Repurposing the Ordering of Routine Laboratory Tests in Hospitalised Medical Patients (RePORT): results of a cluster randomised stepped-wedge quality improvement study

BACKGROUND

Low-value use of laboratory tests is a global challenge. Our objective was to evaluate an intervention bundle to reduce repetitive use of routine laboratory testing in hospitalised patients.

METHODS

We used a stepped-wedge design to implement an intervention bundle across eight medical units. Our intervention included educational tools and social comparison reports followed by peer-facilitated report discussion sessions. The study spanned October 2020-June 2021, divided into control, feasibility testing, intervention and a follow-up period. The primary outcomes were the number and costs of routine laboratory tests ordered per patient-day. We used generalised linear mixed models, and analyses were by intention to treat.

RESULTS

We included a total of 125 854 patient-days. Patient groups were similar in age, sex, Charlson Comorbidity Index and length of stay during the control, intervention and follow-up periods. From the control to the follow-up period, there was a 14% (incidence rate ratio (IRR)=0.86, 95% CI 0.79 to 0.92) overall reduction in ordering of routine tests with the intervention, along with a 14% (β coefficient=-0.14, 95% CI -0.07 to -0.21) reduction in costs of routine testing. This amounted to a total cost savings of $C1.15 per patient-day. There was also a 15% (IRR=0.85, 95% CI 0.79, 0.92) reduction in ordering of all common tests with the intervention and a 20% (IRR=1.20, 95% CI 1.10 to 1.30) increase in routine test-free patient-days. No worsening was noted in patient safety endpoints with the intervention.

CONCLUSIONS

A multifaceted intervention bundle using education and facilitated multilevel social comparison was associated with a safe and effective reduction in use of routine daily laboratory testing in hospitals. Further research is needed to understand how system-level interventions may increase this effect and which intervention elements are necessary to sustain results.

Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study

BACKGROUND

Patients experiencing early pregnancy loss often first present to the emergency department (ED) where they can be managed non-operatively through expectant or medical management, or surgically by the obstetrical team. Studies have reported that physician gender can influence clinical decision making, but there is limited research on this phenomenon in the ED. The objective of this study was to determine whether emergency physician gender is associated with early pregnancy loss management.

METHODS

Data were retrospectively collected from patients who presented to Calgary EDs with a non-viable pregnancy from 2014 to 2019. Pregnancies >12 weeks gestational age were excluded. The emergency physicians included saw at least 15 cases of pregnancy loss over the study period. The primary outcome was obstetrical consult rates by male versus female emergency physicians. Secondary outcomes included rates of initial surgical evacuation via dilation and curettage (D&C) procedures, ED returns, returns to care for D&Cs and total D&C rates. Data were analysed using χ², Fisher's exact and Mann-Whitney U tests, as appropriate. Multivariable logistic regression models accounted for physician age, years of practice, training programme and type of pregnancy loss.

RESULTS

98 emergency physicians and 2630 patients from 4 ED sites were included. 76.5% of the physicians were male accounting for 80.4% of pregnancy loss patients. Patients seen by female physicians were more likely to receive an obstetrical consultation (adjusted OR (aOR) 1.50, 95% CI 1.22 to 1.83) and initial surgical management (aOR 1.35, 95% CI 1.08 to 1.69). ED return rates and total D&C rates were not associated with physician gender.

CONCLUSION

Patients seen by female emergency physicians had higher rates of obstetrical consultation and initial operative management compared with those seen by male emergency physicians, but outcomes were similar. Additional research is required to determine why these gender differences exist and how these discrepancies may impact the care of early pregnancy loss patients.

Management of incomplete and missed spontaneous abortions: a cohort study of trends in Calgary emergency departments

OBJECTIVES

Incomplete and missed spontaneous abortion cases often first present to the emergency department (ED), where they can be managed operatively via dilation and curettage (D&C) or non-operatively through medical or expectant management. The primary objective of this study was to determine how rates of operative management have changed over time across Calgary EDs. The secondary objective was to assess correlates of effectiveness and potential drivers in management including gynecological consults, ED return visits requiring admission, and subsequent D&Cs.

