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Pernía J, Cancho T, Segovia I, de Ponga P, Granda E, Velasco R. Predictive values of indirect ultrasound signs for low risk of acute appendicitis in paediatric patients without visualisation of the appendix on ultrasound. Emerg Med J 2024; 41:475-480. [PMID: 38729752 DOI: 10.1136/emermed-2023-213466] [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: 06/28/2023] [Accepted: 04/30/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND AND OBJECTIVES The ability to rule appendicitis in or out using ultrasound is limited by studies where the appendix is not visualised. We determined whether the absence of indirect ultrasound signs can rule out appendicitis in children undergoing a radiology-performed ultrasound in which the appendix is not visualised METHODS: This was a single-centre retrospective observational study of patients aged 3-13 with a clinical suspicion of acute appendicitis evaluated in a Paediatric Emergency Department in Spain from 1 January 2013 to 31 December 2019. For those patients who had formal ultrasound, direct and indirect findings of ultrasound were abstracted from the ultrasound report. The surgical pathology report was established as the gold standard in patients who underwent an appendectomy. In those who did not, appendicitis was considered not to be present if there was no evidence in their charts that they had undergone an appendectomy or conservative therapy for appendicitis during the episode. The main outcome variable was the diagnosis of acute appendicitis. For patients undergoing ultrasound, the independent association of each indirect ultrasound sign with the diagnosis of appendicitis in patients without a visualised appendix was analysed using logistic regression. RESULTS We included 1756 encounters from 1609 different episodes. Median age at the first visit of each episode was 10.1 years (IQR, 7.7-11.9) and 921 (57.2%) patients were men. There were 730 (41.6%) encounters with an Alvarado score ≤3, 695 (39.6%) with a score 4-6 and 331 (18.9%) with a score ≥7. Appendicitis was diagnosed in 293 (17.8%) episodes. Ultrasonography was performed in 1115 (61.6%) encounters, with a visualised appendix in 592 (53.1%).The ultrasound findings independently associated with appendicitis in patients without a visualised appendix were the presence of free intra-abdominal fluid in a small quantity (OR:5.0 (95% CI 1.7 to 14.6)) or in an abundant quantity (OR:30.9 (95% CI 3.8 to 252.7)) and inflammation of the peri-appendiceal fat (OR:7.2 (95% CI 1.4 to 38.0)). The absence of free fluid and inflammation of the peri-appendiceal fat ruled out acute appendicitis in patients with an Alvarado score <7 with a sensitivity of 84.6% (95% CI 57.8 to 95.7) and a negative predictive value of 99.4% (95% CI 97.8 to 99.8). CONCLUSIONS Patients with an Alvarado score <7 and without a visualised appendix on ultrasound but who lack free fluid and inflammation of the peri-appendiceal fat are at very low risk of acute appendicitis.
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Affiliation(s)
- Juan Pernía
- Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Teresa Cancho
- Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Inés Segovia
- Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Elena Granda
- Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Roberto Velasco
- Pediatric Emergency Unit, Parc Taulí Hospital Universitari. Institut d'Investigacio i Innovacio Parc Tauli (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Catalunya, Spain
- Paediatrics & Child Health, University College Cork, Cork, Ireland
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Scheijmans JCG, Bom WJ, Deniz RS, van Geloven AAW, Boermeester MA. Diagnostic accuracy of doctors at the emergency department and radiologists in differentiating between complicated and uncomplicated acute appendicitis. Eur J Trauma Emerg Surg 2024; 50:837-845. [PMID: 38228896 PMCID: PMC11249706 DOI: 10.1007/s00068-023-02442-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/28/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE To determine the accuracy of final judgements of doctors at the emergency department (ED) and radiologists to differentiate between complicated and uncomplicated acute appendicitis, because these have different treatment options. METHODS This prospective, multicenter study included adult patients with imaging-confirmed acute appendicitis, operated with intention to appendectomy. Both doctors at ED and radiologists assessed appendicitis severity as a final judgement of "uncomplicated" or "complicated" appendicitis. Doctors at ED integrated clinical, laboratory, and imaging findings. Radiologists relied solely on imaging findings. Outcomes were accuracy of these judgements for diagnosis of complicated appendicitis compared to the reference standard by an adjudication committee. RESULTS After imaging, 1070 patients with confirmed acute appendicitis were included. Doctors at ED accurately labelled 656 of 701 (93.6%) patients with true uncomplicated appendicitis as uncomplicated, and 163 of 369 (44.2%) patients with true complicated appendicitis were labelled as complicated. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) for complicated appendicitis were 44.2%, 93.6%, and 78.4% and 76.1%, respectively. Comparable accuracy was found for the radiologist's assessment in 941 patients, with true positive rates of 92.2% (581 of 630 patients) for uncomplicated appendicitis and 46.6% (145 of 311 patients) for complicated appendicitis. CONCLUSION More than half of all patients with true complicated appendicitis is incorrectly classified as uncomplicated appendicitis according to the judgements of doctors at ED, integrating clinical, laboratory, and imaging results, and of radiologists assessing diagnostic imaging. These judgements are thereby not sufficiently reliable in ruling out complicated appendicitis.
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Affiliation(s)
- Jochem C G Scheijmans
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Wouter J Bom
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rabia S Deniz
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
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Baird EW, Lammers DT, Abraham PJ, Hashmi ZG, Griffin RL, Stephens SW, Jansen JO, Holcomb JB. Outcomes of patients enrolled in a prospective and randomized trial on basis of gestalt assessment or ABC score. J Trauma Acute Care Surg 2024; 96:876-881. [PMID: 38342992 DOI: 10.1097/ta.0000000000004276] [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: 05/23/2024]
Abstract
BACKGROUND The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial rapidly enrolled patients based on an Assessment of Blood Consumption (ABC) ≥ 2 score, or physician gestalt (PG) when ABC score was <2. The objective of this study was to describe what patients were enrolled by the two methods and whether patient outcomes differed based on these enrollments. We hypothesized that there would be no differences in outcomes based on whether patients were enrolled via ABC score or PG. METHODS Patients were enrolled with an ABC ≥ 2 or by PG when ABC was <2 by the attending trauma surgeon. We compared 1-hour, 3-hour, 6-hour, 12-hour, 18-hour, and 24-hour mortality, 30-day mortality, time to hemostasis, emergent surgical or interventional radiology procedure and the proportion of patients who required either >10 units of blood in 24 hours or >3 units in 1 hour. RESULTS Of 680 patients, 438 (64%) were enrolled on the basis of an ABC score ≥2 and 242 (36% by PG when the ABC score was <2). Patients enrolled by PG were older (median, 44; interquartile range [IQR], 28-59; p < 0.001), more likely to be White (70.3% vs. 60.3%, p = 0.014), and more likely to have been injured by blunt mechanisms (77.3% vs. 37.2%, p < 0.001). They were also less hypotensive and less tachycardic than patients enrolled by ABC score (both p < 0.001). The groups had similar Injury Severity Scores in the ABC ≥ 2 and PG groups (26 and 27, respectively) and were equally represented (49.1% and 50.8%, respectively) in the 1:1:1 treatment arm. There were no significant differences between the ABC score and PG groups for mortality at any point. Time to hemostasis (108 for patients enrolled on basis of Gestalt, vs. 100 minutes for patients enrolled on basis of ABC score), and the proportion of patients requiring a massive transfusion (>10 units/24 hours) (44.2% vs. 47.3%), or meeting the critical administration threshold (>3 unit/1 hour) (84.7% vs. 89.5%) were similar ( p = 0.071). CONCLUSION Early identification of trauma patients likely to require a massive transfusion is important for clinical care, resource use, and selection of patients for clinical trials. Patients enrolled in the PROPPR trial based on PG when the ABC score was <2 represented 36% of the patients and had identical outcomes to those enrolled on the basis of an ABC score of ≥2. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Emily W Baird
- From the Department of Surgery (E.W.B., P. J. A.), Center for Injury Science (D.T.L., Z.G.H., R.L.G., S.W.S., J.O.J., J.B.H.), University of Alabama at Birmingham, Birmingham, AL
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4
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Pernía JV, Cancho T, Segovia I, Granda E, Velasco R. Diagnostic performance of serum biomarkers in acute appendicitis in children. Eur J Emerg Med 2024; 31:74-76. [PMID: 38116728 DOI: 10.1097/mej.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Affiliation(s)
- Juan Ventura Pernía
- Pediatric Emergency Unit, Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid
| | - Teresa Cancho
- Pediatric Emergency Unit, Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid
| | - Inés Segovia
- Pediatric Emergency Unit, Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid
| | - Elena Granda
- Pediatric Emergency Unit, Pediatrics Department, Hospital Universitario Rio Hortega, Valladolid
| | - Roberto Velasco
- Pediatric Emergency Unit, Pediatrics Department, Hospital Universitari Parc Tauli
- Institut d'Investigació i Innovació I3PT, Sabadell, Spain
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Shiber J, Fontane E, Patel J, Akinleye A, Kerwin A, Chiu W, Scalea T. Gestalt clinical severity score (GCSS) as a predictor of patient severity of illness or injury. Am J Emerg Med 2023; 66:11-15. [PMID: 36640694 DOI: 10.1016/j.ajem.2023.01.005] [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: 10/10/2022] [Revised: 11/26/2022] [Accepted: 01/02/2023] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To determine if clinical judgement is accurate to predict the severity of injury or illness, and can be used at patient arrival when other formal scoring systems are not yet available. DESIGN A multicenter pilot study using a prospective observational convenience sample of patients arriving by EMS to the emergency department (ED) or Trauma Center. SETTING Two urban, Level 1 trauma centers at academic tertiary care hospitals. PATIENTS Medical and trauma patients age 18 and older transported by EMS (N = 216). Exclusion criteria (prior to arrival): intubation, assisted ventilation (BVM or NPPV), CPR in progress, prisoners, or previously present motor or speech deficits. MEASUREMENTS Completion of a novel 15-point scale of Verbal, Motor, and Facial Expression within 1-2 min of arrival by a clinician outside of the treatment team. Primary endpoint was the immediate disposition from the ED or Trauma Center: Home, Brief Observation (<24 h), Admission to Floor, ICU (OR and IR as surrogates since these patients ultimately go to the ICU), or Morgue. RESULTS Univariate analysis revealed a strong, positive monotonic correlation between GCSS and disposition (Rho = 0.693, p < .0001). Multivariable logistic regression revealed the "best" model included GCSS and age (group 18-44 years old versus all the other age groups) (p < .0001). There was a 156% increase in the odds of being discharged home (versus being admitted) for a one-unit increase in GCSS (OR = 2.56, 95% CI 1.94, 3.37). CONCLUSIONS Physicians can make accurate predictions of severity of injury and illness using a gestalt method and the scoring system we have developed as patient disposition correlates well with GCSS score. GCSS is most accurate with the 18-44 age group.
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Affiliation(s)
| | | | - Jignesh Patel
- Houston Methodist Hospital, Houston, TX, United States of America
| | | | - Andy Kerwin
- UT HSC, Memphis, TN, United States of America.
| | - William Chiu
- UMMS/R Adams Cowley STC, Baltimore, MD, United States of America.
| | - Thomas Scalea
- UMMS/R Adams Cowley STC, Baltimore, MD, United States of America.
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Cheng MT, Sung CW, Ko CH, Chen YC, Liew CQ, Ling DA, Liao ECW, Lu TC, Ku NW, Fu LC, Huang CH, Tsai CL. Physician gestalt for emergency department triage: A prospective videotaped study. Acad Emerg Med 2022; 29:1050-1056. [PMID: 35785459 DOI: 10.1111/acem.14557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/26/2022] [Accepted: 06/29/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Appropriate triage in patients presenting to the emergency department (ED) is often challenging. Little is known about the role of physician gestalt in ED triage. We aimed to compare the accuracy of emergency physician gestalt against the currently used computerized triage process. METHODS We conducted a prospective observational study in the ED at an academic medical center. Adult patients aged ≥20 years were included and underwent a standard triage protocol. The patients underwent system-based triage using the computerized software the Taiwan Triage and Acuity Scale. The entire triage process was recorded, and triage data were collected. Five physician raters provided triage levels (physician-based) according to their perceived urgency after reviewing videos. The primary outcome was hospital admission. The secondary outcomes were ED length of stay (EDLOS) and charges. RESULTS In total, 656 patients were recruited (mean age 52 years, 50% male). The median system-based triage level was 3. By contrast, the median physician-based triage level was 4. The physician raters tended to provide lower triage levels than the system, with an average difference of 1. There was modest concordance between the two triage methods (correlation coefficient 0.30), with a weighted kappa coefficient of 0.18. The area under the receiver operating curve for the system- and physician-based triage in predicting hospital admission were similar (0.635 vs. 0.631, p = 0.896). Attending physicians appeared to have better performance than residents in predicting admission. The variation explained (R2 ) in EDLOS and charges were similar between the two triage methods (R2 = 3% for EDLOS, 7%-9% for charges). CONCLUSIONS Emergency physician gestalt for triage showed similar performance to a computerized system; however, physicians redistributed patients to lower triage levels. Physician gestalt has advantages for identifying low-risk patients. This approach may avoid undue time pressure for health care providers and promote rapid discharge.
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Affiliation(s)
- Ming-Tai Cheng
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chia-Hsin Ko
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yun Chang Chen
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Hsinchu, Taiwan
| | - Chiat Qiao Liew
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Dean-An Ling
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Edward Che-Wei Liao
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Chien Lu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nai-Wen Ku
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Chen Fu
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Zisman A, Novi B, Gaughan J, Carr L. Factors affecting utilization of CT scan following ultrasound evaluation of suspected appendicitis. J Osteopath Med 2022; 122:313-318. [PMID: 35245969 DOI: 10.1515/jom-2021-0251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT When evaluating a pediatric patient in the emergency department for suspected appendicitis, a provider is often faced with the dilemma of deciding if a computed tomography (CT) scan is warranted when-as is most often the case-ultrasound results do not yield a definitive diagnosis. The potential risks of radiation must be weighed against numerous aspects of a patient's background, physical exam, and already-obtained workup. OBJECTIVES This study aims to aid in future decision making of providers in their evaluation of patients with suspected appendicitis, to help facilitate a more comprehensive answer to the "next-steps" in the question of equivocal ultrasound, and to create a pathway utilizing lab results, physical exam findings, and pertinent positives and negatives in patient history to facilitate a more objective decision-making process for ordering a CT scan. METHODS A retrospective chart review was performed for patients who were evaluated for possible appendicitis at our institution between October 2016 and October 2017 and whose ultrasound results were equivocal. We determined what factors led to increased frequency of obtaining CT scans. RESULTS Statistical analysis showed that several factors were independently associated with the increased likelihood of having a CT scan performed. When considered in combination with the other parameters, it was found that older children, males, report of right lower quadrant (RLQ) pain, and presence of RLQ tenderness on physical exam were all associated with a significantly higher likelihood of having a CT scan performed. CONCLUSIONS When combined with present algorithms and protocols already in use, this information can assist the provider in making prudent decisions for their patients with the potential for reduced provider bias.
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Affiliation(s)
- Adam Zisman
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Brian Novi
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA, USA.,St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - John Gaughan
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Lauren Carr
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA, USA
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Mangus CW, Mahajan P. Decision Making: Healthy Heuristics and Betraying Biases. Crit Care Clin 2021; 38:37-49. [PMID: 34794630 DOI: 10.1016/j.ccc.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Critical care settings are unpredictable, dynamic environments where clinicians face high decision density in suboptimal conditions (stress, time constraints, competing priorities). Experts have described two systems of human decision making: one fast and intuitive; the other slow and methodical. Heuristics, or mental shortcuts, a key feature of intuitive reasoning, are often accurate, applied instinctively, and essential for efficient diagnostic decision making. Heuristics are also prone to failures, or cognitive biases, which can lead to diagnostic errors. A variety of strategies have been proposed to mitigate biases; however, current understanding of such interventions to optimize diagnostic safety is still incomplete.
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Affiliation(s)
- Courtney W Mangus
- Departments of Emergency Medicine and Pediatrics, University of Michigan, 1540 East Hospital Drive, CW 2-737, SPC 4260, Ann Arbor, MI 48109-4260, USA.
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, 1540 East Hospital Drive, CW 2-737, SPC 4260, Ann Arbor, MI 48109-4260, USA
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Scott KP, Lacy A, Freeman C, Barrett TW. Predicting Outcomes in Pediatric Pneumonia: Are We Omnipotent or Incompetent?: October 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 78:570-571. [PMID: 34563303 DOI: 10.1016/j.annemergmed.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kelly P Scott
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron Lacy
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Clifford Freeman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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10
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Barak-Corren Y, Agarwal I, Michelson KA, Lyons TW, Neuman MI, Lipsett SC, Kimia AA, Eisenberg MA, Capraro AJ, Levy JA, Hudgins JD, Reis BY, Fine AM. Prediction of patient disposition: comparison of computer and human approaches and a proposed synthesis. J Am Med Inform Assoc 2021; 28:1736-1745. [PMID: 34010406 DOI: 10.1093/jamia/ocab076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/20/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the accuracy of computer versus physician predictions of hospitalization and to explore the potential synergies of hybrid physician-computer models. MATERIALS AND METHODS A single-center prospective observational study in a tertiary pediatric hospital in Boston, Massachusetts, United States. Nine emergency department (ED) attending physicians participated in the study. Physicians predicted the likelihood of admission for patients in the ED whose hospitalization disposition had not yet been decided. In parallel, a random-forest computer model was developed to predict hospitalizations from the ED, based on data available within the first hour of the ED encounter. The model was tested on the same cohort of patients evaluated by the participating physicians. RESULTS 198 pediatric patients were considered for inclusion. Six patients were excluded due to incomplete or erroneous physician forms. Of the 192 included patients, 54 (28%) were admitted and 138 (72%) were discharged. The positive predictive value for the prediction of admission was 66% for the clinicians, 73% for the computer model, and 86% for a hybrid model combining the two. To predict admission, physicians relied more heavily on the clinical appearance of the patient, while the computer model relied more heavily on technical data-driven features, such as the rate of prior admissions or distance traveled to hospital. DISCUSSION Computer-generated predictions of patient disposition were more accurate than clinician-generated predictions. A hybrid prediction model improved accuracy over both individual predictions, highlighting the complementary and synergistic effects of both approaches. CONCLUSION The integration of computer and clinician predictions can yield improved predictive performance.
