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Background: The Rochester Epidemiology Project (REP) medical records-linkage system offers a unique opportunity to integrate medical and residency data with existing environmental data, to estimate individual-level exposures. Our primary aim was to provide an archetype of this integration. Our secondary aim was to explore the association between groundwater inorganic nitrogen concentration and adverse child and adolescent health outcomes. Methods: We conducted a nested case-control study in children, aged seven to eighteen, from six counties of southeastern Minnesota. Groundwater inorganic nitrogen concentration data were interpolated, to estimate exposure across our study region. Residency data were then overlaid, to estimate individual-level exposure for our entire study population (n = 29,270). Clinical classification software sets of diagnostic codes were used to determine the presence of 21 clinical conditions. Regression models were adjusted for age, sex, race, and rurality. Results: The analyses support further investigation of associations between nitrogen concentration and chronic obstructive pulmonary disease and bronchiectasis (OR: 2.38, CI: 1.64–3.46) among boys and girls, thyroid disorders (OR: 1.44, CI: 1.05–1.99) and suicide and intentional self-inflicted injury (OR: 1.37, CI: >1.00–1.87) among girls, and attention deficit conduct and disruptive behavior disorders (OR: 1.34, CI: 1.24–1.46) among boys. Conclusions: Investigators with environmental health research questions should leverage the well-enumerated population and residency data in the REP.

Objective To assess the potential impact of Pharmacogenomic (PGx) variation in cytochrome P450 2D6 (CYP2D6) enzyme function, using loss in quality-adjusted life years (QALYs) associated with treatment problems, and the willingness to pay to avoid treatment problems from patients’ and payers’ perspectives. Patients and Methods The study included patients prescribed tramadol or codeine, or both, between January 1, 2005, and December 31, 2017. Demographic information and adverse drug events, including adverse drug events and poor pain control, were collected from the electronic health records using natural language processing techniques and review by trained abstractors. Patients’ willingness to pay and QALY estimates were based on comprehensive literature review. The CYP2D6 phenotypes were divided into 4 groups: ultra-rapid metabolizers, normal metabolizers, intermediate metabolizers, and poor metabolizers. Results Among the 2860 identified patients, 63 (2%) were ultrarapid metabolizers, 1449 (50%) were normal metabolizers, 1155 (40%) were intermediate metabolizers, and 193 (7%) were poor metabolizers. The patients’ average estimated willingness-to-pay value to avoid treatment problems was $23 per month; poor metabolizers developed problems with the highest estimated willingness-to-pay value ($32 per month). The mean QALY loss among all patients was 0.024 QALYs (8.8 healthy days); poor metabolizers had the highest loss (0.027 QALYs, 9.9 healthy days). Conclusion Patients with various phenotypes developed different treatment problem profiles. Poor CYP2D6 metabolizers developed problems with highest willingness to pay, and they might potentially benefit most from PGx-guided treatment and problem prevention.

Aim: Pharmacogenomics (PGx) holds potential to improve patient treatment; yet, effective patient educational materials are limited. Materials & methods: Using a ‘think aloud’ technique, we sought to understand comprehension and perceptions of a multimedia PGx results packet including a cover letter with QR code to an educational video, brochure and prototype report in the context of PGx case vignettes. Results: The cover letter and video components were viewed less favorably due to excess detail, complex jargon and technology challenges. Recommendations were to enhance comprehension and utility and to customize materials to each patient’s medications or disease conditions. Conclusion: Educational materials were revised to improve comprehension and usability, and diminish concerns to better prepare patients to understand the importance of discussing test results with their provider.

Background Persons with low socioeconomic status may be disproportionately at risk for multimorbidity. Methods Adults aged ≥20 years on 4/1/2015 from 7 counties in Minnesota were identified using the Rochester Epidemiology Project (population-based sample). A composite measure of neighborhood socioeconomic disadvantage, the area deprivation index (ADI), was estimated at the census block group level (n = 251). The prevalence of 21 chronic conditions was obtained to calculate the proportion of persons with multimorbidity (≥2 chronic conditions) and severe multimorbidity (≥5 chronic conditions). Hierarchical logistic regression was used to estimate the association of ADI with multimorbidity and severe multimorbidity using odds ratios (OR). Results Among 198,941 persons (46.7% male, 30.6% aged ≥60 years), the age- and sex-standardized (to the United States 2010 census) median prevalence (Q1, Q3) was 23.4% (21.3%, 25.9%) for multimorbidity and 4.8% (4.0%, 5.7%) for severe multimorbidity. Compared with persons in the lowest quintile of ADI, persons in the highest quintile had a 50% increased risk of multimorbidity (OR 1.50, 95% CI 1.39–1.62) and a 67% increased risk of severe multimorbidity (OR 1.67, 95% CI 1.51–1.86) after adjusting for age, sex, race, and ethnicity. Associations were stronger after further adjustment for individual level of education; persons in the highest quintile had a 78% increased risk of multimorbidity (OR 1.78, 95% CI 1.62–1.96) and a 92% increased risk of severe multimorbidity (OR 1.92, 95% CI 1.72–2.13). There was evidence of interactions between ADI and age, between ADI and sex, and between ADI and education. After age 70 years, no difference in the risk of multimorbidity was observed across quintiles of ADI. The pattern of increasing multimorbidity with increasing ADI was more pronounced in women. Finally, there was less variability across quintiles of ADI for the most highly educated group. Conclusions Higher ADI was associated with increased risk of multimorbidity, and the associations were strengthened after adjustment for individual level of education, suggesting that neighborhood context plays a role in health above and beyond individual measures of socioeconomic status. Furthermore, associations were more pronounced in younger persons and women, highlighting the importance of interventions to prevent chronic conditions in younger women, in particular.

