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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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2
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Turkistani MH, Amer RR. Utilizing Triage Data for Medical Imaging Studies in the Emergency Department. Cureus 2023; 15:e41234. [PMID: 37529516 PMCID: PMC10387579 DOI: 10.7759/cureus.41234] [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: 06/30/2023] [Indexed: 08/03/2023] Open
Abstract
The use of radiological images is widespread in the emergency department (ED) as physicians commonly rely on them during initial evaluations to confirm diagnoses, contributing to prolonged waiting times. This study aimed to determine the relationship between commonly gathered triage data and the need for radiological imaging. Data were collected from electronic charts that contained routinely collected hospital data at the time of triage in the King Abdulaziz Medical City (KAMC) in Riyadh ED. The binary logistic regression results demonstrated a statistically significant relationship between age and radiological imaging ordered in the ED. Each one-unit increase in age corresponded to a 0.983-fold increase in the likelihood of ordering radiological imaging (odds ratio: 0.983, 95% confidence interval: 0.972-0.995, p = 0.004). In contrast, hypertension, diabetes, and heart failure were independent predictors of the need for radiological imaging in the ED (p >0.05). Patient data that are immediately available during ED triage can be used to predict the need for radiological imaging during ED visits. Such models can identify patients who may require radiological imaging during ED visits and expedite patient disposition.
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Affiliation(s)
| | - Roaa R Amer
- Emergency Department, King Abdulaziz Medical City, Riyadh, SAU
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3
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Pierre K, Haneberg AG, Kwak S, Peters KR, Hochhegger B, Sananmuang T, Tunlayadechanont P, Tighe PJ, Mancuso A, Forghani R. Applications of Artificial Intelligence in the Radiology Roundtrip: Process Streamlining, Workflow Optimization, and Beyond. Semin Roentgenol 2023; 58:158-169. [PMID: 37087136 DOI: 10.1053/j.ro.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 04/24/2023]
Abstract
There are many impactful applications of artificial intelligence (AI) in the electronic radiology roundtrip and the patient's journey through the healthcare system that go beyond diagnostic applications. These tools have the potential to improve quality and safety, optimize workflow, increase efficiency, and increase patient satisfaction. In this article, we review the role of AI for process improvement and workflow enhancement which includes applications beginning from the time of order entry, scan acquisition, applications supporting the image interpretation task, and applications supporting tasks after image interpretation such as result communication. These non-diagnostic workflow and process optimization tasks are an important part of the arsenal of potential AI tools that can streamline day to day clinical practice and patient care.
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Affiliation(s)
- Kevin Pierre
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Adam G Haneberg
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Division of Medical Physics, Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Sean Kwak
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL
| | - Keith R Peters
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Bruno Hochhegger
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Thiparom Sananmuang
- Department of Diagnostic and Therapeutic Radiology and Research, Faculty of Medicine Ramathibodi Hospital, Ratchathewi, Bangkok, Thailand
| | - Padcha Tunlayadechanont
- Department of Diagnostic and Therapeutic Radiology and Research, Faculty of Medicine Ramathibodi Hospital, Ratchathewi, Bangkok, Thailand
| | - Patrick J Tighe
- Departments of Anesthesiology & Orthopaedic Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Anthony Mancuso
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Reza Forghani
- Radiomics and Augmented Intelligence Laboratory (RAIL), Department of Radiology and the Norman Fixel Institute for Neurological Diseases, University of Florida College of Medicine, Gainesville, FL; Department of Radiology, University of Florida College of Medicine, Gainesville, FL; Division of Medical Physics, Department of Radiology, University of Florida College of Medicine, Gainesville, FL.
