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Bowness JS, Metcalfe D, El-Boghdadly K, Thurley N, Morecroft M, Hartley T, Krawczyk J, Noble JA, Higham H. Artificial intelligence for ultrasound scanning in regional anaesthesia: a scoping review of the evidence from multiple disciplines. Br J Anaesth 2024; 132:1049-1062. [PMID: 38448269 DOI: 10.1016/j.bja.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/09/2024] [Accepted: 01/24/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Artificial intelligence (AI) for ultrasound scanning in regional anaesthesia is a rapidly developing interdisciplinary field. There is a risk that work could be undertaken in parallel by different elements of the community but with a lack of knowledge transfer between disciplines, leading to repetition and diverging methodologies. This scoping review aimed to identify and map the available literature on the accuracy and utility of AI systems for ultrasound scanning in regional anaesthesia. METHODS A literature search was conducted using Medline, Embase, CINAHL, IEEE Xplore, and ACM Digital Library. Clinical trial registries, a registry of doctoral theses, regulatory authority databases, and websites of learned societies in the field were searched. Online commercial sources were also reviewed. RESULTS In total, 13,014 sources were identified; 116 were included for full-text review. A marked change in AI techniques was noted in 2016-17, from which point on the predominant technique used was deep learning. Methods of evaluating accuracy are variable, meaning it is impossible to compare the performance of one model with another. Evaluations of utility are more comparable, but predominantly gained from the simulation setting with limited clinical data on efficacy or safety. Study methodology and reporting lack standardisation. CONCLUSIONS There is a lack of structure to the evaluation of accuracy and utility of AI for ultrasound scanning in regional anaesthesia, which hinders rigorous appraisal and clinical uptake. A framework for consistent evaluation is needed to inform model evaluation, allow comparison between approaches/models, and facilitate appropriate clinical adoption.
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Affiliation(s)
- James S Bowness
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, UK.
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK; Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK. https://twitter.com/@TraumaDataDoc
| | - Kariem El-Boghdadly
- Department of Anaesthesia and Peri-operative Medicine, Guy's & St Thomas's NHS Foundation Trust, London, UK; Centre for Human and Applied Physiological Sciences, King's College London, London, UK. https://twitter.com/@elboghdadly
| | - Neal Thurley
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Megan Morecroft
- Faculty of Medicine, Health & Life Sciences, University of Swansea, Swansea, UK
| | - Thomas Hartley
- Intelligent Ultrasound, Cardiff, UK. https://twitter.com/@tomhartley84
| | - Joanna Krawczyk
- Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, UK
| | - J Alison Noble
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK. https://twitter.com/@AlisonNoble_OU
| | - Helen Higham
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. https://twitter.com/@HelenEHigham
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Singh A, Wade RG, Metcalfe D, Perry DC. Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review. JAMA 2024:2817545. [PMID: 38619828 DOI: 10.1001/jama.2024.2404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Importance Delayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life, and premature osteoarthritis. Objective To evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants. Data Sources Systematic search of CINAHL, Embase, MEDLINE, and the Cochrane Library from the inception of each database until October 31, 2023. Study Selection The 9 included studies reported the diagnostic accuracy of the clinical examination (index test) in infants aged 3 months or younger and a diagnostic hip ultrasound (reference test). The Graf method of ultrasound assessment was used to classify hip abnormalities. Data Extraction and Synthesis The Rational Clinical Examination scale was used to assign levels of evidence and the Quality Assessment of Diagnostic Accuracy Studies tool was used to assess bias. Data were extracted using the individual hip as the unit of analysis; the data were pooled when the clinical examinations were evaluated by 3 or more of the included studies. Main Outcomes and Measures Sensitivity, specificity, and likelihood ratios (LRs) of identifying a dislocated hip were calculated. Results Among infants screened with a clinical examination and a diagnostic ultrasound in 5 studies, the prevalence of a dislocated hip (n = 37 859 hips) was 0.94% (95% CI, 0.28%-2.0%). There were 8 studies (n = 44 827 hips) that evaluated use of the Barlow maneuver and the Ortolani maneuver (dislocate and relocate an unstable hip); the maneuvers had a sensitivity of 46% (95% CI, 26%-67%), a specificity of 99.1% (95% CI, 97.9%-99.6%), a positive LR of 52 (95% CI, 21-127), and a negative LR of 0.55 (95% CI, 0.37-0.82). There were 3 studies (n = 22 472 hips) that evaluated limited hip abduction and had a sensitivity of 13% (95% CI, 3.3%-37%), a specificity of 97% (95% CI, 87%-99%), a positive LR of 3.6 (95% CI, 0.72-18), and a negative LR of 0.91 (95% CI, 0.76-1.1). One study (n = 13 096 hips) evaluated a clicking sound and had a sensitivity of 13% (95% CI, 6.4%-21%), a specificity of 92% (95% CI, 92%-93%), a positive LR of 1.6 (95% CI, 0.91-2.8), and a negative LR of 0.95 (95% CI, 0.88-1.0). Conclusions and Relevance In studies in which all infant hips were screened for developmental dysplasia of the hip, the prevalence of a dislocated hip was 0.94%. A positive LR for the Barlow and Ortolani maneuvers was the finding most associated with an increased likelihood of a dislocated hip. Limited hip abduction or a clicking sound had no clear diagnostic utility.
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Affiliation(s)
- Abhinav Singh
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Ryckie George Wade
- Academic Department of Plastic and Reconstructive Surgery, University of Leeds, Leeds, England
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Daniel C Perry
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
- Department of Child Health, Alder Hey Children's Hospital, University of Liverpool, Liverpool, England
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Rios Diaz AJ, Bevilacqua LA, Habarth-Morales TE, Zalewski A, Metcalfe D, Costanzo C, Yeo CJ, Palazzo F. Primary anastomosis with diverting loop ileostomy vs. Hartmann's procedure for acute diverticulitis: what happens after discharge? Results of a nationwide analysis. Surg Endosc 2024:10.1007/s00464-024-10752-8. [PMID: 38580758 DOI: 10.1007/s00464-024-10752-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/14/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Current guidelines recommend resection with primary anastomosis with diverting loop ileostomy over Hartmann's procedure if deemed safe for acute diverticulitis. The primary objective of the current study was to compare the utilization of these strategies and describe nationwide ostomy closure patterns and readmission outcomes within 1 year of discharge. METHODS This was a retrospective, population-based, cohort study of United States Hospitals reporting to the Nationwide Readmissions Database from January 2011 to December 2019. There were 35,774 patients identified undergoing non-elective primary anastomosis with diverting loop ileostomy or Hartmann's procedure for acute diverticulitis. Rates of ostomy closure, unplanned readmissions, and complications were compared. Cox proportional hazards and logistic regression models were used to control for patient and hospital-level confounders as well as severity of disease. RESULTS Of the 35,774 patients identified, 93.5% underwent Hartmann's procedure. Half (47.2%) were aged 46-65 years, 50.8% female, 41.2% publicly insured, and 91.7% underwent open surgery. Primary anastomosis was associated with higher rates of 1-year ostomy closure (83.6% vs. 53.4%, p < 0.001) and shorter time-to-closure [median 72 days (Interquartile range 49-103) vs. 115 (86-160); p < 0.001]. Primary anastomosis was associated with increased unplanned readmissions [Hazard Ratio = 2.83 (95% Confidence Interval 2.83-3.37); p < 0.001], but fewer complications upon stoma closure [Odds Ratio 0.51 (95% 0.42-0.63); p < 0.001]. There were no differences in complications between primary anastomosis and Hartmann's procedure during index admission [Odds Ratio = 1.13 (95% Confidence Interval 0.96-1.33); p = 0.137]. CONCLUSION Patients who undergo primary anastomosis for acute diverticulitis are more likely to undergo ostomy reversal and experience fewer postoperative complications upon stoma reversal. These data support the current national guidelines that recommend primary anastomosis in appropriate cases of acute diverticulitis requiring operative treatment.