Objective To identify risk factors associated with severe COVID-19 infection in a defined Midwestern US population overall and within different age groups. Patients and Methods We used the Rochester Epidemiology Project research infrastructure to identify persons residing in a defined 27-county Midwestern region who had positive results on polymerase chain reaction tests for COVID-19 between March 1, 2020, and September 30, 2020 (N=9928). Age, sex, race, ethnicity, body mass index, smoking status, and 44 chronic disease categories were considered as possible risk factors for severe infection. Severe infection was defined as hospitalization or death caused by COVID-19. Associations between risk factors and severe infection were estimated using Cox proportional hazard models overall and within 3 age groups (0 to 44, 45 to 64, and 65+ years). Results Overall, 474 (4.8%) persons developed severe COVID-19 infection. Older age, male sex, non-White race, Hispanic ethnicity, obesity, and a higher number of chronic conditions were associated with increased risk of severe infection. After adjustment, 36 chronic disease categories were significantly associated with severe infection. The risk of severe infection varied significantly across age groups. In particular, persons 0 to 44 years of age with cancer, chronic neurologic disorders, hematologic disorders, ischemic heart disease, and other endocrine disorders had a greater than 3-fold increased risk of severe infection compared with persons of the same age without those conditions. Associations were attenuated in older age groups. Conclusion Older persons are more likely to experience severe infections; however, severe cases occur in younger persons as well. Our data provide insight regarding younger persons at especially high risk of severe COVID-19 infection.

PurposeThe depth and breadth of clinical data within electronic health record (EHR) systems paired with innovative machine learning methods can be leveraged to identify novel risk factors for complex diseases. However, analysing the EHR is challenging due to complexity and quality of the data. Therefore, we developed large electronic population-based cohorts with comprehensive harmonised and processed EHR data.ParticipantsAll individuals 30 years of age or older who resided in Olmsted County, Minnesota on 1 January 2006 were identified for the discovery cohort. Algorithms to define a variety of patient characteristics were developed and validated, thus building a comprehensive risk profile for each patient. Patients are followed for incident diseases and ageing-related outcomes. Using the same methods, an independent validation cohort was assembled by identifying all individuals 30 years of age or older who resided in the largely rural 26-county area of southern Minnesota and western Wisconsin on 1 January 2013.Findings to dateFor the discovery cohort, 76 255 individuals (median age 49; 53% women) were identified from which a total of 9 644 221 laboratory results; 9 513 840 diagnosis codes; 10 924 291 procedure codes; 1 277 231 outpatient drug prescriptions; 966 136 heart rate measurements and 1 159 836 blood pressure (BP) measurements were retrieved during the baseline time period. The most prevalent conditions in this cohort were hyperlipidaemia, hypertension and arthritis. For the validation cohort, 333 460 individuals (median age 54; 52% women) were identified and to date, a total of 19 926 750 diagnosis codes, 10 527 444 heart rate measurements and 7 356 344 BP measurements were retrieved during baseline.Future plansUsing advanced machine learning approaches, these electronic cohorts will be used to identify novel sex-specific risk factors for complex diseases. These approaches will allow us to address several challenges with the use of EHR.

Background Prior reports indicate that living in a rural area may be associated with worse health outcomes. However, data on rurality and heart failure (HF) outcomes are scarce. Methods and Results Residents from 6 southeastern Minnesota counties with a first‐ever code for HF ( International Classification of Diseases, Ninth Revision [ ICD‐9 ], code 428, and International Classification of Diseases, Tenth Revision [ ICD‐10 ] code I50) between January 1, 2013 and December 31, 2016, were identified. Resident address was classified according to the rural‐urban commuting area codes. Rurality was defined as living in a nonmetropolitan area. Cox regression was used to analyze the association between living in a rural versus urban area and death; Andersen‐Gill models were used for hospitalization and emergency department visits. Among 6003 patients with HF (mean age 74 years, 48% women), 43% lived in a rural area. Rural patients were older and had a lower educational attainment and less comorbidity compared with patients living in urban areas ( P Conclusions Among patients with HF, living in a rural area is associated with an increased risk of death and fewer emergency department visits and hospitalizations. Further study to identify and address the mechanisms through which rural residence influences mortality and healthcare utilization in HF is needed in order to reduce disparities in rural health.

