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Wu RR, Adjei-Poku MN, Kelz RR, Peck GL, Hwang U, Cappola AR, Friedman AB. Trends in visits, imaging, and diagnosis for emergency department abdominal pain presentations in the United States, 2007-2019. Acad Emerg Med 2024. [PMID: 39313946 DOI: 10.1111/acem.15017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 08/13/2024] [Accepted: 08/26/2024] [Indexed: 09/25/2024]
Abstract
OBJECTIVES Abdominal pain is the most common reason for visit (RFV) to the emergency department (ED) for adults, yet no standardized diagnostic pathway exists for abdominal pain. Optimal management is age-specific; symptoms, diagnoses, and prognoses differ between young and old adults. Availability and knowledge of the effectiveness of various imaging modalities have also changed over time. We compared diagnostic imaging rates for younger versus older adults to identify practice patterns of abdominal imaging across age groups over time. METHODS We analyzed weighted, nationally representative data from the National Hospital Ambulatory Medical Care Survey 2007-2019 for adult ED visits with a primary RFV of abdominal pain. We included 23,364 sampled visits, representing 123 million visits. RESULTS From 2007 to 2019, total visits increased for ages 18-45 (p < 0.001), 46-64 (p < 0.001), and 65+ (p = 0.032). The percentage of visits with primary RFV of abdominal pain increased from 9.4% to 11.6% for ages 18-45, 7.8%-9.0% for ages 46-64, and 6.0%-6.5% for 65+. Computed tomography (CT) scan rates increased over time from 26.2% of all patients receiving a CT scan to 42.6%. Relative percentage change in abdominal CT scans was greatest for older adults, with a 30.3% increase, compared to 24.0% for middle-aged adults and 15.0% for young adults. Test positivity, defined as receiving an emergency general surgical diagnosis after CT or ultrasound, increased from 17.2% in 2007 to 22.9% in 2019 (p < 0.01). Of the older adults with abdominal pain in 2019, 13% received an X-ray only, which is neither sensitive nor specific for acute pathology in older adults. CONCLUSIONS Despite more abdominal pain ED visits and increased imaging rates per visit, test positivity continues to rise. Our findings do not support claims that CT and ultrasound are being used less appropriately over time, but demonstrate widespread use of X-rays, which are potentially ineffective for abdominal pain.
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Affiliation(s)
- Rachel R Wu
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael N Adjei-Poku
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Gregory L Peck
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Ula Hwang
- Departments of EM and Population Health, NYU Grossman School of Medicine, New York, New York, USA
- Geriatric Research, Education, and Clinical Center for James J Peters VAMC, New York, Bronx, USA
| | - Anne R Cappola
- Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ari B Friedman
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Lacson R, Pianykh O, Hartmann S, Johnston H, Daye D, Flores E, Kapoor N, Khorasani R. Factors Associated With Timeliness and Equity of Access to Outpatient MRI Examinations. J Am Coll Radiol 2024; 21:1049-1057. [PMID: 38215805 DOI: 10.1016/j.jacr.2023.12.028] [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: 11/07/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVE The role of MRI in guiding patients' diagnosis and treatment is increasing. Therefore, timely MRI performance prevents delays that can impact patient care. We assessed the timeliness of performing outpatient MRIs using the socio-ecological model approach and evaluated multilevel factors associated with delays. METHODS This institutional review board-approved study included outpatient MRI examinations ordered between October 1, 2021, and December 31, 2022, for performance at a large quaternary care health system. Mean order-to-performed (OtoP) interval (in days) and prolonged OtoP interval (defined as >10 days) for MRI orders with an expected date of 1 day to examination performance were measured. Logistic regression was used to assess patient-level (demographic and social determinants of health), radiology practice-level, and community-level factors associated with prolonged OtoP interval. RESULTS There were 126,079 MRI examination orders with expected performance within 1 day placed during the study period (56% of all MRI orders placed). After excluding duplicates, there were 97,160 orders for unique patients. Of the MRI orders, 48% had a prolonged OtoP interval, and mean OtoP interval was 18.5 days. Factors significantly associated with delay in MRI performance included public insurance (odds ratio [OR] = 1.11, P < .001), female gender (OR = 1.11, P < .001), radiology subspecialty (ie, cardiac, OR = 1.71, P < .001), and patients from areas that are most deprived (ie, highest Area Deprivation Index quintile, OR = 1.70, P < .001). DISCUSSION Nearly half of outpatient MRI orders were delayed, performed >10 days from the expected date selected by the ordering provider. Addressing multilevel factors associated with such delays may help enhance timeliness and equity of access to MRI examinations, potentially reducing diagnostic errors and treatment delays.
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Affiliation(s)
- Ronilda Lacson
- Associate Director, Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, and Associate Professor of Radiology, Harvard Medical School, Boston, Massachusetts.
| | - Oleg Pianykh
- Assistant Professor of Radiology, Harvard Medical School, Boston, Massachusetts; and Director of Medical Analytics, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sean Hartmann
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Heather Johnston
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Dania Daye
- Assistant Professor of Radiology, Harvard Medical School, Boston, Massachusetts; and Quality Director, Interventional Radiology Division, and Co-Director of IR Research, Division of Vascular and Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Efren Flores
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Associate Professor of Radiology, Harvard Medical School, Boston, Massachusetts; and Vice Chair, Diversity, Equity & Inclusion, Mass General Brigham, Boston, Massachusetts; Vice Chair of Radiology, Distinguished Chair, Medical Informatics, and Director of Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Professor of Radiology, Harvard Medical School, Boston, Massachusetts; and Vice Chair, Radiology Quality and Safety, Mass General Brigham, Boston, Massachusetts
| | - Neena Kapoor
- Director of Diversity, Inclusion, and Equity and Quality and Safety Officer, Department of Radiology, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; and Assistant Professor of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Ramin Khorasani
- Vice Chair of Radiology, Distinguished Chair, Medical Informatics, and Director of Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Professor of Radiology, Harvard Medical School, Boston, Massachusetts; and Vice Chair, Radiology Quality and Safety, Mass General Brigham, Boston, Massachusetts
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Lin LT, Lin SF, Chao CC, Lin HA. Predictors of 72-h unscheduled return visits with admission in patients presenting to the emergency department with abdominal pain. Eur J Med Res 2023; 28:288. [PMID: 37592352 PMCID: PMC10433659 DOI: 10.1186/s40001-023-01256-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/30/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Unscheduled return visits (URVs) to the emergency department (ED) constitute a crucial indicator of patient care quality. OBJECTIVE We aimed to analyze the clinical characteristics of patients who visited the ED with abdominal pain and to identify the risk of URVs with admission (URVAs) from URVs without admission (URVNAs). METHODS This retrospective study included adult patients who visited the ED of Taipei Medical University Hospital because of abdominal pain and revisited in 72 h over a 5-year period (January 1, 2014, to December 31, 2018). Multivariable logistic regression analysis was employed to identify risk factors for URVAs and receiver operating characteristic (ROC) curve analysis was performed to determine the efficacy of variables predicting URVAs and the optimal cut-off points for the variables. In addition, a classification and regression tree (CART)-based scoring system was used for predicting risk of URVA. RESULTS Of 702 eligible patients with URVs related to abdominal pain, 249 had URVAs (35.5%). In multivariable analysis, risk factors for URVAs during the index visit included execution of laboratory tests (yes vs no: adjusted odds ratio [AOR], 4.32; 95% CI 2.99-6.23), older age (≥ 40 vs < 40 years: AOR, 2.10; 95% CI 1.10-1.34), Level 1-2 triage scores (Levels 1-2 vs Levels 3-5: AOR, 2.30; 95% CI 1.26-4.19), and use of ≥ 2 analgesics (≥ 2 vs < 2: AOR, 2.90; 95% CI 1.58-5.30). ROC curve analysis results revealed the combination of these 4 above variables resulted in acceptable performance (area under curve: 0.716). The above 4 variables were used in the CART model to evaluate URVA propensity. CONCLUSIONS Elder patients with abdominal pain who needed laboratory workup, had Level 1-2 triage scores, and received ≥ 2 doses of analgesics during their index visits to the ED had higher risk of URVAs.
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Affiliation(s)
- Li-Tsung Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 501 St Paul St, Baltimore, MD, 21202, USA
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sheng-Feng Lin
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, Taipei Medical University Hospital, No. 250, Wuxing St, Xinyi District, Taipei, 110, Taiwan
| | - Chun-Chieh Chao
- Department of Emergency Medicine, Taipei Medical University Hospital, No. 250, Wuxing St, Xinyi District, Taipei, 110, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, No. 250, Wuxing St, Xinyi District, Taipei, 110, Taiwan.
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University Hospital, Taipei, Taiwan.
- Graduate Institute of Public Health, College of Public Health, Taipei Medical University, No. 252, Wuxing St, Xinyi District, Taipei, 110, Taiwan.
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Kim D, Woodham BL, Chen K, Kuganathan V, Edye MB. Rapid MRI Abdomen for Assessment of Clinically Suspected Acute Appendicitis in the General Adult Population: a Systematic Review. J Gastrointest Surg 2023; 27:1473-1485. [PMID: 37081221 PMCID: PMC10366263 DOI: 10.1007/s11605-023-05626-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/27/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVES To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits. METHODS We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations. RESULTS Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93-97%) and 93% (95% CI: 80-98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available. CONCLUSIONS MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation.
