Implementation of the Canadian CT Head Rule and Its Association With Use of Computed Tomography Among Patients With Head Injury.

STUDY OBJECTIVE: Approximately 1 in 3 computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the association of implementation of the Canadian CT Head Rule on head CT imaging in community emergency departments (EDs). METHODS: We conducted an interrupted time-series analysis of encounters from January 2014 to December 2015 in 13 Southern California EDs. Adult health plan members with a trauma diagnosis and Glasgow Coma Scale score at ED triage were included. A multicomponent intervention included clinical leadership endorsement, physician education, and integrated clinical decision support. The primary outcome was the proportion of patients receiving a head CT. The unit of analysis was ED encounter, and we compared CT use pre- and postintervention with generalized estimating equations segmented logistic regression, with physician as a clustering variable. Secondary analysis described the yield of identified head injuries pre- and postintervention. RESULTS: Included were 44,947 encounters (28,751 preintervention and 16,196 postintervention), resulting in 14,633 (32.6%) head CTs (9,758 preintervention and 4,875 postintervention), with an absolute 5.3% (95% confidence interval [CI] 2.5% to 8.1%) reduction in CT use postintervention. Adjusted pre-post comparison showed a trend in decreasing odds of imaging (odds ratio 0.98; 95% CI 0.96 to 0.99). All but one ED reduced CTs postintervention (0.3% to 8.7%, one ED 0.3% increase), but no interaction between the intervention and study site over time existed (P=.34). After the intervention, diagnostic yield of CT-identified intracranial injuries increased by 2.3% (95% CI 1.5% to 3.1%). CONCLUSION: A multicomponent implementation of the Canadian CT Head Rule was associated with a modest reduction in CT use and an increased diagnostic yield of head CTs for adult trauma encounters in community EDs.

Use of posttreatment imaging and biomarkers in survivors of early-stage breast cancer: Inappropriate surveillance or necessary care?

BACKGROUND: Advanced imaging and serum biomarkers are commonly used for surveillance in patients with early-stage breast cancer, despite recommendations against this practice. Incentives to perform such low-value testing may be less prominent in integrated health care delivery systems. The purpose of the current study was to evaluate and compare the use of these services within 2 integrated systems: Kaiser Permanente (KP) and Intermountain Healthcare (IH). The authors also sought to distinguish the indication for testing: diagnostic purposes or routine surveillance. METHODS: Patients with American Joint Committee on Cancer stage 0 to II breast cancer diagnosed between 2009 and 2010 were identified and the use of imaging and biomarker tests over an 18-month period were quantified, starting at 1 year after diagnosis. Chart abstraction was performed on a random sample of patients who received testing to identify the indication for testing. Multivariate regression was used to explore associations with the use of nonrecommended care. RESULTS: A total of 6585 patients were identified; 22% had stage 0 disease, 44% had stage I disease, and 34% had stage II disease. Overall, 24% of patients received at least 1 imaging test (25% at KP vs 22% at IH; P = .009) and 28% of patients received at least 1 biomarker (36% at KP vs 13% at IH; P<.001). Chart abstraction revealed that 84% of imaging tests were performed to evaluate symptoms or signs. Virtually all biomarkers were ordered for routine surveillance. Stage of disease, medical center that provided the services, and provider experience were found to be significantly associated with the use of biomarkers. CONCLUSIONS: Advanced imaging was most often performed for appropriate indications, but biomarkers were used for nonrecommended surveillance. Distinguishing between inappropriate use for surveillance and appropriate diagnostic testing is essential when evaluating adherence to recommendations.

Recent Trends in the Identification of Incidental Pulmonary Nodules.

