Automated Patient-Specific Reporting for Chronic Disease Management in the Clinical Laboratory

Dr Glenn EdwardsMBBS, MD, FRCPA

Medical Director, St John of God PathologyPerth, Western Australia

glenn.edwards@sjog.org.au

Disclosures• Former CEO & Medical Director, Pacific Knowledge Systems• Owns stock in PKS

Cost of Chronic DiseaseCost of Chronic Disease

2007 National Diabetes Fact Sheet Total: 23.6 million children and adults in the United States (7.8% of

population)Cost of Diabetes (Direct + Indirect)

• $174 billion: Total costs of diagnosed diabetes in the US in 2007• Including undiagnosed diabetes, pre-diabetes, and gestational diabetes:

$218 billion.

Heart Disease• The leading cause of death in US. (> 650,000 deaths/yr = 27%)• Direct + Indirect cost: $475.3 billion in 2009

Chronic Kidney Disease• 1 in 3 adults at increased risk; 1 in 7 adults have some sign of CKD• Risk of death from CVD is 20 x need for dialysis or transplantation• Cost (Medicare): $20.7 billion

Interpretative ReportingInterpretative Reporting

• Testing guidelines improve outcomes and cost• …but poor compliance and considerable variation

• Physicians want • higher quality information and advice• more engagement with laboratory/clinical pathologists• support for compliance

• Current status• vast majority of lab tests not interpreted by lab• most discussion around esoteric testing• RippleDown shown to support automated commenting in clinical lab

• Current lab role: Reactive, Result-focussed• Our goal: Pro-active, Patient-focussed

Automated support for Automated support for pathologist opinionspathologist opinions

• LabWizard (RippleDown-based reporting application) • Interfaced to LabTrak LIS

• Incremental knowledge acquisition based on live cases

• Supports pathologist opinion writing

• Focus on chronic disease• Common, high volume tests (lipids, glucose, HbA1c, GTT, etc)

• Opinions designed to • Reinforce management according to guidelines• Detect guideline non-compliance• Identify clinical management priorities & variation• Make specific recommendations to correct non-compliance

• NOT canned comments – must be close match to manual task

GuidelinesGuidelines

• Guidelines for the Assessment of Absolute Cardiovascular Risk (National Heart Foundation of Australia, 2009)

• Position Statement on Lipid Management (National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand, 2005)

• Diabetes Management in General Practice, 2009/10 (Diabetes Australia and Royal Australian College of General Practitioners)

• Chronic Kidney Disease (CKD) Management in General Practice (Kidney Health Australia, Melbourne, 2007)

• (Local practice)

• (Local opinion)

Key compliance issuesKey compliance issues

• identifying patients known to be at increased absolute risk for CVD• identifying patients, not known to be at increased risk, who require risk assessment • providing an internet URL as information to doctors • identifying low- and high-risk individuals for CHD• recommending LDL-cholesterol target levels relevant to risk category• identifying non-compliance with LDL-cholesterol targets• recommending statin therapy for patients at increased risk for CHD• identifying patients with various hyperlipidaemias• recommending target levels for triglycerides and HDL-cholesterol• recommending triglyceride-lowering therapy for resistant hypertiglyceridaemia• identifying patients at risk for Familial Hypercholesterolaemia• identifying patients who require testing for secondary causes of hyperlipidaemia

• Hypothyroidism, Liver disease, Renal disease

• identifying patients at risk for diabetes• recommending follow up testing for abnormal glucose tests

• On current or previous results

• identifying patients who require recurrent follow up (eg impaired glucose tolerance)• recommending timing and selection of appropriate tests for follow up testing• In diabetes, identifying non-compliance and recommending corrective action with:

• annual HbA1c testing for people with diabetes• annual urine microalbumin testing for people with diabetes• annual assessment of lipid profile in people with diabetes• more frequent HbA1c testing in people with poor glycaemic control• annual eGFR testing in people at increased risk for chronic kidney disease