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Affiliation(s)
- Dongchan Kim
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Benjamin Luke Woodham
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
- Department of General Surgery, Blacktown and Mount Druitt Hospitals, Blacktown Road, Blacktown, N.S.W. Australia
| | - Kathryn Chen
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Vinushan Kuganathan
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Michael Benjamin Edye
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
- Department of General Surgery, Blacktown and Mount Druitt Hospitals, Blacktown Road, Blacktown, N.S.W. Australia
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Soltani M, Batt RJ, Bavafa H, Patterson BW. Does What Happens in the ED Stay in the ED? The Effects of Emergency Department Physician Workload on Post-ED Care Use. MANUFACTURING & SERVICE OPERATIONS MANAGEMENT : M & SOM 2022; 24:3079-3098. [PMID: 36452218 PMCID: PMC9707701 DOI: 10.1287/msom.2022.1110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Problem definition Emergency department (ED) crowding has been a pressing concern in healthcare systems in the U.S. and other developed countries. As such, many researchers have studied its effects on outcomes within the ED. In contrast, we study the effects of ED crowding on system performance outside the ED-specifically, on post-ED care utilization. Further, we explore the mediating effects of care intensity in the ED on post-ED care use. Methodology/results We utilize a dataset assembled from more than four years of microdata from a large U.S. hospital and exhaustive billing data in an integrated health system. By using count models and instrumental variable analyses to answer the proposed research questions, we find that there is an increasing concave relationship between ED physician workload and post-ED care use. When ED workload increases from its 5th percentile to the median, the number of post-discharge care events (i.e., medical services) for patients who are discharged home from the ED increases by 5% and it is stable afterwards. Further, we identify physician test-ordering behavior as a mechanism for this effect: when the physician is busier, she responds by ordering more tests for less severe patients. We document that this "extra" testing generates "extra" post-ED care utilization for these patients. Managerial implications This paper contributes new insights on how physician and patient behaviors under ED crowding impact a previously unstudied system performance measure: post-ED care utilization. Our findings suggest that prior studies estimating the cost of ED crowding underestimate the true effect, as they do not consider the "extra" post-ED care utilization.
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Affiliation(s)
- Mohamad Soltani
- Alberta School of Business, University of Alberta, Edmonton, AB T6G 2R6
| | - Robert J Batt
- Wisconsin School of Business, University of Wisconsin-Madison, Madison, WI 53706
| | - Hessam Bavafa
- Wisconsin School of Business, University of Wisconsin-Madison, Madison, WI 53706
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705
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6
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Morgenstern J, Challen K, Heitz C, Milne WK. Hot off the press: Low-risk, recurrent abdominal pain in the emergency department. Acad Emerg Med 2022; 29:1275-1277. [PMID: 35790050 DOI: 10.1111/acem.14556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 01/25/2023]
Affiliation(s)
| | | | - Corey Heitz
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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7
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Triche BL, Annamalai A, Pooler BD, Glazer JM, Zadra JD, Barclay-Buchanan CJ, Hekman DJ, Mao L, Pickhardt PJ, Lubner MG. Positive oral contrast material for CT evaluation of non-traumatic abdominal pain in the ED: prospective assessment of diagnostic confidence and throughput metrics. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:2956-2967. [PMID: 35739367 DOI: 10.1007/s00261-022-03574-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Evaluate the impact of positive oral contrast material (POCM) for non-traumatic abdominal pain on diagnostic confidence, diagnostic rate, and ED throughput. MATERIALS AND METHODS ED oral contrast guidelines were changed to limit use of POCM. A total of 2,690 abdominopelvic CT exams performed for non-traumatic abdominal pain were prospectively evaluated for diagnostic confidence (5-point scale at 20% increments; 5 = 80-100% confidence) during a 24-month period. Impact on ED metrics including time from CT order to exam, preliminary read, ED length of stay (LOS), and repeat CT scan within 7 days was assessed. A subset of cases (n = 729) was evaluated for diagnostic rate. Data were collected at 2 time points, 6 and 24 months following the change. RESULTS A total of 38 reviewers were participated (28 trainees, 10 staff). 1238 exams (46%) were done with POCM, 1452 (54%) were performed without POCM. For examinations with POCM, 80% of exams received a diagnostic confidence score of 5 (mean, 4.78 ± 0.43; 99% ≥ 4), whereas 60% of exams without POCM received a score of 5 (mean, 4.51 ± 0.70; 92% ≥ 4; p < .001). Trainees scored 1,523 exams (57%, 722 + POCM, 801 -POCM) and showed even lower diagnostic confidence in cases without PCOM compared with faculty (mean, 4.43 ± 0.68 vs. 4.59 ± 0.71; p < 0.001). Diagnostic rate in a randomly selected subset of exams (n = 729) was 54.2% in the POCM group versus 56.1% without POCM (p < 0.655). CT order to exam time decreased by 31 min, order to preliminary read decreased by 33 min, and ED LOS decreased by 30 min (approximately 8% of total LOS) in the group without POCM compared to those with POCM (p < 0.001 for all). 205 patients had a repeat scan within 7 days, 74 (36%) had IV contrast only, 131 (64%) had both IV and oral contrast on initial exam. Findings were consistent both over a 6-month evaluation period as well as the full 24-month study period. CONCLUSION Limiting use of POCM in the ED for non-traumatic abdominal pain improved ED throughput but impaired diagnostic confidence, particularly in trainees; however, it did not significantly impact diagnostic rates nor proportion of repeat CT exams.
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Affiliation(s)
- Benjamin L Triche
- Department of Radiology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Arvind Annamalai
- Department of Radiology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - B Dustin Pooler
- Department of Radiology, University of Wisconsin - Madison, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Joshua M Glazer
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
| | - Jacob D Zadra
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
| | - Ciara J Barclay-Buchanan
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
| | - Daniel J Hekman
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA
| | - Lu Mao
- Department of Radiology, University of Wisconsin - Madison, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin - Madison, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin - Madison, 600 Highland Avenue, Madison, WI, 53792, USA
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Wong D, Matini L, Kormilitzin A, Kantschuster R, Simadibrata DM, Lyden S, Wilson J, Brain OA, Palmer R, Ambrose T, Satsangi J, South M, Geddes J, Bodger K, Travis SPL, Walsh A. Patient-reported Outcomes: the ICHOM Standard Set for Inflammatory Bowel Disease in Real-life Practice Helps Quantify Deficits in Current Care. J Crohns Colitis 2022; 16:1874-1881. [PMID: 35868223 PMCID: PMC9721458 DOI: 10.1093/ecco-jcc/jjac099] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patient-reported outcome measures [PROMs] are key to documenting outcomes that matter most to patients and are increasingly important to commissioners of health care seeking value. We report the first series of the ICHOM Standard Set for Inflammatory Bowel Disease [IBD]. METHODS Patients treated for ulcerative colitis [UC] or Crohn's disease [CD] in our centre were offered enrolment into the web-based TrueColours-IBD programme. Through this programme, e-mail prompts linking to validated questionnaires were sent for symptoms, quality of life, and ICHOM IBD outcomes. RESULTS The first 1299 consecutive patients enrolled [779 UC, 520 CD] were studied with median 270 days of follow-up (interquartile range [IQR] 116, 504). 671 [52%] were female, mean age 42 years (standard deviation [sd] 16), mean body mass index [BMI] 26 [sd 5.3]. At registration, 483 [37%] were using advanced therapies. Median adherence to fortnightly quality of life reporting and quarterly outcomes was 100% [IQR 48, 100%] and 100% [IQR 75, 100%], respectively. In the previous 12 months, prednisolone use was reported by 229 [29%] patients with UC vs 81 [16%] with CD, p <0.001; 202 [16%] for <3 months; and 108 [8%] for >3 months. An IBD-related intervention was reported by 174 [13%] patients, and 80 [6%] reported an unplanned hospital admission. There were high rates of fatigue [50%] and mood disturbance [23%]. CONCLUSIONS Outcomes reported by patients illustrate the scale of the therapeutic deficit in current care. Proof of principle is demonstrated that PROM data can be collected continuously with little burden on health care professionals. This may become a metric for quality improvement programmes or to compare outcomes.
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Affiliation(s)
- Darren Wong
- Corresponding author: Dr Alissa Walsh, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford OX3 9DU, UK. E-mail:
| | - Lawrence Matini
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | | | - Ramona Kantschuster
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Daniel Martin Simadibrata
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Sara Lyden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Jean Wilson
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Oliver A Brain
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Rebecca Palmer
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Tim Ambrose
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Jack Satsangi
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Matthew South
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Keith Bodger
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Simon P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
| | - Alissa Walsh
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust and NIHR Biomedical Research Centre, Oxford, UK
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9
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Broder JS, Oliveira J E Silva L, Bellolio F, Freiermuth CE, Griffey RT, Hooker E, Jang TB, Meltzer AC, Mills AM, Pepper JD, Prakken SD, Repplinger MD, Upadhye S, Carpenter CR. Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department. Acad Emerg Med 2022; 29:526-560. [PMID: 35543712 DOI: 10.1111/acem.14495] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 02/07/2023]
Abstract
This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
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Affiliation(s)
- Joshua S Broder
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Richard T Griffey
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Edmond Hooker
- Department of Health Services Administration, Xavier University, Cincinnati, Ohio, USA
| | - Timothy B Jang
- Department of Emergency Medicine, University of California Los Angeles, UCLA Santa Monica Medical Center, Torrance, California, USA
| | - Andrew C Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
| | | | | | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
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10
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Bruno MA, Fotos JS, Pitot M, Franceschi AM, Neutze JA, Willis MH, Wasserman E, Snyder BL, Cruciata G, Stuckey HL, Wintermark M. Factors Driving Resistance to Clinical Decision Support: Finding Inspiration in Radiology 3.0. J Am Coll Radiol 2022; 19:366-376. [DOI: 10.1016/j.jacr.2021.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023]
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11
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Cullison KM, Franck N. Clinical Decision Rules in the Evaluation and Management of Adult Gastrointestinal Emergencies. Emerg Med Clin North Am 2021; 39:719-732. [PMID: 34600633 DOI: 10.1016/j.emc.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Although abdominal pain is a common chief complaint in the emergency department, only 1 in 6 patients with abdominal pain are diagnosed with a gastrointestinal (GI) emergency. These patients often undergo extensive testing as well as hospitalizations to rule out an acute GI emergency and there is evidence that not all patients benefit from such management. Several clinical decision rules (CDRs) have been developed for the diagnosis and management of patients with suspected acute appendicitis and upper GI bleeding to identify those patients who may safely forgo further testing or hospital admission. Further validation studies demonstrating the superiority of these CDRs over contemporary practice are needed.
