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Alba AC, Darzi AJ, Buchan TA, Kum E, Uhlman K, Aleksova N, Orchanian-Cheff A, Kugathasan L, Foroutan F, McGinn T, Guyatt G. The design of studies testing the effectiveness of risk-guided care has many challenges: a scoping review addressing key considerations. J Clin Epidemiol 2023; 164:15-26. [PMID: 37852391 DOI: 10.1016/j.jclinepi.2023.10.002] [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: 08/17/2023] [Revised: 09/26/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES Studies evaluating the effectiveness of care based on patients' risk of adverse outcomes (risk-guided care) use a variety of study designs. In this scoping review, using examples, we review characteristics of relevant studies and present key design features to optimize the trustworthiness of results. STUDY DESIGN AND SETTING We searched five online databases for studies evaluating the effect of risk-guided care among adults on clinical outcomes, process, or cost. Pairs of reviewers independently performed screening and data abstraction. We descriptively summarized the study design and characteristics. RESULTS Among 14,561 hits, we identified 116 eligible studies. Study designs included randomized controlled trials (RCTs), post hoc analysis of RCTs, and retrospective or prospective cohort studies. Challenges and sources of bias in the design included limited performance of predictive models, contamination, inadequacy to address the credibility of subgroup effects, absence of differences in care across risk strata, reporting only process measures as opposed to clinical outcomes, and failure to report benefits and harms. CONCLUSION To assess the benefit of risk-guided care, RCTs provide the most trustworthy evidence. Observational studies offer an alternative but are hampered by confounding and other limitations. Reaching valid conclusions when testing risk-guided care requires addressing the challenges identified in our review.
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Affiliation(s)
- Ana C Alba
- Ted Rogers Center for Heart Research, Peter Munk Cardiac Center, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Tayler A Buchan
- Ted Rogers Center for Heart Research, Peter Munk Cardiac Center, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Elena Kum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn Uhlman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Natasha Aleksova
- Ted Rogers Center for Heart Research, Peter Munk Cardiac Center, Toronto, Ontario, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Lakshmi Kugathasan
- Ted Rogers Center for Heart Research, Peter Munk Cardiac Center, Toronto, Ontario, Canada
| | - Farid Foroutan
- Ted Rogers Center for Heart Research, Peter Munk Cardiac Center, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thomas McGinn
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Stevens ER, Agbakoba R, Mann DM, Hess R, Richardson SI, McGinn T, Smith PD, Halm W, Mundt MP, Dauber-Decker KL, Jones SA, Feldthouse DM, Kim EJ, Feldstein DA. Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial. BMC Med Inform Decis Mak 2023; 23:260. [PMID: 37964232 PMCID: PMC10644670 DOI: 10.1186/s12911-023-02368-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 11/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Overprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model. METHODS Following qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout. DISCUSSION This study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303 .
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Affiliation(s)
| | | | - Devin M Mann
- NYU Grossman School of Medicine, New York, NY, USA
| | - Rachel Hess
- University of Utah Health, Salt Lake City, UT, USA
| | | | | | - Paul D Smith
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Wendy Halm
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- University of Wisconsin School of Nursing, Madison, WI, USA
| | - Marlon P Mundt
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | | | - Eun Ji Kim
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - David A Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Solomon J, Dauber-Decker K, Richardson S, Levy S, Khan S, Coleman B, Persaud R, Chelico J, King D, Spyropoulos A, McGinn T. Integrating Clinical Decision Support Into Electronic Health Record Systems Using a Novel Platform (EvidencePoint): Developmental Study. JMIR Form Res 2023; 7:e44065. [PMID: 37856193 PMCID: PMC10623239 DOI: 10.2196/44065] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 06/21/2023] [Accepted: 07/31/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Through our work, we have demonstrated how clinical decision support (CDS) tools integrated into the electronic health record (EHR) assist providers in adopting evidence-based practices. This requires confronting technical challenges that result from relying on the EHR as the foundation for tool development; for example, the individual CDS tools need to be built independently for each different EHR. OBJECTIVE The objective of our research was to build and implement an EHR-agnostic platform for integrating CDS tools, which would remove the technical constraints inherent in relying on the EHR as the foundation and enable a single set of CDS tools that can work with any EHR. METHODS We developed EvidencePoint, a novel, cloud-based, EHR-agnostic CDS platform, and we will describe the development of EvidencePoint and the deployment of its initial CDS tools, which include EHR-integrated applications for clinical use cases such as prediction of hospitalization survival for patients with COVID-19, venous thromboembolism prophylaxis, and pulmonary embolism diagnosis. RESULTS The results below highlight the adoption of the CDS tools, the International Medical Prevention Registry on Venous Thromboembolism-D-Dimer, the Wells' criteria, and the Northwell COVID-19 Survival (NOCOS), following development, usability testing, and implementation. The International Medical Prevention Registry on Venous Thromboembolism-D-Dimer CDS was used in 5249 patients at the 2 clinical intervention sites. The intervention group tool adoption was 77.8% (4083/5249 possible uses). For the NOCOS tool, which was designed to assist with triaging patients with COVID-19 for hospital admission in the event of constrained hospital resources, the worst-case resourcing scenario never materialized and triaging was never required. As a result, the NOCOS tool was not frequently used, though the EvidencePoint platform's flexibility and customizability enabled the tool to be developed and deployed rapidly under the emergency conditions of the pandemic. Adoption rates for the Wells' criteria tool will be reported in a future publication. CONCLUSIONS The EvidencePoint system successfully demonstrated that a flexible, user-friendly platform for hosting CDS tools outside of a specific EHR is feasible. The forthcoming results of our outcomes analyses will demonstrate the adoption rate of EvidencePoint tools as well as the impact of behavioral economics "nudges" on the adoption rate. Due to the EHR-agnostic nature of EvidencePoint, the development process for additional forms of CDS will be simpler than traditional and cumbersome IT integration approaches and will benefit from the capabilities provided by the core system of EvidencePoint.
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Affiliation(s)
- Jeffrey Solomon
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Katherine Dauber-Decker
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Safiya Richardson
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Sera Levy
- Department of Psychiatry, Heersink School of Medicine, University of Alabama at Birmingham Medicine, Birmingham, AL, United States
| | - Sundas Khan
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Benjamin Coleman
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Rupert Persaud
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - John Chelico
- Physician Enterprise, CommonSpirit Health, Chicago, IL, United States
| | - D'Arcy King
- School of Psychology, Fielding Graduate University, Santa Barbara, CA, United States
| | - Alex Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Thomas McGinn
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
- Physician Enterprise, CommonSpirit Health, Chicago, IL, United States
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Feldstein DA, Barata I, McGinn T, Heineman E, Ross J, Kaplan D, Bullaro F, Khan S, Kuehnel N, Berger RP. Disseminating child abuse clinical decision support among commercial electronic health records: Effects on clinical practice. JAMIA Open 2023; 6:ooad022. [PMID: 37063409 PMCID: PMC10101685 DOI: 10.1093/jamiaopen/ooad022] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/08/2023] [Accepted: 03/28/2023] [Indexed: 04/18/2023] Open
Abstract
Objectives The use of electronic health record (EHR)-embedded child abuse clinical decision support (CA-CDS) may help decrease morbidity from child maltreatment. We previously reported on the development of CA-CDS in Epic and Allscripts. The objective of this study was to implement CA-CDS into Epic and Allscripts and determine its effects on identification, evaluation, and reporting of suspected child maltreatment. Materials and Methods After a preimplementation period, CA-CDS was implemented at University of Wisconsin (Epic) and Northwell Health (Allscripts). Providers were surveyed before the go-live and 4 months later. Outcomes included the proportion of children who triggered the CA-CDS system, had a positive Child Abuse Screen (CAS) and/or were reported to Child Protective Services (CPS). Results At University of Wisconsin (UW), 3.5% of children in the implementation period triggered the system. The CAS was positive in 1.8% of children. The proportion of children reported to CPS increased from 0.6% to 0.9%. There was rapid uptake of the abuse order set.At Northwell Health (NW), 1.9% of children in the implementation period triggered the system. The CAS was positive in 1% of children. The child abuse order set was rarely used. Preimplementation, providers at both sites were similar in desire to have CA-CDS system and perception of CDS in general. After implementation, UW providers had a positive perception of the CA-CDS system, while NW providers had a negative perception. Discussion CA-CDS was able to be implemented in 2 different EHRs with differing effects on clinical care and provider feedback. At UW, the site with higher uptake of the CA-CDS system, the proportion of children who triggered the system and the rate of positive CAS was similar to previous studies and there was an increase in the proportion of cases of suspected abuse identified as measured by reports to CPS. Our data demonstrate how local environment, end-users' opinions, and limitations in the EHR platform can impact the success of implementation. Conclusions When disseminating CA-CDS into different hospital systems and different EHRs, it is critical to recognize how limitations in the functionality of the EHR can impact the success of implementation. The importance of collecting, interpreting, and responding to provider feedback is of critical importance particularly with CDS related to child maltreatment.
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Affiliation(s)
- David A Feldstein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Isabel Barata
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Thomas McGinn
- CommonSpirit Health, Chicago, Illinois, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Emily Heineman
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Dana Kaplan
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Francesca Bullaro
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Sundas Khan
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs (VA) Medical Center, Houston, Texas, USA
| | - Nicholas Kuehnel
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rachel P Berger
- Corresponding Author: Rachel P. Berger, MD, MPH, Division of Child Advocacy, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA;
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Leung T, Dauber-Decker K, Solomon J, Khan S, Barnaby D, Chelico J, Qiu M, Liu Y, Mann D, Pekmezaris R, McGinn T, Diefenbach M. Nudging Health Care Providers' Adoption of Clinical Decision Support: Protocol for the User-Centered Development of a Behavioral Economics-Inspired Electronic Health Record Tool. JMIR Res Protoc 2023; 12:e42653. [PMID: 36652293 PMCID: PMC9892982 DOI: 10.2196/42653] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The improvements in care resulting from clinical decision support (CDS) have been significantly limited by consistently low health care provider adoption. Health care provider attitudes toward CDS, specifically psychological and behavioral barriers, are not typically addressed during any stage of CDS development, although they represent an important barrier to adoption. Emerging evidence has shown the surprising power of using insights from the field of behavioral economics to address psychological and behavioral barriers. Nudges are formal applications of behavioral economics, defined as positive reinforcement and indirect suggestions that have a nonforced effect on decision-making. OBJECTIVE Our goal is to employ a user-centered design process to develop a CDS tool-the pulmonary embolism (PE) risk calculator-for PE risk stratification in the emergency department that incorporates a behavior theory-informed nudge to address identified behavioral barriers to use. METHODS All study activities took place at a large academic health system in the New York City metropolitan area. Our study used a user-centered and behavior theory-based approach to achieve the following two aims: (1) use mixed methods to identify health care provider barriers to the use of an active CDS tool for PE risk stratification and (2) develop a new CDS tool-the PE risk calculator-that addresses behavioral barriers to health care providers' adoption of CDS by incorporating nudges into the user interface. These aims were guided by the revised Observational Research Behavioral Information Technology model. A total of 50 clinicians who used the original version of the tool were surveyed with a quantitative instrument that we developed based on a behavior theory framework-the Capability-Opportunity-Motivation-Behavior framework. A semistructured interview guide was developed based on the survey responses. Inductive methods were used to analyze interview session notes and audio recordings from 12 interviews. Revised versions of the tool were developed that incorporated nudges. RESULTS Functional prototypes were developed by using Axure PRO (Axure Software Solutions) software and usability tested with end users in an iterative agile process (n=10). The tool was redesigned to address 4 identified major barriers to tool use; we included 2 nudges and a default. The 6-month pilot trial for the tool was launched on October 1, 2021. CONCLUSIONS Clinicians highlighted several important psychological and behavioral barriers to CDS use. Addressing these barriers, along with conducting traditional usability testing, facilitated the development of a tool with greater potential to transform clinical care. The tool will be tested in a prospective pilot trial. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/42653.
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Affiliation(s)
| | | | - Jeffrey Solomon
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Sundas Khan
- Baylor College of Medicine, Houston, TX, United States
| | - Douglas Barnaby
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | | | - Michael Qiu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Yan Liu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Devin Mann
- New York University Grossman School of Medicine, New York, NY, United States
| | - Renee Pekmezaris
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Thomas McGinn
- Baylor College of Medicine, Houston, TX, United States.,CommonSpirit Health, Chicago, IL, United States
| | - Michael Diefenbach
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
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6
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Zhang NJ, Rameau P, Julemis M, Liu Y, Solomon J, Khan S, McGinn T, Richardson S. Automated Pulmonary Embolism Risk Assessment Using the Wells Criteria: Validation Study. JMIR Form Res 2022; 6:e32230. [PMID: 35225812 PMCID: PMC8922138 DOI: 10.2196/32230] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/05/2021] [Accepted: 12/27/2021] [Indexed: 01/23/2023] Open
Abstract
Background Computed tomography pulmonary angiography (CTPA) is frequently used in the emergency department (ED) for the diagnosis of pulmonary embolism (PE), while posing risk for contrast-induced nephropathy and radiation-induced malignancy. Objective We aimed to create an automated process to calculate the Wells score for pulmonary embolism for patients in the ED, which could potentially reduce unnecessary CTPA testing. Methods We designed an automated process using electronic health records data elements, including using a combinatorial keyword search method to query free-text fields, and calculated automated Wells scores for a sample of all adult ED encounters that resulted in a CTPA study for PE at 2 tertiary care hospitals in New York, over a 2-month period. To validate the automated process, the scores were compared to those derived from a 2-clinician chart review. Results A total of 202 ED encounters resulted in a completed CTPA to form the retrospective study cohort. Patients classified as “PE likely” by the automated process (126/202, 62%) had a PE prevalence of 15.9%, whereas those classified as “PE unlikely” (76/202, 38%; Wells score >4) had a PE prevalence of 7.9%. With respect to classification of the patient as “PE likely,” the automated process achieved an accuracy of 92.1% when compared with the chart review, with sensitivity, specificity, positive predictive value, and negative predictive value of 93%, 90.5%, 94.4%, and 88.2%, respectively. Conclusions This was a successful development and validation of an automated process using electronic health records data elements, including free-text fields, to classify risk for PE in ED visits.
