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Smit MJD, Nijholt W, Bakker MH, Visser A. The predictive value of masticatory function for adverse health outcomes in older adults: a systematic review. J Nutr Health Aging 2024; 28:100210. [PMID: 38489994 DOI: 10.1016/j.jnha.2024.100210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/31/2023] [Indexed: 03/17/2024]
Abstract
Masticatory function is associated with a variety of health outcomes. The aim of this systematic review is to clarify the predictive value of masticatory function for adverse health outcomes, such as frailty, sarcopenia and malnutrition, in older adults. An online literature search covered articles published in English or Dutch in three databases (PubMed, Embase and CINAHL, last searched November 4th 2022). Inclusion criteria were: an observational study design, focus on adults aged ≥65 years and evaluation of the association between masticatory function and health outcomes. Reviews and articles published before the year 2000 were excluded. Methodological quality and risk of bias were assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the U.S. National Institutes of Health. Study population demographics, methods for assessing masticatory function, and the association between masticatory function and adverse health outcomes were extracted. From the 34 included studies, 5 studies had a prospective design, 2 had a retrospective design, and the other 27 studies had cross-sectional design. The majority of the studies were conducted in Japan (74%, n = 26). Twenty studies (59%) used one indicator for masticatory function, the other 41% used two (n = 9) or more (n = 5) indicators. Masticatory function was most frequently assessed with the maximum occlusal force (MOF) (79%, n = 27). The identified health outcomes were clustered into 6 categories: physical parameters and sarcopenia, history of falling, nutritional status, frailty, cognitive function and mortality. Despite the complex and multidimensional character of both masticatory function and most identified adverse health outcomes, some significant associations were reported. Prospective studies showed that reduced masticatory function in older adults is associated with incidence of frailty and frailty progression, cognitive decline and all-cause mortality. Regarding the other identified adverse health outcomes, i.e., physical measures and sarcopenia, history of falling and nutritional status, only cross-sectional studies were available and results were less concordant. As all prospective studies showed that reduced masticatory function in older adults is associated with adverse health outcomes, prevention of decline of masticatory function by adequate oral care may contribute to healthy ageing.
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Affiliation(s)
- Menke J de Smit
- Department of Gerodontology, Center for Dentistry and Oral Hygiene, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Willemke Nijholt
- Department of Gerodontology, Center for Dentistry and Oral Hygiene, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mieke H Bakker
- Department of Gerodontology, Center for Dentistry and Oral Hygiene, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Anita Visser
- Department of Gerodontology, Center for Dentistry and Oral Hygiene, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Gerodontology, College of Dental Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Bailey C, Deane H, O'Brien A, Dalziel K. An economic evaluation of point-of-care ultrasound for children presenting to the emergency department with suspected septic arthritis of the hip. AUST HEALTH REV 2024; 48:37-44. [PMID: 38266497 DOI: 10.1071/ah23214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/05/2024] [Indexed: 01/26/2024]
Abstract
Objective Diagnosing septic arthritis of the hip in children is time-sensitive, with earlier diagnosis improving outcomes. Point-of-care ultrasound (POCUS) requires specialised training and resources in emergency departments (ED) to potentially lower costs through reducing patient time in ED. We aimed to compare the costs of using POCUS for suspected septic arthritis of the hip to current practice. Methods This study is embedded in a retrospective review of 190 cases of suspected cases of septic hip joint collected over 5 years to investigate patient length of stay and time to perform ultrasound. We multiplied time use by cost per bed hour comparing current practice with POCUS. The POCUS arm included training and equipment costs. Scenario, sensitivity, and threshold analyses were conducted. Costs were calculated in Australian dollars for 2022. Results The current practice arm took 507 min from initial patient assessment to ultrasound examination, compared with 96 min for the POCUS arm. Cost per bed hour was estimated at $207 from hospital data. Total cost savings for POCUS compared to current practice were $35 821 per year assuming 38 cases of suspected arthritis of the hip per year, saving 228 bed hours per year. All scenario and sensitivity analyses were cost saving. Threshold analysis indicated that if the cost of a paediatric ED bed was higher than $51 per hour, POCUS would be cost saving. Conclusion There was significant cost saving potential for hospitals by switching to POCUS for suspected septic arthritis of the hip.