METHODS

Sunrise Clinical Manager (electronic medical system) was accessed to collect data for patients who presented to a Calgary ED with an incomplete or missed spontaneous abortion from 2014 to 2019. Patients requiring resuscitation and those with complications were excluded. Return to care for D&C and ED revisits requiring admission were used as a proxy for failed non-operative management. Trends in management are reported using 95% confidence intervals.

RESULTS

Of the 3845 patients included, 1110 (28.9%) received a D&C on initial ED visit. The remaining 2735 (71.1%) were initially managed non-operatively. Rates of D&Cs decreased 11.6% from 2014 to 2019, 95% CI (6.5%, 16.8%). There was minimal change in the rates of gynecological consults, ED returns requiring admission, and returns to care resulting in D&Cs over time.

CONCLUSIONS

The management of incomplete and missed spontaneous abortions has shifted toward non-operative management over 6 years in Calgary. As this is not associated with increased ED returns requiring admission or subsequent D&Cs, the shift appears to be appropriate. As gynecological consults were consistent over time, further knowledge translation around non-operative spontaneous abortion management may be useful for ED physicians.

A Realist Evaluation of a 72-Hour Readmission Audit and Feedback (A&F) Intervention in Emergency Medicine

Introduction

Audit and feedback (A&F) interventions are intended to increase accountability and improve the quality of care; however, their impact can vary significantly. As performance feedback is implemented in healthcare, there is a growing need to determine how users interact with the data and how systems can achieve more consistent performance outcomes. This study aimed to understand the contexts, mechanisms, and outcomes of an emergency department 72-hour readmission A&F intervention.

Methods

Semi-structured interviews with key stakeholders were conducted and analyzed using thematic and template analysis techniques specifically aimed at identifying context, mechanism, and outcome configurations.

Results

Seventeen (17) physician interviews were conducted. We identified five outcomes of the intervention and the contexts and mechanisms contributing to them. Importantly, we identified that this A&F strategy could potentially have positive (improved follow-up of cases, improved discharge communication) and negative impacts (increased physician anxiety, potentially increased resource use) on physicians and departmental efficiency.

Conclusion

The 72-hour readmission alert A&F intervention generates a number of distinct outcome patterns that result from a variety of mechanisms acting in different contexts. Knowledge of these context-mechanism-outcome relationships may help implementers design and tailor performance feedback strategies.

Impact of an education and multilevel social comparison–based intervention bundle on use of routine blood tests in hospitalised patients at an academic tertiary care hospital: a controlled pre-intervention post-intervention study

Background

Repetitive inpatient laboratory testing contributes to waste in healthcare. We evaluated an intervention bundle combining education and multilevel social comparison feedback to safely reduce repetitive use of inpatient routine laboratory tests.

Methods

This non-randomised controlled pre-intervention post-intervention study was conducted in four adult hospitals from October 2016 to March 2018. In the medical teaching unit (MTU) of the intervention site, learners received education and aggregate social comparison feedback and attending internists received individual comparison feedback on routine laboratory test utilisation. MTUs of the remaining three sites served as control units. Number and cost of routine laboratory tests ordered per patient-day before and after the intervention was compared with the control units, adjusting for patient factors. Safety endpoints included number of critically abnormal laboratory test results, number of stat laboratory test orders, patient length of stay, transfer rate to the ICU, and 30-day readmission and mortality.

Results

A total of 14 000 patients were included. Pre-intervention and post-intervention groups were similar in age, sex, Charlson Comorbidity Index and length of stay. From the pre-intervention period to the post-intervention period, significantly fewer routine laboratory tests were ordered at the intervention MTU (incidence rate ratio=0.89; 95% CI 0.79 to 1.00; p=0.048) with associated costs savings of $C68 877 (p=0.020) as compared with the control sites. The variability in the ordering pattern of internists at the intervention site also decreased post-intervention. No worsening was noted in the safety endpoints between the pre-intervention and post-intervention period at the intervention unit compared with the controls.

