Military Medicine's Value to US Health Care and Public Health: Bringing Battlefield Lessons Home

Importance

Military medicine in the US was established to treat wounded and ill service members and to protect the health and well-being of our military forces at home and abroad. To accomplish these tasks, it has developed the capacity to rapidly adapt to the changing nature of war and emerging health threats; throughout our nation's history, innovations developed by military health professionals have been quickly adopted by civilian medicine and public health for the benefit of patients in the US and around the world.

Observations

From the historical record and published studies, we cite notable examples of how military medicine has advanced civilian health care and public health. We also describe how military medicine research and development differs from that done in the civilian world. During the conflicts in Afghanistan and Iraq, military medicine's focused approach to performance improvement and requirements-driven research cut the case fatality rate from severe battlefield wounds in half, to the lowest level in the history of warfare.

Conclusions and Relevance

Although innovations developed by military medicine regularly inform and improve civilian health care and public health, the architects of these advances and the methods they use are often overlooked. Enhanced communication and cooperation between our nation's military and civilian health systems would promote reciprocal learning, accelerate collaborative research, and strengthen our nation's capacity to meet a growing array of health and geopolitical threats.

Graduate Medical Education in the Military Health System: Strategic Analysis and Options

INTRODUCTION

At the request of then-Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, Defense Health Horizons (DHH) examined options for shaping Graduate Medical Education (GME) in the Military Health System (MHS) in order to achieve the goals of a medically ready force and a ready medical force.

MATERIALS AND METHODS

The DHH interviewed service GME directors, key designated institutional officials, and subject-matter experts on GME in the military and civilian health care systems.

RESULTS

This report proposes numerous short- and long-term courses of action in three areas:1. Balancing the allocation of GME resources to suit the needs of active duty and garrisoned troops. We recommend developing a clear, tri-service mission and vision for GME in the MHS and expanding collaborations with outside institutions in order to prepare an optimal mix of physicians and ensure that trainees meet requirements for clinical experience.2. Improving the recruitment and tracking of GME students, as well as the management of accessions. We recommend several measures to improve the quality of incoming students, to track the performance of students and medical schools, and to foster a tri-service approach to accessions.3. Aligning MHS with the tenets of the Clinical Learning Environment Review to advance a culture of safety and to help the MHS become a high reliability organization (HRO). We recommend several actions to strengthen patient care and residency training and to develop a systematic approach to MHS management and leadership.

CONCLUSION

Graduate Medical Education (GME) is vital to produce the future physician workforce and medical leadership of the MHS. It also provides the MHS with clinically skilled manpower. Graduate Medical Education (GME) research sows the seeds for future discoveries to improve combat casualty care and other priority objectives of the MHS. Although readiness is the MHS's top mission, GME is also vital to meeting the other three components of the quadruple aim (better health, better care, and lower costs). Properly managed and adequately resourced GME can accelerate the transformation of the MHS into an HRO. Based on our analysis, DHH believes that there are numerous opportunities for MHS leadership to strengthen GME so it is more integrated, jointly coordinated, efficient, and productive. All physicians emerging from military GME should understand and embrace team-based practice, patient safety, and a systems-oriented focus. This will ensure that those we prepare to be the military physicians of the future are prepared to meet the needs of the line, to protect the health and safety of deployed warfighters, and to provide expert and compassionate care to garrisoned service members, families, and military retirees.

A Primer on the Military Health System's Approach to Medical Research and Development

The Military Health System (MHS) has a medical research program aimed at a wide range of health-, disease-, and injury-related topic areas that works with civilian academic institutions and the biomedical industry to accomplish its goals. There are many opportunities for civilian academic institutions and the biomedical industry to engage with this program, but its unique features are important to understand to optimize the chances for successful partnerships. Unlike the National Institutes of Health, which uses an "investigator-initiated" approach, the Department of Defense (DoD) aligns its funding with specific needs, also referred to as requirements; thus, DoD research is often described as "requirements-driven" research. At the highest level, requirements are aligned with the National Security Strategy and National Defense Strategy, though requirements documents list specific areas in medicine with unmet needs. Military labs and the Uniformed Services University of the Health Sciences, which can also receive DoD appropriations to conduct medical research, serve as hubs that interface with civilian academic institutions and the biomedical industry and organize and track the overall progress of DoD investments. As a mechanism to propel findings from "bench to bedside," the military budgets funds for the various phases of research and development for a given topic area. Research programs are most effective when they are integrated into the MHS learning health system, which allows MHS clinical communities to inform and track research investments and evaluate the utility of research products in real clinical practice settings. This Perspective provides introductory information and a basic framework for those interested in performing DoD-funded medical research or collaborating with researchers in military labs. It is hoped that as academic institutions and the biomedical industry look to increase efficiency in medical research, they will find ways to engage with DoD research opportunities and consider elements of the military's approach useful.

