Implementation of Electronic Health Record Integration and Clinical Decision Support to Improve Emergency Department Prescription Drug Monitoring Program Use.

STUDY OBJECTIVE(S): To evaluate the implementation of 3 electronic health record (EHR)-based interventions to increase prescription drug monitoring program (PDMP) use in the emergency department (ED): EHR-PDMP integration, addition of a PDMP risk score, and addition of EHR-based clinical decision support alert to review the PDMP when prescribing an opioid. METHODS: Three intervention stages were implemented using a prospective stepped-wedge design at 5 university-affiliated EDs split into 3 practice groups. The PDMP use and prescribing rates during the 3 stages were compared with baseline before EHR integration and a sustainability stage where the clinical decision support alert was removed, but EHR integration and risk score remained. Generalized linear mixed model with logit link function and a random intercept for clinicians was analyzed. RESULTS: The ED provider PDMP review before opioid prescribing was low in all stages. The highest review rate occurred during interruptive clinical decision support alerts, 23.8% (interquartile range 10.6 to 37.5). Overall, opioid prescribing declined, and PDMP review was not associated with a decrease in opioid prescribing. PDMP review was associated with a reduction in the probability of prescribing an opioid as the number of prior opioid prescriptions increased (odds ratio: 0.92 [95% confidence interval: 0.91 to 0.94] for every additional prescription). CONCLUSION: The EHR-PDMP integration did not increase PDMP use in the ED, but a PDMP risk score and a clinical decision support alert were associated with modest increases in the probability of PDMP review. When the PDMP is reviewed, ED clinicians are less likely to prescribe opioids to patients with a high number of prior opioid prescriptions.

Using Outbreak Data for Hypothesis Generation: A Vehicle Prediction Tool for Disease Outbreaks Caused by Salmonella and Shiga Toxin-Producing Escherichia coli.

Hypothesis generation about potential food and other exposures is a critical step in an enteric disease outbreak investigation, helping to focus investigation efforts and use of limited resources. Historical outbreak data are an important source of information for hypothesis generation, providing data on common food- and animal-pathogen pairs and other epidemiological trends. We developed a model to predict vehicles for Shiga toxin-producing Escherichia coli and Salmonella outbreaks using demographic and outbreak characteristics from outbreaks in the Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System (1998-2019) and Animal Contact Outbreak Surveillance System (2009-2019). We evaluated six algorithmic methods for prediction based on their ability to predict multiple class probabilities, selecting the random forest prediction model, which performed best with the lowest Brier score (0.0953) and highest accuracy (0.54). The model performed best for outbreaks transmitted by animal contact and foodborne outbreaks associated with eggs, meat, or vegetables. Expanding the criteria to include the two highest predicted vehicles, 83% of egg outbreaks were predicted correctly, followed by meat (82%), vegetables (74%), poultry (67%), and animal contact (62%). The model performed less well for fruit and poultry vehicles, and it did not predict any dairy outbreaks. The final model was translated into a free, publicly available online tool that can be used by investigators to provide data-driven hypotheses about outbreak vehicles as part of ongoing outbreak investigations. Investigators should use the tool for hypothesis generation along-side other sources, such as food-pathogen pairs, descriptive data, and case exposure assessments. The tool should be implemented in the context of individual outbreaks and with an awareness of its limitations, including the heterogeneity of outbreaks and the possibility of novel food vehicles.

Association of Emergency Department Opioid Administration With Ongoing Opioid Use: A Retrospective Cohort Study of Patients With Back Pain.

OBJECTIVES: Opioids are commonly administered in the emergency department (ED) and prescribed for the treatment of back pain. It is important to understand the unintended consequences of this approach to inform treatment decisions and the consideration of alternative treatments. Recent evidence has shown that ED opioid prescriptions are associated with future opioid use. The objective of this study was to measure the association of opioid administration in the ED to patients treated for back pain with future opioid use. METHODS: This is a retrospective study of opioid-naïve adults discharged from the ED with a diagnosis of back pain. Patients were stratified by opioid therapy (none, ED administration only, prescription only, or ED administration + prescription). Relative risks of ongoing opioid use (filling >90-day supply in 180 days following ED visit as documented in the prescription drug monitoring program) were calculated for each opioid-therapy group and compared to the no-opioid group. RESULTS: We identified 24,487 opioid naïve back pain patients. The median age was 38 years, 55% were female, and 56% were non-Hispanic white. A total of 41% received no opioid, 10% were only administered an opioid in the ED, 18% only received a prescription, and 31% received an opioid in the ED + prescription. The adjusted relative risks of ongoing use compared to the no opioid group were as follows: ED only 1.9, prescription only 2.1, and ED + prescription 2.3. The increased risk persisted for other definitions of ongoing use and after adjustment for baseline pain scores. CONCLUSIONS: For opioid-naïve patients with back pain, both administration of an opioid in the ED and opioid prescriptions are associated with a doubling of the risk of ongoing opioid use compared to patients not treated with opioids. This supports the consideration of minimizing exposure to opioids while treating back pain in the ED.