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Affiliation(s)
- Arturo J Rios Diaz
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lisa A Bevilacqua
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Alicja Zalewski
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - David Metcalfe
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Caitlyn Costanzo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
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4
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Metcalfe D, Novak A, Paul I, Bowness JS. Ultrasound-guided fascia iliaca blocks for hip fracture: is the juice worth the squeeze? Emerg Med J 2024:emermed-2024-213978. [PMID: 38519122 DOI: 10.1136/emermed-2024-213978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 03/24/2024]
Affiliation(s)
- David Metcalfe
- Oxford Trauma & Emergency Care (OxTEC), Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Immanuel Paul
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James S Bowness
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Anaesthesia, Aneurin Bevan Health Board, Newport, UK
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5
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Wilson S, Dainty J, Quinlan J, Sampson FC, Metcalfe D, Keating L. Pain in the ED: does anyone manage it well? Emerg Med J 2024:emermed-2023-213797. [PMID: 38519121 DOI: 10.1136/emermed-2023-213797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/24/2024]
Affiliation(s)
- Sarah Wilson
- Emergency Department, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Jack Dainty
- University of East Anglia Norwich Medical School, Norwich, Norfolk, UK
| | - Jane Quinlan
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | | | - David Metcalfe
- Emergency Department, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- Oxford Trauma and Emergency Care (OxTEC), Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Liza Keating
- Emergency Department & Intensive Care Unit, Royal Berkshire NHS Foundation Trust, Reading, UK
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6
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Metcalfe D, Perry DC. Surgically reducing displaced distal radial fractures in children. Bone Joint J 2024; 106-B:16-18. [PMID: 38160688 DOI: 10.1302/0301-620x.106b1.bjj-2023-1112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Displaced fractures of the distal radius in children are usually reduced under sedation or general anaesthesia to restore anatomical alignment before the limb is immobilized. However, there is growing evidence of the ability of the distal radius to remodel rapidly, raising doubts over the benefit to these children of restoring alignment. There is now clinical equipoise concerning whether or not young children with displaced distal radial fractures benefit from reduction, as they have the greatest ability to remodel. The Children's Radius Acute Fracture Fixation Trial (CRAFFT), funded by the National Institute for Health and Care Research, aims to definitively answer this question and determine how best to manage severely displaced distal radial fractures in children aged up to ten years.
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Affiliation(s)
- David Metcalfe
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Emergency Research in Oxford, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Daniel C Perry
- Institute of Population Health, University of Liverpool, Liverpool, UK
- Alder Hey Orthopaedics, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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7
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Metcalfe D, Hoeritzauer I, Angus M, Novak A, Hutton M, Woodfield J. Diagnosis of cauda equina syndrome in the emergency department. Emerg Med J 2023; 40:787-793. [PMID: 37669831 DOI: 10.1136/emermed-2023-213151] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023]
Abstract
Cauda equina syndrome (CES) is a spinal emergency that can be challenging to identify from among the many patients presenting to EDs with low back and/or radicular leg pain. This article presents a practical guide to the assessment and early management of patients with suspected CES as well as an up-to-date review of the most important studies in this area that should inform clinical practice in the ED.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ingrid Hoeritzauer
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Michelle Angus
- Complex Spinal Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Alex Novak
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mike Hutton
- Exeter Spinal Surgery Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Julie Woodfield
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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8
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Machado GC, Metcalfe D, Underwood M, Maher CG. Back pain: a target for reducing hospital admissions? Lancet Rheumatol 2023; 5:e643-e645. [PMID: 38251529 DOI: 10.1016/s2665-9913(23)00266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Gustavo C Machado
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, NSW 2050, Australia.
| | - David Metcalfe
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Emergency Medicine Research in Oxford, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK; University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Chris G Maher
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, NSW 2050, Australia
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9
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Burckett-St Laurent D, Metcalfe D, Sutcliffe E, Yap C. 'Plan A' for ultrasound-guided regional anaesthesia in the Emergency Department. Emerg Med J 2023; 40:691-692. [PMID: 37611956 DOI: 10.1136/emermed-2023-213354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/26/2023] [Indexed: 08/25/2023]
Affiliation(s)
| | - David Metcalfe
- Oxford Trauma and Emergency Care (OxTEC), University of Oxford, Oxford, UK
- Emergency Medicine Research in Oxford (EMROx), John Radcliffe Hospital, Oxford, UK
| | - Elliot Sutcliffe
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Christopher Yap
- Emergency Department, Northern General Hospital, Sheffield, UK
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10
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Coventry L, Oldrini I, Dean B, Novak A, Duckworth A, Metcalfe D. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J 2023; 40:576-582. [PMID: 37169546 DOI: 10.1136/emermed-2023-213119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/22/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Plain radiographs cannot identify all scaphoid fractures; thus ED patients with a clinical suspicion of scaphoid injury often undergo immobilisation despite normal imaging. This study determined (1) the prevalence of scaphoid fracture among patients with a clinical suspicion of scaphoid injury with normal radiographs and (2) whether clinical features can identify patients that do not require immobilisation and further imaging. METHODS This systematic review of diagnostic test accuracy studies included all study designs that evaluated predictors of scaphoid fracture among patients with normal initial radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analyses included all studies. RESULTS Eight studies reported data on 1685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 9.0%. Most studies were at overall low risk of bias but two were at unclear risk; all eight were at low risk for applicability concerns. The most accurate clinical predictors of occult scaphoid fracture were pain when the examiner moved the wrist from a pronated to a supinated position against resistance (sensitivity 100%, specificity 97.9%, LR+ 45.0, 95% CI 6.5 to 312.5), supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR+ 3.7, 95% CI 2.2 to 6.1), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR+ 2.3, 95% CI 1.8 to 3.0) and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR+ 2.0, 95% CI 1.2 to 3.2). Absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1%, specificity 48.4%, LR- 0.2, 95% CI 0.0 to 0.7). CONCLUSION No single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation. TRIAL REGISTRATION NUMBER CRD42021290224.
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Affiliation(s)
- Laura Coventry
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Ilaria Oldrini
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Ben Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Population Health Sciences, Usher Institute,University of Edinburgh, Edinburgh, UK
| | - David Metcalfe
- Warwick Medical School, University of Warwick, Coventry, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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11
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Glover SJ, Metcalfe D, Erasu V, Panduro T, Gibbs W, Paul I, Novak A, Shanahan TAG. Journal update monthly top five. Emerg Med J 2023; 40:614-615. [PMID: 37487634 DOI: 10.1136/emermed-2023-213454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Samuel Jonathan Glover
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Metcalfe
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vishakha Erasu
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tine Panduro
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - William Gibbs
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Immanuel Paul
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research in Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Thomas Alexander Gerrard Shanahan
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Emergency Department, Royal Oldham Hospital, Oldham, UK
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12
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Ali MS, Khattak M, Metcalfe D, Perry DC. Radiological hip shape and patient-reported outcome measures in healed Perthes' disease. Bone Joint J 2023; 105-B:711-716. [PMID: 37257855 DOI: 10.1302/0301-620x.105b6.bjj-2022-1421.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Aims This study aimed to evaluate the relationship between hip shape and mid-term function in Perthes' disease. It also explored whether the modified three-group Stulberg classification can offer similar prognostic information to the five-group system. Methods A total of 136 individuals aged 12 years or older who had Perthes' disease in childhood completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility score (function), Nonarthritic Hip Score (NAHS) (function), EuroQol five-dimension five-level questionnaire (EQ-5D-5L) score (quality of life), and the numeric rating scale for pain (NRS). The Stulberg class of the participants' hip radiographs were evaluated by three fellowship-trained paediatric orthopaedic surgeons. Hip shape and Stulberg class were compared to PROM scores. Results A spherical hip was associated with the highest function and quality of life, and lowest pain. Conversely, aspherical hips exhibited the lowest functional scores and highest pain. The association between worsening Stulberg class (i.e. greater deviation from sphericity) and worse outcome persisted after adjustment for age and sex in relation to PROMIS (predicted mean difference -1.77 (95% confidence interval (CI) -2.70 to -0.83)), NAHS (-5.68 (95% CI -8.45 to -2.90)), and NRS (0.61 (95% CI 0.14 to 1.08)), but not EQ-5D-5L (-0.03 (95% CI -0.72 to 0.11)). Conclusion Patient-reported outcomes identify lower function, quality of life, and higher pain in aspherical hips. The magnitude of symptoms deteriorated with time. Hip sphericity (i.e. the modified three-group classification of spherical, oval, and aspherical) appeared to offer similar levels of detail to the five-group Stulberg classification.
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Affiliation(s)
- Mohammed S Ali
- Trauma and Orthopaedics Department, Aintree University Hospital, Liverpool, UK
- Department of Women's and Children's Health, Institute of Translational Medicine, Liverpool Women's Hospital, Liverpool, UK
| | - Mohammed Khattak
- Trauma and Orthopaedics Department, Alder Hey Children's Hospital, Liverpool, UK
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel C Perry
- Department of Women's and Children's Health, Institute of Translational Medicine, Liverpool Women's Hospital, Liverpool, UK
- Trauma and Orthopaedics Department, Alder Hey Children's Hospital, Liverpool, UK
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13
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Metcalfe D, Lancaster S, Keene D. Revisiting the humble ankle sprain. Emerg Med J 2023:emermed-2023-213287. [PMID: 37173123 DOI: 10.1136/emermed-2023-213287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/16/2023] [Indexed: 05/15/2023]
Affiliation(s)
- David Metcalfe
- Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
- Emergency Medicine Research in Oxford (EMROx), John Radcliffe Hospital, Oxford, UK
| | | | - David Keene
- Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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14
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Zogg CK, Metcalfe D, Sokas CM, Dalton MK, Hirji SA, Davis KA, Haider AH, Cooper Z, Lichtman JH. Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes. Ann Surg 2023; 277:e204-e211. [PMID: 33914485 PMCID: PMC8384940 DOI: 10.1097/sla.0000000000004805] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes. SUMMARY BACKGROUND DATA The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression. RESULTS A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions. CONCLUSION The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, CT
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
- Yale School of Public Health, New Haven, CT
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Claire M. Sokas
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | - Michael K. Dalton
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sameer A. Hirji
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Adil H. Haider
- The Aga Khan University Medical College, Karachi, Pakistan
| | - Zara Cooper
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
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Abstract
Economic evaluation provides a framework for assessing the costs and consequences of alternative programmes or interventions. One common vehicle for economic evaluations in the healthcare context is the decision-analytic model, which synthesizes information on parameter inputs (for example, probabilities or costs of clinical events or health states) from multiple sources and requires application of mathematical techniques, usually within a software program. A plethora of decision-analytic modelling-based economic evaluations of orthopaedic interventions have been published in recent years. This annotation outlines a number of issues that can help readers, reviewers, and decision-makers interpret evidence from decision-analytic modelling-based economic evaluations of orthopaedic interventions.Cite this article: Bone Joint J 2023;105-B(1):17-20.