Brief, Web-based Education Improves Lay Rescuer Application of a Tourniquet to Control Life-threatening Bleeding

OBJECTIVE

The objective was to determine whether brief, Web-based instruction several weeks prior to tourniquet application improves layperson success compared to utilizing just-in-time (JiT) instructions alone.

BACKGROUND

Stop the Bleed is a campaign to educate laypeople to stop life-threatening hemorrhage. It is based on U.S. military experience with lifesaving tourniquet use. While previous research shows simple JiT instructions boost laypeople's success with tourniquet application, the optimal approach to educate the public is not yet known.

METHODS

This is a prospective, nonblinded, randomized study. Layperson participants from the Washington, DC, area were randomized into: 1) an experimental group that received preexposure education using a website and 2) a control group that did not receive preexposure education. Both groups received JiT instructions. The primary outcome was the proportion of subjects that successfully applied a tourniquet to a simulated amputation. Secondary outcomes included mean time to application, mean placement position, ability to distinguish bleeding requiring a tourniquet from bleeding requiring direct pressure only, and self-reported comfort and willingness to apply a tourniquet.

RESULTS

Participants in the preexposure group applied tourniquets successfully 75% of the time compared to 50% success for participants with JiT alone (p < 0.05, risk ratio = 1.48, 95% confidence interval = 1.21-1.82). Participants place tourniquets in a timely fashion, are willing to use them, and can recognize wounds requiring tourniquets.

CONCLUSIONS

Brief, Web-based training, combined with JiT education, may help as many as 75% of laypeople properly apply a tourniquet. These findings suggest that this approach may help teach the public to Stop the Bleed.

Borrow or Serve? An Economic Analysis of Options for Financing a Medical School Education

PURPOSE

To understand the long-term economic implications of key pathways for financing a medical school education.

METHOD

The authors calculated the net present value (NPV) of cash flow over a 30-year career for a 2013 matriculant associated with (1) self-financing, (2) federally guaranteed loans, (3) the Public Service Loan Forgiveness program, (4) the National Health Service Corps, (5) the Armed Forces Health Professions Scholarship Program, and (6) matriculation at the Uniformed Services University of the Health Sciences. They calculated the NPV for students pursuing one of four specialties in two cities with divergent tax policies. Borrowers were assumed to have a median level of debt ($180,000), and conservative projections of inflation, discount rates, and income growth were employed. Sensitivity analyses examined different discount and income growth rates, alternative repayment strategies, and various lengths of public-sector service by scholarship recipients.

RESULTS

For those wealthy enough to pay cash or fortunate enough to secure a no-strings scholarship, self-financing produced the highest NPV in almost every scenario. Borrowers start practice $300,000 to $400,000 behind their peers who secure a national service scholarship, but those who enter a highly paid specialty, such as orthopedic surgery, overtake their national service counterparts 4 to 11 years after residency. Those in lower-paid specialties take much longer. Borrowers who enter primary care never close the gap.

CONCLUSIONS

Over time, the value of a medical degree offsets the high up-front cost. Debt avoidance confers substantial economic benefits, particularly for students interested in primary care.

The impact of anesthesiologists on coronary artery bypass graft surgery outcomes

BACKGROUND

One of every 150 hospitalized patients experiences a lethal adverse event; nearly half of these events involves surgical patients. Although variations in surgeon performance and quality have been reported in the literature, less is known about the influence of anesthesiologists on outcomes after major surgery. Our goal of this study was to determine whether there is significant variation in outcomes between anesthesiologists after controlling for patient case mix and hospital quality.

METHODS

Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 7920 patients undergoing isolated coronary artery bypass graft surgery. Multivariable logistic regression modeling was used to examine the variation in death or major complications (Q-wave myocardial infarction, renal failure, stroke) across anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality.

RESULTS

Anesthesiologist performance was quantified using fixed-effects modeling. The variability across anesthesiologists was highly significant (P < 0.001). Patients managed by low-performance anesthesiologists (corresponding to the 25th percentile of the distribution of anesthesiologist risk-adjusted outcomes) experienced nearly twice the rate of death or serious complications (adjusted rate 3.33%; 95% confidence interval [CI], 3.09%-3.58%) as patients managed by high-performance anesthesiologists (corresponding to the 75th percentile) (adjusted rate 1.82%; 95% CI, 1.58%-2.10%). This performance gap was observed across all patient risk groups.