Average-risk colorectal cancer (CRC) screening is broadly recommended, using one of several endorsed test options. However, CRC screening participation rates remain below national goals. To gain further insights regarding recent, population-based patterns in overall and test-specific CRC screening participation, we conducted a retrospective study of adults, ages 50–75 years, utilizing comprehensive data resources from the Rochester Epidemiology Project (REP). Among residents of Olmsted County, MN eligible and due for CRC screening, we identified 5818 residents across three annual cohorts who completed screening between 1/1/2016 and 12/31/2018. We summarized CRC screening rates as incidence per 1000 population and used Poisson regression to test for overall and mode-specific CRC trends. We also analyzed rates of follow-up colonoscopy within 6-months after a positive stool-based screening result. While no significant differences over time were observed in overall CRC screening incidence rates among those due for screening, we observed a statistically significant increase in mt-sDNA test and statistically significant decreases in screening colonoscopy and FIT/FOBT test completion rates; differences in screening overall and by modality were observed by age, sex, and race/ethnicity. The diagnostic colonoscopy follow-up rate within six months after a positive stool-based test was significantly higher following mt-sDNA (84.9%) compared to FIT/FOBT (42.6%). In this retrospective, population-based study, overall CRC screening incidence rates remained stable from 2016 to 2018, while test-specific rates for mt-sDNA significantly increased and decreased for colonoscopy and FIT/FOBT. Adherence with follow-up colonoscopy after a positive stool-based test was significantly higher among patients who underwent mt-sDNA screening compared to FIT/FOBT.

Background Persons with low socioeconomic status may be disproportionately at risk for multimorbidity. Methods Adults aged ≥20 years on 4/1/2015 from 7 counties in Minnesota were identified using the Rochester Epidemiology Project (population-based sample). A composite measure of neighborhood socioeconomic disadvantage, the area deprivation index (ADI), was estimated at the census block group level (n = 251). The prevalence of 21 chronic conditions was obtained to calculate the proportion of persons with multimorbidity (≥2 chronic conditions) and severe multimorbidity (≥5 chronic conditions). Hierarchical logistic regression was used to estimate the association of ADI with multimorbidity and severe multimorbidity using odds ratios (OR). Results Among 198,941 persons (46.7% male, 30.6% aged ≥60 years), the age- and sex-standardized (to the United States 2010 census) median prevalence (Q1, Q3) was 23.4% (21.3%, 25.9%) for multimorbidity and 4.8% (4.0%, 5.7%) for severe multimorbidity. Compared with persons in the lowest quintile of ADI, persons in the highest quintile had a 50% increased risk of multimorbidity (OR 1.50, 95% CI 1.39–1.62) and a 67% increased risk of severe multimorbidity (OR 1.67, 95% CI 1.51–1.86) after adjusting for age, sex, race, and ethnicity. Associations were stronger after further adjustment for individual level of education; persons in the highest quintile had a 78% increased risk of multimorbidity (OR 1.78, 95% CI 1.62–1.96) and a 92% increased risk of severe multimorbidity (OR 1.92, 95% CI 1.72–2.13). There was evidence of interactions between ADI and age, between ADI and sex, and between ADI and education. After age 70 years, no difference in the risk of multimorbidity was observed across quintiles of ADI. The pattern of increasing multimorbidity with increasing ADI was more pronounced in women. Finally, there was less variability across quintiles of ADI for the most highly educated group. Conclusions Higher ADI was associated with increased risk of multimorbidity, and the associations were strengthened after adjustment for individual level of education, suggesting that neighborhood context plays a role in health above and beyond individual measures of socioeconomic status. Furthermore, associations were more pronounced in younger persons and women, highlighting the importance of interventions to prevent chronic conditions in younger women, in particular.

Electronic health records (EHRs) are widely adopted with a great potential to serve as a rich, integrated source of phenotype information. Computational phenotyping, which extracts phenotypes from EHR data automatically, can accelerate the adoption and utilization of phenotype-driven efforts to advance scientific discovery and improve healthcare delivery. A list of computational phenotyping algorithms has been published but data fragmentation, i.e., incomplete data within one single data source, has been raised as an inherent limitation of computational phenotyping. In this study, we investigated the impact of diverse data sources on two published computational phenotyping algorithms, rheumatoid arthritis (RA) and type 2 diabetes mellitus (T2DM), using Mayo EHRs and Rochester Epidemiology Project (REP) which links medical records from multiple health care systems. Results showed that both RA (less prevalent) and T2DM (more prevalent) case selections were markedly impacted by data fragmentation, with positive predictive value (PPV) of 91.4 and 92.4%, false-negative rate (FNR) of 26.6 and 14% in Mayo data, respectively, PPV of 97.2 and 98.3%, FNR of 5.2 and 3.3% in REP. T2DM controls also contain biases, with PPV of 91.2% and FNR of 1.2% for Mayo. We further elaborated underlying reasons impacting the performance.

