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Introduction: This study assessed the effect of the COVID-19 pandemic on preventive care imaging and potential disparities because preventive care may be perceived as nonurgent. The objective was to identify the associations between the COVID-19 pandemic and changes in preventive imaging volumes for patients in general and as affected by race and ethnicities. Methods: The authors performed a retrospective observational study by extracting the weekly volumes of all imaging studies between January 7, 2019 and May 1, 2022 from a radiology data warehouse at a tertiary care medical center (n=92,105 preventive imaging studies and 3,493,063 total radiology imaging studies) and compared preshutdown with postshutdown periods using a 2-sample t-test. Additional comparisons stratified by race and ethnicity were performed for mammograms and bone density examinations using interrupted time series models with negative binomial error distribution to assess the immediate level change and trends over time of preventive imaging volumes after shutdown. Results: The authors found a significant decrease in bilateral mammograms, bone density examinations, and aortic ultrasound examinations in the postshutdown period compared with those in the preshutdown period (p<0.001, p=0.003, and p=0.001, respectively). There were no significant changes in low-dose computed tomography chest examinations (p=0.46). The shutdown was associated with a significant immediate decrease in mammograms in the Hispanic and Latino group to approximately three quarters of its preshutdown level (p=0.04). For bone density examinations, postshutdown weekly volumes tripled compared with the preshutdown volumes for Hispanic or Latino patients and doubled for non-Hispanic Black patients (p<0.0001 for both). In comparison, a significant decrease was seen for Other patients (reduced to nearly a fifth of preshutdown volume) (p<0.0001). Conclusions: There was a significant decrease in overall volume of bilateral mammograms, bone density examinations, and aortic ultrasound examinations after pandemic shutdown. For mammograms, some of this decreasing trend was already seen before shutdown (such as for patients with Other race), so the shutdown was only specifically associated with an immediate decrease in mammogram levels in the Hispanic and Latino group. For bone density examinations, the shutdown was unexpectedly associated with an increase in volumes for Hispanic or Latino patients and non-Hispanic Black patients, which was countered by a significant steep decrease in volumes only for patients of Other race. Health systems should carefully explore their preventive screening examination volumes to determine which patients should be actively engaged to assure catch up on recommended care.
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Background: The interplay between SARS-CoV-2 and contemporaneous bacterial or fungal culture growth may have crucial implications for clinical outcomes of hospitalized patients. This study aimed to quantify the effect of microbiological culture positivity on mortality among hospitalized patients with SARS-CoV-2. Methods: In this retrospective cohort study, we included adult hospitalized patients from OPTUM COVID-19 specific data set, who tested positive for SARS-CoV-2 within 14 days of hospitalization between 01/20/2020 and 01/20/2022. We examined outcomes of individuals with organisms growing on cultures from the bloodstream infections (BSIs), urinary tract, and respiratory tract, and a composite of the three sites. We used propensity score matching on covariates included demographics, comorbidities, and hospitalization clinical parameters. In a sensitivity analysis, we included same covariates but excluded critical care variables such as length of stay, intensive care unit stays, mechanical ventilation, and extracorporeal membrane oxygenation. Results: The cohort included 104,560 SARS-CoV-2 positive adult hospitalized patients across the United States. The unadjusted mortality odds increased significantly with BSIs (98.7%) and with growth on respiratory cultures (RC) (176.6%), but not with growth on urinary cultures (UC). Adjusted analyses showed that BSIs and positive RC independently contribute to mortality, even after accounting for critical care variables. Conclusions: In SARS-CoV-2-positive hospitalized patients, positive bacterial and fungal microbiological cultures, especially BSIs and RC, are associated with an increased risk of mortality even after accounting for critical care variables associated with disease severity. These findings underscore the importance of stringent infection control and the effective management of secondary infections to improve patient outcomes.