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Affiliation(s)
- Kevin M Cullison
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, 545 1st Avenue, New York, NY 10016, USA.
| | - Nathan Franck
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, 545 1st Avenue, New York, NY 10016, USA
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12
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Brower C, Rehani MM. Radiation risk issues in recurrent imaging. Br J Radiol 2021; 94:20210389. [PMID: 34161140 PMCID: PMC9328055 DOI: 10.1259/bjr.20210389] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023] Open
Abstract
Millions of patients benefit from medical imaging every single day. However, we have entered an unprecedented era in imaging practices wherein 1 out of 125 patients can be exposed to effective dose >50 mSv from a single CT exam and 3 out of 10,000 patients undergoing CT exams could potentially receive cumulative effective doses > 100 mSv in a single day. Recurrent imaging with CT, fluoroscopically guided interventions, and hybrid imaging modalities such as positron emission tomography/computed tomography (PET/CT) is more prevalent today than ever before. Presently, we do not know the cumulative doses that patients may be receiving across all imaging modalities combined. Furthermore, patients with diseases with longer life expectancies are being exposed to high doses of radiation enabling radiation effects to manifest over a longer time period. The emphasis in the past on improving justification of imaging and optimization of technique and practice has proved useful. While that must continue, the current situation requires imaging device manufacturers to urgently develop imaging technologies that are safer for patients as high doses have been observed in patients where imaging has been justified through clinical decision-support and optimized by keeping doses below the national benchmark doses. There is a need to have a critical look at the fundamental principles of radiation protection as cumulative doses are likely to increase in the coming years.
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Tunc E, Fraundorf E, Worley S, Aquino M, Magnuson D, Lampl BS, Jennings S, Fertel BS. The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED. Am J Emerg Med 2021; 50:211-217. [PMID: 34392140 DOI: 10.1016/j.ajem.2021.07.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 07/27/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. METHODS This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). RESULTS 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). CONCLUSIONS A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.
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Affiliation(s)
- Emine Tunc
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
| | - Erika Fraundorf
- Division of Pediatric Emergency Medicine, Emergency Services Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Michael Aquino
- Division of Pediatric Radiology, Imaging Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - David Magnuson
- Division of Pediatric Surgery, Digestive Disease Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Brooke S Lampl
- Division of Pediatric Radiology, Imaging Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Stephanie Jennings
- Division of Pediatric Hospital Medicine, Pediatric Institute, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America
| | - Baruch S Fertel
- Emergency Services Institute and Enterprise Quality and Safety, Cleveland Clinic Health System and Lerner College of Medicine in Cleveland Ohio, United States of America.
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14
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Increasing Utilization of Emergency Department Neuroimaging from 2007 to 2017. AJR Am J Roentgenol 2021; 218:165-173. [PMID: 34346786 DOI: 10.2214/ajr.21.25864] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: The volume of emergency department (ED) visits and neuroimaging have grown since the start of the century. Little is known about this growth in the commercially insured and Medicare Advantage populations. Objective: To evaluate changing emergency department utilization of neuroimaging from 2007 to 2017 in both commercially insured and Medicare Advantage enrollees. Methods: Using patient-level claims from Optum's De-identified Clinformatics Data Mart database, which annually includes approximately 12 to 14 million commercial and Medicare Advantage health plan enrollees, annual ED utilization of head computed tomography (CT), head magnetic resonance (MR), head CT angiography (CTA), neck CTA, head MR angiography (MRA), neck MRA, and carotid duplex ultrasound (CDUS) were assessed from 2007 through 2017. To account for an aging sample population, utilization rates were adjusted using annual relative proportions of age groups and stratified by patient demographics, payer type, and provider state. Results: Between 2007 and 2017, age-adjusted ED neuroimaging utilization rates per 1000 ED visits increased 72% overall (compound annual growth rate [CAGR] 5%). This overall increase corresponded to an increase of 69% for head CT (CAGR 5%); 67% for head MRI (CAGR 5%); 1100% for head CTA (CAGR 25%); 1300% for neck CTA (CAGR 27%); 36% for head MRA (CAGR 3%); 52% for neck MRA (CAGR 4%); and a decrease of 8% for CDUS (CAGR -1%). The utilization of head CT and CTA of the head and neck per 1000 ED visits continuously increased in those 65 or older by 48% (CAGR 4%) and 1011% (CAGR 24%). Conclusion: Neuroimaging utilization in the ED grew considerably between 2007 and 2017, with growth of head and neck CTA far outpacing other modalities. Unenhanced head CT remains by far the dominant ED neuroimaging examination. Clinical Impact: The rapid growth of head and neck CTA observed in the fee-for-service Medicare population is also observed in the commercially insured and Medicare Advantage populations. The appropriateness of this growth should be monitored as the indications for CTA expand.
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15
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Nepal P, Wells M, Ojili V, Khandelwal K, Lalwani N, Khandelwal A. Problem-solving with MRI in acute abdominopelvic conditions, part 1: gastrointestinal, hepatobiliary, and pancreatic diseases. Emerg Radiol 2021; 28:1161-1172. [PMID: 34247289 DOI: 10.1007/s10140-021-01960-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/25/2021] [Indexed: 01/11/2023]
Abstract
The purpose of this article is to review the benefit and added value and advantages of magnetic resonance imaging (MRI) compared with other cross-sectional imaging in patients presenting with abdominopelvic emergencies. During the past decade, there has been increased utilization of MRI in the emergency department with widespread availability of MR scanners, improvement in rapid imaging techniques, and methods to overcome motion-related artifacts. This has benefited patients at higher risk of radiation, particularly children and pregnant women, and patients with contraindications to iodinated contrast including allergy and renal dysfunction. Still the challenges are: on site MR scanner in the emergency department, after-hour services, as well as availability of time slot to rapidly scan emergency patient. MRI has additional advantages over other imaging modalities due to its high contrast resolution, which allows it to better characterize tissue and fluid collections, and may avoid the need for intravenous contrast. Radiologists must be familiar with the role and added value of MRI, spectrum of imaging findings, and problem-oriented modified MR protocols in abdominal and pelvic emergencies. In part 1, we will discuss the utility of MRI in gastrointestinal, hepatobiliary, and pancreatic diseases. In part 2, the authors will focus on the key MR imaging features of female pelvic gynecological diseases, pregnancy related complications, abdominal vascular complications, and renal diseases.
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Affiliation(s)
- Pankaj Nepal
- Department of Radiology, St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Michael Wells
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Vijayanadh Ojili
- Department of Radiology, University of Texas Health, San Antonio, TX, USA
| | - Kanika Khandelwal
- Department of Hospital Internal Medicine, Mayo Clinic, Austin, MN, USA
| | - Neeraj Lalwani
- Department of Radiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Ashish Khandelwal
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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16
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Jeong Y, Shin CI, Jae HJ, Kim JH, Chung JW. Analysis of the Rate of Discrepancy between Preliminary Reports by Radiology Residents and Final Reports by Certified Radiologists for Emergency Radiology Studies in a University Hospital. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:1186-1195. [PMID: 36238406 PMCID: PMC9432356 DOI: 10.3348/jksr.2020.0189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/22/2020] [Accepted: 01/06/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Younbeom Jeong
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Cheong-Il Shin
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
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17
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Morris M, Destian S, Chu Y, Klumpp M, Zohrabian VM. Investigation of Whole Spine MRI in the Emergency Department at Two Large Tertiary Care Academic Medical Centers in the United States. Curr Probl Diagn Radiol 2020; 50:637-645. [PMID: 32839068 DOI: 10.1067/j.cpradiol.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES The impact of emergent whole spine magnetic resonance imaging (WS-MRI) on patient management has not been extensively studied to date. Here, we explore indications, results, and outcomes associated with WS-MRI performed through the emergency departments (EDs) of 2 large tertiary care, academic medical centers in the Northeastern United States. We hypothesize that given a relatively low barrier to entry, coupled with lack of appropriateness guidelines, a sizeable proportion of WS-MRI studies performed emergently do not result in spine findings necessitating inpatient admission for immediate treatment. MATERIALS AND METHODS We retrospectively studied 335 adult patients (≥18 years) who underwent WS-MRI through the ED between 2016 and 2019. The demographic data collected included, age, sex, chief complaint, history of spine disease, and date and type of last spine imaging prior to ED presentation. Data compiled from the time of ED visit included WS-MRI result and patient disposition, including reason for hospital admission, by which patients were categorized into groups to allow for ease of comparisons. Hypergeometric tests were used to determine statistically significant associations between random discrete variables. RESULTS Trauma was the most frequent chief complaint, comprising 35% (n = 117) of all presentations, followed by pain (25%, n = 84), motor deficit (16%, n = 55), sensory disturbance (12%, n = 41), bowel, and/or bladder dysfunction (9%, n = 30), and subjective or objective fevers with suspicion for spine infection (2%, n = 8). The largest proportion of WS-MRI studies revealed degenerative disc disease (DDD) as the principal result (41%, n = 139). 52% of all patients were either discharged directly from the ED (41%) or admitted for a non-spine issue after WS-MRI (11%); of these numbers, 61% underwent WS-MRI and no other imaging study in the ED. In patients who presented with a chief complaint of pain, DDD was often the principal WS-MRI finding (54%), albeit this association was not statistically significant. DDD, nonetheless, was positively associated with a discharge from the ED (P <0.001). Trauma was positively associated with fracture or ligamentous/soft tissue injury (P <0.001) on WS-MRI and hospital admission for a spine issue (P <0.01). CONCLUSION That just under half of patients in our study were admitted for spine-related pathology suggests that WS-MRI is valuable in the emergent setting. At the same time, however, that over half of patients were not subsequently admitted for a spine-related issue points to the possibility of further refining which patients would benefit most from WS-MRI. WS-MRI may be less helpful in patients presenting with pain, though may be higher-yield in those with trauma, motor deficits, and bowel/bladder complaints. Although MRI is highly sensitive in ruling out emergent central nervous system pathology, given the resource-intensive nature of the test, it is prudent to carefully select which patients should undergo emergent WS-MRI, especially in instances when more cost-effective, alternative diagnostic approaches, including detailed neurological exam, computed tomography, or localized/targeted MRI, are possible.
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Affiliation(s)
- Montana Morris
- Yale School of Medicine, Department of Radiology & Biomedical Imaging, New Haven, CT
| | - Sylvie Destian
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Youngmin Chu
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Matthew Klumpp
- SUNY Upstate Medical University, Department of Radiology, Syracuse, NY
| | - Vahe M Zohrabian
- Yale School of Medicine, Department of Radiology & Biomedical Imaging, New Haven, CT.
