Hypertension: Warren J

Warren J, Gaikwad R, Mabotuwana T, Kennelly J, Kenealy T. · Section for Epidemiology and Biostatistics / Department of Computer Science, University of Auckland, Auckland, New Zealand. · N Z Med J. · Pubmed #19079437 No free full text.

Abstract: AIM: To assess use of Electronic Medical Records (EMRs) to identify patient cases for potential quality improvement in use of blood pressure-lowering medications in general practice. SETTING: One metropolitan general practice in Auckland with a high proportion of Pacific patients. PARTICIPANTS: Patients registered as regular patients with the practice; classified within the previous 5 years as having hypertension; with at least one prescription for antihypertensive medication in the year prior to the evaluation period of 9 May to 8 November 2007. INTERVENTION: Iterative discussion of quality improvement opportunities and review of EMRs with a panel of practice clinicians to identify agreed quality indicators based on EMR data. This resulted in a set of eight evidence-based criteria for patients classified with hypertension, implemented as database queries, which identify cases for potential quality improvement. The panel conducted blind assessment of antihypertensive therapy on a sample of 20 cases matching at least one criterion and 20 cases that met no criterion; the case classifications based on the database queries were then revealed for direct comment and consideration by the panel. RESULTS: Of 517 eligible patients, 209 (40.4%) met one or more of the eight criteria. Of these 209, 110 (21.3%) met only criteria related to persistence of medication possession and/or blood pressure recording. After assessment of the 40-patient sample by the practice GPs, the eight criteria taken as a whole had a Positive Predictive Value of 70% (95% CI 46-88%) and Negative Predictive Value of 70% for clinician assessment of suboptimal therapy and/or process. CONCLUSION: EMRs can provide moderately reliable identification of patients with suboptimal management of blood pressure in general practice. It should be noted, however, that the complexity of required query formulation is substantial with current tools. Identification of patients with poor persistence of antihypertensive therapy is the most promising outcome for follow-up investigation. The study needs to be replicated in a range of different practice settings.

Chung J, Caumartin Y, Warren J, Luke PP. · Department of Surgery, Division of Urology, University of Western Ontario, Canada. · Am J Transplant. · Pubmed #18444936 No free full text.

Abstract: The acute Page kidney phenomenon occurs as a consequence of external compression of the renal parenchyma leading to renal ischemia and hypertension. Between January 2000 and September 2007, 550 kidney transplants and 518 ultrasound-guided kidney biopsies were performed. During that time, four recipients developed acute oligo-anuria following ultrasound-guided allograft biopsy. Emergent doppler-ultrasounds were performed demonstrating absence of diastolic flow as well as a sub-capsular hematoma of the kidney. Prompt surgical exploration with allograft capsulotomy was performed in all cases. Immediately after capsulotomy, intraoperative Doppler study demonstrated robust return of diastolic flow. Three patients maintained good graft function, and one kidney was lost due to acute antibody-mediated rejection. We conclude that postbiopsy anuria associated with a subcapsular hematoma and acute absence of diastolic flow on doppler ultrasound should be considered pathognomonic of APK. All renal transplant specialists should be able to recognize this complication, because immediate surgical decompression can salvage the allograft.

Gaikwad R, Warren J, Kenealy T. · Department of Computer Science, The University of Auckland, New Zealand. · Stud Health Technol Inform. · Pubmed #17911839 No free full text.

Abstract: Chronic disease management represents one of the challenges for health informatics and demands the appropriate application of information technology for improved patient care. This paper presents an approach to quality assurance reporting wherein the recommendations of evidence-based clinical practice guidelines are considered in the context of empirical therapeutic state-transitions (in terms of changes in individual patient prescriptions over time). We apply a Transition-based Audit Report (TAR) model to antihypertensive prescribing and related data as stored in a New Zealand General Practice Management System database. The results provide a set of quality indicators and specific patient cohorts for potential practice quality improvement with strong linkage to the selected guidelines and observed practice patterns. We see the TAR model primarily as a tool to enable internal quality improvement efforts, but also to be of relevance for focusing pay-for-performance programs.

Warren J, Gadzhanova S, Stanek J, Iankov I. · Advanced Computing Reseach Centre, University of South Australia. · AMIA Annu Symp Proc. · Pubmed #16779147 links to  free full text

Abstract: Increasing uptake of electronic medical records (EMRs) offers opportunities for analysis and quality assurance of clinical practice; but making appropriate inferences about chronic disease management is non-trivial. We propose a state-transition model for analysis of chronic disease therapy by community practices based on clinical practice guidelines. We abstract guideline recommendations to key therapeutic states, and map electronic prescribing data into a series of states and transitions, which can then be interpreted with respect to the recommendations of the guideline. By applying our approach to a patient cohort diagnosed with both hypertension and diabetes mellitus, we demonstrate that the method identifies cases at risk of suboptimal care, deserving further review by General Practitioners (GPs).

Barretto SA, Warren J, Goodchild A, Bird L, Heard S, Stumptner M. · Advanced Computing Research Centre, University of South Australia. · AMIA Annu Symp Proc. · Pubmed #14728135 links to  free full text

Abstract: The promise of electronic decision support to promote evidence based practice remains elusive in the context of chronic disease management. We examine the problem of achieving a close relationship of Electronic Health Record (EHR) content to other components of a clinical information system (guidelines, decision support and workflow), particularly linking the decisions made by providers back to the guidelines. We use the openEHR architecture, which allows extension of a core Reference Model via Archetypes to refine the detailed information recording options for specific classes of encounter. We illustrate the use of openEHR for tracking the relationship of a series of clinical encounters to a guideline via a case study of guideline-compliant treatment of hypertension in diabetes. This case study shows the contribution guideline content can have on problem-specific EHR structure and demonstrates the potential for a constructive interaction of electronic decision support and the EHR.

Warren J, Bolton P. · School of Computer and Information Science, University of South Australia, Mawson Lakes, Australia. · Top Health Inf Manage. · Pubmed #11680277 No free full text.

Abstract: Statistical relationships among symptoms, diagnoses and treatments can be inferred from large data-bases of health records. We investigate how these "empirical norms" can be utilized to improve the efficiency and quality assurance capability of on-line systems in General Practice medicine. Using a survey-based database of General Practice records, we assess hotlists (case sensitive menus) of diagnoses to speed data entry. We also explore norm violation as an indicator of poor quality in practice or data recording. We find that efficient hotlists of diagnoses can be generated from symptoms. Also, we find that less frequently used hypertension treatments are assessed as of a lower quality than more common ones. The results support the hypothesis that empirical norms have a role to play in improved General Practice systems.

Warren J. · No affiliation provided · Clin Med. · Pubmed #17992766 No free full text.

This publication has no abstract.

Ritter J, Warren J. · No affiliation provided · Br J Clin Pharmacol. · Pubmed #16487235 links to  free full text

This publication has no abstract.