CONCLUSIONS

The rate of death or major complications among patients undergoing coronary artery bypass graft surgery varies markedly across anesthesiologists. These findings suggest that there may be opportunities to improve perioperative management to improve outcomes among high-risk surgical patients.

The community college pathway to medical school: a road less traveled

Underrepresented minority and first-generation college students are more likely than white students to attend a community college before transferring to a four-year school. Talamantes and colleagues report in this issue that, according to their study of 2012 medical school applicants and matriculants, community-college-first applicants were significantly less likely to be admitted to medical school even after other important predictors, including grade point average and Medical College Admission Test scores, were taken into consideration. These findings suggest that rather than appreciating the "distance traveled" and obstacles overcome by applicants who got their start at a community college, medical school admissions committees may be consciously or subconsciously discounting their achievements. The authors of this Commentary consider the study by Talamantes and colleagues as well as other recent data related to community college graduates and emphasize that community colleges attract many high-achieving applicants who for any of several reasons-limited finances, inadequate advising, insufficient financial aid, or a need to stay close to home-choose not to enroll in a four-year college right away. They argue that if medical school leaders are serious about lowering the social, racial, and economic barriers to medical school, they must start viewing two years of premedical education at a community college as an asset rather than a liability.

The effect of malpractice reform on emergency department care

BACKGROUND

Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.

METHODS

Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.

RESULTS

For eight of the nine state-outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.

CONCLUSIONS

Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.).

Facilitating access to antiviral medications and information during an influenza pandemic: engaging with the public on possible new strategies

Antiviral medications can decrease the severity and duration of influenza, but they are most effective if started within 48 hours of the onset of symptoms. In a severe influenza pandemic, normal channels of obtaining prescriptions and medications could become overwhelmed. To assess public perception of the acceptability and feasibility of alternative strategies for prescribing, distributing, and dispensing antivirals and disseminating information about influenza and its treatment, the Institute of Medicine, with technical assistance from the Centers for Disease Control and Prevention (CDC), convened public engagement events in 3 demographically and geographically diverse communities: Fort Benton, MT; Chattanooga, TN; and Los Angeles, CA. Participants were introduced to the issues associated with pandemic influenza and the challenges of ensuring timely public access to information and medications. They then discussed the advantages and disadvantages of 5 alternative strategies currently being considered by the CDC and its partners. Participants at all 3 venues expressed high levels of acceptance for each of the proposed strategies and contributed useful ideas to support their implementation. This article discusses the key findings from these sessions.

The association of trauma center closures with increased inpatient mortality for injured patients

BACKGROUND

Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed.

METHODS

We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure.

RESULTS

The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51).

CONCLUSION

Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure.

LEVEL OF EVIDENCE

Prognostic and epidemiologic, level III.

Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value

New medical technologies are a leading driver of U.S. health care spending. This article identifies promising policy options to change which medical technologies are created, with two related policy goals: (1) Reduce total health care spending with the smallest possible loss of health benefits, and (2) ensure that new medical products that increase spending are accompanied by health benefits that are worth the spending increases. The analysis synthesized information from peer-reviewed and other literature, a panel of technical advisors convened for the project, and 50 one-on-one expert interviews. The authors also conducted case studies of eight medical products. The following features of the U.S. health care environment tend to increase spending without also conferring major health benefits: lack of basic scientific knowledge about some disease processes, costs and risks of U.S. Food and Drug Administration (FDA) approval, limited rewards for medical products that could lower spending, treatment creep, and the medical arms race. The authors identified ten policy options that would help advance the two policy goals. Five would do so by reducing the costs and/or risks of invention and obtaining FDA approval: (1) Enable more creativity in funding basic science, (2) offer prizes for inventions, (3) buy out patents, (4) establish a public-interest investment fund, and (5) expedite FDA reviews and approvals. The other five options would do so by increasing market rewards for products: (1) Reform Medicare payment policies, (2) reform Medicare coverage policies, (3) coordinate FDA approval and Centers for Medicare & Medicaid Services coverage processes, (4) increase demand for technologies that decrease spending, and (5) produce more and more-timely technology assessments.

What it will take to achieve the as-yet-unfulfilled promises of health information technology

A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually. Seven years later the empirical data on the technology's impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion. In our view, the disappointing performance of health IT to date can be largely attributed to several factors: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT. We believe that the original promise of health IT can be met if the systems are redesigned to address these flaws by creating more-standardized systems that are easier to use, are truly interoperable, and afford patients more access to and control over their health data. Providers must do their part by reengineering care processes to take full advantage of efficiencies offered by health IT, in the context of redesigned payment models that favor value over volume.