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Affiliation(s)
| | | | | | - Yan Liu
- Northwell Health, Manhasset, NY, United States
| | | | - Sundas Khan
- Northwell Health, Manhasset, NY, United States
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7
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Adhikari P, Ajaj R, Alpízar-Venegas M, Amaudruz PA, Auty DJ, Batygov M, Beltran B, Benmansour H, Bina CE, Bonatt J, Bonivento W, Boulay MG, Broerman B, Bueno JF, Burghardt PM, Butcher A, Cadeddu M, Cai B, Cárdenas-Montes M, Cavuoti S, Chen M, Chen Y, Cleveland BT, Corning JM, Cranshaw D, Daugherty S, DelGobbo P, Dering K, DiGioseffo J, Di Stefano P, Doria L, Duncan FA, Dunford M, Ellingwood E, Erlandson A, Farahani SS, Fatemighomi N, Fiorillo G, Florian S, Flower T, Ford RJ, Gagnon R, Gallacher D, García Abia P, Garg S, Giampa P, Goeldi D, Golovko V, Gorel P, Graham K, Grant DR, Grobov A, Hallin AL, Hamstra M, Harvey PJ, Hearns C, Hugues T, Ilyasov A, Joy A, Jigmeddorj B, Jillings CJ, Kamaev O, Kaur G, Kemp A, Kochanek I, Kuźniak M, Lai M, Langrock S, Lehnert B, Leonhardt A, Levashko N, Li X, Lidgard J, Lindner T, Lissia M, Lock J, Longo G, Machulin I, McDonald AB, McElroy T, McGinn T, McLaughlin JB, Mehdiyev R, Mielnichuk C, Monroe J, Nadeau P, Nantais C, Ng C, Noble AJ, O’Dwyer E, Oliviéro G, Ouellet C, Pal S, Pasuthip P, Peeters SJM, Perry M, Pesudo V, Picciau E, Piro MC, Pollmann TR, Rand ET, Rethmeier C, Retière F, Rodríguez-García I, Roszkowski L, Ruhland JB, Sánchez-García E, Santorelli R, Sinclair D, Skensved P, Smith B, Smith NJT, Sonley T, Soukup J, Stainforth R, Stone C, Strickland V, Stringer M, Sur B, Tang J, Vázquez-Jáuregui E, Viel S, Walding J, Waqar M, Ward M, Westerdale S, Willis J, Zuñiga-Reyes A. Pulse-shape discrimination against low-energy Ar-39 beta decays in liquid argon with 4.5 tonne-years of DEAP-3600 data. Eur Phys J C Part Fields 2021; 81:823. [PMID: 34720726 PMCID: PMC8550104 DOI: 10.1140/epjc/s10052-021-09514-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/30/2021] [Indexed: 06/13/2023]
Abstract
The DEAP-3600 detector searches for the scintillation signal from dark matter particles scattering on a 3.3 tonne liquid argon target. The largest background comes from 39 Ar beta decays and is suppressed using pulse-shape discrimination (PSD). We use two types of PSD estimator: the prompt-fraction, which considers the fraction of the scintillation signal in a narrow and a wide time window around the event peak, and the log-likelihood-ratio, which compares the observed photon arrival times to a signal and a background model. We furthermore use two algorithms to determine the number of photons detected at a given time: (1) simply dividing the charge of each PMT pulse by the mean single-photoelectron charge, and (2) a likelihood analysis that considers the probability to detect a certain number of photons at a given time, based on a model for the scintillation pulse shape and for afterpulsing in the light detectors. The prompt-fraction performs approximately as well as the log-likelihood-ratio PSD algorithm if the photon detection times are not biased by detector effects. We explain this result using a model for the information carried by scintillation photons as a function of the time when they are detected.
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Affiliation(s)
- P. Adhikari
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - R. Ajaj
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - M. Alpízar-Venegas
- Instituto de Física, Universidad Nacional Autónoma de México, A. P. 20-364, 01000 Mexico, D.F. Mexico
| | | | - D. J. Auty
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - M. Batygov
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
| | - B. Beltran
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - H. Benmansour
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - C. E. Bina
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - J. Bonatt
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | | | - M. G. Boulay
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - B. Broerman
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - J. F. Bueno
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - P. M. Burghardt
- Department of Physics, Technische Universität München, 80333 Munich, Germany
| | - A. Butcher
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX UK
| | | | - B. Cai
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - M. Cárdenas-Montes
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, 28040 Madrid, Spain
| | - S. Cavuoti
- Physics Department, Università degli Studi “Federico II” di Napoli, 80126 Naples, Italy
- INFN Napoli, 80126 Naples, Italy
- INAF-Astronomical Observatory of Capodimonte, Salita Moiariello 16, 80131 Naples, Italy
| | - M. Chen
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - Y. Chen
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - B. T. Cleveland
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
- SNOLAB, Lively, ON P3Y 1M3 Canada
| | - J. M. Corning
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - D. Cranshaw
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - S. Daugherty
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
| | - P. DelGobbo
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - K. Dering
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - J. DiGioseffo
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - P. Di Stefano
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - L. Doria
- PRISMA+ Cluster of Excellence and Institut für Kernphysik, Johannes Gutenberg-Universität Mainz, 55128 Mainz, Germany
| | | | - M. Dunford
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - E. Ellingwood
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - A. Erlandson
- Canadian Nuclear Laboratories Ltd, Chalk River, ON K0J 1J0 Canada
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - S. S. Farahani
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | | | - G. Fiorillo
- Physics Department, Università degli Studi “Federico II” di Napoli, 80126 Naples, Italy
- INFN Napoli, 80126 Naples, Italy
| | - S. Florian
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - T. Flower
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - R. J. Ford
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
- SNOLAB, Lively, ON P3Y 1M3 Canada
| | - R. Gagnon
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - D. Gallacher
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - P. García Abia
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, 28040 Madrid, Spain
| | - S. Garg
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - P. Giampa
- TRIUMF, Vancouver, BC V6T 2A3 Canada
| | - D. Goeldi
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - V. Golovko
- Canadian Nuclear Laboratories Ltd, Chalk River, ON K0J 1J0 Canada
| | - P. Gorel
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
- SNOLAB, Lively, ON P3Y 1M3 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - K. Graham
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - D. R. Grant
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - A. Grobov
- National Research Centre Kurchatov Institute, Moscow, 123182 Russia
- National Research Nuclear University MEPhI, Moscow, 115409 Russia
| | - A. L. Hallin
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - M. Hamstra
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - P. J. Harvey
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - C. Hearns
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - T. Hugues
- AstroCeNT, Nicolaus Copernicus Astronomical Center, Polish Academy of Sciences, Rektorska 4, 00-614 Warsaw, Poland
| | - A. Ilyasov
- National Research Centre Kurchatov Institute, Moscow, 123182 Russia
- National Research Nuclear University MEPhI, Moscow, 115409 Russia
| | - A. Joy
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - B. Jigmeddorj
- Canadian Nuclear Laboratories Ltd, Chalk River, ON K0J 1J0 Canada
| | - C. J. Jillings
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
- SNOLAB, Lively, ON P3Y 1M3 Canada
| | - O. Kamaev
- Canadian Nuclear Laboratories Ltd, Chalk River, ON K0J 1J0 Canada
| | - G. Kaur
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - A. Kemp
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX UK
| | - I. Kochanek
- INFN Laboratori Nazionali del Gran Sasso, 67100 Assergi, AQ Italy
| | - M. Kuźniak
- AstroCeNT, Nicolaus Copernicus Astronomical Center, Polish Academy of Sciences, Rektorska 4, 00-614 Warsaw, Poland
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - M. Lai
- Physics Department, Università degli Studi di Cagliari, 09042 Cagliari, Italy
- INFN Cagliari, Cagliari, 09042 Italy
| | - S. Langrock
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - B. Lehnert
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Present Address: Nuclear Science Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720 USA
| | - A. Leonhardt
- Department of Physics, Technische Universität München, 80333 Munich, Germany
| | - N. Levashko
- National Research Centre Kurchatov Institute, Moscow, 123182 Russia
- National Research Nuclear University MEPhI, Moscow, 115409 Russia
| | - X. Li
- Physics Department, Princeton University, Princeton, NJ 08544 USA
| | - J. Lidgard
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | | | - M. Lissia
- INFN Cagliari, Cagliari, 09042 Italy
| | - J. Lock
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - G. Longo
- Physics Department, Università degli Studi “Federico II” di Napoli, 80126 Naples, Italy
- INFN Napoli, 80126 Naples, Italy
| | - I. Machulin
- National Research Centre Kurchatov Institute, Moscow, 123182 Russia
- National Research Nuclear University MEPhI, Moscow, 115409 Russia
| | - A. B. McDonald
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - T. McElroy
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - T. McGinn
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - J. B. McLaughlin
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX UK
- TRIUMF, Vancouver, BC V6T 2A3 Canada
| | - R. Mehdiyev
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - C. Mielnichuk
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - J. Monroe
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX UK
| | - P. Nadeau
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - C. Nantais
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - C. Ng
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - A. J. Noble
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - E. O’Dwyer
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - G. Oliviéro
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - C. Ouellet
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - S. Pal
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - P. Pasuthip
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - S. J. M. Peeters
- University of Sussex, Sussex House, Brighton, East Sussex BN1 9RH UK
| | - M. Perry
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - V. Pesudo
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, 28040 Madrid, Spain
| | - E. Picciau
- Physics Department, Università degli Studi di Cagliari, 09042 Cagliari, Italy
- INFN Cagliari, Cagliari, 09042 Italy
| | - M.-C. Piro
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - T. R. Pollmann
- Department of Physics, Technische Universität München, 80333 Munich, Germany
- Present Address: Nikhef and the University of Amsterdam, Science Park, 1098 XG Amsterdam, The Netherlands
| | - E. T. Rand
- Canadian Nuclear Laboratories Ltd, Chalk River, ON K0J 1J0 Canada
| | - C. Rethmeier
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | | | - I. Rodríguez-García
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, 28040 Madrid, Spain
| | - L. Roszkowski
- AstroCeNT, Nicolaus Copernicus Astronomical Center, Polish Academy of Sciences, Rektorska 4, 00-614 Warsaw, Poland
- BP2, National Centre for Nuclear Research, ul. Pasteura 7, 02-093 Warsaw, Poland
| | - J. B. Ruhland
- Department of Physics, Technische Universität München, 80333 Munich, Germany
| | - E. Sánchez-García
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, 28040 Madrid, Spain
| | - R. Santorelli
- Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas, 28040 Madrid, Spain
| | - D. Sinclair
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - P. Skensved
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - B. Smith
- TRIUMF, Vancouver, BC V6T 2A3 Canada
| | - N. J. T. Smith
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
- SNOLAB, Lively, ON P3Y 1M3 Canada
| | - T. Sonley
- SNOLAB, Lively, ON P3Y 1M3 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - J. Soukup
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - R. Stainforth
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - C. Stone
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - V. Strickland
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
| | - M. Stringer
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - B. Sur
- Canadian Nuclear Laboratories Ltd, Chalk River, ON K0J 1J0 Canada
| | - J. Tang
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - E. Vázquez-Jáuregui
- Department of Physics and Astronomy, Laurentian University, Sudbury, ON P3E 2C6 Canada
- Instituto de Física, Universidad Nacional Autónoma de México, A. P. 20-364, 01000 Mexico, D.F. Mexico
| | - S. Viel
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - J. Walding
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX UK
| | - M. Waqar
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- Arthur B. McDonald Canadian Astroparticle Physics Research Institute, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - M. Ward
- Department of Physics, Engineering Physics and Astronomy, Queen’s University, Kingston, ON K7L 3N6 Canada
| | - S. Westerdale
- Department of Physics, Carleton University, Ottawa, ON K1S 5B6 Canada
- INFN Cagliari, Cagliari, 09042 Italy
| | - J. Willis
- Department of Physics, University of Alberta, Edmonton, AB T6G 2R3 Canada
| | - A. Zuñiga-Reyes
- Instituto de Física, Universidad Nacional Autónoma de México, A. P. 20-364, 01000 Mexico, D.F. Mexico
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Richardson S, Dauber-Decker KL, McGinn T, Barnaby DP, Cattamanchi A, Pekmezaris R. Barriers to the Use of Clinical Decision Support for the Evaluation of Pulmonary Embolism: Qualitative Interview Study. JMIR Hum Factors 2021; 8:e25046. [PMID: 34346901 PMCID: PMC8374661 DOI: 10.2196/25046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/05/2021] [Accepted: 04/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinicians often disregard potentially beneficial clinical decision support (CDS). OBJECTIVE In this study, we sought to explore the psychological and behavioral barriers to the use of a CDS tool. METHODS We conducted a qualitative study involving emergency medicine physicians and physician assistants. A semistructured interview guide was created based on the Capability, Opportunity, and Motivation-Behavior model. Interviews focused on the barriers to the use of a CDS tool built based on Wells' criteria for pulmonary embolism to assist clinicians in establishing pretest probability of pulmonary embolism before imaging. RESULTS Interviews were conducted with 12 clinicians. Six barriers were identified, including (1) Bayesian reasoning, (2) fear of missing a pulmonary embolism, (3) time pressure or cognitive load, (4) gestalt includes Wells' criteria, (5) missed risk factors, and (6) social pressure. CONCLUSIONS Clinicians highlighted several important psychological and behavioral barriers to CDS use. Addressing these barriers will be paramount in developing CDS that can meet its potential to transform clinical care.
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Affiliation(s)
- Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | | | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Douglas P Barnaby
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Partnerships for Research in Implementation Science for Equity (PRISE) Center, University of California San Francisco, San Francisco, CA, United States
| | - Renee Pekmezaris
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
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9
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Goldin M, Lin SK, Kohn N, Qiu M, Cohen SL, Barish MA, Gianos E, Diaz A, Richardson S, Giannis D, Chatterjee S, Coppa K, Hirsch JS, Ngu S, Firoozan S, McGinn T, Spyropoulos AC. External validation of the IMPROVE-DD risk assessment model for venous thromboembolism among inpatients with COVID-19. J Thromb Thrombolysis 2021; 52:1032-1035. [PMID: 34146235 PMCID: PMC8214061 DOI: 10.1007/s11239-021-02504-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 01/20/2023]
Abstract
There is a need to discriminate which COVID-19 inpatients are at higher risk for venous thromboembolism (VTE) to inform prophylaxis strategies. The IMPROVE-DD VTE risk assessment model (RAM) has previously demonstrated good discrimination in non-COVID populations. We aimed to externally validate the IMPROVE-DD VTE RAM in medical patients hospitalized with COVID-19. This retrospective cohort study evaluated the IMPROVE-DD VTE RAM in adult patients with COVID-19 admitted to one of thirteen Northwell Health hospitals in the New York metropolitan area between March 1, 2020 and April 27, 2020. VTE was defined as new-onset symptomatic deep venous thrombosis or pulmonary embolism. To assess the predictive value of the RAM, the receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Of 9407 patients who met study criteria, 274 patients developed VTE with a prevalence of 2.91%. The VTE rate was 0.41% for IMPROVE-DD score 0–1 (low risk), 1.21% for score 2–3 (moderate risk), and 5.30% for score ≥ 4 (high risk). Approximately 45.7% of patients were classified as high VTE risk, 33.3% moderate risk, and 21.0% low risk. Discrimination of low versus moderate-high VTE risk demonstrated sensitivity 0.971, specificity 0.215, PPV 0.036, and NPV 0.996. ROC AUC was 0.703. In this external validation study, the IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized COVID-19 patients at low, moderate, and high VTE risk.
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Affiliation(s)
- Mark Goldin
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
- North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Stephanie K Lin
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | - Nina Kohn
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
| | - Michael Qiu
- Department of Information Services, Northwell Health, New Hyde Park, USA
| | - Stuart L Cohen
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
| | - Matthew A Barish
- North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Eugenia Gianos
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Division of Cardiology, Lenox Hill Hospital, Northwell Health, New York, USA
| | - Anise Diaz
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | - Safiya Richardson
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
| | - Dimitrios Giannis
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
| | - Saurav Chatterjee
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Kevin Coppa
- Department of Information Services, Northwell Health, New Hyde Park, USA
| | - Jamie S Hirsch
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA
- Department of Information Services, Northwell Health, New Hyde Park, USA
| | - Sam Ngu
- Department of Medicine, Northwell Health, Manhasset, USA
| | | | - Thomas McGinn
- CommonSpirit Health, Baylor College of Medicine, Houston, TX, USA
| | - Alex C Spyropoulos
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA.
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, USA.
