Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients: Protocol for a Multisite Randomized Controlled Trial

Joshua Chodosh, Karen Connor, Nicole Fowler, Sujuan Gao, Anthony Perkins, Corita Grudzen, Frank Messina, Michael Mangold, Jessica Smilowitz, Malaz Boustani, Soo Borson, Joshua Chodosh, Karen Connor, Nicole Fowler, Sujuan Gao, Anthony Perkins, Corita Grudzen, Frank Messina, Michael Mangold, Jessica Smilowitz, Malaz Boustani, Soo Borson

Abstract

Background: Older adults with cognitive impairment have more emergency department visits and 30-day readmissions and are more likely to die after visiting the emergency department than people without cognitive impairment. Emergency department providers frequently do not identify cognitive impairment. Use of cognitive screening tools, along with better understanding of root causes for emergency department visits, could equip health care teams with the knowledge needed to develop individually tailored care management strategies for post-emergency department care. By identifying and directly addressing patients' and informal caregivers' (or care partners') psychosocial and health care needs, such strategies could reduce the need for repeat acute care. We have used the terms "caregiver" and "care partner" interchangeably.

Objective: We aimed to describe the protocol for a randomized controlled trial of a new care management intervention, the Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients (POISED) trial, compared with usual care. We described the research design, intervention, outcome measures, data collection techniques, and analysis plans.

Methods: Emergency department patients who were aged ≥75 years and screened positive for cognitive impairment via either the Mini-Cog or the proxy-reported Short Informant Questionnaire on Cognitive Decline in the Elderly, with a planned discharge to home, were recruited to participate with their identified informal (family or friend) caregiver in the 2-site POISED randomized controlled trial at New York University Langone Health and Indiana University. The intervention group received 6 months of care management from the POISED Care Team of registered nurses and specialty-trained paraprofessionals, who perform root cause analyses, administer standardized assessments, provide advice, recommend appropriate referrals, and, when applicable, implement dementia-specific comorbid condition protocols. The control group received care as recommended at emergency department discharge (usual care) and were given information about resources for further cognitive assessment. The primary outcome is repeat emergency department use; secondary outcomes include caregiver activation for patient health care management, caregiver depression, anxiety, and experience of social support as important predisposing and time-varying enabling and need characteristics. Data were collected from questionnaires and patients' electronic health records.

Results: Recruitment was conducted between March 2018 and May 2021. Study findings will be published in peer-reviewed journals and presented to peer audiences, decision makers, stakeholders, and other interested persons.

Conclusions: The POISED intervention is a promising approach to tailoring care management based on root causes for emergency department admission of patients with cognitive impairment with the aim of reducing readmissions. This trial will provide insights for caregivers and emergency department and primary care providers on appropriate, personalized, and proactive treatment plans for older adults with cognitive impairment. The findings will be relevant to audiences concerned with quality of life for individuals with cognitive impairment and their caregivers.

Trial registration: ClinicalTrials.gov NCT03325608; https://ichgcp.net/clinical-trials-registry/NCT03325608.

International registered report identifier (irrid): DERR1-10.2196/36607.

Keywords: care management; cognitive impairment; dementia; emergency department; root cause analysis.

Conflict of interest statement

Conflicts of Interest: Several measures used in this research were developed by coauthors and were used without conditions in this study.

©Joshua Chodosh, Karen Connor, Nicole Fowler, Sujuan Gao, Anthony Perkins, Corita Grudzen, Frank Messina, Michael Mangold, Jessica Smilowitz, Malaz Boustani, Soo Borson. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 20.10.2022.

Figures

Figure 1
Figure 1
Conceptual model. ADRD: Alzheimer disease/Alzheimer Disease–Related Disorders; CG: caregiver; CR: care recipient; POISED: Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients. Please refer to Table 1 for a more detailed list of measured factors within each category.
Figure 2
Figure 2
Recruitment or enrollment flowchart. IQ-CODE: Informant Questionnaire on Cognitive Decline in the Elderly; IU: Indiana University; NYU: New York University; POISED: Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients.