Timeliness of Care for High-acuity Conditions at Hospital-affiliated Freestanding Emergency Departments.

BACKGROUND: Hospital-affiliated freestanding emergency departments (FREDs) are rapidly proliferating in some states and have been the subject of recent policy debate. As FREDs' role in acute care delivery is expanding in certain regions, little is known about the quality of care that they provide for their sickest patients. Our aim was to compare timeliness of emergent care at FREDs and hospital-based EDs (HEDs) for patient visits with selected high-acuity and time-sensitive conditions. METHODS: We performed a retrospective observational analysis of adult patient visit data from 19 FREDs and five HEDs from one health system over a 1-year period. Median times to events and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated via Cox regression. RESULTS: The median time to electrocardiogram for visits with chest pain was 10 minutes at FREDs and 9 minutes at HEDs (HR = 0.91 [CI = 0.87 to 0.96]). Time to cardiac catheterization lab for visits with ST-segment elevation myocardial infarction (STEMI) was 78 minutes at FREDs, inclusive of transfer time, and 31 minutes at HEDs (HR = 0.41 [CI = 0.24 to 0.71]). Time to computed tomography for visits with stroke was 37 minutes at FREDs and 29 minutes at HEDs (HR = 0.42 [CI = 0.31 to 0.58]). Among visits with sepsis, FREDs had longer times to lactate collection (HR = 0.41 [CI = 0.30 to 0.56]), blood culture collection (HR = 0.24 [CI = 0.11 to 0.51]), and antibiotic administration (HR = 0.61 [CI = 0.26 to 1.42]). Beta agonists were administered for visits with asthma exacerbations in 24 minutes at FREDs and 44 minutes at HEDs (HR = 2.50 [CI = 2.34 to 2.68]), with similar times for anticholinergic and corticosteroid administration. CONCLUSIONS: Freestanding EDs provided more timely care than HEDs for visits with asthma exacerbation and less timely care for acute chest pain, stroke, and sepsis, although absolute differences were small. Even though STEMI patients at FREDs required transfer for catheterization, they tended to receive care in line with national guidelines.

Characteristics and Operational Performance of Hospital-affiliated Freestanding Emergency Departments.

BACKGROUND: As there has been increasing pressure on acute care services to redefine how their care is delivered, hospital-affiliated freestanding emergency departments (FREDs) have rapidly expanded in some markets. Little is known about the populations served or the quality of care provided by these facilities. OBJECTIVE: The objective of this study was to compare patient visit characteristics, geographic catchment areas, and operational performance between hospital-affiliated FREDs and hospital-based emergency departments (HEDs). RESEARCH DESIGN: This was a population-based retrospective observational analysis of 19 FREDs and 5 HEDs in a single health system over a 1-year period. We abstracted patient visit data from the electronic health record and supplemented catchment area data with the 2016 American Community Survey. We analyzed lengths of stay using generalized linear models adjusted for age, severity, and insurance status. RESULTS: FREDs had lower proportions of visits from nonwhite patients and more visits from privately insured patients than HEDs, with similar proportions of uninsured patient visits. These trends were mirrored in catchment area analyses. FRED visits were lower acuity, with fewer imaging and laboratory tests performed. The adjusted mean length of stay for discharged patients was 109 minutes for FREDs compared with 169 minutes for HEDs. For admitted or transferred patients, adjusted lengths of stay were 213 minutes at FREDs and 287 minutes at HEDs. CONCLUSIONS: Hospital-affiliated FREDs serve more affluent and less diverse patient populations and geographic communities. Relative to HEDs, they have lower acuity patient visits with fewer tests, and they have shorter lengths of stay, even after adjustment for patient visit characteristics.

Video delivery of toxicology educational content versus textbook for asynchronous learning, using acetaminophen overdose as a topic.