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Affiliation(s)
- Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Oldrini I, Coventry L, Novak A, Gwilym S, Metcalfe D. 1632 Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies. J Accid Emerg Med 2022. [DOI: 10.1136/emermed-2022-rcem2.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aims, Objectives and BackgroundPre-reduction radiographs are conventionally used to exclude important fracture before attempts to reduce a dislocated shoulder in the Emergency Department. However, this step increases cost, exposes patients to ionising radiation, and might delay closed reduction. Some studies have suggested that pre-reduction imaging may be omitted for a sub-group of patients with shoulder dislocations.The objective was to determine whether clinical predictors can identify patients that might safely undergo closed reduction of a dislocated shoulder without pre-reduction radiographs.Method and DesignA systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data were pooled and meta-analysed by fitting univariate random effects and multi-level mixed effects logistic regression models.Results and ConclusionEight studies reported data on 2,087 shoulder dislocations and 343 concomitant fractures. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (LR+ 1.8 [95% CI 1.5–2.1]; LR- 0.4 [0.2–0.6]), female sex (LR+ 2.0 [1.6–2.4], LR- 0.7 [0.6–0.8]), first time dislocation (LR+ 1.7 [1.4–2.0]; LR-0.2 [0.1–0.5]), and presence of humeral ecchymosis (LR+ 3.0–5.7; LR- 0.8–1.1). The most important mechanisms of injury were: high-energy mechanism fall (LR+ 2.0–9.8), fall >1 flight of stairs (LR+ 3.8 [95% CI 0.6–13.1]; LR- 1.0 [95% CI 0.9–1.0]), and motor vehicle collision (LR+ 2.3 [0.5–4.0]; LR- 0.9 [0.9–1.0]). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6–99.2%) and specificity (33.3%, 23.1–45.3%) but the Fresno-Quebec rule maintained 100% sensitivity across three studies that included 564 shoulder dislocations and 98 fractures.In conclusion, the Fresno-Quebec Rule has undergone both internal and external validation and may now have a role in clinical practice.
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Coventry L, Oldrini I, Novak A, Dean B, Metcalfe D. 1695 Which clinical features best predict occult scaphoid fracture? A systematic review and meta-analysis. Emerg Med J 2022. [DOI: 10.1136/emermed-2022-rcem2.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aims, Objectives and BackgroundScaphoid fractures require early identification to avoid complications such as painful non-union, avascular necrosis, and chronic wrist pain. Unfortunately, plain radiographs are insufficiently sensitive and so patients may require immobilisation and further imaging (e.g. MRI) despite normal initial radiographs.The aim of this systematic review was to determine which clinical features best predict the presence of an occult scaphoid fracture that warrants immobilisation and further imaging.Method and DesignA systematic review of diagnostic test accuracy studies was undertaken. All study designs were included if they evaluated predictors of scaphoid fracture amongst patients with normal initial scaphoid radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Depending on the number of studies, data were presented as individual data points, ranges, or meta-analysed by fitting either univariate random effects or multi-level mixed effects logistic regression models.Results and ConclusionEight studies reported data on 1,685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 7.3%. The most accurate predictors of occult scaphoid fracture were pain with supination against resistance (sensitivity 100%, specificity 97.9%, LR 45.0 [95% CI 6.5–312.5], supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR 3.7 [95% CI 2.2–6.1]), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR 2.3 [95% CI 1.8–3.0]), and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR 2.0 [95% CI 1.2–3.2]). The absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1, specificity 48.4, LR- 0.2 [95% CI 0.4–0.7]).In conclusion, no single feature can satisfactorily exclude occult scaphoid fracture. However, a number of clinical findings significantly affect the pre-test likelihood of fracture. Future work should determine whether combinations of clinical findings can be used to guide which patients require immobilisation and further imaging despite normal initial radiographs.
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Oldrini I, Coventry L, Novak A, Gwilym S, Metcalfe D. Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies. Emerg Med J 2022; 40:379-384. [PMID: 36450522 DOI: 10.1136/emermed-2022-212696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/21/2022] [Indexed: 12/02/2022]
Abstract
BackgroundPrereduction radiographs are conventionally used to exclude fracture before attempts to reduce a dislocated shoulder in the ED. However, this step increases cost, exposes patients to ionising radiation and may delay closed reduction. Some studies have suggested that prereduction imaging may be omitted for a subgroup of patients with shoulder dislocations.ObjectivesTo determine whether clinical predictors can identify patients who may safely undergo closed reduction of a dislocated shoulder without prereduction radiographs.MethodsA systematic review and meta-analysis of diagnostic test accuracy studies that have evaluated the ability of clinical features to identify concomitant fractures in patients with shoulder dislocation. The search was updated to 23 June 2022 and language limits were not applied. All fractures were included except for Hill-Sachs lesions. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were pooled and meta-analysed by fitting univariate random effects and multilevel mixed effects logistic regression models.ResultsEight studies reported data on 2087 shoulder dislocations and 343 concomitant fractures. The most important potential sources of bias were unclear blinding of those undertaking the clinical (6/8 studies) and radiographic (3/8 studies) assessment. The prevalence of concomitant fracture was 17.5%. The most accurate clinical predictors were age >40 (positive likelihood ratio (LR+) 1.8, 95% CI 1.5 to 2.1; negative likelihood ratio (LR−) 0.4, 95% CI 0.2 to 0.6), female sex (LR+ 2.0, 95% CI 1.6 to 2.4; LR− 0.7, 95% CI 0.6 to 0.8), first-time dislocation (LR+ 1.7, 95% CI 1.4 to 2.0; LR− 0.2, 95% CI 0.1 to 0.5) and presence of humeral ecchymosis (LR+ 3.0–5.7, LR− 0.8–1.1). The most important mechanisms of injury were high-energy mechanism fall (LR+ 2.0–9.8, LR− 0.4–0.8), fall >1 flight of stairs (LR+ 3.8, 95% CI 0.6 to 13.1; LR− 1.0, 95% CI 0.9 to 1.0) and motor vehicle collision (LR+ 2.3, 95% CI 0.5 to 4.0; LR− 0.9, 95% CI 0.9 to 1.0). The Quebec Rule had a sensitivity of 92.2% (95% CI 54.6% to 99.2%) and a specificity of 33.3% (95% CI 23.1% to 45.3%), but the Fresno-Quebec rule identified all clinically important fractures across two studies: sensitivity of 100% (95% CI 89% to 100%) in the derivation dataset and 100% (95% CI 90% to 100%) in the validation study. The specificity of the Fresno-Quebec rule ranged from 34% (95% CI 28% to 41%) in the derivation dataset to 24% (95% CI 16% to 33%) in the validation study.ConclusionClinical prediction rules may have a role in supporting shared decision making after shoulder dislocation, particularly in the prehospital and remote environments when delay to imaging is anticipated.