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Richardson S, Gitlin J, Kozel Z, Levy S, Rahman H, Hirsch JS, McGinn T, Diefenbach MA. In-Hospital 30-Day Survival Among Young Adults With Coronavirus Disease 2019: A Cohort Study. Open Forum Infect Dis 2021; 8:ofab233. [PMID: 34183983 PMCID: PMC8135976 DOI: 10.1093/ofid/ofab233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 05/05/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Our objective was to characterize young adult patients hospitalized with coronavirus disease 2019 (COVID-19) and identify predictors of survival at 30 days. METHODS This retrospective cohort study took place at 12 acute care hospitals in the New York City area. Patients aged 18-39 hospitalized with confirmed COVID-19 between March 1 and April 27, 2020 were included in the study. Demographic, clinical, and outcome data were extracted from electronic health record reports. RESULTS A total of 1013 patients were included in the study (median age, 33 years; interquartile range [IQR], 28-36; 52% female). At the study end point, 940 (92.8%) patients were discharged alive, 18 (1.8%) remained hospitalized, 5 (0.5%) were transferred to another acute care facility, and 50 (4.9%) died. The most common comorbidities in hospitalized young adult patients were obesity (51.2%), diabetes mellitus (14.8%), and hypertension (13%). Multivariable analysis revealed that obesity (adjusted hazard ratio [aHR], 2.71; 95% confidence interval [CI], 1.28-5.73; P = .002) and Charlson comorbidity index score (aHR, 1.20; 95% CI, 1.07-1.35; P = .002) were independent predictors of in-hospital 30-day mortality. CONCLUSIONS Obesity was identified as the strongest negative predictor of 30-day in-hospital survival in young adults with COVID-19.
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Affiliation(s)
- Safiya Richardson
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Jordan Gitlin
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Zachary Kozel
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Sera Levy
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Husneara Rahman
- Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Great Neck, New York, USA
| | - Jamie S Hirsch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Thomas McGinn
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Michael A Diefenbach
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
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11
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Bolourani S, Brenner M, Wang P, McGinn T, Hirsch JS, Barnaby D, Zanos TP. A Machine Learning Prediction Model of Respiratory Failure Within 48 Hours of Patient Admission for COVID-19: Model Development and Validation. J Med Internet Res 2021; 23:e24246. [PMID: 33476281 PMCID: PMC7879728 DOI: 10.2196/24246] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/18/2020] [Accepted: 01/18/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Predicting early respiratory failure due to COVID-19 can help triage patients to higher levels of care, allocate scarce resources, and reduce morbidity and mortality by appropriately monitoring and treating the patients at greatest risk for deterioration. Given the complexity of COVID-19, machine learning approaches may support clinical decision making for patients with this disease. OBJECTIVE Our objective is to derive a machine learning model that predicts respiratory failure within 48 hours of admission based on data from the emergency department. METHODS Data were collected from patients with COVID-19 who were admitted to Northwell Health acute care hospitals and were discharged, died, or spent a minimum of 48 hours in the hospital between March 1 and May 11, 2020. Of 11,525 patients, 933 (8.1%) were placed on invasive mechanical ventilation within 48 hours of admission. Variables used by the models included clinical and laboratory data commonly collected in the emergency department. We trained and validated three predictive models (two based on XGBoost and one that used logistic regression) using cross-hospital validation. We compared model performance among all three models as well as an established early warning score (Modified Early Warning Score) using receiver operating characteristic curves, precision-recall curves, and other metrics. RESULTS The XGBoost model had the highest mean accuracy (0.919; area under the curve=0.77), outperforming the other two models as well as the Modified Early Warning Score. Important predictor variables included the type of oxygen delivery used in the emergency department, patient age, Emergency Severity Index level, respiratory rate, serum lactate, and demographic characteristics. CONCLUSIONS The XGBoost model had high predictive accuracy, outperforming other early warning scores. The clinical plausibility and predictive ability of XGBoost suggest that the model could be used to predict 48-hour respiratory failure in admitted patients with COVID-19.
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Affiliation(s)
- Siavash Bolourani
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Max Brenner
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Ping Wang
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Thomas McGinn
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Jamie S Hirsch
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Douglas Barnaby
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Theodoros P Zanos
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
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12
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Spyropoulos AC, Cohen SL, Gianos E, Kohn N, Giannis D, Chatterjee S, Goldin M, Lesser M, Coppa K, Hirsch JS, McGinn T, Barish MA. Validation of the IMPROVE-DD risk assessment model for venous thromboembolism among hospitalized patients with COVID-19. Res Pract Thromb Haemost 2021; 5:296-300. [PMID: 33733028 PMCID: PMC7938615 DOI: 10.1002/rth2.12486] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Antithrombotic guidance statements for hospitalized patients with coronavirus disease 2019 (COVID-19) suggest a universal thromboprophylactic strategy with potential to escalate doses in high-risk patients. To date, no clear approach exists to discriminate patients at high risk for venous thromboembolism (VTE). OBJECTIVES The objective of this study is to externally validate the IMPROVE-DD risk assessment model (RAM) for VTE in a large cohort of hospitalized patients with COVID-19 within a multihospital health system. METHODS This retrospective cohort study evaluated the IMPROVE-DD RAM on adult inpatients with COVID-19 hospitalized between March 1, 2020, and April 27, 2020. Diagnosis of VTE was defined by new acute deep venous thrombosis or pulmonary embolism by Radiology Department imaging or point-of-care ultrasound. The receiver operating characteristic (ROC) curve was plotted and area under the curve (AUC) calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using standard methods. RESULTS A total of 9407 patients were included, with a VTE prevalence of 2.9%. The VTE rate was 0.4% for IMPROVE-DD score 0-1 (low risk), 1.3% for score 2-3 (moderate risk), and 5.3% for score ≥ 4 (high risk). Approximately 45% of the total population scored high VTE risk, while 21% scored low VTE risk. IMPROVE-DD discrimination of low versus medium/high risk showed sensitivity of 0.971, specificity of 0.218, PPV of 0.036, and NPV of 0.996. ROC AUC was 0.702. CONCLUSIONS The IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized patients with COVID-19 as low, moderate, and high VTE risk in this large external validation study with potential to individualize thromboprophylactic strategies.
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Affiliation(s)
- Alex C. Spyropoulos
- Feinstein Institutes for Medical ResearchNorthwell HealthManhassetNYUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellNorthwell HealthHempsteadNYUSA
| | - Stuart L. Cohen
- Feinstein Institutes for Medical ResearchNorthwell HealthManhassetNYUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellNorthwell HealthHempsteadNYUSA
| | - Eugenia Gianos
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellNorthwell HealthHempsteadNYUSA
- Division of CardiologyLenox Hill HospitalNorthwell Health, New YorkNYUSA
| | - Nina Kohn
- Feinstein Institutes for Medical ResearchNorthwell HealthManhassetNYUSA
| | - Dimitrios Giannis
- Feinstein Institutes for Medical ResearchNorthwell HealthManhassetNYUSA
| | - Saurav Chatterjee
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellNorthwell HealthHempsteadNYUSA
- North Shore University HospitalNorthwell HealthManhassetNYUSA
| | - Mark Goldin
- Feinstein Institutes for Medical ResearchNorthwell HealthManhassetNYUSA
- North Shore University HospitalNorthwell HealthManhassetNYUSA
| | - Marty Lesser
- Feinstein Institutes for Medical ResearchNorthwell HealthManhassetNYUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellNorthwell HealthHempsteadNYUSA
| | - Kevin Coppa
- Department of Information ServicesNorthwell HealthNew Hyde ParkNYUSA
| | - Jamie S. Hirsch
- Feinstein Institutes for Medical ResearchNorthwell HealthManhassetNYUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellNorthwell HealthHempsteadNYUSA
- Department of Information ServicesNorthwell HealthNew Hyde ParkNYUSA
| | - Thomas McGinn
- Feinstein Institutes for Medical ResearchNorthwell HealthManhassetNYUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellNorthwell HealthHempsteadNYUSA
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13
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McGinn T, Feldstein DA, Barata I, Heineman E, Ross J, Kaplan D, Richardson S, Knox B, Palm A, Bullaro F, Kuehnel N, Park L, Khan S, Eithun B, Berger RP. Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record. Int J Med Inform 2020; 147:104349. [PMID: 33360791 PMCID: PMC8351590 DOI: 10.1016/j.ijmedinf.2020.104349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 08/25/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs. METHODS Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS. RESULTS Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves. CONCLUSIONS Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.
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Affiliation(s)
- Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Baylor College of Medicine, Houston, Texas, United States
| | - David A Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Isabel Barata
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Emily Heineman
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Joshua Ross
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Dana Kaplan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Barbara Knox
- Children's Hospital at Providence/Alaska Child Abuse Response and Evaluation Services, United States; University of Washington, Seattle, Washington, United States
| | - Amanda Palm
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Francesca Bullaro
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Nicholas Kuehnel
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Linda Park
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Sundas Khan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Benjamin Eithun
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.
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14
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Tóth V, Meytlis M, Barnaby DP, Bock KR, Oppenheim MI, Al-Abed Y, McGinn T, Davidson KW, Becker LB, Hirsch JS, Zanos TP. Let Sleeping Patients Lie, avoiding unnecessary overnight vitals monitoring using a clinically based deep-learning model. NPJ Digit Med 2020; 3:149. [PMID: 33299116 PMCID: PMC7666176 DOI: 10.1038/s41746-020-00355-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 10/20/2020] [Indexed: 12/23/2022] Open
Abstract
Impaired sleep for hospital patients is an all too common reality. Sleep disruptions due to unnecessary overnight vital sign monitoring are associated with delirium, cognitive impairment, weakened immunity, hypertension, increased stress, and mortality. It is also one of the most common complaints of hospital patients while imposing additional burdens on healthcare providers. Previous efforts to forgo overnight vital sign measurements and improve patient sleep used providers’ subjective stability assessment or utilized an expanded, thus harder to retrieve, set of vitals and laboratory results to predict overnight clinical risk. Here, we present a model that incorporates past values of a small set of vital signs and predicts overnight stability for any given patient-night. Using data obtained from a multi-hospital health system between 2012 and 2019, a recurrent deep neural network was trained and evaluated using ~2.3 million admissions and 26 million vital sign assessments. The algorithm is agnostic to patient location, condition, and demographics, and relies only on sequences of five vital sign measurements, a calculated Modified Early Warning Score, and patient age. We achieved an area under the receiver operating characteristic curve of 0.966 (95% confidence interval [CI] 0.956–0.967) on the retrospective testing set, and 0.971 (95% CI 0.965–0.974) on the prospective set to predict overnight patient stability. The model enables safe avoidance of overnight monitoring for ~50% of patient-nights, while only misclassifying 2 out of 10,000 patient-nights as stable. Our approach is straightforward to deploy, only requires regularly obtained vital signs, and delivers easily actionable clinical predictions for a peaceful sleep in hospitals.
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Affiliation(s)
- Viktor Tóth
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Marsha Meytlis
- Department of Information Services, Northwell Health, New Hyde Park, NY, USA
| | - Douglas P Barnaby
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kevin R Bock
- Department of Information Services, Northwell Health, New Hyde Park, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Michael I Oppenheim
- Department of Information Services, Northwell Health, New Hyde Park, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Yousef Al-Abed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Karina W Davidson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Lance B Becker
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jamie S Hirsch
- Department of Information Services, Northwell Health, New Hyde Park, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Theodoros P Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA. .,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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15
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Mann D, Hess R, McGinn T, Richardson S, Jones S, Palmisano J, Chokshi SK, Mishuris R, McCullagh L, Park L, Dinh-Le C, Smith P, Feldstein D. Impact of Clinical Decision Support on Antibiotic Prescribing for Acute Respiratory Infections: a Cluster Randomized Implementation Trial. J Gen Intern Med 2020; 35:788-795. [PMID: 32875505 PMCID: PMC7652959 DOI: 10.1007/s11606-020-06096-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/30/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Clinical decision support (CDS) is a promising tool for reducing antibiotic prescribing for acute respiratory infections (ARIs). OBJECTIVE To assess the impact of previously effective CDS on antibiotic-prescribing rates for ARIs when adapted and implemented in diverse primary care settings. DESIGN Cluster randomized clinical trial (RCT) implementing a CDS tool designed to guide evidence-based evaluation and treatment of streptococcal pharyngitis and pneumonia. SETTING Two large academic health system primary care networks with a mix of providers. PARTICIPANTS All primary care practices within each health system were invited. All providers within participating clinic were considered a participant. Practices were randomized selection to a control or intervention group. INTERVENTIONS Intervention practice providers had access to an integrated clinical prediction rule (iCPR) system designed to determine the risk of bacterial infection from reason for visit of sore throat, cough, or upper respiratory infection and guide evidence-based evaluation and treatment. MAIN OUTCOME(S) Change in overall antibiotic prescription rates. MEASURE(S) Frequency, rates, and type of antibiotics prescribed in intervention and controls groups. RESULTS 33 primary care practices participated with 541 providers and 100,573 patient visits. Intervention providers completed the tool in 6.9% of eligible visits. Antibiotics were prescribed in 35% and 36% of intervention and control visits, respectively, showing no statistically significant difference. There were also no differences in rates of orders for rapid streptococcal tests (RR, 0.94; P = 0.11) or chest X-rays (RR, 1.01; P = 0.999) between groups. CONCLUSIONS The iCPR tool was not effective in reducing antibiotic prescription rates for upper respiratory infections in diverse primary care settings. This has implications for the generalizability of CDS tools as they are adapted to heterogeneous clinical contexts. TRIAL REGISTRATION Clinicaltrials.gov (NCT02534987). Registered August 26, 2015 at https://clinicaltrials.gov.
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Affiliation(s)
- Devin Mann
- New York University School of Medicine, New York, NY, USA.
| | - Rachel Hess
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thomas McGinn
- Hofstra Northwell School of Medicine, New York, NY, USA
| | | | - Simon Jones
- New York University School of Medicine, New York, NY, USA
| | | | | | | | | | - Linda Park
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Paul Smith
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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16
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Lisker G, Narasimhan M, Greenberg H, Ramdeo R, McGinn T. “Ambulatory Management of Moderate to High Risk COVID-19 Patients: The Coronavirus Related Outpatient Work Navigators (CROWN) Protocol”. Home Health Care Management & Practice 2020. [PMCID: PMC7565243 DOI: 10.1177/1084822320964196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
During the height of the novel 2019 coronavirus disease (COVID-19) pandemic in New York City, area hospitals were filled to 150% capacity, and there was a significant fear among the public of going to the hospital. Many hospitalized patients were treated with therapies that could be administered in a home setting under proper monitoring. We designed the CROWN Program, a Home-Care based ambulatory protocol to evaluate, monitor, and treat moderate to high risk COVID-19 patients in their homes, with escalation to hospital care when necessary. Patients were evaluated with telehealth visits with a Pulmonologist, and a Home-Care protocol, including RN visit, pulse-oximetry, and oxygen, lab-work, intravenous fluids, medication if needed patient data, comorbidities, and symptoms were collected. Labs, including COVID-19 PCR, D Dimer, CRP, Ferritin, Procalcitonin, CBC, and metabolic panel were measured, as were homecare, home oxygen, and intravenous fluids orders, radiographic studies and initiation of an anticoagulant. Emergency Department visits and need for hospital admission during the study period were recorded. A total of 182 patients were enrolled between the start date of April 27th and June 1st, and fell into two categories: not-admitted (101) and post-discharge (81). Two patients were referred for hospital admission, seven were treated and released from the ED, and one was referred to home hospice. There were no unexpected admissions or deaths. The CROWN program has demonstrated the feasibility and apparent safety of a specialized, Home-Care based protocol for the ambulatory management of moderate to high risk COVID-19 patients.
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Affiliation(s)
- Gita Lisker
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Mangala Narasimhan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Harly Greenberg
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Ramona Ramdeo
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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17
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Abstract
This seroprevalence survey study describes severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity among health care workers at a New York City–based health system by age, sex, race, county of residence, and prior PCR-confirmed viral exposure.