This single arm prospective study assessed the impact of individualized wellness coaching intervention for primary care patients with prediabetes on self-reported changes in physical activity level and food choices. Five hundred sixty adult patients 18 years and older with prediabetes, seen in primary care clinic, were invited to participate in 12 weeks wellness coaching sessions delivered by certified coaches. Responses from questionnaires at baseline, 6 and 12 weeks were analyzed. Of 168 consented patients, 99 completed at least one coaching session; majority was elderly, female, overweight or obese. At baseline, 50% had, Highlights • Wellness coaching alone as an effective preventive strategy in patients with prediabetes is proposed. • It can be incorporated in primary care practice. • A 12 weeks session resulted in improved physical activity and healthy eating behavior. • Self-efficacy and quality of life were also increased with coaching. • Significant changes were seen in 6 weeks with sustained effect up to 24 weeks.

Unfavorable lipid levels during childhood are associated with subsequent development of atherosclerotic cardiovascular disease. The American Academy of Pediatrics and National Heart, Lung and Blood Institute in 2011 recommended universal lipid screening for children between ages 9–11 years and between ages 17–21 years. The objective of the study was to determine temporal trends in lipid testing among children and young adults in a mid-western population. The Rochester Epidemiology Project database was used to identify lipid testing in ages 2–21 years (n = 51,176) in the Olmsted County population from January 1, 2008 through December 31, 2014. Generalized estimating equations with Poisson distribution were used to test for temporal trends in lipid testing across the age groups. There was modest increase in lipid testing in children in the age groups, 9–11 years and 17–21 years (1.5% in 2008 to 2.2% in 2014, P, Highlights • In 2011, universal lipid screening was recommended for children and young adults. • We investigated temporal trends in lipid testing in a mid-western community. • There was only a minimal increase in rates of lipid testing. • There is need for improve guideline dissemination and implementation.

David T Eton,1,2 Jennifer L Ridgeway,1,2 Mark Linzer,3 Deborah H Boehm,4 Elizabeth A Rogers,5 Kathleen J Yost,1,2 Lila J Finney Rutten,1,2 Jennifer L St Sauver,1,2 Sara Poplau,4 Roger T Anderson6 1Department of Health Sciences Research, 2Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 3Division of General Internal Medicine, Hennepin County Medical Center, 4Minneapolis Medical Research Foundation, 5Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, 6Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA Purpose: Having multiple chronic conditions (MCCs) can lead to appreciable treatment and self-management burden. Healthcare provider relational quality (HPRQ) – the communicative and interpersonal skill of the provider – may mitigate treatment burden and promote self-management. The objectives of this study were to 1) identify the associations between HPRQ, treatment burden, and psychosocial outcomes in adults with MCCs, and 2) determine if certain indicators of HPRQ are more strongly associated than others with these outcomes.Patients and methods: This is a cross-sectional survey study of 332 people with MCCs. Patients completed a 7-item measure of HPRQ and measures of treatment and self-management burden, chronic condition distress, self-efficacy, provider satisfaction, medication adherence, and physical and mental health. Associations between HPRQ, treatment burden, and psychosocial outcomes were determined using correlational analyses and independent samples t-tests, which were repeated in item-level analyses to explore which indicators of HPRQ were most strongly associated with the outcomes.Results: Most respondents (69%) were diagnosed with ≥3 chronic conditions. Better HPRQ was found to be associated with less treatment and self-management burden and better psychosocial outcomes (P

Objective: To understand the interaction of multimorbidity and functional limitations in determining health-care utilization and survival in older adults. Methods: Olmsted County, Minnesota, residents aged 60–89 years in 2005 were categorized into four cohorts based on the presence or absence of multimorbidity (≥3 chronic conditions from a list of 18) and functional limitations (≥1 limitation in an activity of daily living from a list of 9), and were followed through December 31, 2016. Andersen–Gill and Cox regression estimated hazard ratios (HRs) for emergency department (ED) visits, hospitalizations, and death using persons with neither multimorbidity nor functional limitations as the reference (interaction analyses). Results: Among 13,145 persons, 34% had neither multimorbidity nor functional limitations, 44% had multimorbidity only, 4% had functional limitations only, and 18% had both. Over a median follow-up of 11 years, 5906 ED visits, 2654 hospitalizations, and 4559 deaths occurred. Synergistic interactions on an additive scale of multimorbidity and functional limitations were observed for all outcomes; however, the magnitude of the interactions decreased with advancing age. The HR (95% confidence interval) for death among persons with both multimorbidity and functional limitations was 5.34 (4.40–6.47) at age 60–69, 4.16 (3.59–4.83) at age 70–79, and 2.86 (2.45–3.35) at age 80–89 years. Conclusion: The risk of ED visits, hospitalizations, and death among persons with both multimorbidity and functional limitations is greater than additive. The magnitude of the interaction was strongest for the youngest age group, highlighting the importance of interventions to prevent and effectively manage multimorbidity and functional limitations early in life.