Conclusions

Combination of education and multilevel social comparison feedback significantly and safely led to cost savings through reduced use of routine laboratory tests in hospitalised patients.

Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery

BACKGROUND

The reporting of adverse events (AE) remains an important part of quality improvement in thoracic surgery. The best methodology for AE reporting in surgery is unclear. An AE reporting system using an electronic discharge summary with embedded data collection fields, specifying surgical procedure and complications, was developed. The data are automatically transferred daily to a web-based reporting system.

METHODS

We determined the accuracy and sustainability of this electronic real time data collection system (ERD) by comparing the completeness of record capture on procedures and complications with coded discharge data (administrative data), and with the standard of chart audit at two intervals. All surgical procedures performed for 2 consecutive months at initiation (Ti) and 1 year later (T1yr) were audited by an objective trained abstractor. A second abstractor audited 10% of the charts.

RESULTS

The ERD captured 71/72 (99%) of charts at Ti and 56/65 (86%) at T1yr. Comparing the presence/absence of complications between ERD and chart audit demonstrated at Ti a high sensitivity and specificity, positive predictive value (PPV) of 95.5%, negative predictive value (NPV) of 93.9% with a kappa of 0.872 (95% CI 0.750 to 0.994), and at T1yr a sensitivity, specificity, PPV and NPV of 100% with a kappa of 1.0 (95% CI 1.0). Comparing the presence/absence of complications between administrative data and chart audit at Ti demonstrated a low sensitivity, high specificity and a kappa of 0.471 (95% CI 0.256 to 0.686), and at T1yr a low sensitivity, high specificity of 85% and a kappa of 0.479 (95% CI 0.245 to 0.714).

CONCLUSIONS

We found that the ERD can provide accurate real time AE reporting in thoracic surgery, has advantages over previous reporting methodologies and is an alternative system for surgical clinical teams developing AE reporting systems.

Sex-related Differences in Emergency Department Renal Colic Management: Females Have Fewer Computed Tomography Scans but Similar Outcomes

BACKGROUND

Sex-related differences occur in many areas of medicine. Emergency department (ED) studies have suggested differences in access to care, diagnostic imaging use, pain management, and intervention. We investigated sex-based differences in the care and outcomes for ED patients with acute renal colic.

METHODS

This was a multicenter population-based retrospective observational cohort study using administrative data and supplemented by structured chart review. All patients seen in Calgary Health Region EDs between January 1 and December 31, 2014, with an ED diagnosis of renal colic based on the following ICD-10 codes were eligible for inclusion: calculus of kidney (N200), calculus of ureter (N201), calculus of kidney with calculus of ureter (N202), hydronephrosis with renal and ureteral calculous obstruction (N132), unspecified renal colic (N23), and unspecified urinary calculus (N209). ED visit data and test results were accessed in the regional ED clinical database. Stone characteristics were captured from diagnostic imaging reports. Regional hospital databases were used to identify subsequent ED encounters, hospital admissions, and surgical procedures within 60 days. Outcomes were stratified by sex. The primary outcome, intended as a marker of overall effectiveness of ED care, was the unscheduled 7-day ED revisit rate among patients who were discharged home after their index ED visit. Secondary outcomes included ED pain management as reflected by administration of narcotics or intravenous nonsteroidals, the performance of advanced imaging-either ultrasound (US) or computed tomography (CT), and the proportion of patients who required hospitalization or surgical intervention within 60 days.