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Affiliation(s)
| | - Grace Sembajwe
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | | | - Bruce Farber
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Tylis Chang
- Northwell Health Laboratories, Northwell Health, Lake Success, New York
| | - Thomas McGinn
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Karina W. Davidson
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
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18
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Levy TJ, Richardson S, Coppa K, Barnaby DP, McGinn T, Becker LB, Davidson KW, Cohen SL, Hirsch JS, Zanos T. Development and Validation of a Survival Calculator for Hospitalized Patients with COVID-19. medRxiv 2020:2020.04.22.20075416. [PMID: 32511640 PMCID: PMC7276996 DOI: 10.1101/2020.04.22.20075416] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chinese studies reported predictors of severe disease and mortality associated with coronavirus disease 2019 (COVID-19). A generalizable and simple survival calculator based on data from US patients hospitalized with COVID-19 has not yet been introduced. OBJECTIVE Develop and validate a clinical tool to predict 7-day survival in patients hospitalized with COVID-19. DESIGN Retrospective and prospective cohort study. SETTING Thirteen acute care hospitals in the New York City area. PARTICIPANTS Adult patients hospitalized with a confirmed diagnosis of COVID-19. The development and internal validation cohort included patients hospitalized between March 1 and May 6, 2020. The external validation cohort included patients hospitalized between March 1 and May 5, 2020. MEASUREMENTS Demographic, laboratory, clinical, and outcome data were extracted from the electronic health record. Optimal predictors and performance were identified using least absolute shrinkage and selection operator (LASSO) regression with receiver operating characteristic curves and measurements of area under the curve (AUC). RESULTS The development and internal validation cohort included 11 095 patients with a median age of 65 years [interquartile range (IQR) 54-77]. Overall 7-day survival was 89%. Serum blood urea nitrogen, age, absolute neutrophil count, red cell distribution width, oxygen saturation, and serum sodium were identified as the 6 optimal of 42 possible predictors of survival. These factors constitute the NOCOS (Northwell COVID-19 Survival) Calculator. Performance in the internal validation, prospective validation, and external validation were marked by AUCs of 0.86, 0.82, and 0.82, respectively. LIMITATIONS All participants were hospitalized within the New York City area. CONCLUSIONS The NOCOS Calculator uses 6 factors routinely available at hospital admission to predict 7-day survival for patients hospitalized with COVID-19. The calculator is publicly available at https://feinstein.northwell.edu/NOCOS.
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19
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Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA 2020; 323:2052-2059. [PMID: 32320003 PMCID: PMC7177629 DOI: 10.1001/jama.2020.6775] [Citation(s) in RCA: 6175] [Impact Index Per Article: 1543.8] [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: 11/14/2022]
Abstract
IMPORTANCE There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19). OBJECTIVE To describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system. DESIGN, SETTING, AND PARTICIPANTS Case series of patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York, within the Northwell Health system. The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates. EXPOSURES Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample among patients requiring admission. MAIN OUTCOMES AND MEASURES Clinical outcomes during hospitalization, such as invasive mechanical ventilation, kidney replacement therapy, and death. Demographics, baseline comorbidities, presenting vital signs, and test results were also collected. RESULTS A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female). The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1). CONCLUSIONS AND RELEVANCE This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.
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Affiliation(s)
- Safiya Richardson
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Jamie S. Hirsch
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
- Department of Information Services, Northwell Health, New Hyde Park, New York
| | - Mangala Narasimhan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - James M. Crawford
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Thomas McGinn
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
| | - Karina W. Davidson
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York
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20
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Cohen SL, Feizullayeva C, McCandlish JA, Sanelli PC, McGinn T, Brenner B, Spyropoulos AC. Comparison of international societal guidelines for the diagnosis of suspected pulmonary embolism during pregnancy. Lancet Haematol 2020; 7:e247-e258. [PMID: 32109405 DOI: 10.1016/s2352-3026(19)30250-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 10/24/2022]
Abstract
Pregnancy-associated pulmonary embolism is one of the leading causes of maternal mortality. Diagnosis of pulmonary embolism in pregnancy is challenging, with symptoms of pulmonary embolism mimicking those of pregnancy. Several key components such as clinical prediction tools, risk stratification, laboratory tests, and imaging widely used for diagnosis of pulmonary embolism in the non-pregnant population show limitations for diagnosis in pregnancy. Further, because of the difficulty of studying pregnant patients, high-quality research evaluating the performance of these diagnostic components in pregnancy is scarce. Seven international medical society guidelines present clinical diagnostic pathways for evaluation of pulmonary embolism in pregnancy that show conflicting recommendations on the use of these diagnostic components. This Review assesses all key components of diagnostic clinical pathways recommended by guidelines for evaluation of pulmonary embolism in pregnancy, reviews current evidence, compares the guideline recommendations with respect to each key component, and provides our preferred diagnostic pathway. It provides the guidelines and available data needed for informed decision making to diagnose pulmonary embolism in pregnancy.
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Affiliation(s)
- Stuart L Cohen
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - John A McCandlish
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Georgia Institute of Technology, Atlanta, GA, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Thomas McGinn
- Department of Medicine, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Benjamin Brenner
- Institute of Hematology, Rambam Health Care Campus and Technion, Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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21
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Cohen SL, Wang J, Mankerian M, Feizullayeva C, McCandlish JA, Barnaby D, Sanelli P, McGinn T. Evaluation of CTPA interpreted as limited in pregnant patients suspected for pulmonary embolism. Emerg Radiol 2019; 27:165-171. [PMID: 31813073 DOI: 10.1007/s10140-019-01728-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 06/21/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study is to determine the rates of CT pulmonary angiography (CTPA) interpreted as limited and severely limited in pregnant patients suspected for pulmonary embolism (PE), and to evaluate factors that influence these rates. METHODS This is a retrospective study with CTPA for evaluation of PE in pregnancy across a large health system from 2006 to 2017. CTPA was classified as limited from the radiology report with a subset of those studies classified as severely limited. Bivariate and multivariate analysis was performed for limited and severely limited rates with maternal age and patient size as a continuous variable and race, trimester, patient location study priority status, and result of chest radiograph before CTPA as categorical variables. RESULTS 874 patients with 33% of studies limited and 4% of studies severely limited. Multivariate logistic regression of CTPA studies revealed decreasing patient age (OR 0.967, p = 0.0129) and increasing patient size (OR 1.013, p < 0.0001). Studies performed in the second trimester (OR 1.869, p = 0.0242) and third trimester (OR 2.314, p = 0.0021) were more likely to be reported as limited (each p < 0.05). Increasing patient size (OR 1.017, p = 0.0046) was the only significant predictor of severely limited versus non-severely limited studies. CONCLUSION CTPA interpreted as limited in pregnancy are common and may be associated with younger age, larger patient size, and second and third trimesters. However, severely limited interpretations are much less common, with patient size the only significant predictor.
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Affiliation(s)
- S L Cohen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA. .,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA. .,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA. .,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.
| | - J Wang
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | - M Mankerian
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - C Feizullayeva
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | | | - D Barnaby
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Northwell Health Emergency Medicine, Manhasset, NY, USA
| | - P Sanelli
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Northwell Health Imaging, 600 Community Drive, Manhasset, NY, 11030, USA.,Imaging Clinical Effectiveness & Outcomes Research Program at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA
| | - T McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Feinstein Institute for Medical Research at Northwell Health, 600 Community Drive, Manhasset, NY, 11030, USA.,Northwell Health Internal Medicine, Manhasset, NY, USA
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22
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Mishuris RG, Palmisano J, McCullagh L, Hess R, Feldstein DA, Smith PD, McGinn T, Mann DM. Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings. BMJ Health Care Inform 2019; 26:bmjhci-2019-100088. [PMID: 31630113 PMCID: PMC7062348 DOI: 10.1136/bmjhci-2019-100088] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Effective implementation of technologies into clinical workflow is hampered by lack of integration into daily activities. Normalisation process theory (NPT) can be used to describe the kinds of 'work' necessary to implement and embed complex new practices. We determined the suitability of NPT to assess the facilitators, barriers and 'work' of implementation of two clinical decision support (CDS) tools across diverse care settings. METHODS We conducted baseline and 6-month follow-up quantitative surveys of clinic leadership at two academic institutions' primary care clinics randomised to the intervention arm of a larger study. The survey was adapted from the NPT toolkit, analysing four implementation domains: sense-making, participation, action, monitoring. Domains were summarised among completed responses (n=60) and examined by role, institution, and time. RESULTS The median score for each NPT domain was the same across roles and institutions at baseline, and decreased at 6 months. At 6 months, clinic managers' participation domain (p=0.003), and all domains for medical directors (p<0.003) declined. At 6 months, the action domain decreased among Utah respondents (p=0.03), and all domains decreased among Wisconsin respondents (p≤0.008). CONCLUSIONS This study employed NPT to longitudinally assess the implementation barriers of new CDS. The consistency of results across participant roles suggests similarities in the work each role took on during implementation. The decline in engagement over time suggests the need for more frequent contact to maintain momentum. Using NPT to evaluate this implementation provides insight into domains which can be addressed with participants to improve success of new electronic health record technologies. TRIAL REGISTRATION NUMBER NCT02534987.
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Affiliation(s)
| | - Joseph Palmisano
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lauren McCullagh
- Northwell Health and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Rachel Hess
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David A Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Paul D Smith
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Thomas McGinn
- Northwell Health and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Devin M Mann
- New York University School of Medicine, New York City, New York, USA
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23
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Affiliation(s)
- Karina W Davidson
- Northwell Health, Long Island, New York
- Donald and Barbara Zucker School of Medicine at Hofstra University, Long Island, New York
| | - Thomas McGinn
- Northwell Health, Long Island, New York
- Donald and Barbara Zucker School of Medicine at Hofstra University, Long Island, New York
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24
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Umapathi P, Samson M, Hajizadeh N, Lin T, Conway GA, Gullar E, O'Rourke B, McGinn T, Jones SR, DeMazumder D. Abstract 936: Entropyx of Cardiac Rhythm Uniquely Predicts Mortality in a Multi-site Polysomnography (psg) Study of Ambulatory Asymptomatic Community Adults With Heart Failure. Circ Res 2019. [DOI: 10.1161/res.125.suppl_1.936] [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: 11/16/2022]
Abstract
Introduction:
Heart failure (HF) is associated with high rates of mortality and hospital readmission. Current strategies for risk stratification are limited. Recently, we introduced EntropyX, a novel measure of non-linear patterns underlying physiological variability using newer concepts of entropy estimation and machine learning. EntropyX of cardiac repolarization (EntropyX
QT
) enhanced the predictive value of all established risk factors in a multicenter study of HF patients (PMID: 27044982). Herein, we test the
hypothesis
that EntropyX of ventricular activation (EntropyX
RR
) during sleep enhances the performance of established mortality risk factors in asymptomatic community adults with HF. We interpret our results in context of fundamental mechanistic studies in animal models and modern theories of systems biology.
Methods & Results:
We followed 96 NYHA class I HF adults in sinus rhythm for 6.5±3.0 years (1994-2011; SHHS NCT#00005275). Baseline exposures included demographics, history, medications, labs, PSG metrics [e.g., sleep disordered breathing (SDB)], ECG analyses [e.g., heart rate (HRV), QT variability (QTV)], and EntropyX
RR
. The cohort had mean age of 70±10 years, 49% women, 11% African Americans, and 46 deaths (48%; N=35 from cardiovascular events) over 4.6±2.6 years. After adjusting for exposures, the adjusted hazard ratios (4th to 1st quartile) for mortality for EntropyX
RR
was 2.3 (95% CI, 1.1-4.6) and age was 4.5 (1.9-10.3), consistent with machine learning-based classification and regression tree analysis. Addition of EntropyX
RR
to a multivariate model (comprised of age, diabetes, myocardial infarction, SDB) improved continuous net reclassification by 43% (37-48).
Conclusions:
EntropyX
RR
during sleep predicts mortality over follow-up of asymptomatic community adults with HF, independent of conventional risk factors and linear/deterministic measures (e.g., HRV, QTV, SDB). Unlike simpler concepts of RR variability, EntropyX
RR
is a fundamentally different measure, reflecting the complexity of multi-directional physiological network properties that regulate homeostatic function under changing conditions. This new paradigm complements conventional measures of risk and has potential for broad application.
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Affiliation(s)
| | - Mackenzie Samson
- The Artificial Intelligence Cntr of Excellence, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Negin Hajizadeh
- Cntr for Health Innovations and Outcomes Rsch, The Feinstein Institute for Med Rsch, Northwell Health, North Shore, NY
| | | | - Ginger A Conway
- Div of Cardiology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Elliseo Gullar
- Dept of Epidemiology and Welch Cntr for Prevention, Epidemiology, and Clinical Rsch, Johns Hopkins Bloomberg Sch of Public Health, Baltimore, MD
| | - Brian O'Rourke
- Div of Cardiology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Thomas McGinn
- Cntr for Health Innovations and Outcomes Rsch, The Feinstein Institute for Med Rsch, Northwell Health, North Shore, NY
| | - Steven R Jones
- Div of Cardiology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
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25
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Richardson S, Feldstein D, McGinn T, Park LS, Khan S, Hess R, Smith PD, Mishuris RG, McCullagh L, Mann D. Live Usability Testing of Two Complex Clinical Decision Support Tools: Observational Study. JMIR Hum Factors 2019; 6:e12471. [PMID: 30985283 PMCID: PMC6487349 DOI: 10.2196/12471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/10/2019] [Accepted: 01/30/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Potential of the electronic health records (EHR) and clinical decision support (CDS) systems to improve the practice of medicine has been tempered by poor design and the resulting burden they place on providers. CDS is rarely tested in the real clinical environment. As a result, many tools are hard to use, placing strain on providers and resulting in low adoption rates. The existing CDS usability literature relies primarily on expert opinion and provider feedback via survey. This is the first study to evaluate CDS usability and the provider-computer-patient interaction with complex CDS in the real clinical environment. OBJECTIVE This study aimed to further understand the barriers and facilitators of meaningful CDS usage within a real clinical context. METHODS This qualitative observational study was conducted with 3 primary care providers during 6 patient care sessions. In patients with the chief complaint of sore throat, a CDS tool built with the Centor Score was used to stratify the risk of group A Streptococcus pharyngitis. In patients with a chief complaint of cough or upper respiratory tract infection, a CDS tool built with the Heckerling Rule was used to stratify the risk of pneumonia. During usability testing, all human-computer interactions, including audio and continuous screen capture, were recorded using the Camtasia software. Participants' comments and interactions with the tool during clinical sessions and participant comments during a postsession brief interview were placed into coding categories and analyzed for generalizable themes. RESULTS In the 6 encounters observed, primary care providers toggled between addressing either the computer or the patient during the visit. Minimal time was spent listening to the patient without engaging the EHR. Participants mostly used the CDS tool with the patient, asking questions to populate the calculator and discussing the results of the risk assessment; they reported the ability to do this as the major benefit of the tool. All providers were interrupted during their use of the CDS tool by the need to refer to other sections of the chart. In half of the visits, patients' clinical symptoms challenged the applicability of the tool to calculate the risk of bacterial infection. Primary care providers rarely used the incorporated incentives for CDS usage, including progress notes and patient instructions. CONCLUSIONS Live usability testing of these CDS tools generated insights about their role in the patient-provider interaction. CDS may contribute to the interaction by being simultaneously viewed by the provider and patient. CDS can improve usability and lessen the strain it places on providers by being short, flexible, and customizable to unique provider workflow. A useful component of CDS is being as widely applicable as possible and ensuring that its functions represent the fastest way to perform a particular task.