Bioterrorism and biological threats dominate federal health security research; other priorities get scant attention

The federal government plays a critical role in achieving national health security by providing strategic guidance and funding research to help prevent, respond to, mitigate, and recover from disasters, epidemics, and acts of terrorism. In this article we describe the first-ever inventory of nonclassified national health security-related research funded by civilian agencies of the federal government. Our analysis revealed that the US government's portfolio of health security research is currently weighted toward bioterrorism and emerging biological threats, laboratory methods, and development of biological countermeasures. Eight of ten other priorities identified in the Department of Health and Human Services' National Health Security Strategy-such as developing and maintaining a national health security workforce or incorporating recovery into planning and response-receive scant attention. We offer recommendations to better align federal spending with health security research priorities, including the creation of an interagency working group charged with minimizing research redundancy and filling persistent gaps in knowledge.

Should payment policy be changed to allow a wider range of EMS transport options?

The Institute of Medicine and other national organizations have asserted that current payment policies strongly discourage emergency medical services (EMS) providers from transporting selected patients who call 911 to non-ED settings (eg, primary care clinics, mental health centers, dialysis centers) or from treating patients on scene. The limited literature available is consistent with the view that current payment policies incentivize transport of all 911 callers to a hospital ED, even those who might be better managed elsewhere. However, the potential benefits and risks of altering existing policy have not been adequately explored. There are theoretical benefits to encouraging EMS personnel to transport selected patients to alternate settings or even to provide definitive treatment on scene; however, existing evidence is insufficient to confirm the feasibility or safety of such a policy. In light of growing concerns about the high cost of emergency care and heavy use of EDs, assessing EMS transport options should be a high-priority topic for outcomes research.

Qualitative factors in patients who die shortly after emergency department discharge

OBJECTIVES

Early death after emergency department (ED) discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. The goal in this hypothesis-generating study was to identify patient and process of care themes that may provide possible explanations for early postdischarge mortality.

METHODS

This was a qualitative analysis of medical records of adult patients who visited the ED of any of six hospitals in an integrated health system (Kaiser Permanente Southern California [KPSC]) and died within 7 days of discharge in 2007 and 2008. Nonmembers, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patients with do not attempt resuscitation or do not intubate orders (DNAR/DNI) were excluded. Under the guidance of two qualitative research scientists, a team of three emergency physicians used grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge.

RESULTS

The source population consisted of a total of 290,092 members with 446,120 discharges from six KPSC EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient-level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill-appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process-of-care factors included a discrepancy in history of present illness, incomplete physical examination, and change of discharge plan by a third party, such as a consulting or admitting physician.

CONCLUSIONS

In this hypothesis-generating study, qualitative research techniques were used to identify clinical and process-of-care factors in patients who died within days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.

The Evolving Role of Emergency Departments in the United States

The research described in this article was performed to develop a more complete picture of how hospital emergency departments (EDs) contribute to the U.S. health care system, which is currently evolving in response to economic, clinical, and political pressures. Using a mix of quantitative and qualitative methods, it explores the evolving role that EDs and the personnel who staff them play in evaluating and managing complex and high-acuity patients, serving as the key decisionmaker for roughly half of all inpatient hospital admissions, and serving as "the safety net of the safety net" for patients who cannot get care elsewhere. The report also examines the role that EDs may soon play in either contributing to or helping to control the rising costs of health care.

Systematic review of strategies to manage and allocate scarce resources during mass casualty events

STUDY OBJECTIVE

Efficient management and allocation of scarce medical resources can improve outcomes for victims of mass casualty events. However, the effectiveness of specific strategies has never been systematically reviewed. We analyze published evidence on strategies to optimize the management and allocation of scarce resources across a wide range of mass casualty event contexts and study designs.

METHODS

Our literature search included MEDLINE, Scopus, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Database of Systematic Reviews, from 1990 through late 2011. We also searched the gray literature, using the New York Academy of Medicine's Grey Literature Report and key Web sites. We included both English- and foreign-language articles. We included studies that evaluated strategies used in actual mass casualty events or tested through drills, exercises, or computer simulations. We excluded studies that lacked a comparison group or did not report quantitative outcomes. Data extraction, quality assessment, and strength of evidence ratings were conducted by a single researcher and reviewed by a second; discrepancies were reconciled by the 2 reviewers. Because of heterogeneity in outcome measures, we qualitatively synthesized findings within categories of strategies.