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Objective: Social media's arrival eased the sharing of mis- and disinformation. False information proved challenging throughout the coronavirus disease 2019 (COVID-19) pandemic with many clinicians and researchers analyzing the "infodemic." We systemically reviewed and synthesized COVID-19 mis- and disinformation literature, identifying the prevalence and content of false information and exploring mitigation and prevention strategies. Design: We identified and analyzed publications on COVID-19-related mis- and disinformation published from March 1, 2020, to December 31, 2022, in PubMed. We performed a manual topic review of the abstracts along with automated topic modeling to organize and compare the different themes. We also conducted sentiment (ranked -3 to +3) and emotion analysis (rated as predominately happy, sad, angry, surprised, or fearful) of the abstracts. Results: We reviewed 868 peer-reviewed scientific publications of which 639 (74%) had abstracts available for automatic topic modeling and sentiment analysis. More than a third of publications described mitigation and prevention-related issues. The mean sentiment score for the publications was 0.685, and 56% of studies had a negative sentiment (fear and sadness as the most common emotions). Conclusions: Our comprehensive analysis reveals a significant proliferation of dis- and misinformation research during the COVID-19 pandemic. Our study illustrates the pivotal role of social media in amplifying false information. Research into the infodemic was characterized by negative sentiments. Combining manual and automated topic modeling provided a nuanced understanding of the complexities of COVID-19-related misinformation, highlighting themes such as the source and effect of misinformation, and strategies for mitigation and prevention.
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Pediatricians' use of electronic health record (EHR) systems has become nearly ubiquitous in the United States, yet many systems lack full functionality to deliver effective and efficient pediatric care. This clinical report seeks to provide a compendium of core pediatric functionality of importance to child health care providers that may serve as the focus for EHR developers and clinicians as they evaluate their EHR needs. Also reviewed are important but less critical functions, any of which might be of importance in a specific pediatric context. The major areas described here are immunization management, growth and development, social drivers of health tracking, decision support for orders, patient identification, data normalization, privacy, and system functionality standards in pediatric contexts.
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Registros Eletrônicos de Saúde , Pediatria , Humanos , Pediatria/normas , Criança , Estados UnidosRESUMO
Context: Primary hyperparathyroidism (PHPT) increases the risk of bone loss, debilitating fractures, kidney stones, impaired renal function, and neurocognitive symptoms. Studies describing the natural history of PHPT have been limited to small samples, single institutions, or specific populations. Objective: We assessed the natural history of PHPT through a large, diverse national cohort from an electronic health record dataset representing more than 100 million patients. Methods: The TriNetX database was queried for adult patients with PHPT. We extracted demographics, comorbidities, and longitudinal biochemistries. Primary outcomes included major osteoporotic fracture (MOF) and chronic kidney disease (CKD). Outcomes were stratified by treatment strategy (surgical parathyroidectomy [PTX] vs nonsurgical) and age. Results: Among 50 958 patients with PHPT, 26.5% were treated surgically at a median of 0.3 years postdiagnosis. At diagnosis, median age was 65 years, 74.0% were female, and median calcium level was 10.9â mg/dL. Black and older patients underwent PTX less frequently than White and younger patients. MOF 10-year incidence was 5.20% (PTX) and 7.91% (nonsurgical), with median 1.7-year delay with PTX compared to nonsurgical. PTX-associated MOF absolute risk reduction was 0.83% (age < 65 years) and 3.33% (age ≥ 65 years). CKD 10-year incidence was 21.2% (PTX) and 33.6% (nonsurgical), with median 1.9-year delay with PTX. PTX-associated CKD absolute risk reduction was 12.2% (age < 65 years) and 9.5% (age ≥ 65 years). Conclusion: We report 1 of the largest, representative, population-based natural histories of PHPT with different management strategies. A minority of patients underwent PTX, especially in older age. Patients managed surgically had lower incidence of fracture and CKD, and older patients experienced differential benefit.
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BACKGROUND: The increased prevalence of antimicrobial resistant (AMR) infections is a significant global health threat, resulting in increased morbidity, mortality, and costs. The drivers of AMR are complex and potentially impacted by socioeconomic factors. We investigated the relationships between geographic and socioeconomic factors and AMR. METHODS: We collected select patient bacterial culture results from 2015 to 2020 from electronic health records (EHR) of two expansive healthcare systems within the Dallas-Fort Worth, TX (DFW) metropolitan area. Among individuals with EHR records who resided in the four most populus counties in DFW, culture data were aggregated. Case counts for each organism studied were standardized per 1,000 persons per area population. Using residential addresses, the cultures were geocoded and linked to socioeconomic index values. Spatial autocorrelation tests identified geographic clusters of high and low AMR organism prevalence and correlations with established socioeconomic indices. RESULTS: We found significant clusters of AMR organisms in areas with high levels of deprivation, as measured by the Area Deprivation Index (ADI). We found a significant spatial autocorrelation between ADI and the prevalence of AMR organisms, particularly for AmpC and MRSA with 14% and 13%, respectively, of the variability in prevalence rates being attributable to their relationship with the ADI values of the neighboring locations. CONCLUSIONS: We found that areas with a high ADI are more likely to have higher rates of AMR organisms. Interventions that improve socioeconomic factors such as poverty, unemployment, decreased access to healthcare, crowding, and sanitation in these areas of high prevalence may reduce the spread of AMR.