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Affiliation(s)
- Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - David Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Linda S Park
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Sundas Khan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Rachel Hess
- School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Paul D Smith
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | | | - Lauren McCullagh
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Devin Mann
- New York University School of Medicine, New York, NY, United States
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26
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Khan S, Richardson S, Liu A, Mechery V, McCullagh L, Schachter A, Pardo S, McGinn T. Improving Provider Adoption With Adaptive Clinical Decision Support Surveillance: An Observational Study. JMIR Hum Factors 2019; 6:e10245. [PMID: 30785410 PMCID: PMC6401673 DOI: 10.2196/10245] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 10/28/2018] [Accepted: 11/25/2018] [Indexed: 01/12/2023] Open
Abstract
Background Successful clinical decision support (CDS) tools can help use evidence-based medicine to effectively improve patient outcomes. However, the impact of these tools has been limited by low provider adoption due to overtriggering, leading to alert fatigue. We developed a tracking mechanism for monitoring trigger (percent of total visits for which the tool triggers) and adoption (percent of completed tools) rates of a complex CDS tool based on the Wells criteria for pulmonary embolism (PE). Objective We aimed to monitor and evaluate the adoption and trigger rates of the tool and assess whether ongoing tool modifications would improve adoption rates. Methods As part of a larger clinical trial, a CDS tool was developed using the Wells criteria to calculate pretest probability for PE at 2 tertiary centers’ emergency departments (EDs). The tool had multiple triggers: any order for D-dimer, computed tomography (CT) of the chest with intravenous contrast, CT pulmonary angiography (CTPA), ventilation-perfusion scan, or lower extremity Doppler ultrasound. A tracking dashboard was developed using Tableau to monitor real-time trigger and adoption rates. Based on initial low provider adoption rates of the tool, we conducted small focus groups with key ED providers to elicit barriers to tool use. We identified overtriggering of the tool for non-PE-related evaluations and inability to order CT testing for intermediate-risk patients. Thus, the tool was modified to allow CT testing for the intermediate-risk group and not to trigger for CT chest with intravenous contrast orders. A dialogue box, “Are you considering PE for this patient?” was added before the tool triggered to account for CTPAs ordered for aortic dissection evaluation. Results In the ED of tertiary center 1, 95,295 patients visited during the academic year. The tool triggered for an average of 509 patients per month (average trigger rate 2036/30,234, 6.73%) before the modifications, reducing to 423 patients per month (average trigger rate 1629/31,361, 5.22%). In the ED of tertiary center 2, 88,956 patients visited during the academic year, with the tool triggering for about 473 patients per month (average trigger rate 1892/29,706, 6.37%) before the modifications and for about 400 per month (average trigger rate 1534/30,006, 5.12%) afterward. The modifications resulted in a significant 4.5- and 3-fold increase in provider adoption rates in tertiary centers 1 and 2, respectively. The modifications increased the average monthly adoption rate from 23.20/360 (6.5%) tools to 81.60/280.20 (29.3%) tools and 46.60/318.80 (14.7%) tools to 111.20/263.40 (42.6%) tools in centers 1 and 2, respectively. Conclusions Close postimplementation monitoring of CDS tools may help improve provider adoption. Adaptive modifications based on user feedback may increase targeted CDS with lower trigger rates, reducing alert fatigue and increasing provider adoption. Iterative improvements and a postimplementation monitoring dashboard can significantly improve adoption rates.
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Affiliation(s)
- Sundas Khan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Safiya Richardson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Andrew Liu
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Vinodh Mechery
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Lauren McCullagh
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Andy Schachter
- Office of Chief Informatics Officer, Northwell Health, Manhasset, NY, United States
| | - Salvatore Pardo
- Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
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27
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Mann D, Hess R, McGinn T, Mishuris R, Chokshi S, McCullagh L, Smith PD, Palmisano J, Richardson S, Feldstein DA. Adaptive design of a clinical decision support tool: What the impact on utilization rates means for future CDS research. Digit Health 2019; 5:2055207619827716. [PMID: 30792877 PMCID: PMC6376549 DOI: 10.1177/2055207619827716] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/10/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE We employed an agile, user-centered approach to the design of a clinical decision support tool in our prior integrated clinical prediction rule study, which achieved high adoption rates. To understand if applying this user-centered process to adapt clinical decision support tools is effective in improving the use of clinical prediction rules, we examined utilization rates of a clinical decision support tool adapted from the original integrated clinical prediction rule study tool to determine if applying this user-centered process to design yields enhanced utilization rates similar to the integrated clinical prediction rule study. MATERIALS & METHODS: We conducted pre-deployment usability testing and semi-structured group interviews at 6 months post-deployment with 75 providers at 14 intervention clinics across the two sites to collect user feedback. Qualitative data analysis is bifurcated into immediate and delayed stages; we reported on immediate-stage findings from real-time field notes used to generate a set of rapid, pragmatic recommendations for iterative refinement. Monthly utilization rates were calculated and examined over 12 months. RESULTS We hypothesized a well-validated, user-centered clinical decision support tool would lead to relatively high adoption rates. Then 6 months post-deployment, integrated clinical prediction rule study tool utilization rates were substantially lower than anticipated based on the original integrated clinical prediction rule study trial (68%) at 17% (Health System A) and 5% (Health System B). User feedback at 6 months resulted in recommendations for tool refinement, which were incorporated when possible into tool design; however, utilization rates at 12 months post-deployment remained low at 14% and 4% respectively. DISCUSSION Although valuable, findings demonstrate the limitations of a user-centered approach given the complexity of clinical decision support. CONCLUSION Strategies for addressing persistent external factors impacting clinical decision support adoption should be considered in addition to the user-centered design and implementation of clinical decision support.
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Affiliation(s)
- Devin Mann
- Department of Population Health, New York University School of Medicine, United States of America
| | - Rachel Hess
- Department of Population Sciences, University of Utah School of Medicine, United States of America
| | - Thomas McGinn
- Division of General Internal Medicine, Hofstra Northwell School of Medicine, United States of America
| | - Rebecca Mishuris
- Department of Medicine, Boston University, United States of America
| | - Sara Chokshi
- Department of Population Health, New York University School of Medicine, United States of America
| | - Lauren McCullagh
- Division of General Internal Medicine, Hofstra Northwell School of Medicine, United States of America
| | - Paul D Smith
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, United States of America
| | - Joseph Palmisano
- Department of Medicine, Boston University, United States of America
| | - Safiya Richardson
- Division of General Internal Medicine, Hofstra Northwell School of Medicine, United States of America
| | - David A Feldstein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, United States of America
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Davidson KW, Cheung YK, McGinn T, Wang YC. Expanding the Role of N-of-1 Trials in the Precision Medicine Era: Action Priorities and Practical Considerations. NAM Perspect 2018. [DOI: 10.31478/201812d] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | | | - Thomas McGinn
- Donald and Barbara Zucker School of Medicine at Hofstra University
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29
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Richardson S, Solomon P, O'Connell A, Khan S, Gong J, Makhnevich A, Qiu G, Zhang M, McGinn T. A Computerized Method for Measuring Computed Tomography Pulmonary Angiography Yield in the Emergency Department: Validation Study. JMIR Med Inform 2018; 6:e44. [PMID: 30361200 PMCID: PMC6231863 DOI: 10.2196/medinform.9957] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/16/2018] [Accepted: 07/06/2018] [Indexed: 11/13/2022] Open
Abstract
Background Use of computed tomography pulmonary angiography (CTPA) in the assessment of pulmonary embolism (PE) has markedly increased over the past two decades. While this technology has improved the accuracy of radiological testing for PE, CTPA also carries the risk of substantial iatrogenic harm. Each CTPA carries a 14% risk of contrast-induced nephropathy and a lifetime malignancy risk that can be as high as 2.76%. The appropriate use of CTPA can be estimated by monitoring the CTPA yield, the percentage of tests positive for PE. This is the first study to propose and validate a computerized method for measuring the CTPA yield in the emergency department (ED). Objective The objective of our study was to assess the validity of a novel computerized method of calculating the CTPA yield in the ED. Methods The electronic health record databases at two tertiary care academic hospitals were queried for CTPA orders completed in the ED over 1-month periods. These visits were linked with an inpatient admission with a discharge diagnosis of PE based on the International Classification of Diseases codes. The computerized the CTPA yield was calculated as the number of CTPA orders with an associated inpatient discharge diagnosis of PE divided by the total number of orders for completed CTPA. This computerized method was then validated by 2 independent reviewers performing a manual chart review, which included reading the free-text radiology reports for each CTPA. Results A total of 349 CTPA orders were completed during the 1-month periods at the two institutions. Of them, acute PE was diagnosed on CTPA in 28 studies, with a CTPA yield of 7.7%. The computerized method correctly identified 27 of 28 scans positive for PE. The one discordant scan was tied to a patient who was discharged directly from the ED and, as a result, never received an inpatient discharge diagnosis. Conclusions This is the first successful validation study of a computerized method for calculating the CTPA yield in the ED. This method for data extraction allows for an accurate determination of the CTPA yield and is more efficient than manual chart review. With this ability, health care systems can monitor the appropriate use of CTPA and the effect of interventions to reduce overuse and decrease preventable iatrogenic harm.
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Affiliation(s)
- Safiya Richardson
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Philip Solomon
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Alexander O'Connell
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Sundas Khan
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Jonathan Gong
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Alex Makhnevich
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Guang Qiu
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Meng Zhang
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Thomas McGinn
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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30
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Amaudruz PA, Baldwin M, Batygov M, Beltran B, Bina CE, Bishop D, Bonatt J, Boorman G, Boulay MG, Broerman B, Bromwich T, Bueno JF, Burghardt PM, Butcher A, Cai B, Chan S, Chen M, Chouinard R, Cleveland BT, Cranshaw D, Dering K, DiGioseffo J, Dittmeier S, Duncan FA, Dunford M, Erlandson A, Fatemighomi N, Florian S, Flower A, Ford RJ, Gagnon R, Giampa P, Golovko VV, Gorel P, Gornea R, Grace E, Graham K, Gulyev E, Hakobyan R, Hall A, Hallin AL, Hamstra M, Harvey PJ, Hearns C, Jillings CJ, Kamaev O, Kemp A, Kuźniak M, Langrock S, La Zia F, Lehnert B, Lidgard JJ, Lim C, Lindner T, Linn Y, Liu S, Majewski P, Mathew R, McDonald AB, McElroy T, McGinn T, McLaughlin JB, Mead S, Mehdiyev R, Mielnichuk C, Monroe J, Muir A, Nadeau P, Nantais C, Ng C, Noble AJ, O'Dwyer E, Ohlmann C, Olchanski K, Olsen KS, Ouellet C, Pasuthip P, Peeters SJM, Pollmann TR, Rand ET, Rau W, Rethmeier C, Retière F, Seeburn N, Shaw B, Singhrao K, Skensved P, Smith B, Smith NJT, Sonley T, Soukup J, Stainforth R, Stone C, Strickland V, Sur B, Tang J, Taylor J, Veloce L, Vázquez-Jáuregui E, Walding J, Ward M, Westerdale S, Woolsey E, Zielinski J. First Results from the DEAP-3600 Dark Matter Search with Argon at SNOLAB. Phys Rev Lett 2018; 121:071801. [PMID: 30169081 DOI: 10.1103/physrevlett.121.071801] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 05/17/2018] [Indexed: 06/08/2023]
Abstract
This Letter reports the first results of a direct dark matter search with the DEAP-3600 single-phase liquid argon (LAr) detector. The experiment was performed 2 km underground at SNOLAB (Sudbury, Canada) utilizing a large target mass, with the LAr target contained in a spherical acrylic vessel of 3600 kg capacity. The LAr is viewed by an array of PMTs, which would register scintillation light produced by rare nuclear recoil signals induced by dark matter particle scattering. An analysis of 4.44 live days (fiducial exposure of 9.87 ton day) of data taken during the initial filling phase demonstrates the best electronic recoil rejection using pulse-shape discrimination in argon, with leakage <1.2×10^{-7} (90% C.L.) between 15 and 31 keV_{ee}. No candidate signal events are observed, which results in the leading limit on weakly interacting massive particle (WIMP)-nucleon spin-independent cross section on argon, <1.2×10^{-44} cm^{2} for a 100 GeV/c^{2} WIMP mass (90% C.L.).
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Affiliation(s)
- P-A Amaudruz
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - M Baldwin
- Rutherford Appleton Laboratory, Harwell Oxford, Didcot OX11 0QX, United Kingdom
| | - M Batygov
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
| | - B Beltran
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - C E Bina
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - D Bishop
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - J Bonatt
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - G Boorman
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - M G Boulay
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - B Broerman
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - T Bromwich
- University of Sussex, Sussex House, Brighton, East Sussex BN1 9RH, United Kingdom
| | - J F Bueno
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - P M Burghardt
- Department of Physics, Technische Universität München, 80333 Munich, Germany
| | - A Butcher
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - B Cai
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - S Chan
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - M Chen
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - R Chouinard
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - B T Cleveland
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
| | - D Cranshaw
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - K Dering
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - J DiGioseffo
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - S Dittmeier
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - F A Duncan
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
| | - M Dunford
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - A Erlandson
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
- Canadian Nuclear Laboratories Ltd, Chalk River, Ontario K0J 1J0, Canada
| | - N Fatemighomi
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - S Florian
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - A Flower
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - R J Ford
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
| | - R Gagnon
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - P Giampa
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - V V Golovko
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Canadian Nuclear Laboratories Ltd, Chalk River, Ontario K0J 1J0, Canada
| | - P Gorel
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
| | - R Gornea
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - E Grace
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - K Graham
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - E Gulyev
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - R Hakobyan
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - A Hall
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - A L Hallin
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - M Hamstra
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - P J Harvey
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - C Hearns
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - C J Jillings
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
| | - O Kamaev
- Canadian Nuclear Laboratories Ltd, Chalk River, Ontario K0J 1J0, Canada
| | - A Kemp
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - M Kuźniak
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - S Langrock
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
| | - F La Zia
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - B Lehnert
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - J J Lidgard
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - C Lim
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - T Lindner
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - Y Linn
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - S Liu
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - P Majewski
- Rutherford Appleton Laboratory, Harwell Oxford, Didcot OX11 0QX, United Kingdom
| | - R Mathew
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - A B McDonald
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - T McElroy
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - T McGinn
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - J B McLaughlin
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - S Mead
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - R Mehdiyev
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - C Mielnichuk
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - J Monroe
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - A Muir
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - P Nadeau
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
| | - C Nantais
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - C Ng
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - A J Noble
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - E O'Dwyer
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - C Ohlmann
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - K Olchanski
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - K S Olsen
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - C Ouellet
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - P Pasuthip
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - S J M Peeters
- University of Sussex, Sussex House, Brighton, East Sussex BN1 9RH, United Kingdom
| | - T R Pollmann
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Department of Physics, Technische Universität München, 80333 Munich, Germany
| | - E T Rand
- Canadian Nuclear Laboratories Ltd, Chalk River, Ontario K0J 1J0, Canada
| | - W Rau
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - C Rethmeier
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - F Retière
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - N Seeburn
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - B Shaw
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - K Singhrao
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - P Skensved
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - B Smith
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
| | - N J T Smith
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
| | - T Sonley
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
| | - J Soukup
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - R Stainforth
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - C Stone
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - V Strickland
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - B Sur
- Canadian Nuclear Laboratories Ltd, Chalk River, Ontario K0J 1J0, Canada
| | - J Tang
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - J Taylor
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - L Veloce
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - E Vázquez-Jáuregui
- Department of Physics and Astronomy, Laurentian University, Sudbury, Ontario P3E 2C6, Canada
- SNOLAB, Lively, Ontario P3Y 1M3, Canada
- Instituto de Física, Universidad Nacional Autónoma de México, A. P. 20-364, México D. F. 01000, Mexico
| | - J Walding
- Royal Holloway University London, Egham Hill, Egham, Surrey TW20 0EX, United Kingdom
| | - M Ward
- Department of Physics, Engineering Physics, and Astronomy, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - S Westerdale
- Department of Physics, Carleton University, Ottawa, Ontario K1S 5B6, Canada
| | - E Woolsey
- Department of Physics, University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - J Zielinski
- TRIUMF, Vancouver, British Columbia V6T 2A3, Canada
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Neumann I, Alonso-Coello P, Vandvik PO, Agoritsas T, Mas G, Akl EA, Brignardello-Petersen R, Emparanza J, McCullagh L, De Sitio C, McGinn T, Almodaimegh H, Almodaimegh K, Rivera S, Rojas L, Stirnemann J, Irani J, Hlais S, Mustafa R, Bdair F, Aly A, Kristiansen A, Izcovich A, Ramirez A, Brozek J, Guyatt G, Schünemann HJ. Do clinicians want recommendations? A multicenter study comparing evidence summaries with and without GRADE recommendations. J Clin Epidemiol 2018. [PMID: 29530644 DOI: 10.1016/j.jclinepi.2018.02.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Evidence-based clinical practice guidelines provide recommendations to assist clinicians in decision-making and to reduce the gap between best current research evidence and clinical practice. However, some argue that providing preappraised evidence summaries alone, rather than recommendations, is more appropriate. The objective of the study is to evaluate clinicians' preferences, and understanding of the evidence and intended course of action in response to evidence summaries with and without recommendations. STUDY DESIGN SETTING We included practicing clinicians attending educational sessions across 10 countries. Clinicians were randomized to receive relevant clinical scenarios supported by research evidence of low or very low certainty and accompanied by either strong or weak recommendations developed with the GRADE system. Within each group, participants were further randomized to receive the recommendation plus the corresponding evidence summary or the evidence summary alone. We evaluated participants' preferences and understanding for the presentation strategy, as well as their intended course of action. RESULTS One hundred eighty-nine of 219 (86%) and 201 of 248 (81%) participants preferred having recommendations accompanying evidence summaries for both strong and weak recommendations, respectively. Across all scenarios, less than half of participants correctly interpreted information provided in the evidences summaries (e.g., estimates of effect, certainty in the research evidence). The presence of a recommendation resulted in a more appropriate intended course of action for two scenarios involving strong recommendations. CONCLUSION Evidence summaries alone are not enough to impact clinicians' course of action. Clinicians clearly prefer having recommendations accompanying evidence summaries in the context of low or very low certainty of evidence (Trial registration NCT02006017).