References

    1. Kasper J, Freedman V, Spillman B. Disability and care needs of older Americans by dementia status: an analysis of the 2011 national health and aging trends study. ASPE. 2016. [2016-01-10]. .
    1. Gillespie R, Mullan J, Harrison L. Managing medications: the role of informal caregivers of older adults and people living with dementia. A review of the literature. J Clin Nurs. 2014 Dec;23(23-24):3296–308. doi: 10.1111/jocn.12519.
    1. Lowthian J, Straney LD, Brand CA, Barker AL, Smit PD, Newnham H, Hunter P, Smith C, Cameron PA. Unplanned early return to the emergency department by older patients: the Safe Elderly Emergency Department Discharge (SEED) project. Age Ageing. 2016 Mar;45(2):255–61. doi: 10.1093/ageing/afv198.afv198
    1. Pines JM, Mullins PM, Cooper JK, Feng LB, Roth KE. National trends in emergency department use, care patterns, and quality of care of older adults in the United States. J Am Geriatr Soc. 2013 Jan;61(1):12–7. doi: 10.1111/jgs.12072.
    1. Schumacher JG. Emergency medicine and older adults: continuing challenges and opportunities. Am J Emerg Med. 2005 Jul;23(4):556–60. doi: 10.1016/j.ajem.2004.12.011.S0735675705001154
    1. McCusker J, Roberge D, Vadeboncoeur A, Verdon J. Safety of discharge of seniors from the emergency department to the community. Healthc Q. 2009;12 Spec No Patient:24–32. doi: 10.12927/hcq.2009.20963.
    1. Hastings SN, Schmader KE, Sloane RJ, Weinberger M, Goldberg KC, Oddone EZ. Adverse health outcomes after discharge from the emergency department--incidence and risk factors in a veteran population. J Gen Intern Med. 2007 Nov;22(11):1527–31. doi: 10.1007/s11606-007-0343-9.
    1. McCusker J, Cardin S, Bellavance F, Belzile E. Return to the emergency department among elders: patterns and predictors. Acad Emerg Med. 2000 Mar;7(3):249–59. doi: 10.1111/j.1553-2712.2000.tb01070.x.
    1. Aminzadeh F, Dalziel W. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002 Mar;39(3):238–47. doi: 10.1067/mem.2002.121523.S0196064402530614
    1. Banerjee A, Mbamalu D, Ebrahimi S, Khan A, Chan T. The prevalence of polypharmacy in elderly attenders to an emergency department - a problem with a need for an effective solution. Int J Emerg Med. 2011 Jun 02;4(1):22. doi: 10.1186/1865-1380-4-22. doi: 10.1186/1865-1380-4-22.1865-1380-4-22
    1. Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med. 2001 Dec;38(6):666–71. doi: 10.1067/mem.2001.119456.S0196-0644(01)94923-6
    1. Brown JD, Hutchison LC, Li C, Painter JT, Martin BC. Predictive validity of the beers and screening tool of older persons' potentially inappropriate prescriptions (STOPP) criteria to detect adverse drug events, hospitalizations, and emergency department visits in the United States. J Am Geriatr Soc. 2016 Jan;64(1):22–30. doi: 10.1111/jgs.13884.
    1. Grief C. Patterns of ED use and perceptions of the elderly regarding their emergency care: a synthesis of recent research. J Emerg Nurs. 2003 Apr;29(2):122–6. doi: 10.1067/men.2003.65.S0099176703000722
    1. Meurer W, Potti T, Kerber K, Sasson C, Macy M, West B, Losman E. Potentially inappropriate medication utilization in the emergency department visits by older adults: analysis from a nationally representative sample. Acad Emerg Med. 2010 Mar;17(3):231–7. doi: 10.1111/j.1553-2712.2010.00667.x. doi: 10.1111/j.1553-2712.2010.00667.x.ACEM667
    1. Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006 Sep 25;166(17):1822–8. doi: 10.1001/archinte.166.17.1822.166/17/1822
    1. Naylor MD, Hirschman KB, Hanlon AL, Bowles KH, Bradway C, McCauley KM, Pauly MV. Effects of alternative interventions among hospitalized, cognitively impaired older adults. J Comp Eff Res. 2016 May;5(3):259–72. doi: 10.2217/cer-2015-0009.
    1. Guttman A, Afilalo M, Guttman R, Colacone A, Robitaille C, Lang E, Rosenthal S. An emergency department-based nurse discharge coordinator for elder patients: does it make a difference? Acad Emerg Med. 2004 Dec;11(12):1318–27. doi: 10.1197/j.aem.2004.07.006. 11/12/1318
