn followed infrequently. In the Cox Proportional hazards model, treatment with prednisone alone or with no medication was associated with a hazard ratio (HR) of death = 6.1 ( 95% CI 1.1, 34; p=0.04) and HR=13 (95% CI 1.5, 106; p=0.02)  respectively compared with patients treated with a combination of immunosuppressive therapy with or without prednisone, adjusted for age at SLE diagnosis, sex, transplant status, and the frequency of rheumatology visits after the development of endstage renal disease.

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QI Exercise using Clinical Looking Glass was initiated in a pilot study of third year medical students on their medical clerkship rotation.  We found that CLG was a useful tool in stimulating QI issues in clinical care.

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Abdominal surgery is thought to be a risk factor for Clostridium dificile-associated diarrhea (CDAD).  The aims of this study were to discern pre-operative factors associated with postoperative CDAD, examine outcomes after postoperative CDAD, and compare outcomes of postoperative versus medical CDAD.  Conclusion:  CDAD is an infrequent complicatino after abdominal operations.  Several avoidable preoperative exposures (eg, antibiotic and PPI user) were identified that increased the risk of postoperative CDAD.  Postoperative CDAD is associated with decreased risk of mortality when compared with CDAD on the medical service.

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Keene and Colleagues used the Quality Duration Calculator (now Time in Range) analytic to assess adequacy of glycemic control in ICU patients.  This powerful analytic allows users to summarize any continuous variable across time.

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Winner of the 2010 Best Clinical Article for the Journal of the American College of Radiology used Clinical Looking Glass to evaluate radiation exposure in patient cohorts undergoing standard care.

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Using Clinical Looking Glass Drs. Boucai and Surks established that Reference limits for TSH differ between races and with age. Use of race- and age-specific reference limits decreases misclassification of patients with lowered or raised TSH in an urban practice.

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Segal and colleagues used Clinical Looking Glass to evaluate the impact of a Medicare Reimbursement Policy Change for Rehabilitation on the Mortality and Readmission experience of elderly patients.

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For patients with chronically uncontrolled diabetes, is the Chronic Care Model (CCM) more effective than standard delivery of primary care at reducing hemoglobin A1c (HbA1c) values?

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Can early exposure to a novel hospital-based, medical informatics system increase internal medicine residents’ interest and involvement in clinical research and quality improvement programs?

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Necrotizing fasciitis (NF) is an uncommon infection of the subcutaneous tissue and superficial fascia. Any delay in treatment can lead to catastrophic results with high mortality. It is well known that patients with systemic lupus erythematosus (SLE) are at increased risk of infection, from the disease and/or its treatment.

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Academic medical centers are increasingly employing hospitalists to staff teaching wards. Although studies have demonstrated reduced lengths of stay (LOSs) associated with hospitalist care, it is unclear which patients are most likely to benefit.

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Improving care of people with diabetes has become a major goal for many institutions. This is particularly important in the Bronx because we deal with a large underserved population of ethnic/racial minorities that is susceptible to more diabetes and further complications.

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The right-shifted oxyhemoglobin dissociation curve of sickle cell disease (SCD) has been thought to result in abnormally low arterial oxygen saturation (SO2), even when oxygen partial pressure (PO2) is normal. However, without polymer formation (minimal under normoxic conditions), HbS oxygen affinity is normal. We hypothesized that in SCD, in vivo SO2 is normal when PO2 is normal.

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Lower socioeconomic status is associated with increased morbidity and mortality in comparison to higher socioeconomics status. We examined whether socioeconomic status was associated with disease prevalence in a geographically distinct locale in New York City (NYC).

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Using Clinical Looking Glass to Determine the Impact of an Intervention on Physician Prescribing of Contraceptives and Folate

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A Case Example of Using Clinical Looking Glass to Conduct Research
 

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A worrisome increase in mortality has been reported recently following the initiation of a computerized physician order entry (CPOE) system in a critically ill pediatric transport population. We tested the hypothesis that such a mortality increase did not occur after the initiation of CPOE in a pediatric population that was directly admitted to the neonatal and pediatric intensive care units at Montefiore Medical Center during two 6-month periods before CPOE and one 6-month period immediately after CPOE was initiated.

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Few studies have demonstrated a benefit of filter placement in the setting of VTE in addition to continuation of anticoagulation. To determine the value of IVC filter placement, we examined outcomes for patients with a VTE who ubsequently received an IVC filter in addition to treatment with therapeutic levels of anticoagulation after filter placement.

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Factors associated with early asthma readmission have not been fully studied. To identify predictors of early readmission, we performed a matched case-control study of children discharged with primary diagnosis of asthma.

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Clinical Pathophysiology Conference
Red, White, Blue and Yellow: A Fatal Combination of Raynaud’s and Jaundice

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Performance Report for BPHC Cluster Health Care for the Homeless and Public Housing Primary Care Programs Children’s Health Project of Montefiore Medical Center

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Objectives: To describe the risk factors, etiology and referral patterns of elderly patients treated for minor burns in an urban emergency department.

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This study examines the wait time from sign-in to triage and triage to MD contact for walk-in visits to the Adult Emergency Department at Moses.

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