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Zhijun Yin, Jeremy Warner, Bradley Malin Vanderbilt University Medical Center Twitter: #AMIA2018

Learning When Communications Between Healthcare Providers Indicate Hormonal Therapy Medication Discontinuation. Zhijun Yin, Jeremy Warner, Bradley Malin Vanderbilt University Medical Center Twitter: #AMIA2018. Hormonal Therapy is Important.

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Zhijun Yin, Jeremy Warner, Bradley Malin Vanderbilt University Medical Center Twitter: #AMIA2018

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  1. Learning When Communications Between Healthcare Providers Indicate Hormonal Therapy Medication Discontinuation Zhijun Yin, Jeremy Warner, Bradley Malin Vanderbilt University Medical Center Twitter: #AMIA2018

  2. Hormonal Therapy is Important • Adjuvant treatment after surgery for patients with hormone-receptor-positive breast cancer to reduce rateofcancer recurrence andmortality • Patients with this treatment are prescribed medications for at least five yearsto maximize its benefits • Taking Tamoxifen (a hormonal therapy medication) for five years reduces breast cancer mortality by 33% (EBCTCG, 2011) • Early Breast Cancer Trialists’ Collaborative Group and others. 2011. Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant Tamoxifen: patient-level meta-analysis of Randomised Trials. The lancet 378, 9793 (2011), 771–784. AMIA 2018 | amia.org

  3. Adhering to This Treatment is Difficult AMIA 2018 | amia.org

  4. Previous Research • PatientGeneratedContent • Onlinecommunication(onlineforums,patientportal) • InterviewsandSurveys • StructuredElectronicMedicalRecords • Demographicinformation • Labtesting,ICD9,CPT,medications • While evidenceshowed that the clinical notes composed by healthcare providers can be effectively leveraged to predict health outcomes, • few studies investigate the associations between healthcare providers communicationsand apatient’s health-relatedbehavior. AMIA 2018 | amia.org

  5. ResearchHypothesis • The messages between healthcare providers, as documented in the EMRs, can provide intuition intohormonal therapymedication discontinuation. AMIA 2018 | amia.org

  6. ResearchPipeline MessageVolumeandRate 2.InvestigateMessagingPatterns MessagesBetweenHealthcareProviders 3.TopicAnalysis 1.BuildStudyCohort MessageTopics ControlVariables:Age,Race,CancerStage,HormonalTherapyMedications StudyCohort 4.SurvivalAnalysis MedicationDiscontinuationEvents AMIA 2018 | amia.org

  7. ResearchPipeline MessageVolumeandRate 2.InvestigateMessagingPatterns MessagesBetweenHealthcareProviders 3.TopicAnalysis 1.BuildStudyCohort MessageTopics ControlVariables:Age,Race,CancerStage,HormonalTherapyMedications StudyCohort 4.SurvivalAnalysis MedicationDiscontinuationEvents AMIA 2018 | amia.org

  8. BuildingStudyCohort • WereliedonVUMCCancerRegistry,andfocusedonpatientswho • DiagnosedwithStageItoIIIbreastcancer • Prescribedatleastoneoffollowingmedications: AromataseInhibitors (AIs,includingAnastrozole,Exemestane,  Letrozole),  Selective Estrogen Receptor Modulators (SERMs,includingRaloxifene, or Tamoxifen) • Beganhormonaltherapyafterthefirstmessagecommunicatedbetweenhealthcareproviders • Notreportedasdeceased AMIA 2018 | amia.org

  9. IdentifyingDiscontinuationEvents Wereliedon medication entry dates recorded in the EMR system 1,183 (45.9%) 1,082 (41.9%) 314 (12.2%) • T0 represents thestart of treatment • T5 represents theend ofafive-yeartreatmentprotocol • Tmax+0.5represents six months afterthe latest date of a medication entry AMIA 2018 | amia.org

  10. ResearchPipeline MessageVolumeandRate 2.InvestigateMessagingPatterns MessagesBetweenHealthcareProviders 3.TopicAnalysis 1.BuildStudyCohort MessageTopics ControlVariables:Age,Race,CancerStage,HormonalTherapyMedications StudyCohort 4.SurvivalAnalysis MedicationDiscontinuationEvents AMIA 2018 | amia.org

  11. MessagingPatterns Note that approximately 90% of the patients are affiliated with fewer than 250 messages A histogram of the messaging volume between healthcare providers AMIA 2018 | amia.org

  12. MessagingPatterns • The message rate dropped quickly after taking hormonal therapy • Before the first year of taking hormonal therapy, • patients with medication discontinuation events tend to affiliate with higher messaging rates between healthcare providers • After this point, • these patients are affiliated with lower messaging rates Illustrationofhowmessagingratechangesalongthetreatmenttimeline AMIA 2018 | amia.org

  13. MessagingPatterns • The extreme messaging rates between healthcare providers are affiliated with higher probability of medication discontinuation Illustrationofmessaging rate with respect to the probability of discontinuingmedication AMIA 2018 | amia.org

  14. TopicAnalysis MessageVolumeandRate 2.InvestigateMessagingPatterns MessagesBetweenHealthcareProviders 3.TopicAnalysis 1.BuildStudyCohort MessageTopics ControlVariables:Age,Race,CancerStage,HormonalTherapyMedications StudyCohort 4.SurvivalAnalysis MedicationDiscontinuationEvents AMIA 2018 | amia.org