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Affiliation(s)
- Ilaria Oldrini
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Laura Coventry
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Alex Novak
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Steve Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Trauma Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Metcalfe
- Warwick Medical School, University of Warwick, Coventry, UK
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Metcalfe D, Parsons NR, Costa ML. Sterile versus non-sterile gloves for traumatic wounds in the ED. J Accid Emerg Med 2022; 39:648-649. [PMID: 35882524 DOI: 10.1136/emermed-2022-212517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/11/2022] [Indexed: 11/03/2022]
Affiliation(s)
- David Metcalfe
- Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK .,Warwick Medical School, University of Warwick, Coventry, UK
| | - Nick R Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
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20
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Rios-Diaz AJ, Lamm R, Metcalfe D, Devin CL, Pucci MJ, Palazzo F. National recurrence of pancreatitis and readmissions after biliary pancreatitis. Surg Endosc 2022; 36:7399-7408. [PMID: 35233658 DOI: 10.1007/s00464-022-09153-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND National and international guidelines support early cholecystectomy after mild gallstone pancreatitis but a recent nationwide study suggested these recommendations are not universally followed. Our study sought to quantify the national utilization of same hospitalization cholecystectomy versus non-operative management (NOM) and its association with pancreatitis recurrence, readmissions, and costs after mild gallstone pancreatitis (GP). METHODS Adult patients admitted with mild GP were identified from the Nationwide Readmission Database 2010-2015. Primary outcomes included the rate of cholecystectomy during the index admission as well as pancreatitis recurrence and readmission at 30 and 180 days (30d, 180d) comparing NOM to same hospitalization cholecystectomy. Mortality upon readmission, total length of stay (LOS), and total costs (combined index-readmission hospital costs) were also explored. Cox proportional hazards regression and generalized linear models controlled for patient/hospital confounders. RESULTS Among the 65,067 patients identified, 30% underwent cholecystectomy. The NOM cohort was older (58 vs. 50 years), had more comorbidities (Charlson index > 2, 23.5% vs. 11.5%), fewer female patients (56.7% vs. 67%) and less discharge-to-home (84.9% vs. 94.4%) (all p < 0.001). NOM was associated with increase in recurrence and unplanned readmissions at 30d [Hazard Ratio 3.53 (95% CI 2.92-4.27), 2.41 (2.11-2.74), respectively], and 180d [4.27 (3.65-4.98), 2.78 (2.54-3.04), respectively], as well as increased mortality during 180d readmission 1.88 (1.06-3.35). This approach was also associated with significant increase in LOS [predicted mean difference 2.79 days (95% CI 2.46-3.12)] and total costs [$2507.89 ($1714.4-$3301.4)]. CONCLUSIONS In the USA, most patients presenting with mild GP do not undergo same hospitalization cholecystectomy. This strategy results in higher recurrent pancreatitis, mortality during readmission, and an additional $4.85 M/year in hospital costs nationwide. These data support same hospitalization cholecystectomy as the gold standard for mild GP.
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Affiliation(s)
- Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA.
| | - Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - David Metcalfe
- Rheumatology and Musculoskeletal Sciences (NDORMS), Nuffield Department of Orthopedics, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Courtney L Devin
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
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Soltan AAS, Yang J, Pattanshetty R, Novak A, Yang Y, Rohanian O, Beer S, Soltan MA, Thickett DR, Fairhead R, Zhu T, Eyre DW, Clifton DA, Watson A, Bhargav A, Tough A, Rogers A, Shaikh A, Valensise C, Lee C, Otasowie C, Metcalfe D, Agarwal E, Zareh E, Thangaraj E, Pickles F, Kelly G, Tadikamalla G, Shaw G, Tong H, Davies H, Bahra J, Morgan J, Wilson J, Cutteridge J, O'Byrne K, Farache Trajano L, Oliver M, Pikoula M, Mendoza M, Keevil M, Faisal M, Dole N, Deal O, Conway-Jones R, Sattar S, Kundoor S, Shah S, Muthusami V. Real-world evaluation of rapid and laboratory-free COVID-19 triage for emergency care: external validation and pilot deployment of artificial intelligence driven screening. Lancet Digit Health 2022; 4:e266-e278. [PMID: 35279399 PMCID: PMC8906813 DOI: 10.1016/s2589-7500(21)00272-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 11/24/2021] [Indexed: 12/14/2022]
Abstract
Background Uncertainty in patients' COVID-19 status contributes to treatment delays, nosocomial transmission, and operational pressures in hospitals. However, the typical turnaround time for laboratory PCR remains 12–24 h and lateral flow devices (LFDs) have limited sensitivity. Previously, we have shown that artificial intelligence-driven triage (CURIAL-1.0) can provide rapid COVID-19 screening using clinical data routinely available within 1 h of arrival to hospital. Here, we aimed to improve the time from arrival to the emergency department to the availability of a result, do external and prospective validation, and deploy a novel laboratory-free screening tool in a UK emergency department. Methods We optimised our previous model, removing less informative predictors to improve generalisability and speed, developing the CURIAL-Lab model with vital signs and readily available blood tests (full blood count [FBC]; urea, creatinine, and electrolytes; liver function tests; and C-reactive protein) and the CURIAL-Rapide model with vital signs and FBC alone. Models were validated externally for emergency admissions to University Hospitals Birmingham, Bedfordshire Hospitals, and Portsmouth Hospitals University National Health Service (NHS) trusts, and prospectively at Oxford University Hospitals, by comparison with PCR testing. Next, we compared model performance directly against LFDs and evaluated a combined pathway that triaged patients who had either a positive CURIAL model result or a positive LFD to a COVID-19-suspected clinical area. Lastly, we deployed CURIAL-Rapide alongside an approved point-of-care FBC analyser to provide laboratory-free COVID-19 screening at the John Radcliffe Hospital (Oxford, UK). Our primary improvement outcome was time-to-result, and our performance measures were sensitivity, specificity, positive and negative predictive values, and area under receiver operating characteristic curve (AUROC). Findings 72 223 patients met eligibility criteria across the four validating hospital groups, in a total validation period spanning Dec 1, 2019, to March 31, 2021. CURIAL-Lab and CURIAL-Rapide performed consistently across trusts (AUROC range 0·858–0·881, 95% CI 0·838–0·912, for CURIAL-Lab and 0·836–0·854, 0·814–0·889, for CURIAL-Rapide), achieving highest sensitivity at Portsmouth Hospitals (84·1%, Wilson's 95% CI 82·5–85·7, for CURIAL-Lab and 83·5%, 81·8–85·1, for CURIAL-Rapide) at specificities of 71·3% (70·9–71·8) for CURIAL-Lab and 63·6% (63·1–64·1) for CURIAL-Rapide. When combined with LFDs, model predictions improved triage sensitivity from 56·9% (51·7–62·0) for LFDs alone to 85·6% with CURIAL-Lab (81·6–88·9; AUROC 0·925) and 88·2% with CURIAL-Rapide (84·4–91·1; AUROC 0·919), thereby reducing missed COVID-19 cases by 65% with CURIAL-Lab and 72% with CURIAL-Rapide. For the prospective deployment of CURIAL-Rapide, 520 patients were enrolled for point-of-care FBC analysis between Feb 18 and May 10, 2021, of whom 436 received confirmatory PCR testing and ten (2·3%) tested positive. Median time from arrival to a CURIAL-Rapide result was 45 min (IQR 32–64), 16 min (26·3%) sooner than with LFDs (61 min, 37–99; log-rank p<0·0001), and 6 h 52 min (90·2%) sooner than with PCR (7 h 37 min, 6 h 5 min to 15 h 39 min; p<0·0001). Classification performance was high, with sensitivity of 87·5% (95% CI 52·9–97·8), specificity of 85·4% (81·3–88·7), and negative predictive value of 99·7% (98·2–99·9). CURIAL-Rapide correctly excluded infection for 31 (58·5%) of 53 patients who were triaged by a physician to a COVID-19-suspected area but went on to test negative by PCR. Interpretation Our findings show the generalisability, performance, and real-world operational benefits of artificial intelligence-driven screening for COVID-19 over standard-of-care in emergency departments. CURIAL-Rapide provided rapid, laboratory-free screening when used with near-patient FBC analysis, and was able to reduce the number of patients who tested negative for COVID-19 but were triaged to COVID-19-suspected areas. Funding The Wellcome Trust, University of Oxford Medical and Life Sciences Translational Fund.
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Zogg CK, Metcalfe D, Judge A, Perry DC, Costa ML, Gabbe BJ, Schoenfeld AJ, Davis KA, Cooper Z, Lichtman JH. Learning From England's Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Hip Fracture Outcomes. Ann Surg 2022; 275:506-514. [PMID: 33491982 PMCID: PMC9233527 DOI: 10.1097/sla.0000000000004305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate England's Best Practice Tariff (BPT) and consider potential implications for Medicare patients should the US adopt a similar plan. SUMMARY BACKGROUND DATA Since the beginning of the Affordable Care Act, Medicare has renewed efforts to improve the outcomes of older adults through introduction of an expanding set of alternative-payment models. Among trauma patients, recommended arrangements met with mixed success given concerns about the heterogeneous nature of trauma patients and resulting outcome variation. A novel approach taken for hip fractures in England could offer a viable alternative. METHODS Linear regression, interrupted time-series, difference-in-difference, and counterfactual models of 2000 to 2016 Medicare (US), HES-APC (England) death certificate-linked claims (≥65 years) were used to: track US hip fracture trends, look at changes in English hip fracture trends before-and-after BPT implementation, compare changes in US-versus-English mortality, and estimate total/theoretical lives saved. RESULTS A total of 806,036 English and 3,221,109 US hospitalizations were included. After BPT implementation, England's 30-day mortality decreased by 2.6 percentage-points (95%CI: 1.7-3.5) from a baseline of 9.9% (relative reduction 26.3%). 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000 to 2016, US outcomes were stagnant (P > 0.05), resulting in an inversion of the countries' mortality and >38,000 potential annual US lives saved. CONCLUSIONS Process measure pay-for-performance led to significant improvements in English hip fracture outcomes. As efforts to improve US older adult health continue to increase, there are important lessons to be learned from a successful initiative like the BPT.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, Connecticut
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Yale School of Public Health, New Haven, Connecticut
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Daniel C. Perry
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Belinda J. Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew J. Schoenfeld
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts
| | | | - Zara Cooper
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Rios-Diaz AJ, Bevilacqua LA, Metcalfe D, Yeo CJ, Palazzo F. Are Traditional Metrics Sufficient to Capture the True Burden of Venous Thromboembolism after Elective Major Surgery? A Nationwide Analysis of 844,101 Patients and 30 Major Surgical Procedures. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rios-Diaz AJ, Zalewski A, Bevilacqua LA, Metcalfe D, Costanzo C, Yeo CJ, Palazzo F. Primary Anastomosis with Diverting Loop Ileostomy vs Hartmann’s Procedure for Acute Diverticulitis: What Happens after Discharge? Results of a Nationwide Analysis. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Osteoporotic hip fractures have a profound impact on the physical health and psychosocial wellbeing of patients. In addition, osteoporosis has considerable economic implications and is projected to become an increasing burden on developed economies over the coming decades. Nevertheless, the risk factors for both osteoporosis and hip fracture are both well understood and preventable, often with only minor lifestyle changes. This narrative review explores the pathological process underlying osteoporosis and considers how each of the major risk factors contributes to the pathology of this disease. It is hoped that a greater understanding of individual risk factors will result in renewed efforts to promote increased bone density before patients present with hip fracture.