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Affiliation(s)
- Cate Bailey
- Melbourne Health Economics, Melbourne School of Population and Global Health University of Melbourne, 207 Bouverie Street, Vic. 3035, Australia
| | - Heather Deane
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Vic., Australia
| | - Adam O'Brien
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Vic., Australia
| | - Kim Dalziel
- Melbourne Health Economics, Melbourne School of Population and Global Health University of Melbourne, 207 Bouverie Street, Vic. 3035, Australia
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Potter E, Cid Serra X, Johnson D. Point-of-care ultrasound: ready for prime time in internal medicine? Intern Med J 2023; 53:1942-1945. [PMID: 37997277 DOI: 10.1111/imj.16272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/09/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Elizabeth Potter
- Departments of General Medicine and Hospital in the Home, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Ximena Cid Serra
- Department of General Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Douglas Johnson
- Department of General Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Aladham R, Liu S, Naqvi TZ. Impact of physician performed point of care ultrasound (POCUS) during first outpatient cardiology consultation on patient management and downstream testing. Echocardiography 2023. [PMID: 37151118 DOI: 10.1111/echo.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/19/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Goal directed point of care ultrasound (POCUS) is a bedside tool to assist with clinical diagnosis. We examined the impact of POCUS performed by consulting cardiologist (CC) during initial cardiology consult on clinical management and downstream testing. METHODS Sixty-nine study patients (pts) seen in a general cardiology outpatient clinic of a tertiary center by an expert imaging CC were compared to a control group of 65 pts seen by three different CCs without POCUS during the same time-period, in whom the first standard echo (SE) was performed after the initial visit. RESULTS Baseline characteristics were similar between the two groups for age, cardiac risk factors, and referral diagnoses. Echo findings on POCUS and by SE (mean delay of 17.2 days after visit) in the control group were comparable for RV size and function and for valvular heart disease. More patients with lower LVEF, higher LV filling pressures, new regional wall motion abnormalities, and increased aortic root size were present among POCUS group resulting in greater yield of echo abnormalities. There were more cardiovascular medication changes at the first visit (15.3% vs. 5.7%, p < .01), less referral for noninvasive stress testing (10% vs. 29%, p < .01), more advanced cardiac testing and subspecialty referrals (29% vs. 18% pts, p = .06), in the study compared to the control group after cardiology visit. CONCLUSION POCUS at time of consultation detects more abnormal echo findings, results in more medication adjustments, less referral for noninvasive stress testing, earlier referral for advanced cardiac diagnostic imaging, and subspecialty cardiac referrals.
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Affiliation(s)
- Raed Aladham
- Department of Cardiovascular Disease, Echocardiography Division, Mayo Clinic, Scottsdale, Arizona, USA
| | - Shuang Liu
- Department of Cardiovascular Disease, Echocardiography Division, Mayo Clinic, Scottsdale, Arizona, USA
| | - Tasneem Z Naqvi
- Department of Cardiovascular Disease, Echocardiography Division, Mayo Clinic, Scottsdale, Arizona, USA
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Cid-Serra X, Royse A, Canty D, Johnson DF, Maier AB, Fazio T, El-Ansary D, Royse CF. Effect of a Multiorgan Focused Clinical Ultrasonography on Length of Stay in Patients Admitted With a Cardiopulmonary Diagnosis: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2138228. [PMID: 34932107 PMCID: PMC8693211 DOI: 10.1001/jamanetworkopen.2021.38228] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE There are accumulating data about the utility of diagnostic multiorgan focused clinical ultrasonography (FCU) in the assessment of patients admitted with cardiopulmonary symptoms. OBJECTIVE To determine whether adding multiorgan FCU to the initial clinical evaluation of patients admitted with cardiopulmonary symptoms reduces hospital length of stay, hospital readmissions, and in-hospital costs. DESIGN, SETTING, AND PARTICIPANTS This is a prospective, parallel-group, superiority, randomized clinical trial with a 1:1 allocation ratio. The study was conducted at The Royal Melbourne Hospital, a tertiary public hospital located in Melbourne, Victoria, Australia. Adults aged 18 years or older admitted to the internal medicine ward with a cardiopulmonary diagnosis were enrolled between September 2018 and December 2019 and were followed up until hospital discharge. Data analysis was performed from August 2020 to January 2021. INTERVENTIONS The intervention involved an internal medicine physician-performed heart, lung, and 2-point vein compression FCU in addition to standard clinical evaluation. MAIN OUTCOMES AND MEASURES The primary outcome was the difference in the mean