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Characterizing Functional Health Status of Surgical Patients in Clinical Notes Characterizing Functional Health Status of Surgical Patients in Clinical Notes

Characterizing Functional Health Status of Surgical Patients in Clinical Notes - PowerPoint Presentation

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Characterizing Functional Health Status of Surgical Patients in Clinical Notes - PPT Presentation

Skube SJ Lindemann EA Arsoniadis EG Akre M Wick EC Melton GB Background Functional health status is an individuals ability to perform daily activities required to meet basic needs fulfill usual roles and maintain their health and wellbeing ID: 786498

status functional phrases health functional status health phrases quality surgical clinical results assistance requires care physical surgery improvement hospital

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Slide1

Characterizing Functional Health Status of Surgical Patients in Clinical Notes

Skube SJ,

Lindemann

EA

,

Arsoniadis

EG,

Akre

M, Wick EC, Melton GB

Slide2

BackgroundFunctional health status

is an individual’s ability to perform daily activities required to meet basic needs, fulfill usual roles, and maintain their health and well-being

Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes. JAMA. 1995;273(1):59-65.

Slide3

BackgroundFunctional status is important in:

Determination of overall general health

Assists in estimating perioperative risk

Factors in occurrence of adverse events

More broadly, functional status can be correlated with one’s overall health and quality of life

Huysmans HA, van Ark E. Predictors of perioperative mortality, morbidity and late quality of life in coronary bypass surgery.

Eur

Heart J. 1989;10

Suppl

H:10-2.

Carmon E,

Keidar

A,

Ravid

A, Goldman G,

Rabau

M. The correlation between quality of life and functional outcome in ulcerative colitis patients after

proctocolectomy

ileal

pouch anal anastomosis. Colorectal Dis. 2003;5(3):228-32.

Crawford RS, Cambria RP,

Abularrage

CJ, Conrad MF, Lancaster RT, Watkins MT, et al. Preoperative functional status predicts perioperative outcomes after

infrainguinal

bypass surgery. J

Vasc

Surg. 2010;51(2):351-8; discussion 8-9.

Albright EL, Davenport DL, Roth JS. Preoperative functional health status impacts outcomes after ventral hernia repair. Am Surg. 2012;78(2):230-4.

Slide4

Background

Hays RD,

Bjorner

JB,

Revicki

DA, Spritzer KL,

Cella

D. Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items.

Qual

Life Res. 2009;18(7):873-80.

Searle SD,

Mitnitski

A,

Gahbauer

EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC

Geriatr

. 2008;8:24.

Jetté

M, Sidney K,

Blümchen

G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity.

Clin

Cardiol

. 1990;13(8):555-65.

Organization WH. How to use the ICF: A practical manual for using the International Classification of Functioning, Disability and Health (ICF). Exposure draft for comment. Geneva: WHO; October 2013.

Slide5

Use Case

Outcomes databases such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) offer high quality data for quality improvement and research efforts

Complex data is currently collected manually by trained surgical clinical reviewers

Assess functional status in the use case of the NSQIP database

Ingraham AM, Richards KE, Hall BL,

Ko

CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach.

Adv

Surg. 2010;44:251.

Hollenbeak

CS,

Boltz

MM, Wang L,

Schubart

J,

Ortenzi

G, Zhu J, et al. Cost-effectiveness of the National Surgical Quality Improvement Program. Ann Surg. 2011;254(4):619-24.

Dimick

JB, Chen SL, Taheri PA, Henderson WG,

Khuri

SF, Campbell DA. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am

Coll

Surg. 2004;199(4):531-7.

Slide6

Hypothesis

It may be possible to improve automated abstraction efforts for complex, poorly defined elements such as functional health status

Significant data related to functional health status is found in free-text documentation in clinical notes

Objective

To understand the value of clinical notes in determining functional health status

To develop a library of terms associated with functional health status

Slide7

Methods

Slide8

Methods

Karnofsky

Performance Score

100

No complaints, no evidence of disease

90

Able to complete major activities; minor signs and symptoms of disease

80

Normal activity with effort; some signs and symptoms of disease

70

Care of self; unable to carry on normal activities or do active work

60

Requires occasional assistance; able to care for most of personal needs

50

Requires considerable assistance and frequent medical care

40

Disabled; requires special care and assistance

30

Severely disabled; hospital admission is indicated; death not imminent

20

Very sick; hospital admission necessary and active treatment necessary

10Moribund; fatal processes progressing0Death

Following chart review, NSQIP functional health status score and Karnofsky score were calculated based only on functional health status associated terms

NSQIP functional status scale

Independent

Does not require assistance from another person for any activities of daily living, including one who functions independently with the use of prosthetics, equipment, and/or devices.

Partially Dependent

Requires some assistance from another person for activities of daily living regardless of use of prosthetics, equipment, and/or devices.

Totally Dependent

Requires total assistance for all activities of daily living.

Slide9

Results1,353 clinical notes were reviewed

1,328 phrases were associated with functional health status

Of the 75 charts reviewed:

39 patients (52%) were male

Median age was 51.5 (range 21-91)

Slide10

Results

The most common specialties for chart encounters were urology (17.3%), orthopedic surgery (14.7%), gynecologic surgery (13.3%) and neurosurgery (13.3%)

Most phrases were recorded by a staff physician (59.9%) or an advanced practice provider (13.7%)

Clinical Note Type

Phrases n (%)

History & Physical

440 (33.1%)

Anesthesia Pre-Op Assessment

338 (25.5%)

Office Visit

237 (17.8%)

Progress Note

160 (12.0%)

Consultation Note

69 (5.2%)

Emergency Department Visit

51 (3.8%)

Telephone Note

23 (1.7%)

Operative Note

8 (0.6%)

Discharge Summary2 (0.2%)Clinical Note Section  History of Present Illness327 (24.6%)

Not Applicable215 (16.2%) Assessment/Plan199 (15.0%) Review of Systems185 (13.9%) Physical Exam156 (11.7%)

Past Medical History

141 (10.6%)

Social History

38 (2.9%)

Past Surgical History

26(2.0%)

Chief Complaint

18 (1.4%)

Form Elements

14 (1.1%)

Operative Indications

9 (0.7%)

Slide11

Results

Phrases

related to functional health status were categorized into 7 major categories:

Diagnoses

Activity/Care needs

Physical exam elements

Functional

scores

10% of functional status associated phrases assessed for inter-rater agreement (90.7%,

κ

=

0.737)

Assistive equipment

Symptoms

Surgical history

Slide12

Results

Phrases Grouped by NSQIP Functional Category

Slide13

Results

scoliosis

kyphosis

lumbar stenosis

subdural hemorrhage

chronic pain

neurogenic bladder

spinal cord injury

multiple sclerosis

meningioma

CNS lymphoma

hemiplegia

monoplegia

autism

learning disability

Mobius Syndrome

paraplegia

ulcer

neurogenic bowel

hip fracture

dementia

malnutritionSpina Bifidahydrocephalusdecubitus ulcerparalysisPoliopost-Polio syndromes

hyperreflexiaspasticityLyme DiseaseChiari Malformationweaknessspasmodic dysphonialimb hypogenesiscongenital deformity

radiculitis

Cauda Equina

stroke

critical limb ischemia

seizure

Alzheimer Disease

Parkinson Disease

mental retardation

Cerebral Palsy

cognitive defects

dysreflexia

developmental delay

 

Diagnoses (472 phrases, 47 unique)

“The patient has two, clean sacral pressure ulcers.”

“She has progressive multiple sclerosis.”

Slide14

Results

spinal cord stimulator

indwelling Foley

wheelchair

motorized wheelchair

Baclofen pump

urinary catheters

home oxygen

lift chair

walker

bath bench

leg brace

foot brace

knee brace

torso brace

neck brace

crutches

scooter

intrathecal pump

home ramp

prosthesis

ostomy pouchJay cushionRoho cushionHoyer liftshower chaircaneBiPAP

hospital bedstretchergrab barsventilator Assistive Equipment (110 phrases, 31 unique) “The patient requires a hospital bed at home with transportation via stretcher from the hospital.”

Slide15

Results

pain

weakness

shortness of breath

tingling

numbness

spasticity

fatigue

secretion problems

multiple falls

hematuria with cath

urinary incontinence

fecal incontinence

altered sensation

paresis

paresthesias

radiculopathy

worsening gait

swelling

urinary retention

neuropathy

worsening motor functionworsening neurologic statusseizuresunresponsivecombative behaviorconstant movementmemory deficit

slurred speech    Symptoms (95 phrases, 28 unique)“She has experienced fecal incontinence since the onset of her disease”

Slide16

Results

epidural injection

below knee amputation

thoracic spine surgery

artificial urinary sphincter

suprapubic catheter placement

Mitrofanoff

ventriculo-peritoneal shunt

ventriculo-pleural shunt

neck fusion

above knee amputation

tracheostomy

colostomy

craniotomy

urinary diversion

nephrostomy tubes

percutaneous gastrostomy

ileal conduit

Monti

bladder augmentation

urostomy

disarticula-tiongastro-jejunostomy  Surgical Terms (80 phrases, 22 unique)“A urostomy

was performed for persistent incontinence”

Slide17

Results

Activity/Care Needs (297 phrases)

Many phrases with varying levels of dependence/assistance

“He requires full assistance with transfers”

Physical Exam Elements (154 phrases, 87 unique)

General/Appearance-Cognitive-Motor/Strength/Sensation

“No motor or sensation of the lower extremities”

Functional Scores (120 phrases)

Useful, but infrequent

Karnofsky

Score, 70”

Slide18

Results

Slide19

Results

Slide20

DiscussionFunctional status is a complex topic that can vary by provider and has not been well integrated into electronic medical records and clinical workflows

As functional status complexity increases, there was wider variability in categorical designation (NSQIP and

Karnofsky

Score)

Slide21

Limitations

Retrospective review

Undocumented factors

Single institution

Underrepresentation of physical and occupational therapists

Slide22

Future Plans

Publish a database of functional status terms

Improve automated detection techniques for functional health status determinations

Slide23

ConclusionFunctional status can be found in clinical notes through diagnoses, activity and home care descriptions, physical exam elements, functional scores, assistive equipment, symptoms, and surgical procedures

There is a lack of standardized functional health status documentation

Phrases found in this study could be used to assist in the automation of detection of functional health status

Slide24

Acknowledgements

Project Mentor: Genevieve Melton-

Meaux

, MD, PhD

This research was supported by the University of Minnesota Academic Health Center Faculty Development Award, Agency for Healthcare Research and Quality (R01HS24532), National Institutes of Health (NIH) Clinical and Translational Science Award (CTSA) program (UL1TR000114), NIH/National Institute of General Medical Sciences (NIGMS) (R01GM120079), Fairview Health Services, and University of Minnesota Physicians.

Slide25

Thank You