    1. Biese K, Lamantia M, Shofer F, McCall B, Roberts E, Stearns SC, Principe S, Kizer JS, Cairns CB, Busby-Whitehead J. A randomized trial exploring the effect of a telephone call follow-up on care plan compliance among older adults discharged home from the emergency department. Acad Emerg Med. 2014 Feb;21(2):188–95. doi: 10.1111/acem.12308. doi: 10.1111/acem.12308.
    1. Hustey F, Meldon S. Prevalence and documentation of impaired mental status in elderly emergency department patients. Acad Emerg Med. 2000 Oct;7(10):1166.
    1. Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003 May;41(5):678–84. doi: 10.1067/mem.2003.152.S0196064403001689
    1. Salen P, Heller M, Oller C, Reed J. The impact of routine cognitive screening by using the clock drawing task in the evaluation of elderly patients in the emergency department. J Emerg Med. 2009 Jul;37(1):8–12. doi: 10.1016/j.jemermed.2007.06.031.S0736-4679(07)00540-9
    1. Fonseca JA, Ducksbury R, Rodda J, Whitfield T, Nagaraj C, Suresh K, Stevens T, Walker Z. Factors that predict cognitive decline in patients with subjective cognitive impairment. Int Psychogeriatr. 2015 Oct;27(10):1671–7. doi: 10.1017/S1041610215000356.S1041610215000356
    1. Chodosh J, Petitti D, Elliott M, Hays R, Crooks V, Reuben D, Galen Buckwalter J, Wenger N. Physician recognition of cognitive impairment: evaluating the need for improvement. J Am Geriatr Soc. 2004 Jul;52(7):1051–9. doi: 10.1111/j.1532-5415.2004.52301.x.JGS52301
    1. Callahan CM, Hendrie HC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med. 1995 Mar 15;122(6):422–9. doi: 10.7326/0003-4819-122-6-199503150-00004.
    1. LaMantia MA, Stump TE, Messina FC, Miller DK, Callahan CM. Emergency department use among older adults with dementia. Alzheimer Dis Assoc Disord. 2016;30(1):35–40. doi: 10.1097/WAD.0000000000000118.
    1. Oliveira D, Zarit SH, Orrell M. Health-promoting self-care in family caregivers of people with dementia: the views of multiple stakeholders. Gerontologist. 2019 Sep 17;59(5):e501–11. doi: 10.1093/geront/gnz029.5430246
    1. Schulz R, Martire LM. Family caregiving of persons with dementia: prevalence, health effects, and support strategies. Am J Geriatr Psychiatry. 2004;12(3):240–9.S1064-7481(12)61774-6
    1. Cuijpers P. Depressive disorders in caregivers of dementia patients: a systematic review. Aging Ment Health. 2005 Jul;9(4):325–30. doi: 10.1080/13607860500090078.H77P0180460X0QGH
    1. Schubert CC, Boustani M, Callahan CM, Perkins AJ, Hui S, Hendrie HC. Acute care utilization by dementia caregivers within urban primary care practices. J Gen Intern Med. 2008 Nov;23(11):1736–40. doi: 10.1007/s11606-008-0711-0.
    1. Beck A, Jacobsohn G, Hollander M, Gilmore-Bykovskyi A, Werner N, Shah M. Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: a multiple-perspective qualitative study. Dementia (London) 2021 Feb;20(2):613–32. doi: 10.1177/1471301220905233.
    1. Vickrey B, Mittman B, Connor K, Pearson M, Della Penna RD, Ganiats T, Demonte RJ, Chodosh J, Cui X, Vassar S, Duan N, Lee M. The effect of a disease management intervention on quality and outcomes of dementia care: a randomized, controlled trial. Ann Intern Med. 2006 Nov 21;145(10):713–26. doi: 10.7326/0003-4819-145-10-200611210-00004.145/10/713
    1. Chodosh J, Mittman BS, Connor KI, Vassar SD, Lee ML, DeMonte RW, Ganiats TG, Heikoff LE, Rubenstein LZ, Della Penna RD, Vickrey BG. Caring for patients with dementia: how good is the quality of care? Results from three health systems. J Am Geriatr Soc. 2007 Aug;55(8):1260–8. doi: 10.1111/j.1532-5415.2007.01249.x.JGS1249
    1. Gaugler JE, Reese M, Mittelman MS. Effects of the NYU caregiver intervention-adult child on residential care placement. Gerontologist. 2013 Dec;53(6):985–97. doi: 10.1093/geront/gns193. gns193
    1. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000 Nov;15(11):1021–7. doi: 10.1002/1099-1166(200011)15:11<1021::aid-gps234>;2-6.10.1002/1099-1166(200011)15:11<1021::AID-GPS234>;2-6
    1. Jorm AF, Jacomb PA. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): socio-demographic correlates, reliability, validity and some norms. Psychol Med. 1989 Nov;19(4):1015–22. doi: 10.1017/s0033291700005742.