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Affiliation(s)
- Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Alameda 340, Santiago 8331150, Chile.
| | - Pablo Alonso-Coello
- Centro Cochrane Iberoamericano, Instituto de Investigación Biomédica (CIBERESP-IIB Sant Pau), C/ Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Per Olav Vandvik
- Department of Medicine, Innlandet Hospital Trust-division Gjøvik, Kyrre Greppsgt.11, Gjøvik 2819, Norway
| | - Thomas Agoritsas
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Gabrielle-Perret-Gentil 4 Geneva 14 1211, Switzerland
| | - Gemma Mas
- Centro Cochrane Iberoamericano, Instituto de Investigación Biomédica (CIBERESP-IIB Sant Pau), C/ Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box: 11-0236, Riad-El-Solh Beirut, Beirut 1107 2020, Lebanon
| | - Romina Brignardello-Petersen
- Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Av Libertador Bernardo O'Higgins 1058, Santiago, Región Metropolitana 8330111, Chile
| | - Jose Emparanza
- Clinical Epidemiology Unit, (CASPe-CIBER-ESP), Donostia University Hospital, Paseo Doctor Beriguistain 109, San Sebastian 20014, Spain
| | - Lauren McCullagh
- Department of Medicine, North Shore-LIJ Health System, 600 Community Drive, Suite 300, Manhasset 11030, NY, USA
| | - Catherine De Sitio
- Department of Medicine, North Shore-LIJ Health System, 600 Community Drive, Suite 300, Manhasset 11030, NY, USA
| | - Thomas McGinn
- Medicine Service Line Northwell Health, 300 Community Drive, Manhasset 11030, NY, USA
| | - Hind Almodaimegh
- College of Pharmacy-Female Branch, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, PO BOX 22490, Riyadh 11426, Saudi Arabia
| | - Khalid Almodaimegh
- Family Medicine and Diabetology, Al-Iman Hospital, Riyadh 11544, Saudi Arabia
| | - Solange Rivera
- Department of Family Medicine, Pontificia Universidad Catolica de Chile, Alameda 340, Santiago 8331150, Chile
| | - Luis Rojas
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Alameda 340, Santiago 8331150, Chile
| | - Jérôme Stirnemann
- Department of General Internal Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1211, Switzerland
| | - Jihad Irani
- University of Balamand, Faculty of Medicine & Medical Sciences, Beirut, Lebanon
| | - Sani Hlais
- Family Medicine Departments, American University of Beirut and Saint Joseph University, Beirut, Lebanon
| | - Reem Mustafa
- University of Missouri-Kansas City School of Medicine, M4-303 2411 Holmes St., Kansas City 64108-2792, MO, USA
| | - Fadi Bdair
- Mosaic Life Care, 011 E St Maartens Dr, St Joseph 64506, MO, USA
| | - Abdelrahman Aly
- University of Missouri-Kansas City School of Medicine, M4-303 2411 Holmes St., Kansas City 64108-2792, MO, USA
| | - Annette Kristiansen
- Department of Internal Medicine, Sykehuset Innlandet Hospital Trust, Gjøvik, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ariel Izcovich
- Department of Internal Medicine, Hospital Alemán, Pueyrredón 1640, Buenos Aires C1118AAT, Argentina
| | - Anggie Ramirez
- International Health Central American Institute Foundation & Cochrane Central America & Spanish Caribbean Branch of the Iberoamerican Cochrane Centre, San Jose, Costa Rica Costa Rica, San José, Santa Ana, Condominio Santa Ana Hills #43, San Jose Zip Code: 10-901, Costa Rica
| | - Jan Brozek
- Department of Clinical Epidemiology and Biostatistics and Department of Medicine, McMaster University, Main Street West 1200, Hamilton L8S4L8, Ontario, Canada
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics and Department of Medicine, McMaster University, Main Street West 1200, Hamilton L8S4L8, Ontario, Canada
| | - Holger J Schünemann
- Department of Clinical Epidemiology and Biostatistics and Department of Medicine, McMaster University, Main Street West 1200, Hamilton L8S4L8, Ontario, Canada
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Mathew A, McLeggon JA, Mehta N, Leung S, Barta V, McGinn T, Nesrallah G. Mortality and Hospitalizations in Intensive Dialysis: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2018; 5:2054358117749531. [PMID: 29348924 PMCID: PMC5768251 DOI: 10.1177/2054358117749531] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 06/14/2017] [Accepted: 09/30/2017] [Indexed: 11/15/2022] Open
Abstract
Background: Survival and hospitalization are critically important outcomes considered when choosing between intensive hemodialysis (HD), conventional HD, and peritoneal dialysis (PD). However, the comparative effectiveness of these modalities is unclear. Objective: We had the following aims: (1) to compare the association of mortality and hospitalization in patients undergoing intensive HD, compared with conventional HD or PD and (2) to appraise the methodological quality of the supporting evidence. Data Sources: MEDLINE, Embase, ISI Web of Science, CENTRAL, and nephrology conference abstracts. Study Eligibility, Participants, and Interventions: We included cohort studies with comparator arm, and randomized controlled trials (RCTs) with >50% of adult patients (≥18 years) comparing any form of intensive HD (>4 sessions/wk or >5.5 h/session) with any form of chronic dialysis (PD, HD ≤4 sessions/wk or ≤5.5 h/session), that reported at least 1 predefined outcome (mortality or hospitalization). Methods: We used the GRADE approach to systematic reviews and quality appraisal. Two reviewers screened citations and full-text articles, and extracted study-level data independently, with discrepancies resolved by consensus. We pooled effect estimates of randomized and observational studies separately using generic inverse variance with random effects models, and used fixed-effects models when only 2 studies were available for pooling. Predefined subgroups for the intensive HD cohorts were classified by nocturnal versus short daily HD and home versus in-center HD. Results: Twenty-three studies with a total of 70 506 patients were included. Of the observational studies, compared with PD, intensive HD had a significantly lower mortality risk (hazard ratio [HR]: 0.67; 95% confidence interval [CI]: 0.53-0.84; I2 = 91%). Compared with conventional HD, home nocturnal (HR: 0.46; 95% CI: 0.38-0.55; I2 = 0%), in-center nocturnal (HR: 0.73; 95% CI: 0.60-0.90; I2 = 57%) and home short daily (HR: 0.54; 95% CI: 0.31-0.95; I2 = 82%) intensive regimens had lower mortality. Of the 2 RCTs assessing mortality, in-center short daily HD had lower mortality (HR: 0.54; 95% CI: 0.31-0.93), while home nocturnal HD had higher mortality (HR: 3.88; 95% CI: 1.27-11.79) in long-term observational follow-up. Hospitalization days per patient-year (mean difference: –1.98; 95% CI: –2.37 to −1.59; I2 = 6%) were lower in nocturnal compared with conventional HD. Quality of evidence was similarly low or very low in RCTs (due to imprecision) and observational studies (due to residual confounding and selection bias). Limitations: The overall quality of evidence was low or very low for critical outcomes. Outcomes such as quality of life, transplantation, and vascular access outcomes were not included in our review. Conclusions: Intensive HD regimens may be associated with reduced mortality and hospitalization compared with conventional HD or PD. As the quality of supporting evidence is low, patients who place a high value on survival must be adequately advised and counseled of risks and benefits when choosing intensive dialysis. Practice guidelines that promote shared decision-making are likely to be helpful.
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Affiliation(s)
- Anna Mathew
- McMaster University, Hamilton, Ontario, Canada
| | - Jody-Ann McLeggon
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Nirav Mehta
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Samuel Leung
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Valerie Barta
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Thomas McGinn
- Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Gihad Nesrallah
- Department of Nephrology, Humber River Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Ontario, Canada
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Mathew AT, Rosen L, Pekmezaris R, Kozikowski A, Ross DW, McGinn T, Kalantar-Zadeh K, Fishbane S. Potentially Avoidable Readmissions in United States Hemodialysis Patients. Kidney Int Rep 2017; 3:343-355. [PMID: 29725638 PMCID: PMC5932139 DOI: 10.1016/j.ekir.2017.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 04/24/2017] [Revised: 10/22/2017] [Accepted: 10/30/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Patients with end-stage kidney disease have a high risk of 30-day readmission to hospital. These readmissions are financially costly to health care systems and are associated with poor health-related quality of life. The objective of this study was to describe and analyze the frequency, causes, and predictors of 30-day potentially avoidable readmission to hospital in patients on hemodialysis. Methods We conducted a retrospective cohort study using the US Renal Data System data from January 1, 2008, to December 31, 2008. A total of 107,940 prevalent United States hemodialysis patients with 248,680 index hospital discharges were assessed for the main outcome of 30-day potentially avoidable readmission, as identified by a computerized algorithm. Results Of 83,209 30-day readmissions, 59,045 (70.1%) resulted in a 30-day potentially avoidable readmission. The geographic distribution of 30-day potentially avoidable readmission in the United States varied by state. Characteristics associated with 30-day potentially avoidable readmission included the following: younger age, shorter time on hemodialysis, at least 3 or more hospitalizations in preceding 12 months, black race, unemployed status, treatment at a for-profit facility, longer length of index hospital stay, and index hospitalizations that involved a surgical procedure. The 5-, 15-, and 30-day potentially avoidable readmission cumulative incidences were 6.0%, 15.1%, and 25.8%, respectively. Conclusion Patients with end-stage kidney disease on maintenance hemodialysis are at high risk for 30-day readmission to hospital, with nearly three-quarters (70.1%) of all 30-day readmissions being potentially avoidable. Research is warranted to develop cost-effective and transferrable interventions that improve care transitions from hospital to outpatient hemodialysis facility and reduce readmission risk for this vulnerable population.
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Affiliation(s)
- Anna T Mathew
- McMaster University, Hamilton Health Sciences Center, Hamilton, Ontario, Canada
| | - Lisa Rosen
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Renee Pekmezaris
- Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
| | - Andrzej Kozikowski
- Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
| | - Daniel W Ross
- Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
| | - Thomas McGinn
- Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, California, USA.,Fielding School of Public Health at UCLA, Los Angeles, California, USA.,Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California, USA
| | - Steven Fishbane
- Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York, USA
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Alba AC, Agoritsas T, Walsh M, Hanna S, Iorio A, Devereaux PJ, McGinn T, Guyatt G. Discrimination and Calibration of Clinical Prediction Models: Users' Guides to the Medical Literature. JAMA 2017; 318:1377-1384. [PMID: 29049590 DOI: 10.1001/jama.2017.12126] [Citation(s) in RCA: 798] [Impact Index Per Article: 114.0] [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: 01/08/2023]
Abstract
Accurate information regarding prognosis is fundamental to optimal clinical care. The best approach to assess patient prognosis relies on prediction models that simultaneously consider a number of prognostic factors and provide an estimate of patients' absolute risk of an event. Such prediction models should be characterized by adequately discriminating between patients who will have an event and those who will not and by adequate calibration ensuring accurate prediction of absolute risk. This Users' Guide will help clinicians understand the available metrics for assessing discrimination, calibration, and the relative performance of different prediction models. This article complements existing Users' Guides that address the development and validation of prediction models. Together, these guides will help clinicians to make optimal use of existing prediction models.
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Affiliation(s)
- Ana Carolina Alba
- Heart Failure and Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Divisions of Clinical Epidemiology and General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Michael Walsh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Steven Hanna
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thomas McGinn
- Feinstein Institute for Medical Research, Northwell School of Medicine, Hofstra University, Hempstead, New York
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Richardson S, Mishuris R, O'Connell A, Feldstein D, Hess R, Smith P, McCullagh L, McGinn T, Mann D. "Think aloud" and "Near live" usability testing of two complex clinical decision support tools. Int J Med Inform 2017; 106:1-8. [PMID: 28870378 DOI: 10.1016/j.ijmedinf.2017.06.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [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: 11/28/2016] [Revised: 06/16/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Low provider adoption continues to be a significant barrier to realizing the potential of clinical decision support. "Think Aloud" and "Near Live" usability testing were conducted on two clinical decision support tools. Each was composed of an alert, a clinical prediction rule which estimated risk of either group A Streptococcus pharyngitis or pneumonia and an automatic order set based on risk. The objective of this study was to further understanding of the facilitators of usability and to evaluate the types of additional information gained from proceeding to "Near Live" testing after completing "Think Aloud". METHODS This was a qualitative observational study conducted at a large academic health care system with 12 primary care providers. During "Think Aloud" testing, participants were provided with written clinical scenarios and asked to verbalize their thought process while interacting with the tool. During "Near Live" testing participants interacted with a mock patient. Morae usability software was used to record full screen capture and audio during every session. Participant comments were placed into coding categories and analyzed for generalizable themes. Themes were compared across usability methods. RESULTS "Think Aloud" and "Near Live" usability testing generated similar themes under the coding categories visibility, workflow, content, understand-ability and navigation. However, they generated significantly different themes under the coding categories usability, practical usefulness and medical usefulness. During both types of testing participants found the tool easier to use when important text was distinct in its appearance, alerts were passive and appropriately timed, content was up to date, language was clear and simple, and each component of the tool included obvious indicators of next steps. Participant comments reflected higher expectations for usability and usefulness during "Near Live" testing. For example, visit aids, such as automatically generated order sets, were felt to be less useful during "Near-Live" testing because they would not be all inclusive for the visit. CONCLUSIONS These complementary types of usability testing generated unique and generalizable insights. Feedback during "Think Aloud" testing primarily helped to improve the tools' ease of use. The additional feedback from "Near Live" testing, which mimics a real clinical encounter, was helpful for eliciting key barriers and facilitators to provider workflow and adoption.