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4
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Bhaumik D, Bhaumik SS, Thaker AA, Timpone VM, Bills CB, Patten L, Pattee J, Chow D, Sugrue LP, Callen AL. Ordering Characteristics Predictive of Noncontrast CT Head Positivity in the Emergency Department. Acad Radiol 2023; 30:492-498. [PMID: 35654657 DOI: 10.1016/j.acra.2022.05.001] [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: 01/19/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 01/25/2023]
Abstract
RATIONALE AND OBJECTIVES Recent decades have seen a steady increase in noncontrast head CT utilization in the emergency department with a concurrent rise in the practice of physician assistants (PAs) and nurse practitioners (NPs). The goal of this study was to identify ordering and patient characteristics predictive of positive noncontrast head CTs in the ED. We hypothesized NP/PAs would have lower positivity rates compared to physicians, suggestive of relative overutilization. MATERIALS AND METHODS We retrospectively identified ED patients who underwent noncontrast head CTs at a single institution: a nonlevel 1 trauma center, during a 7-year period, recording examination positivity, ordering provider training/experience, and multiple additional ordering/patient attributes. Exam positivity was defined as any intracranial abnormality necessitating a change in acute management, such as acute hemorrhage, hydrocephalus, herniation, or worsening prior findings. RESULTS 6624 patients met inclusion criteria. 4.6% (280/6107) of physician exams were positive while 3.7% (19/517) of NP/PA exams were positive; however, differences were not significant. Increasing provider experience was not associated with positivity. Attributes with increased positivity were patient age (p < 0.001), daytime exam (p < 0.05), and indications regarding malignancy (p < 0.001) or focal neurologic deficit (p = 0.001). Attributes with decreased positivity were indications of trauma (p < 0.001) or vertigo/dizziness (p < 0.05). CONCLUSION We found no significant difference in rates of exam positivity between physicians and NP/PAs, even accounting for years of experience. This suggests increasing utilization of head CTs in the ED is not due to the increasing presence of NP/PAs, and may be reflective of general practice trends and clear diagnostic algorithms leading to head CT.
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Affiliation(s)
- Debayan Bhaumik
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Smitha S Bhaumik
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ashesh A Thaker
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Vincent M Timpone
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Luke Patten
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jack Pattee
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel Chow
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Leo P Sugrue
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Andrew L Callen
- Department of Radiology, University of Colorado Anschutz Medical Campus, 1635 Aurora Ct, Aurora, CO 80045, USA.
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5
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Christensen EW, Liu CM, Duszak R, Hirsch JA, Swan TL, Rula EY. Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2241297. [PMID: 36355374 PMCID: PMC9650604 DOI: 10.1001/jamanetworkopen.2022.41297] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
IMPORTANCE The use of nonphysician practitioners (NPPs) in the emergency department (ED) continues to expand, yet little is known about associations between NPPs and ED imaging use. OBJECTIVE To investigate whether the state share of ED visits for which an NPP was the clinician of record is associated with imaging studies ordered, given that state NPP share is associated with state-level NPP scopes of practice. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared diagnostic imaging ordering patterns associated with ED visits based on 2005-2020 Medicare claims for a nationally representative 5% sample of fee-for-service beneficiaries. For all 50 states and the District of Columbia, the state NPP share of ED visits by year was used to represent state-specific practice patterns for NPPs and physicians and how those patterns have evolved over time. The analysis controlled for patient demographic characteristics, Charlson Comorbidity Index scores, ED visit severity, year, and principal diagnosis. EXPOSURES The share of ED visits in each state in each year (state share) for which an NPP was the evaluation and management clinician. MAIN OUTCOMES AND MEASURES The main outcomes were the number and modality of imaging studies associated with ED visits. Analyses were by logistic regression and generalized linear model with γ-distribution and log-link function. RESULTS Among 16 922 274 ED visits, 60.0% involved women, and patients' mean (SD) age was 70.3 (16.1) years. The share of all ED visits with an NPP as the clinician increased from 6.1% in 2005 to 16.6% in 2020. Compared with no NPPs, the presence of NPPs in the ED was associated with 5.3% (95% CI, 5.1%-5.5%) more imaging studies per ED visit, including a 3.4% (95% CI, 3.2%-3.5%) greater likelihood of any imaging order per ED visit and 2.2% (95% CI, 2.0%-2.3%) more imaging studies ordered per visit involving imaging. CONCLUSIONS AND RELEVANCE In this study, use of NPPs in the ED was associated with higher imaging use compared with the use of only physicians in the ED. Although expanded use of NPPs in the ED may improve patient access, the costs and radiation exposure associated with more imaging warrants additional study.
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Affiliation(s)
- Eric W. Christensen
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
- Health Services Management, University of Minnesota, St Paul
| | - Chi-Mei Liu
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Richard Duszak
- Department of Radiology, University of Mississippi Medical Center, Jackson
| | - Joshua A. Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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6
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Knighton AJ, Wolfe D, Hunt A, Neeley A, Shrestha N, Hess S, Hellewell J, Snow G, Srivastava R, Nelson D, Schunk JE. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study. Ann Emerg Med 2022; 80:332-343. [PMID: 35752519 PMCID: PMC9509420 DOI: 10.1016/j.annemergmed.2022.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs). METHODS Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician. RESULTS During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified. CONCLUSION Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.