RATIONALE: Pulmonary nodules are common incidental findings, but information about their incidence in the era of computed tomography (CT) is lacking. OBJECTIVES: To examine recent trends in pulmonary nodule identification. METHODS: We used electronic health records and natural language processing to identify members of an integrated health system who had nodules measuring 4 to 30 mm. We calculated rates of chest CT imaging, nodule identification, and receipt of a new lung cancer diagnosis within 2 years of nodule identification, and standardized rates by age and sex to estimate the frequency of nodule identification in the U.S. population in 2010. MEASUREMENTS AND MAIN RESULTS: Between 2006 and 2012, more than 200,000 adult members underwent 415,581 chest CT examinations. The annual frequency of chest CT imaging increased from 1.3 to 1.9% for all adult members, whereas the frequency of nodule identification increased from 24 to 31% for all scans performed. The annual rate of chest CT increased from 15.4 to 20.7 per 1,000 person-years, and the rate of nodule identification increased from 3.9 to 6.6 per 1,000 person-years, whereas the rate of a new lung cancer diagnosis remained stable. By extrapolation, more than 4.8 million Americans underwent at least one chest CT scan and 1.57 million had a nodule identified, including 63,000 who received a new lung cancer diagnosis within 2 years. CONCLUSIONS: Incidental pulmonary nodules are an increasingly common consequence of routine medical care, with an incidence that is much greater than recognized previously. More frequent nodule identification has not been accompanied by increases in the diagnosis of cancerous nodules.

Integrating qualitative research methods into care improvement efforts within a learning health system: addressing antibiotic overuse.

BACKGROUND: Despite reports advocating for integration of research into healthcare delivery, scant literature exists describing how this can be accomplished. Examples highlighting application of qualitative research methods embedded into a healthcare system are particularly needed. This article describes the process and value of embedding qualitative research as the second phase of an explanatory, sequential, mixed methods study to improve antibiotic stewardship for acute sinusitis. METHODS: Purposive sampling of providers for in-depth interviews improved understanding of unwarranted antibiotic prescribing and elicited stakeholder recommendations for improvement. Qualitative data collection, transcription and constant comparative analyses occurred iteratively. RESULTS: Emerging themes and sub-themes identified primary drivers of unwarranted antibiotic prescribing patterns and recommendations for improving practice. These findings informed the design of a health system intervention to improve antibiotic stewardship for acute sinusitis. Core components of the intervention are also described. CONCLUSION: Qualitative research can be effectively applied in learning healthcare systems to elucidate quantitative results and inform improvement efforts.

Clinical course and long-term follow-up of patients receiving implantable cardioverter-defibrillators.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) are increasingly used for primary and secondary prevention of sudden cardiac death. Defibrillators were introduced into clinical practice in 1980. Since that time, factors affecting long-term survival and the natural history of defibrillator patients have not been described. OBJECTIVES: The purpose of this study was to identify clinical predictors of long-term survival in patients receiving ICDs. METHODS: The prognostic value of several clinical variables on the likelihood of survival or appropriate ICD therapy in 1,382 consecutive patients receiving ICDs from 1980 to 2003 were evaluated. Data were collected at the time of device implantation, and follow-up was completed through March 2005. RESULTS: In 70 +/- 51 months of follow-up (range 0-282 months), 792 patients died and 421 patients received appropriate ICD therapy at least once. Age, left ventricular ejection fraction, New York Heart Association (NYHA) functional class, Charlson comorbidity index, and antiarrhythmic drug use correlated with mortality. beta-Blocker and angiotensin-converting enzyme inhibitor use was associated with improved survival. Only NYHA functional class correlated with ICD therapy. Patients free of shocks for the first 5 years after ICD implantation had continued risk of arrhythmia recurrence. CONCLUSION: The heart failure characteristics of patients predicted ICD shock probability and survival better than the arrhythmia characteristics or the underlying heart disease. Antiarrhythmic drug use was associated with increased mortality. Beta-blocker and angiotensin-converting enzyme inhibitor use was associated with improved survival. A measurable arrhythmic risk even after prolonged shock-free intervals indicates the need for continued ICD therapy in all patients with appropriate ICD indications.

Low-value care for acute sinusitis encounters: who's choosing wisely?