    1. Jorm A. The Informant Questionnaire on cognitive decline in the elderly (IQCODE): a review. Int Psychogeriatr. 2004 Sep;16(3):275–93. doi: 10.1017/s1041610204000390.
    1. Jorm A. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and cross-validation. Psychol Med. 1994 Feb;24(1):145–53. doi: 10.1017/s003329170002691x.
    1. McCarten JR, Anderson P, Kuskowski MA, McPherson SE, Borson S, Dysken MW. Finding dementia in primary care: the results of a clinical demonstration project. J Am Geriatr Soc. 2012 Feb;60(2):210–7. doi: 10.1111/j.1532-5415.2011.03841.x.
    1. Rosenbloom M, Barclay TR, Borson S, Werner AM, Erickson LO, Crow JM, Lakshminarayan K, Stuck LH, Hanson LR. Screening positive for cognitive impairment: impact on healthcare utilization and provider action in primary and specialty care practices. J Gen Intern Med. 2018 Oct;33(10):1746–51. doi: 10.1007/s11606-018-4606-4. 10.1007/s11606-018-4606-4
    1. Gelberg L, Andersen R, Leake B. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health Serv Res. 2000 Feb;34(6):1273–302.
    1. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Social Behav. 1995 Mar;36(1):1. doi: 10.2307/2137284.
    1. Odenheimer G, Borson S, Sanders AE, Swain-Eng RJ, Kyomen HH, Tierney S, Gitlin LN, Forciea MA, Absher J, Shega J, Johnson J. Quality improvement in neurology: dementia management quality measures. Neurology. 2013 Oct 22;81(17):1545–9. doi: 10.1212/WNL.0b013e3182a956bf. WNL.0b013e3182a956bf
    1. Callahan C, Boustani M, Unverzagt F, Austrom M, Damush T, Perkins A, Fultz B, Hui S, Counsell S, Hendrie H. Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial. JAMA. 2006 May 10;295(18):2148–57. doi: 10.1001/jama.295.18.2148.295/18/2148
    1. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002 Oct 09;288(14):1775–9. doi: 10.1001/jama.288.14.1775.jip21004
    1. Williams JW, Plassman BL, Burke J, Benjamin S. Preventing Alzheimer's disease and cognitive decline. Evid Rep Technol Assess (Full Rep) 2010 Apr;(193):1–727.
    1. Chodosh J, Connor K, Vassar S, Pearson M, Lee M, Mittman B, Ganz D, Vickrey B. Implementing dementia care management in a Medicare managed care plan: a randomized controlled trial. J Am Geriatr Soc. 2015;63
    1. Tan ZS, Jennings L, Reuben D. Coordinated care management for dementia in a large academic health system. Health Aff (Millwood) 2014 Apr;33(4):619–25. doi: 10.1377/hlthaff.2013.1294. 33/4/619
    1. Reuben DB, Evertson LC, Wenger NS, Serrano K, Chodosh J, Ercoli L, Tan ZS. The University of California at Los Angeles Alzheimer's and Dementia Care program for comprehensive, coordinated, patient-centered care: preliminary data. J Am Geriatr Soc. 2013 Dec;61(12):2214–8. doi: 10.1111/jgs.12562.
    1. Callahan CM, Sachs GA, Lamantia MA, Unroe KT, Arling G, Boustani MA. Redesigning systems of care for older adults with Alzheimer's disease. Health Aff (Millwood) 2014 Apr;33(4):626–32. doi: 10.1377/hlthaff.2013.1260. 33/4/626
    1. Coleman EA, Smith JD, Frank JC, Min S, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004 Nov;52(11):1817–25. doi: 10.1111/j.1532-5415.2004.52504.x.JGS52504
    1. Parry C, Coleman E, Smith J, Frank J, Kramer A. The care transitions intervention: a patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serv Q. 2003;22(3):1–17. doi: 10.1300/J027v22n03_01.
    1. Coleman EA, Roman SP, Hall KA, Min S. Enhancing the care transitions intervention protocol to better address the needs of family caregivers. J Healthc Qual. 2015;37(1):2–11. doi: 10.1097/01.JHQ.0000460118.60567.fe.01445442-201501000-00002
    1. Cottingham AH, Alder C, Austrom MG, Johnson CS, Boustani MA, Litzelman DK. New workforce development in dementia care: screening for "caring": preliminary data. J Am Geriatr Soc. 2014 Jul;62(7):1364–8. doi: 10.1111/jgs.12886.
    1. Sadak T, Korpak A, Borson S. Measuring caregiver activation for health care: validation of PBH-LCI:D. Geriatr Nurs. 2015;36(4):284–92. doi: 10.1016/j.gerinurse.2015.03.003.S0197-4572(15)00150-0
    1. Latino R. Patient Safety The PROACT Root Cause Analysis Approach. Boca Raton, FL: Taylor and Francis; 2008.