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Affiliation(s)
| | - Doug Wolfe
- Intermountain Healthcare, Salt Lake City, UT
| | | | | | | | - Steven Hess
- Intermountain Healthcare, Salt Lake City, UT
| | | | | | - Rajendu Srivastava
- Intermountain Healthcare, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT
| | - Douglas Nelson
- Intermountain Healthcare, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT
| | - Jeff E Schunk
- University of Utah School of Medicine, Salt Lake City, UT
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7
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Saffo S, Rodwin B, Dalton R, Tarabar A, Merchant N. Utilization of an Internal Medicine Triaging Resident in the Emergency Department Reduces Preventable Admissions and Improves Trainee Experiences. South Med J 2022; 115:707-711. [PMID: 36055659 DOI: 10.14423/smj.0000000000001434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Increasing patient care requirements and suboptimal communication between emergency department (ED) and Internal Medicine (IM) services may lead to inefficient hospital utilization, lapses in transitions of care, and reduced trainee satisfaction in the inpatient setting. Furthermore, a lack of triaging roles for IM trainees has been a common limitation in graduate medical education. We aimed to demonstrate that the addition of an IM triaging resident (TR) in the ED may represent an innovative solution to these problems. METHODS A single-center pilot study was performed. An IM trainee served as the TR at a tertiary Veterans Affairs hospital for 2 weeks. The TR evaluated medical patients in a parallel manner with ED physicians and assisted in the initial management, disposition, and transitions of care under the supervision of an IM attending physician. Hospital utilization and patient safety were tracked using electronic records, and trainee satisfaction was measured using daily surveys administered to IM resident teams. RESULTS Of the 62 cases evaluated by the TR for medical admission, 26 (42%) represented preventable admissions; 12 (46%) of those patients were discharged from the ED, representing a 19% overall reduction. There were statistically significant improvements in trainee experiences relating to patient flow (P < 0.01) and initial patient management (P < 0.02), and our intervention did not have a negative impact on ED performance metrics or patient safety. CONCLUSIONS Expansion of this model in select integrated health systems may improve graduate medical education and healthcare system performance. Future iterations of this study can aim to improve transitions of care between ambulatory and inpatient providers and limit the overuse of antimicrobial agents, radiography, and consultative services.
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Affiliation(s)
- Saad Saffo
- From the Department of Internal Medicine, Yale University School of Medicine, New Haven, and Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, and Department of Emergency Medicine, Yale University School of Medicine, New Haven, and Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Benjamin Rodwin
- From the Department of Internal Medicine, Yale University School of Medicine, New Haven, and Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, and Department of Emergency Medicine, Yale University School of Medicine, New Haven, and Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Robert Dalton
- From the Department of Internal Medicine, Yale University School of Medicine, New Haven, and Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, and Department of Emergency Medicine, Yale University School of Medicine, New Haven, and Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Asim Tarabar
- From the Department of Internal Medicine, Yale University School of Medicine, New Haven, and Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, and Department of Emergency Medicine, Yale University School of Medicine, New Haven, and Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Naseema Merchant
- From the Department of Internal Medicine, Yale University School of Medicine, New Haven, and Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, and Department of Emergency Medicine, Yale University School of Medicine, New Haven, and Emergency Medicine Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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Kim SH, Song H, Valentine MA. Learning in Temporary Teams: The Varying Effects of Partner Exposure by Team Member Role. ORGANIZATION SCIENCE 2022. [DOI: 10.1287/orsc.2022.1585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In many workplaces, temporary teams convene to coordinate complex work, despite team members having not worked together before. Most related research has found consistent performance benefits when members of temporary teams work together multiple times (team familiarity). Recent work in this area broke new conceptual ground by instead exploring the learning and performance benefits that team members gain by being exposed to many new partners (partner exposure). In contrast to that new work that examined partner exposure between team members who are peers, in this paper, we extend this research by developing and testing theory about the performance effects of partner exposure for team members whose roles are differentiated by authority and skill. We use visit-level data from a hospital emergency department and leverage the ad hoc assignment of attendings, nurses, and residents to teams and the round-robin assignment of patients to these teams as our identification strategy. We find a negative performance effect of both nurses’ and resident trainees’ partner exposure to more attendings and of attendings’ and nurses’ exposure to more residents. In contrast, both attendings and residents experience a positive impact on performance from working with more nurses. The respective effects of residents working with more attendings and with more nurses is attenuated on patient cases with more structured workflows. Our results suggest that interactions with team members in decision-executing roles, as opposed to decision-initiating roles, is an important but often unrecognized part of disciplinary training and team learning.