Background The aging population has led to an increase in cognitive impairment (CI) resulting in significant costs to patients, their families, and society. A research endeavor on a large cohort to better understand the frequency and severity of CI is urgent to respond to the health needs of this population. However, little is known about temporal trends of patient health functions (i.e., activity of daily living [ADL]) and how these trends are associated with the onset of CI in elderly patients. Also, the use of a rich source of clinical free text in electronic health records (EHRs) to facilitate CI research has not been well explored. The aim of this study is to characterize and better understand early signals of elderly patient CI by examining temporal trends of patient ADL and analyzing topics of patient medical conditions in clinical free text using topic models. Methods The study cohort consists of physician-diagnosed CI patients (n = 1,435) and cognitively unimpaired (CU) patients (n = 1,435) matched by age and sex, selected from patients 65 years of age or older at the time of enrollment in the Mayo Clinic Biobank. A corpus analysis was performed to examine the basic statistics of event types and practice settings where the physician first diagnosed CI. We analyzed the distribution of ADL in three different age groups over time before the development of CI. Furthermore, we applied three different topic modeling approaches on clinical free text to examine how patients’ medical conditions change over time when they were close to CI diagnosis. Results The trajectories of ADL deterioration became steeper in CI patients than CU patients approximately 1 to 1.5 year(s) before the actual physician diagnosis of CI. The topic modeling showed that the topic terms were mostly correlated and captured the underlying semantics relevant to CI when approaching to CI diagnosis. Conclusions There exist notable differences in temporal trends of basic and instrumental ADL between CI and CU patients. The trajectories of certain individual ADL, such as bathing and responsibility of own medication, were closely associated with CI development. The topic terms obtained by topic modeling methods from clinical free text have a potential to show how CI patients’ conditions evolve and reveal overlooked conditions when they close to CI diagnosis.

Background: Health and Wellness Coaching has been shown to enhance treatment outcomes in the primary care setting. However, little is known about the experience and perceptions of patients who worked with a wellness coach as an integrated member of their primary health-care team. Objective: This project assessed patients’ experience and obtained their perceptions on barriers and facilitators to participation in a primary care–based wellness coaching program. Method: A survey was mailed to 99 primary care patients with prediabetes who participated in a 12-week wellness coaching program. Results: Sixty-two (63%) completed the survey; responders felt that participation in the wellness coaching program helped move them toward healthier lifestyle behavior and created a personal vision of wellness. Major themes associated with participation were supportive coaching relationship, increased self-accountability, increased goal-setting, and healthy behavior strategies. No significant barrier to participation was reported. Conclusion: Participants reported highly positive experience with the program; how to best integrate health and wellness coaching into the primary care setting needs to be explored.

Background Each year, human papillomavirus (HPV) causes 30,000 cancers in the USA despite the availability of effective and safe vaccines. Uptake of HPV vaccine has been low and lags behind other adolescent vaccines. This protocol describes a multilevel intervention to improve HPV vaccination rates. Methods Using a cluster randomized trial, we will evaluate the independent and combined impact of two evidence-based implementation strategies with innovative enhancements on HPV vaccination rates for female and male patients. The clusters are six primary care sites providing care to pediatric populations. We will use a stepped-wedge cluster randomized design, including process evaluation, to test the hypothesis that compared with the current course of care and a practice-level intervention using reminder-recall interventions coupled with provider-level audit and feedback with education increases HPV vaccination rates in exposed clusters. The factorial design allows us to use a single trial to test these two interventions and to assess each individually and in combination. Our design has four 12-month steps. The first step will be a baseline period; data collected during it will provide a within-practice control group for each cluster. Second, two clusters will be randomly assigned to receive intervention 1 (reminder and recall), and two clusters will be randomly selected to receive intervention 2 (audit and feedback with education). Third, the other two clusters will be randomly allocated to intervention 1 or 2. Clusters initially with intervention 1 will be randomly allocated to 1 + 2 or 1; clusters initially with intervention 2 will be randomly allocated to 1 + 2 or 2. Fourth, all clusters will receive both interventions. To ensure balance of patient numbers across interventions, we will use block randomization at the first step, with the six clusters grouped into three pairs according to volume. Our primary outcome will be vaccination rates. Discussion Results of our clinical trial and process evaluation will provide evidence showing whether practice- and provider-level interventions improve HPV vaccination rates and will offer insight into contextual factors associated with direction and magnitude of trial outcomes. Trial registration ClinicalTrials.gov, NCT03501992, registered April 18, 2018. Electronic supplementary material The online version of this article (10.1186/s13012-018-0778-x) contains supplementary material, which is available to authorized users.

Summary Background The benefit of routinely measuring autoimmune biomarkers to evaluate patients with interstitial lung disease (ILD) remains debated outside specific contexts such as connective tissue disease (CTD). This study aimed at evaluating the influence of biomarkers on outcome on patients with ILD in a case-control study at a tertiary referral center. We hypothesized that patients with positive autoimmune biomarkers have increased odds of developing ILD even in the absence of CTD. Methods We reviewed the medical records of 3573 patients seen at the ILD clinic in Mayo Clinic Rochester between September 2001 and September 2006. We assessed their clinical course through June 25, 2013. We included patients with patterns of ILD most often associated with CTD (n = 1256) while excluding patients with other known causes of ILD. Controls (n = 2317) included cases seen at the ILD clinic without evidence of ILD. Results We identified 930 (26%) cases of ILD alone, 124 (3%) CTD alone, 326 (9%) ILD combined with CTD, and 2193 (61%) with no ILD or CTD. Positive antinuclear antibodies (ANA), rheumatoid factor and aldolase were associated with ILD. After adjustment for age, gender, race, smoking history and CTD, ANA remained an independent risk factor for ILD (OR 1.70, 95% CI 1.33–2.17). Among patients with ILD, the presence of CTD but not biomarker alone was associated with a better survival. Conclusion In this study, the presence of positive biomarkers was associated with increased odds of ILD, even in the absence of overt CTD, but was not associated with a better outcome.