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OBJECTIVES: In 2005, the American Academy of Pediatrics founded the Partnership for Policy Implementation (PPI). The PPI has collaborated with authors to improve the quality of clinical guidelines, technical reports, and policies that standardize care delivery, improve care quality and patient outcomes, and reduce variation and costs. METHODS: In this article, we describe how the PPI trained informaticians apply a variety of tools and techniques to these guidance documents, eliminating ambiguity in clinical recommendations and allowing guideline recommendations to be implemented by practicing clinicians and electronic health record (EHR) developers more easily. RESULTS: Since its inception, the PPI has participated in the development of 45 published and 27 in-progress clinical practice guidelines, policy statements, technical and clinical reports, and other projects endorsed by the American Academy of Pediatrics. The partnership has trained informaticians to apply a variety of tools and techniques to eliminate ambiguity or lack of decidability and can be implemented by practicing clinicians and EHR developers. CONCLUSIONS: With the increasing use of EHRs in pediatrics, the need for medical societies to improve the clarity, decidability, and actionability of their guidelines has become more important than ever.
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Pediatria , Guias de Prática Clínica como Assunto , Humanos , Pediatria/normas , Pediatria/organização & administração , Estados Unidos , Sociedades Médicas , Registros Eletrônicos de Saúde/normas , Política de SaúdeRESUMO
Analyzing data from a national deidentified electronic health record-based data set using a matched case-control study design, we found that antibiotic use and severity of illness were independent risk factors for healthcare-associated candidemia in adult patients hospitalized with SARS-CoV-2 infection. Interleukin-6 inhibitor and corticosteroid use were not independent risk factors.
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With advances in medical care, more youth with intellectual and/or developmental disabilities (IDD) are transitioning into adulthood. Patient- and family-centered, integrated care is warranted around this time of transition. Support teams (including the youth, caregivers, teachers, and pediatricians) should engage in transition planning, ideally starting between 12 and 14 years of age, to identify and develop resources to support the maturing youth's capacity for independent decision-making. Care teams should consider the varied levels of alternative decision-making support, which may include supported decision-making, medical proxy decision-making, power of attorney, and/or establishment of legal guardianship arrangements, to support the youth's health and well-being optimally. Ultimately, if independent decision-making is not appropriate, the goal for youth with IDD should be the least restrictive alternative, while preserving human rights and human dignity and promoting their autonomy. These considerations review alternative decision-making support, concepts, and legal requirements available for youth with IDD and their care teams. Pediatricians can support youth with IDD and their families in the transition process and decision-making autonomy by actively engaging the youth in care decisions, supporting needs for augmentative communication, fostering their expression of preferences and understanding of care decisions, and linking them to resources such as the medical-legal partnership model.
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Tomada de Decisões , Deficiências do Desenvolvimento , Deficiência Intelectual , Transição para Assistência do Adulto , Humanos , Deficiências do Desenvolvimento/terapia , Adolescente , Deficiência Intelectual/terapia , Deficiência Intelectual/psicologia , Criança , Tutores LegaisRESUMO
Importance: Patients with inequitable access to patient portals frequently present to emergency departments (EDs) for care. Little is known about portal use patterns among ED patients. Objectives: To describe real-time patient portal usage trends among ED patients and compare demographic and clinical characteristics between portal users and nonusers. Design, Setting, and Participants: In this cross-sectional study of 12 teaching and 24 academic-affiliated EDs from 8 health systems in California, Connecticut, Massachusetts, Ohio, Tennessee, Texas, and Washington, patient portal access and usage data were evaluated for all ED patients 18 years or older between April 5, 2021, and April 4, 2022. Exposure: Use of the patient portal during ED visit. Main Outcomes and Measures: The primary outcomes were the weekly proportions of ED patients who logged into the portal, viewed test results, and viewed clinical notes in real time. Pooled random-effects models were used to evaluate temporal trends and demographic and clinical characteristics associated with real-time portal use. Results: The study included 1â¯280â¯924 unique patient encounters (53.5% female; 0.6% American Indian or Alaska Native, 3.7% Asian, 18.0% Black, 10.7% Hispanic, 0.4% Native Hawaiian or Pacific Islander, 66.5% White, 10.0% other race, and 4.0% with missing race or ethnicity; 91.2% English-speaking patients; mean [SD] age, 51.9 [19.2] years). During the study, 17.4% of patients logged into the portal while in the ED, whereas 14.1% viewed test results and 2.5% viewed clinical notes. The odds of accessing the portal (odds ratio [OR], 1.36; 95% CI, 1.19-1.56), viewing test results (OR, 1.63; 95% CI, 1.30-2.04), and viewing clinical notes (OR, 1.60; 95% CI, 1.19-2.15) were higher at the end of the study vs the beginning. Patients with active portal accounts at ED arrival had a higher odds of logging into the portal (OR, 17.73; 95% CI, 9.37-33.56), viewing test results (OR, 18.50; 95% CI, 9.62-35.57), and viewing clinical notes (OR, 18.40; 95% CI, 10.31-32.86). Patients who were male, Black, or without commercial insurance had lower odds of logging into the portal, viewing results, and viewing clinical notes. Conclusions and Relevance: These findings suggest that real-time patient portal use during ED encounters has increased over time, but disparities exist in portal access that mirror trends in portal usage more generally. Given emergency medicine's role in caring for medically underserved patients, there are opportunities for EDs to enroll and train patients in using patient portals to promote engagement during and after their visits.