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Beyond Access Block: Understanding the Role of Health Literacy and Self-Efficacy in Low-Acuity Emergency Department Patients. Ochsner J 2020; 20:161-169. [PMID: 32612470 PMCID: PMC7310186 DOI: 10.31486/toj.19.0047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Health literacy, self-efficacy, and patient satisfaction are factors associated with healthcare utilization. The relationships among these factors and their combined impact on patients’ self-rated health have historically been studied in chronic disease populations. This study assessed low-acuity emergency department (ED) patients’ ratings of these factors, the relationships among these factors, and their effect on re-presentation rates to the ED. Methods: In this single-arm cohort survey, patients provided demographic data, completed health literacy and self-efficacy assessments prior to being seen by a physician, and completed a discharge perceptions questionnaire that included a global satisfaction question at the time of departure. Three months later, patients answered a telephone survey to measure post-ED visit health outcomes. Results: Health literacy (r=0.114, P=0.023) and self-efficacy (r=0.469, P<0.001) were both independently and positively associated with self-rated health. Neither factor was associated with patient satisfaction. Self-rated health was negatively associated with return ED visits (r=–0.137, P=0.011). Conclusion: Existing research shows that health literacy has a linear association with self-efficacy and self-rated health. The results of this study suggest that in the context of low-acuity ED patients, health literacy and self-efficacy affect patients’ understanding of their health status (self-rated health) but do not lead to better utilization of healthcare resources. Improvement of health literacy and self-efficacy, specifically to increase self-rated health, may provide a future avenue of intervention to reduce low-acuity ED patient re-presentation.
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Madurska MJ, Anderson RG, Anderson DJ, McNeill CJ, Jansen JO, Stuart WP, Morrison JJ. Mesenteric vascular disease: A population-based cohort study. Vascular 2020; 29:54-60. [PMID: 32605533 DOI: 10.1177/1708538120937954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Mesenteric vascular disease carries a high risk of mortality and morbidity; however, due to obscure clinical presentation, it can be under-recognized. Currently, epidemiology of mesenteric vascular disease remains poorly defined. The aim of this study is to analyze changes in Scottish mortality rates from mesenteric vascular disease overtime. METHODS This is a retrospective, longitudinal population-based cohort study using data extracted from death certificates and Scottish Index of Multiple Deprivation. All deaths related to a vascular disorder of the intestines recorded as an underlying cause of death between 1979 and 2014 were identified using International Classification of Disease-9 or International Classification of Disease-10 code groups. Data included demographics and location of death. The residence postcodes were used to classify socio-economic status using the Scottish Index of Multiple Deprivation. RESULTS From 2,142,921 deaths over 36 years, 14,530 (0.7%) were due to mesenteric vascular disease with a median (interquartile range) age of 77 and a 2:1 female to male gender ratio. The mean ± standard deviation age significantly increased from 72.6 ± 12.1 in 1979 to 76.8 ± 11.1 in 2014 (p < 0.001, R2 = 0.772). Males were consistently younger than females at the time of death. The two lowest Scottish Index of Multiple Deprivation categories accounted for half of the cohort, throughout the study period (p = 0.068). The adjusted death rate per 100,000 population increased from 7.6 in 1979 to 12.1 in 2014. CONCLUSIONS The reported death rates of mesenteric vascular disease in Scotland between 1979 and 2014 have nearly doubled. Mesenteric vascular disease affects twice as many women as men and is associated with social deprivation. The increased reporting of mesenteric vascular disease is likely due to increased recognition and incidence. These implications should be considered when planning healthcare provision in Scotland.
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Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | | | | | | | - Jan O Jansen
- University of Alabama at Birmingham Hospital, Birmingham, USA
| | | | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
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20
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Wintermark M, Willis MH, Hom J, Franceschi AM, Fotos JS, Mosher T, Cruciata G, Reuss T, Horton R, Fredericks N, Burleson J, Haines B, Bruno M. Everything Every Radiologist Always Wanted (and Needs) to Know About Clinical Decision Support. J Am Coll Radiol 2020; 17:568-573. [DOI: 10.1016/j.jacr.2020.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/26/2019] [Accepted: 03/19/2020] [Indexed: 12/18/2022]
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21
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Zellner MB, Uhlig WC. Implementation of a point spread function method to analyze flash radiography images: Image enhancement, movie generation, and projection detangling. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2020; 91:013104. [PMID: 32012589 DOI: 10.1063/1.5119323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 12/15/2019] [Indexed: 06/10/2023]
Abstract
This work investigates how one can postprocess a series of flash-generated X-ray radiographs with known point spread functions and collection geometries to produce radiographs with enhanced image quality and/or to approximate a multiframe X-ray movie by spatially correlating temporally sequenced images. To produce images with enhanced quality, one collects multiple individual projections, simultaneously, and then uses the known point spread function and acquisition geometry to correlate and integrate the numerous projections as if they were acquired from approximately the same perspective. If using sources of similar spectral characteristics, the outcome correlates with that which would be produced from a multiflash integration, where one benefits from an increase in flux of X-ray photons. If using sources of different spectral characteristics, a composite radiograph can be produced where the unique source spectrum can be matched to known material absorption cross-sections to accentuate radiographic features within the target material. To produce multiframe movies, similar mathematics are applied to images collected throughout a timespan over which the object changes. The aforementioned processes' mathematics and examples are demonstrated for the case in which the individual projections are completely separable on the detector with no overlap. Finally, a potential method is discussed for separation of images in the case where multiple radiograph projections are overlapped and entangled on the detector.
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Affiliation(s)
- Michael B Zellner
- U.S. Army Combat Capabilities Development Command Army Research Laboratory, Aberdeen Proving Ground, Aberdeen, Maryland 21005, USA
| | - W Casey Uhlig
- U.S. Army Combat Capabilities Development Command Army Research Laboratory, Aberdeen Proving Ground, Aberdeen, Maryland 21005, USA
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22
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Lu YT, Haase SC, Chung TT, Chung KC, Sears ED. The Impact of Pre-Referral Advanced Diagnostic Testing on Wait Time to See a Hand Surgeon for Common Upper-Extremity Conditions. J Hand Surg Am 2019; 44:1013-1020.e2. [PMID: 31677910 PMCID: PMC7429450 DOI: 10.1016/j.jhsa.2019.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 07/09/2019] [Accepted: 09/25/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE We sought to evaluate the use of pre- and post-referral advanced diagnostic testing among patients with 3 common hand conditions, rates of subsequent tests, and differences in wait time to see a hand surgeon. METHODS We analyzed a single academic tertiary care center administrative database of encounters from 2006 to 2015 to identify adult patients who were referred to a hand surgeon for 3 conditions (carpal tunnel syndrome [CTS], soft tissue masses [STM], and joint pain [JP]). We recorded patient characteristics, use and timing of diagnostic tests, and wait time for the initial hand surgeon evaluation. RESULTS Among patients who received advanced diagnostic tests before the surgeon evaluation, CTS patients had the highest rate of receiving pre-referral advanced testing (53.4%) compared with JP (10.6% ) and STM patients (5.8%). The CTS patients had the highest rates of repeat testing (19.5%) compared with patients with JP (1.4%) and STM (0%). Across all 3 conditions, patients who received pre-referral advanced testing waited an additional 19 to 94 days to see a surgeon, compared with patients who received only post-referral testing or no testing. CONCLUSIONS Use of pre-referral advanced diagnostic tests is associated with an increased time to see a hand surgeon for common hand conditions. CLINICAL RELEVANCE Hand surgeons should have a role in identifying patients who do or do not benefit from advanced testing before referral to ensure that tests ordered before consultation are useful to both patients and treating surgeons.
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Affiliation(s)
- Yu-Ting Lu
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine
| | - Steven C. Haase
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine
| | - Ting-Ting Chung
- Center for Big Data Analytics and Statistics and Division of Rheumatology, Allergy and Immunology, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kevin C. Chung
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine,Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Erika D. Sears
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine,Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI,Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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23
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The prevalence of pathological findings identified by next day abdominal ultrasound in patients discharged from the emergency department. CAN J EMERG MED 2019; 21:793-797. [PMID: 31771685 DOI: 10.1017/cem.2019.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A common strategy for managing emergency department (ED) patients with low-risk abdominal pain is to discharge them home and arrange for next day outpatient ultrasound for further assessment. The objective was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days. METHODS This was a retrospective chart review of non-pregnant patients ages 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound. RESULTS Of the 299 included patients, 252 (84.3%) were female and mean (SD) age was 28.4 (6.0) years. Twenty-three (7.7%) patients had ultrasounds requiring intervention within 14 days of imaging. Of these, eight (34.8%) had appendicitis, five (21.7%) had cholecystitis, four (17.4%) had urological pathology, three (13.0%) had gynecological pathology, and three (13.0%) had gastrointestinal diagnoses. Of note, 14 (60.9%) patients requiring follow-up or intervention within 14 days had symptoms that improved or resolved at the time of the outpatient ultrasound. For the 277 (92.6%) patients not requiring intervention, 117 (42.2%) had improved, 89 (32.1%) were unchanged, 50 (18.1%) had resolved, and 5 (1.8%) had worsened symptoms at the time of the follow-up ultrasound. Of the non-intervention patients, 13 (4.7%) went on to have alternative imaging, including magnetic resonance imaging, computed tomography, and a sonohysterogram. CONCLUSIONS Next-day ultrasound imaging remains a good way of identifying patients with serious pathology not appreciated at the time of their ED visit.