length of hospital stay, defined as the number of hours from admission to the internal medicine ward to hospital discharge. A difference of 24 hours was defined as clinically important. Secondary outcomes included hospital readmissions at 30 days and hospital care costs. RESULTS A total of 250 participants were enrolled and 2 were excluded, leaving 248 participants (mean [SD] age, 80.1 [11.0] years; 121 women [48.7%]) in the final analysis. There were 124 patients in the intervention group and 124 patients in the control group. The most common initial diagnoses were acute decompensated heart failure (113 patients [45.5%]), pneumonia (45 patients [18.1%]), and exacerbated chronic pulmonary disease (32 patients [12.9%]). The length of hospital stay was 113.4 hours (95% CI, 91.7-135.1 hours) in the FCU group and 125.3 hours (95% CI, 101.7-148.8 hours) in the control group (P = .53). The 30-day readmission rate was not different between groups (FCU vs control, 20 of 124 patients [16.1%] vs 15 of 124 patients [12.0%]), nor were total in-hospital costs (FCU vs control, A$7831.1 [95% CI, A$5586.1-A$10 076.1] vs A$7895.7 [95% CI, A$6385.9-A$9.405.5]). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, adult patients admitted to an internal medicine ward with a cardiopulmonary diagnosis, who underwent multiorgan FCU of the heart, lungs, and lower extremities veins during their initial clinical assessment, did not have a shorter hospital length of stay by more than 24 hours, compared with patients who received standard care. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry Identifier: ACTRN12618001442291.
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Affiliation(s)
- Ximena Cid-Serra
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alistair Royse
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Canty
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Anesthesia and Perioperative Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Douglas F. Johnson
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of General Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrea B. Maier
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universitet, Amsterdam, The Netherlands
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Tim Fazio
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Health Intelligence Unit, Melbourne Health, Melbourne, Victoria, Australia
- Department of Medicine and Radiology, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Doa El-Ansary
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Melbourne, Victoria, Australia
- Department of Surgery, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Clinical Research Institute, Westmead Private Hospital, Westmead, Sydney, New South Wales, Australia
| | - Colin F. Royse
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Outcomes Research Consortium, The Cleveland Clinic, Cleveland, Ohio
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Rusiecki D, Douglas SL, Bell C. Point-of-Care Ultrasound Use and Monetary Outcomes in a Single-Payer Health Care Setting. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1803-1809. [PMID: 33169875 DOI: 10.1002/jum.15560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/21/2020] [Accepted: 10/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Point-of-care ultrasound (POCUS) is a widely used diagnostic modality in the emergency physician's tool kit. The effect on health care costs is disputed. This study examined whether POCUS was associated with system-level cost savings. Secondary objectives included adverse patient outcomes and the association between POCUS use and diagnostic costs in specific patient groups. METHODS The Point-of-Care Ultrasound Use and Monetary Outcomes study was a single-center prospective observational study. A convenience sample of emergency medicine physicians working from July to October 2019 were included after using POCUS as part of their assessment. The cost of patient investigations was compared with those proposed by a control group of physicians simultaneously on shift, who were blinded to the POCUS findings. Ethical approval was obtained from the Queen's University Health Sciences Research Ethics Board. RESULTS Fifty patient assessments using POCUS were included. Overall, the median investigation cost in United States dollars in the POCUS group was $102.00 (interquartile range [IQR], $39.80-$167.90) versus $122.40 (IQR, $70.96-$175.60) in controls (P = .08). When stratified by disposition, POCUS use in patients discharged home resulted in a median expenditure of $71.80 (IQR, $36.48-$116.70) versus $122.70 (IQR, $71.18-$183.20; P < .001). Significant cost savings were also found in flank pain presentations (median, $138.90; IQR, $136.60-$186.10; P = .01). There were no differences in the quantity of investigations ordered, the patient emergency department repeated presentation rate, or safety outcomes at 7 days. CONCLUSIONS Point-of-care ultrasound use was not associated with significant cost savings in our overall population. The subgroup analysis revealed significant POCUS-associated cost savings in patients discharged home and those presenting with flank pain. Notably, POCUS was not associated with an increase in adverse patient safety outcomes.