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Serviço Hospitalar de Emergência , Portais do Paciente , Humanos , Feminino , Serviço Hospitalar de Emergência/estatística & dados numéricos , Masculino , Portais do Paciente/estatística & dados numéricos , Estudos Transversais , Pessoa de Meia-Idade , Adulto , Estados Unidos , Idoso , Adulto JovemRESUMO
This Viewpoint provides recommendations and stakeholder actions to support safe and equitable use of artificial intelligence (AI) in pediatric clinical settings.
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Inteligência Artificial , Pediatria , Humanos , CriançaRESUMO
OBJECTIVES: Iron-deficiency anemia (IDA) is a common health problem worldwide, and up to 10% of adult patients with incidental IDA may have gastrointestinal cancer. A diagnosis of IDA can be established through a combination of laboratory tests, but it is often underrecognized until a patient becomes symptomatic. Based on advances in machine learning, we hypothesized that we could reduce the time to diagnosis by developing an IDA prediction model. Our goal was to develop 3 neural networks by using retrospective longitudinal outpatient laboratory data to predict the risk of IDA 3 to 6 months before traditional diagnosis. METHODS: We analyzed retrospective outpatient electronic health record data between 2009 and 2020 from an academic medical center in northern Texas. We included laboratory features from 30,603 patients to develop 3 types of neural networks: artificial neural networks, long short-term memory cells, and gated recurrent units. The classifiers were trained using the Adam Optimizer across 200 random training-validation splits. We calculated accuracy, area under the receiving operating characteristic curve, sensitivity, and specificity in the testing split. RESULTS: Although all models demonstrated comparable performance, the gated recurrent unit model outperformed the other 2, achieving an accuracy of 0.83, an area under the receiving operating characteristic curve of 0.89, a sensitivity of 0.75, and a specificity of 0.85 across 200 epochs. CONCLUSIONS: Our results showcase the feasibility of employing deep learning techniques for early prediction of IDA in the outpatient setting based on sequences of laboratory data, offering a substantial lead time for clinical intervention.
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Anemia Ferropriva , Aprendizado Profundo , Humanos , Anemia Ferropriva/diagnóstico , Estudos Retrospectivos , Feminino , Pessoa de Meia-Idade , Masculino , Adulto , Idoso , Redes Neurais de Computação , Diagnóstico Precoce , Registros Eletrônicos de Saúde , Sensibilidade e EspecificidadeRESUMO
OBJECTIVES: To evaluate usability of and clinician satisfaction with the electronic health record (EHR) in the context of caring for children with medical complexity (CMC) at a large academic pediatric hospital and to identify key areas for targeted improvements. METHODS: Cross-sectional study of pediatric faculty and advanced practice providers across several pediatric specialties using an online Research Electronic Data Capture survey. EHR usability was measured with 6 validated questions from the National Usability-Focused Health Information System Scale, and satisfaction with common EHR functionalities was measured with 6 original Likert-scale questions and 3 free-text questions. Results were analyzed with bivariate testing. RESULTS: More than half of providers completed the survey (n = 81, response rate 56%). When asked 6 positively-phrased, validated usability questions, a majority of respondents either agreed or were neutral. Respondents were most dissatisfied with information quality of the summary view and most satisfied with physician communication. Older respondents were less satisfied with EHR usability (P < .01). Focusing on functionalities needed for CMC, the majority of respondents were dissatisfied with the chart review process. More respondents were dissatisfied with order entry (P = .002) and documentation (P = .017) when caring for CMC compared with caring for other patients. The most cited challenges were locating recent patient data, performing an accurate medication reconciliation, and lack of specialized documentation templates. CONCLUSIONS: Clinicians are less satisfied with common EHR functionalities when caring for CMC compared with caring for all other patients. Targeted interventions to improve usability and common EHR functionalities for CMC are necessary to improve the user experience.