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Hanna TN, Duszak R, Chahine A, Zygmont ME, Herr KD, Horný M. The Introduction and Development of the H-index for Imaging Utilizers: A Novel Metric for Quantifying Utilization of Emergency Department Imaging. Acad Emerg Med 2019; 26:1125-1134. [PMID: 31535443 DOI: 10.1111/acem.13765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/05/2019] [Accepted: 04/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective was to develop a novel metric for quantifying patient-level utilization of emergency department (ED) imaging. METHODS Using 2009 to 2015 Truven Health MarketScan commercial claims and encounters database, all ED visits and associated imaging services were identified. To measure imaging resource intensity, total imaging relative value units (RVUs) were calculated for each patient per ED visit. An individual's annual imaging h-index is defined as the largest number, h, such that h ED visits by that individual in a given year is associated with total medical imaging RVUs of a value of at least h. RESULTS Over 7 years, in a sample of 86,506,362 privately insured individuals (232,919,808 person-years) in all 50 states and the District of Columbia, 38,973,716 ED visits were identified. A total of 9.5% of person-years had one ED visit and 2.7% had two or more (the remainder had none). From 2009 to 2015, the percentage of ED patients undergoing imaging increased from 25.1% to 34.6%. Individuals with two or more ED visits each associated with two or more imaging RVUs (ED imaging h-index ≥ 2) comprised 0.2% of the sample and 1.4% of ED visitors; however, they accounted for 4.0% of ED visits and the use of 18.6% of imaging resources. From 2009 to 2015, imaging resource allocation for such patients increased from 16.5% to 21.0%. CONCLUSIONS The ED imaging h-index allows identification of patients who undergo significant ED imaging, based on a single-digit patient-specific metric that incorporates both annual ED visit number and medical imaging resource intensity per visit. While ED patients with an ED imaging h-index ≥ 2 represented a minuscule fraction of privately insured individuals, they were associated with one-fifth of all ED imaging resources.
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Affiliation(s)
- Tarek N. Hanna
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Amanda Chahine
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Matthew E. Zygmont
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Keith D. Herr
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
| | - Michal Horný
- Department of Radiology and Imaging Sciences Emory University Atlanta GA
- Department of Health Policy and Management Rollins School of Public Health Emory University Atlanta GA
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Choosing wisely in the ED: The diagnostic cascade of needless medical testing in a two-level study. Am J Emerg Med 2019; 37:1705-1708. [DOI: 10.1016/j.ajem.2018.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 11/20/2022] Open
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Bax T, Macha M, Mayberry J. The utility of CT scan for the diagnostic evaluation of acute abdominal pain. Am J Surg 2019; 217:959-966. [DOI: 10.1016/j.amjsurg.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/16/2019] [Accepted: 02/06/2019] [Indexed: 02/08/2023]
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Cross R, Bhat R, Li Y, Plankey M, Maloy K. Emergency Department Computed Tomography Use for Non-traumatic Abdominal Pain: Minimal Variability. West J Emerg Med 2018; 19:782-796. [PMID: 30202488 PMCID: PMC6123098 DOI: 10.5811/westjem.2018.6.37381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 06/17/2018] [Accepted: 06/21/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Variability in the use of computed tomography (CT) between providers in the emergency department (ED) suggests that CT is ordered on a provider rather than a patient level. We aimed to evaluate the variability of CT ordering practices for non-traumatic abdominal pain (NTAP) across physicians in the ED using patient-visit and physician-level factors. Methods We conducted a retrospective study among 6,409 ED visits for NTAP from January 1 to December 31, 2012, at a large, urban, academic, tertiary-care hospital. We used a two-level hierarchical logistic regression model to estimate inter-physician variation. Intraclass correlation coefficient (ICC) was calculated. Results The hierarchical logistic regression analyses showed that patient-visit factors including younger age, arrival mode by ambulance, prior CT, >79 ED arrivals in the previous four hours, and ultrasound had statistically significant negative associations with physician CT ordering, while surgical team admission and white blood count (WBC) >12.5 K/millimeter cubed (mm3) had statistically significant positive associations with physician CT ordering. With physician-level factors, only physicians with >21 years experience after medical school graduation showed statistical significance negatively associated with physician CT ordering. Our data demonstrated increased CT ordering from the mean in only one out of 43 providers (2.3%), which indicated limited variation across physicians to order CT. After adjusting for patient-visit and physician-level factors, the calculated ICC was 1.46%. Conclusion We found minimal physician variability in CT ordering practices for NTAP. Patient-visit factors such as age, arrival mode, admission team, prior CT, ED arrivals in previous four hours, ultrasound, and WBC count were found to largely influence CT ordering practices.
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Affiliation(s)
- Roderick Cross
- Georgetown University Hospital/Washington Hospital Center, Department of Emergency Medicine, Washington, District of Columbia
| | - Rahul Bhat
- Georgetown University Hospital/Washington Hospital Center, Department of Emergency Medicine, Washington, District of Columbia
| | - Ying Li
- Georgetown University Medical Center, Department of Medicine, Washington, District of Columbia
| | - Michael Plankey
- Georgetown University Medical Center, Department of Medicine, Washington, District of Columbia
| | - Kevin Maloy
- Georgetown University Hospital/Washington Hospital Center, Department of Emergency Medicine, Washington, District of Columbia
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The Impact of Risk Standardization on Variation in CT Use and Emergency Physician Profiling. AJR Am J Roentgenol 2018; 211:392-399. [PMID: 29975119 DOI: 10.2214/ajr.17.19188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to use detailed electronic health record data to profile the use of condition-specific, risk-standardized imaging by emergency physicians. MATERIALS AND METHODS CT utilization in four emergency departments in a single health care system was retrospectively analyzed. The primary outcome for analysis was indication-specific, risk-standardized CT utilization. We constructed seven clinical cohorts on the basis of the presence or absence of a traumatic indication for the most frequently performed CT studies. Risk standardization was performed using machine learning algorithms and hierarchic logistic regression models. Variation in CT utilization for each cohort was analyzed using coefficients of variation and box plots, the effect of risk standardization on physician profiling was determined using slope diagrams and kappa values, and within-physician correlation was assessed using correlation coefficients and matrices. RESULTS For the seven cohorts, the number of physicians ordering more than 25 CT studies for a particular indication ranged from 70 to 88, and the number of ED visits ranged from 17,458 to 117,489. The unadjusted variation was large for each indication (coefficient of variation, 30.2-57.9). Risk standardization resulted in reduced but persistent variation for all indications (coefficient of variation, 12.3-22.3). Among indication-specific models, risk standardization resulted in reclassification by two or more deciles for 14.0-39.1% of physicians. The R value for within-physician correlation varied from 0.02 to 0.80 and was highest between chest and abdominal imaging for trauma. CONCLUSION In this multisite study of CT utilization, risk standardization had a substantial impact on variation in CT utilization and emergency physician profiling. Administrators and payers should include risk standardization in future measures of physician imaging to ensure valid assessment of performance and achieve improvements in emergency care value.
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Schoel L, Maizlin II, Koppelmann T, Onwubiko C, Shroyer M, Douglas A, Russell RT. Improving imaging strategies in pediatric appendicitis: a quality improvement initiative. J Surg Res 2018; 230:131-136. [PMID: 30100029 DOI: 10.1016/j.jss.2018.04.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/23/2018] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Data from the American College of Surgeons National Surgical Quality Improvement Program identified our hospital as an outlier for preoperative computed tomography (CT) use in the diagnosis of acute appendicitis in children. We performed a quality improvement project to reduce this utilization in favor of ultrasound-based diagnoses (ultrasonography [US]) through creation and implementation of an evidence-based appendicitis algorithm. METHODS Over a 2-y period (1 y preceding and 1 y following institution of the algorithm), the clinical information of all pediatric patients operated on for suspicion of acute appendicitis following imaging studies in our institution was collated. Basic characteristics were compared before and after protocol implementation using the chi-square test for categorical variables and the nonparametric, independent sample test of medians for numerical variables. Imaging modalities used and clinical outcomes were compared using chi-square analysis. RESULTS A total of 227 patients (117 preprotocol and 110 postprotocol implementation) were evaluated in our emergency department and operated on for suspicion of acute appendicitis. There were no differences in age, sex, race, or body mass index between the two periods. There were also no differences in length of stay (P = 0.27), acute and perforated appendicitis rates (P = 0.59), negative appendectomy rates (P = 0.40), or postoperative complications (P = 0.19). There was a significant reduction in the utilization of CT, from 65.8% to 22.0%, with a concurrent increase in the utilization of US (P < 0.001). CONCLUSIONS With the implementation of a standardized, multidisciplinary algorithm, CT utilization was decreased and concurrently US utilization was increased without sacrificing diagnostic accuracy or patient outcomes.
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Affiliation(s)
- Leah Schoel
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Ilan I Maizlin
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Tal Koppelmann
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Chinwendu Onwubiko
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Michelle Shroyer
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Ann Douglas
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Robert T Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama.
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Bellolio MF, Bellew SD, Sangaralingham LR, Campbell RL, Cabrera D, Jeffery MM, Shah ND, Hess EP. Access to primary care and computed tomography use in the emergency department. BMC Health Serv Res 2018; 18:154. [PMID: 29499700 PMCID: PMC5834877 DOI: 10.1186/s12913-018-2958-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 02/21/2018] [Indexed: 01/17/2023] Open
Abstract
Background The decision to obtain a computed tomography CT scan in the emergency department (ED) is complex, including a consideration of the risk posed by the test itself weighed against the importance of obtaining the result. In patients with limited access to primary care follow up the consequences of not making a diagnosis may be greater than for patients with ready access to primary care, impacting diagnostic reasoning. We set out to determine if there is an association between CT utilization in the ED and patient access to primary care. Methods We performed a cross-sectional study of all ED visits in which a CT scan was obtained between 2003 and 2012 at an academic, tertiary-care center. Data were abstracted from the electronic medical record and administrative databases and included type of CT obtained, demographics, comorbidities, and access to a local primary care provider (PCP). CT utilization rates were determined per 1000 patients. Results A total of 595,895 ED visits, including 98,001 visits in which a CT was obtained (16.4%) were included. Patients with an assigned PCP accounted for 55% of all visits. Overall, CT use per 1000 ED visits increased from 142.0 in 2003 to 169.2 in 2012 (p < 0.001), while the number of annual ED visits remained stable. CT use per 1000 ED visits increased from 169.4 to 205.8 over the 10-year period for patients without a PCP and from 118.9 to 142.0 for patients with a PCP. Patients without a PCP were more likely to have a CT performed compared to those with a PCP (OR 1.57, 95%CI 1.54 to 1.58; p < 0.001). After adjusting for age, gender, year of visit and number of comorbidities, patients without a PCP were more likely to have a CT performed (OR 1.20, 95% CI 1.18 to 1.21, p < 0.001). Conclusions The overall rate of CT utilization in the ED increased over the past 10 years. CT utilization was significantly higher among patients without a PCP. Increased availability of primary care, particularly for follow-up from the ED, could reduce CT utilization and therefore decrease costs, ED lengths of stay, and radiation exposure.