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Affiliation(s)
- Daniel Rusiecki
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Stuart L Douglas
- Departments of Emergency Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
- Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Colin Bell
- Departments of Emergency Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
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van Rijn RR, Stafrace S, Arthurs OJ, Rosendahl K. Non-radiologist-performed point-of-care ultrasonography in paediatrics - European Society of Paediatric Radiology position paper. Pediatr Radiol 2021; 51:161-167. [PMID: 33211186 PMCID: PMC7796864 DOI: 10.1007/s00247-020-04843-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/07/2020] [Accepted: 09/07/2020] [Indexed: 12/22/2022]
Abstract
Non-radiologist point-of-care ultrasonography (US) is increasingly implemented in paediatric care because it is believed to facilitate a timely diagnosis, such as in ascites or dilated renal pelvicalyceal systems, and can be used to guide interventional procedures. To date, all policy statements have been published by non-radiologic societies. The European Society of Paediatric Radiology hereby issues a position statement on paediatric non-radiologist point-of-care US from the point of view of those leading on children's imaging, i.e. paediatric radiologists. In this position statement, we will address the boundaries, education, credentialing, quality control, reporting and storage of images in paediatric practice.
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Affiliation(s)
- Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital-Amsterdam UMC, University of Amsterdamn, Meibergdreef 9, 1105 AZ, Amsterdam Zuid-Oost, the Netherlands.
| | - Samuel Stafrace
- Department of Diagnostic Imaging, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine, Doha, Qatar
| | - Owen J Arthurs
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
- UCL GOS Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Karen Rosendahl
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
- The Arctic University of Norway, Tromsø, Norway
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Barchiesi M, Bulgheroni M, Federici C, Casella F, Medico MD, Torzillo D, Janu VP, Tarricone R, Cogliati C. Impact of point of care ultrasound on the number of diagnostic examinations in elderly patients admitted to an internal medicine ward. Eur J Intern Med 2020; 79:88-92. [PMID: 32703675 DOI: 10.1016/j.ejim.2020.06.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/04/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022]
Affiliation(s)
- M Barchiesi
- Medicina ad Indirizzo Fisiopatologico, Ospedale Luigi Sacco, ASST FBF Sacco, Milan, Italy
| | - M Bulgheroni
- Medicina ad Indirizzo Fisiopatologico, Ospedale Luigi Sacco, ASST FBF Sacco, Milan, Italy
| | - C Federici
- Centre for Research on Health and Social Care Management (CERCAS), SDA Bocconi School of Management, Milan, Italy
| | - F Casella
- Medicina ad Indirizzo Fisiopatologico, Ospedale Luigi Sacco, ASST FBF Sacco, Milan, Italy.
| | - M Del Medico
- Medicina ad Indirizzo Fisiopatologico, Ospedale Luigi Sacco, ASST FBF Sacco, Milan, Italy
| | - D Torzillo
- Medicina ad Indirizzo Fisiopatologico, Ospedale Luigi Sacco, ASST FBF Sacco, Milan, Italy
| | - V Popescu Janu
- Medicina ad Indirizzo Fisiopatologico, Ospedale Luigi Sacco, ASST FBF Sacco, Milan, Italy
| | - R Tarricone
- Centre for Research on Health and Social Care Management (CERCAS), SDA Bocconi School of Management, Milan, Italy
| | - C Cogliati
- Medicina ad Indirizzo Fisiopatologico, Ospedale Luigi Sacco, ASST FBF Sacco, Milan, Italy
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Kumar A, Weng Y, Wang L, Bentley J, Almli M, Hom J, Witteles R, Ahuja N, Kugler J. Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial. J Hosp Med 2020; 15:e1-e6. [PMID: 32118565 DOI: 10.12788/jhm.3351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/03/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage. OBJECTIVE This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS. METHODS Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures. RESULTS Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores. CONCLUSIONS Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.