RESULTS

From 5,716 potentially relevant citations, 74 studies met inclusion criteria. Strategies included reducing demand for health care services (18 studies), optimizing use of existing resources (50), augmenting existing resources (5), implementing crisis standards of care (5), and multiple categories (4). The evidence was sufficient to form conclusions on 2 strategies, although the strength of evidence was rated as low. First, as a strategy to reduce demand for health care services, points of dispensing can be used to efficiently distribute biological countermeasures after a bioterrorism attack or influenza pandemic, and their organization influences speed of distribution. Second, as a strategy to optimize use of existing resources, commonly used field triage systems do not perform consistently during actual mass casualty events. The number of high-quality studies addressing other strategies was insufficient to support conclusions about their effectiveness because of differences in study context, comparison groups, and outcome measures. Our literature search may have missed key resource management and allocation strategies because of their extreme heterogeneity. Interrater reliability was not assessed for quality assessments or strength of evidence ratings. Publication bias is likely, given the large number of studies reporting positive findings.

CONCLUSION

The current evidence base is inadequate to inform providers and policymakers about the most effective strategies for managing or allocating scarce resources during mass casualty events. Consensus on methodological standards that encompass a range of study designs is needed to guide future research and strengthen the evidence base. Evidentiary standards should be developed to promote consensus interpretations of the evidence supporting individual strategies.

The challenges and rewards of engaging a skeptical public

Findings published in this issue suggest that a substantial subset of the Israeli public generally trusts government, yet is determined to make their own judgments about the need for precautionary action in certain types of public health emergencies. This reflective approach, which may be common in other countries as well, poses a substantial challenge to achieving desired levels of compliance, particularly when the threat requires swift and concerted action. The aim of this commentary is to discuss both the challenges and the rewards of engaging a public that wants to weigh evidence prior to taking action in an emergency, rather than defer to expert judgment. While engaging a skeptical public can be difficult, a reflective public acknowledges that preparedness is a shared responsibility of government and individuals and may be receptive to messages about the need for household and community self-sufficiency in a disaster. This is a commentary on the article "Analysis of Public Responses to Preparedness Policies" by Velan and colleagues.

Where Americans get acute care: increasingly, it's not at their doctor's office

Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care--treatment for newly arising health problems--are made to patients' personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.

Feasibility of web-based self-triage by parents of children with influenza-like illness: a cautionary tale

IMPORTANCE

Self-triage using web-based decision support could be a useful way to encourage appropriate care-seeking behavior and reduce health system surge in epidemics. However, the feasibility and safety of this strategy have not previously been evaluated.

OBJECTIVE

To assess the usability and safety of Strategy for Off-site Rapid Triage (SORT) for Kids, a web-based decision support tool designed to translate clinical guidance developed by the Centers for Disease Control and Prevention to help parents and adult caregivers determine if a child with influenza-like illness requires immediate care in an emergency department (ED).

DESIGN

Prospective pilot validation study conducted between February 8 and April 30, 2012. Staff who abstracted medical records and made follow-up calls were blinded to the SORT algorithm's assessment of the child's level of risk.

SETTING

Two pediatric emergency departments in the National Capital Region.

PARTICIPANTS

Convenience sample of 294 parents and adult caregivers who were at least 18 years of age; able to read and speak English; and the parent or legal guardian of a child 18 years or younger presenting to 1 of 2 EDs with signs and symptoms meeting Centers for Disease Control and Prevention criteria for influenza-like illness.

INTERVENTION

Completion of the SORT for Kids survey.

MAIN OUTCOME MEASURES

Caregiver ratings of the website's usability and the sensitivity of the underlying algorithm for identifying children who required immediate ED management of influenza-like illness, defined as receipt of 1 or more of 5 essential clinical services.

RESULTS

Ninety percent of participants reported that the website was "very easy" to understand and use. Ratings did not differ by respondent race, ethnicity, or educational attainment. Of the 15 patients whose initial ED visit met explicit criteria for clinical necessity, the Centers for Disease Control and Prevention algorithm classified 14 as high risk, resulting in an overall sensitivity of 93.3% (exact 95% CI, 68.1%-99.8%). Specificity of the algorithm was poor.

CONCLUSIONS AND RELEVANCE

This pilot study suggests that web-based decision support to help parents and adult caregivers self-triage children with influenza-like illness is feasible. However, prospective refinement of the clinical algorithm is needed to improve its specificity without compromising patient safety.