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Affiliation(s)
- M Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA. .,Kern Center for the Science of Heath Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Shawna D Bellew
- Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Lindsey R Sangaralingham
- Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,Kern Center for the Science of Heath Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,Kern Center for the Science of Heath Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Erik P Hess
- Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Trends and Variation in the Utilization and Diagnostic Yield of Chest Imaging for Medicare Patients With Suspected Pulmonary Embolism in the Emergency Department. AJR Am J Roentgenol 2018; 210:572-577. [DOI: 10.2214/ajr.17.18586] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Koliani-Pace J, Vaughn B, Herzig SJ, Davis RB, Gashin L, Obuch J, Cheifetz AS. Utility of Emergency Department Use of Abdominal Pelvic Computed Tomography in the Management of Crohn's Disease. J Clin Gastroenterol 2017; 50:859-864. [PMID: 26974753 PMCID: PMC5018411 DOI: 10.1097/mcg.0000000000000508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOAL The primary aim of this study was to determine predictors of clinically significant computed tomography (CT) scans, paying particular attention to findings of previous CT scans. BACKGROUND Use of CT to assess patients with Crohn's disease (CD) in the Emergency Department (ED) is both costly and exposes patients to high levels of ionizing radiation while not clearly improving outcomes. STUDY Patients with CD who underwent CT scan in the Emergency Department from 2008 to 2011 at a tertiary referral center were assessed for clinically significant findings. A multivariable generalized estimating equation model with logit link and exchangeable working correlation structure was constructed to assess for independent predictors of CT scans with clinically significant findings. RESULTS A total of 118 patients with CD underwent 194 CT scans. Ninety-two of 194 (47%) CT scans demonstrated clinically significant findings. Predictors of clinically significant CT scans included ileal disease involvement [odds ratios (OR) 3.47, P=0.01] and white blood cell count >12 (OR 2.1, P=0.03). Most notably, patients with a CT scan without clinically significant findings performed in the preceding month were significantly less likely to have a clinically significant CT scan (OR 0.23, P=0.005). CONCLUSIONS Patients with CD who had a CT scan without significant findings the month prior are unlikely to have clinically significant CT findings. Ileal disease and an elevated white blood cell are predictive of clinically significant CT scans.
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Affiliation(s)
- Jenna Koliani-Pace
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Byron Vaughn
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215
- University of Minnesota, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Minneapolis, MN 55454
| | - Shoshana J. Herzig
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Roger B. Davis
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Laurie Gashin
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Joshua Obuch
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Adam S. Cheifetz
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215
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Tonolini M, Valconi E, Vanzulli A, Bianco R. Radiation overexposure from repeated CT scans in young adults with acute abdominal pain. Emerg Radiol 2017; 25:21-27. [DOI: 10.1007/s10140-017-1554-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/08/2017] [Indexed: 12/13/2022]
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Standardized ultrasound templates for diagnosing appendicitis reduce annual imaging costs. J Surg Res 2017; 221:77-83. [PMID: 29229156 DOI: 10.1016/j.jss.2017.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/13/2017] [Accepted: 07/03/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Ultrasound is preferred over computed tomography (CT) for diagnosing appendicitis in children to avoid undue radiation exposure. We previously reported our experience in instituting a standardized appendicitis ultrasound template, which decreased CT rates by 67.3%. In this analysis, we demonstrate the ongoing cost savings associated with using this template. METHODS Retrospective chart review for the time period preceding template implementation (June 2012-September 2012) was combined with prospective review through December 2015 for all patients in the emergency department receiving diagnostic imaging for appendicitis. The type of imaging was recorded, and imaging rates and ultrasound test statistics were calculated. Estimated annual imaging costs based on pretemplate ultrasound and CT utilization rates were compared with post-template annual costs to calculate annual and cumulative savings. RESULTS In the pretemplate period, ultrasound and CT rates were 80.2% and 44.3%, respectively, resulting in a combined annual cost of $300,527.70. Similar calculations were performed for each succeeding year, accounting for changes in patient volume. Using pretemplate rates, our projected 2015 imaging cost was $371,402.86; however, our ultrasound rate had increased to 98.3%, whereas the CT rate declined to 9.6%, yielding an annual estimated cost of $224,853.00 and a savings of $146,549.86. Since implementation, annual savings have steadily increased for a cumulative cost savings of $336,683.83. CONCLUSIONS Standardizing ultrasound reports for appendicitis not only reduces the use of CT scans and the associated radiation exposure but also decreases annual imaging costs despite increased numbers of imaging studies. Continued cost reduction may be possible by using diagnostic algorithms.
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Abstract
BACKGROUND AND AIMS The prevalence and incidence of inflammatory bowel disease (IBD) in North America is among the highest in the world and imparts substantial direct and indirect medical costs. The Choosing Wisely Campaign was launched in wide variety of medical specialties and disciplines to reduce unnecessary or harmful tests or treatment interventions. METHODS The Choosing Wisely list for IBD was developed by the Canadian IBD Network for Research and Growth in Quality Improvement (CINERGI) in collaboration with Crohn's and Colitis Canada (CCC) and the Canadian Association of Gastroenterology (CAG). Using a modified Delphi process, 5 recommendations were selected from an initial list of 30 statements at a face-to-face consensus meeting. RESULTS The 5 things physicians and patients should question: (1) Don't use steroids (e.g., prednisone) for maintenance therapy in IBD; (2) Don't use opioids long-term to manage abdominal pain in inflammatory bowel disease (IBD); (3) Don't unnecessarily prolong the course of intravenous corticosteroids in patients with acute severe ulcerative colitis (UC) in the absence of clinical response; (4) Don't initiate or escalate long-term medical therapies for the treatment of IBD based only on symptoms; and (5) Don't use abdominal computed tomography (CT) scan to assess IBD in the acute setting unless there is suspicion of a complication (obstruction, perforation, abscess) or a non-IBD etiology for abdominal symptoms. CONCLUSIONS The Choosing Wisely recommendations will foster patient-physician discussions to optimize IBD therapy, reduce adverse effects from testing and treatment, and reduce medical expenditure.
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Gundareddy VP, Maruthur NM, Chibungu A, Bollampally P, Landis R, Eid SM. Association Between Radiologic Incidental Findings and Resource Utilization in Patients Admitted With Chest Pain in an Urban Medical Center. J Hosp Med 2017; 12:323-328. [PMID: 28459900 DOI: 10.12788/jhm.2722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Increasing use of testing among hospitalized patients has resulted in an increase in radiologic incidental findings (IFs), which challenge the provision of high-value care in the hospital setting. OBJECTIVE To understand impact of radiologic incidental findings on resource utilization in patients hospitalized with chest pain. DESIGN Retrospective observational cross sectional study. SETTING Academic medical center. PARTICIPANTS Adult patients hospitalized with principal diagnosis of chest pain. MEASUREMENTS Demographic, imaging, and length of stay (LOS) data were abstracted from the medical charts. We used multiple logistic regression to evaluate factors associated with radiologic IFs and negative binomial regression to evaluate the association between radiologic IFs and LOS. RESULTS 1811 consecutive admissions with chest pain were analyzed retrospectively over a period of 24 months; 376 patients were included in the study after exclusion criteria were applied and readmissions removed. Of these, 197 patients (52%) had 364 new radiologic IFs on imaging; most IFs were of minor (50%) or moderate clinical significance (42%), with only 7% of major significance. Odds of finding radiologic IFs increased with age (adjusted odds ratio, 1.04; 95% confidence interval [CI], 1.01-1.06) and was associated with a 26% increase in LOS (adjusted incidence rate ratio, 1.26; 95% CI, 1.07-1.49). CONCLUSION Radiologic IFs were very common among patients hospitalized with chest pain of suspected cardiac origin and independently associated with an increase in the LOS. Interventions to address radiologic IFs may reduce LOS and, thereby, support high-value care. Journal of Hospital Medicine 2017;12:323-328.
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Affiliation(s)
- Venkat P Gundareddy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nisa M Maruthur
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
| | - Abednego Chibungu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Regina Landis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Lehtimäki TT, Valtonen H, Miettinen P, Juvonen P, Paajanen H, Vanninen R. A randomised clinical trial of routine versus selective CT imaging in acute abdomen: Impact of patient age on treatment costs and hospital resource use. Eur J Radiol 2017; 87:1-7. [DOI: 10.1016/j.ejrad.2016.11.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 09/06/2016] [Accepted: 11/27/2016] [Indexed: 10/20/2022]
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Mullins PM, Mazer-Amirshahi M, Pines JM. Alcohol-Related Visits to US Emergency Departments, 2001-2011. Alcohol Alcohol 2016; 52:119-125. [PMID: 27998923 DOI: 10.1093/alcalc/agw074] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 11/14/2022] Open
Abstract
AIMS Alcohol intoxication is a source of significant illness and injury commonly resulting in emergency department (ED) visits. We characterize recent trends in alcohol-related visits to US EDs using nationally representative data. METHODS We conducted a retrospective review of data on national ED visits among patients aged 18 years or older with alcohol intoxication between 2001 and 2011 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Demographic and resource utilization trends in alcohol-related visits were examined. We also assessed ED length of stay (LOS) across the study period, as well as the total hours spent on ED care for alcohol-related complaints. RESULTS Between 2001-2002 and 2010-2011, alcohol-related visits increased from 2,459,748 to 3,856,346 (P = 0.049). Utilization of resources such as laboratory tests, medications and radiography increased, with the use of advanced imaging (i.e. computed tomography and magnetic resonance imaging) increasing 232.2% (P < 0.001) from 2001-2002 to 2010-2011. Overall LOS increased 16.1% (P = 0.028), while LOS among patients admitted to the hospital increased 24.9% (P = 0.076). Total alcohol-related hours spent in EDs nationwide increased from 5.6 million in 2001 to 11.6 million in 2011, an increase of 108.5% (P < 0.001) compared with an increase in overall ED hours of 54.0% (P < 0.001). CONCLUSION Alcohol-related ED visits are increasing at a greater rate than overall ED visits and represent a growing burden on hospital resources.