    1. The five whys technique. Asian Development Bank. 2016. [2016-01-25]. .
    1. Borson S, Scanlan J, Sadak T, Lessig M, Vitaliano P. Dementia Services Mini-Screen: a simple method to identify patients and caregivers in need of enhanced dementia care services. Am J Geriatr Psychiatry. 2014 Aug;22(8):746–55. doi: 10.1016/j.jagp.2013.11.001. S1064-7481(13)00401-6
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606–13. doi: 10.1046/j.1525-1497.2001.016009606.x. jgi01114
    1. Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the patient health questionnaire-9. Med Care. 2004 Dec;42(12):1194–201. doi: 10.1097/00005650-200412000-00006.00005650-200412000-00006
    1. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092–7. doi: 10.1001/archinte.166.10.1092.166/10/1092
    1. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007 Mar 06;146(5):317–25. doi: 10.7326/0003-4819-146-5-200703060-00004.146/5/317
    1. Callahan CM, Boustani MA, Weiner M, Beck RA, Livin LR, Kellams JJ, Willis DR, Hendrie HC. Implementing dementia care models in primary care settings: The Aging Brain Care Medical Home. Aging Ment Health. 2011 Jan;15(1):5–12. doi: 10.1080/13607861003801052. 927972577
    1. Boustani MA, Sachs GA, Alder CA, Munger S, Schubert CC, Guerriero Austrom M, Hake AM, Unverzagt FW, Farlow M, Matthews BR, Perkins AJ, Beck RA, Callahan CM. Implementing innovative models of dementia care: The Healthy Aging Brain Center. Aging Ment Health. 2011 Jan;15(1):13–22. doi: 10.1080/13607863.2010.496445. 932727367
    1. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705–14. doi: 10.1016/0277-9536(91)90150-b.
    1. Gjesfjeld C, Greeno CG, Kim KH. A confirmatory factor analysis of an abbreviated social support instrument: the MOS-SSS. Res Social Work Pract. 2007 Nov 29;18(3):231–7. doi: 10.1177/1049731507309830.
    1. Monahan PO, Boustani MA, Alder C, Galvin JE, Perkins AJ, Healey P, Chehresa A, Shepard P, Bubp C, Frame A, Callahan C. Practical clinical tool to monitor dementia symptoms: the HABC-Monitor. Clin Interv Aging. 2012;7:143–57. doi: 10.2147/CIA.S30663. doi: 10.2147/CIA.S30663.cia-7-143
    1. Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994 Dec;44(12):2308–14. doi: 10.1212/wnl.44.12.2308.
    1. Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983 Dec;31(12):721–7. doi: 10.1111/j.1532-5415.1983.tb03391.x.
    1. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. doi: 10.1016/0021-9681(87)90171-8.
    1. HCAHPS Survey. HCAHPS. [2022-01-09]. .
    1. Sadak T, Wright J, Borson S. Managing your loved one's health: development of a new care management measure for dementia family caregivers. J Appl Gerontol. 2018 May;37(5):620–43. doi: 10.1177/0733464816657472.0733464816657472
    1. Dour HJ, Wiley JF, Roy-Byrne P, Stein MB, Sullivan G, Sherbourne CD, Bystritsky A, Rose RD, Craske MG. Perceived social support mediates anxiety and depressive symptom changes following primary care intervention. Depress Anxiety. 2014 May;31(5):436–42. doi: 10.1002/da.22216.
    1. Green SB, Byar DP. The effect of stratified randomization on size and power of statistical tests in clinical trials. J Chronic Dis. 1978;31(6-7):445–54. doi: 10.1016/0021-9681(78)90008-5.
    1. Kernan WN, Viscoli CM, Makuch RW, Brass LM, Horwitz RI. Stratified randomization for clinical trials. J Clin Epidemiol. 1999 Jan;52(1):19–26. doi: 10.1016/s0895-4356(98)00138-3.S0895435698001383
    1. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992 Jun;45(6):613–9. doi: 10.1016/0895-4356(92)90133-8.0895-4356(92)90133-8
    1. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009 Apr;42(2):377–81. doi: 10.1016/j.jbi.2008.08.010. S1532-0464(08)00122-6
    1. McDonald C, Overhage J, Barnes M, Schadow G, Blevins L, Dexter P, Mamlin B, INPC Management Committee The Indiana network for patient care: a working local health information infrastructure. An example of a working infrastructure collaboration that links data from five health systems and hundreds of millions of entries. Health Aff (Millwood) 2005;24(5):1214–20. doi: 10.1377/hlthaff.24.5.1214.24/5/1214

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever