The retrospective chart review: important methodological considerations

The Data Error Criteria (DEC) for retrospective studies: development and preliminary application

Retrospective chart review (RCR) studies rely on the collection and analysis of documented clinical data, a process that can be prone to errors. The aim of this study was to develop a defined set of criteria to evaluate RCR datasets for potential data errors. The Data Error Criteria (DEC) were developed by identifying data coding and data entry errors via literature review and then classifying them based on error types. Three components comprise the DEC: general errors, numerical-specific errors, and categorical variable-specific errors. Two reviewers independently applied these criteria via a manual review process to an existing de-identified database. A total of 10,168 errors were identified out of a total of 28,656 data points. The total number of errors included redundancies as certain errors may be included in multiple categories. These included 2515 general errors, 39 numerical-specific errors, and 7614 categorical variable-specific errors. Input-related categorical variable-specific errors occurred most frequently, followed by errors secondary to blank cells. Inter-rater agreement was near perfect for all categories. Identifying errors outlined in the DEC can be crucial for the data analysis stage as they can lead to inaccurate calculations and delay study timelines. The DEC offers a framework to evaluate datasets while reducing time and efforts needed to create high-quality RCR-related databases.

Assessment and rehabilitation of acquired communication disorders in Aboriginal and Torres Strait Islander adults with stroke or traumatic brain injury: a retrospective chart review

PURPOSE

Speech-language pathologists' (SLP) management practices for Aboriginal and Torres Strait Islander adults with acquired communication disorder (ACD), following stroke or traumatic brain injury (TBI), are not well understood. This study explores SLPs' management approaches for ACDs for Aboriginal and Torres Strait Islander adults post-stroke or TBI.

MATERIALS AND METHODS

SLPs' documented notes were analysed from a two-year retrospective medical record review of Aboriginal and Torres Strait Islander adults (≥18 years), admitted to a regional Queensland hospital with principal diagnoses of stroke or TBI.

RESULTS

SLPs frequently used informal approaches to assess ACDs. English-language formal assessment tools were also used in conjunction with the informal approaches. ACD diagnosis was more common in stroke than TBI patients. One-third of patients with ACD received inpatient rehabilitation at the study site. SLPs infrequently documented cultural or linguistic adaptions to assessment or interventions.

CONCLUSIONS

Informal approaches to assess ACDs were commonly employed which may be because they are perceived to be more culturally appropriate. Clinical guidelines for stroke and TBI should accommodate the diversity of cultures and languages. Better consideration of Aboriginal and Torres Strait Islander communication styles and incorporation of these into SLP ACD management approaches may facilitate accurate diagnosis and culturally safe rehabilitation services.Implications for RehabilitationInformal approaches for assessment and intervention of ACDs, that incorporate yarning and salient tasks, are likely to be more culturally appropriate and safe for Aboriginal and Torres Strait Islander peoples.More flexibility and guidance in the use of culturally and linguistically appropriate alternative assessment approaches are required in the National stroke guidelines for Aboriginal and Torres Strait Islander peoples.The adoption of enhanced models of culturally secure ACD service provision, that incorporate frequent SLP engagement with an Aboriginal or Torres Strait Islander support person during assessment and rehabilitation, are needed.There is an imperative for health professionals to actively account for culture and language difference in rehabilitation practices to ensure Indigenous peoples worldwide receive equitable and culturally-responsive services.

Effectiveness and Safety of Enoxaparin Versus Unfractionated Heparin as Thromboprophylaxis in Hospitalized COVID-19 Patients: Real-World Evidence

BACKGROUND

Coronavirus 2019 (COVID-19) patients are at risk of thrombosis. Literature that compares the effectiveness of enoxaparin to unfractionated heparin (UFH) in COVID-19 patients is scarce.

OBJECTIVE

We aimed to evaluate the effectiveness and safety of enoxaparin compared with UFH when used at their standard/intermediate dosing in COVID-19 patients.

METHODS

This was a retrospective study conducted at a large COVID-19 center located in Eastern Province, Saudi Arabia. Confirmed COVID-19 cases (≥18 years old) admitted between January and December 2020 were randomly screened for inclusion. Exclusion criteria were patients receiving therapeutic anticoagulation, on chronic anticoagulation, had active bleeding, a platelet count <25 × 109/L, or an incomplete electronic file. The primary endpoint was the occurrence of any thrombotic event (pulmonary embolism, deep venous thrombosis, stroke, or myocardial infarction) or mortality. Secondary endpoints were major or minor bleeding. We applied inverse propensity score weighting (IPTW) with survival analysis to analyze the primary endpoint. Logistic regression was used for the secondary endpoint.

RESULTS

A total of 980 patients were included (enoxaparin, n = 470 and UFH, n = 510) with a mean age (±SD) of 47.7 (± 12.3) for the enoxaparin arm and 52 (±13.9) for the UFH arm. There was a statistically significant difference in the primary endpoint with an adjusted hazard ratio (aHR) of 0.46 (95%CI: 0.22 to 0.96, P = 0.039) in favor of the enoxaparin arm. There was no statistically significant difference in major or minor bleeding rates between the two arms.

CONCLUSION AND RELEVANCE

When compared with UFH, enoxaparin was associated with a significant reduction in thrombotic events or mortality among COVID-19 patients. The results need confirmation from randomized controlled trials.

Epigastric hernias in children and the use of ultrasound in its diagnosis

Introduction

There is a paucity of clinical data on pediatric epigastric hernias despite them accounting for up to 6% of all hernia repairs in children. We aimed to provide additional data to supplement those 117 cases of a recent systematic review and to further clarify the role of ultrasound in diagnosing pediatric epigastric hernia.

Methods

We retrospectively included all 60 patients treated for epigastric hernias in children in two tertiary pediatric surgical departments within 12 years. Associations were tested via point-biserial correlation analyses.

Results

Epigastric hernias primarily affected preschool children with a median age of 39 months. The vast majority of patients (88%) presented with swelling that was occasionally (30%) accompanied by pain. Fascial defects could be found during clinical examination in 45% of patients with a median size of 5 mm (95% CI 3 to 10). Smaller defects were less likely to be palpable (r=−0.44, 95% CI −0.08 to −0.7, p=0.021). Likewise, ultrasound was used more frequently with smaller fascial defect sizes (r=−0.51, 95% CI −0.16 to −0.74, p=0.007). Laparoscopic repair was used in 11 patients (19%) and more often (4/11) in combination with another simultaneous procedure than open repair (11/48).

Conclusions

Epigastric hernias are primarily a condition of the preschool child. Ultrasound can be beneficial if the diagnosis cannot be made clinically; otherwise, it is abdicable if it does not change the management of the patient’s epigastric hernia. Laparoscopic repairs might be beneficial for children with multiple defects or simultaneous procedures.

A Primer to Experimental and Nonexperimental Quantitative Research: The Example Case of Tobacco-Related Mouth Cancer

OBJECTIVES

To present a comprehensive overview of key constructs of experimental and nonexperimental quantitative research, drawing on one example case from cancer care.

DATA SOURCES

Published scientific articles, research textbooks, and expert advice were used in this article.

CONCLUSION

Quantitative research turns information collected about people or about processes into numerical data. Depending on the underlying purpose, the goal is to address questions that have to do with intervention, prognosis, causation, association, description, or assessment. In experimental research, an intervention is manipulated. True experimental research (randomized controlled trial) controls confounding variables via use of both randomization and a control group; quasi-experimental research misses one or both of these elements. In either case, the aim is to generate evidence to confidently say that an intervention is the true cause of an observed outcome. Nonexperimental research is multifaceted. Cohorts and case-control studies can be used to test cause-and-effect relationships where experimental research is unethical or impractical. Correlational research aims to explore possible associations (exploratory) or help anticipate outcomes (predictive) and, quite often, is the precursor of experimental research. Descriptive research (simple, comparative, survey, retrospective chart review) can be used to describe and assess situations, conditions, or behaviors.

IMPLICATIONS FOR NURSING PRACTICE

Understanding the different aims and goals of the different types of quantitative research can help increase capacity and confidence in understanding, appraising, and applying quantitative evidence among health care students, professionals, and novice researchers in the quest for the provision of quality cancer care.

Use of Antibiotics in Poisonous Ingestions of Corrosives and Organophosphates: A Retrospective Cohort Study

The use of antibiotics following oral poisoning by corrosives and organophosphates is controversial. We assessed the clinical outcomes of using antibiotics in acute poisonous ingestion involving corrosives or organophosphates by conducting a retrospective cohort study of patients presenting to the emergency department following ingestion of corrosives or organophosphates who received either antibiotics or supportive care. The endpoints included clinical stability, length of stay (LOS), and mortality. Of 95 patients, 40 received antibiotics and 55 received supportive care. The median age was 2.1 and 2.7 years, respectively (p = 0.053). Bacterial growth was shown in only 2 of 28 cultures (both were respiratory), but with hospital-acquired organisms as it was shown ≥4 days post-admission. Clinical stability rates were 60% and 89.1% in the antibiotic and supportive care groups, respectively (p < 0.001). Median LOS was 3 vs. 0 days (p < 0.001), and no mortality was recorded. NG/G-tube placement was the only factor associated with clinical failure (OR, 20.97; 95% CI, 2.36-186.13). Antibiotic use was not associated with higher chances of clinical stability, which may suggest that their use was unnecessary. Clinicians are encouraged to use antibiotics wisely, and only in the presence of a clear indication of an infection. This study provides a basis for future prospective studies to confirm its findings.

Prescribing errors in children: what is the impact of a computerized physician order entry?

Prescribing errors represent a safety risk for hospitalized patients, especially in pediatrics. Computerized physician order entry (CPOE) might reduce prescribing errors, although its effect has not yet been thoroughly studied on pediatric general wards. This study investigated the impact of a CPOE on prescribing errors in children on general wards at the University Children's Hospital Zurich. We performed medication reviews on a total of 1000 patients before and after the implementation of a CPOE. The CPOE included limited clinical decision support (CDS) such as drug-drug interaction check and checks for duplicates. Prescribing errors, their type according to the PCNE classification, their severity (adapted NCC MERP index), as well as the interrater reliability (Cohen's kappa), were analyzed. Potentially harmful errors were significantly reduced from 18 errors/100 prescriptions (95% CI: 17-20) to 11 errors/100 prescriptions (95% CI: 9-12) after CPOE implementation. A large number of errors with low potential for harm (e.g., "missing information") was reduced after the introduction of the CPOE, and consequently, the overall severity of potential harm increased post-CPOE. Despite general error rate reduction, medication reconciliation problems (PCNE error 8), such as drugs prescribed on paper as well as electronically, significantly increased after the introduction of the CPOE. The most common pediatric prescribing errors, the dosing errors (PCNE errors 3), were not altered on a statistically significant level after the introduction of the CPOE. Interrater reliability showed moderate agreement (Κ = 0.48).  Conclusion: Patient safety increased by reducing the rate of prescribing errors after CPOE implementation. The reason for the observed increase in medication reconciliation problems might be the hybrid system with remaining paper prescriptions for special medication. The lacking effect on dosing errors could be explained by the fact that a web application CDS covering dosing recommendations (PEDeDose) was already in use before the implementation of the CPOE. Further investigations should focus on eliminating hybrid systems, interventions to increase the usability of the CPOE, and full integration of CDS tools such as automated dose checks into the CPOE. What is Known: • Prescribing errors, especially dosing errors, are a common safety threat for pediatric inpatients. •The introduction of a CPOE may reduce prescribing errors, though pediatric general wards are poorly studied. What is New: •To our knowledge, this is the first study on prescribing errors in pediatric general wards in Switzerland investigating the impact of a CPOE. •We found that the overall error rate was significantly reduced after the implementation of the CPOE. The severity of potential harm was higher in the post-CPOE period, which implies that low-severity errors were substantially reduced after CPOE implementation. Dosing errors were not reduced, but missing information errors and drug selection errors were reduced. On the other hand, medication reconciliation problems increased.

Electronic surveillance criteria for non-ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity

OBJECTIVE

Surveillance of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses.

METHODS

We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans' Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa).

RESULTS

Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP.

CONCLUSIONS

Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.

Patient characteristics in sepsis-related deaths: prevalence of advanced frailty, comorbidity, and age in a Norwegian hospital trust

OBJECTIVE

To examine the prevalence of advanced frailty, comorbidity, and age among sepsis-related deaths in an adult hospital population.

METHODS

Retrospective chart reviews of deceased adults within a Norwegian hospital trust, with a diagnosis of infection, over 2 years (2018-2019). The likelihood of sepsis-related death was evaluated by clinicians as sepsis-related, possibly sepsis-related, or not sepsis-related.

RESULTS

Of 633 hospital deaths, 179 (28%) were sepsis-related, and 136 (21%) were possibly sepsis-related. Among these 315 patients whose deaths were sepsis-related or possibly sepsis-related, close to three in four patients (73%) were either 85 years or older, living with severe frailty (Clinical Frailty Scale, CFS, score of 7 or more), or an end-stage condition prior to the admission. Among the remaining 27%, 15% were either 80-84 years old, living with frailty corresponding to a CFS score of 6, or severe comorbidity, defined as 5 points or more on the Charlson Comorbidity Index (CCI). The last 12% constituted the presumably healthiest cluster, but in this group as well, the majority died with limitations of care due to their premorbid functional status and/ or comorbidity. Findings remained stable if the population was limited to sepsis-related deaths on clinicians' reviews or those fulfilling the Sepsis-3 criteria.

CONCLUSIONS

Advanced frailty, comorbidity, and age were predominant in hospital fatalities where infection contributed to death, with or without sepsis. This is of importance when considering sepsis-related mortality in similar populations, the applicability of study results to everyday clinical work, and future study designs.

The level of adherence to best-practice guidelines by interprofessional teams with and without acute care nurse practitioners in cardiac surgery: A study protocol

BACKGROUND

Acute care nurse practitioners (ACNPs) in postoperative cardiac surgery settings provide significant benefits to patients and organizations. Recent studies have suggested that ACNPs increase the level of adherence to best-practice guidelines by interprofessional teams. It is however, unknown whether interprofessional teams with ACNP are associated with higher levels of adherence to best-practice guidelines compared to interprofessional teams without ACNPs. Furthermore, no extraction tool is available to measure the level of adherence to best-practice guidelines by interprofessional teams in postoperative cardiac surgery settings. This project aims to measure and examine the level of adherence to best-practice guidelines of interprofessional teams with and without ACNPs in a postoperative cardiac surgery setting in Québec, Canada.

METHODS

A retrospective observational study will be conducted of 300 patients hospitalized between January 1, 2019 and January 31, 2020 in a postoperative cardiac surgery unit in Québec, Canada. Data will be collected from patient health records and electronic databases. An extraction tool will be developed based on systematic review of the literature, and will include best-practice guidelines and confounding variables related to patient and interprofessional teams' characteristics. Content and criterion validation, and a pilot-test will be conducted for the development of the tool. A multivariate linear regression model will be developed and adjusted for confounding variables to examine the association between interprofessional teams with and without ACNPs, and level of adherence to best-practice guidelines by those teams.

DISCUSSION

This project represents the first study to measure and examine the level of adherence to best-practice guidelines by interprofessional teams with and without ACNPs in a postoperative cardiac surgery setting. The findings of this project will generate empirical data focusing on the contribution of ACNPs within interprofessional teams, and ultimately enhance the delivery of high quality and evidence-based care for patients and families.

Redesigning care for back pain in an Australian hospital setting: A service evaluation to identify need for change

OBJECTIVE

This needs assessment study examined current processes of physiotherapy care for adults with back pain in a large teaching hospital serving a multicultural community in Sydney, Australia. Evaluation of current practices is a necessary first step in the design of a patient-centred, multidisciplinary service that promotes best practice in back pain management.

METHODS

We conducted a retrospective service evaluation in the physiotherapy outpatient department by reviewing clinical data on episode of care and processes of care for adults managed for back pain over a 6-month period using a defined protocol (n = 252).

RESULTS

Patients (median age = 56 years; 72.2% born outside of Australia) were referred from various internal and external sources, with 79.8% having chronic back pain. The median length of episode of care was 8 weeks. Active interventions were almost universally used (98.4% of records). Key aspects of assessment were frequently recorded (84.5%-98% of records), but psychosocial risk assessment was not routinely recorded. Aspects of longitudinal management planning, including goal setting, outcome measurement, and routine follow-up, were also not routinely recorded.

CONCLUSIONS

This study demonstrated that physiotherapy processes of care in this setting followed key messages of best practice particularly with regard to interventions, in contrast to other settings and jurisdictions. However, the brief episodes of care and less evident focus on psychosocial aspects might not align with the needs of the majority with chronic back pain. These findings suggest the need to reframe processes of care with a biopsychosocial approach and structure episodes of care towards long-term management solutions.

Sodium polystyrene sulfonate versus sodium zirconium cyclosilicate for the treatment of hyperkalemia in the emergency department

BACKGROUND

Hyperkalemia accounts for over 800,000 emergency department (ED) visits in the United States each year, and has been associated with significant morbidity and mortality likely due to fatal cardiac dysrhythmias. Previous studies have demonstrated reductions in mortality when potassium levels are normalized in the ED. Cation exchange resins, such as sodium polystyrene sulfonate (SPS) and sodium zirconium cyclosilicate (SZC), may be administered as a means of definitively eliminating potassium from the body. This practice is based on physician preference and is not supported by high quality data. Two studies evaluating the use of cation exchange resins versus standard treatment in the ED demonstrated reductions in serum potassium levels within two hours of administration; however, there have been no published studies investigating these agents in a head-to-head comparison.

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety of SPS versus SZC in lowering serum potassium in patients presenting to the ED with hyperkalemia.

METHODS

This was an institutional review board-approved, retrospective cohort study conducted at a single-site ED. All patients who received medications under the "ED Hyperkalemia Treatment" order set between August 26, 2019 and May 13, 2021 were eligible for inclusion. The primary outcome was the change in serum potassium from baseline to first repeat level following SPS or SZC administration in the ED.

RESULTS

A total of 885 patients were screened with 54 patients in the SPS group and 51 patients in the SZC group included in the final analyses. The mean change in serum potassium from baseline to first repeat level following administration of the cation exchange resin was -1.1 mEq/L for both groups.

CONCLUSION

Administration of SPS or SZC for the treatment of hyperkalemia in the ED resulted in similar reductions in serum potassium.

Identifying monoclonal gammopathy of undetermined significance from electronic health records

BACKGROUND

Monoclonal gammopathy of undetermined significance (MGUS) precedes multiple myeloma (MM). Use of electronic health records may facilitate large-scale epidemiologic research to elucidate risk factors for the progression of MGUS to MM or other lymphoid malignancies.

AIMS

We evaluated the accuracy of an electronic health records-based approach for identifying clinically diagnosed MGUS cases for inclusion in studies of patient outcomes/ progression risk.

METHODS AND RESULTS

Data were retrieved from Kaiser Permanente Southern California's comprehensive electronic health records, which contain documentation of all outpatient and inpatient visits, laboratory tests, diagnosis codes and a cancer registry. We ascertained potential MGUS cases diagnosed between 2008 and 2014 using the presence of an MGUS ICD-9 diagnosis code (273.1). We initially excluded those diagnosed with MM within 6 months after MGUS diagnosis, then subsequently those with any lymphoid malignancy diagnosis from 2007 to 2014. We reviewed medical charts for 100 randomly selected potential cases for evidence of a physician diagnosis of MGUS, which served as our gold standard for case confirmation. To assess sensitivity, we also investigated the presence of the ICD-9 code in the records of 40 randomly selected and chart review-confirmed MGUS cases among patients with a laboratory report of elevated circulating monoclonal (M-) protein (a key test for MGUS diagnosis) and no subsequent lymphoid malignancy (as described above). The positive predictive value (PPV) for the ICD-9 code was 98%. All MGUS cases confirmed by chart review also had confirmatory laboratory test results. Of the confirmed cases first identified via M-protein test results, 88% also had the ICD-9 diagnosis code.

CONCLUSION

The diagnosis code-based approach has excellent PPV and likely high sensitivity for detecting clinically diagnosed MGUS. The generalizability of this approach outside an integrated healthcare system warrants further evaluation.

Falls in Patients With Communication Disability Secondary to Stroke

Patients with stroke are at high risk of falls during inpatient rehabilitation admission. Communication disability is common following stroke; however, this population is often excluded from falls research. This study aimed to examine the falls of patients with communication disability following stroke, including the circumstances, contributing factors, and outcomes of the fall. This medical record review used the Generic Reference Model of patient safety as the analytical lens and data were analyzed descriptively. The study included 109 patients who experienced 308 falls. The most common type of fall was an "unwitnessed roll from bed." Patient factors contributed to half of all falls, injuries occurred in 15% of falls, and impacts to the hospital system included additional costs and staffing. Understanding the reasons why patients are attempting to get out of bed may identify ways to reduce the risk and incidence of falls in this population.

Ménière's Disease: Insights from an Italian Nationwide Survey

The aim of the present study was to obtain data from a large community sample of patients with Ménière's disease (MD) in Italy through a web-based nationwide survey. Demographic, clinical, and epidemiological features of MD among members of the Italian Association of Ménière's Disease (AMMI) were collected through a web-based survey. The questionnaire was posted on the AMMI website between 01/SEP/2021 and 31/OCT/2021. A total of 520 patients (374 F, 146 M) with MD were included. The age at interview (average ± standard deviation, SD) was 51.4 ± 10.9 years, with a disease duration of 9.9 ± 9.8 years. Eighty percent of cases were unilateral. No patients reported neurocognitive disorders or Parkinson's disease. A positive family history of MD was reported in 13% of participants, while a history of allergic diseases was reported in 33%. Comorbid thyroid disorders were present in 25% of participants, and 28% used betahistine as the main treatment. To our knowledge, this is the first study that has investigated the epidemiology and current patterns of care of MD in Italy, using an anonymous survey directly sent to patients, thus implying their active participation. We hope that future studies will support the utilization of web-based surveys to address the unmet needs in the management of patients with MD.

The impact of road safety strategy and policy on admissions to a national rehabilitation hospital; a 5-year retrospective review and reflection on trauma data

BACKGROUND

Globally, road traffic collisions (RTCs) are a common cause of death and disability. Although many countries, including Ireland, have road safety and trauma strategies, the impact on rehabilitation services is unclear. This study explores how admissions with RTC related injuries to a rehabilitation facility has changed over 5 years and how they contrast to major trauma audit (MTA) serious injury data from the same timeframe.

METHODS

A retrospective review of healthcare records with data abstraction in accordance with best practice was performed. Fisher's exact test and binary logistic regression were used to determine associations and statistical process control was used to analyse variation. All patients discharged with an International Classification of Diseases (ICD) 10 coded diagnosis of Transport accidents from 2014 to 2018 were included. In addition, serious injury data was abstracted from MTA reports.

RESULTS

338 cases were identified. Of these, 173 did not meet the inclusion criteria (readmissions) and were excluded. The total number analyzed was 165. Of these, 121 (73%) were male and 44 (27%) were female and 115 (72%) were under 40 years of age. The majority [128 (78%)] had traumatic brain injuries (TBI), 33 (20%) had traumatic spinal cord injuries and 4 (2.4%) had traumatic amputation The numbers varied over the time period of the study but showed normal variation and not special cause variation which suggests no significant impact of policy in the time frame. There was a large discrepancy between the number of severe TBIs reported in the MTA reports and the numbers admitted with RTC related TBI to the National Rehabilitation University Hospital (NRH). This suggests there may be many people not accessing the specialist rehabilitation services they require.

CONCLUSION

Data linkage between administrative and health datasets does not currently exist but offers huge potential for understanding the trauma and rehabilitation ecosystem in detail. This is required to better understand the impact of strategy and policy.

Diagnostic performance of biomarker S100B and guideline adherence in routine care of mild head trauma

BACKGROUND

The Scandinavian Neurotrauma Committee (SNC) has recommended the use of serum S100B as a biomarker for mild low-risk Traumatic brain injuries (TBI). This study aimed to assess the adherence to the SNC guidelines in clinical practice and the diagnostic performance of S100B in patients with TBI. The aims of this study were to examine adherence to the SNC guideline and the diagnostic accuracy of serum protein S100B.

METHODS

Data of consecutive patients of 18 years and above who presented to the emergency department (ED) at Helsingborg Hospital with isolated head injuries, were retrieved from hospital records. Patients with multitrauma, follow-up visits, and visits managed by a nurse without physician involvement were excluded.

RESULTS

A total of 1671 patients were included of which 93 (5.6%) had intracranial hemorrhage. CT scans were performed in 62% of patients. S100B was measured in 26% of patients and 30% of all measurements targeted the low-risk mild head injuries indicated by the guideline. S100B's recommended cut-off value (≥ 0.10 µg/L) had a 100% sensitivity, 47% specificity, 10.1% positive predictive value, and 100% negative predictive value-if applied to the target SNC category (SNC 4). If applied to all patients tested, the sensitivity was 93% for traumatic intracranial hemorrhage (TICH). Current ED practices were adherent to the SNC guideline in 55% of patients. Non-adherent practices occurred in 64% of patients with low-risk mild head injuries (SNC4) including overtesting or undertesting of S100B and CT scans.

CONCLUSION

Adherence to guidelines was low and associated with a higher admission rate than non-adherence practice but no significant increase in missed TICH or death associated with non-adherence to guideline was found. In routine care, we found that the sensitivity and NPV of serum protein S100B was excellent and safely ruled out TICH when measured in the patient category recommended by the guideline. However, measuring serum protein S100B in patients not recommended by the guideline rendered unacceptably low sensitivity with possible missed TICHs as a consequence. To further delineate the magnitude and impact of non-adherence, more studies are needed.

Reference values for paediatric abdominal aorta on B-mode ultrasound - an outer-to-outer methodology

BACKGROUND

B-mode ultrasound is versatile and safe. The sequelae of aortic disorders in children range from stunted growth in hypoplasia to 90% fatality in ruptured aneurysms. Thus, age-based reference values are necessary for early detection of abnormal aortic dimensions.

OBJECTIVE

To create age-based reference values of paediatric aorta diameters from B-mode ultrasound using the outer-to-outer method.

MATERIALS AND METHODS

A retrospective review was done of records of peak systolic anteroposterior aortic diameters, obtained during abdominal ultrasound in children ages 2 days to 17 years between January 2016 and December 2019. Cases were grouped into five age groups.

