Cocaine Testing among PatientsCocaine Testing among Patients Admitted with Myocardial

Infarction: A Case Example of Using ClinicalA Case Example of Using Clinical

Looking Glass to Conduct R hResearch

Will Southern, MDHillary Kunins, MD, MS

Goals of our talkGoals of our talk

1 To present a model of a research1. To present a model of a research question appropriate for investigation using Clinical Looking Glass (CLG).using Clinical Looking Glass (CLG).

2. To demonstrate strategies to obtain variables from CLG.variables from CLG.

3. To demonstrate the results of an analysis using CLG data.using CLG data.

4. NOT: a training in the use of CLG –Trainings are available!a gs a e a a ab e

BackgroundBackground• Screening for illicit drug use is an accepted practice in

health carehealth care.

• Cocaine use is associated with chest pain syndromes p yand with acute myocardial infarction.

• The decision to test a patient for cocaine use may be• The decision to test a patient for cocaine use may be influenced by many factors.

• A positive test for cocaine has clinical implications.

• Patients who test negative for cocaine use do not require• Patients who test negative for cocaine use do not require special management for acute MI.

Background - continuedBackground continued

• Substance users are stigmatized,Substance users are stigmatized, – Does stigma affect their quality of care?

• Racial disparities in quality of care are known to exist for cardiovascular disease– Do race and suspicion of substance abuse interact to

affect quality of care for MI care?

Research QuestionsResearch Questions

1. Is race independently associated with1. Is race independently associated with screening for illicit drug use in the acute MI setting?

2. Is race independently associated with a positive test result among those tested for cocaine?

3. Are there racial differences in the association b b i i f illi i dbetween between suspicion of illicit drug use and quality of care for an acute MI?

Methods: Data SourceMethods: Data Source

Clinical Information System (CIS) atClinical Information System (CIS) at Montefiore.

Clinical Looking Glass web interfaceClinical Looking Glass – web interface.

Study SampleStudy Sample

• Admissions for an acute MI during a 5-Admissions for an acute MI during a 5year period, 2001-2005 selected by ICD codecode.

Methods: OutcomesMethods: OutcomesOutcome measures:

• 1. Receipt of a test for cocaine within 5 days of p yadmission.

• 2. Result of a test for cocaine within 5 days of d i iadmission.

• 3. Receipt of “appropriate care” for MI:Catheterization within 30 days– Catheterization within 30 days

– Receipt of appropriate medications: b-blocker (among cocaine-negative), calcium-channel blocker ( i iti )(among cocaine-positive)

Methods: Predictor VariablesMethods: Predictor Variables

What is the main predictor variable?What is the main predictor variable?1. Race

What are the other predictor variables?1 Age1. Age2. Gender3. Co-morbidities – must measure by ICD3. Co morbidities must measure by ICD coding

e.g. Hypertension, Diabetes

What I want:A Spreadsheet

•MRN•Age

•Beta Blocker: yes/no•Ca Ch Blocker: yes/no•Age

•Sex•Race/Ethnicity

•Ca-Ch Blocker: yes/no•Cardiac Cath: yes/no•Time to cath

•Cocaine test: yes/no•Cocaine test date•Cocaine test result

•Diabetes: yes/no•Hypertension: yes/no

Cocaine test result

Making the Spreadsheet: Many smallerMaking the Spreadsheet: Many smaller spreadsheets, and Merge

• MRN• Age• Sex• Race/Ethnicity

} “Cohort Builder”

• Cocaine test: yes/no• Cocaine test date• Cocaine test result } “Show Labs”

• Beta Blocker: yes/no• Ca-Ch Blocker: yes/no } “Show Meds”

• Cardiac Cath: yes/no• Time to cath

• Diabetes: yes/no

}

}“Time to Event”

“Time to Event”y• Hypertension: yes/no• Dyslipidemia: yes/no

} Time to Event(Multiple searches)

Features of Clinical Looking GlassFeatures of Clinical Looking Glass• MRN• Age } Cohort Builder: Defining the population being studied

and the INDEX DATE:• Sex• Race/Ethnicity

• Cocaine test: yes/no}

} and the INDEX DATE:All patients with an acute MI

Sh L b R lt f l t d l b t t d i• Cocaine test: yes/no• Cocaine test date• Cocaine test result

}

} Show Labs: Results of selected lab tests done in atime frame for an already defined Cohort

• Beta Blocker: yes/no• Ca-Ch Blocker: yes/no }

}

Show Meds: Medication orders within a time framefor an already defined Cohort

Time to Event: Time to a predefined event eg Encounter• Cardiac Cath: yes/no• Time to cath

• Diabetes: yes/no

}

}

Time to Event: Time to a predefined event eg Encounter,Procedure, Mortality, Finding

Time to E ent In this case looking for enco nters /• Diabetes: yes/no• Hypertension: yes/no• Dyslipidemia: yes/no} Time to Event: In this case looking for encounters w/

Dx of HTN (Multiple searches)

Features of Clinical Looking GlassFeatures of Clinical Looking Glass• MRN• Age } Cohort Builderg• Sex• Race/Ethnicity

} Cohort Builder

Defining the Population:

•The Qualifying event: Discharged with ICD-9 410.0-410.9

•The Time Range: 1/1/2000 through 12/31/2004

•The Index Date: date of admissionThe Index Date: date of admission

Features of Clinical Looking GlassFeatures of Clinical Looking Glass• Cocaine test: yes/no• Cocaine test date } Show Labs• Cocaine test result } Show Labs

Pulling laboratory data:

•Use a predefined Cohort: All 5yr MIs•Use a predefined Cohort: All 5yr MIs

•Specify time range: within 5 days after index date

•Which labs: Cocaine test (think both U-tox, Serum Tox)

Features of Clinical Looking GlassFeatures of Clinical Looking Glass

• Beta Blocker: yes/no• Ca-Ch Blocker: yes/no } Show Meds• Ca-Ch Blocker: yes/no }

Looking for Medication Orders:

• Predefined Cohort: All 5 yr MIs

• Time range: anytime during admission

• Which Meds: need to define what is a B-BlockerWhich Meds: need to define what is a B Blocker

• Inpatient orders vs Rx Pad

Features of Clinical Looking GlassFeatures of Clinical Looking Glass

• Cardiac Cath: yes/noTi t th } Time to Event• Time to cath } Time to Event

Very Flexible Tool:

•Defining the Event: Encounter, Procedure, Mortality, Findingg , , y, g

•In This Example: Procedure-Cardiac Catheterization

•Use a Previously Defined Cohort: All 5 yr MIs

D fi Ti R 30 d ft i d•Define a Time Range: 30 days after index

Features of Clinical Looking GlassFeatures of Clinical Looking Glass

• Diabetes: yes/no } Time to Eventy• Hypertension: yes/no } Time to Event

Defining the Event: Multiple ChoicesDefining the Event: Multiple Choices

• Look forward for discharges with ICD-9 for HTN

• Look backward for discharges with ICD-9 for HTN

• Look backward for Clinic Visits with ICD-9 for HTN

Discharged with Hypertension(within 90 days after index)

Discharged with Hypertension(within 1825 days before index)

Clinic Visit with Hypertension(within 1825 days before index)

Finishing Up:Finishing Up:

• Merge on clg-MRN:Merge on clg MRN:

M d D t tMerged Dataset

• Clean data

Cleaned Dataset

Characteristics of 5926 Persons i h A MI 2001 200with Acute MI, 2001-2005

N (%)N (%)Mean Age (SD) 68 (14)

Race/EthnicityRace/EthnicityHispanic 1415 (24)White 1920 (32)

Black 998 (17)Other Race 297 (5)Unknown 1296 (22)Unknown 1296 (22)

Male Gender 3292 (56)

Characteristics of Persons with MI Tested for Cocaine

Tested (n=311, 5%)

Race*BlackHispanic

101 (10%)99 (7%)Hispanic

White99 (7%)65 (3%)

Gender*MaleFemale

236 (7%)75 (3%)

Hypertension*HypertensionYesNo

252 (6%)59 (4%)

* p< 0.05

Characteristics of Patients with Positive Cocaine Results

P iti ( 34)Positive (n=34)

RaceHispanic 14 (14%)HispanicBlackWhite

14 (14%)11 (11%)4 (3%)

GenderMaleFemale

27 (12%)7 (9%)Female 7 (9%)

HypertensionNo Hypertension

6 (11%)28 (11%)

Receipt of Care by Persons with MI Tested for Cocaine Compared with those Not Testedp

Tested (n=311, 5%) Not Tested (n=5615, 95% )

B-blocker 261 (84%) 4748 (85%)

Ca-channel bl k

70 (23%) 1277 (23%)blocker

Catheterization* 163 (52%) 1996 (35%)Catheterization* 163 (52%) 1996 (35%)

*p<0.05

Adjusted Odds of Receiving BB, CaChBl, Cath among those receiving a test forCath among those receiving a test for

cocaine (stratified by race)

White OR Black OR

Beta Blocker 1.0 0.8

Ca Channel 1 2 1 5Ca Channel Blocker

1.2 1.5

Cath 1 3 0 6*Cath 1.3 0.6

Adjusted for age, sex, HTN*p<0.05

Receipt of Care by Persons with MI Tested for Cocaine

Test Positive (34, 11%) Test Negative (271, 89%)

B-blocker* 21 (62%) 236 (87%)

Ca-channel blocker*

17 (50%) 51 (19%)

Catheterization* 12 (35%) 148 (55%)

*p<0.05

Adjusted odds of quality outcomes amongAdjusted odds of quality outcomes among those testing positive for cocaine

.White OR Black OR

Beta-blocker 0.004* 0.1*

C h 28* 4 1*Ca-ch blocker

28* 4.1*

C th 0 6 0 7Cath 0.6 0.7

Adjusted for age, sex, HTN

Conclusions– Black patients who are tested (suspected of

cocaine use) are less likely to receive a catheterization than Blacks who are not tested for cocaine. This was not true for white patientspatients.

– Among tested patients, both whites and blacks were less likely to receive a cath if theblacks were less likely to receive a cath if the test result was positive (but not statistically significant). g )