LabWizard case viewLabWizard case view

Patient-specific reportPatient-specific report

Patient-specific reportsPatient-specific reports

• Archive: 8,695 total patient reports

• Unique opinions: 2,406

• Opinions given on 5 or fewer occasions: 2,188 (91%)

Specific, low frequency Specific, low frequency commentscomments

• Results in diabetic range noted. Absolute Risk for CVD: ASSESS. LDL remains ABOVE target for high risk individuals. If diabetes not confirmed clinically, suggest glucose tolerance test. Also suggest check urine microalbumin:creatinine ratio (ACR). Given : 5

• Total cholesterol > 7.5 mmol/L. Absolute Risk for CVD: INCREASED. LDL is ABOVE target for high risk individuals. Consider statin therapy. Aim for LDL < 2.5 mmol/L. Consider possible Familial Hypercholesterolaemia when LDL > 4.9 mmol/L. Suggest review for clinical stigmata of FH (eg tendon xanthomata, corneal arcus), review family history, and repeat full lipid profile. Also suggest check TSH to exclude sub-clinical hypothyroidism. Given : 5

• Absolute Risk for CVD: ASSESS IF INDICATED (www.heartfoundation.org.au). LDL is now WITHIN target for high risk individuals. Given : 4

• Absolute Risk for CVD: ASSESS. LDL is WITHIN target for high risk individuals. Dyslipidaemic pattern, with raised triglycerides and low HDL. Aim for triglycerides < 1.5 mmol/L and HDL > 1.0 mmol/L. Suggest check fasting glucose. Given : 4

Incremental Knowledge Incremental Knowledge AcquisitionAcquisition

Rules built per day

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Key findingsKey findings

• Acceptance by pathologist group• Patient specific

• Addressed entire patient record

• Doctor specific• Modified for diabetes specialists, cardiologists and nephrologists

• Guideline concordance• Near-natural language• Opinions closely match to pathologists level of uncertainty

• Ambiguous or missing data• Customise commentary

• Manual validation of relevant cases• Filtered by clinical relevance, rather than “abnormal” values

• AV customised according to need

• Minimal impact on TAT

ConclusionsConclusions

• Rippledown-based expert systems facilitate comprehensive provision of pathologist opinions

• Applicable to all areas of clinical pathology• Support best clinical practice in chronic disease • Not only “esoteric” tests

• Focus of clinical interpretation• Trends• Guideline/best practice compliance• Therapy• Care planning• … not just diagnosis

• Restores clinical dialogue for lab/clinical pathologist

Automated Patient-Specific Reporting for Chronic Disease Management in the Clinical Laboratory

Dr Glenn EdwardsMBBS, MD, FRCPA

St John of God PathologyPerth, Western Australia

glenn.edwards@sjog.org.au

ConclusionsConclusions

The myriad guidelines….The myriad guidelines….

> 15% Absolute Risk of CVD in 5 years

• Diabetes and age > 60yrs• Diabetes with microalbuminuria

• Males : ACR > 2.5 mg/mmol• Females : ACR > 3.5 mg/mmol

• Moderate or severe CKD• eGFR < 45 mL/min/1.73m2

• Known diagnosis of Familial Hypercholesterolaemia• Hypertension

• SBP >= 180 mmHg• DBP >= 110 mmHg

• Serum total cholesterol > 7.5 mmol/L

Rules by typeRules by type

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Non-compliance with guidelines in Non-compliance with guidelines in chronic diseasechronic disease

Impact of education campaign

Stern E. et al Int J Clin Pract. 2005 Oct;59(10):1126-30

Compliance Before After

Annual HbA1c 60% 85%

HbA1c < 7% 38% 50%

Annual eye clinic 65% 75%

Annual microalbumin 27% 37%

““Non-compliance”Non-compliance”

Total DMs 292 (13%)

% of DMs

HbA1c overdue 27.00 9.25

ACR overdue 88.00 30.14

Total pts with overdue 90.00 30.82