RESULTS

A total of 643 cases (49% female) were recruited into the study. Only 488 cases (76%) had values for the proximal, mid and distal aorta. The cumulative mean age was 9.5±5.1 years while the mean aortic diameter ranged from 0.3 cm to 1.8 cm. Tables of aortic diameters and reference ranges are presented. There was no significant sex difference. Significant positive correlation was only seen between age and aortic diameters (Pearson's r ranges from 0.66 to 0.91).

CONCLUSION

An age-based paediatric aortic reference table from B-mode ultrasound using outer-to-outer measurement in a Nigerian population is reported.

The RITA-T (Rapid Interactive Screening Test for Autism in Toddlers) Community Model to Improve Access and Early Identification of Autism in Young Children

Objective: To evaluate improved identification and the generalization of the RITA-T (Rapid interactive Screening Test for Autism in Toddlers) model through partnerships with Primary Care (PC), Early Intervention (EI), and Autism Diagnosticians. Methods: Over 3 years (2018-2021), 15 EI and 9 PC (MD and NP) centers participated in this project. We trained providers on the RITA-T and established screening models. We reviewed charts of all toddlers referred through this model and compared wait times, and diagnoses, to those evaluated through regular referral in a tertiary-based autism clinic. We also examined the RITA-T psychometrics. Results: 377 toddlers met our inclusion criteria. Wait time for diagnosis was an average of 2.8 months and led to further collaboration between community providers. RITA-T cut-off scores stayed consistent. Providers reported improved confidence and easy integration of this model. Conclusions: This model is generalizable and improves the Early Identification of ASD.

Association between ambient fine particulate matter and adult outpatient visits for rheumatoid arthritis in Beijing, China

The association between fine particulate matter (PM_2.5) and rheumatoid arthritis (RA) is currently unclear, especially in Beijing, a city with severe air pollution. Our study aimed to explore the relationship between short-term outdoor exposure to PM_2.5 and RA outpatient visits using a time-series analysis in Beijing. We used the Beijing's Medical Claims for Employees database to identify patients with RA in 2010-2012. A generalized additive model with a Poisson link was used to estimate the percentage change in RA outpatient visits after the PM_2.5 concentration increased by 10 μg/m³. From January 1, 2010, to June 30, 2012, a total of 541,061 RA outpatient visits were identified. During the study period, the average daily (standard deviation) concentration of PM_2.5 was 99.5 (75.3) µg/m³. A 10 µg/m³ increase in PM_2.5 concentration was correlated with a 0.21% (95% CI, 0.18-0.23%) increase in outpatient visits for RA on the same day. A significant association for the cumulative effect of PM_2.5 was found, and the largest significant association was observed for a lag of 0-3 days (0.26%; 95% CI, 0.23-0.29%). Stratified analyses revealed that females (0.29%, 95% CI: 0.26-0.33%) and 18-65 years old patients (0.29%, 95% CI: 0.25-0.32%) were most susceptible to the effects of PM_2.5 exposure. The current findings showed that short-term exposure to PM_2.5 was followed by an increase in the number of outpatient visits for RA in Beijing. Future studies should investigate the mechanisms underlying this association.

ChartWalk: Navigating large collections of text notes in electronic health records for clinical chart review

Before seeing a patient for the first time, healthcare workers will typically conduct a comprehensive clinical chart review of the patient's electronic health record (EHR). Within the diverse documentation pieces included there, text notes are among the most important and thoroughly perused segments for this task; and yet they are among the least supported medium in terms of content navigation and overview. In this work, we delve deeper into the task of clinical chart review from a data visualization perspective and propose a hybrid graphics+text approach via ChartWalk, an interactive tool to support the review of text notes in EHRs. We report on our iterative design process grounded in input provided by a diverse range of healthcare professionals, with steps including: (a) initial requirements distilled from interviews and the literature, (b) an interim evaluation to validate design decisions, and (c) a task-based qualitative evaluation of our final design. We contribute lessons learned to better support the design of tools not only for clinical chart reviews but also other healthcare-related tasks around medical text analysis.

Retrospective application of algorithms to improve identification of pregnancy outcomes from the electronic health record

OBJECTIVE

To improve upon the accuracy of ICD codes for identifying maternal and neonatal outcomes by developing algorithms that incorporate readily available EHR data.

STUDY DESIGN

Algorithms were developed for gestational hypertension (GHTN), pre-eclampsia (PreE), gestational diabetes mellitus (GDM) and were compared to ICD codes and chart review. Accuracy and sensitivity analyses were calculated with their respective 95% confidence limits for each of the comparisons between algorithms, ICD codes alone, and chart review.

RESULTS

Sensitivity of GHTN ICD codes was 8.1% vs. 83.8% for the algorithm when compared to chart review. In comparison to chart review, sensitivity of ICD codes for PreE was 7.5% vs. 71.4% for the algorithm. GDM had similar sensitivity rates for both ICD codes and the algorithm.

CONCLUSION

Application of algorithms, validated by chart review, enhanced capture of several outcomes. Algorithms should be obligatory adjunct tools to the ICD codes for identification of outcomes of interest.

Overt and Occult Hypoxemia in Patients Hospitalized With COVID-19

Progressive hypoxemia is the predominant mode of deterioration in COVID-19. Among hypoxemia measures, the ratio of the Pao2 to the Fio2 (P/F ratio) has optimal construct validity but poor availability because it requires arterial blood sampling. Pulse oximetry reports oxygenation continuously (ratio of the Spo2 to the Fio2 [S/F ratio]), but it is affected by skin color and occult hypoxemia can occur in Black patients. Oxygen dissociation curves allow noninvasive estimation of P/F ratios (ePFRs) but remain unproven.

OBJECTIVES

Measure overt and occult hypoxemia using ePFR.

DESIGN SETTING AND PARTICIPANTS

We retrospectively studied COVID-19 hospital encounters (n = 5,319) at two academic centers (University of Virginia [UVA] and Emory University).

MAIN OUTCOMES AND MEASURES

We measured primary outcomes (death or ICU transfer within 24 hr), ePFR, conventional hypoxemia measures, baseline predictors (age, sex, race, comorbidity), and acute predictors (National Early Warning Score [NEWS] and Sequential Organ Failure Assessment [SOFA]). We updated predictors every 15 minutes. We assessed predictive validity using adjusted odds ratios (AORs) and area under the receiver operating characteristic curves (AUROCs). We quantified disparities (Black vs non-Black) in empirical cumulative distributions using the Kolmogorov-Smirnov (K-S) two-sample test.

RESULTS

Overt hypoxemia (low ePFR) predicted bad outcomes (AOR for a 100-point ePFR drop: 2.7 [UVA]; 1.7 [Emory]; p < 0.01) with better discrimination (AUROC: 0.76 [UVA]; 0.71 [Emory]) than NEWS (0.70 [both sites]) or SOFA (0.68 [UVA]; 0.65 [Emory]) and similar to S/F ratio (0.76 [UVA]; 0.70 [Emory]). We found racial differences consistent with occult hypoxemia. Black patients had better apparent oxygenation (K-S distance: 0.17 [both sites]; p < 0.01) but, for comparable ePFRs, worse outcomes than other patients (AOR: 2.2 [UVA]; 1.2 [Emory]; p < 0.01).

CONCLUSIONS AND RELEVANCE

The ePFR was a valid measure of overt hypoxemia. In COVID-19, it may outperform multi-organ dysfunction models. By accounting for biased oximetry as well as clinicians' real-time responses to it (supplemental oxygen adjustment), ePFRs may reveal racial disparities attributable to occult hypoxemia.

The Effect of Surgeon Referral and a Radiation Oncologist Productivity-Based Metric on Radiation Therapy Receipt Among Elderly Women With Early Stage Breast Cancer: Analysis From a Tertiary Cancer Network

Purpose

: Guidelines for early-stage breast cancer allow for radiation therapy (RT) omission after breast conserving surgery among older women, though high utilization of RT persists. This study explored surgeon referral and the effect of a productivity-based bonus metric for radiation oncologists in an academic institution with centralized quality assurance review.

Methods and materials

: We evaluated patients ≥70 years of age treated with breast conserving surgery for estrogen receptor (ER)+ pT1N0 breast cancer at a single tertiary cancer network between 2015 and 2018. The primary outcomes were radiation oncology referral and RT receipt. Covariables included patient and physician characteristics and treatment decisions before versus after productivity metric implementation. Univariable generalized linear effects models explored associations between these outcomes and covariables.

Results

: Of 703 patients included, 483 (69%) were referred to radiation oncology and 273 (39%) received RT (among those referred, 57% received RT). No difference in RT receipt pre- versus post-productivity metric implementation was observed (P = .57). RT receipt was associated with younger patient age (70-74 years; odds ratio [OR], 2.66; 95% confidence interval [CI], 1.54-4.57) and higher grade (grade 3; OR, 7.75; 95% CI, 3.33-18.07). Initial referral was associated with younger age (70-74; OR, 5.64; 95% CI, 3.37-0.45) and higher performance status (Karnofsky performance status ≥90; OR, 5.34; 95% CI, 2.63-10.83).

Conclusions

: Nonreferral to radiation oncology accounted for half of RT omission but was based on age and Karnofsky performance status, in accordance with guidelines. Lack of radiation oncologist practice change in response to misaligned financial incentives is reassuring, potentially reflecting incentive design and/or centralized quality assurance review. Multi-institutional studies are needed to confirm these findings.

An approach to data collection in compassionate use/managed access

Compassionate Use (CU)/Managed Access programs provide access to locally unapproved medicines. As these programs become more global and involve a broader range of products, determining whether patients derive benefit from treatment could provide insights into therapeutic use in a real-word setting with diverse pools of patients. CU primary purpose is to provide treatment and it is not targeting research. However, it is increasingly considered as a source of real-world data. In the absence of a harmonized framework on CU data collection, Novartis developed a company-wide guidance to collect baseline patient data and prospective follow-up information at product resupply. Although this approach has recently been implemented and utilization of this data has been mainly internal to the company so far, the prospective collection of key efficacy parameters in patients receiving therapies via CU could potentially be used as a supportive set of information collected in a real-world setting to be submitted in addition to clinical trial data, if not as a main source of data for regulatory submission.

The epidemiology of and management of pediatric patients with head trauma: a hospital-based study from Southern Sweden

BACKGROUND

Traumatic brain injury (TBI) is a common cause of morbidity and mortality in children worldwide. In Scandinavia, the epidemiology of pediatric head trauma is poorly documented. This study aimed to investigate and compare the epidemiology and management of pediatric patients with isolated head trauma (IHT) and head trauma in connection with multitrauma (MHT).

METHODS

We conducted a retrospective review of medical records of patients < 18 years of age who attended any of the five emergency departments (ED) in Scania County in Sweden in 2016 due to head trauma. Clinical data of patients with IHT were analyzed and compared with those of patients with MHT.

RESULTS

We identified 5046 pediatric patients with head trauma, 4874 with IHT and 186 with MHT, yielding an incidence of ED visits due to head trauma of 1815/100,000 children/year. There was male predominance, and the median age was four years. Falls were the dominating trauma mechanism in IHT patients, while motor vehicle accidents dominated in MHT patients. The frequencies of CT head-scans, ward admissions and intracranial injuries (ICI) were 5.4%, 11.1% and 0.7%, respectively. Four patients (0.08%) required neurosurgical intervention. The relative risks for CT-scans and admissions to a hospital ward and ICI were 10, 4.5 and 19 times higher for MHT compared with IHT patients.

CONCLUSION

Head trauma is a common cause of ED visits in our study. Head-CTs and ICIs were less frequent than in previous studies. MHT patients had higher rates of CT-scans, admissions, and ICIs than IHT patients, suggesting that they are separate entities that should ideally be managed using different guidelines to optimize the use of CT-scans of the head.

Complications following metal bar removal after Nuss repair are rare in a duocentric retrospective evaluation

PURPOSE

Minimally invasive pectus excavatum repair has gained widespread acceptance and its results and complications are well-described. However, there is a substantial debate on the risks and frequencies of complications following metal bar removal. We, therefore, aimed to analyse all complications that occurred during and after metal bar removal at our two paediatric surgical centres.

METHODS

Bar removal surgeries were identified via procedural codes and electronic records were reviewed using a pre-specified data extraction chart. Both intra- and postoperative complications were included and the latter scored according to Clavien-Dindo. We analysed the influence of the pre-specified potential predictors age, sex, and the number of implanted metal bars on the occurrence of complications using logistic regression.

RESULTS

We included 279 patients with a median age of 19 years (interquartile range 17-20 years). 15 patients experienced 17 complications. Of 11 postoperative complications, only an enlarging pleural effusion required a chest drain in local anaesthesia, resulting in a Claven-Dindo grade IIIa, whereas the remainder were classified as grade I. Neither age (adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.84-1.13, P = 0.73), nor sex (aOR 0.88, 95% CI 0.19-4.07, P = 0.87) or the number of bars (aOR 0.64, 95% CI 0.15-2.71, P = 0.547) did influence the occurrence of complications.

CONCLUSION

Complications following metal bar removal were scarce in our duocentric retrospective series and usually of minor relevance. However, to address the perceived paucity of data on the frequency and severity of complications following metal bar removal, further studies, including large database research is necessary.

Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review

BACKGROUND

Among older adults with delirium and positive urinalysis, antibiotic treatment for urinary tract infection is common practice, but unsupported by literature or guidelines. We sought to: i) determine the rate of antibiotic treatment and the proportion of asymptomatic patients (other than delirium) in this patient population, and ii) examine the effect of antibiotic treatment on delirium resolution and adverse outcomes.

METHODS

A health record review was conducted at a tertiary academic centre from January to December 2020. Inclusion criteria were age ≥ 65, positive delirium screening assessment, positive urinalysis, and admission to general medical units. Outcomes included rates of antibiotic treatment, delirium on day 7 of admission, and 30-day adverse outcomes. We compared delirium and adverse outcome rates in antibiotic-treated vs. non-treated groups. We conducted subgroup analyses among asymptomatic patients.

RESULTS

We included 150 patients (57% female, mean age 85.4 years). Antibiotics were given to 86%. The asymptomatic subgroup (delirium without urinary symptoms or fever) comprised 38% and antibiotic treatment rate in this subgroup was 68%. There was no significant difference in delirium rate on day 7 between antibiotic-treated vs. non-treated groups, (entire cohort RR 0.94 [0.41-2.16] and asymptomatic subgroup RR 0.69 [0.22-2.15]) or in 30-day adverse outcomes.

CONCLUSIONS

Older adults with delirium and positive urinalysis in general medical inpatient units were frequently treated with antibiotics - often despite the absence of urinary or other infectious symptoms. We failed to find evidence that antibiotic treatment in this population is associated with delirium resolution on day 7 of admission.

The association between chiropractic integration in an Ontario community health centre and continued prescription opioid use for chronic non-cancer spinal pain: a sequential explanatory mixed methods study

BACKGROUND

Emerging evidence suggests that access to chiropractic care may reduce the likelihood of initiating an opioid prescription for spinal pain; however, the impact of chiropractic care for patients already prescribed opioids is uncertain. We undertook a sequential explanatory mixed methods study to evaluate the association between initiating chiropractic care and continued opioid use among adult patients attending an Ontario community health centre (CHC) and receiving opioid therapy for chronic non-cancer spinal pain.

METHODS

We conducted a retrospective cohort study of 210 patient records between January 1, 2014 and December 31, 2020. We used generalized estimating equations, adjusted for patient demographics, co-morbidities, visit frequency, and calendar year, to evaluate the association between receipt versus non-receipt of chiropractic services and continued opioid use (e.g., unique opioid fills, number of refills, and dosages) up to one year following the index chiropractic visit. We also completed follow-up interviews with 14 patients and nine general practitioners from the CHC and integrated these data with our quantitative findings.

RESULTS

Over 12-month follow-up, there were lower rates of opioid fills (incidence rate ratio [IRR] = 0.66; 95% confidence interval [CI], 0.52-0.83) and refills (IRR = 0.27; 95% CI, 0.17-0.42) among chiropractic recipients (n = 49) versus non-recipients (n = 161). Although patients who did and did not receive chiropractic care began the study with the same dose of opioids, recipients were less likely to be prescribed higher-dose opioids (i.e., ≥ 50 mg morphine equivalents daily) compared to non-recipients at three months (odds ratio [OR] = 0.14; 95% CI, 0.04-0.47), six months (OR = 0.14; 95% CI, 0.05-0.40), nine months (OR = 0.19; 95% CI, 0.07-0.57), and 12 months (OR = 0.22; 95% CI, 0.08-0.62). Interviews suggested that patient self-efficacy, limited effectiveness of opioids for chronic pain, stigma regarding use of opioids, and access to chiropractic treatment were important influencing factors.

CONCLUSION

We found that continued prescription opioid use among patients with chronic non-cancer spinal pain who received chiropractic care was lower than in patients who did not receive chiropractic care. Four themes emerged in our qualitative interviews to help provide a richer understanding of this association. Randomized controlled trials are needed to establish the effect of chiropractic care on opioid use for chronic spinal pain.

Retrospective observational studies: Lights and shadows for medical writers

A retrospective study (by definition non-interventional) is a purely observational review and/or reassessment of database records with the aim of analyzing previous events of interest. The ethical and scientific standards for conducting biomedical research with humans have been established in international guidelines. Nevertheless, the reporting of ethical considerations in human research is not yet agreed upon globally, although some progress has been made in recent years. If a study has been granted exemption from ethics approval, this should be indicated in the manuscript (including the reasons for the exemption) and, if formal review by an ethics committee is not available, a statement should be included indicating that the research was conducted according to the principles of the Declaration of Helsinki. Editors play an important role in adherence to these ethical requirements for all submitted and published research papers in their journals. This short review paper focuses on the main lights and shadows of ethical aspects for conducting retrospective observational studies in humans and implications for medical writers.

Classifying Types of Visual Loss Linked With Function to Inform Referral to Vision Rehabilitation for Older Adults in Singapore

Objective: Visual impairment restricts performance in activities of daily living. The aim of this study was to classify types of visual loss associated with function in older adults based on clinical data and World Health Organization (WHO) acuity and visual field criteria. Methods: Seven hundred retrospective medical records of older adults seen at the outpatient ophthalmology clinics of a Singapore hospital were reviewed. Extracted data was mapped to the WHO low vision criteria. A flow chart was developed to classify the main types of visual loss aligned with function. Results: The flow chart developed describes four major types of visual loss: (1) full visual field with decreased visual acuity, (2) any visual field loss with greater than ten degrees of available field, (3) peripheral field loss with less than 10° of available field, and (4) any visual field loss due to a cortical event. Within each major type, sub-categories were identified reflecting the complexity of the visual impact of the eye conditions. Conclusion: The flow chart can be applied to outpatient records to identify older adults with different types of visual loss to inform targeted rehabilitation linked with function.

Development and Validation of a Machine Learning Approach Leveraging Real-World Clinical Narratives as a Predictor of Survival in Advanced Cancer

PURPOSE

Predicting short-term mortality in patients with advanced cancer remains challenging. Whether digitalized clinical text can be used to build models to enhance survival prediction in this population is unclear.

MATERIALS AND METHODS

We conducted a single-centered retrospective cohort study in patients with advanced solid tumors. Clinical correspondence authored by oncologists at the first patient encounter was extracted from the electronic medical records. Machine learning (ML) models were trained using narratives from the derivation cohort, before being tested on a temporal validation cohort at the same site. Performance was benchmarked against Eastern Cooperative Oncology Group performance status (PS), comparing ML models alone (comparison 1) or in combination with PS (comparison 2), assessed by areas under receiver operating characteristic curves (AUCs) for predicting vital status at 11 time points from 2 to 52 weeks.

RESULTS

ML models were built on the derivation cohort (4,791 patients from 2001 to April 2017) and tested on the validation cohort of 726 patients (May 2017-June 2019). In 441 patients (61%) where clinical narratives were available and PS was documented, ML models outperformed the predictivity of PS (mean AUC improvement, 0.039, P < .001, comparison 1). Inclusion of both clinical text and PS in ML models resulted in further improvement in prediction accuracy over PS with a mean AUC improvement of 0.050 ( P < .001, comparison 2); the AUC was > 0.80 at all assessed time points for models incorporating clinical text. Exploratory analysis of oncologist's narratives revealed recurring descriptors correlating with survival, including referral patterns, mobility, physical functions, and concomitant medications.

CONCLUSION

Applying ML to oncologists' narratives with or without including patient's PS significantly improved survival prediction to 12 months, suggesting the utility of clinical text in building prognostic support tools.

Assessment of Walking Speed and Distance Post-Stroke Increases After Providing a Theory-Based Toolkit

BACKGROUND AND PURPOSE

While underutilized, poststroke administration of the 10-m walk test (10mWT) and 6-minute walk test (6MWT) can improve care and is considered best practice. We aimed to evaluate provision of a toolkit designed to increase use of these tests by physical therapists (PTs).

METHODS

In a before-and-after study, 54 PTs and professional leaders in 9 hospitals were provided a toolkit and access to a clinical expert over a 5-month period. The toolkit comprised a guide, smartphone app, and video, and described how to set up walkways, implement learning sessions, administer walk tests, and interpret and apply test results clinically. The proportion of hospital visits for which each walk test score was documented at least once (based on abstracted health records of ambulatory patients) were compared over 8-month periods pre- and post-intervention using generalized mixed models.

RESULTS

Data from 347 and 375 pre- and postintervention hospital visits, respectively, were analyzed. Compared with preintervention, the odds of implementing the 10mWT were 12 times greater (odds ratio [OR] = 12.4, 95% confidence interval [CI] 5.8, 26.3), and of implementing the 6MWT were approximately 4 times greater (OR = 3.9, 95% CI 2.3, 6.7), post-intervention, after adjusting for hospital setting, ambulation ability, presence of aphasia and cognitive impairment, and provider-level clustering. Unadjusted change in the percentage of visits for which the 10mWT/6MWT was documented at least once was smallest in acute care settings (2.0/3.8%), and largest in inpatient and outpatient rehabilitation settings (28.0/19.9% and 29.4/23.4%, respectively).

DISCUSSION AND CONCLUSIONS

Providing a comprehensive toolkit to hospitals with professional leaders likely contributed to increasing 10mWT and 6MWT administration during inpatient and outpatient stroke rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A390 ).

Establishing a Valid, Reliable, and Efficient Chart Review Process for Research in Pediatric Integrated Primary Care Psychology

Retrospective chart review is an accessible form of research that is commonly used across medical fields but is underutilized in behavioral health. As a relatively newer area of research, the field of pediatric integrated primary care (IPC) would particularly benefit from guidelines for conducting a methodologically sound chart review study. Here, we use our experiences building a chart review procedure for a pediatric IPC research project to offer strategies for optimizing reliability (consistency), validity (accuracy), and efficiency. We aim to provide guidance for conducting a chart review study in the specific setting of pediatric IPC so that researchers can apply this methodology toward generating research in this field.

Association of Chiropractic Care With Receiving an Opioid Prescription for Noncancer Spinal Pain Within a Canadian Community Health Center: A Mixed Methods Analysis

OBJECTIVE

The purpose of this study was to examine the association between receipt of chiropractic services and initiating a prescription for opioids among adult patients with noncancer spinal pain in a Canadian community health center.

METHODS

In this sequential explanatory mixed methods analysis, we conducted a retrospective study of 945 patient records (January 2014 to December 2020) and completed interviews with 14 patients and 9 general practitioners. We used Cox proportional hazards regression analyses, adjusted for patient demographics, comorbidities, visit frequency, and calendar year to evaluate the association between receipt of chiropractic care and time to first opioid prescription up to 1 year after presentation. Qualitative data were analyzed thematically and integrated with our quantitative findings.

RESULTS

There were 24% of patients (227 of 945) with noncancer spinal pain who received a prescription for opioids. The risk of initiating a prescription for opioids at 1 year after presentation was 52% lower in chiropractic recipients vs nonrecipients (hazard ratio [HR], 0.48; 99% confidence interval [CI], 0.29-0.77) and 71% lower in patients who received chiropractic services within 30 days of their index visit (HR, 0.29; 99% CI, 0.13-0.68). Patients whose index visit date was in a more recent calendar year were also less likely to receive opioids (HR, 0.86; 99% CI, 0.76-0.97). Interviews suggested that self-efficacy, access to chiropractic services, opioid stigma, and treatment impact were influencing factors.

CONCLUSION

Patients with noncancer spinal pain who received chiropractic care were less likely to obtain a prescription for opioids than patients who did not receive chiropractic care.

A comparison of three thromboprophylaxis regimens in critically ill COVID-19 patients: An analysis of real-world data

Introduction

Thrombotic complications of coronavirus disease 2019 (COVID-19) have received considerable attention. Although numerous conflicting findings have compared escalated thromboprophylaxis doses with a standard dose to prevent thrombosis, there is a paucity of literature comparing clinical outcomes in three different anticoagulation dosing regimens. Thus, we investigated the effectiveness and safety profiles of standard, intermediate, and high-anti-coagulation dosing strategies in COVID-19 critically ill patients.

Methodology

This retrospective multicenter cohort study of intensive care unit (ICU) patients from the period of April 2020 to August 2021 in four Saudi Arabian centers. Inclusion criteria were age ≥ 18 years, diagnosis with severe or critical COVID-19 infection, and receiving prophylactic anticoagulant dose within 24-48 h of ICU admission. The primary endpoint was a composite of thrombotic events, with mortality rate and minor or major bleeding serving as secondary endpoints. We applied survival analyses with a matching weights procedure to control for confounding variables in the three arms.

Results

A total of 811 patient records were reviewed, with 551 (standard-dose = 192, intermediate-dose = 180, and high-dose = 179) included in the analysis. After using weights matching, we found that the standard-dose group was not associated with an increase in the composite thrombotic events endpoint when compared to the intermediate-dose group {19.8 vs. 25%; adjusted hazard ratio (aHR) =1.46, [95% confidence of interval (CI), 0.94-2.26]} or when compared to high-dose group [19.8 vs. 24%; aHR = 1.22 (95% CI, 0.88-1.72)]. Also, there were no statistically significant differences in overall in-hospital mortality between the standard-dose and the intermediate-dose group [51 vs. 53.4%; aHR = 1.4 (95% CI, 0.88-2.33)] or standard-dose and high-dose group [51 vs. 61.1%; aHR = 1.3 (95% CI, 0.83-2.20)]. Moreover, the risk of major bleeding was comparable in all three groups [standard vs. intermediate: 4.8 vs. 2.8%; aHR = 0.8 (95% CI, 0.23-2.74); standard vs. high: 4.8 vs. 9%; aHR = 2.1 (95% CI, 0.79-5.80)]. However, intermediate-dose and high-dose were both associated with an increase in minor bleeding incidence with aHR = 2.9 (95% CI, 1.26-6.80) and aHR = 3.9 (95% CI, 1.73-8.76), respectively.