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Affiliation(s)
- Song-Hee Kim
- SNU Business School, Seoul National University, Seoul 08826, South Korea
| | - Hummy Song
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Melissa A. Valentine
- Department of Management Science and Engineering, Stanford University, Stanford, California 94305
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9
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Li J, Ramgopal S, Marin JR. Racial and ethnic differences in low-value pediatric emergency care. Acad Emerg Med 2022; 29:698-709. [PMID: 35212440 DOI: 10.1111/acem.14468] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED). METHODS We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital. RESULTS We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients. CONCLUSIONS NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.
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Affiliation(s)
- Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School Boston Massachusetts USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine UPMC Children's Hospital of Pittsburgh University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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10
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Kapoor N, Lacson R, Khorasani R. Workflow Applications of Artificial Intelligence in Radiology and an Overview of Available Tools. J Am Coll Radiol 2021; 17:1363-1370. [PMID: 33153540 DOI: 10.1016/j.jacr.2020.08.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 12/18/2022]
Abstract
In the past decade, there has been tremendous interest in applying artificial intelligence (AI) to improve the field of radiology. Currently, numerous AI applications are in development, with potential benefits spanning all steps of the imaging chain from test ordering to report communication. AI has been proposed as a means to optimize patient scheduling, improve worklist management, enhance image acquisition, and help radiologists interpret diagnostic studies. Although the potential for AI in radiology appears almost endless, the field is still in the early stages, with many uses still theoretical, in development, or limited to single institutions. Moreover, although the current use of AI in radiology has emphasized its clinical applications, some of which are in the distant future, it is increasingly clear that AI algorithms could also be used in the more immediate future for a variety of noninterpretive and quality improvement uses. Such uses include the integration of AI into electronic health record systems to reduce unwarranted variation in radiologists' follow-up recommendations and to improve other dimensions of radiology report quality. In the end, the potential of AI in radiology must be balanced with acknowledgment of its current limitations regarding generalizability and data privacy.
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Affiliation(s)
- Neena Kapoor
- Director of Diversity, Inclusion, and Equity, Department of Radiology, Brigham and Women's Hospital; Quality and Patient Safety Officer, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Ronilda Lacson
- Director of Education, Center for Evidence-Based Imaging, Brigham and Women's Hospital; Director of Clinical Informatics, Harvard Medical School Library of Evidence, Boston, Massachusetts
| | - Ramin Khorasani
- Director of the Center of Evidence Imaging and Vice Chair of Quality/Safety, Department of Radiology, Center for Evidence Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Are chest X-rays valuable for patients presenting to emergency departments with acute abdominal pain? Australas Emerg Care 2021; 25:84-87. [PMID: 33879427 DOI: 10.1016/j.auec.2021.03.009] [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: 12/17/2020] [Revised: 03/23/2021] [Accepted: 03/23/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency department patients presenting with acute abdominal pain are often prescribed a chest X-ray; however, the value of chest X-rays in acute abdominal pain is poorly understood. The aim of this study was to assess the value of chest X-rays in acute abdominal pain. METHODS A retrospective analysis of 944 chest X-rays performed for acute abdominal pain was conducted. Patient clinical information, radiology reports, and findings of other diagnostic investigations were also collected. MedCal® software was used to calculate diagnostic performance of chest X-rays. A Chi-Square test was used to assess the association between positive chest X-ray findings and both age and gender. RESULTS Of the 944 chest X-rays identified as satisfying inclusion factors, only 10 cases (approximately 1%) demonstrated pathology that was likely to be the cause of the abdominal pain. Further analysis demonstrated the following performance metrics at 95%CI: sensitivity (12.8; 8.78-17.72); specificity (100; 98.4-100); positive predictive value (100%); negative predictive value (52.76; 51.54-53.98); accuracy (55.82; 51.17-60.40). CONCLUSION Chest X-ray has limited sensitivity and diagnostic value in patients presenting to the emergency department with abdominal pain and does not appear to be a useful diagnostic investigation for abdominal pain.