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Affiliation(s)
- Andre Kumar
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Yingjie Weng
- Quantitative Science Unit, Stanford University School of Medicine, Stanford, California
| | - Libo Wang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Bentley
- Quantitative Science Unit, Stanford University School of Medicine, Stanford, California
| | - Marta Almli
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Hom
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald Witteles
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Neera Ahuja
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - John Kugler
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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10
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Van Schaik GWW, Van Schaik KD, Murphy MC. Point-of-Care Ultrasonography (POCUS) in a Community Emergency Department: An Analysis of Decision Making and Cost Savings Associated With POCUS. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2133-2140. [PMID: 30593670 DOI: 10.1002/jum.14910] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/12/2018] [Accepted: 11/22/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Point-of-care ultrasonography (POCUS) is an increasingly integral part of emergency medicine. This study investigated community emergency department physicians' choices regarding ultrasonography as a branch point in clinical decision making. METHODS During shifts covering all days of the week and all time-spans over a 3-month period, emergency department physicians were interviewed whenever POCUS was used. Questions focused on the role of POCUS in clinical management and on tests avoided because of ultrasonography use. Cost savings attributable to POCUS were calculated using Center for Medicare and Medicaid Services and FairHealth data. Anonymization of data precluded follow-up testing to account for misdiagnosis. RESULTS On average, POCUS use eliminated $1134.31 of additional testing for privately insured patients, $2826.31 for out-of-network or uninsured patients, and $181.63 for Center for Medicare and Medicaid Services patients. Differences were significant when the total cost of eliminated additional testing was compared to a baseline of no savings (p < .001). Aggregate cost savings remained significant when analyses were broadened to include POCUS encounters that did not yield changes in management (p < .001). CONCLUSIONS When physicians' clinical expertise suggests that POCUS may be indicated, its use results in significant cost savings, even in encounters in which management is not directly impacted. POCUS, when incorporated earlier and more frequently into community hospital emergency medicine diagnostic protocols, can lower direct and indirect costs associated with diagnostic workups. Community emergency departments, in particular, would benefit from additional investigation informing specific guidelines for the integration of POCUS into clinical management and the role that this has in cost savings.
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Affiliation(s)
- Graham W W Van Schaik
- Harvard Business School, Boston, Massachusetts, USA
- Vanderbilt Medical School, Nashville, Tennessee, USA
| | | | - Michael C Murphy
- Department of Emergency Medicine, Mt. Auburn Hospital, Cambridge, Massachusetts, USA
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11
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Kumar A, Kugler J, Jensen T. Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments. J Gen Intern Med 2019; 34:1025-1031. [PMID: 30924088 PMCID: PMC6544692 DOI: 10.1007/s11606-019-04945-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Point-of-care ultrasonography (POCUS) has the potential to transform healthcare delivery through its diagnostic expediency. Trainee competency with POCUS is now mandated for emergency medicine through the Accreditation Council for Graduate Medical Education (ACGME), and its use is expanding into other medical specialties, including internal medicine. However, a key question remains: how does one define "competency" with this emerging technology? As our trainees become more acquainted with POCUS, it is vital to develop validated methodology for defining and measuring competency amongst inexperienced users. As a framework, the assessment of competency should include evaluations that assess the acquisition and application of POCUS-related knowledge, demonstration of technical skill (e.g., proper probe selection, positioning, and image optimization), and effective integration into routine clinical practice. These assessments can be performed across a variety of settings, including web-based applications, simulators, standardized patients, and real clinical encounters. Several validated assessments regarding POCUS competency have recently been developed, including the Rapid Assessment of Competency in Echocardiography (RACE) or the Assessment of Competency in Thoracic Sonography (ACTS). However, these assessments focus mainly on technical skill and do not expand upon other areas of this framework, which represents a growing need. In this review, we explore the different methodologies for evaluating competency with POCUS as well as discuss current progress in the field of measuring trainee knowledge and technical skill.