Background Communication between patients with limited English proficiency (LEP) and telephone triage services has not been previously explored. The purpose of this study was to determine the utilization characteristics of a primary care triage call center by patients with LEP. Methods This was a retrospective cohort study of the utilization of a computer-aided, nurse-led telephone triage system by English proficiency status of patients empaneled to a large primary care practice network in the Midwest United States. Interpreter Services (IS) need was used as a proxy for LEP. Results Call volumes between the 587 adult patients with LEP and an age-frequency matched cohort of English-Proficient (EP) patients were similar. Calls from patients with LEP were longer and more often made by a surrogate. Patients with LEP received recommendations for higher acuity care more frequently (49.4% versus 39.0%; P

The prevalence of childhood obesity has increased over the past 3 decades. This study was designed to understand how childhood body mass index (BMI) influences later risk of obesity. We calculated BMIs for children residing in Olmsted County, Minnesota, between January 1, 2005 and December 31, 2012 using medical records data. We defined homogenous BMI trajectory clusters using a nonparametric hill-climbing algorithm. Overall, 16,538 (47%) children had >3 weight assessments at least 1 year apart and were included in the analyses. Within the 8-year follow-up period, children who were younger than 2 years and overweight had a 3- fold increase of obesity (adjusted hazard ratio [HR] = 3.24; 95% confidence interval [CI] = 2.69-3.89) and those aged 5 years and overweight had a 10-fold increased risk of obesity (adjusted HR = 9.97, 95% CI = 8.55-11.62). Three distinct BMI trajectories could be distinguished prior to 5 years of age. The risk of developing obesity in those who are overweight increased dramatically with increasing age. Interventions to prevent obesity need to occur prior to school age to prevent children from entering unhealthy BMI trajectories.

Purpose The purpose of this project was to expand the Rochester Epidemiology Project (REP) medical records linkage infrastructure to include data from oral healthcare providers. The goal of this linkage is to facilitate research studies examining the role of oral health in overall health and quality of life. Participants Eight dental practices joined the REP between 2011 and 2015. The REP study team has linked oral healthcare information with medical record information from local healthcare providers for 31 750 participants who have resided in Olmsted County, Minnesota. Overall, 17 718 (56%) participants are women, 14 318 (45%) are 40 years of age or older and 26 090 (82%) are white. Findings to date A first study using this new information was recently completed. This resource was used to determine whether the 2007 guidelines from the American Heart Association affected prescription rates of antibiotics to patients with moderate-risk cardiac conditions prior to dental procedures. The REP infrastructure was used to identify a series of patients diagnosed with moderate-risk cardiac conditions by the local healthcare providers (n=1351), and to abstract antibiotic prescriptions from dental records both pre-2007 and post-2007. Antibiotic prescriptions prior to dental procedures declined from 62% to 7% following the change in guidelines. Future plans Dental data from participating practitioners will be updated on an annual basis, and new dental data will be linked to patient medical records. In addition, we will continue to invite new dental practices to participate in the REP. Finally, we will continue to use this research infrastructure to investigate associations between oral and medical health, and will present findings at conferences and in the scientific literature.

Lila J Finney Rutten,1 Sana N Vieux,2 Jennifer L St Sauver,1 Neeraj K Arora,2 Richard P Moser,2 Ellen Burke Beckjord,3 Bradford W Hesse2 1Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; 2Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA; 3Biobehavioral Medicine in Oncology Program, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA Purpose: Despite considerable potential for improving health care quality, adoption of new technologies, such as electronic medical records (EMRs), requires prudence, to ensure that such tools are designed, implemented, and used meaningfully to facilitate patient-centered communication and care processes, and better health outcomes. The association between patients’ perceptions of health care provider use of EMRs and health care quality ratings was assessed. Method: Data from two iterations of the Health Information National Trends Survey, fielded in 2011 and 2012, were pooled for these analyses. The data were collected via mailed questionnaire, using a nationally representative listing of home addresses as the sampling frame (n=7,390). All data were weighted to provide representative estimates of quality of care ratings and physician use of EMR, in the adult US population. Descriptive statistics, t-tests, and multivariable linear regression analyses were conducted. Results: EMR use was reported significantly more frequently by females, younger age groups, non-Hispanic whites, and those with higher education, higher incomes, health insurance, and a usual source of health care. Respondents who reported physician use of EMRs had significantly higher ratings of care quality (Beta=4.83, standard error [SE]=1.7, P