  15. TopicExtraction • Wereliedonword2vec+clusteringapproach Word2vec Clustering Words • Byapplyingthe elbow ruleonthestandarddeviationofclustersize, we selected 150 topics for further analysis AMIA 2018 | amia.org

  16. SurvivalAnalysis MessageVolumeandRate 2.InvestigateMessagingPatterns MessagesBetweenHealthcareProviders 3.TopicAnalysis 1.BuildStudyCohort MessageTopics ControlVariables:Age,Race,CancerStage,HormonalTherapyMedications StudyCohort 4.SurvivalAnalysis MedicationDiscontinuationEvents AMIA 2018 | amia.org

  17. SurvivalAnalysis • Coxmodel • ControlVariables: • Age • Race • Cancerstage • Medication(AI,SERM) • Topicrelatedvariables: • Averagemessagingrate • TF-IDFvaluesofeachtopic AMIA 2018 | amia.org

  18. SurvivalAnalysis • ModelFitting • Concordanceof0.736 • ControlVariables: • Taking AI (HR = 0.812 , P <0.001) • Messagingrate( HR = 1.482, P < 0.001) AMIA 2018 | amia.org

  19. Topics with Increased Risk of Medication Discontinuation • NotificationthatamessagehasNOTbeenreadbya patient • Word samples (HR=1.172, P=0.009): • text, myhealthatvanderbilt, automated, original,physician,callers, advises • Message example: • “…*Automated notification*: A message sent to a patient via MyHealthAtVanderbilt more than 120 hours agohad not yet been read by the patient as of **DATE…” AMIA 2018 | amia.org

  20. Topics with Increased Risk of Medication Discontinuation • Clinicaltrials • Word samples (HR=1.097, P=0.003): • trial, eligible, study, trials, phase, studies, screen • Word Samples (HR=1.077, P=0.004) • declined, cancelled, offered, canceled, transportation, refused, ride, missed, moving, keeping • Message example: • “…  I spoke with **NAME regarding her head CT results. Unfortunately she is not eligible for the clinical trial. Please cancel the PET-CT tomorrow and all other study related appointments. …” AMIA 2018 | amia.org

  21. Topics with Increased Risk of Medication Discontinuation • Inpatientprocedure • Word samples (HR=1.092, P=0.013): • inpatient, discharged, discharging, admitted, admission, admit, hospital, nursing, nhc, hosp • Message example: • “…    Ms. **NAME and her supportive daughter have been to the ED several times in the last few months and has even required admission for her severe case of acid reflux. We are trying to reduce her admissions and risk for exposure to MDR bacteria …” AMIA 2018 | amia.org

  22. Topics with Decreased Risk of Medication Discontinuation • Positivecommunication • Word samples (HR=0.901, P=0.013): • willing, prefer, wish, wants, like, asked, prefers, told, wishes, encourage, wanting, encouraged, needs, lets, advised, wanted • Message example: • “…  I encouraged pt that these were normal results, but that the lightheadedness was not normal. I advised her to increase protein at breakfast for “lasting energy” to get her through her workout, such as adding boiled eggs …” AMIA 2018 | amia.org

  23. Topics with Decreased Risk of Medication Discontinuation • Stablehealthconditions • Word samples (HR=0.896, P=0.008): • unchanged, stable, shows, showed, normal, wnl, compared, showing, appear, looked • Message example: • “… Let her know bone density is unchanged, very stable and encourage her to sign up for mhav …” AMIA 2018 | amia.org

  24. Topics with Decreased Risk of Medication Discontinuation • Prescriptions • Word samples (HR=0.869, P=0.004): • cozaar, spironolactone, benicar, amlodipine, losartan, avapro, chlorthalidone, metoprolol, norvasc, ramipril, glipizide, atenolol • Word samples (HR=0.861, P=0.002): • 200mg, 400mg, 150mg, 300mg, 15mg, 100mg, 50mg, 30mg, 60mg, 2mg, 80mg, 120mg, 180mg, 160mg, 240mg, 4mg • Message example • “… DSR-pharm called req refill on metoprolol 50mg  #180 last refill **DATE pharm# ***PHONE …” AMIA 2018 | amia.org

  25. Implications • Patients with a high rate of messages (between theirhealthcare providers) are likely to be complex medically or psychosocially, which would naturally correlate with medicationdiscontinuation • The topic-related findings suggested that, in comparison toself-reported treatment experiences, where rich emotions, feelings and detailed side effects are described, messagesbetween healthcare providers contain factors mainly from the perspectives of the clinical practice • Thesefactorsmaybeuseful(ifcombinedwithstructureddatafromapatient’sEMRs)forbuildingpredictionmodeltosenseapatient’spotentialmedicationdiscontinuation AMIA 2018 | amia.org

  26. LimitationandFutureWork • The data in this study is derived from a single healthcare organization, which may limit thegenerality of our findings • Someword clustersarenotinterpretable,and they canberefinedbyincorporatingdomainknowledge,orapplyingword2vectrainedbyusingalargerdocumentcorpus • It would be useful to integratecommunications between healthcare providers and patients into medication discontinuation investigation AMIA 2018 | amia.org

  27. OurWorkonPatients’MessagesinJAMIA The therapy is making me sick: how online portal communicationsbetween breast cancer patients andphysicians indicate medicationdiscontinuation Zhijun Yin,Morgan Harrell,Jeremy L Warner,Qingxia Chen,Daniel Fabbri,Bradley A Malin AMIA 2018 | amia.org

  28. Thank you! zhijun.yin@vanderbilt.edu

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