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Affiliation(s)
- Andre Kumar
- Department of Medicine, Stanford University School of Medicine, Pasteur Drive, Stanford, CA, USA.
| | - John Kugler
- Department of Medicine, Stanford University School of Medicine, Pasteur Drive, Stanford, CA, USA
| | - Trevor Jensen
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Abstract
PURPOSE Over the past 10 years, successful ultrasound integration into medical education has resulted in 8 residencies and 52 undergraduate medical schools requiring ultrasound training for graduation. Physician assistants (PAs) are trained in the medical model, yet very little is known about the integration of ultrasound into their curricula. This study examined how ultrasound is used, if at all, in the PA education curricula. METHODS Physician assistant program directors (PDs) were sent a survey addressing ultrasound integration into their curricula. Questions focused on the use of ultrasound to teach didactic courses and on inclusion of point-of-care ultrasound (POCUS) scanning skills as an adjunct to the physical examination. The survey also asked about students' feelings toward ultrasound integration into the curricula. RESULTS Investigators contacted 201 PDs, and 107 (53.2%) PDs responded. Twenty-five of the respondents (23.4%) reported using ultrasound in the basic sciences. The top 3 reasons for not including ultrasound in preclinical courses were no ultrasound machine, expense, and no faculty trained in ultrasound. Seventy-three of the respondents (68.2%) thought that POCUS scanning skills should be included in the curriculum. More than 83% felt that faculty or adjunct faculty should teach those skills. CONCLUSION This survey demonstrated that there is great interest in integrating ultrasound into the PA curriculum but that many challenges inhibit implementation. Lack of access to ultrasound machines and to trained faculty are the biggest challenges to integrating ultrasound into the PA curriculum. Physician assistant programs face content and competency challenges similar to those that medical schools face, as well as several challenges that are unique to PA education. Future research is needed to address these issues.
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Point-of-care ultrasonography in the allergy and immunology clinic. Ann Allergy Asthma Immunol 2019; 123:42-47. [PMID: 30776445 DOI: 10.1016/j.anai.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 02/09/2019] [Accepted: 02/10/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To summarize evidence supporting the use of point-of-care ultrasonography as a clinical tool for allergists and immunologists. DATA SOURCES Cochrane Library, Medline, EMBASE, and Scopus databases were searched for articles published before December 18, 2018. STUDY SELECTIONS We included any retrospective or prospective study that evaluated ultrasonography in allergy and immunology and epinephrine autoinjector (EAI) needle length. RESULTS The standard EAI needle length may be inadequate for intramuscular delivery of epinephrine, particularly for women, at risk of anaphylaxis. In patients who weigh less than 15 kg, the lengths of commercially available EAIs may be too long, risking inadvertent intraosseous injection and resultant complications. Ultrasonography can be routinely used in the allergy clinic to guide needle length and angle for subcutaneous allergen immunotherapy injections to minimize systemic adverse effects. CONCLUSION Point-of-care ultrasonography can be a useful tool to enhance patient care and safety in an allergy clinic. Ideally, all patients prescribed EAIs should have ultrasonographic measurement of the skin to muscle distance and skin to bone distance to assist in identifying patients at risk of subcutaneous or intraosseous injection in anaphylaxis and those at risk of intramuscular injection during subcutaneous allergen immunotherapy injections.