RESULTS

From January 1 to December 31, 2014, a total of 3,104 eligible patients were studied: 1,111 women (35.8%) and 1,993 men (64.2%). Baseline characteristics, access times, analgesic use, and admission rates were similar in both groups. Men were more likely to have CT (68.9% vs. 58.5%, difference = 10.4%, 95% confidence interval [CI] = 6.8 to 14.0) while women were more likely to have US (20.8% vs. 9.6%, difference = 11.2%, 95% CI = 8.4 to 13.9). At 7 days, 17.9% of women and 19.0% of men who were discharged after their index ED visit required an ED revisit (difference = 1.1%, 95% CI = -2.8 to 4.9). Men were more likely to be hospitalized at 7 days (9.8% vs. 6.5%, difference = 3.3%, 95% CI = 0.6 to 6.0).

CONCLUSION

This study shows greater reliance on US in females but no other sex-specific differences in the management of ED patients with acute renal colic. Higher CT use in men was not associated with improved outcomes, and we found no important differences in access to care, diagnostic or treatment intensity, or revisit rates as a marker of care effectiveness.

Computerized physician order entry and decision support improves ED analgesic ordering for renal colic

OBJECTIVES

Computerized physician order entry (CPOE) offers the potential for safer, faster patient care, as well as greater use of evidence-based therapy via built-in decision support. However, the effectiveness of CPOE in yielding these benefits has shown mixed results in the emergency department (ED) setting. Our objective was to evaluate the impact of CPOE implementation on analgesic prescribing and dosing practices for renal colic presentations.

METHODS

This retrospective pre/post comparative study was conducted in 3 tertiary hospitals that implemented CPOE in 2010. Two patient groups were compared: prior to (pre-CPOE) and after (post-CPOE) CPOE implementation. Each group consisted of 230 randomly selected, high-acuity patients presenting to the ED with renal colic. The primary outcome was the proportion of patients receiving ketorolac in the ED. Secondary outcomes included choice of analgesic and average morphine dose.

RESULTS

The proportion of patients receiving ketorolac significantly increased after CPOE implementation (65.6% pre-CPOE vs 76.5% post-CPOE, P = .015), as did the proportion of patients receiving fentanyl (pre, 9.7%; post, 16.7%; P = .047). Differences in morphine use (pre, 66.0%; post, 69.1%) and average morphine dose (pre, 10.09 mg; post, 12.28 mg) did not reach statistical significance.

CONCLUSIONS

The introduction of CPOE is associated with an increase in ketorolac use for ED renal colic visits. This may reflect the inclusion of ketorolac in the renal colic order set. Computerized physician order entry implementation with condition-specific electronic order sets and decision support may improve evidence-based practice.

Purification of individual varicella-zoster virus (VZV) glycoproteins gpI, gpII, and gpIII and their use in ELISA for detection of VZV glycoprotein-specific antibodies

We have utilized monoclonal antibodies in immune affinity chromatography to purify each of the 3 major glycoproteins of varicella-zoster virus (VZV), gpI, gpII, and gpIII, in immunologically active form. Upon injection into guinea pigs, each preparation elicited the production of specific antibodies capable of immunoprecipitating the homologous glycoprotein and of neutralizing VZV infectivity in vitro. Also, total glycoproteins from VZV-infected cells have been purified by lectin affinity chromatography. Each of the individual purified glycoproteins, as well as total VZV glycoproteins and appropriate uninfected cell protein controls, have been employed as solid-phase reagents in enzyme-linked immunosorbent assay (ELISA) for the detection of antibodies directed against specific VZV glycoproteins. The specificity of the purified glycoproteins as ELISA reagents was verified by the ability of individual monoclonal antibodies to bind specifically to individual glycoprotein preparations. We have demonstrated the utility of the glycoprotein-specific ELISA by detecting antibodies in sera from post-zoster and post-varicella patients. The assay detects antibodies directed against each of the 3 major glycoproteins and is sensitive enough to detect antibodies in a 1:320 000 dilution of some sera. This assay, as well as the purified individual glycoproteins per se, should prove to be very useful reagents in understanding the role of each of gpI, gpII, and gpIII in immunity to VZV.