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Comunicação , Registros Eletrônicos de Saúde , Humanos , Criança , Estudos Transversais , Documentação , DocentesRESUMO
Structured patient data play a key role in all types of clinical research. They are often collected in study databases for research purposes. In order to describe characteristics of a next-generation study database and assess the feasibility of its implementation a proof-of-concept study in a German university hospital was performed. Key characteristics identified include FAIR access to electronic case report forms (eCRF), regulatory compliant Electronic Data Capture (EDC), an EDC with electronic health record (EHR) integration, scalable EDC for medical documentation, patient generated data, and clinical decision support. In a local case study, we then successfully implemented a next-generation study database for 19 EDC systems (n = 2217 patients) that linked to i.s.h.med (Oracle Cerner) with the local EDC system called OpenEDC. Desiderata of next-generation study databases for patient data were identified from ongoing local clinical study projects in 11 clinical departments at Heidelberg University Hospital, Germany, a major tertiary referral hospital. We compiled and analyzed feature and functionality requests submitted to the OpenEDC team between May 2021 and July 2023. Next-generation study databases are technically and clinically feasible. Further research is needed to evaluate if our approach is feasible in a multi-center setting as well.
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Direct Secure Messaging (DSM) is a sender-initiated communication technology for exchanging patient-specific information among clinicians and disparate healthcare organizations. As DSM adoption increases it becomes more difficult for clinicians and staff to manage the volume and variety of external data received. This can lead to information hazards that can produce cognitive overload and decrease the ability of clinicians to process patient data when reviewing multiple sources. While DSM is one of many options for electronically exchanging health information, we have found that poor user awareness of DSM features and variable EHR capabilities for sending, receiving, and managing messages and their contents demonstrate that additional work is needed to achieve DSM's potential as a low-barrier, ubiquitous option for clinical interoperability. This paper reviews these problems from end-user perspective and offers best-practices for both senders and recipients of DSM.
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Prática de Grupo , Humanos , Tecnologia da Informação , Fluxo de TrabalhoRESUMO
BACKGROUND: In 2011, the American Board of Medical Specialties established clinical informatics (CI) as a subspecialty in medicine, jointly administered by the American Board of Pathology and the American Board of Preventive Medicine. Subsequently, many institutions created CI fellowship training programs to meet the growing need for informaticists. Although many programs share similar features, there is considerable variation in program funding and administrative structures. OBJECTIVES: The aim of our study was to characterize CI fellowship program features, including governance structures, funding sources, and expenses. METHODS: We created a cross-sectional online REDCap survey with 44 items requesting information on program administration, fellows, administrative support, funding sources, and expenses. We surveyed program directors of programs accredited by the Accreditation Council for Graduate Medical Education between 2014 and 2021. RESULTS: We invited 54 program directors, of which 41 (76%) completed the survey. The average administrative support received was $27,732/year. Most programs (85.4%) were accredited to have two or more fellows per year. Programs were administratively housed under six departments: Internal Medicine (17; 41.5%), Pediatrics (7; 17.1%), Pathology (6; 14.6%), Family Medicine (6; 14.6%), Emergency Medicine (4; 9.8%), and Anesthesiology (1; 2.4%). Funding sources for CI fellowship program directors included: hospital or health systems (28.3%), clinical departments (28.3%), graduate medical education office (13.2%), biomedical informatics department (9.4%), hospital information technology (9.4%), research and grants (7.5%), and other sources (3.8%) that included philanthropy and external entities. CONCLUSION: CI fellowships have been established in leading academic and community health care systems across the country. Due to their unique training requirements, these programs require significant resources for education, administration, and recruitment. There continues to be considerable heterogeneity in funding models between programs. Our survey findings reinforce the need for reformed federal funding models for informatics practice and training.