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Crespo MDA, Zogg C, Novak A, Metcalfe D. 171 Early senior assessment and access to CT in an emergency department. Arch Emerg Med 2020. [DOI: 10.1136/emj-2020-rcemabstracts.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aims/Objectives/BackgroundThe Rapid Assessment and Treatment (RAT) model provides early senior assessment of undifferentiated ‘majors’ patients and has been proposed as a strategy for improving Emergency Department (ED) efficiency. One goal of RAT is to organise essential imaging at an earlier stage within the patient’s ED journey. This study aimed to identify any potential early impact of a RAT initiative on time to imaging for patients requiring CT head.Methods/DesignElectronic health record data were extracted for all patients that underwent head CT while in the ED over a 54-month period (48 months pre-intervention and 6 post-intervention) at a single Major Trauma Centre in England. Interrupted time series analysis was used to estimate any effect of RAT on time from ED arrival to imaging.Results/ConclusionsThere was a pre-existing gradual trend over the entire time series towards patients waiting less time for CT. Although time to CT appeared to increase when the RAT model was implemented, this change was small and not statistically significant (9.8 [95% CI -1.6 to 21.3] minutes). Following RAT implementation, the pre-existing trend towards quicker access to CT resumed but without any change in the slope of the line.This early evaluation did not identify an association between RAT implementation and speed of access to CT head. The system may mature over time and further evaluations will be necessary to identify delayed effects on access to imaging as well as other process measures intended to improve ED safety and efficiency.
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Rios-Diaz AJ, Zalewski A, Cunning JR, Metcalfe D, Palazzo F. Are We out of the Woods after Discharge? Nationwide Clostridium Difficile Infection Burden after Major Operation. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Aims This study explores the reported rate of surgical site infection (SSI) after hip fracture surgery in published studies concerning patients treated in the UK. Methods Studies were included if they reported on SSI after any type of surgical treatment for hip fracture. Each study required a minimum of 30 days follow-up and 100 patients. Meta-analysis was undertaken using a random effects model. Heterogeneity was expressed using the I2 statistic. Risk of bias was assessed using a modified Newcastle-Ottawa Scale (NOS) system. Results There were 20 studies reporting data from 88,615 patients. Most were retrospective cohort studies from single centres. The pooled incidence was 2.1% (95% confidence interval (CI) 1.54% to 2.62%) across ‘all types’ of hip fracture surgery. When analyzed by operation type, the SSI incidences were: hemiarthroplasty 2.87% (95% CI 1.99% to 3.75%) and sliding hip screw 1.35% (95% CI 0.78% to 1.93%). There was considerable variation in definition of infection used, as well as considerable risk of bias, particularly as few studies actively screened participants for SSI. Conclusion Synthesis of published estimates of infection yield a rate higher than that seen in national surveillance procedures. Biases noted in all studies would trend towards an underestimate, largely due to inadequate follow-up.
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Affiliation(s)
- James Masters
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joon Soo Ha
- The Royal College of Surgeons of England, London, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Metcalfe D, Pitkeathley C, Herring J. 'Advice, not orders'? The evolving legal status of clinical guidelines. J Med Ethics 2020; 47:medethics-2020-106592. [PMID: 32878917 DOI: 10.1136/medethics-2020-106592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 06/11/2023]
Abstract
Healthcare professionals are expected to deliver care that is consistent with clinical guidelines. In this article, we show that the English courts are increasingly willing to be persuaded by written guidelines when determining the standard of care in cases of alleged clinical negligence. This reflects a wider shift in the approach taken by courts in a number of common law jurisdictions around the world. However, we argue that written guidelines are still only one element that courts should consider when determining the standard of care. It is possible to deliver perfect care that deviates from professional guidelines and even to deliver negligent care by uncritically following a guideline that is flawed. We further argue that written guidelines are relevant beyond defining the accepted standard of care. This is because the decision to deviate from a guideline suggests the existence of multiple approaches that should be discussed with patients as part of ensuring informed consent. It is therefore likely that written guidelines will become an even more prominent feature of the medicolegal landscape in future years.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
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Affiliation(s)
- Andrew Judge
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
- Biomedical Research Centre, National Institute for Health Research, University of Bristol, Bristol, UK
| | - David Metcalfe
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael R Whitehouse
- Biomedical Research Centre, National Institute for Health Research, University of Bristol, Bristol, UK
| | - Nick Parsons
- Statistics and Epidemiology, Warwick Medical School, University of Warwich, Warwick, UK
| | - Matt Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Zogg CK, Scott JW, Metcalfe D, Gluck AR, Curfman GD, Davis KA, Dimick JB, Haider AH. Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients. JAMA Surg 2020; 154:402-411. [PMID: 30601888 DOI: 10.1001/jamasurg.2018.5177] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation. Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act. Design, Setting, and Participants Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states. Interventions/Exposure Policy implementation in January 2014. Main Outcomes and Measures Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation. Results A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation. Conclusions and relevance This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | - John W Scott
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - David Metcalfe
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Abbe R Gluck
- Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | - Gregory D Curfman
- Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
| | | | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Affiliation(s)
- Benjamin Ollivere
- Division of Rheumatology, Orthopaedics & Sports medicine, Dermatology, University of Nottingham, Queens Medical Centre, Nottingham, UK
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre for Critical Care Research, John Radcliffe Hospital, Oxford, UK
| | - Daniel C Perry
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre for Critical Care Research, John Radcliffe Hospital, Oxford, UK
| | - Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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Abstract
IMPORTANCE Hip osteoarthritis (OA) is a common cause of pain and disability. OBJECTIVE To identify the clinical findings that are most strongly associated with hip OA. DATA SOURCES Systematic search of MEDLINE, PubMed, EMBASE, and CINAHL from inception until November 2019. STUDY SELECTION Included studies (1) quantified the accuracy of clinical findings (history, physical examination, or simple tests) and (2) used plain radiographs as the reference standard for diagnosing hip OA. DATA EXTRACTION AND SYNTHESIS Studies were assigned levels of evidence using the Rational Clinical Examination scale and assessed for risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool. Data were extracted using individual hips as the unit of analysis and only pooled when findings were reported in 3 or more studies. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, and likelihood ratios (LRs). RESULTS Six studies were included, with data from 1110 patients and 1324 hips, of which 509 (38%) showed radiographic evidence of OA. Among patients presenting to primary care physicians with hip or groin pain, the affected hip showed radiographic evidence of OA in 34% of cases. A family history of OA, personal history of knee OA, or pain on climbing stairs or walking up slopes all had LRs of 2.1 (sensitivity range, 33%-68%; specificity range, 68%-84%; broadest LR range: 95% CI, 1.1-3.8). To identify patients most likely to have OA, the most useful findings were squat causing posterior pain (sensitivity, 24%; specificity, 96%; LR, 6.1 [95% CI, 1.3-29]), groin pain on passive abduction or adduction (sensitivity, 33%; specificity, 94%; LR, 5.7 [95% CI, 1.6-20]), abductor weakness (sensitivity, 44%; specificity, 90%; LR, 4.5 [95% CI, 2.4-8.4]), and decreased passive hip adduction (sensitivity, 80%; specificity, 81%; LR, 4.2 [95% CI, 3.0-6.0]) or internal rotation (sensitivity, 66%; specificity, 79%; LR, 3.2 [95% CI, 1.7-6.0]) as measured by a goniometer or compared with the contralateral leg. The presence of normal passive hip adduction was most useful for suggesting the absence of OA (negative LR, 0.25 [95% CI, 0.11-0.54]). CONCLUSIONS AND RELEVANCE Simple tests of hip motion and observing for pain during that motion were helpful in distinguishing patients most likely to have OA on plain radiography from those who will not. A combination of findings efficiently detects those most likely to have severe hip OA.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Daniel C Perry
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Henry A Claireaux
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - David L Simel
- Durham Veterans Affairs Health System, Durham, North Carolina
- Duke University, Durham, North Carolina
| | - Cheryl K Zogg
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Metcalfe D, Zogg CK, Haut ER, Pawlik TM, Haider AH, Perry DC. Data resource profile: State Inpatient Databases. Int J Epidemiol 2019; 48:1742-1742h. [PMID: 31280297 PMCID: PMC6929527 DOI: 10.1093/ije/dyz117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 02/06/2023] Open
Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | | | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Harvard Medical School, Boston, MA, USA
| | - Daniel C Perry
