Discordant Cardiopulmonary Resuscitation and Code Status at Death

A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury

BACKGROUND

Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes. This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation.

METHODS

The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a "Living Guideline" process model for the VTE prevention CDS system.

DISCUSSION

The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics.

TRIAL REGISTRATION

Clinicaltrials.gov - NCT05628207. Prospectively registered 11/28/2022, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05628207 .

Re-Aiming Equity Evaluation in Clinical Decision Support: A Scoping Review of Equity Assessments in Surgical Decision Support Systems

OBJECTIVE

We critically evaluated the surgical literature to explore the prevalence and describe how equity assessments occur when using clinical decision support systems.

BACKGROUND

Clinical decision support (CDS) systems are increasingly used to facilitate surgical care delivery. Despite formal recommendations to do so, equity evaluations are not routinely performed on CDS systems and underrepresented populations are at risk of harm and further health disparities. We explored surgical literature to determine frequency and rigor of CDS equity assessments and offer recommendations to improve CDS equity by appending existing frameworks.

METHODS

We performed a scoping review up to Augus 25, 2021 using PubMed and Google Scholar for the following search terms: clinical decision support, implementation, RE-AIM, Proctor, Proctor's framework, equity, trauma, surgery, surgical. We identified 1415 citations and 229 abstracts met criteria for review. A total of 84 underwent full review after 145 were excluded if they did not assess outcomes of an electronic CDS tool or have a surgical use case.

RESULTS

Only 6% (5/84) of surgical CDS systems reported equity analyses, suggesting that current methods for optimizing equity in surgical CDS are inadequate. We propose revising the RE-AIM framework to include an Equity element (RE 2 -AIM) specifying that CDS foundational analyses and algorithms are performed or trained on balanced datasets with sociodemographic characteristics that accurately represent the CDS target population and are assessed by sensitivity analyses focused on vulnerable subpopulations.

CONCLUSION

Current surgical CDS literature reports little with respect to equity. Revising the RE-AIM framework to include an Equity element (RE 2 -AIM) promotes the development and implementation of CDS systems that, at minimum, do not worsen healthcare disparities and possibly improve their generalizability.

Application of Critical Race Theory in Palliative Care Research: A Scoping Review

CONTEXT

Structural racism negatively impacts individuals and populations. In the medical literature, including that of palliative care, structural racism's influence on interracial differences in outcomes remains poorly examined. Examining the contribution of structural racism to outcomes is paramount to promoting equity.

OBJECTIVES

We examined portrayals of race and racial differences in outcomes in the palliative care literature and created a framework using critical race theory (CRT) to aid in this examination.

METHODS

We reviewed the CRT literature and iteratively developed a rubric to examine when and how differences between races are described. Research articles published in The Journal of Pain and Symptom Management presenting empiric data specifically including findings about racial differences were examined independently by three reviewers using the rubric.

RESULTS

Fifty-seven articles met inclusion criteria. Articles that specifically described racial differences were common in the topic areas of quality (75% of articles), hospice (53%), palliative care services (40%) and spirituality/religion (40%). The top three reasons posited for racial differences were patient preference (26%), physician bias (23%), and cultural barriers (21%). Using the CRT rubric we found that 65% of articles posited that a racial difference was something that needed to be rectified, while articles rarely provided narrative (5%) or other data on perspectives of people of color (11%) to explain assumptions about differences.

CONCLUSION

Palliative care research frequently highlights racial differences in outcomes. Articles that examine racial differences often assume that differences need to be fixed but posit reasons for differences without the narratives of those most affected by them.

Treatments costs associated with inpatient clinical deterioration

AIMS

This study aimed to quantify the health economic treatment costs of clinical deterioration of patients within 72 h of admission via the emergency department.

METHODS

This study was conducted between March 2018 and February 2019 in two hospitals in regional New South Wales, Australia. All patients admitted via the emergency department were screened for clinical deterioration (defined as initiation of a medical emergency team call, cardiac arrest or unplanned admission to Intensive Care Unit) within 72 h through the site clinical deterioration databases. Patient characteristics, including pre-existing conditions, diagnosis and administrative data were collected.

RESULTS

1600 patients clinically deteriorated within 72 h of hospital admission. Linked treatment cost data were available for 929 (58%) of these patients across 352 Australian Refined Diagnosis Related Groups. The average (standard deviation) treatment costs for patients who deteriorated within 72 h was $26,778 ($34,007) compared to $7727 ($12,547). The average hospital length of stay of the deterioration group was nearly 8 days longer than patients without deterioration. When controlling for length of stay and Australian Refined Diagnosis Related Group codes, the incremental cost per episode of deterioration was $14,134.

CONCLUSION

Clinical deterioration within 72 h of admission is associated with increased treatment costs irrespective of diagnosis, hospital length of stay and age. Implementation of interventions known to prevent patient deterioration require evaluation.

Racial/Ethnic Disparities in Hospital Admissions from COVID-19 and Determining the Impact of Neighborhood Deprivation and Primary Language

Background Despite past and ongoing efforts to achieve health equity in the United States, persistent disparities in socioeconomic status along with multilevel racism maintain disparate outcomes and appear to be amplified by COVID-19. Objective Measure socioeconomic factors and primary language effects on the risk of COVID-19 severity across and within racial/ethnic groups. Design Retrospective cohort study. Setting Health records of 12 Midwest hospitals and 60 clinics in the U.S. between March 4, 2020 to August 19, 2020. Patients PCR+ COVID-19 patients. Exposures Main exposures included race/ethnicity, area deprivation index (ADI), and primary language. Main Outcomes and Measures The primary outcome was COVID-19 severity using hospitalization within 45 days of diagnosis. Logistic and competing-risk regression models (censored at 45 days and accounting for the competing risk of death prior to hospitalization) assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race effects of ADI and primary language were measured using logistic regression. Results 5,577 COVID-19 patients were included, 866 (n=15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p<0.001) and more likely to be male (n=425 [49.1%] vs. 2,049 [43.5%], p=0.002). Of those requiring hospitalization, 43.9% (n=381), 19.9% (n=172), 18.6% (n=161), and 11.8% (n=102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity; Hispanic patients (OR 3.8, 95% CI 2.72-5.30), Asians (OR 2.39, 95% CI 1.74-3.29), and Blacks (OR 1.50, 95% CI 1.15-1.94). ADI was not associated with hospitalization. Non-English speaking (OR 1.91, 95% CI 1.51-2.43) significantly increased odds of hospital admission across and within minority groups. Conclusions Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the continued concern that racism contributes to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity across and within minority groups.