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Adult Emergency Department Patients with Acute Asthma

and Survey of Local Asthma Centers: 36th Multicenter Airway Research Collaboration (MARC-36) Study

Site Training

Web & Audio Meeting

• Webinar has no audio function

• For audio function:– Please dial 800-501-8979– Then enter the access code (7265276)

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Study LeadershipCarlos Camargo, MD, DrPH (Principal Investigator)Kohei Hasegawa, MD, MPH (Co-investigator)

Project Coordination: Dr Hasegawa & Ms Sullivan.Funded by a grant from Novartis to MGH (Camargo).

Emergency Medicine Network (www.emnet-usa.org),Dept. of Emergency Medicine, MGH, Boston, MA

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1. Overview

2. Chart review

3. Survey

4. REDCap

Outline of Presentation

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1. Overview

2. Chart review

3. Survey

4. REDCap

Outline of Presentation

1. To describe adult ED patients with acute asthma, with a focus on the characteristics of patients with a high number of ED asthma visits in the 12 months before their index visit

Aims

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2. To evaluate the concordance of current ED management of acute asthma with the 2007 National Asthma Education and Prevention Program (NAEPP) guideline.

3. To determine the characteristics of local hospital-affiliated asthma centers and the services they provide.

Aims (continued)

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Acute asthma accounts for almost 2 million ED visits/yr, representing a high-risk population.

Our survey of 177 US asthma centers in 2004 demonstrated suboptimal care in the asthma centers

Current data are scarce on the epidemiology of this patient population, asthma care in ED, and the status of asthma centers.

MARC-36 will address these knowledge gaps.

Significance

Study Design

The MARC-36 study consists of two parts:

1. Chart review of 2,000 ED asthma patients in 50 EDs across the USA

2. Online survey about asthma centers affiliated with participating hospitals

– Conducted by EMNet Coordinating Center

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1. Overview

2. Chart review

3. Survey

4. REDCAP

Outline of Presentation

Identification of Visits

• Use ICD-9-CM codes 493.xx to identify all visits with a principal ED or hospital discharge diagnosis of asthma during a 12-month period– Identify 12-month period from January 1, 2011 to

December 31, 2012 (i.e., 24-month window)– We encourage all sites to start with calendar year

2012 (i.e., January 2012 to December 2012) • The ED visit chosen for chart review will be

selected at random from all asthma-related ED visits over the 12-month period

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1) Asthma ED visit made by adult patient aged 18 to 54 years

AND

2) a history of asthma before the index visit

Inclusion Criteria

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1) History of COPD, emphysema, or chronic bronchitis

2) Transfer visits3) Repeat visit by the same subject

-- the visit that was randomly chosen first will be retained for chart review

4) Visits not prompted, in large part, by an asthma exacerbation, per judgment of the chart reviewer

Exclusion Criteria

Random Sampling

1. Create a list of eligible ED visits during a 12-month period

2. Send the number of eligible visits to EMNet Coordinating Center

3. EMNet will assign randomly-generated Study IDs to the visits, and send a list of them to the site

4. Sites review the charts in order (ie, ID 1, 2, 3, ….) until they have reviewed 40 eligible cases

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Random Sampling1. Creating a list at the siteName Visit Date Running Visit #

Carlos Jan 1 1

Carlos May 1 2

Debbie May 1 3

… … …

Kohei Dec 1 70

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Random Sampling2. Sending running # to EMNet

Name Visit Date Running #

Carlos Jan 1 1

Carlos May 1 2

Debbie May 1 3

… … …

Kohei Dec 1 70

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Random Sampling3. Random ID assigned by EMNet

Running # Study ID

1 23

2 1

3 70

… …

70 2

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Random Sampling4. Reviewing charts in order

Name MRN Running # Study ID

Carlos Jan 1 1 23

Carlos May 1 2 1

Debbie May 1 3 70

… … … …

Kohei Dec 1 70 218

Repeated visits?the visit that was randomly chosen first will be retained for chart review

Name Visit date Running # Study ID

Carlos Jan 1 1 23

Carlos May 1 2 1

Debbie May 1 3 70

… … … …

Kohei Dec 1 70 219

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111 01Site-specific 3 digit number

Patient number

Study ID#

0

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All data to be entered into Research Electronic Data Capture (REDCap)

We will review basics of REDCap in the final section of this presentation.

Data Entry: REDCap

General informationED records vs. Non-ED records• Most of the information should be available in

the ED records

• Some variables may require review of non-ED records, such as primary care physicians, specialists, and hospitalizations

Examples age of first asthma diagnosis, number of hospitalizations, medication non-adherence, laboratory tests, and weight

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Decision rules for conflicting results

Among the patient’s records• Inpatient > specialist > PCP > ED record

Between providers within the same visit• Attending > resident > PA/NP > student

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No vs. Not Documented/Unknown

• “NO” -- if, after review of all charts, the treatment was not consistently documented– eg, there is the patient medication list and an

inhaled corticosteroid is not listed

• “Not documented/Unknown” -- if insufficient documentation was available to inform the variable– eg, if the medication list is missing, do not

assume “No”

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Variables

• Demographics• Past asthma history• Chronic asthma medications• ED presentation• ED treatments• ED disposition• Laboratory testing over 12 mo

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• Using the Excel sheet (Chart Review Log), enter patient PHI (eg, name, date of birth, medical record number, home ZIP code, visit date)

• Maintain the tracking form locally; do NOT send it to the EMNet Coordinating Center.