Objectives: Advances in technology have brought with them innovations in delivery of medical educational content; for example, audio and video podcasts, flipped classroom learning, and e-books. These new modalities may be useful for delivery of content asynchronously, as an adjunct to traditional lecture-based and bedside clinical teaching. Here, we measured the differences in knowledge acquisition between medical students using a video-based content delivery method and students using a traditional method of asynchronous content delivery (a textbook chapter). We also measured student preferences regarding asynchronous content delivery. Methods: A 4.5-minute educational video was created by a content expert using VideoScribe software. Acetaminophen toxicity was selected as the sample topic. Survey Monkey software was used to create a pre-test, post-test, and to gather data regarding student preferences. Students were given the pre-test, then they were randomized to either read a chapter on acetaminophen overdose from an emergency medicine reference text or to view the video; they were then given the post-test and the preferences survey. The results were then categorized and analysed using descriptive statistics and linear regression. Results: Sixty-nine student responses were initiated, 14 of whom did not complete the full survey, leaving 55 students who were included in the final analysis. Fifteen first year, 27 second-year, 8 third-year, and 5 fourth-year students participated. Twenty-eight students were randomized to reading the textbook chapter, and 31 were randomized to view the video; 4 students in the textbook group did not finish the educational activity. On average, students who took the video training correctly answered 1.1 (95% CI: 0.1-2.2, p = .03) more questions correctly after adjusting for pretest score and year in medical school than those who read the textbook chapter. A preference for watching a video over reading a textbook chapter was expressed by 78.4% of students, while 98% of students either agreed or strongly agreed with the statement that they would be comfortable using the internet to learn new concepts. No students reported that they were very satisfied and 57% of students reported being satisfied reading the textbook chapter, while 93.3% were either satisfied or very satisfied viewing the video. Conclusions: Video delivery of educational content was associated with higher student satisfaction and relative improvement in score compared to textbook. Students overall expressed comfort using the internet and new technology to obtain new medical education. The authors were involved with creation of the video and quiz, which may confound results. Future exploration into retention of knowledge could be warranted.

Temperament Similarities and Differences: A Comparison of Factor Structures from the Behavioral Style Questionnaire in Children with and Without Autism Spectrum Disorder.

The majority of studies of temperament in children with autism spectrum disorder (ASD) use scales normed on typical populations. The present study examined a widely used measure of temperament, the Behavioral Style Questionnaire (McDevitt and Carey in Behavioral Styles Questionnaire, Behavioral-Developmental Initiatives Scottsdale, AZ, 1975) to determine whether it contains the temperament traits theorized by its creators. Neither confirmatory nor exploratory factor analysis, using a sample of children with ASD and a population comparison group, identified the theorized nine temperament factors; many items did not strongly load on any of the original factors. A 10 factor solution best described the ASD data and a 9 factor solution best described the typical group's data. There were substantial similarities in the 9 factor solutions, but groups differed from one another enough to question construct similarity for several factors. These results highlight that more basic psychometric research is needed to better understand the BSQ in children with ASD.

Influence of family demographic factors on social communication questionnaire scores.

This study examined the effect of demographic factors on Social Communication Questionnaire (SCQ) scores in children aged 30-68 months. Diagnoses of ASD were made after a gold standard evaluation that included the Autism Diagnostic Observation Schedule (ADOS), and the Autism Diagnostic Interview Revised (ADI-R). The relationship of demographic variables to SCQ scores was compared in two source populations: (a) children recruited from clinical and educational sources serving children who have ASD or other developmental disorders (CE) and (b) children recruited from birth certificates to represent the general population (BC). The impact of the demographic variables-child sex, child age, maternal language, maternal ethnicity, maternal education, maternal race, and household income-on total SCQ score were studied to examine their impact on the SCQ's performance. Demographic factors predicting the SCQ total score were used to generate ROCs. Factors that had a significant influence on SCQ performance were identified by examining the area under the ROCs. Optimal SCQ cut-points were generated for significant factors using the Youden's Index. Overall male sex, lower household income, lower maternal education and Black race predicted higher SCQ scores. In this sample, the most common optimum value for the SCQ cut-point across the different sociodemographic groups was 11. Autism Res 2018, 11: 695-706. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Screeners are used to help identify children who are more likely to have ASD than their peers. Ideally screeners should be accurate for different groups of children and families. This study examined how well the Social Communication Questionnaire (SCQ) predicts ASD. We found that male sex, lower household income, lower maternal education and Black race were associated with higher SCQ scores. In this study an SCQ cut-point of 11 worked best across the different sociodemographic groups in our sample.

Screening for Autism with the SRS and SCQ: Variations across Demographic, Developmental and Behavioral Factors in Preschool Children.

The Social Communication Questionnaire (SCQ) and the Social Responsiveness Scales (SRS) are commonly used screeners for autism spectrum disorder (ASD). Data from the Study to Explore Early Development were used to examine variations in the performance of these instruments by child characteristics and family demographics. For both instruments, specificity decreased as maternal education and family income decreased. Specificity was decreased with lower developmental functioning and higher behavior problems. This suggests that the false positive rates of the SRS and the SCQ are associated with child characteristics and family demographic factors. There is a need for ASD screeners that perform well across socioeconomic and child characteristics. Clinicians should be mindful of differential performance of these instruments in various groups of children.