We assessed changes in adherence to screening mammography recommendations with the introduction of the new U.S. Preventive Services Task Force (USPSTF) recommendations in 2009.Using the Rochester Epidemiology Project data linkage system, we examined mammography screening from 2004 to 2013 in 31,377 women 40years of age and older residing in Olmsted County, MN before and after the 2009 change in recommendations. Chi-square was used to compare screening rates before and after changes in recommendations overall, by age group, and by baseline adherence.Among women 40 years and older, declines in screening were observed: 69% of the population was adherent in 2004-2005, 61% in 2006-2009 and 53% in 2010-2013. Absolute decreases in screening were observed from pre- to post-change for those ages 40-49 (4%), 50-74 (9%), and those 75+ (19%, all p0.0001). Relative declines in screening rates were observed among women aged 70-74 years who were non-adherent at baseline and among women who were adherent at baseline, overall, and in each age group (all p.001).Declines in screening, both absolute and relative, were most pronounced among women who were adherent at baseline. Research is needed to assess factors that influence screening in the context of evolving recommendations.

To analyze longitudinal trends in the incidence, etiology, and treatment of hepatocellular carcinoma (HCC) in community residents in Olmsted County, Minnesota, and their survival.Olmsted County residents 20 years or older with HCC newly diagnosed from January 1, 1976, through December 31, 2008, were identified using a community-wide medical record linkage system (Rochester Epidemiology Project). The incidence rate of HCC was calculated by age and sex according to the 2000 US Census population. Temporal trends of HCC etiology, treatment, and patient survival were assessed.The age- and sex-adjusted incidence rate for HCC in Olmsted County was 3.5 per 100,000 person-years for the first era (1976-1990), 3.8 per 100,000 for the second era (1991-2000), and 6.9 per 100,000 for the third era (2001-2008). Alcohol use was the most common risk factor in the first and second eras and chronic hepatitis C virus in the third. The proportion attributed to nonalcoholic fatty liver disease was small (5/47 [10.6%] in the third era). Because the proportion of patients receiving curative treatment increased over time, survival also improved, with a median survival time of 3, 6, and 9 months in the first, second, and third eras, respectively (P=.01).In this midwestern US community, the incidence of HCC has increased, primarily due to hepatitis C virus. Although there was a demonstrable improvement in the outcome of HCC in community residents over time, the overall prognosis remains poor.

To determine if polymorphisms in the cyclooxygenase 2 (COX-2) enzyme gene (prostaglandin synthase 2; PTGS2) were associated with development of benign prostate enlargement (BPE), and whether associations were modified by use of nonsteroidal anti-inflammatory drugs (NSAIDs).Participants were men residing in Olmsted County, MN, who were between 40 and 79 years of age in 1990 (N= 356). Prostate volume was measured by transrectal ultrasound and men reported all the medications that they were taking at the time of the examination. Men were followed biennially for 16 years. Ten tagging single nucleotide polymorphisms (SNPs) in the PTGS2 gene were typed using the Illumina GoldenGate(TM) Assay. Associations between SNPs and development of BPE (volume30 mL) were assessed by Cox proportional hazards models. Models were also stratified by NSAID use.We observed significant associations between four polymorphisms in the PTGS2 gene and development of BPE (all P0.05). These associations were not observed among men who used NSAIDs.Variants in the PTGS2 gene may increase the risk of prostate enlargement, but the increased risk may be minimized by use of NSAIDs.

Study Type – Prognosis (cohort) Level of Evidence 2a OBJECTIVES To measure prostate volume doubling times (PVDTs) for a large sample of community men followed serially by transrectal ultrasonography (TRUS), and to determine whether specific characteristics are associated with a rapid PVDT. SUBJECTS AND METHODS A subsample of 446 subjects from a larger cohort of American white men aged 40–79 years were evaluated biennially for a median (range) follow-up of 10 (3–14) years. Mixed-effects regression models were used to estimate prostate growth rates and PVDT for subjects with three or more or with five or more serial biennial TRUS PV measurements. RESULTS The median (25–75th percentile) PVDT was 32.6 (24.6–44.0) years. The average annual increase in PV was 2.2%. The PVDT distribution was constant in men of all age groups studied (r

To report rates of amenorrhea and treatment failure after global endometrial ablation and to estimate the association between patient factors and these outcomes by developing and validating prediction models.From January 1998 through December 2005, 816 women underwent global endometrial ablation with either a thermal balloon ablation or radio frequency ablation device; 455 were included in a population-derived cohort (for model development), and 361 were included in a referral-derived cohort (for model validation). Amenorrhea was defined as cessation of bleeding from immediately after ablation through at least 12 months after the procedure. Treatment failure was defined as hysterectomy or reablation for patients with bleeding or pain. Logistic and Cox proportional hazard regression models were used in model development and validation of potential predictors of outcomes.The amenorrhea rate was 23% (95% confidence interval [CI] 19-28%) and the 5-year cumulative failure rate was 16% (95% CI 10-20%). Predictors of amenorrhea were age 45 years or older (adjusted odds ratio [aOR] 2.6, 95% CI 1.6-4.3); uterine length less than 9 cm (aOR 1.8, 95% CI 1.1-3.1); endometrial thickness less than 4 mm (aOR 2.7, 95% CI 1.2-6.3); and use of radio-frequency ablation instead of thermal balloon ablation (aOR 2.8, 95% CI 1.7-4.9). Predictors of treatment failure included age younger than 45 years (adjusted hazard ratio [aHR] 2.6, 95% CI 1.3-5.1); parity of 5 or greater (aHR 6.0, 95% CI 2.5-14.8); prior tubal ligation (aHR 2.2, 95% CI 1.2-4.0); and history of dysmenorrhea (aHR 3.7, 95% CI 1.6-8.5). After global endometrial ablation, 23 women (5.1%, 95% CI 3.2-7.5%) had pelvic pain, three (0.7%, 95% CI 0.1-1.9%) were pregnant, and none (95% CI 0-0.8%) had endometrial cancer.Population-derived rates and predictors of treatment outcomes after global endometrial ablation may help physicians offer optimal preprocedural patient counseling.II.