Conclusion

Among COVID-19 patients admitted to the ICU, the three dosing regimens did not significantly affect the composite of thrombotic events and mortality. Compared with the standard-dose regimen, intermediate and high-dosing thromboprophylaxis were associated with a higher risk of minor but not major bleeding. Thus, these data recommend a standard dose as the preferred regimen.

Using the Global Trigger Tool in surgical and neurosurgical patients: A feasibility study

BACKGROUND

The Global Trigger Tool (GTT) has become a worldwide used method for estimating adverse events through a retrospective patient record review. However, little is known about the facilitators and the challenges in the GTT-implementation process. Thus, this study followed two aims: First, to apply a comprehensive set of feasibility criteria to qualitatively and systematically assess the GTT-implementation process in three departments of German university hospitals. Second, to identify the facilitators and the obstacles met in the GTT-implementation process and to derive recommendations for supporting other hospitals in implementing the GTT in clinical practice.

METHODS

The study used a qualitative documentary method based on process documentation, with written and verbal feedback from the reviewer, as well as evaluating the study sites during the implementation process. The study was conducted in three departments, each in a different German university hospital. The authors applied a comprehensive set of 22 feasibility criteria assessing the level of challenge in GTT implementation. The results were synthesized and they focused on the facilitators and the challenges.

RESULTS

Of these 22 feasibility criteria, nine were assessed as a low-level challenge, eleven regarded as a moderate-level challenge, and two with a problematic level of challenge. In particular, the lack of time and staff resources, the quality of the information in the patient records, organizational procedures, and local issues, posed major challenges in the implementation process. By contrast, the use of local coordinators and an external expert made important contributions to the GTT implementation.

CONCLUSIONS

Considering the facilitators and the obstacles beforehand may help with the implementation of the GTT in routine practice. In particular, early and effective planning can reduce or prevent critical challenges in terms of time, staff resources, and organizational aspects.

Effectiveness of Multimodal Chiropractic Care Featuring Spinal Manipulation for Persistent Spinal Pain Syndrome Following Lumbar Spine Surgery: Retrospective Chart Review of 31 Adults in Hong Kong

BACKGROUND The term "persistent spinal pain syndrome type 2" (PSPS-2) has been proposed by the International Association for the Study of Pain to replace the term "failed back surgery syndrome". This retrospective study aimed to evaluate effectiveness of multimodal care featuring chiropractic spinal manipulation (CSMT) in 31 adults in Hong Kong with PSPS-2. MATERIAL AND METHODS We identified new adult patients with PSPS-2 receiving CSMT from 2016 to 2018. Demographic and clinical data and baseline/follow-up numeric pain rating scale (NPRS) and Oswestry Disability Index (ODI) scores were extracted. Multiple linear regression was used to examine posttreatment NPRS and ODI reduction, with clinical variables as covariates. RESULTS Of 6589 patients with low back pain, 31 met criteria (mean age 52.2±13.7 years). Surgeries included laminectomy (81%), discectomy (13%), and fusion (6%). Mean baseline NRPS was 6.6±1.9; ODI was 43.8±15.1%. Patients received CSMT (100%), drop technique (81%), passive modalities (65%), soft tissue manipulation (13%), flexion-distraction (13%), and mechanical traction (13%). Mean posttreatment NPRS was 0.6±1.0; ODI was 2.4±3.3%. All patients had a minimum clinically important difference for NPRS (≥2/10) and ODI (≥30%). One year after treatment, 48% maintained improvement, 42% experienced recurrence; in 10%, follow-up was unavailable. Regression analysis identified younger age, shorter symptom duration, and greater baseline NPRS as predictors of NPRS reduction; and greater baseline ODI as a predictor of ODI reduction (all P<0.05). CONCLUSIONS Patients with PSPS-2 improved with multimodal care featuring CSMT, which was more effective in patients with younger age, shorter symptom duration, and higher baseline pain or disability levels.

Machine Learning Methods in Health Economics and Outcomes Research-The PALISADE Checklist: A Good Practices Report of an ISPOR Task Force

Advances in machine learning (ML) and artificial intelligence offer tremendous potential benefits to patients. Predictive analytics using ML are already widely used in healthcare operations and care delivery, but how can ML be used for health economics and outcomes research (HEOR)? To answer this question, ISPOR established an emerging good practices task force for the application of ML in HEOR. The task force identified 5 methodological areas where ML could enhance HEOR: (1) cohort selection, identifying samples with greater specificity with respect to inclusion criteria; (2) identification of independent predictors and covariates of health outcomes; (3) predictive analytics of health outcomes, including those that are high cost or life threatening; (4) causal inference through methods, such as targeted maximum likelihood estimation or double-debiased estimation-helping to produce reliable evidence more quickly; and (5) application of ML to the development of economic models to reduce structural, parameter, and sampling uncertainty in cost-effectiveness analysis. Overall, ML facilitates HEOR through the meaningful and efficient analysis of big data. Nevertheless, a lack of transparency on how ML methods deliver solutions to feature selection and predictive analytics, especially in unsupervised circumstances, increases risk to providers and other decision makers in using ML results. To examine whether ML offers a useful and transparent solution to healthcare analytics, the task force developed the PALISADE Checklist. It is a guide for balancing the many potential applications of ML with the need for transparency in methods development and findings.

Tocilizumab effectiveness in mechanically ventilated COVID-19 patients (T-MVC-19 Study): a multicenter real-world evidence

BACKGROUND

This study aimed to evaluate the effectiveness of tocilizumab in mechanically ventilated patients with coronavirus disease 2019 (COVID-19).

RESEARCH DESIGN AND METHODS

This retrospective multicenter study included adults (≥18 years) diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by real-time polymerase chain reaction (RT-PCR) from nasopharyngeal swab, and requiring invasive mechanical ventilation during admission. Survival analyses with inverse propensity score treatment weighting (IPTW) and propensity score matching (PSM) were conducted. To account for immortal bias, we used Cox proportional modeling with time-dependent covariance. Competing risk analysis was performed for the extubation endpoint.

RESULTS

A total of 556 (tocilizumab = 193, control = 363) patients were included. Males constituted the majority of the participants (69.2% in tocilizumab arm,74.1% in control arm). Tocilizumab was not associated with a reduction in mortality with hazard ratio [(HR) = 0.82,95% confidence interval (95%CI): 0.62-1.10] in the Inverse propensity score weighting (IPTW) analysis and (HR = 0.86,95% CI: 0.64-1.16) in the PSM analysis. However, tocilizumab was associated with an increased rate of extubation (33.6%) compared to the control arm (11.9%); subdistributional hazards (SHR) = 3.1, 95% CI: 1.86-5.16).

CONCLUSIONS

Although tocilizumab was not found to be effective in reducing mortality, extubation rate while on mechanical ventilation was higher among tocilizumab treated group.

Anaphylaxis among elderly emergency department patients in a large health system in New York

BACKGROUND

Anaphylaxis in the elderly is poorly understood.

OBJECTIVE

To elucidate demographic, clinical, and management characteristics of older adults presenting to emergency departments (EDs) with National Institute of Allergy and Infectious Diseases (NIAID) criteria-confirmed anaphylaxis vs milder, non-anaphylactic acute allergic reactions (AARs).

METHODS

A retrospective analysis of ED patients more than or equal to 65 years was conducted, using anaphylaxis International Classification of Diseases, Ninth Revision (ICD-9) codes or ICD-9-based algorithms incorporating the NIAID diagnostic criteria. Descriptive statistics were generated, and the abovementioned characteristics were compared between cohorts.

RESULTS

Of 164 eligible visits, 71 (43.3%), 90 (54.9%), and 3 (1.8%) cases were identified by ICD-9 codes, the algorithms, or both, respectively. Only half fulfilled NIAID diagnostic criteria. Compared with the non-anaphylactic AAR group, criteria-confirmed anaphylaxis group had lower drug allergy rates (43.9% vs 61.0%, P = .03) but higher food allergy rates (26.8% vs 12.2%, P = .02). For the criteria-confirmed anaphylaxis group, presenting signs and symptoms in descending frequency were mucocutaneous, respiratory, cardiovascular, and gastrointestinal. Criteria-confirmed anaphylaxis group had higher rates of prior anaphylaxis (13.4% vs 2.4%, P = .009), pre-ED (12.2% vs 0.0%, P = .001) or ED (72.0% vs 4.9%, P < .001) epinephrine administration, and allergy referral (17.1% vs 2.4%, P = .002). Tryptase levels were rarely ordered, occurring once in the criteria-confirmed anaphylaxis group and never in the non-anaphylactic AAR group. Despite low mortality (n = 1), 64.6% of the criteria-confirmed anaphylaxis cohort required hospitalization, with 23.2% admitted to intensive care unit.