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Affiliation(s)
- Peter M Mullins
- Center for Healthcare Innovation and Policy Research, School of Medicine and Health Sciences, The George Washington University, 2100 Pennsylvania Ave, Suite 300, Washington, DC 20037, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving Street NW, Suite NA 1177, Washington, DC 20010, USA
| | - Jesse M Pines
- Center for Healthcare Innovation and Policy Research, School of Medicine and Health Sciences, The George Washington University, 2100 Pennsylvania Ave, Suite 300, Washington, DC 20037, USA.,Departments of Emergency Medicine and Health Policy and Management, The George Washington University, 2100 Pennsylvania Ave, Suite 300, Washington, DC 20037, USA
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Depinet H, von Allmen D, Towbin A, Hornung R, Ho M, Alessandrini E. Risk Stratification to Decrease Unnecessary Diagnostic Imaging for Acute Appendicitis. Pediatrics 2016; 138:peds.2015-4031. [PMID: 27553220 DOI: 10.1542/peds.2015-4031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There has been an increase in the use of imaging modalities to diagnose appendicitis despite evidence that can help identify children at especially high or low risk of appendicitis who may not benefit. We hypothesized that the passive diffusion of a standardized care pathway (including diagnostic imaging recommendations) would improve the diagnostic workup of appendicitis by safely decreasing the use of unnecessary imaging when compared with historical controls and that an electronic, real-time decision support tool would decrease unnecessary imaging. METHODS We used an interrupted time series trial to compare proportions of patients who underwent diagnostic imaging (computed tomography [CT] and ultrasound) between 3 time periods: baseline historical controls, after passive diffusion of a diagnostic workup clinical pathway, and after introduction of an electronic medical record-embedded clinical decision support tool that provides point-of-care imaging recommendations (active intervention). RESULTS The moderate- and high-risk groups showed lower proportions of CT in the passive and active intervention time periods compared with the historical control group. Proportions of patients undergoing ultrasound in all 3 risk groups showed an increase from the historical baseline. Time series analysis confirmed that time trends within any individual time period were not significant; thus, incidental secular trends over time did not appear to explain the decreased use of CT. CONCLUSIONS Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.
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Affiliation(s)
- Holly Depinet
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Alex Towbin
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard Hornung
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mona Ho
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Hu SY, Hsieh MS, Lin MY, Hsu CY, Lin TC, How CK, Wang CY, Tsai JCH, Wu YH, Chang YZ. Trends of CT utilisation in an emergency department in Taiwan: a 5-year retrospective study. BMJ Open 2016; 6:e010973. [PMID: 27279477 PMCID: PMC4908915 DOI: 10.1136/bmjopen-2015-010973] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To investigate the association between the trends of CT utilisation in an emergency department (ED) and changes in clinical imaging practice and patients' disposition. SETTING A hospital-based retrospective observational study of a public 1520-bed referral medical centre in Taiwan. PARTICIPANTS Adult ED visits (aged ≥18 years) during 2009-2013, with or without receiving CT, were enrolled as the study participants. MAIN OUTCOME MEASURES For all enrolled ED visits, we retrospectively analysed: (1) demographic characteristics, (2) triage categories, (3) whether CT was performed and the type of CT scan, (4) further ED disposition, (5) ED cost and (6) ED length of stay. RESULTS In all, 269 239 adult ED visits (148 613 male patients and 120 626 female patients) were collected during the 5-year study period, comprising 38 609 CT scans. CT utilisation increased from 11.10% in 2009 to 17.70% in 2013 (trend test, p<0.001). Four in 5 types of CT scan (head, chest, abdomen and miscellaneous) were increasingly utilised during the study period. Also, CT was increasingly ordered annually in all age groups. Although ED CT utilisation rates increased markedly, the annual ED visits did not actually increase. Moreover, the subsequent admission rate, after receiving ED CT, declined (59.9% in 2009 to 48.2% in 2013). CONCLUSIONS ED CT utilisation rates increased significantly during 2009-2013. Emergency physicians may be using CT for non-emergent studies in the ED. Further investigation is needed to determine whether increasing CT utilisation is efficient and cost-effective.
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Affiliation(s)
- Sung-Yuan Hu
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medical Research, Center for Translational Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Nursing, College of Health, National Taichung University of Science and Technology, Taichung, Taiwan
- Department of Nursing, College of Nursing, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Ming-Shun Hsieh
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan, Taiwan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Meng-Yu Lin
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chiann-Yi Hsu
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tzu-Chieh Lin
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chorng-Kuang How
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jeffrey Che-Hung Tsai
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Hui Wu
- Department of Laboratory Medicine, Da-Jia Lee's General Hospital, Lee's Medical Corporation, Taichung, Taiwan
- Department of Laboratory Medicine, Yuan-Li Lee's General Hospital, Lee's Medical Corporation, Miaoli, Taiwan
- Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Yan-Zin Chang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Clinical Laboratory, Drug Testing Center, Chung Shan Medical University Hospital, Taichung, Taiwan
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Gunn ML, Marin JR, Mills AM, Chong ST, Froemming AT, Johnson JO, Kumaravel M, Sodickson AD. A report on the Academic Emergency Medicine 2015 consensus conference “Diagnostic imaging in the emergency department: a research agenda to optimize utilization”. Emerg Radiol 2016; 23:383-96. [DOI: 10.1007/s10140-016-1398-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/12/2016] [Indexed: 11/29/2022]
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Aaronson EL, Chang Y, Borczuk P. A prediction model to identify patients without a concerning intraabdominal diagnosis. Am J Emerg Med 2016; 34:1354-8. [PMID: 27113130 DOI: 10.1016/j.ajem.2016.03.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Patients with abdominal diagnoses constitute 5% to 10% of all emergency department (ED) presentations. The goal of this study is to identify which of these patients will have a nonconcerning diagnosis based on demographic, physical examination, and basic laboratory testing. METHODS Consecutive patients from July 2013 to March 2014 discharged with a gastrointestinal (GI) diagnosis who presented to an urban, university-affiliated ED were identified. The cohort was split into a derivation set and a validation set. Using univariate and multivariable logistic regression analysis, a risk score was created based on the deviation data and then tested on the validation data. RESULTS There were 8852 patients with a GI diagnosis during the study period. A total of 7747 (87.5%) of them had a nonconcerning diagnosis. The logistic regression model identified 13 variables that predict a concerning GI diagnosis and created a scoring system ranging from 0 to 20. The area under the receiver operating characteristic was 0.81. When dichotomized at greater than or equal to 7 vs less than 7, the risk score has a sensitivity of 91% (95% confidence interval [CI], 88-94), specificity of 46% (95% CI, 44-48), positive predictive value of 17% (95% CI, 15-19) and negative predictive value of 98% (95% CI, 97-99). CONCLUSION One can determine with a high degree of certainty, based only on an initial evaluation and screening laboratory work (excluding radiology) whether a patient who presents with a GI-related complaint has a nonconcerning diagnosis. This model could be used as a tool to aid in quality assurance when reviewing patients discharged with GI complaints and with future study, as a secondary triage instrument in a crowded ED environment, and aid in resource allocation.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.
| | - Yuchiao Chang
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114
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The Effect of a Full Bladder on Proportions of Diagnostic Ultrasound Studies in Children with Suspected Appendicitis. CAN J EMERG MED 2016; 18:414-419. [PMID: 27039941 DOI: 10.1017/cem.2016.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES We examined the effect of a full bladder on proportions of diagnostic ultrasound (US) studies in children with suspected appendicitis. We also examined the effect of a full bladder on proportions of fully visualized ovaries on US in children with suspected appendicitis. METHODS We conducted a retrospective health record review of children aged 2-17 years presenting to a tertiary pediatric emergency department (ED) with suspected appendicitis who had an ultrasound performed. We compared proportions of diagnostic US studies in children with full and sub-optimally filled bladders. We also compared proportions of ovarian visualization in females with full and sub-optimally filled bladders. RESULTS 678 children were included in our final analysis. The proportion of diagnostic US studies did not vary significantly between groups with a full (132/283, 47%, 95% confidence interval [CI] 38%-56%) or sub-optimally filled bladder (205/395, 52%, 95% CI 47%-57%)(p=0.17). Rates of ovarian visualization were higher in females with a full bladder (196/205, 96%, 95% CI 93%-99%) compared to those with a sub-optimally filled bladder (180/223, 81%, 95% CI 76%-86%) (p<0.01). CONCLUSIONS Administrators and clinical decision makers should consider removing routine bladder filling practice from current pediatric appendicitis protocols in males and in pre-pubertal females where ovarian pathology is not suspected. Selective bladder filling prior to US should be performed in females when ovarian pathology is suspected.
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Golden SK, Harringa JB, Pickhardt PJ, Ebinger A, Svenson JE, Zhao YQ, Li Z, Westergaard RP, Ehlenbach WJ, Repplinger MD. Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT. Emerg Med J 2016; 33:458-64. [PMID: 26935714 DOI: 10.1136/emermed-2015-205301] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 02/10/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether clinical scoring systems or physician gestalt can obviate the need for computed tomography (CT) in patients with possible appendicitis. METHODS Prospective, observational study of patients with abdominal pain at an academic emergency department (ED) from February 2012 to February 2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardised forms prior to CT. Physicians also estimated the likelihood of appendicitis. Test characteristics were calculated using clinical follow-up as the reference standard. Receiver operating characteristic curves were drawn. RESULTS Of the 287 patients (mean age (range), 31 (12-88) years; 60% women), the prevalence of appendicitis was 33%. The Alvarado score had a positive likelihood ratio (LR(+)) (95% CI) of 2.2 (1.7 to 3) and a negative likelihood ratio (LR(-)) of 0.6 (0.4 to 0.7). The modified Alvarado score (MAS) had LR(+) 2.4 (1.6 to 3.4) and LR(-) 0.7 (0.6 to 0.8). The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score had LR(+) 1.3 (1.1 to 1.5) and LR(-) 0.5 (0.4 to 0.8). Physician-determined likelihood of appendicitis had LR(+) 1.3 (1.2 to 1.5) and LR(-) 0.3 (0.2 to 0.6). When combined with physician likelihoods, LR(+) and LR(-) was 3.67 and 0.48 (Alvarado), 2.33 and 0.45 (RIPASA), and 3.87 and 0.47 (MAS). The area under the curve was highest for physician-determined likelihood (0.72), but was not statistically significantly different from the clinical scores (RIPASA 0.67, Alvarado 0.72, MAS 0.7). CONCLUSIONS Clinical scoring systems performed equally well as physician gestalt in predicting appendicitis. These scores do not obviate the need for imaging for possible appendicitis when a physician deems it necessary.
