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Francisco MZ, Altmayer S, Hochhegger B. Reply to the Letter to the Editor: Apropriateness and imaging outcomes of ultrasound, CT, and MR in the emergency department. Emerg Radiol 2024; 31:789-790. [PMID: 39088103 DOI: 10.1007/s10140-024-02271-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/06/2024] [Indexed: 08/02/2024]
Affiliation(s)
| | | | - Bruno Hochhegger
- Department of Radiology, University of Florida, Gainesville, FL, USA.
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Plante J, Kucksdorf J, Ruzich J, Young JL, Rhon DI. Do Maladaptive Imaging Beliefs Predict Self-Reported Pain Interference and Physical Function in Patients With Musculoskeletal Disorders? J Orthop Sports Phys Ther 2024; 54:608-617. [PMID: 39213308 DOI: 10.2519/jospt.2024.12625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
OBJECTIVE: To determine if maladaptive imaging beliefs correlated with, and predicted pain interference and physical function outcomes in people with musculoskeletal pain disorders. DESIGN: A prospective cohort study of patients with musculoskeletal disorders receiving outpatient physical therapy from April 2022 to August 2023. METHODS: Four questions about imaging were asked to assess maladaptive beliefs, the need to rule out serious conditions, guide treatment, determine diagnosis, and validate symptoms. Correlations with beliefs and outcomes were assessed using Kendall's tau rank and Spearman's rho correlation coefficients. Generalized linear models determined if these beliefs predicted outcomes at baseline and 6 weeks. RESULTS: The cohort included 152 participants (mean [standard deviation] age: 56.13 [15.13]; 32.2% male). Maladaptive imaging beliefs correlated positively with pain interference and negatively with physical function. The need to rule out serious conditions and validate symptoms correlated with pain interference (range: τb = 0.17, 0.20; P = .003, .0121) and physical function (range: ρ = -0.22, -0.22; P = .006, .008). All but 1 belief correlated with pain interference (range: τb = 0.19, 0.24; P<.001, .004) and physical function (range: ρ = -0.26, -0.21; P = .001, .009) at 6 weeks. Each additional belief slightly increased pain interference at 6 weeks (β = 0.01; 95% CI: 0.001, 0.03; P = .04) and lowered physical function at both baseline (β = -0.97; 95% CI: -1.66, -0.28; P = .01) and 6 weeks (β = -0.76; 95% CI: -1.37, -0.15; P = .02). CONCLUSION: Maladaptive imaging beliefs were significantly (albeit weakly) correlated with pain and physical function. Each additional maladaptive imaging belief increased pain interference at 6 weeks and lowered physical function at baseline and 6 weeks. Beliefs about the necessity of imaging to properly manage musculoskeletal disorders may influence outcomes. J Orthop Sports Phys Ther 2024;54(9):1-10. Epub 5 July 2024. doi:10.2519/jospt.2024.12625.
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Rowe BH, Yang E, Corrick S, Hussain MW. Reducing computed tomography (CT) imaging for adults with minor traumatic brain injuries in the emergency department. BMJ 2024; 386:e074867. [PMID: 39137946 DOI: 10.1136/bmj-2023-074867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Affiliation(s)
- Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Science, University of Alberta
| | - Esther Yang
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- SPOR SUPPORT Unit, Alberta Health Services (AHS), Edmonton
| | - Shaina Corrick
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - M Wasif Hussain
- Department of Medicine, Division of Neurology, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta
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Mehan WA, Shin D, Buch K. Multisystem factors contributing to redundant intracranial vascular imaging in the ED. Emerg Radiol 2024; 31:447-453. [PMID: 38769220 DOI: 10.1007/s10140-024-02240-2] [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: 03/08/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE To evaluate the multisystem factors contributing to redundant neurovascular orders in the ED. METHODS This was an IRB-approved, retrospective study, performed at a single institution examining a 5-year history of redundant CTA/MRA head and neck (HN) exams performed in the ED for patients with no documented clinical change in mental status/neurological exam necessitating additional imaging. Factors contributing to redundant ordering including provider experience, synchronous order placement, and radiologist recommendations were examined. Additionally, the impact of duplicative imaging in terms of medical cost and ED length of stay was evaluated. RESULTS 250 patients met inclusion criteria with both CTA/MRA of the HN performed during a single ED encounter (total 500 exams). 190 (76%) redundant exams were not recommended by a radiologist and contributed to an added ED length of stay of 3.6 h on average. Provider experience was not a significant contributing factor. 60 (24%) of redundant exams were recommended by a radiologist and were most frequently CTAs needed to clarify an area of artifact/high-grade stenosis/occlusion on a primary MRA exam. CONCLUSION Evaluation of contributing factors to redundant CTA/MRA HN exams ordering has highlighted multiple associated factors including provider experience, recommendations by radiologists for clarification of MRA findings, as well as systems processes related to synchronous CTA/MRA order placement.
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Affiliation(s)
- William A Mehan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Donghoon Shin
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Karen Buch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Kwee RM, Toxopeus R, Kwee TC. Imaging overuse in the emergency department: The view of radiologists and emergency physicians. Eur J Radiol 2024; 176:111536. [PMID: 38820950 DOI: 10.1016/j.ejrad.2024.111536] [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: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024]
Abstract
PURPOSE To identify the perceived factors contributing to imaging overuse in the emergency department, according to radiologists and emergency physicians. METHOD A survey study on imaging overuse in the emergency department was conducted among 66 radiologists and 425 emergency physicians. Five-point Likert scales (not a problem at all/strongly disagree [score 1] to very serious problem/strongly agree [score 5]) were used to score the various aspects of overimaging. RESULTS Both radiologists and emergency physicians gave a median score of 4 to the question if imaging overuse is a problem in their emergency department. CT accounts for the vast majority of imaging overuse, according to both radiologists (84.8%) and emergency physicians (75.3%). Defensive medicine/fear of malpractice, the presence of less experienced staff, and easy access to imaging all were given a median score of 4 as factors that influence imaging overuse, by both physician groups. Median ratings regarding the influence of pressure from patients and a lack of time to examine patients on imaging overuse varied between 3 and 4 for radiologists and emergency physicians. Pressure from consultants to perform imaging, the use of imaging to decrease turnaround time in the emergency department, a lack of space in the emergency department, a lack of proper medical education, and inability to access outside imaging studies, were also indicated to give rise to imaging overuse. CONCLUSIONS Imaging overuse in the emergency department (particularly CT overuse) is a problem according to most radiologists and emergency physicians, and is driven by several factors.
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Affiliation(s)
- Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Romy Toxopeus
- Medical Imaging Center, Department of Radiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Thomas C Kwee
- Medical Imaging Center, Department of Radiology, University of Groningen, University Medical Center Groningen, the Netherlands.
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Yan L, Karamchandani K, Gaiser RR, Carr ZJ. Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review. Anesth Analg 2024; 139:68-77. [PMID: 37874227 DOI: 10.1213/ane.0000000000006666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.
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Affiliation(s)
- Luying Yan
- From the Yale University School of Medicine, New Haven, Connecticut
| | - Kunal Karamchandani
- Department of Anesthesiology
- University of Texas, Southwestern Medical School, Dallas, Texas
| | - Robert R Gaiser
- From the Yale University School of Medicine, New Haven, Connecticut
- Department of Anesthesiology
| | - Zyad J Carr
- From the Yale University School of Medicine, New Haven, Connecticut
- Department of Anesthesiology
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AlSulami AF, AlGhamdi MA, Gaafar AM, Hamam AF. More Is Actually Less: Practitioners' Perspective of Unnecessary Medical Testing in Saudi Arabian Emergency Departments. Cureus 2024; 16:e62384. [PMID: 39006660 PMCID: PMC11246772 DOI: 10.7759/cureus.62384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/16/2024] Open
Abstract
Background The overuse of medical testing, be it ancillary testing or imaging, has been identified as a problem in all healthcare systems in the world. As the Kingdom of Saudi Arabia marches towards the 2030 vision of healthcare transformation, we have sought to get a perspective on medically unnecessary tests being conducted in Saudi Arabian emergency departments (EDs), the reasons behind this phenomenon, and possible solutions to it. Methods This is a cross-sectional survey among emergency medicine physicians (EMPs) working in Saudi Arabian EDs, taken through a self-filled online questionnaire, about their ordering habits, what they believe to be unnecessary testing in their practice, the practice of their colleagues, and other Saudi EMPs as a whole. Subjects have also been asked about the reasons why such practices are occurring and possible solutions to reduce such overuse of unnecessary tests in Saudi EDs. Results A total of 182 EMPs were surveyed from the different regions of the Kingdom, and CT head for patients presenting with asymptomatic stroke, and asymptomatic TBI were the most overused scans (both 44%). The most overused advanced body imaging was CT kidney-ureters-bladder (KUB) at 41.5%, while the most overused ancillary tests were complete blood count (CBC) and liver transaminases. The most common reason for the practice was found to be fear of medicolegal proceedings (70.9%). Continuous education of EMPs and increasing ED staffing were found to be the most helpful solutions to reduce unnecessary testing in the ED (70.9% and 67%, respectively). Conclusion It is clear from our data that overuse of medical tests and imaging is still a prominent practice. CT head in asymptomatic patients seems to be the most commonly overused imaging in Saudi EDs. Ancillary testing and unnecessary ordering of CBCs and transaminases seem to stem from fear of EMPs from legal consequences. More control over medical test ordering needs to be exercised to reduce these practices.
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Affiliation(s)
| | | | - Amro M Gaafar
- Emergency Medicine, King Fahad Armed Forces Hospital, Jeddah, SAU
| | - Anas F Hamam
- Emergency Medicine, King Fahad Armed Forces Hospital, Jeddah, SAU
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Kisembo HN, Malumba R, Sematimba H, Ankunda R, Nalweyiso ID, Malwadde EK, Rutebemberwa E, Kasasa S, Salama DH, Kawooya MG. Understanding the factors that influence CT utilization for mild traumatic brain injury in a low resource setting - a qualitative study using the Theoretical Domains Framework. Afr J Emerg Med 2024; 14:103-108. [PMID: 38756826 PMCID: PMC11096711 DOI: 10.1016/j.afjem.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction In low resource settings (LRS), utilization of Computed Tomography scan (CTS) for mild traumatic brain injuries (mTBIs) presents unique challenges and considerations given the limited infrastructure, financial resources, and trained personnel. The Theoretical Domains Framework (TDF) offers a comprehensive theoretical lens to explore factors influencing the decision-making to order CTS for mTBI by imaging referrers (IRs). Objectives The primary objective was to explore IRs' beliefs about factors influencing CT utilization in mTBIs using TDF in Uganda.Differences in the factors influencing CTS ordering behavior across specialties, levels of experience, and hospital category were also explored. Materials and Methods In-depth semi-structured interviews guided by TDF were conducted among purposively selected IRs from 6 tertiary public and private hospitals with functional CTS services. A thematic analysis was performed with codes and emerging themes developed based on the TDF. Results Eleven IRs including medical officers, non-neurosurgeon specialists and neurosurgeons aged on average 42 years (SD+/-12.3 years) participated.Identified factors within skills domain involved IRs' clinical assessment and decision-making abilities, while beliefs about capabilities and consequences encompassed their confidence in diagnostic abilities and perceptions of CTS risks and benefits. The environmental context and resources domain addressed the availability of CT scanners and financial constraints. The knowledge domain elicited IRs' understanding of clinical guidelines and evidence-based practices while social influences considered peer influence and institutional culture. For memory, attention & decision processes domain, IRs adherence to guidelines and intentions to order CT scans were cited. Conclusion Using TDF, IRs identified several factors believed to influence decision making to order CTS in mTBI in a LRS. The findings can inform stakeholders to develop targeted strategies and evidence-based interventions to optimize CT utilization in mTBI such as; educational programs, workflow modifications, decision support tools, and infrastructure improvements, among others.
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Affiliation(s)
- Harriet Nalubega Kisembo
- Makerere University, College of Health Sciences, School of Medicine
- Department of Radiology, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Richard Malumba
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | - Henry Sematimba
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | - Racheal Ankunda
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
| | | | - Elsie-Kiguli Malwadde
- African Centre for Global Health and Social Transformation (ACHEST), Kampala, Uganda
| | - Elizeus Rutebemberwa
- School of Public Health, Department of Health Policy & Management, Makerere University, Kampala, Uganda
| | - Simon Kasasa
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | | | - Michael Grace Kawooya
- Ernest cook Ultrasound Research and Education Institute, Mengo Hospital, Kampala, Uganda
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Francisco MZ, Altmayer S, Carlesso L, Zanon M, Eymael T, Lima JE, Watte G, Hochhegger B. Appropriateness and imaging outcomes of ultrasound, CT, and MR in the emergency department: a retrospective analysis from an urban academic center. Emerg Radiol 2024; 31:367-372. [PMID: 38664279 DOI: 10.1007/s10140-024-02226-0] [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: 01/28/2024] [Accepted: 03/26/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE To evaluate the appropriateness and outcomes of ultrasound (US), computed tomography (CT), and magnetic resonance (MR) orders in the ED. METHODS We retrospectively reviewed consecutive US, CT, and MR orders for adult ED patients at a tertiary care urban academic center from January to March 2019. The American College of Radiology Appropriateness Criteria (ACRAC) guidelines were primarily used to classify imaging orders as "appropriate" or "inappropriate". Two radiologists in consensus judged specific clinical scenarios that were unavailable in the ACRAC. Final imaging reports were compared with the initial clinical suspicion for imaging and categorized into "normal", "compatible with initial diagnosis", "alternative diagnosis", or "inconclusive". The sample was powered to show a prevalence of inappropriate orders of 30% with a margin of error of 5%. RESULTS The rate of inappropriate orders was 59.4% for US, 29.1% for CT, and 33.3% for MR. The most commonly imaged systems for each modality were neuro (130/330) and gastrointestinal (95/330) for CT, genitourinary (132/330) and gastrointestinal (121/330) for US, neuro (273/330) and gastrointestinal (37/330) for MR. Compared to inappropriately ordered tests, the final reports of appropriate orders were nearly three times more likely to demonstrate findings compatible with the initial diagnosis for all modalities: US (45.5 vs. 14.3%, p < 0.001), CT (46.6 vs. 14.6%, p < 0.001), and MR (56.3 vs. 21.8%, p < 0.001). Inappropriate orders were more likely to show no abnormalities compared to appropriate orders: US (65.8 vs. 38.8%, p < 0.001), CT (62.5 vs. 34.2%, p < 0.001), and MR (61.8 vs. 38.7%, p < 0.001). CONCLUSION The prevalence of inappropriate imaging orders in the ED was 59.4% for US, 29.1% for CT, and 33.3% for MR. Appropriately ordered imaging was three times more likely to yield findings compatible with the initial diagnosis across all modalities.
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Affiliation(s)
| | | | - Lucas Carlesso
- Universidade Federal de Ciencias da Saude de Porto Alegre, Porto Alegre, Brazil
| | - Matheus Zanon
- Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Thales Eymael
- Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Guilherme Watte
- Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
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Abu Awwad D, Ekpo E. Imaging of the adjacent upper limb: Outcomes and diagnostic yield. Radiography (Lond) 2024; 30:753-758. [PMID: 38432174 DOI: 10.1016/j.radi.2024.02.014] [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: 12/30/2023] [Revised: 02/02/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Injuries to extremities are a common presentation to emergency departments and may be associated with multiple abnormalities. Patients may be referred for X-ray imaging of multiple adjacent regions, but the diagnostic outcomes of these X-ray examinations have not been fully explored. The aim of this study was to assess the diagnostic efficacy of X-ray examinations of adjacent body regions in the upper limb. METHODS Upper limb X-rays examinations performed over six months were collected from two hospitals, and all patients who had adjacent regions X-rayed were included. Using the radiology reports as a reference standard, the diagnostic yield of these additional adjacent X-ray examinations was assessed. Descriptive statistics and Pearson's Chi Square were used for data analysis. RESULTS 591 patients had 1455 X-ray examinations, ranging from two to six X-ray requests. More than 80% of X-ray examinations were due to an injury, but less than 60% had symptoms mentioned in the clinical history. Overall, 39.1% of initial examinations reported a new finding but only 1.5% of all subsequent imaging had a new abnormality detected. Examinations with symptoms specified in the clinical history were more likely to detect new findings (p=<0.001). CONCLUSION Imaging is an essential diagnostic tool in medical settings, but all radiographic tests should be justified, and adjacent imaging has a low diagnostic yield, hence, all limbs should be carefully assessed individually to assess the need for imaging. Every request should be justified based on presentation and symptoms, particularly when multiple areas may be impacted. IMPLICATIONS FOR PRACTICE Radiographic imaging is easily accessible but adherence to guidelines and assessing the diagnostic yield of common examinations is important to ensure benefits to patients.
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Affiliation(s)
- D Abu Awwad
- Discipline of Medical Imaging Sciences, The University of Sydney, Susan Wakil Health Building, Camperdown, Sydney, Australia.
| | - E Ekpo
- Discipline of Medical Imaging Sciences, The University of Sydney, Susan Wakil Health Building, Camperdown, Sydney, Australia.
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Altinger G, Sharma S, Maher CG, Cullen L, McCaffery K, Linder JA, Buchbinder R, Harris IA, Coiera E, Li Q, Howard K, Coggins A, Middleton PM, Gunja N, Ferguson I, Chan T, Tambree K, Varshney A, Traeger AC. Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial. BMJ Open 2024; 14:e079870. [PMID: 38548366 PMCID: PMC10982715 DOI: 10.1136/bmjopen-2023-079870] [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: 09/15/2023] [Accepted: 02/08/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain. METHODS AND ANALYSIS NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. ETHICS AND DISSEMINATION This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications. TRIAL REGISTRATION NUMBER ACTRN12623001000695.
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Affiliation(s)
- Gemma Altinger
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sweekriti Sharma
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey A Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute, Sydney, New South Wales, Australia
| | - Enrico Coiera
- Centre for Health Informatics, Macquarie University, Sydney, New South Wales, Australia
| | - Qiang Li
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kirsten Howard
- Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Coggins
- Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Emergency Research Institute, Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, New South Wales, Australia
- South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Naren Gunja
- Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
- Digital Health Solutions, Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ian Ferguson
- South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Trevor Chan
- Emergency Care Institute, The Agency for Clinical Innovation, St Leonards Sydney, City of Willoughby, Australia
| | - Karen Tambree
- Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Ajay Varshney
- Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
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Alattar Z, Keric N. Evaluation of Abdominal Emergencies. Surg Clin North Am 2023; 103:1043-1059. [PMID: 37838455 DOI: 10.1016/j.suc.2023.05.010] [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] [Indexed: 10/16/2023]
Abstract
Early primary assessment and abdominal examination can often be enough to triage the patient with abdominal pain into those with less severe underlying pathologic condition from those with more acute findings. A focused history of the patient can then allow the clinician to develop their differential diagnosis. Once the differential diagnoses are determined, diagnostic imaging and laboratory findings can help confirm the diagnosis and allow for expeditious treatment and intervention.
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Affiliation(s)
- Zana Alattar
- University of Arizona College of Medicine-Phoenix, 1441 North 12th Street, First Floor, Phoenix, AZ 85006, USA
| | - Natasha Keric
- University of Arizona College of Medicine-Phoenix, Banner-University Medical Center Phoenix, 1441 North 12th Street, First Floor, Phoenix, AZ 85006, USA.
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Barash Y, Klang E, Konen E, Sorin V. ChatGPT-4 Assistance in Optimizing Emergency Department Radiology Referrals and Imaging Selection. J Am Coll Radiol 2023; 20:998-1003. [PMID: 37423350 DOI: 10.1016/j.jacr.2023.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/19/2023] [Accepted: 06/29/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE The quality of radiology referrals influences patient management and imaging interpretation by radiologists. The aim of this study was to evaluate ChatGPT-4 as a decision support tool for selecting imaging examinations and generating radiology referrals in the emergency department (ED). METHODS Five consecutive clinical notes from the ED were retrospectively extracted, for each of the following pathologies: pulmonary embolism, obstructing kidney stones, acute appendicitis, diverticulitis, small bowel obstruction, acute cholecystitis, acute hip fracture, and testicular torsion. A total of 40 cases were included. These notes were entered into ChatGPT-4, requesting recommendations on the most appropriate imaging examinations and protocols. The chatbot was also asked to generate radiology referrals. Two independent radiologists graded the referral on a scale ranging from 1 to 5 for clarity, clinical relevance, and differential diagnosis. The chatbot's imaging recommendations were compared with the ACR Appropriateness Criteria (AC) and with the examinations performed in the ED. Agreement between readers was assessed using linear weighted Cohen's κ coefficient. RESULTS ChatGPT-4's imaging recommendations aligned with the ACR AC and ED examinations in all cases. Protocol discrepancies between ChatGPT and the ACR AC were observed in two cases (5%). ChatGPT-4-generated referrals received mean scores of 4.6 and 4.8 for clarity, 4.5 and 4.4 for clinical relevance, and 4.9 from both reviewers for differential diagnosis. Agreement between readers was moderate for clinical relevance and clarity and substantial for differential diagnosis grading. CONCLUSIONS ChatGPT-4 has shown potential in aiding imaging study selection for select clinical cases. As a complementary tool, large language models may improve radiology referral quality. Radiologists should stay informed about this technology and be mindful of potential challenges and risks.
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Affiliation(s)
- Yiftach Barash
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; DeepVision Lab, Chaim Sheba Medical Center, Tel Hashomer, Israel.
| | - Eyal Klang
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Head, Sami Sagol AI Hub, ARC, Chaim Sheba Medical Center, Tel Hashomer, Israel; DeepVision Lab, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Eli Konen
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Head, Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Vera Sorin
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; DeepVision Lab, Chaim Sheba Medical Center, Tel Hashomer, Israel
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16
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Markus T, Saban M, Sosna J, Assaf J, Cohen D, Vaknin S, Luxenburg O, Singer C, Shaham D. Does clinical decision support system promote expert consensus for appropriate imaging referrals? Chest-abdominal-pelvis CT as a case study. Insights Imaging 2023; 14:45. [PMID: 36929357 PMCID: PMC10020384 DOI: 10.1186/s13244-023-01371-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/03/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES We assessed the appropriateness of chest-abdominal-pelvis (CAP) CT scan use in the Emergency Department (ED), based on expert physicians and the ESR iGuide, a clinical decision support system (CDSS). METHODS A retrospective cross-study was conducted. We included 100 cases of CAP-CT scans ordered at the ED. Four experts rated the appropriateness of the cases on a 7-point scale, before and after using the decision support tool. RESULTS Before using the ESR iGuide the overall mean rating of the experts was 5.2 ± 1.066, and it increased slightly after using the system (5.85 ± 0.911 (p < 0.01)). Using a threshold of 5 (on a 7-level scale), the experts considered only 63% of the tests appropriate before using the ESR iGuide. The number increased to 89% after consultation with the system. The degree of overall agreement among the experts was 0.388 before ESR iGuide consultation and 0.572 after consultation. According to the ESR iGuide, for 85% of the cases, CAP CT was not a recommended option (score 0). Abdominal-Pelvis CT was "usually appropriate" for 65 out of the 85 (76%) cases (score 7-9). 9% of the cases did not require CT as first exam modality. CONCLUSIONS According to both the experts and the ESR iGuide, inappropriate testing was prevalent, in terms of both frequency of the scans and also inappropriately chosen body regions. These findings raise the need for unified workflows that might be achieved using a CDSS. Further studies are needed to investigate the CDSS contribution to the informed decision-making and increased uniformity among different expert physicians when ordering the appropriate test.
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Affiliation(s)
- Talya Markus
- Department of Radiology, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Mor Saban
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba medical center, Ramat Gan, Israel.,Nursing Department, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo, Israel
| | - Jacob Sosna
- Department of Radiology, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel.
| | - Jacob Assaf
- Emergency Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Dotan Cohen
- Department of Radiology, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - Sharona Vaknin
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba medical center, Ramat Gan, Israel
| | - Osnat Luxenburg
- Medical Technology, Health Information and Research Directorate, Ministry of Health, Jerusalem, Israel
| | - Clara Singer
- The Gertner Institute for Epidemiology and Health Policy Research, Sheba medical center, Ramat Gan, Israel
| | - Dorith Shaham
- Department of Radiology, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel
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Pourvaziri A, Mojtahed A, Hahn PF, Gee MS, Kambadakone A, Sahani DV. Renal lesion characterization: clinical utility of single-phase dual-energy CT compared to MRI and dual-phase single-energy CT. Eur Radiol 2023; 33:1318-1328. [PMID: 36074261 DOI: 10.1007/s00330-022-09106-6] [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: 01/27/2022] [Revised: 07/13/2022] [Accepted: 08/10/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To assess the impact of dual-energy CT (DECT) utilization in practice by measuring the readers' confidence, the need for additional image requests, and diagnostic performance in renal lesion assessment, compared to single-energy CT (SECT) using contrast-enhanced MRI to establish the reference standard. MATERIALS AND METHODS Sixty-nine patients (M/F = 47/22) who underwent a dual-phase renal SECT (n = 34) or DECT (n = 35) and had a contrast-enhanced MRI within 180 days were retrospectively collected. Three radiologists assessed images on different sessions (SECT, DECT, and MRI) for (1) likely diagnosis (enhancing/non-enhancing); (2) diagnostic confidence (5-point Likert scale); (3) need for additional imaging test (yes/no); and (4) need for follow-up imaging (yes/no). Diagnostic accuracy was compared using AUC; p value < 0.05 was considered significant. RESULTS One hundred fifty-six lesions consisting of 18% enhancing (n = 28/156, mean size: 30.37 mm, range: 9.9-94 mm) and 82% non-enhancing (n = 128/156, mean size: 23.91 mm, range: 5.0-94.2 mm) were included. The confidence level was significantly lower for SECT than their MRI (4.50 vs. 4.80, p value < 0.05) but not significantly different for DECT and the corresponding MRI (4.78 vs. 4.78, p > 0.05). There were significantly more requests for additional imaging in the SECT session than the corresponding MRI (20% vs. 4%), which was not significantly different between DECT and their MRI counterpart session (5.7% vs. 4.9%). Inter-reader agreement was almost perfect for DECT and MRI (kappa: 0.8-1) and substantial in SECT sessions (kappa: 0.6-0.8) with comparable diagnostic accuracy between SECT, DECT, and MRI (p value > 0.05). CONCLUSION Single-phase DECT allows confident and reproducible characterization of renal masses with fewer recommendation for additional and follow-up imaging tests than dual-phase SECT and a performance similar to MRI. KEY POINTS • DECT utilization leads to similar additional image requests to MRI (5.7% vs. 4.9%, p value > 0.05), whereas single-energy CT utilization leads to significantly higher image requests (20% vs. 4%, p value < 0.05). • DECT and MRI utilization bring highly reproducible results with almost perfect inter-reader agreement (kappa: 0.8-1), better than the inter-reader agreement in SECT utilization (kappa: 0.6-0.8). • Readers' confidence was not significantly altered between DECT and their MRI readout session (p value > 0.05). In contrast, confidence in the diagnosis was significantly lower in the SECT session than their MRI readout (p value < 0.05).
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Affiliation(s)
- Ali Pourvaziri
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA.
| | - Amirkasra Mojtahed
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Peter F Hahn
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Avinash Kambadakone
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Dushyant V Sahani
- Department of Radiology, University of Washington, Seattle, WA, 98195, USA
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18
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Newman C, Nandurkar R, Holcdorf D, Gerstenmaier J, Tagkalidis P, Clements W. Role of CT angiography and therapeutic anticoagulation in patients presenting to the emergency department with acute gastrointestinal bleeding. J Med Imaging Radiat Oncol 2023; 67:37-44. [PMID: 35394116 DOI: 10.1111/1754-9485.13410] [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: 03/24/2021] [Revised: 02/24/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Acute gastrointestinal bleeding (GIB) is associated with morbidity and mortality. There can be a low threshold for practitioners to assess for active GIB and computed tomography angiography (CTA) examinations are performed frequently, even for stable patients and those who are therapeutically anticoagulated. We aimed to assess the predictive value of CTA for acute GIB and the influence of CTA on treatment. METHODS Retrospective single-centre study over a 2-year period. RESULTS A total of 227 patients with mean age 67.7 years (SD 17.86), 58.6% male. 84.4% were for lower GIB. 49 patients were on therapeutic anticoagulation (21.6%). 45 CTAs were positive (19.8%). 22 patients received embolisation, and 15 received acute endoscopic treatment. CTA sensitivity was 68.6% and specificity 89.1%. The PPV was 53.3% and NPV 93.9%. The odds ratio of a positive CTA requiring treatment for patients on therapeutic anticoagulation was 1.1 (P = 0.932) compared with the odds of patients not taking therapeutic anticoagulation 21.5 (P < 0.001). The risk ratio for requiring treatment if not taking anticoagulation was 6.2. A total of 19 patients (9.1%) met the definition of CI-AKI as a result of the CTA. A pre-existing eGFR of less than 20 was associated with significantly increased odds of developing CI-AKI (OR 3.95, P = 0.031, 95%CI 1.135-13.782). CONCLUSIONS The presence of anticoagulation has a significant impact on the decision not to perform interventional treatments on patients with acute GIB when CTA is positive. Anticoagulant reversal and volume resuscitation are important front-line measures, and CTA may have a role for those anticoagulated who are haemodynamically unstable after resuscitation.
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Affiliation(s)
- Chris Newman
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Rohan Nandurkar
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - David Holcdorf
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jan Gerstenmaier
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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Dreger M. Exploring determinants and regional variation of diagnostic imaging utilization rates in German inpatient care. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 175:76-80. [PMID: 36335010 DOI: 10.1016/j.zefq.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/24/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Germany ranks high concerning the per capita supply of computer tomographs (CT) and positron emission tomographs (PET) which may incentivize supply-induced use. Beyond that, international comparison shows high per capita examinations. However, misuse of diagnostic imaging may cause harm to patients and the health care system. The use of diagnostic imaging in Germany has been insufficiently studied so far. Therefore, the study aimed to determine the extent of regional differences as well as supply and demand side factors of per capita CT and PET examinations in German inpatient care. METHODS Cartographic visualizations and a random intercept model controlling for the regional disease burden, ambulatory provided supply and demand, and population deprivation between 2010 and 2017 for CT and between 2016 and 2017 for PET were applied. For this purpose, the Nationwide hospital discharge data (DRG statistics), hospital structured quality reports, the National Association of Statutory Health Insurance Physicians, the Central Research Institute of Ambulatory Health Care in Germany, and the German Index of Socioeconomic Deprivation were used. RESULTS We found a substantial regional variation of examination rates (-63 to +108% for CT and from -94 up to +847% for PET). Regarding PET, the supply structures have a significant impact on examinations per 1,000 inhabitants (28.46, p < .000). Both devices were used in correlation with the regional disease burden. Ambulatory and inpatient CT examination rates were positively associated. DISCUSSION The regional differences identified are to some extent attributable to the regional burden of disease and thus warranted. Although the inpatient PET supply influences utilization rates, the direction of the effect should be investigated more closely for valid statements. The findings in terms of CT should be treated with caution. The cartographic distribution and examination rates indicate global overuse. The clear separation of inpatient and ambulatory sectors leads to misallocation of scarce resources, medically unnecessary multiple examinations, and capacity utilization problems. CONCLUSION The results obtained have great potential for assessing and analyzing the adoption and rapid expansion of imaging technologies. Capacity utilization figures should be the focus of further research to assess utilization rates both economically and medically. Policy makers should address ongoing issues of operational and organizational separation of inpatient and ambulatory sectors in the German health care system.
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Affiliation(s)
- Marie Dreger
- Technische Universität Berlin, Department of Health Care Management, Berlin, Germany.
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20
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Thull-Freedman J. Reducing overuse of CT imaging in pediatric trauma: a model example of the Model for Improvement. CAN J EMERG MED 2022; 24:469-470. [PMID: 35917029 DOI: 10.1007/s43678-022-00347-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Jennifer Thull-Freedman
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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21
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Dunne CL, Elzinga JL, Vorobeichik A, Sudershan S, Keto-Lambert D, Lang E, Dowling S. A Systematic Review of Interventions to Reduce Computed Tomography Usage in the Emergency Department. Ann Emerg Med 2022; 80:548-560. [PMID: 35927114 DOI: 10.1016/j.annemergmed.2022.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/26/2022] [Accepted: 06/02/2022] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE Unnecessary computed tomography (CT) scans burden the health care system, leading to increased emergency department (ED) wait times and lengths of stay, costing almost a billion dollars annually. This study aimed to describe ED-based interventions that are most effective at reducing CT imaging while maintaining diagnostic accuracy and patient safety. METHODS Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Google Scholar were searched until December 31, 2020. Randomized and nonrandomized studies that assessed the effect of an ED-based intervention on CT scan usage were included. Abstract screening, data extraction, and quality assessment were conducted in duplicate. The Grading of Recommendation Assessment, Development and Evaluation framework, with the Risk of Bias 2 and Risk of Bias in Nonrandomized Studies - of Interventions tools, was used to determine the certainty of evidence. Significant clinical and statistical heterogeneity precluded meta-analysis; hence, a narrative synthesis was conducted. RESULTS A total of 149 studies were included of 5,667 screened abstracts, with substantial interrater reliability among reviewers (Cohen's κ>0.60). The CT reduction strategies were categorized into 15 single and 11 multimodal interventions by consensus review. Interventions that consistently reduced CT usage included diagnostic pathways, alternative test availability, specialist involvement, and provider feedback. Family/patient education, clinical decision support tools, or passive guideline dissemination did not consistently reduce usage. Only 44% of studies reported unintended consequences of reduction strategies; however, these showed no increase in missed diagnoses or patient harm. The interventions that engaged multiple specialties during planning/implementation had a greater reduction effect than ED only. The certainty of evidence for the primary outcome was very low. CONCLUSION Multidisciplinary-led interventions that provided an alternative to CT imaging were the most effective at reducing usage and did so without compromising patient safety.
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Affiliation(s)
- Cody L Dunne
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Jason L Elzinga
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Allen Vorobeichik
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjana Sudershan
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Diana Keto-Lambert
- Alberta SPOR SUPPORT Unit, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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22
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Juang WC, Chiou SMJ, Yang HL, Li YC. Exploring emergency physicians’ knowledge, attitudes, and behaviour towards Choosing Wisely in Taiwan. PLoS One 2022; 17:e0271346. [PMID: 35819965 PMCID: PMC9275691 DOI: 10.1371/journal.pone.0271346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/28/2022] [Indexed: 11/27/2022] Open
Abstract
Background In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign to reduce unnecessary care. However, it is unclear how much emergency physicians in Taiwan understand about Choosing Wisely. The purpose of this study was to explore the knowledge, attitude, and behaviour of emergency physicians in Taiwan regarding Choosing Wisely and its related factors; the intention was to identify the baseline knowledge on the basis of which to promote Choosing Wisely in Taiwan. Methods This was a cross-sectional study including emergency physicians in Taiwan as research subjects who answered online questionnaires. A 42-item questionnaire was designed according to the Knowledge, Attitude, and Behaviour model (KAB). The questionnaire linkages were delivered to emergency physicians through social media (eg., Line, Facebook) and received assistance from different hospital directors. A total of 162 valid questionnaires were collected. Data analyses include t-test, analysis of variance, chi-square test, Pearson’s correlation, and multivariate linear regression model. Results The study determined that although only 38.9% of emergency physicians had heard of Choosing Wisely, the mean correct rate of knowledge score among emergency physicians was 70.1%. Attitude and the behaviour related to Choosing Wisely were positively associated, which means that the more positive the attitude towards Choosing Wisely is, the more positive the behaviour towards Choosing Wisely is. In multiple linear regression analyses, having served as a supervisor, belonging to divisions of health insurance service, and having heard of Choosing Wisely (P < 0.05) positively affect the knowledge of Choosing Wisely, but age presented a negative association. Conclusion This study found that physicians’ knowledge does not influence their attitudes and behaviours, which may be related to barriers of practicing Choosing Wisely activities. To effectively promote Choosing Wisely campaign, it is recommended to focus on the significant factors associated with emergency physicians’ perceptions regarding knowledge, attitude, and behavior of Choosing Wisely. Based on these factors, appropriate practice guidelines for Choosing Wisely can be formulated and promoted.
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Affiliation(s)
- Wang-Chuan Juang
- Department of Quality Management Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
| | - Sonia Ming-Jiu Chiou
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
| | - Hui-Ling Yang
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Department of Planning, Kaohsiung Municipal Min-Sheng Hospital, Kaohsiung, Taiwan
| | - Ying-Chun Li
- Department of Business Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat‐sen University, Kaohsiung, Taiwan
- * E-mail:
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Korenstein D, Scherer LD, Foy A, Pineles L, Lydecker AD, Owczarzak J, Magder L, Brown JP, Pfeiffer CD, Terndrup C, Leykum L, Stevens D, Feldstein DA, Weisenberg SA, Baghdadi JD, Morgan DJ. Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing. Am J Med 2022; 135:e182-e193. [PMID: 35307357 PMCID: PMC9728553 DOI: 10.1016/j.amjmed.2022.02.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Variation in clinicians' diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization. METHODS We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins. RESULTS Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty. CONCLUSIONS Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers.
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Affiliation(s)
- Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Laura D Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science (ACCORDS); Division of Cardiology, University of Colorado School of Medicine, Aurora; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Colo
| | - Andrew Foy
- Department of Medicine; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pa
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Alison D Lydecker
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jill Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Jessica P Brown
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Christopher D Pfeiffer
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland; Division of Hospital and Specialty Medicine, VA Portland Health Care System, Ore
| | - Christopher Terndrup
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland
| | - Luci Leykum
- Department of Medicine, Dell Medical School, the University of Texas at Austin; South Texas Veterans Health Care System, San Antonio
| | - Deborah Stevens
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - David A Feldstein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Scott A Weisenberg
- Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore; VA Maryland Healthcare System, Baltimore
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore; VA Maryland Healthcare System, Baltimore
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The HINTS examination and STANDING algorithm in acute vestibular syndrome: A systematic review and meta-analysis involving frontline point-of-care emergency physicians. PLoS One 2022; 17:e0266252. [PMID: 35511910 PMCID: PMC9070939 DOI: 10.1371/journal.pone.0266252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/16/2022] [Indexed: 12/22/2022] Open
Abstract
This systematic review aims to evaluate whether point-of-care emergency physicians, without special equipment, can perform the HINTS examination or STANDING algorithm to differentiate between central and non-central vertigo in acute vestibular syndrome with diagnostic accuracy and reliability comparable to more specialized physicians (neuro-ophthalmologists and neuro-otologists). Previous research has concluded that emergency physicians are unable to utilize the HINTS examination with sufficient accuracy, without providing any appropriate education or training. A comprehensive systematic search was performed using MEDLINE, Embase, the Cochrane CENTRAL register of controlled trials, Web of Science Core Collection, Scopus, Google Scholar, the World Health Organization International Clinical Trials Registry Platform, and conference programs and abstracts from six medical organizations. Of the 1,757 results, only 21 were eligible for full-text screening. Two further studies were identified by a manual search of references and an electronic search for any missed studies associated with the authors. Five studies were included in the qualitative synthesis. For the STANDING algorithm, there were two studies of 450 patients who were examined by 11 emergency physicians. Our meta-analysis showed that emergency physicians who had received prior education and training were able to utilize the STANDING algorithm with a sensitivity of 0.96 (95% confidence interval: 0.87–1.00) and a specificity of 0.88 (0.85–0.91). No data was available for the HINTS examination. When emergency physicians are educated and trained, they can use the STANDING algorithm with confidence. There is a lack of evidence regarding the HINTS examination; however, two ongoing studies seek to remedy this deficit.
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Alalshaikh A, Alyahya B, Almohawes M, Alnowiser M, Ghandour M, Alyousef M, Abuguyan F, Almehlisi A, Altuwaijri F, Alageel M. Emergency Medicine Physicians' Views on Providing Unnecessary Management in the Emergency Department. Open Access Emerg Med 2022; 14:183-193. [PMID: 35502332 PMCID: PMC9056043 DOI: 10.2147/oaem.s341709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/15/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose To assess the views of emergency medicine physicians (EMPs) on the practice of providing unnecessary medical management in the emergency department. Methods All EMPs in Saudi Arabia were approached to participate in this cross-sectional study. A self-administered online survey that collected the participants' demographic information and opinions regarding the unnecessary management provided by EMPs in Saudi Arabia was conducted between December 2020 and February 2021. SPSS 22.0 was used to analyze the data. Results A total of 181 EMPs returned the questionnaire. More than 80% of the participants believed that EMPs order unnecessary tests or procedures at least a few times per week. The major reasons for ordering unnecessary medical tests or procedures were "concern about malpractice issues" (60.8%), "not having enough time with a patient for meaningful discussion" (47%), and "just to be safe" (46.4%). More than 55% of the respondents also believed that EMPs are in the best position to address the problem of unnecessary testing. Conclusion Most of the EMPs who participated in this study recognized that ordering unnecessary tests is a serious problem that happens on a daily basis. Many factors and reasons were described by the participants, and multiple possible solutions were suggested to help overcome the issue. Evaluating physicians' perspectives on the issue is a key step in addressing the problem and implementing appropriate interventions.
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Affiliation(s)
| | - Bader Alyahya
- Emergency Medicine Department, King Saud University, Riyadh, Saudi Arabia
| | | | | | | | | | - Fahad Abuguyan
- Emergency Medicine Department, King Saud University, Riyadh, Saudi Arabia
| | | | - Fawaz Altuwaijri
- Emergency Medicine Department, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Alageel
- Emergency Medicine Department, King Saud University, Riyadh, Saudi Arabia
- Emergency Medicine Department, The University of British Columbia, Vancouver, BC, Canada
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Yang S, Orlova Y, Lipe A, Boren M, Hincapie-Castillo JM, Park H, Chang CY, Wilson DL, Adkins L, Lo-Ciganic WH. Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007-2018 National Hospital Ambulatory Medical Care Survey Data. J Clin Med 2022; 11:jcm11051401. [PMID: 35268492 PMCID: PMC8910868 DOI: 10.3390/jcm11051401] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 12/10/2022] Open
Abstract
We examined trends in management of headache disorders in United States (US) emergency department (ED) visits. We conducted a cross-sectional study using 2007−2018 National Hospital Ambulatory Medical Care Survey data. We included adult patient visits (≥18 years) with a primary ED discharge diagnosis of headache. We classified headache medications by pharmacological group: opioids, butalbital, ergot alkaloids/triptans, acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, diphenhydramine, corticosteroids, and intravenous fluids. To obtain reliable estimates, we aggregated data into three time periods: 2007−2010, 2011−2014, and 2015−2018. Using multivariable logistic regression, we examined medication, neuroimaging, and outpatient referral trends, separately. Among headache-related ED visits, opioid use decreased from 54.1% in 2007−2010 to 28.3% in 2015−2018 (Ptrend < 0.001). There were statistically significant increasing trends in acetaminophen/NSAIDs, diphenhydramine, and corticosteroids use (all Ptrend < 0.001). Changes in butalbital (6.4%), ergot alkaloid/triptan (4.7%), antiemetic (59.2% in 2015−2018), and neuroimaging (37.3%) use over time were insignificant. Headache-related ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007−2010 to 79.7% in 2015−2018 (Ptrend = 0.02). Reflecting evidence-based guideline recommendations for headache management, opioid use substantially decreased from 2007 to 2018 among US headache-related ED visits. Future studies are warranted to identify strategies to promote evidence-based treatment for headaches (e.g., sumatriptan, dexamethasone) and appropriate outpatient referral and reduce unnecessary neuroimaging orders in EDs.
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Affiliation(s)
- Seonkyeong Yang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Yulia Orlova
- Neurology Department, College of Medicine, University of Florida, Gainesville, FL 32611, USA;
| | - Abigale Lipe
- College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (A.L.); (M.B.)
| | - Macy Boren
- College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (A.L.); (M.B.)
| | - Juan M. Hincapie-Castillo
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA
| | - Ching-Yuan Chang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Lauren Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL 32611, USA;
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA
- Correspondence: ; Tel.: +1-352-273-6255
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Bratvold RB, Kjosavik SR. I would rather be vaguely right than precisely wrong. Scand J Prim Health Care 2022; 40:1-2. [PMID: 35354420 PMCID: PMC9090353 DOI: 10.1080/02813432.2022.2057028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Reidar Brumer Bratvold
- Department of Petroleum Engineering Faculty of Science and Technology, University of Stavanger, Stavanger, Norway
| | - Svein R. Kjosavik
- The General Practice and Care Coordination Research Group, Stavanger University Hospital, Stavanger, Norway Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Kini V, Breathett K, Groeneveld PW, Ho PM, Nallamothu BK, Peterson PN, Rush P, Wang TY, Zeitler EP, Borden WB. Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000105. [PMID: 35189687 PMCID: PMC9909614 DOI: 10.1161/hcq.0000000000000105] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Low-value health care services that provide little or no benefit to patients are common, potentially harmful, and costly. Nearly half of the patients in the United States will receive at least 1 low-value test or procedure annually, creating risk of avoidable complications from subsequent cascades of care and excess costs to patients and society. Reducing low-value care is of particular importance to cardiovascular health given the high prevalence and costs of cardiovascular disease in the United States. This scientific statement describes the current scope and impact of low-value cardiovascular care; reviews existing literature on patient-, clinician-, health system-, payer-, and policy-level interventions to reduce low-value care; proposes solutions to achieve meaningful and equitable reductions in low-value care; and suggests areas for future research priorities.
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Bone I. The art of doing nothing. Pract Neurol 2022; 22:264-265. [DOI: 10.1136/practneurol-2022-003393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
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Trend in radiologist workload compared to number of admissions in the emergency department. Eur J Radiol 2022; 149:110195. [DOI: 10.1016/j.ejrad.2022.110195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 12/11/2022]
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Ha NT, Abdullah L, Bulsara M, Celenza A, Doust J, Fatovich D, McRobbie D, Mountain D, O’Leary P, Slavotinek J, Wright C, Youens D, Moorin R. The use of computed tomography in the management of injury in tertiary emergency departments in Western Australia: Evidence of overtesting? Acad Emerg Med 2022; 29:193-205. [PMID: 34480498 DOI: 10.1111/acem.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/29/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality. METHODS A total of 411,155 injury-related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury-related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT. RESULTS While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi-/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories. CONCLUSIONS The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care.
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Affiliation(s)
- Ninh T. Ha
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Lana Abdullah
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Max Bulsara
- Institute for Health Research University of Notre Dame Fremantle Western Australia Australia
- Centre for Health Services Research School of Population and Global Health The University of Western Australia Perth Western Australia Australia
| | - Antonio Celenza
- Department of Emergency Medicine Sir Charles Gairdner Hospital Nedlands Western Australia Australia
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
| | - Jenny Doust
- Centre for Longitudinal and Life Course Research Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Daniel Fatovich
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
- Emergency Department Royal Perth Hospital Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Western Australia Australia
| | - Donald McRobbie
- School of Physical Sciences University of Adelaide Adelaide South Australia Australia
| | - David Mountain
- Department of Emergency Medicine Sir Charles Gairdner Hospital Nedlands Western Australia Australia
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
- Curtin University Medical School Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Peter O’Leary
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Obstetrics and Gynaecology Medical School Faculty of Health and Medical Sciences The University of Western Australia Perth Western Australia Australia
- PathWest Laboratory Medicine QE2 Medical Centre Nedlands Western Australia Australia
| | - John Slavotinek
- SA Medical Imaging SA Health and College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Cameron Wright
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Fiona Stanley Hospital Murdoch Western Australia Australia
- Division of Internal Medicine Medical School Faculty of Health and Medical Sciences University of Western Australia Perth Western Australia Australia
- School of Medicine College of Health and Medicine University of Tasmania Hobart Tasmania Australia
| | - David Youens
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Rachael Moorin
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Centre for Health Services Research School of Population and Global Health The University of Western Australia Perth Western Australia Australia
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Santing J, Lee YX, van der Naalt J, van den Brand C, Jellema K. Mild traumatic brain injury in elderly patients receiving direct oral anticoagulants: A systematic review and meta-analysis. J Neurotrauma 2022; 39:458-472. [DOI: 10.1089/neu.2021.0435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Juliette Santing
- Medisch Centrum Haaglanden Westeinde, 2901, Neurology, Lijnbaan 12, Den Haag, Netherlands, 2501 CK, ,
| | - Ying Xing Lee
- Medisch Centrum Haaglanden Westeinde, 2901, Neurology, Den Haag, Zuid-Holland, Netherlands
| | | | - Crispijn van den Brand
- Haaglanden Medical Center, Department of Emergency Medicine, Lijnbaan 32, The Hague, Zuid-Holland, Netherlands, 2512VA
| | - Korné Jellema
- Medisch Centrum Haaglanden, 2901, Den Haag, Zuid-Holland, Netherlands
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Breivold J, Rø KI, Hjörleifsson S. Conditions for gatekeeping when GPs consider patient requests unreasonable: a focus group study. Fam Pract 2022; 39:125-129. [PMID: 34173654 PMCID: PMC8769277 DOI: 10.1093/fampra/cmab072] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor-patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed. OBJECTIVE To explore Norwegian GPs' perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider 'unreasonable'. METHODS A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation. RESULTS The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an 'unreasonable' patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs' gatekeeping role among peers and from authorities. CONCLUSION Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required.
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Affiliation(s)
- Jørgen Breivold
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Karin Isaksson Rø
- Institute for studies of the Medical Profession, The Norwegian Medical Association, Oslo, Norway
| | - Stefán Hjörleifsson
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Research Unit for General Practice NORCE, Bergen, Norway
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Hughes KE, Cahir TM, Nordlund D, Keim SM, Hughes PG. Fear Not: Utilizing Simulation for Medical Malpractice Education. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2022; 9:23821205221096269. [PMID: 35493963 PMCID: PMC9052229 DOI: 10.1177/23821205221096269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 04/05/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Medical malpractice payouts across specialties totaled over $4.03 billion USD in 2019. It is estimated that over 72% of Emergency Medicine (EM) physicians will be involved in a medical malpractice lawsuit by age 55. The majority of EM residencies do not include adequate education on medicolegal risk mitigation and litigation. The purpose of the study is implementation of an innovative interprofessional simulation to target this education gap. METHODS An anonymous pre- and post-survey was distributed to participating EM providers electronically. The surveys evaluated baseline medicolegal knowledge, self-rated deposition comfort and concern regarding malpractice litigation. The simulation event involved an interactive lecture on basic tenets of medical malpractice and state legal statutes from medicolegal experts. Resident physician volunteers acted as defendant physicians during simulated depositions using a redacted, closed malpractice case. RESULTS Eighty EM providers attended the event over two days. All attendees completed the pre-survey (80/80), and 66.3% (53/80) completed the post-survey. The majority incorrectly answered 4 of 5 medicolegal questions. The mean comfort level regarding being deposed is 1.53 ± 0.94 on a 1-5 Likert scale (extremely uncomfortable to extremely comfortable); the mean level of concern/fear of malpractice litigation is 3.38 ± 0.95 on a 1-5 Likert scale (not at all to extremely concerned). There was a statistically significant increase in deposition comfort level post-event (1.83, P < .01). CONCLUSION The majority of EM physicians are inexperienced and concerned regarding litigation. After participating in an educational event and observing a simulated deposition, physicians reported an increased comfort level regarding being deposed in the future.
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Affiliation(s)
- Kate E. Hughes
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | | | - Diana Nordlund
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Samuel M. Keim
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Patrick G. Hughes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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Chauvin A, Lang E, Bossuyt P. When less is more: mitigating the harms and risks of over-testing through shared decision making. CAN J EMERG MED 2021; 24:126-127. [PMID: 34792794 DOI: 10.1007/s43678-021-00231-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Anthony Chauvin
- Emergency Department and PreHospital EMS, Service d'Accueil des Urgences/SMUR, Lariboisière's Hospital, Assistance Publique Hôpitaux de Paris, Paris University, 2 rue Ambroise Paré, 75010, Paris, France. .,Inserm U942 MASCOT, Université de Paris, Paris, France.
| | - Eddy Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Patrick Bossuyt
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Hendley NW, Moskop J, Ashburn NP, Mahler SA, Stopyra JP. The ethical dilemma of emergency department patients with low-risk chest pain. J Accid Emerg Med 2021; 38:851-854. [PMID: 33687992 PMCID: PMC9035338 DOI: 10.1136/emermed-2020-209900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 02/01/2023]
Abstract
Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were developed to aid providers in risk stratifying patients with possible ACS and have become central components of current ED practice guidelines. Nevertheless, the fear of missing ACS continues to be a strong motivator for ED providers to pursue further testing for their patients. An ethical dilemma arises when the provider must balance the risk of ACS if the patient is discharged compared with the potential harms caused by a cardiac workup. Providers should be familiar with the ethical principles relevant to this dilemma in order to determine what is in the best interests of the patient.
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Affiliation(s)
- Nella W Hendley
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - John Moskop
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - SA Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Abstract
AIM Defensive medicine refers to practices with low marginal benefit to patients that doctors may undertake to protect themselves from legal liability. We aimed to develop a scale to measure the practice of defensive medicine. METHOD We identified aspects of defensive medicine previously reported in the literature and conducted and analyzed semi-structured interviews with 21 physicians in Sakarya to augment and clarify these aspects between May 15, 2018, and June 15, 2018. Informed by these results, we developed, pilot tested, refined, and fielded a 10-item survey to 1724 doctors in Turkey between April 1, 2019, and July 16, 2019. We examined the psychometric properties of the scale using exploratory (EFA) and confirmatory factor analyses (CFA). RESULTS The 10-item scale provided measures of 2 factors: positive defensive medicine (assurance) and negative defensive medicine (avoidance), with Cronbach's alpha >0.8 for the scale and both subscales in both the EFA and CFA subsamples and excellent goodness-of-fit measures. CONCLUSIONS We developed a highly reliable scale to measure positive and negative defensive medicine practice that may be suitable for future research on physician decision making.
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Affiliation(s)
- Özgün Ünal
- Department of Healthcare Management, Business Faculty, Sakarya University, Sakarya, Turkey
| | - Mahmut Akbolat
- Department of Healthcare Management, Business Faculty, Sakarya University, Sakarya, Turkey
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38
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Allen R, Cai AG, Tepler P, deSouza IS. The "NUTS" statistic: Applying an EBM disease model to defensive medicine. J Healthc Risk Manag 2021; 41:9-12. [PMID: 34528329 DOI: 10.1002/jhrm.21486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 12/28/2022]
Abstract
Physicians believe that malpractice concerns result in unnecessary testing, and many emergency physicians state that avoiding malpractice is a contributing factor to ordering medically unnecessary tests. Unfortunately, defensive medicine does not come without possible harm to patients who may be subject to non-beneficial, downstream testing, procedures, and hospitalizations. We submit a novel statistic, "NUTS" or "Number of Unnecessary Tests to avoid one Suit. " We calculated a NUTS of 4737 for troponin testing in ED patients with suspected myocardial infarction, meaning a clinician will need to order 4737 medically unnecessary troponin tests to avoid one missed myocardial infarction lawsuit. The NUTS framework offers us an evidence-based lens to examine defensive medicine less superstitiously and more based on currently available data.
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Affiliation(s)
- Robert Allen
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA.,Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
| | - Angela G Cai
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA.,Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
| | - Peter Tepler
- Department of Emergency Medicine, Jackson South Medical Center, Miami, Florida, USA
| | - Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA.,Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
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39
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Richardson S, Dauber-Decker KL, McGinn T, Barnaby DP, Cattamanchi A, Pekmezaris R. Barriers to the Use of Clinical Decision Support for the Evaluation of Pulmonary Embolism: Qualitative Interview Study. JMIR Hum Factors 2021; 8:e25046. [PMID: 34346901 PMCID: PMC8374661 DOI: 10.2196/25046] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/05/2021] [Accepted: 04/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinicians often disregard potentially beneficial clinical decision support (CDS). OBJECTIVE In this study, we sought to explore the psychological and behavioral barriers to the use of a CDS tool. METHODS We conducted a qualitative study involving emergency medicine physicians and physician assistants. A semistructured interview guide was created based on the Capability, Opportunity, and Motivation-Behavior model. Interviews focused on the barriers to the use of a CDS tool built based on Wells' criteria for pulmonary embolism to assist clinicians in establishing pretest probability of pulmonary embolism before imaging. RESULTS Interviews were conducted with 12 clinicians. Six barriers were identified, including (1) Bayesian reasoning, (2) fear of missing a pulmonary embolism, (3) time pressure or cognitive load, (4) gestalt includes Wells' criteria, (5) missed risk factors, and (6) social pressure. CONCLUSIONS Clinicians highlighted several important psychological and behavioral barriers to CDS use. Addressing these barriers will be paramount in developing CDS that can meet its potential to transform clinical care.
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Affiliation(s)
- Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | | | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Douglas P Barnaby
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Partnerships for Research in Implementation Science for Equity (PRISE) Center, University of California San Francisco, San Francisco, CA, United States
| | - Renee Pekmezaris
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
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40
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Hartmann DA. Managing the tempo of the emergency department as an off-service intern. AEM EDUCATION AND TRAINING 2021; 5:e10577. [PMID: 34124523 PMCID: PMC8171787 DOI: 10.1002/aet2.10577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 06/12/2023]
Affiliation(s)
- David A Hartmann
- Department of Neurology & Neurological SciencesStanford UniversityStanfordCAUSA
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41
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Chen B, Chapman C, Bauer Floyd S, Mobley J, Brooks J. State medical malpractice laws and utilization of surgical treatment for rotator cuff tear and proximal humerus fracture: an observational cohort study. BMC Health Serv Res 2021; 21:516. [PMID: 34049554 PMCID: PMC8161917 DOI: 10.1186/s12913-021-06544-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/13/2021] [Indexed: 12/02/2022] Open
Abstract
Background How much does the medical malpractice system affect treatment decisions in orthopaedics? To further this inquiry, we sought to assess whether malpractice liability is associated with differences in surgery rates among elderly orthopaedic patients. Methods Medicare data were obtained for patients with a rotator cuff tear or proximal humerus fracture in 2011. Multivariate regressions were used to assess whether the probability of surgery is associated with various state-level rules that increase or decrease malpractice liability risks. Results Study results indicate that lower liability is associated with higher surgery rates. States with joint and several liability, caps on punitive damages, and punitive evidence rule had surgery rates that were respectively 5%-, 1%-, and 1%-point higher for rotator cuff tears, and 2%-, 2%- and 1%-point higher for proximal humerus fractures. Conversely, greater liability is associated with lower surgery rates, respectively 6%- and 9%-points lower for rotator cuff patients in states with comparative negligence and pure comparative negligence. Conclusions Medical malpractice liability is associated with orthopaedic treatment choices. Future research should investigate whether treatment differences result in health outcome changes to assess the costs and benefits of the medical liability system. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06544-8.
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Affiliation(s)
- Brian Chen
- Department of Health Services Policy and Management, University of South Carolina, 915 Greene Street Suite 354, Columbia, SC, 29205, USA.
| | - Cole Chapman
- Department of Pharmacy Practice and Science, University of Iowa, 345 CPB, 180 South Grand Ave, Iowa City, IA, 52242, USA
| | - Sarah Bauer Floyd
- College of Behavioral, Social and Health Sciences, Clemson University, 116 Edwards Hall, Clemson, SC, 29634, USA
| | - John Mobley
- University of South Carolina School of Medicine Greenville , 607 Grove Rd, SC, 29605, Greenville, USA
| | - John Brooks
- Department of Health Services Policy and Management, University of South Carolina, 915 Greene Street Suite 302, Columbia, SC, 29205, USA
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42
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Yang Y, Huo H, Jiang J, Sun X, Guan Y, Guo X, Wan X, Liu S. Clinical decision-making framework against over-testing based on modeling implicit evaluation criteria. J Biomed Inform 2021; 119:103823. [PMID: 34044155 DOI: 10.1016/j.jbi.2021.103823] [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] [Received: 10/08/2020] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 12/25/2022]
Abstract
Different statistical methods include various subjective criteria that can prevent over-testing. However, no unified framework that defines generalized objective criteria for various diseases is available to determine the appropriateness of diagnostic tests recommended by doctors. We present the clinical decision-making framework against over-testing based on modeling the implicit evaluation criteria (CDFO-MIEC). The CDFO-MIEC quantifies the subjective evaluation process using statistics-based methods to identify over-testing. Furthermore, it determines the test's appropriateness with extracted entities obtained via named entity recognition and entity alignment. More specifically, implicit evaluation criteria are defined-namely, the correlation among the diagnostic tests, symptoms, and diseases, confirmation function, and exclusion function. Additionally, four evaluation strategies are implemented by applying statistical methods, including the multi-label k-nearest neighbor and the conditional probability algorithms, to model the implicit evaluation criteria. Finally, they are combined into a classification and regression tree to make the final decision. The CDFO-MIEC also provides interpretability by decision conditions for supporting each clinical decision of over-testing. We tested the CDFO-MIEC on 2,860 clinical texts obtained from a single respiratory medicine department in China with the appropriate confirmation by physicians. The dataset was supplemented with random inappropriate tests. The proposed framework excelled against the best competing text classification methods with a Mean_F1 of 0.9167. This determined whether the appropriate and inappropriate tests were properly classified. The four evaluation strategies captured the features effectively, and they were imperative. Therefore, the proposed CDFO-MIEC is feasible because it exhibits high performance and can prevent over-testing.
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Affiliation(s)
- Yang Yang
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin 150001, China
| | - Hongxing Huo
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin 150001, China
| | - Jingchi Jiang
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin 150001, China
| | - Xuemei Sun
- Hospital of Harbin Institute of Technology, Harbin 150003, China
| | - Yi Guan
- School of Computer Science and Technology, Harbin Institute of Technology, Harbin 150001, China.
| | - Xitong Guo
- School of Management, Harbin Institute of Technology, Harbin 150001, China
| | - Xiang Wan
- Shenzhen Research Institute of Big Data, Shenzhen 518000, China
| | - Shengping Liu
- Unisound AI Technology Co., Ltd, Beijing 100083, China
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43
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Wernz C, Song Y, Hughes DR. How hospitals can improve their public quality metrics: a decision-theoretic model. Health Care Manag Sci 2021; 24:702-715. [PMID: 33991292 DOI: 10.1007/s10729-021-09551-7] [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: 11/15/2019] [Accepted: 01/29/2021] [Indexed: 10/21/2022]
Abstract
The public reporting of hospitals' quality of care is providing additional motivation for hospitals to deliver high-quality patient care. Hospital Compare, a consumer-oriented website by the Centers for Medicare and Medicaid Services (CMS), provides patients with detailed quality of care data on most US hospitals. Given that many quality metrics are the aggregate result of physicians' individual clinical decisions, the question arises if and how hospitals could influence their physicians so that their decisions positively contribute to hospitals' quality goals. In this paper, we develop a decision-theoretic model to explore how three different hospital interventions-incentivization, training, and nudging-may affect physicians' decisions. We focus our analysis on Outpatient Measure 14 (OP-14), which is an imaging quality metric that reports the percentage of outpatients with a brain computed tomography (CT) scan, who also received a same-day sinus CT scan. In most cases, same-day brain and sinus CT scans are considered unnecessary, and high utilizing hospitals aim to reduce their OP-14 metric. Our model captures the physicians' imaging decision process accounting for medical and behavioral factors, in particular the uncertainty in clinical assessment and a physician's diagnostic ability. Our analysis shows how hospital interventions of incentivization, training, and nudging affect physician decisions and consequently OP-14. This decision-theoretic model provides a foundation to develop insights for policy makers on the multi-level effects of their policy decisions.
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Affiliation(s)
- Christian Wernz
- Department of Data Science, University of Virginia Health System, Charlottesville, VA, USA.
| | - Yongjia Song
- Department of Industrial Engineering, Clemson University, Clemson, SC, USA
| | - Danny R Hughes
- School of Economics, Georgia Institute of Technology, Atlanta, GA, USA
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44
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Mengou IV, Yakar D, Kasalak Ö, Kwee TC. Towards a benchmark of abdominal CT use during duty shifts: 15-year sample from the Netherlands. Abdom Radiol (NY) 2021; 46:1761-1767. [PMID: 33078244 PMCID: PMC8096762 DOI: 10.1007/s00261-020-02818-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/05/2020] [Accepted: 10/10/2020] [Indexed: 12/21/2022]
Abstract
Purpose To investigate temporal changes in the utilization and patient impact of abdominal CT during duty shifts in the past 15 years. Methods This study included a random sample of 1761 abdominal CT scans that were made during evening and night duty shifts in a tertiary care center between 2005 and 2019. Results The number of CT scans significantly increased (almost threefold) between 2005 and 2019 (Mann–Kendall tau of 0.829, P < 0.001). The proportion of negative CT scans (i.e., the absence of findings related to the reason that the CT scan was made and no disease deterioration or other new and clinically relevant findings compared to a previous imaging examination when available) was 40.0% (700/1749) in the entire 15-year study frame and did not significantly change over time (Mann–Kendall tau of − 0.219, P = 0.276). The overall frequency of same-day hospital discharge after negative CT was 20.6% (150/729) in the past 15 years and showed a significant increase over time (Mann–Kendall tau of 0.505, P = 0.010). The overall proportion of CT scans with incidental findings was 3.4% (60/1761) and remained statistically stable over the past 15 years (Mann–Kendall tau of − 0.057, P = 0.804). Conclusion Over the past 15 years, the number of CT scans and the frequency of same-day hospital discharge after negative CT have increased, while the proportions of negative CT scans and incidental findings have remained stable in our tertiary care center. The data from this study can be used for interinstitutional benchmarking to define, monitor, and improve the appropriateness of imaging utilization.