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Affiliation(s)
- Yuval Barak-Corren
- Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Isha Agarwal
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kenneth A Michelson
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Todd W Lyons
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark I Neuman
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amir A Kimia
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew A Eisenberg
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew J Capraro
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jason A Levy
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joel D Hudgins
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ben Y Reis
- Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew M Fine
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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11
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Fatemi Y, Bell LM. Clinician Gestalt in Managing Pediatric Pneumonia: Can We Predict the Future? Pediatrics 2021; 147:peds.2020-048637. [PMID: 33903164 DOI: 10.1542/peds.2020-048637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yasaman Fatemi
- Divisions of Infectious Diseases and.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Louis M Bell
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania .,General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
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12
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Peyrony O, Marbeuf-Gueye C, Truong V, Giroud M, Rivière C, Khenissi K, Legay L, Simonetta M, Elezi A, Principe A, Taboulet P, Ogereau C, Tourdjman M, Ellouze S, Fontaine JP. Accuracy of Emergency Department Clinical Findings for Diagnosis of Coronavirus Disease 2019. Ann Emerg Med 2020; 76:405-412. [PMID: 32563600 PMCID: PMC7241345 DOI: 10.1016/j.annemergmed.2020.05.022] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 01/08/2023]
Abstract
Study objective We seek to describe the medical history and clinical findings of patients attending the emergency department (ED) with suspected coronavirus disease 2019 (COVID-19) and estimate the diagnostic accuracy of patients’ characteristics for predicting COVID-19. Methods We prospectively enrolled all patients tested for severe acute respiratory syndrome coronavirus 2 by reverse-transcriptase polymerase chain reaction in our ED from March 9, 2020, to April 4, 2020. We abstracted medical history, physical examination findings, and the clinical probability of COVID-19 (low, moderate, and high) rated by emergency physicians, depending on their clinical judgment. We assessed diagnostic accuracy of these characteristics for COVID-19 by calculating positive and negative likelihood ratios. Results We included 391 patients, of whom 225 had positive test results for severe acute respiratory syndrome coronavirus 2. Reverse-transcriptase polymerase chain reaction result was more likely to be negative when the emergency physician thought that clinical probability was low, and more likely to be positive when he or she thought that it was high. Patient-reported anosmia and the presence of bilateral B lines on lung ultrasonography had the highest positive likelihood ratio for the diagnosis of COVID-19 (7.58, 95% confidence interval [CI] 2.36 to 24.36; and 7.09, 95% CI 2.77 to 18.12, respectively). The absence of a high clinical probability determined by the emergency physician and the absence of bilateral B lines on lung ultrasonography had the lowest negative likelihood ratio for the diagnosis of COVID-19 (0.33, 95% CI 0.25 to 0.43; and 0.26, 95% CI 0.15 to 0.45, respectively). Conclusion Anosmia, emergency physician estimate of high clinical probability, and bilateral B lines on lung ultrasonography increased the likelihood of identifying COVID-19 in patients presenting to the ED.
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Affiliation(s)
- Olivier Peyrony
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Carole Marbeuf-Gueye
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Vy Truong
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marion Giroud
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Clémentine Rivière
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Khalil Khenissi
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Léa Legay
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie Simonetta
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arben Elezi
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alessandra Principe
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Taboulet
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Carl Ogereau
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mathieu Tourdjman
- Santé Publique France, Paris, France; Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sami Ellouze
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Paul Fontaine
- Emergency Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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