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CJEM Debate Series: #PoCUS–All physicians practicing emergency medicine should be competent in the use of point-of-care ultrasound. CAN J EMERG MED 2018; 20:329-333. [DOI: 10.1017/cem.2018.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Ma IWY, Arishenkoff S, Wiseman J, Desy J, Ailon J, Martin L, Otremba M, Halman S, Willemot P, Blouw M. Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med 2017; 32:1052-1057. [PMID: 28497416 PMCID: PMC5570740 DOI: 10.1007/s11606-017-4071-5] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/05/2017] [Accepted: 04/13/2017] [Indexed: 11/29/2022]
Abstract
Bedside point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. At present, no consensus exists for what POCUS curriculum is appropriate for internal medicine residency training programs. This document details the consensus-based recommendations by the Canadian Internal Medicine Ultrasound (CIMUS) group, comprising 39 members, representing 14 institutions across Canada. Guiding principles for selecting curricular content were determined a priori. Consensus was defined as agreement by at least 80% of the members on POCUS applications deemed appropriate for teaching and assessment of trainees in the core (internal medicine postgraduate years [PGY] 1-3) and expanded (general internal medicine PGY 4-5) training programs. We recommend four POCUS applications for the core PGY 1-3 curriculum (inferior vena cava, lung B lines, pleural effusion, and abdominal free fluid) and three ultrasound-guided procedures (central venous catheterization, thoracentesis, and paracentesis). For the expanded PGY 4-5 curriculum, we recommend an additional seven applications (internal jugular vein, lung consolidation, pneumothorax, knee effusion, gross left ventricular systolic function, pericardial effusion, and right ventricular strain) and four ultrasound-guided procedures (knee arthrocentesis, arterial line insertion, arterial blood gas sampling, and peripheral venous catheterization). These recommendations will provide a framework for training programs at a national level.
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Affiliation(s)
- Irene W Y Ma
- Department of Medicine, University of Calgary, Calgary, AB, Canada.
- W21C, University of Calgary, Calgary, AB, Canada.
| | | | | | - Janeve Desy
- Department of Medicine, University of Calgary, Calgary, AB, Canada
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Monti J. Revolution or Evolution? A Proposal for the Integration of Point-of-Care Ultrasound Into Physician Assistant Clinical Practice. J Physician Assist Educ 2017; 28:27-32. [PMID: 28114159 DOI: 10.1097/jpa.0000000000000101] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Advances in technology and increased affordability of machines have allowed ultrasound to become ubiquitous across the spectrum of medical care. Increasing portability has brought ultrasound to the point of care in multiple medical specialties. Formal ultrasound training is rapidly being incorporated into multispecialty residency programs and undergraduate medical education curricula, yet little formal training exists for physician assistants (PAs) on this emerging clinical adjunct. This article outlines recommendations for and barriers to the incorporation of bedside ultrasound into PA clinical practice.
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Affiliation(s)
- Jonathan Monti
- Jonathan Monti, DScPA, PA-C, RDMS, is director of the US Army/Baylor Emergency Medicine Physician Assistant Residency Program and deputy director of the Emergency Ultrasound Fellowship Program in the Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis McChord, Tacoma, Washington
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Abstract
PURPOSE OF REVIEW Point of care ultrasound continues to become more prevalent in the diagnosis and management of many disease states. In this review, we focus on the use of bedside lung ultrasound (LUS) in the diagnosis of pneumonia. We describe the sonographic findings associated with pneumonia and the recent literature exploring its use in different settings and patient populations. RECENT FINDINGS The limited sensitivity of chest radiography in the diagnosis of pneumonia has been well described. Ultrasound is an attractive option because of its low cost, lack of ionizing radiation, portability, and repeatability. An alveolar or focal interstitial pattern has been described as the usual sonographic findings in pneumonia. Multiple studies have compared LUS with chest radiography in pneumonia, and have shown that LUS is at least equivalent, and in many instances superior, to chest radiography. SUMMARY Point of care LUS is an invaluable tool in the diagnosis of multiple pulmonary conditions, including pneumonia. Its use in real time with clinical correlation makes it an ideal tool for rapid diagnosis, especially in situations with unstable patients or in low-resource settings.
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Abstract
Over the past few decades, point-of-care ultrasound (PoCUS) has come to play a major role in the practice of emergency medicine. Despite its numerous benefits, there has been a slow uptake of PoCUS use in rural emergency departments. Surveys conducted across Canada and the United States have identified a lack of equipment, training, funding, quality assurance, and an inability to maintain skills as major barriers to PoCUS use. Potential solutions include expanding residency training in ultrasound skills, extending funding for PoCUS training to rural physicians in practice, moving PoCUS training courses to rural sites, and creating telesonography training for rural physicians. With these barriers identified and solutions proposed, corrective measures must be taken so that the benefits of PoCUS are extended to patients in rural Canada where, arguably, it has the greatest potential for benefit when access to advanced imaging is not readily available.
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