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Affiliation(s)
- Sean K Golden
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - John B Harringa
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin-Madison, Wisconsin, USA
| | - Alexander Ebinger
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - James E Svenson
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - Ying-Qi Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
| | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Michael D Repplinger
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA Department of Radiology, University of Wisconsin-Madison, Wisconsin, USA
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Repplinger MD, Levy JF, Peethumnongsin E, Gussick ME, Svenson JE, Golden SK, Ehlenbach WJ, Westergaard RP, Reeder SB, Vanness DJ. Systematic review and meta-analysis of the accuracy of MRI to diagnose appendicitis in the general population. J Magn Reson Imaging 2015; 43:1346-54. [PMID: 26691590 DOI: 10.1002/jmri.25115] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 11/24/2015] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To perform a systematic review and meta-analysis of all published studies since 2005 that evaluate the accuracy of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis in the general population presenting to emergency departments. MATERIALS AND METHODS All retrospective and prospective studies evaluating the accuracy of MRI to diagnose appendicitis published in English and listed in PubMed, Web of Science, Cinahl Plus, and the Cochrane Library since 2005 were included. Excluded studies were those without an explicitly stated reference standard, with insufficient data to calculate the study outcomes, or if the population enrolled was limited to pregnant women or children. Data were abstracted by one investigator and confirmed by another. Data included the number of true positives, true negatives, false positives, false negatives, number of equivocal cases, type of MRI scanner, type of MRI sequence, and demographic data including study setting and gender distribution. Summary test characteristics were calculated. Forest plots and a summary receiver operator characteristic plot were generated. RESULTS Ten studies met eligibility criteria, representing patients from seven countries. Nine were prospective and two were multicenter studies. A total of 838 subjects were enrolled; 406 (48%) were women. All studies routinely used unenhanced MR images, although two used intravenous contrast-enhancement and three used diffusion-weighted imaging. Using a bivariate random-effects model the summary sensitivity was 96.6% (95% confidence interval [CI]: 92.3%-98.5%) and summary specificity was 95.9% (95% CI: 89.4%-98.4%). CONCLUSION MRI has a high sensitivity and specificity for the diagnosis of appendicitis, similar to that reported previously for computed tomography. J. Magn. Reson. Imaging 2016;43:1346-1354.
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Affiliation(s)
- Michael D Repplinger
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Joseph F Levy
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Erica Peethumnongsin
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Megan E Gussick
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - James E Svenson
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sean K Golden
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - William J Ehlenbach
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Scott B Reeder
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - David J Vanness
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Moore CL, Broder J, Gunn ML, Bhargavan-Chatfield M, Cody D, Cullison K, Daniels B, Gans B, Kennedy Hall M, Gaines BA, Goldman S, Heil J, Liu R, Marin JR, Melnick ER, Novelline RA, Pare J, Repplinger MD, Taylor RA, Sodickson AD. Comparative Effectiveness Research: Alternatives to "Traditional" Computed Tomography Use in the Acute Care Setting. Acad Emerg Med 2015; 22:1465-73. [PMID: 26576033 DOI: 10.1111/acem.12831] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/12/2015] [Indexed: 01/07/2023]
Abstract
Computed tomography (CT) scanning is an essential diagnostic tool and has revolutionized care of patients in the acute care setting. However, there is widespread agreement that overutilization of CT, where benefits do not exceed possible costs or harms, is occurring. The goal was to seek consensus in identifying and prioritizing research questions and themes that involve the comparative effectiveness of "traditional" CT use versus alternative diagnostic strategies in the acute care setting. A modified Delphi technique was used that included input from emergency physicians, emergency radiologists, medical physicists, and an industry expert to achieve this.
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Affiliation(s)
- Christopher L. Moore
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Joshua Broder
- Department of Surgery; Section of Emergency Medicine; Duke University; Durham NC
| | - Martin L. Gunn
- Department of Radiology; University of Washington; Seattle WA
| | | | - Dianna Cody
- Department of Imaging Physics; University of Texas Houston; Houston TX
| | - Kevin Cullison
- Department of Emergency Medicine; Washington University; St. Louis MO
| | - Brock Daniels
- Department of Emergency Medicine; University of California Davis; Davis CA
| | - Bradley Gans
- Department of Radiology; Ohio State University; Cleveland WA
| | - M. Kennedy Hall
- Department of Emergency Medicine; University of Washington; Seattle WA
| | - Barbara A. Gaines
- Division of Pediatric General and Thoracic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Sarah Goldman
- Department of Emergency Medicine; Jacobi Medical Center; New York NY
| | - John Heil
- medint Holdings; LLC d.b.a Imalogix; King of Prussia PA
| | - Rachel Liu
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Jennifer R. Marin
- Departments of Pediatrics and Emergency Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA
- Department of Pediatrics; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Edward R. Melnick
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | | | - Joseph Pare
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Michael D. Repplinger
- Departments of Emergency Medicine and Radiology; University of Wisconsin School of Medicine and Public Health; Madison WI
| | - Richard A. Taylor
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
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Berdahl C, Schuur JD, Fisher NL, Burstin H, Pines JM. Policy Measures and Reimbursement for Emergency Medical Imaging in the Era of Payment Reform: Proceedings From a Panel Discussion of the 2015 Academic Emergency Medicine Consensus Conference. Acad Emerg Med 2015; 22:1393-9. [PMID: 26568025 PMCID: PMC4715479 DOI: 10.1111/acem.12829] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 11/28/2022]
Abstract
The Affordable Care Act (ACA) of 2010 is expanding the use of quality measurement and promulgating new payment models that place downward pressure on health care utilization and costs. As emergency department (ED) computed tomography utilization has tripled in the past decade, stakeholders have identified advanced imaging as an area where quality and efficiency measures should expand. On May 12, 2015, Academic Emergency Medicine convened a consensus conference titled "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." As part of the conference, a panel of health care policy leaders and emergency physicians discussed the effect of the ACA and other quality programs on ED diagnostic imaging, specifically the way that quality metrics may affect ED care and how ED diagnostic imaging fits in the broader strategy of the U.S. government. This article discusses the content of the panel's presentations.
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Affiliation(s)
- Carl Berdahl
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Nancy L Fisher
- Centers for Medicare and Medicaid Services, Region 10, Seattle, WA
| | | | - Jesse M Pines
- Departments of Emergency Medicine and Health Policy and Management, The George Washington University, Washington, DC
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Kanzaria HK, Hall MK, Moore CL, Burstin H. Emergency Department Diagnostic Imaging: The Journey to Quality. Acad Emerg Med 2015; 22:1380-4. [PMID: 26575420 DOI: 10.1111/acem.12817] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 06/30/2015] [Indexed: 11/30/2022]
Abstract
Priorities in health care delivery are shifting, with a greater focus on enhancing value, incentivizing quality, and advancing population health. While measurement of quality in emergency department (ED) care is still in its infancy, performance measures are increasingly being linked to reimbursement to encourage the delivery of high-value care. With such changes, there will be growing oversight of diagnostic imaging in all clinical settings, including the ED. Here, the authors examine the current state of quality measurement as it pertains to ED imaging. The authors review relevant policies and discuss both the associated challenges and the facilitators of using quality measures to help optimize ED imaging. Understanding such factors will help ensure the delivery of diagnostic imaging that is appropriate, high-quality, and patient-centered.
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Affiliation(s)
- Hemal K. Kanzaria
- Department of Emergency Medicine; University of California San Francisco & San Francisco General Hospital; San Francisco CA
| | - M. Kennedy Hall
- Division of Emergency Medicine; University of Washington School of Medicine; Seattle WA
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Christopher L. Moore
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
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Temporal Trends in the Incidence and Natural History of Diverticulitis: A Population-Based Study. Am J Gastroenterol 2015; 110:1589-96. [PMID: 26416187 PMCID: PMC4676761 DOI: 10.1038/ajg.2015.302] [Citation(s) in RCA: 203] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/02/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Data on the incidence and natural history of diverticulitis are largely hospital-based and exclude the majority of diverticulitis patients, who are treated in an outpatient setting for uncomplicated diverticulitis. We assessed temporal trends in the epidemiology of diverticulitis in the general population. METHODS Through the Rochester Epidemiology Project we reviewed the records of all individuals with a diagnosis of diverticulitis from 1980 to 2007 in Olmsted County, Minnesota, USA. RESULTS In 1980-1989, the incidence of diverticulitis was 115/100,000 person-years, which increased to 188/100,000 in 2000-2007 (P<0.001). Incidence increased with age (P<0.001); however, the temporal increase was greater in younger people (P<0.001). Ten years after the index and second diverticulitis episodes, 22% and 55% had a recurrence, respectively. This recurrence rate was greater in younger people (hazard ratio (HR) per decade 0.63; 95% confidence interval (CI), 0.59-0.66) and women (HR 0.68; 95% CI, 0.58-0.80). Complications were seen in 12%; this rate did not change over time. Recurrent diverticulitis was associated with a decreased risk of complications (P<0.001). Age was associated with increased risk of local (odds ratio (OR) 1.27 per decade; 95% CI, 1.04-1.57) and systemic (OR 1.83; 95% CI, 1.20-2.80) complications. Survival after diverticulitis was lower in older people (P<0.001) and men (P<0.001) and worsened over time (P<0.001). The incidence of surgery for diverticulitis did not change from 1980 to 2007. CONCLUSIONS The incidence of diverticulitis has increased by 50% in 2000-2007 compared with 1990-1999, and more so in younger people. Complications are relatively uncommon. Recurrent diverticulitis is frequent but typically uncomplicated. Younger people with diverticulitis have less severe disease, more recurrence, and better survival.
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