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Rios-Diaz AJ, Metcalfe D, Devin CL, Berger A, Palazzo F. Six-month readmissions after bariatric surgery: Results of a nationwide analysis. Surgery 2019; 166:926-933. [DOI: 10.1016/j.surg.2019.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/23/2019] [Accepted: 06/04/2019] [Indexed: 01/19/2023]
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Rios-Diaz AJ, Bevilacqua LA, Devin CL, Metcalfe D, Berger AC, Cowan SW, Palazzo F, Evans NR. Nationwide Management and Recurrence of Spontaneous Pneumothorax by Treatment Approach. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Parsons N, Carey-Smith R, Dritsaki M, Griffin X, Metcalfe D, Perry D, Stengel D, Costa M. Statistical significance and p-values: guidelines for use and reporting. Bone Joint J 2019; 101-B:1179-1183. [PMID: 31564151 DOI: 10.1302/0301-620x.101b10.bjj-2019-0890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Nick Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard Carey-Smith
- Sir Charles Gairdner Hospital and The University of Western Australia, Nedlands, Perth, Australia
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Xavier Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Metcalfe
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel Perry
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dirk Stengel
- Department of Trauma and Orthopaedic Surgery, Centre for Clinical Research, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Matthew Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Abstract
Aims This study explores data quality in operation type and fracture classification recorded as part of a large research study and a national audit with an independent review. Patients and Methods At 17 centres, an expert surgeon reviewed a randomly selected subset of cases from their centre with regard to fracture classification using the AO system and type of operation performed. Agreement for these variables was then compared with the data collected during conduct of the World Hip Trauma Evaluation (WHiTE) cohort study. Both types of surgery and fracture classification were collapsed to identify the level of detail of reporting that achieved meaningful agreement. In the National Hip Fracture Database (NHFD), the types of operation and fracture classification were explored to identify the proportion of “highly improbable” combinations. Results The records were reviewed for 903 cases. Agreement for the subtypes of extracapsular fracture was poor; most centres achieved no better than “fair” agreement. When the classification was collapsed to a single option for “extracapsular” fracture, only four centres failed to have at least “moderate” agreement. There was only “moderate” agreement for the subtypes of intracapsular fracture, which improved to “substantial” when collapsed to “intracapsular”. Subtrochanteric fracture types were well reported with “substantial” agreement. There was near “perfect” agreement for internal fixation procedures. “Perfect” or “substantial” agreement was achieved when the type of arthroplasty surgery was reported at the level of “hemiarthroplasty” and “total hip replacement”. When reviewing data submitted to the NHFD, a minimum of 5.2% of cases contained “highly improbable” procedures for the stated fracture classification. Conclusion The complexity of collecting fracture classification data at a national scale compromises the accuracy with which detailed classification systems can be reported. Data around type of surgery performed show similar tendencies. Data capture, reporting, and interpretation in future studies must take this into account. Cite this article: Bone Joint J 2019;101-B:1292–1299
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Affiliation(s)
- James Masters
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - David Metcalfe
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | | | - Juul Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Xavier L. Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Matt L. Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Metcalfe D, Zogg CK, Judge A, Perry DC, Gabbe B, Willett K, Costa ML. Pay for performance and hip fracture outcomes: an interrupted time series and difference-in-differences analysis in England and Scotland. Bone Joint J 2019; 101-B:1015-1023. [PMID: 31362544 PMCID: PMC6683232 DOI: 10.1302/0301-620x.101b8.bjj-2019-0173.r1] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Aims Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. Materials and Methods We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. Results There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. Conclusion This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England. Cite this article: Bone Joint J 2019;101-B:1015–1023.
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Affiliation(s)
- D Metcalfe
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - C K Zogg
- Yale School of Medicine, New Haven, Connecticut, USA
| | - A Judge
- Centre for Statistics in Medicine, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre (NIHR Bristol BRC), University Hospitals Bristol NHS Foundation Trust, University of Bristol, Southmead Hospital, Bristol, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - D C Perry
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - B Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - K Willett
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - M L Costa
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
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Metcalfe D, Masters J, Delmestri A, Judge A, Perry D, Zogg C, Gabbe B, Costa M. Coding algorithms for defining Charlson and Elixhauser co-morbidities in Read-coded databases. BMC Med Res Methodol 2019; 19:115. [PMID: 31170931 PMCID: PMC6554904 DOI: 10.1186/s12874-019-0753-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
Background Comorbidity measures, such as the Charlson Comorbidity Index (CCI) and Elixhauser Method (EM), are frequently used for risk-adjustment by healthcare researchers. This study sought to create CCI and EM lists of Read codes, which are standard terminology used in some large primary care databases. It also aimed to describe and compare the predictive properties of the CCI and EM amongst patients with hip fracture (and matched controls) in a large primary care administrative dataset. Methods Two researchers independently screened 111,929 individual Read codes to populate the 17 CCI and 31 EM comorbidity categories. Patients with hip fractures were identified (together with age- and sex-matched controls) from UK primary care practices participating in the Clinical Practice Research Datalink (CPRD). The predictive properties of both comorbidity measures were explored in hip fracture and control populations using logistic regression models fitted with 30- and 365-day mortality as the dependent variables together with tests of equality for Receiver Operating Characteristic (ROC) curves. Results There were 5832 CCI and 7156 EM comorbidity codes. The EM improved the ability of a logistic regression model (using age and sex as covariables) to predict 30-day mortality (AUROC 0.744 versus 0.686). The EM alone also outperformed the CCI (0.696 versus 0.601). Capturing comorbidities over a prolonged period only modestly improved the predictive value of either index: EM 1-year look-back 0.645 versus 5-year 0.676 versus complete record 0.695 and CCI 0.574 versus 0.591 versus 0.605. Conclusions The comorbidity code lists may be used by future researchers to calculate CCI and EM using records from Read coded databases. The EM is preferable to the CCI but only marginal gains should be expected from incorporating comorbidities over a period longer than 1 year. Electronic supplementary material The online version of this article (10.1186/s12874-019-0753-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Metcalfe
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Headley Way, Oxford, OX3 9BU, UK.
| | - James Masters
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Headley Way, Oxford, OX3 9BU, UK
| | - Antonella Delmestri
- Centre for Statistics in Medicine, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Andrew Judge
- Centre for Statistics in Medicine, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre (NIHR Bristol BRC), University Hospitals Bristol NHS Foundation Trust, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - Daniel Perry
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Headley Way, Oxford, OX3 9BU, UK
| | - Cheryl Zogg
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Headley Way, Oxford, OX3 9BU, UK.,Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Matthew Costa
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Headley Way, Oxford, OX3 9BU, UK
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Abstract
Aims This study sought to determine the proportion of older adults with hip fractures captured by a multicentre prospective cohort, the World Hip Trauma Evaluation (WHiTE), whether there was evidence of selection bias during WHiTE recruitment, and the extent to which the WHiTE cohort is representative of the broader population of older adults with hip fractures. Patients and Methods The characteristics of patients recruited into the WHiTE cohort study were compared with those treated at WHiTE hospitals during the same timeframe and submitted to the National Hip Fracture Database (NHFD). Results Patients recruited to WHiTE were more likely to be admitted from their own home (83.5% vs 80.2%; p < 0.001) and to have a higher median Abbreviated Mental Test Score (AMTS) (9 (interquartile range (IQR) 6 to 10) vs 9 (IQR 5 to 10); p < 0.001) than those who were not recruited. In terms of WHiTE cohort generalizability, participating hospitals included a greater proportion of Major Trauma Centres (47.8% vs 7.8%) and large hospitals (997 (IQR 873 to 1290) vs 707 (459 to 903) beds) with high-volume Emergency Departments (median annual attendances of 43 981 (IQR 37 147 to 54 385) vs 35 964 (IQR 26 229 to 50 551)). However, there were few differences in baseline characteristics between patients in the WHiTE cohort and those recorded in the NHFD. Conclusion There is evidence of a weak selection bias towards recruiting fitter patients within the WHiTE cohort, which will help to put into context the findings of future studies. We conclude that the patients within the WHiTE cohort are representative of the national population of older adults with hip fractures throughout England, Wales, and Northern Ireland. Cite this article: Bone Joint J 2019;101-B:708–714.