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Affiliation(s)
| | | | | | - David Feldstein
- University of Wisconsin School of Medicine and Public Health, United States.
| | - Rachel Hess
- University of Utah School of Medicine, United States.
| | - Paul Smith
- University of Wisconsin School of Medicine and Public Health, United States.
| | | | - Thomas McGinn
- Hofstra Northwell School of Medicine, United States.
| | - Devin Mann
- New York University School of Medicine, United States.
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Feldstein DA, Hess R, McGinn T, Mishuris RG, McCullagh L, Smith PD, Flynn M, Palmisano J, Doros G, Mann D. Design and implementation of electronic health record integrated clinical prediction rules (iCPR): a randomized trial in diverse primary care settings. Implement Sci 2017; 12:37. [PMID: 28292304 PMCID: PMC5351194 DOI: 10.1186/s13012-017-0567-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 11/24/2022] Open
Abstract
Background Clinical prediction rules (CPRs) represent a method of determining individual patient risk to help providers make more accurate decisions at the point of care. Well-validated CPRs are underutilized but may decrease antibiotic overuse for acute respiratory infections. The integrated clinical prediction rules (iCPR) study builds on a previous single clinic study to integrate two CPRs into the electronic health record and assess their impact on practice. This article discusses study design and implementation of a multicenter cluster randomized control trial of the iCPR clinical decision support system, including the tool adaptation, usability testing, staff training, and implementation study to disseminate iCPR at multiple clinical sites across two health care systems. Methods The iCPR tool is based on two well-validated CPRs, one for strep pharyngitis and one for pneumonia. The iCPR tool uses the reason for visit to trigger a risk calculator. Provider completion of the risk calculator provides a risk score, which is linked to an order set. Order sets guide evidence-based care and include progress note documentation, tests, prescription medications, and patient instructions. The iCPR tool was refined based on interviews with providers, medical assistants, and clinic managers, and two rounds of usability testing. “Near live” usability testing with simulated patients was used to ensure that iCPR fit into providers’ clinical workflows. Thirty-three Family Medicine and General Internal Medicine primary care clinics were recruited at two institutions. Clinics were randomized to academic detailing about strep pharyngitis and pneumonia diagnosis and treatment (control) or academic detailing plus use of the iCPR tool (intervention). The primary outcome is the difference in antibiotic prescribing rates between the intervention and control groups with secondary outcomes of difference in rapid strep and chest x-ray ordering. Use of the components of the iCPR will also be assessed. Discussion The iCPR study uses a strong user-centered design and builds on the previous initial study, to assess whether CPRs integrated in the electronic health record can change provider behavior and improve evidence-based care in a broad range of primary care clinics. Trial registration Clinicaltrials.gov (NCT02534987)
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Affiliation(s)
- David A Feldstein
- Division of General Internal Medicine, University of Wisconsin School of Medicine and Public Health, 2828 Marshall Court, Suite 100, Madison, WI, 53705, USA.
| | - Rachel Hess
- Division of Health System Innovation and Research, University of Utah School of Medicine, Williams Building, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Rebecca G Mishuris
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2, Boston, MA, 02118, USA
| | - Lauren McCullagh
- Department of Medicine, Hofstra Northwell School of Medicine, 600 Community Drive, Suite 300, Manhasset, NY, 11030, USA
| | - Paul D Smith
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, WI, 53715, USA
| | - Michael Flynn
- Westridge Health Center, University of Utah School of Medicine, 3730 West 4700 South, West Valley City, UT, 84118, USA
| | - Joseph Palmisano
- Boston University School of Public Health, Fuller Building M-900C, Boston, MA, 02118, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University School of Public Health, Crosstown Center-CT331, Boston, MA, 02118, USA
| | - Devin Mann
- Department of Medicine, New York University School of Medicine, 227 East 30th St. 7th floor, New York, NY, 10016, USA
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Daneshvar F, Weinreich M, Daneshvar D, Sperling M, Salmane C, Yacoub H, Gabriels J, McGinn T, Smith MC. Cardiorespiratory Fitness in Internal Medicine Residents: Are Future Physicians Becoming Deconditioned? J Grad Med Educ 2017; 9:97-101. [PMID: 28261402 PMCID: PMC5330203 DOI: 10.4300/jgme-d-15-00720.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 11/06/2022] Open
Abstract
BACKGROUND Previous studies have shown a falloff in physicians' physical activity from medical school to residency. Poor fitness may result in stress, increase resident burnout, and contribute to mortality from cardiovascular disease and other causes. Physicians with poor exercise habits are also less likely to counsel patients about exercise. Prior studies have reported resident physical activity but not cardiorespiratory fitness age. OBJECTIVE The study was conducted in 2 residency programs (3 hospitals) to assess internal medicine residents' exercise habits as well as their cardiorespiratory fitness age. METHODS Data regarding physical fitness levels and exercise habits were collected in an anonymous cross-sectional survey. Cardiopulmonary fitness age was determined using fitness calculator based on the Nord-Trøndelag Health Study (HUNT). RESULTS Of 199 eligible physicians, 125 (63%) responded to the survey. Of respondents, 11 (9%) reported never having exercised prior to residency and 45 (36%) reported not exercising during residency (P < .001). In addition, 42 (34%) reported exercising every day prior to residency, while only 5 (4%) reported exercising daily during residency (P < .001), with 99 (79%) participants indicating residency obligations as their main barrier to exercise. We found residents' calculated mean fitness age to be 5.6 years higher than their mean chronological age (P < .001). CONCLUSIONS Internal medicine residents reported significant decreases in physical activity and fitness. Residents attributed time constraints due to training as a key barrier to physical activity.
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Affiliation(s)
- Farshid Daneshvar
- Corresponding author: Farshid Daneshvar, MD, Staten Island University Hospital, Department of Medicine, 475 Seaview Avenue, Suite 104, Staten Island, NY 10305, 917.912.7167,
| | | | - Danial Daneshvar
- Corresponding author: Farshid Daneshvar, MD, Staten Island University Hospital, Department of Medicine, 475 Seaview Avenue, Suite 104, Staten Island, NY 10305, 917.912.7167,
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Abstract
BACKGROUND Patients with advanced-stage chronic obstructive pulmonary disease (COPD) may suffer severe respiratory exacerbations and need to decide between accepting life-sustaining treatments versus foregoing these treatments (choosing comfort care only). We designed the InformedTogether decision aid to inform this decision and describe results of a pilot study to assess usability focusing on participants' trust in the content of the decision aid, acceptability, recommendations for improvement, and emotional reactions to this emotionally laden decision. METHODS Study participants ( N = 26) comprising clinicians, patients, and surrogates viewed the decision aid, completed usability tasks, and participated in interviews and focus groups assessing comprehension, trust, perception of bias, and perceived acceptability of InformedTogether. Mixed methods were used to analyze results. RESULTS Almost all participants understood the gist (general meaning) of InformedTogether. However, many lower literacy participants had difficulty answering the more detailed questions related to comprehension, especially when interpreting icon arrays, and many were not aware that they had misunderstood the information. Qualitative analysis showed a range of emotional reactions to the information. Participants with low verbatim comprehension frequently referenced lived experiences when answering knowledge questions, which we termed "alternative knowledge." CONCLUSIONS We found a range of emotional reactions to the information and frequent use of alternative knowledge frameworks for deriving meaning from the data. These observations led to insights into the impact of lived experiences on the uptake of biomedical information presented in decision aids. Communicating prognostic information could potentially be improved by eliciting alternative knowledge as a starting point to build communication, in particular for low literacy patients. Decision aids designed to facilitate shared decision making should elicit this knowledge and help clinicians tailor information accordingly.
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Affiliation(s)
- Negin Hajizadeh
- Department of Medicine, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY (NH, AK, TL, TM, MAD)
| | - Melissa J Basile
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY (MJB, MA)
| | - Andrzej Kozikowski
- Department of Medicine, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY (NH, AK, TL, TM, MAD)
| | - Meredith Akerman
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY (MJB, MA)
| | - Tara Liberman
- Department of Medicine, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY (NH, AK, TL, TM, MAD)
| | - Thomas McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY (NH, AK, TL, TM, MAD)
| | - Michael A Diefenbach
- Department of Medicine, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY (NH, AK, TL, TM, MAD).,Department of Urology, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY (MAD)
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Press A, Khan S, McCullagh L, Schachter A, Pardo S, Kohn N, McGinn T. Avoiding alert fatigue in pulmonary embolism decision support: a new method to examine 'trigger rates'. Evid Based Med 2016; 21:203-207. [PMID: 27664174 PMCID: PMC10658942 DOI: 10.1136/ebmed-2016-110440] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A clinical decision support system (CDSS) is integrated into the electronic health record (EHR) and allows physicians to easily use a clinical decision support (CDS) tool. However, often CDSSs are integrated into the EHR with poor adoption rates. One reason for this is secondary to 'trigger fatigue'. Therefore, we developed a new and innovative usability process named 'sensitivity and specificity trigger analysis' (SSTA) as part of our larger project around a pulmonary embolism decision support tool. SSTA will enable programmers to examine optimal trigger rates prior to the integration of a CDS tool into the EHR, by using a formal method of analysis. We performed a retrospective chart review. The outcome of interest was physician ordering of a CT angiography (CTA). Phrases that signify common symptoms associated with pulmonary embolism were assessed as possible triggers for the CDSS tool. We then analysed each trigger's ability to predict physician ordering of a CTA. We found that the most sensitive way to trigger the Pulmonary Embolism CDS tool while still maintaining a high specificity was by combining 1 or more pertinent symptoms with 1 or more elements of the Wells criteria. This study explored a unique methodology, SSTA, used to limit inaccurate triggering of a CDS tool prior to integration into the EHR. This methodology can be applied to other studies aiming to decrease triggering rates and increase adoption rates of previously validated CDSS tools.
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Affiliation(s)
- Anne Press
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Sundas Khan
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Lauren McCullagh
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Andy Schachter
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Salvatore Pardo
- Department of Emergency Medicine, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Nina Kohn
- Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, New York, USA
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Kronish IM, Moise N, McGinn T, Quan Y, Chaplin W, Gallagher BD, Davidson KW. An Electronic Adherence Measurement Intervention to Reduce Clinical Inertia in the Treatment of Uncontrolled Hypertension: The MATCH Cluster Randomized Clinical Trial. J Gen Intern Med 2016; 31:1294-1300. [PMID: 27255750 PMCID: PMC5071278 DOI: 10.1007/s11606-016-3757-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/09/2016] [Accepted: 05/10/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND To appropriately manage uncontrolled hypertension, clinicians must decide whether blood pressure (BP) is above goal due to a need for additional medication or to medication nonadherence. Yet, clinicians are poor judges of adherence, and uncertainty about adherence may promote inertia with respect to medication modification. OBJECTIVE We aimed to determine the effect of sharing electronically-measured adherence data with clinicians on the management of uncontrolled hypertension. DESIGN This was a cluster randomized trial. PARTICIPANTS Twenty-four primary care providers (12 intervention, 12 usual care; cluster units) and 100 patients with uncontrolled hypertension (65 intervention, 35 usual care) were included in the study. INTERVENTIONS At one visit per patient, clinicians in the intervention group received a report summarizing electronically measured adherence to the BP regimen and recommended clinical actions. Clinicians in the control group did not receive a report. MAIN MEASURES The primary outcome was the proportion of visits with appropriate clinical management (i.e., treatment intensification among adherent patients and adherence counseling among nonadherent patients). Secondary outcomes included patient-rated quality of care and communication during the visit. KEY RESULTS The proportion of visits with appropriate clinical management was higher in the intervention group than the control group (45 out of 65; 69 %) versus (12 out of 35; 34 %; p = 0.001). A higher proportion of adherent patients in the intervention group had their regimen intensified (p = 0.01), and a higher proportion of nonadherent patients in the intervention group received adherence counseling (p = 0.005). Patients in the intervention group were more likely to give their clinician high ratings on quality of care (p = 0.05), and on measures of patient-centered (p = 0.001) and collaborative communication (p = 0.02). CONCLUSIONS Providing clinicians with electronically-measured antihypertensive adherence reports reduces inertia in the management of uncontrolled hypertension. TRIAL REGISTRATION NCT01257347 ; http://clinicaltrials.gov/show/ NCT01257347.
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Affiliation(s)
- Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA.
| | - Nathalie Moise
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - Yan Quan
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA
| | - William Chaplin
- Department of Psychology, St. John's University, Jamaica, NY, USA
| | - Benjamin D Gallagher
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA
| | - Karina W Davidson
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 West 168th Street, PH9-311, New York, NY, 10032, USA
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Abstract
Background . To better inform clinicians on the optimal management of patients on oral anticoagulation who need to undergo surgery or invasive procedures, the authors performed a decision analysis examining whether a perioperative aggressive or minimalist strategy results in greater quality-adjusted survival. Methods . A decision analysis model was created comparing withholding warfarin (minimalist strategy) to withholding warfarin and administering treatment-dose subcutaneous low-molecular-weight heparin (LMWH) or intravenous heparin perioperatively (aggressive strategy). The base-case analysis examined a hypothetical 60-year-old hypertensive individual with mechanical aortic valve replacement undergoing major abdominal surgery. A probabilistic sensitivity analysis was performed using a Monte Carlo simulation with quality-adjusted life expectancy (QALE) as the outcome. Secondary analyses examined patients with a mechanical mitral valve and atrial fibrillation. Sensitivity analyses were performed for each variable. Results . Under the base-case scenario, the minimalist strategy was preferred for 78% of trials in the Monte Carlo simulation, with a mean benefit of 0.003 years (95% confidence interval, -0.005 years to 0.011 years). Sensitivity analyses based on point estimates indicate that the aggressive strategy is preferred when the annual stroke rate is >5.6% or the increase in postoperative major bleeding induced by heparin is <2.0%; however, the benefit is small over the range of plausible values. Conclusions . For most patients with a mechanical aortic valve or atrial fibrillation undergoing major surgery, a minimalist strategy of simply withholding oral anticoagulation provides similar QALE as an aggressive strategy of administering perioperative subcutaneous LMWH or intravenous heparin. The aggressive therapy provides greater QALE for patients at higher risk of stroke (e.g., mechanical mitral valves), although the benefit is small.
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Affiliation(s)
- Andrew S Dunn
- Division of General Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Rosenberg DJ, Press A, Fishbein J, Lesser M, McCullagh L, McGinn T, Spyropoulos AC. External validation of the IMPROVE Bleeding Risk Assessment Model in medical patients. Thromb Haemost 2016; 116:530-6. [PMID: 27307054 DOI: 10.1160/th16-01-0003] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [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: 01/04/2016] [Accepted: 05/13/2016] [Indexed: 11/05/2022]
Abstract
The IMPROVE Bleed Risk Assessment Model (RAM) remains the only bleed RAM in hospitalised medical patients using 11 clinical and laboratory factors. The aim of our study was to externally validate the IMPROVE Bleed RAM. A retrospective chart review was conducted between October 1, 2012 and July 31, 2014. We applied the point scoring system to compute risk scores for each patient in the validation sample. We then dichotomised the patients into those with a score <7 (low risk) vs ≥ 7 (high risk), as outlined in the original study, and compared the rates of any bleed, non-major bleed, and major bleed. Among the 12,082 subjects, there was an overall 2.6 % rate of any bleed within 14 days of admission. There was a 2.12 % rate of any bleed in those patients with a score of < 7 and a 4.68 % rate in those with a score ≥ 7 [Odds Ratio (OR) 2.3 (95 % CI=1.8-2.9), p<0.0001]. MB rates were 1.5 % in the patients with a score of < 7 and 3.2 % in the patients with a score of ≥ 7, [OR 2.2 (95 % CI=1.6-2.9), p<0.0001]. The ROC curve was 0.63 for the validation sample. This study represents the largest externally validated Bleed RAM in a hospitalised medically ill patient population. A cut-off point score of 7 or above was able to identify a high-risk patient group for MB and any bleed. The IMPROVE Bleed RAM has the potential to allow for more tailored approaches to thromboprophylaxis in medically ill hospitalised patients.