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12
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open 2021; 4:e2033710. [PMID: 33512517 PMCID: PMC7846940 DOI: 10.1001/jamanetworkopen.2020.33710] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. OBJECTIVE To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. EXPOSURES Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. RESULTS A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. CONCLUSIONS AND RELEVANCE In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.
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Affiliation(s)
- Jennifer R. Marin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Elchoufi D, Duszak R, Balthazar P, Hanna TN, Sadigh G. Increasing emergency department utilization of brain imaging in patients with primary brain cancer. Emerg Radiol 2020; 28:223-231. [PMID: 32803458 DOI: 10.1007/s10140-020-01836-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/03/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE To study changing emergency department (ED) brain imaging utilization in patients with primary brain cancers. METHODS Using 2006-2014 data from the Nationwide Emergency Department Sample (NEDS), we identified all patients with primary brain cancers visiting EDs and evaluated trends of head CT and brain MRI utilization. Multivariable logistic regression analyses were used to determine patient- and hospital-specific factors associated with brain imaging utilization. RESULTS A weighted cohort of 40,862 ED visits were included (mean age 55; 54% male), increasing from 3932 in 2006 to 5625 in 2014 (+ 43%). A total of 14.4% underwent brain imaging, with 13.2% undergoing CT, 2.3% undergoing MRI, and 1.1% undergoing both modalities. Between 2006 and 2014, there was a 104% increase in the rate of ED brain imaging (from 9.7% in 2006 to 19.8% in 2014). Factors associated with higher utilization of ED brain imaging in adults were non-teaching hospital status and Midwest and Northeast hospital regions (compared with the West). In pediatric patients, higher utilization was associated with older age, higher median household income of patient's ZIP code, and visits in rural, non-teaching hospitals located in the Midwest, South, and Northeast (compared with the West). CONCLUSION In US patients with primary brain cancer, the number of ED visits increased annually, and the utilization of ED head imaging examinations doubled in a recent 9-year period. A variety of sociodemographic characteristics are associated with a higher likelihood of imaging in both adult and pediatric patients.
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Affiliation(s)
- Deema Elchoufi
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd, Suite BG27, Atlanta, GA, 30322, USA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd, Suite BG27, Atlanta, GA, 30322, USA
| | - Patricia Balthazar
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd, Suite BG27, Atlanta, GA, 30322, USA
| | - Tarek N Hanna
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd, Suite BG27, Atlanta, GA, 30322, USA
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd, Suite BG27, Atlanta, GA, 30322, USA.
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14
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Abstract
Emergency department (ED) operations reflect the intersection of factors external and internal to the ED itself, with unique problems posed by community and academic environments. ED crowding is primarily caused by a lack of inpatient beds for patients admitted through the ED. Changes to front-end operations, such as point-of-care testing and putting physicians in triage, can yield benefits in throughput, but require individual cost analyses. Balancing physician workloads can lead to substantial improvements in throughput. Observation pathways can reduce crowding while maintaining safety. Physician and nurse well-being is an underappreciated topic within operations, and demands close attention and further research.
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15
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Scheinfeld MH, Feltus W, DiMarco P, Rooney K, Goldman IA. The Emergency Radiology Dashboard: Facilitating Workflow With Realtime Data. Curr Probl Diagn Radiol 2020; 49:231-233. [PMID: 32376121 DOI: 10.1067/j.cpradiol.2020.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022]
Abstract
Emergency radiology imaging volume varies widely due to predictable (eg, day of the week) and unpredictable factors. This can lead to inefficient or insufficient staffing of radiologists, suboptimal workflow and poor trainee education. In collaboration with the radiology IT division we created and implemented a 2-tiered real-time dashboard to facilitate operational workflow. This allowed us to track overall emergency department patient census, ordered but not yet performed imaging studies, and performed but unread imaging studies. The capability of clicking to obtain information on specific studies was also incorporated. We describe our experience of how this information has improved our workflow, staffing, and trainee education.
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Affiliation(s)
- Meir H Scheinfeld
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Radiology, Division of Emergency Radiology, Bronx, NY.
| | - Whitney Feltus
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Radiology, Division of Emergency Radiology, Bronx, NY
| | | | | | - Inessa A Goldman
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Radiology, Division of Emergency Radiology, Bronx, NY
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