Excel Log - Site Use Only

Season of ED visit

• Date of ED visit is PHI– Collected on Chart Review Log

• Enter the season of ED visit based on the month of ED visit (triage) date– Fall: Sep, Oct, Nov– Winter: Dec, Jan, Feb– Spring: Mar, Apr, May– Summer: June, July, Aug

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Median Household Income

• Estimated by ZIP code (=PHI)– ZIP code will be collected on the Chart Review

Log

• Conversion table (ZIP code – Income) will be posted online www.emnet-usa.org/Marc_36/M36_resources.htm

• Please call EMNet Coordinating Center if the patient’s ZIP code is not on the table.

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Ethnicity and Race

• Consider ethnicity a separate concept from race

• Hispanic Ethnicity– Enter “Yes” if Hispanic, Latino, Spanish origin– Persons of Hispanic origin may be of any race

• Race (check all that apply)– eg, white, black, Asian, other

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Standard Treatment

• Calculate the number of “standard treatments” of inhaled beta-agonist given.

• “Standard treatment” is equal to– 2.5 mg albuterol neb– 4-6 puffs from MDI

• e.g., 10 mg albuterol neb = 4 standard treatments

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Practice Charts• Abstractors will complete 2 practice charts

– assessed vs. ‘‘criterion standard’’ • If an abstractor’s accuracy is less than 80% per

chart, the individual will be retrained• After confirming the accuracy >=80%, 40 chart

review can be started.• Online tools will be available

– eg, Manual of Procedures, ZIP-income table, FAQ

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Practice Charts (continued)

• Practice charts will be posted online (password-secured).– www.emnet-usa.org/Marc_36/login.cfm

• Enter the data to REDCap (PRACTICE DATABASE)

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Practice Chart ID #

111 XP1Reviewer initial or # at the study site (you can decide)

Site-specific 3 digit number

Patient number (P1 and P2)

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1. Overview

2. Chart review

3. Survey

4. REDCap

Outline of Presentation

Surveys

1. Site survey

2. Asthma center survey (conducted by EMNet Coordinating Center)

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1) Site Survey

Online survey of each site will collect data on ED and hospital characteristics, including:– Annual ED visits for acute asthma– Order sets, clinical pathways– Whether or not the hospital has an asthma

center– Contact information of asthma center

director

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Asthma center

• A stand-alone clinic focusing on asthma OR

• A usual allergy or pulmonary clinic that has time set aside for preferential scheduling of individuals with asthma.

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Surveys

1. Site survey

2. Asthma center survey (conducted by EMNet Coordinating Center)

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2) Asthma center survey

• Background: Our survey in 2004 and 2006 showed suboptimal coordination of care w/I asthma centers

• Objective: To determine the characteristics of local hospital-affiliated asthma centers

• Methods: Online survey to asthma center directors, collecting the characteristics (eg, staffing, services available, allergy testing)

• Conducted by EMNet Coordinating Center

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1. Overview

2. Chart review

3. Survey

4. REDCap

Outline of Presentation

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Background

• REDCap (Research Electronic Data Capture) is a secure, web-based application designed exclusively to support data capture for research studies

• Initiated at Vanderbilt University and includes >600 active institutional partners (http://project-redcap.org/)

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Features

• Validation/pop-up alerts to minimize data-entry errors

• Save forms as PDF and print as needed

• No need to transmit data to EMNet Coordinating Center

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Getting Started1. Sign User Agreement

2. Send to EMNet

3. Access granted by Partners (MGH)

4. Log in at https://redcap.partners.org

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Getting Started (continued)

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Data Entry• Select database from “My Projects”

• Use the left-hand toolbar to initiate data entry (Chart Review Form)

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Data Entry (continued)

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Data Entry (continued)

Use your mouse to move from field to field (Note: pressing “Enter” will save and kick you out of the form)

Do not use the browser arrows to move back and forth between screens/forms

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Data Entry (continued)

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Changing Responses• “reset value”

• Response changes to questions with branching logic result in a pop-up box asking for confirmation of the change

Changing Responses (continued)

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Databases

1. Practice Database

2. Participant Database

Practice databases are available for use and are designated by “PRACTICE” in title

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Saving Records• After saving a form, a pop-up box will appear if

a response is missing in a required field

• Return to that field and enter a response

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Saving Records (continued)

• After completing blank fields, you are ready to save form as “complete”

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Tips• Save your work frequently!

– Before you leave a form– Times out

• REDCap is case sensitive

• Use the comment section to record anything that does not fit into form

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REDCap Downtime

Partners or EMNet will communicate scheduled

downtimes (e.g., for system upgrades)

May be unanticipated downtime or other factors that prevent use of REDCap (e.g., problem with local internet connection)

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REDCap Questions?

Problems logging in?

Contact Partners HealthCare EDC Supportedcsupport@partners.org

New user requests, other issues, or questions?Kohei Hasegawa, MD, MPH

khasegawa1@partners.org 617-643-5276

MARC-36 TimelinesJune 2013 IRB application

TrainingSite survey

July-August 2013(September at latest!)

Chart reviewAsthma center surveyData management

September-October 2013

Site queriesClose database

November 2013 Primary data analysisSAEM abstracts 58

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Kohei Hasegawa, MD, MPH khasegawa1@partners.org617-726-5276

Carlos A. Camargo, MD, DrPHccamargo@partners.org 617-726-5276

Questions?