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Affiliation(s)
- D. Metcalfe
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - M. L. Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - N. R. Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - J. Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - J. Masters
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - M. E. Png
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - S. E. Lamb
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - X. L. Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Metcalfe D, Judge A, Perry DC, Gabbe B, Zogg CK, Costa ML. Total hip arthroplasty versus hemiarthroplasty for independently mobile older adults with intracapsular hip fractures. BMC Musculoskelet Disord 2019; 20:226. [PMID: 31101041 PMCID: PMC6525472 DOI: 10.1186/s12891-019-2590-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/25/2019] [Indexed: 01/26/2023] Open
Abstract
Background Displaced intracapsular hip fractures are typically treated with hemiarthroplasty (HA) or total hip arthroplasty (THA). A number of professional bodies recommend considering THA for patients that were independently mobile and cognitively intact before injury. The aim of this study was to compare the outcomes between HA and THA for independently mobile older adults with hip fractures. Methods A systematic review and meta-analysis of RCTs was undertaken alongside analysis of a propensity score matched national cohort of older adults (aged > 60) with hip fractures. Participants were identified for the propensity score matched cohort from the National Hip Fracture Database (NHFD), which was linked to Hospital Episode Statistics (HES) and civil death registration data. The primary outcomes were 12-month dislocation, revision, and mortality. The secondary outcomes were length of stay, discharge home, unplanned re-admission, functional outcomes, and health-related quality of life. Results Five RCTs reported higher THA dislocation but this was not statistically significant (THA risk ratio [RR] 2.77, 95% CI 0.81 to 9.48). However, THA dislocation was significantly higher in the national observational dataset (sub-distribution hazard ratio [SHR] 1.73, 95% CI 1.24 to 2.41). Meta-analysis of data from four RCTs did not identify a significant difference in terms of revision (RR 1.52, 95% CI 0.56 to 4.14). However, THA revision was significantly lower in the national dataset (SHR 0.66, 95% CI 0.48 to 0.90). Meta-analysis of data from 5 RCTs suggested higher mortality amongst patients undergoing HA (RR 0.63, 95% CI 0.38 to 1.04), which was also observed within the national registry dataset (hazard ratio 0.45, 95% CI 0.37 to 0.54). Conclusions National clinical registries can provide important context when interpreting RCT data, which may alone be inadequate for comparing the safety profile of surgical interventions. These data suggest that THA is at significantly higher risk of dislocation but lower risk of revision within 12 months. The finding from both RCT and clinical registry data that THA is associated with lower 12-month mortality amongst the fittest patients with hip fractures requires urgent further study to determine whether or not this can be replicated in other balanced populations. Electronic supplementary material The online version of this article (10.1186/s12891-019-2590-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 9BU, UK.
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 9BU, UK.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Daniel C Perry
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 9BU, UK
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Cheryl K Zogg
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 9BU, UK
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Metcalfe D, Castillo-Angeles M, Rios-Diaz AJ, Havens JM, Haider A, Salim A. Is there a "weekend effect" in emergency general surgery? J Surg Res 2019; 222:219-224. [PMID: 29273370 DOI: 10.1016/j.jss.2017.10.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/25/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Weekend admission is associated with increased mortality across a range of patient populations and health-care systems. The aim of this study was to determine whether weekend admission is independently associated with serious adverse events (SAEs), in-hospital mortality, or failure to rescue (FTR) in emergency general surgery (EGS). METHODS An observational study was performed using the National Inpatient Sample in 2012-2013; the largest all-payer inpatient database in the United States, which represents a 20% stratified sample of hospital discharges. The inclusion criteria were all inpatients with a primary EGS diagnosis. Outcomes were SAE, in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed an SAE). Multivariable logistic regression were used to adjust for patient- (age, sex, race, payer status, and Charlson comorbidity index) and hospital-level (trauma designation and hospital bed size) characteristics. RESULTS There were 1,344,828 individual patient records (6.7 million weighted admissions). The overall rate of SAE was 15.1% (15.1% weekend, 14.9% weekday, P < 0.001), FTR 5.9% (6.2% weekend, 5.9% weekday, P = 0.010), and in-hospital mortality 1.4% (1.5% weekend, 1.3% weekday, P < 0.001). Within logistic regression models, weekend admission was an independent risk factor for development of SAE (adjusted odds ratio 1.08, 1.07-1.09), FTR (1.05, 1.01-1.10), and in-hospital mortality (1.14, 1.10-1.18). CONCLUSIONS This study found evidence that outcomes coded in an administrative data set are marginally worse for EGS patients admitted at weekends. This justifies further work using clinical data sets that can be used to better control for differences in case mix.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.
| | - Manuel Castillo-Angeles
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joaquim M Havens
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
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Abstract
UNLABELLED : media-1vid110.1542/5828355774001PEDS-VA_2018-1067Video Abstract BACKGROUND: Slipped capital femoral epiphysis (SCFE) is believed to be associated with childhood obesity, although the strength of the association is unknown. METHODS We performed a cohort study using routine data from health screening examinations at primary school entry (5-6 years old) in Scotland, linked to a nationwide hospital admissions database. A subgroup had a further screening examination at primary school exit (11-12 years old). RESULTS BMI was available for 597 017 children at 5 to 6 years old in school and 39 468 at 11 to 12 years old. There were 4.26 million child-years at risk for SCFE. Among children with obesity at 5 to 6 years old, 75% remained obese at 11 to 12 years old. There was a strong biological gradient between childhood BMI at 5 to 6 years old and SCFE, with the risk of disease increasing by a factor of 1.7 (95% confidence interval [CI] 1.5-1.9) for each integer increase in BMI z score. The risk of SCFE was almost negligible among children with the lowest BMI. Those with severe obesity at 5 to 6 years old had 5.9 times greater risk of SCFE (95% CI 3.9-9.0) compared with those with a normal BMI; those with severe obesity at 11 to 12 years had 17.0 times the risk of SCFE (95% CI 5.9-49.0). CONCLUSIONS High childhood BMI is strongly associated with SCFE. The magnitude of the association, temporal relationship, and dose response added to the plausible mechanism offer the strongest evidence available to support a causal association.
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Affiliation(s)
- Daniel C Perry
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; .,Alder Hey Children's Hospital, Liverpool, United Kingdom.,Oxford Trauma, Nuffield Department of Orthopaedics Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; and
| | - David Metcalfe
- Oxford Trauma, Nuffield Department of Orthopaedics Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; and
| | - Steven Lane
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Steven Turner
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
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Zogg CK, Scott JW, Metcalfe D, Davis KA, Dimick JB, Haider AH. Association Between Medicaid Eligibility and Gains in Access to Rehabilitative Care: A Difference in Assessment of Affordable Care Act-Related Changes to Insurance Coverage, Outcomes, and Discharge to Rehabilitation among Adult Trauma Patients. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Aims The aim of this study was to describe temporal trends and survivorship of total hip arthroplasty (THA) in very young patients, aged ≤ 20 years. Patients and Methods A descriptive observational study was undertaken using data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man between April 2003 and March 2017. All patients aged ≤ 20 years at the time of THA were included and the primary outcome was revision surgery. Descriptive statistics were used to summarize the data and Kaplan–Meier estimates calculated for the cumulative implant survival. Results A total of 769 THAs were performed in 703 patients. The median follow-up was 5.1 years (interquartile range (IQR) 2.6 to 7.8). Eight patients died and 35 THAs were revised. The use of metal-on-metal (MoM) bearings and resurfacing procedures declined after 2008. The most frequently recorded indications for revision were loosening (20%) and infection (20%), although the absolute risk of these events occurring was low (0.9%). Factors associated with lower implant survival were MoM and metal-on-polyethylene (MoP) bearings and resurfacing arthroplasty ( vs ceramic-on-polyethylene (CoP) and ceramic-on-ceramic (CoC) bearings, p = 0.002), and operations performed by surgeons who undertook few THAs in this age group as recorded in the NJR ( vs those with five or more recorded operations, p = 0.030). Kaplan–Meier estimates showed 96% (95% confidence interval (CI) 94% to 98%) survivorship of implants at five years. Conclusion Within the NJR, the overall survival for very young patients undergoing THA exceeded 96% during the first five postoperative years. In the absence of studies that can better account for differences in the characteristics of the patients, surgeons should consider the association between early revision and the type of implant, the number of THAs performed in these patients, and the bearing surface when performing THA in very young patients. Cite this article: Bone Joint J 2018;100-B:1320–9.