The mitochondrion, conventionally thought to be an organelle specific to energy metabolism, is in fact multifunctional and implicated in many diseases, including cancer. To evaluate whether mitochondria-related genes are associated with increased risk for prostate cancer, we genotyped 24 single-nucleotide polymorphisms (SNP) within the mitochondrial genome and 376 tagSNPs localized to 78 nuclear-encoded mitochondrial genes. The tagSNPs were selected to achieve ≥80% coverage based on linkage disequilibrium. We compared allele and haplotype frequencies in ∼1,000 prostate cancer cases with ∼500 population controls. An association with prostate cancer was not detected for any of the SNPs within the mitochondrial genome individually or for 10 mitochondrial common haplotypes when evaluated using a global score statistic. For the nuclear-encoded genes, none of the tagSNPs were significantly associated with prostate cancer after adjusting for multiple testing. Nonetheless, we evaluated unadjusted P values by comparing our results with those from the Cancer Genetic Markers of Susceptibility (CGEMS) phase I data set. Seven tagSNPs had unadjusted P ≤ 0.05 in both our data and in CGEMS (two SNPs were identical and five were in strong linkage disequilibrium with CGEMS SNPs). These seven SNPs (rs17184211, rs4147684, rs4233367, rs2070902, rs3829037, rs7830235, and rs1203213) are located in genes MTRR, NDUFA9, NDUFS2, NDUFB9, and COX7A2, respectively. Five of the seven SNPs were further included in the CGEMS phase II study; however, none of the findings for these were replicated. Overall, these results suggest that polymorphisms in the mitochondrial genome and those in the nuclear-encoded mitochondrial genes evaluated are not substantial risk factors for prostate cancer. (Cancer Epidemiol Biomarkers Prev 2008;17(12):3558–66)

Background Limited English proficiency is associated with health disparities and suboptimal health outcomes. Although Limited English proficiency is a barrier to effective health care, its association with inpatient health care utilization is unclear. The aim of this study was to examine the association between patients with limited English proficiency, and emergency department visits and hospital admissions. Methods We compared emergency department visits and hospitalizations in 2012 between patients requiring interpreter services and age-matched English-proficient patients (who did not require interpreters), in a retrospective cohort study of adult patients actively empanelled to a large primary health care network in a medium-sized United States city (n = 3,784). Results Patients who required interpreter services had significantly more Emergency Department visits (841 vs 620; P ≤ .001) and hospitalizations (408 vs 343; P ≤ .001) than patients who did not require interpreter services. On regression analysis the risk of a first Emergency Department visit was 60 % higher for patients requiring interpreter services than those who did not (unadjusted hazard ratio [HR], 1.6; 95 % confidence interval (CI), 1.4-1.9; P

Background Immigrants and refugees to the United States have a higher prevalence of depression compared to the general population and are less likely to receive adequate mental health services and treatment. Those with limited English proficiency (LEP) are at an even higher risk of inadequate mental health care. Collaborative care management (CCM) models for depression are effective in achieving treatment goals among a wide range of patient populations, including patients with LEP. The purpose of this study was to assess the utilization of a statewide initiative that uses CCM for depression management, among patients with LEP in a large primary care practice. Methods This was a retrospective cohort study of patients with depression in a large primary care practice in Minnesota. Patients who met criteria for enrollment into the CCM [with a provider-generated diagnosis of depression or dysthymia in the electronic medical records, and a Patient Health Questionnaire-9 (PHQ-9) score ≥10]. Patient-identified need for interpreter services was used as a proxy for LEP. Rates of enrollment into the DIAMOND (Depression Improvement Across Minnesota, Offering A New Direction) program, a statewide initiative that uses CCM for depression management were measured. These rates were compared between eligible patients who require interpreter services versus patients who do not. Results Of the 7561 patients who met criteria for enrollment into the DIAMOND program during the study interval, 3511 were enrolled. Only 18.2 % of the eligible patients with LEP were enrolled into DIAMOND compared with the 47.2 % of the eligible English proficient patients. This finding persisted after adjustment for differences in age, gender and depression severity scores (adjusted OR [95 % confidence interval] = 0.43 [0.23, 0.81]). Conclusions Within primary care practices, tailored interventions are needed, including those that address cultural competence and language navigation, to improve the utilization of this effective model among patients with LEP.