Hepatic estrogen receptors and plasma estrogen-binding activity in the Atlantic salmon

Livers of male and female immature Atlantic Salmon (Salmo salar) contain specific high-affinity [3H]estradiol binding sites in cytosol (Kd 2-4 nM, concentration about 0.6 pmol/g liver). Low levels of high-affinity binding are detectable in salt extracts of nuclei of untreated fish, but injections of estradiol result in transient depletion of the cytosol binder and in accumulation of high levels of binding sites in nuclear salt extracts (Kd 5-6 nM; concentration about 6 pmol/g liver). Both the cytosol and nuclear binding sites are temperature sensitive and are optimally assayed by incubation at 2 degrees. Both are specific for estradiol and diethylstilbestrol (DES) and no significant competition by dihydrotestosterone (DHT), progesterone, or hydrocortisone is seen. The triphenylethylene nonsteroidal antiestrogen, 4-hydroxytamoxifen, exhibits an affinity comparable to that of estradiol. The nuclear binding activity sediments with a coefficient of 3.6 S in salt-containing sucrose density gradients, and is stable on storage at -20 degrees for several months. The cytosol binder on the other hand is not stable on sucrose density gradients or on prolonged storage. Salmon plasma contains two [3H]estradiol binding components, one with a relatively high affinity for [3H]estradiol (kd 13 nM) and the other having a much lower affinity but present in high concentrations. The high-affinity plasma binder exhibits distinctive specificity with no affinity for DES or 4-hydroxytamoxifen but some affinity for DHT and progesterone. These properties serve to distinguish the plasma activity from the intrahepatic estrogen binders. The salmon liver estrogen receptor system has many features in common with typical estradiol receptors from other vertebrates. Immature salmon liver appears to be the richest source of hepatic estrogen receptor so far found for any vitellogenic species.

The effect of molybdate on the intracellular distribution of estrogen receptor in mammary tumors

The addition of sodium molybdate (20 mM) to human breast tumor homogenates results in an increased yield of estrogen receptor sites in the cytosol, but reduces the number of sites detectable in salt extracts of purified nuclei. Only about 25% of the increase in cytosol receptor can be accounted for by the loss of nuclear sites. Addition of molybdate to isolated nuclear salt extracts has no inhibitory effect on the estrogen receptor assay, but addition of the oxyanion to the cytosol after separation of the initial nuclear pellet still gives a significant increase in estradiol binding capacity. Furthermore, addition of molybdate to the suspension from the first nuclear pellet still results in loss of binding sites in the nuclear salt extract. This rules out the possibility that the negative effect of molybdate on nuclear receptor recovery is by its inhibition of cytosol receptor activation and translocation during tissue preparation. The number of nuclei isolated from estrogen receptor-containing tumors does not differ significantly in the presence or absence of molybdate. Estrogen receptor-negative tumors however yield fewer nuclei, particularly when they are processed in the presence of molybdate. We conclude that when homogenization of tumors is carried out in the presence of molybdate, a significant fraction of estrogen receptor which would normally be present in purified nuclei is lost, perhaps by leakage through the nuclear membrane.

Fibronectin distribution pattern and the three-dimensional growth behavior of mammalian cells under anchorage-independent conditions

Several types of normal diploid cells, established "normal" cells, and transformed cells of human and rodent origin have been studied with reference to cell surface fibronectin distribution and their anchorage-independent growth behavior. All cell types that showed intercellular and fibrillar surface fibronectin were anchorage-dependent for growth. Lack of surface fibrillar fibronectin in spontaneously or virus-transformed cells and cells of neoplastic origin was accompanied by anchorage-independent growth potential. The degree of three-dimensional organization of cells under anchorage-independent growth conditions was dependent on the amount of intercellular fibronectin. The significance of these observations to in vivo tumor growth is discussed.