CONCLUSION

Diagnosis of elderly ED patients with anaphylaxis remains suboptimal. Identifying NIAID criteria-confirmed cases remain challenging, using the existing methods. Management of these patients poorly adheres to current guidelines.

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

BACKGROUND

Traumatic brain injury (TBI) is a common injury and constitutes up to 3% of emergency department (ED) visits. Current studies show that TBI is most commonly inflicted in older patients after ground-level falls. These patients often take medications affecting coagulation such as anticoagulants or antiplatelet drugs. Guidelines for ED TBI-management assume that anticoagulation therapy (ACT) confers a higher risk of traumatic intracranial hemorrhage (TICH) than antiplatelet therapy (APT). However, recent studies have challenged this. This study aimed to evaluate if oral anticoagulation and platelet inhibitors affected rate of TICH in head-trauma patients with ground-level falls.

METHODS

This was a retrospective review of medical records during January 1, 2017 to December 31, 2017 and January 1 2020 to December 31, 2020 of all patients seeking ED care because of head-trauma. Patients ≥ 18 years with ground-level falls were included.

RESULTS

The study included 1938 head-trauma patients with ground-level falls. Median age of patients with TICH was 81 years. The RR for TICH in APT-patients compared to patients without medication affecting coagulation was 1.72 (p = 0.01) (95% Confidence Interval (CI) 1.13-2.60) and 1.08 (p = 0.73), (95% CI 0.70-1.67) in ACT-patients. APT was independently associated with TICH in regression analysis (OR 1.59 (95% CI 1.02-2.49), p = 0.041).

CONCLUSION

This study adds to the growing evidence that APT-patients with ground-level falls might have as high or higher risk of TICH than ACT-patients. This is not addressed in the current guidelines which may need to be updated. We therefore recommend broad prospective studies.

Predictors of Acute Care Transfers From Skilled Nursing Facilities: Recommendations for Preventing Unnecessary Hospitalization

Preventing acute care transfers from skilled nursing facilities (SNFs) is a challenge secondary to residents' associated debilitated status and comorbidities. Acute care transfers often result in serious complications and unnecessary health care expenditure. Literature implies that approximately two thirds of these acute care transfers could be prevented using proactive interventions. The purpose of the current study was to identify the predictors of acute care transfers for SNF residents in developing relevant prevention strategies. A retrospective chart review using multivariate logistic regression analysis showed increased odds of SNF hospitalization was significantly associated with impaired cognition, chronic obstructive pulmonary disease, and chronic kidney disease, whereas decreased odds of hospitalization was identified among non-Hispanic White residents. Study recommendations include prompt assessment of comorbid symptomatology among SNF residents for the timely management and prevention of unnecessary acute care transfers. [Research in Gerontological Nursing, xx(x), xx-xx.].

Overt and occult hypoxemia in patients hospitalized with novel coronavirus disease 2019

Background

Progressive hypoxemia is the predominant mode of deterioration in COVID-19. Among hypoxemia measures, the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (P/F ratio) has optimal construct validity but poor availability because it requires arterial blood sampling. Pulse oximetry reports oxygenation continuously, but occult hypoxemia can occur in Black patients because the technique is affected by skin color. Oxygen dissociation curves allow non-invasive estimation of P/F ratios (ePFR) but this approach remains unproven.

Research Question

Can ePFRs measure overt and occult hypoxemia?

Study Design and methods

We retrospectively studied COVID-19 hospital encounters (n=5319) at two academic centers (University of Virginia [UVA] and Emory University). We measured primary outcomes (death or ICU transfer within 24 hours), ePFR, conventional hypoxemia measures, baseline predictors (age, sex, race, comorbidity), and acute predictors (National Early Warning Score (NEWS) and Sepsis-3). We updated predictors every 15 minutes. We assessed predictive validity using adjusted odds ratios (AOR) and area under receiver operating characteristics curves (AUROC). We quantified disparities (Black vs non-Black) in empirical cumulative distributions using the Kolmogorov-Smirnov (K-S) two-sample test.

Results

Overt hypoxemia (low ePFR) predicted bad outcomes (AOR for a 100-point ePFR drop: 2.7 [UVA]; 1.7 [Emory]; p<0.01) with better discrimination (AUROC: 0.76 [UVA]; 0.71 [Emory]) than NEWS (AUROC: 0.70 [UVA]; 0.70 [Emory]) or Sepsis-3 (AUROC: 0.68 [UVA]; 0.65 [Emory]). We found racial differences consistent with occult hypoxemia. Black patients had better apparent oxygenation (K-S distance: 0.17 [both sites]; p<0.01) but, for comparable ePFRs, worse outcomes than other patients (AOR: 2.2 [UVA]; 1.2 [Emory], p<0.01).

Interpretation

The ePFR was a valid measure of overt hypoxemia. In COVID-19, it may outperform multi-organ dysfunction models like NEWS and Sepsis-3. By accounting for biased oximetry as well as clinicians’ real-time responses to it (supplemental oxygen adjustment), ePFRs may enable statistical modelling of racial disparities in outcomes attributable to occult hypoxemia.

Mixed-methods evaluation of three natural language processing modeling approaches for measuring documented goals-of-care discussions in the electronic health record

CONTEXT

Documented goals-of-care discussions are an important quality metric for patients with serious illness. Natural language processing (NLP) is a promising approach for identifying goals-of-care discussions in the electronic health record (EHR).

OBJECTIVES

To compare three NLP modeling approaches for identifying EHR documentation of goals-of-care discussions and generate hypotheses about differences in performance.

METHODS

We conducted a mixed-methods study to evaluate performance and misclassification for three NLP featurization approaches modeled with regularized logistic regression: bag-of-words (BOW), rule-based, and a hybrid approach. From a prospective cohort of 150 patients hospitalized with serious illness over 2018 to 2020, we collected 4391 inpatient EHR notes; 99 (2.3%) contained documented goals-of-care discussions. We used leave-one-out cross-validation to estimate performance by comparing pooled NLP predictions to human abstractors with receiver-operating-characteristic (ROC) and precision-recall (PR) analyses. We qualitatively examined a purposive sample of 70 NLP-misclassified notes using content analysis to identify linguistic features that allowed us to generate hypotheses underpinning misclassification.

RESULTS

All three modeling approaches discriminated between notes with and without goals-of-care discussions (AUCROC: BOW, 0.907; rule-based, 0.948; hybrid, 0.965). Precision and recall were only moderate (precision at 70% recall: BOW, 16.2%; rule-based, 50.4%; hybrid, 49.3%; AUCPR: BOW, 0.505; rule-based, 0.579; hybrid, 0.599). Qualitative analysis revealed patterns underlying performance differences between BOW and rule-based approaches.

CONCLUSION

NLP holds promise for identifying EHR-documented goals-of-care discussions. However, the rarity of goals-of-care content in EHR data limits performance. Our findings highlight opportunities to optimize NLP modeling approaches, and support further exploration of different NLP approaches to identify goals-of-care discussions.

Efficacy and Safety of Ferric Carboxymaltose in the Management of Iron Deficiency Anemia: A Multi-Center Real-World Study from India

Background

Parenteral iron preparations, like ferric carboxymaltose (FCM), are commonly used to manage moderate-to-severe iron deficiency anemia (IDA). Real-world data on efficacy and safety of FCM is limited in India.

Methods

A retrospective, observational and real-world study was conducted to assess the efficacy and safety of FCM in adolescents and adults with IDA across 269 centers in India. Data was retrieved from medical records of patients who received FCM for management of IDA. Physicians’ clinical assessment of efficacy and safety of FCM was also assessed. Data were analyzed for hematological parameters at baseline and at 4 ± 1 week for study population, and for severity of anemia.

Results

In 1800 patients with IDA, intravenous FCM resulted in a significant increase in hemoglobin (Hb) of 2.76 g/dL, serum ferritin of 35.85 µg/L, red blood cell (RBC) count, hematocrit, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) (P < 0.001 for all) at 4 ± 1 week as compared to baseline. In subjects with severe IDA, an increase in Hb was of 3.31 g/dL, serum ferritin increased of 35.84 µg/L, RBC count, hematocrit and MCH improved significantly (P < 0.001 for all). In subjects with moderate IDA, Hb (increase of 2.63 g/dL), serum ferritin (increase of 35.92 µg/L), RBC count, hematocrit, MCV, and MCH improved significantly (P < 0.001 for all). In subjects with mild IDA, only the mean Hb values at 4 weeks were significantly higher (P < 0.001; increased by 1.89 g/dL). Physicians rated efficacy of FCM as very good to good in 97.5% of patients. Similarly, safety of FCM was rated very good to good in 97.2% subjects.

Conclusion

FCM efficiently, safely and quickly corrects moderate-to-severe anemia in Indian patients in a short span of 4 weeks. Physicians’ positive clinical impression of efficacy and safety supports clinical usage of FCM in real-world scenario.

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