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Affiliation(s)
| | | | | | | | | | | | - Alex C Spyropoulos
- Alex C. Spyropoulos, MD, FACP, FCCP, FRCPC, Hofstra, North Shore - LIJ School of Medicine, Lenox Hill Hospital, 130 E 77th St, New York, NY 10075, USA, Tel.: +1 212 434 6776, Fax: +1 212 434 6781, E-mail:
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McGinn T. Putting Meaning into Meaningful Use: A Roadmap to Successful Integration of Evidence at the Point of Care. JMIR Med Inform 2016; 4:e16. [PMID: 27199223 PMCID: PMC4891572 DOI: 10.2196/medinform.4553] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 08/26/2015] [Accepted: 09/22/2015] [Indexed: 11/13/2022] Open
Abstract
Pressures to contain health care costs, personalize patient care, use big data, and to enhance health care quality have highlighted the need for integration of evidence at the point of care. The application of evidence-based medicine (EBM) has great promise in the era of electronic health records (EHRs) and health technology. The most successful integration of evidence into EHRs has been complex decision tools that trigger at a critical point of the clinical visit and include patient specific recommendations.
The objective of this viewpoint paper is to investigate why the incorporation of complex CDS tools into the EMR is equally complex and continues to challenge health service researchers and implementation scientists. Poor adoption and sustainability of EBM guidelines and CDS tools at the point of care have persisted and continue to document low rates of usage. The barriers cited by physicians include efficiency, perception of usefulness, information content, user interface, and over-triggering.
Building on the traditional EHR implementation frameworks, we review keys strategies for successful CDSs: (1) the quality of the evidence, (2) the potential to reduce unnecessary care, (3) ease of integrating evidence at the point of care, (4) the evidence’s consistency with clinician perceptions and preferences, (5) incorporating bundled sets or automated documentation, and (6) shared decision making tools.
As EHRs become commonplace and insurers demand higher quality and evidence-based care, better methods for integrating evidence into everyday care are warranted. We have outlined basic criteria that should be considered before attempting to integrate evidenced-based decision support tools into the EHR.
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Affiliation(s)
- Thomas McGinn
- Hofstra North Shore LII School of Medicine, Manhasset, NY, United States.
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Khan S, McCullagh L, Press A, Kharche M, Schachter A, Pardo S, McGinn T. Formative assessment and design of a complex clinical decision support tool for pulmonary embolism. Evid Based Med 2016; 21:7-13. [PMID: 26718820 PMCID: PMC10687829 DOI: 10.1136/ebmed-2015-110214] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Electronic health record (EHR)-based clinical decision support (CDS) tools are rolled out with the urgency to meet federal requirements without time for usability testing and refinement of the user interface. As part of a larger project to design, develop and integrate a pulmonary embolism CDS tool for emergency physicians, we conducted a formative assessment to determine providers' level of interest and input on designs and content. This was a study to conduct a formative assessment of emergency medicine (EM) physicians that included focus groups and key informant interviews. The focus of this study was twofold, to determine the general attitude towards CDS tool integration and the ideal integration point into the clinical workflow. To accomplish this, we first approached EM physicians in a focus group, then, during key informant interviews, we presented workflow designs and gave a scenario to help the providers visualise how the CDS tool works. Participants were asked questions regarding the trigger location, trigger words, integration into their workflow, perceived utility and heuristic of the tool. Results from the participants' survey responses to trigger location, perceived utility and efficiency, indicated that the providers felt the tool would be more of a hindrance than an aid. However, some providers commented that they had not had exposure to CDS tools but had used online calculators, and thought the tools would be helpful at the point-of-care if integrated into the EHR. Furthermore, there was a preference for an order entry wireframe. This study highlights several factors to consider when designing CDS tools: (1) formative assessment of EHR functionality and clinical environment workflow, (2) focus groups and key informative interviews to incorporate providers' perceptions of CDS and workflow integration and/or (3) the demonstration of proposed workflows through wireframes to help providers visualise design concepts.
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Affiliation(s)
- Sundas Khan
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Lauren McCullagh
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Anne Press
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Manish Kharche
- Department of Medical Informatics and Care Delivery Innovation, Cooper University Health Care, Camden, New Jersey, USA
| | - Andy Schachter
- Department of Information Technology, North Shore-LIJ Health System, Manhasset, New York, USA
| | - Salvatore Pardo
- Department of Emergency Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
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Press A, McCullagh L, Khan S, Schachter A, Pardo S, McGinn T. Usability Testing of a Complex Clinical Decision Support Tool in the Emergency Department: Lessons Learned. JMIR Hum Factors 2015; 2:e14. [PMID: 27025540 PMCID: PMC4797671 DOI: 10.2196/humanfactors.4537] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/02/2015] [Accepted: 06/29/2015] [Indexed: 11/13/2022] Open
Abstract
Background As the electronic health record (EHR) becomes the preferred documentation tool across medical practices, health care organizations are pushing for clinical decision support systems (CDSS) to help bring clinical decision support (CDS) tools to the forefront of patient-physician interactions. A CDSS is integrated into the EHR and allows physicians to easily utilize CDS tools. However, often CDSS are integrated into the EHR without an initial phase of usability testing, resulting in poor adoption rates. Usability testing is important because it evaluates a CDSS by testing it on actual users. This paper outlines the usability phase of a study, which will test the impact of integration of the Wells CDSS for pulmonary embolism (PE) diagnosis into a large urban emergency department, where workflow is often chaotic and high stakes decisions are frequently made. We hypothesize that conducting usability testing prior to integration of the Wells score into an emergency room EHR will result in increased adoption rates by physicians. Objective The objective of the study was to conduct usability testing for the integration of the Wells clinical prediction rule into a tertiary care center’s emergency department EHR. Methods We conducted usability testing of a CDS tool in the emergency department EHR. The CDS tool consisted of the Wells rule for PE in the form of a calculator and was triggered off computed tomography (CT) orders or patients’ chief complaint. The study was conducted at a tertiary hospital in Queens, New York. There were seven residents that were recruited and participated in two phases of usability testing. The usability testing employed a “think aloud” method and “near-live” clinical simulation, where care providers interacted with standardized patients enacting a clinical scenario. Both phases were audiotaped, video-taped, and had screen-capture software activated for onscreen recordings. Results Phase I: Data from the “think-aloud” phase of the study showed an overall positive outlook on the Wells tool in assessing a patient for a PE diagnosis. Subjects described the tool as “well-organized” and “better than clinical judgment”. Changes were made to improve tool placement into the EHR to make it optimal for decision-making, auto-populating boxes, and minimizing click fatigue.
Phase II: After incorporating the changes noted in Phase 1, the participants noted tool improvements. There was less toggling between screens, they had all the clinical information required to complete the tool, and were able to complete the patient visit efficiently. However, an optimal location for triggering the tool remained controversial. Conclusions This study successfully combined “think-aloud” protocol analysis with “near-live” clinical simulations in a usability evaluation of a CDS tool that will be implemented into the emergency room environment. Both methods proved useful in the assessment of the CDS tool and allowed us to refine tool usability and workflow.
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Affiliation(s)
- Anne Press
- Hofstra North Shore-LIJ School of Medicine, Department of Medicine, Manhasset, NY, United States.
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Abstract
OBJECTIVES To examine internal medicine and emergency medicine healthcare provider perceptions of usefulness of specific clinical prediction rules. SETTING The study took place in two academic medical centres. A web-based survey was distributed and completed by participants between 1 January and 31 May 2013. PARTICIPANTS Medical doctors, doctors of osteopathy or nurse practitioners employed in the internal medicine or emergency medicine departments at either institution. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was to identify the clinical prediction rules perceived as most useful by healthcare providers specialising in internal medicine and emergency medicine. Secondary outcomes included comparing usefulness scores of specific clinical prediction rules based on provider specialty, and evaluating associations between usefulness scores and perceived characteristics of these clinical prediction rules. RESULTS Of the 401 healthcare providers asked to participate, a total of 263 (66%), completed the survey. The CHADS2 score was chosen by most internal medicine providers (72%), and Pulmonary Embolism Rule-Out Criteria (PERC) score by most emergency medicine providers (45%), as one of the top three most useful from a list of 24 clinical prediction rules. Emergency medicine providers rated their top three significantly more positively, compared with internal medicine providers, as having a better fit into their workflow (p=0.004), helping more with decision-making (p=0.037), better fitting into their thought process when diagnosing patients (p=0.001) and overall, on a 10-point scale, more useful (p=0.009). For all providers, the perceived qualities of useful at point of care, helps with decision making, saves time diagnosing, fits into thought process, and should be the standard of clinical care correlated highly (≥0.65) with overall 10-point usefulness scores. CONCLUSIONS Healthcare providers describe clear preferences for certain clinical prediction rules, based on medical specialty.
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Affiliation(s)
- Safiya Richardson
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Sundas Khan
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Lauren McCullagh
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Myriam Kline
- Biostatistics Division, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Devin Mann
- Department of Medicine, Boston University, Boston, Massachusetts, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
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Kannry J, McCullagh L, Kushniruk A, Mann D, Edonyabo D, McGinn T. A Framework for Usable and Effective Clinical Decision Support: Experience from the iCPR Randomized Clinical Trial. EGEMS (Wash DC) 2015; 3:1150. [PMID: 26290888 PMCID: PMC4537146 DOI: 10.13063/2327-9214.1150] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The promise of Clinical Decision Support (CDS) has always been to transform patient care and improve patient outcomes through the delivery of timely and appropriate recommendations that are patient specific and, more often than not, are appropriately actionable. However, the users of CDS-providers-are frequently bombarded with inappropriate and inapplicable CDS that often are not informational, not integrated into the workflow, not patient specific, and that may present out of date and irrelevant recommendations. METHODS The integrated clinical prediction rule (iCPR) project was a randomized clinical trial (RCT) conducted to determine if a novel form of CDS, i.e., clinical prediction rules (CPRs), could be efficiently integrated into workflow and result in changes in outcomes (e.g., antibiotic ordering) when embedded within a commercial electronic health record (EHR). We use the lessons learned from the iCPR project to illustrate a framework for constructing usable, useful, and effective actionable CDS while employing off-the-shelf functionality in a production system. Innovations that make up the framework combine the following: (1) active and actionable decision support, (2) multiple rounds of usability testing with iterative development for user acceptance, (3) numerous context sensitive triggers, (4) dedicated training and support for users of the CDS tool for user adoption, and (5) support from clinical and administrative leadership. We define "context sensitive triggers" as being workflow events (i.e., context) that result in a CDS intervention. DISCUSSION Success of the framework can be measured by CDS adoption (i.e., intervention is being used), acceptance (compliance with recommendations), and clinical outcomes (where appropriate). This framework may have broader implications for the deployment of Health Information Technology (HIT). RESULTS AND CONCLUSION iCPR was well adopted(57.4% of users) and accepted (42.7% of users). Usability testing identified and fixed many issues before the iCPR RCT. The level of leadership support and clinical guidance for iCPR was key in establishing a culture of acceptance for both the tool and its recommendations contributing to adoption and acceptance. The dedicated training and support lead to the majority of the residents reporting a high level of comfort with both iCPR tools strep pharyngitis (64.4 percent) and pneumonia (62.7 percent) as well as a high likelihood of using the tools in the future. A surprising framework addition resulted from usability testing: context sensitive triggers.
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Abstract
Introduction: In this special issue of eGEMs, we explore the struggles related to bringing evidence into day-to-day practice, what I define as the “evidence gap.” We are all aware of high quality evidence in the form of guidelines, randomized clinical trials for treatments and diagnostic tests, and clinical prediction rules, which are all readily available online. We also know that electronic health records (EHRs) are now ubiquitous in health care and in most practices across the country. How we marry this high quality evidence and the practice of medicine through effective decision support is a major challenge. About the Issue: All of the articles in this issue explore, in some fashion, CDS systems and how we can best bring providers and their work environment to the evidence. We are at the very early stages of the science of usability. Much more research and funding is needed in this area if we hope to improve the dissemination and implementation of evidence in practice. While the featured examples, techniques, and tools in the special issue are a promising start to improving usability and CDS, many of the papers highlight current gaps in knowledge and a great need for generalizable approaches. The great promise is for “learning” approaches to generate new evidence and to integrate this evidence in reliable, patient-centered ways at scale using new technology. Closing the evidence gap is a real possibility, but only if the community works together to innovate and invest in research on the best ways to disseminate, communicate, and implement evidence in practice.
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Mathew A, Pekmezaris R, Rosen L, Kozikowski A, McGinn T, Kalantar-Zadeh K, Fishbane S. FP684POTENTIALLY PREVENTABLE READMISSIONS IN CHRONIC HEMODIALYSIS PATIENTS. Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv183.02] [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: 11/14/2022] Open
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Rosenberg D, Eichorn A, Alarcon M, McCullagh L, McGinn T, Spyropoulos AC. External validation of the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for medical patients in a tertiary health system. J Am Heart Assoc 2014; 3:e001152. [PMID: 25404191 PMCID: PMC4338701 DOI: 10.1161/jaha.114.001152] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hospitalized medical patients are at risk for venous thromboembolism (VTE). Universal application of pharmacological thromboprophylaxis has the potential to place a large number of patients at increased bleeding risk. In this study, we aimed to externally validate the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk assessment model in a hospitalized general medical population. Methods and Results We identified medical discharges that met the IMPROVE protocol. Cases were defined as hospital‐acquired VTE and confirmed by diagnostic study within 90 days of index hospitalization; matched controls were also identified. Risk factors for VTE were based on the IMPROVE risk assessment model (aged >60 years, prior VTE, intensive care unit or coronary care unit stay, lower limb paralysis, immobility, known thrombophilia, and cancer) and were measured and assessed. A total of 19 217 patients met the inclusion criteria. The overall VTE event rate was 0.7%. The IMPROVE risk assessment model identified 2 groups of the cohort by VTE incidence rate: The low‐risk group had a VTE event rate of 0.42 (95% CI 0.31 to 0.53), corresponding to a score of 0 to 2, and the at‐risk group had a VTE event rate of 1.29 (95% CI 1.01 to 1.57), corresponding to a score of ≥3. Low‐risk status for VTE encompassed 68% of the patient cohort. The area under the receiver operating characteristic curve was 0.702, which was in line with the derivation cohort findings. Conclusions The IMPROVE VTE risk assessment model validation cohort revealed good discrimination and calibration for both the overall VTE risk model and the identification of low‐risk and at‐risk medical patient groups, using a risk score of ≥3. More than two thirds of the entire cohort had a score ≤2.
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Affiliation(s)
- David Rosenberg
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Ann Eichorn
- Krasnoff Quality Management Institute, North Shore LIJ Health System, Manhasset, NY (A.E.)
| | - Mauricio Alarcon
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Lauren McCullagh
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Alex C Spyropoulos
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
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