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Affiliation(s)
- Iliana V Mengou
- Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Derya Yakar
- Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Ömer Kasalak
- Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Thomas C Kwee
- Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
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45
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Klein RP, Velan G, Young N, Shetty A, Moscova M. Quality use of diagnostic imaging in trauma, and the impact on emergency medical practice-a retrospective clinical audit. Emerg Radiol 2021; 28:761-770. [PMID: 33638062 DOI: 10.1007/s10140-021-01921-6] [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] [Received: 12/21/2020] [Accepted: 02/21/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The current study aimed to evaluate the appropriateness of the decisions made to order diagnostic imaging for emergency trauma patients. METHODS A retrospective audit of 642 clinical decisions for 370 non-consecutive trauma cases was conducted at a level 1 adult trauma centre. Radiographs and computed tomography investigations were compared for compliance with the American College of Radiology/European Society of Radiology (ACR/ESR) imaging guidelines. The non-compliant imaging orders were evaluated for the following medical officer ranks: Junior Medical Officer (JMO), Senior Resident Medical Officer (SRMO), Emergency Medicine Registrar (EMR) and Consultants/Career Medical Officer (CMO). The time of imaging order (day/evening or night shift), whether the imaging led to conservative or surgical patient management, and whether the imaging order decisions led to a change in the clinical management of the patient were also considered. RESULTS Non-compliance with the ACR/ESR guidelines was low. At least half of non-compliant decisions made by each level of medical officer resulted in a change in patient management. In total, 11 (65%), 25 (53%), 12 (63%) and 11 (52%) of non-compliant imaging orders placed by JMOs, SRMOs, EMRs and Consultants, respectively, resulted in change of patient management. JMOs and SRMOs ordered a significantly higher proportion of non-compliant imaging studies for conservatively managed patients in comparison to surgically managed patients. CONCLUSION This study highlighted that most non-compliant imaging orders benefited the patient.
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Affiliation(s)
- Robert Peter Klein
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Gary Velan
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Noel Young
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, 2052, Australia.,Department of Radiology, Westmead Hospital, Darcy Rd, Westmead, NSW, 2145, Australia
| | - Amith Shetty
- Department of Emergency Medicine, Westmead Hospital, Darcy Rd, Westmead, NSW, 2145, Australia
| | - Michelle Moscova
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, 2052, Australia.
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46
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Pavlov M, Klobučar L, Klobučar I, Žgela K, Degoricija V. Does shifting to professional emergency department staffing affect the decision for chest radiography? World J Emerg Med 2021; 12:87-92. [PMID: 33727999 DOI: 10.5847/wjem.j.1920-8642.2021.02.001] [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: 11/19/2022] Open
Abstract
BACKGROUND The study aims to determine whether shifting to professional emergency department (ED) teams leads to a higher rate of radiologic workup. METHODS We retrospectively analyzed a total of 2,000 patients presenting to the ED of a tertiary teaching hospital in two time periods: group 1 (G1) comprised 1,000 consecutive patients enrolled from December 21, 2012 to January 5, 2013 (all patients were examined by an internal medicine specialist); group 2 (G2) comprised 1,000 consecutive patients enrolled from December 21, 2018 to January 3, 2019 (all patients were examined by an emergency physician). RESULTS The chest X-ray (CXR) was performed in 40.6% of all patients. There was no difference in the frequency of CXR (38.9% in G1 vs. 42.3% in G2, P=0.152). More CXRs were performed in G2 patients older than 65 years, in female patients older than 65 years, in patients presenting during the evening and night shifts or off-hours, in patients with a history of malignancy, in patients with gastrointestinal bleeding, and in patients with bradycardia, but fewer in patients presenting with arrhythmia. No difference in the rates of pathological CXR was found (47.3% in G1 vs. 52.2% in G2, P=0.186). Compared with G2, higher sensitivity and specificity were obtained for the binary logistic regression model predicting pathological findings in G1. CONCLUSIONS Shifting to professional ED teams does not increase radiologic workup. By implementing deliberate usage of ultrasound, some self-governing procedures, case-oriented investigations, and center-specific recommendations, unnecessary radiologic workup can be avoided. Professional ED teams could lead to a higher standard of emergency care.
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Affiliation(s)
- Marin Pavlov
- Department of Cardiology, Sestre Milosrdnice University Hospital Centre, Zagreb 10000, Croatia
| | - Lucija Klobučar
- Institute of Emergency Medicine, Osijek-Baranja County, Osijek 31000, Croatia
| | - Iva Klobučar
- Department of Cardiology, Sestre Milosrdnice University Hospital Centre, Zagreb 10000, Croatia
| | - Kristina Žgela
- University of Zagreb School of Medicine, Zagreb 10000, Croatia
| | - Vesna Degoricija
- University of Zagreb School of Medicine, Zagreb 10000, Croatia.,Department of Medicine, Sestre milosrdnice University Hospital Centre, Zagreb 10000, Croatia
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47
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Villalobos A, Horný M, Hughes DR, Duszak R. Associations Over Time Between Paid Medical Malpractice Claims and Imaging Utilization in the United States. J Am Coll Radiol 2021; 18:34-41. [DOI: 10.1016/j.jacr.2020.04.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 12/01/2022]
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48
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Omer H, Alameen S, Mahmoud WE, Sulieman A, Nasir O, Abolaban F. Eye lens and thyroid gland radiation exposure for patients undergoing brain computed tomography examination. Saudi J Biol Sci 2021; 28:342-346. [PMID: 33424315 PMCID: PMC7783653 DOI: 10.1016/j.sjbs.2020.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
This study aims to estimate the effective radiation dose and organ dose from head CT procedures. It was conducted in three main private hospitals in Khartoum State-Sudan, using Toshiba machines with 64 slices. The total number of patients included in this study was 142 patients (82 males and 60 females). The effective dose and organ dose were calculated by CT Expo software. The effective dose slightly varied among patients according to gender and age. The effective dose for female patients (5.99 mSv) was higher than that for male patients (5.84 mSv), and the pediatric dose (5.46 mSv) was lower than the adults' dose (5.94 mSv). The dose for eye lens was found lower for male patients (89.117 mSv) than the dose for female patients (94.62) mSv). According to patients' age: the dose received by the lens of the eye was much lower in pediatric (79.93 mSv) than the adults (92.41 mSv). The dose for thyroid in female patients (33.52 mSv) was higher than the male patients (28 mSv). The pediatric dose (28.34 mSv) was lower than the adults' dose (30.64 mSv). Departmental imaging protocol and lack of training among hospital staff are expected to be responsible for these variations. Therefore, this study recommends that the CT technologists be trained on suitable strategies to achieve dose optimization. Moreover, patients' doses must be monitored regularly.
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Affiliation(s)
- Hiba Omer
- Department of Basic Sciences, Deanship of Preparatory Year and Supporting Studies, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 34212, Saudi Arabia
| | - Suhaib Alameen
- Sudan University of Science and Technology College of Medical Radiologic Science, P.O. Box 1908, Khartoum, Sudan
| | - Waleed E. Mahmoud
- Sudan University of Science and Technology College of Medical Radiologic Science, P.O. Box 1908, Khartoum, Sudan
| | - Abdelmoneim Sulieman
- Prince Sattam Bin Abdulaziz University, College of Applied Medical Sciences, Radiology and Medical Imaging Department, PO Box 422, Alkharj 11942, Saudi Arabia
| | - Omaima Nasir
- Department of Biology, Turabah University College, Taif University, P.O.Box 11099, Taif 21944, Saudi Arabia
| | - Fouad Abolaban
- Nuclear Engineering Department, Faculty of Engineering, King Abdulaziz University, P.O. Box 80204 Jeddah 21589 Saudi Arabia
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Smith JS, Shockley J, Anderson S, Liu X(J. Tension in the Emergency Department? The Impact of Flow Stage Times on Managing Patient‐Reported Experiences and Financial Productivity. DECISION SCIENCES 2020. [DOI: 10.1111/deci.12503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jeffery S. Smith
- Department of Supply Chain Management and Analytics Virginia Commonwealth University Richmond VA 23284‐4000
| | - Jeff Shockley
- Department of Supply Chain Management and Analytics Virginia Commonwealth University Richmond VA 23284‐4000
| | - Sidney Anderson
- Department of Marketing Texas State University San Marcos TX 78666
| | - Xiaojin (Jim) Liu
- Department of Supply Chain Management and Analytics Virginia Commonwealth University Richmond VA 23284‐4000
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50
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Francisco MZ, Altmayer S, Verma N, Watte G, Brandao MDC, Barros MC, Mohammed TL, Hochhegger B. Appropriateness of Computed Tomography and Ultrasound for Abdominal Complaints in the Emergency Department. Curr Probl Diagn Radiol 2020; 50:799-802. [PMID: 33250295 DOI: 10.1067/j.cpradiol.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the appropriateness of ultrasound (US) and computed tomography (CT) examinations ordered in the emergency department (ED) for abdominal complaints. MATERIALS AND METHODS We reviewed 154 CTs and 154 US orders for appropriateness using evidence-based recommendations by the American College of Radiology. The sample was powered to show a prevalence of inappropriate orders of 25% with a margin of error of 7.5%. Findings in the final reports were compared to the initial clinical diagnosis classified in 4 categories: normal, compatible with initial diagnosis, alternative diagnosis, and inconclusive. We also evaluated the frequency in which a second imaging modality was ordered on the same visit. RESULTS A total of 135 CT and 143 US examinations had complete clinical information to allow evaluation of order appropriateness. The rate of inappropriate orders was 36.3% for CT and 84.4% for US. The final report of appropriate orders was significantly more likely to demonstrate findings compatible with the initial diagnosis for both CT (76.7% vs 20.4%, P < 0.0001) and US (38.9% vs 14.4%, P = 0.0093). Inappropriately ordered CT scans were more likely to show no abnormalities (46.9 vs 16.3%, P = 0.0001). An additional imaging order with a secondary modality was requested in 20% of the inappropriate US orders, and 8.2% of the inappropriate CT orders. CONCLUSION The prevalence of inappropriate examinations in the ED was 36.3% for CT and 84.4% for US. Appropriately ordered exams were more likely to yield imaging findings compatible with the initial diagnosis for both modalities.
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Affiliation(s)
| | - Stephan Altmayer
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Nupur Verma
- Department of Radiology, University of Florida, Gainesville, FL
| | - Guilherme Watte
- Universidade Federal de Ciencias da Saude de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Marina de Campos Brandao
- Universidade Federal de Ciencias da Saude de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Marcelo Cardoso Barros
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Bruno Hochhegger
- Universidade Federal de Ciencias da Saude de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
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