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Affiliation(s)
- D. Metcalfe
- Associate Professor of Orthopaedic and Trauma Surgery Oxford Trauma, NuffieldDepartment of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK and Consultant Orthopaedic Surgeon, Alder Hey Children’s Hospital, Liverpool, UK
| | - N. Peterson
- Specialty Registrar in Trauma & Orthopaedic Surgery, Alder Hey Children’s Hospital, Liverpool, UK
| | - J. M. Wilkinson
- Department of Oncology and Metabolism, University of Sheffield, Sorby Wing, Northern General Hospital, Sheffield, UK
| | - D. C. Perry
- Associate Professor of Orthopaedic and Trauma Surgery Oxford Trauma, NuffieldDepartment of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK and Consultant Orthopaedic Surgeon, Alder Hey Children’s Hospital, Liverpool, UK
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Metcalfe D, Rios Diaz AJ, Olufajo OA, Massa MS, Ketelaar NABM, Flottorp SA, Perry DC. Impact of public release of performance data on the behaviour of healthcare consumers and providers. Cochrane Database Syst Rev 2018; 9:CD004538. [PMID: 30188566 PMCID: PMC6513271 DOI: 10.1002/14651858.cd004538.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is becoming increasingly common to publish information about the quality and performance of healthcare organisations and individual professionals. However, we do not know how this information is used, or the extent to which such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers, and purchasers. OBJECTIVES To estimate the effects of public release of performance data, from any source, on changing the healthcare utilisation behaviour of healthcare consumers, providers (professionals and organisations), and purchasers of care. In addition, we sought to estimate the effects on healthcare provider performance, patient outcomes, and staff morale. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trials registers on 26 June 2017. We checked reference lists of all included studies to identify additional studies. SELECTION CRITERIA We searched for randomised or non-randomised trials, interrupted time series, and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or professionals. Each study had to report at least one main outcome related to selecting or changing care. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers, and healthcare purchasers), performance data, main outcomes (choice of healthcare provider, and improvement by means of changes in care), and other outcomes (awareness, attitude, knowledge of performance data, and costs). Given the substantial degree of clinical and methodological heterogeneity between the studies, we presented the findings for each policy in a structured format, but did not undertake a meta-analysis. MAIN RESULTS We included 12 studies that analysed data from more than 7570 providers (e.g. professionals and organisations), and a further 3,333,386 clinical encounters (e.g. patient referrals, prescriptions). We included four cluster-randomised trials, one cluster-non-randomised trial, six interrupted time series studies, and one controlled before-after study. Eight studies were undertaken in the USA, and one each in Canada, Korea, China, and The Netherlands. Four studies examined the effect of public release of performance data on consumer healthcare choices, and four on improving quality.There was low-certainty evidence that public release of performance data may make little or no difference to long-term healthcare utilisation by healthcare consumers (3 studies; 18,294 insurance plan beneficiaries), or providers (4 studies; 3,000,000 births, and 67 healthcare providers), or to provider performance (1 study; 82 providers). However, there was also low-certainty evidence to suggest that public release of performance data may slightly improve some patient outcomes (5 studies, 315,092 hospitalisations, and 7502 providers). There was low-certainty evidence from a single study to suggest that public release of performance data may have differential effects on disadvantaged populations. There was no evidence about effects on healthcare utilisation decisions by purchasers, or adverse effects. AUTHORS' CONCLUSIONS The existing evidence base is inadequate to directly inform policy and practice. Further studies should consider whether public release of performance data can improve patient outcomes, as well as healthcare processes.
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Affiliation(s)
- David Metcalfe
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)John Radcliffe HospitalHeadley WayOxfordUKOX3 9DU
| | - Arturo J Rios Diaz
- Thomas Jefferson University HospitalDepartment of Surgery1100 Walnut StreetPhiladelphiaPAUSA19107
| | - Olubode A Olufajo
- Howard‐Harvard Health Sciences Outcomes Research Center Howard University College of MedicineDepartment of Surgery2041 Georgia Ave, NWWashingtonDCUSA20060
| | - M. Sofia Massa
- University of OxfordNuffield Department of Population HealthBig Data Institute, Old Road CampusOxfordUKOX3 7LF
| | - Nicole ABM Ketelaar
- Saxion University of Applied SciencesSocial Work Research GroupEnschedeNetherlands
| | - Signe A. Flottorp
- Norwegian Institute of Public HealthPO box 222 SkøyenOsloNorway0213
- University of OsloInstitute of Health and SocietyP.O box 1130 BlindernOsloNorway0318
| | - Daniel C Perry
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)John Radcliffe HospitalHeadley WayOxfordUKOX3 9DU
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Robinson BT, Metcalfe D, Cuff AV, Pidgeon TE, Hewitt KJ, Gibbs VN, Rossiter DJ, Griffin XL. Surgical techniques for autologous bone harvesting from the iliac crest in adults. Hippokratia 2018. [DOI: 10.1002/14651858.cd011783.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Benjamin T Robinson
- University Hospitals Coventry & Warwickshire NHS Trust; Clifford Bridge Road Coventry UK CV2 2DX
| | - David Metcalfe
- University of Oxford; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); John Radcliffe Hospital Headley Way Oxford UK OX3 9DU
| | - Andrew V Cuff
- Rotherham NHS Foundation Trust; Physiotherapy Department; Moorgate Road Rotherham South Yorkshire UK S60 2UD
| | - Thomas E Pidgeon
- University Hospitals Coventry & Warwickshire NHS Trust; Clifford Bridge Road Coventry UK CV2 2DX
| | | | - Victoria N Gibbs
- University Hospitals Coventry & Warwickshire NHS Trust; Clifford Bridge Road Coventry UK CV2 2DX
| | - Daniel J Rossiter
- University Hospitals Coventry & Warwickshire NHS Trust; Clifford Bridge Road Coventry UK CV2 2DX
| | - Xavier L Griffin
- University of Oxford, John Radcliffe Hospital; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); Kadoorie Centre Headley Way Oxford UK OX3 9DU
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Abstract
OBJECTIVES To describe the epidemiology of slipped capital femoral epiphysis (SCFE), to examine associations with childhood obesity and socioeconomic deprivation, and to explore factors associated with diagnostic delays. DESIGN Historic cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink and Hospital Episode Statistics. SETTING All contacts with healthcare services, including emergency presentations, outpatient appointments, inpatient admissions and primary care visits, within the UK National Health Service. PATIENTS All individuals <16 years old with a diagnosis of SCFE and whose electronic medical record was held by one of 650 primary care practices in the UK between 1990 and 2013. MAIN OUTCOME MEASURES Annual incidence, missed opportunities for diagnosis and diagnostic delay. RESULTS Over the 23-year period the incidence remained constant at 4.8 (95% CI 4.4 to 5.2) cases per 100,000 0-16-year-olds. There was a strong association with socioeconomic deprivation. Predisease obesity was also strongly associated with SCFE; mean predisease z-score of body mass index was 1.43 (95% CI 1.20 to 1.68) compared with the UK reference mean. Diagnostic delays were common, with most children (75.4%) having multiple primary care contacts with relevant symptomatology, and those who presented with knee pain having significantly longer diagnostic delay (median 161 (IQR 27-278) days) than those with hip pain (20 (5-126)) or gait abnormalities (21 (7-72)). CONCLUSIONS SCFE has a strong association with both area-level socioeconomic deprivation and predisease obesity. The majority of patients with SCFE are initially misdiagnosed and those presenting with knee pain are particularly at risk.
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Affiliation(s)
- Daniel C Perry
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Tjeerd Van Staa
- Health eResearch Centre, University of Manchester, Manchester, UK
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Yorkgitis BK, Olufajo OA, Metcalfe D, Reznor G, Havens JM, Cooper Z, Salim A. Do Transferred Patients Increase the Risk of Venous Thromboembolism in Trauma Centers? Am Surg 2017; 83:1241-1245. [PMID: 29183526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Trauma patients often require initial stabilization followed by transfer for ongoing trauma care. Thus, the administration of VTE prophylaxis is often delayed until admission to the receiving hospital. It is unclear if transfer status is a risk factor for VTE. The National Trauma Database v6.2 was used to identify patients admitted to Level I and II trauma centers. Exclusions included patients on anticoagulation, <18 years, known VTE before trauma, or pregnant. Patients transferred were compared with nontransferred patients. Analysis included 736,374 patients with 189,166 (25.69%) transferred patients within 24 hours of injury. Using weighted measures, VTE was identified in 11,619 (1.50%) patients. The VTE rate was significantly higher in the transferred group compared with the nontransferred group (1.73% vs 1.42%, P = 0.002) including deep venous thrombosis (1.39% vs 1.14%, P = 0.004) and pulmonary embolism (0.45% vs 0.39%, P = 0.003). Multivariable analyses adjusting for patient-level risk factors demonstrated that transfer was associated with a higher likelihood of VTE (aOR 1.18; 95% CI: 1.09-1.28, P ≤ 0.001), pulmonary embolism (aOR 1.21; 95% CI: 1.11-1.33, P ≤ 0.001), and deep venous thrombosis (aOR 1.17; 95% CI: 1.07-1.28, P = 0.0004). Transfer status of trauma patients is a risk factor for VTE. Accepting a transferred patient results in an increased VTE risk and may not be reflective of the quality of care at the receiving facility.
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