OBJECTIVES: To assess acute sinusitis (AS) encounters in primary care (PC), urgent care (UC), and emergency department (ED) settings for adherence to recommendations to avoid low-value care. STUDY DESIGN: A retrospective, observational study of adult AS encounters (2010-2012) within a large integrated healthcare system. METHODS: We compared ED and UC encounters with PC visits, adjusting for differences in patient characteristics. PRIMARY OUTCOMES: adherence to recommendations to avoid antibiotics and a computed tomography (CT) scan of the face, head, or sinuses. SECONDARY OUTCOMES: length of symptoms and adherence with AS recommendations. RESULTS: Of 152,774 AS encounters, 89.2% resulted in antibiotics and 1.1% resulted in a CT scan. Compared with PC encounters, ED encounters were less likely to result in antibiotics (adjusted odds ratio [AOR], 0.57; 95% CI, 0.50-0.65) but more likely to result in a CT scan (AOR, 59.4; 95% CI, 51.3-68.7), while UC encounters were more likely to result in both antibiotics (AOR, 1.12; 95% CI, 1.08-1.17) and CT imaging (AOR, 2.4; 95% CI, 2.1-2.7). Chart review of encounters resulting in antibiotics found that 50% were inappropriately prescribed for symptoms of ≤7 days' duration (95% CI, 41%-58%), while 35% were appropriately prescribed for symptoms of ≥14 days' duration (95% CI, 27%-44%). Only 29% (95% CI, 22%-36%) of encounters were consistent with guideline-adherent care. CONCLUSIONS: AS encounters in an integrated health system infrequently result in CT imaging, but antibiotic treatment is common. Differences exist across acute care settings, but improved antibiotic stewardship is needed in all settings.

Use of imaging for staging of early-stage breast cancer in two integrated health care systems: adherence with a choosing wisely recommendation.

PURPOSE: Advanced imaging is commonly used for staging of early-stage breast cancer, despite recommendations against this practice. The objective of this study was to evaluate and compare use of imaging for staging of breast cancer in two integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was routine or used for diagnostic purposes. METHODS: We identified patients with stages 0 to IIB breast cancer diagnosed between 2010 and 2012. Using KP and IH electronic health records, we identified use of computed tomography, positron emission tomography, or bone scintigraphy 30 days before diagnosis to 30 days postsurgery. We performed chart abstraction on a random sample of patients who received a presurgical imaging test to identify indication. RESULTS: For the sample of 10,010 patients, mean age at diagnosis was 60 years (range, 22 to 99 years); with 21% stage 0, 47% stage I, and 32% stage II. Overall, 15% of patients (n = 1,480) received at least one imaging test during the staging window, 15% at KP and 14% at IH (P = .5). Eight percent of patients received imaging before surgery, and 7% postsurgery. We found significant intraregional variation in imaging use. Chart abstraction (n = 129, 16% of patients who received presurgical imaging) revealed that 48% of presurgical imaging was diagnostic. CONCLUSION: Use of imaging for staging of low-risk breast cancer was similar in both systems, and slightly lower than has been reported in the literature. Approximately half of imaging tests were ordered in response to a sign or symptom.

Impact of diabetes mellitus on treatment outcomes of patients with active tuberculosis.

Diabetes mellitus (DM) is an emerging chronic health condition of developed and developing countries. We conducted a retrospective cohort study of patients with active, culture-confirmed tuberculosis (TB) in Maryland to determine the impact of DM on TB treatment outcomes. Of 297 TB patients, 42 (14%) had DM. Patients with diabetes had 2.0 times higher odds of death than patients without diabetes (95% confidence interval [CI] 0.74-5.2, P = 0.18). Adjusting for human immunodeficiency virus (HIV), age, weight, and foreign birth, the odds of death were 6.5 times higher in patients with diabetes than patients without diabetes (95% CI 1.1-38.0, P = 0.039). In pulmonary TB patients, time to sputum culture conversion was longer in patients with diabetes than patients without diabetes (median 49 versus 39 days, P = 0.09). Two-month culture conversion proportions were similar (70% and 69%). Treatment failure occurred in 4.1% of patients without diabetes and 6.7% of patients with diabetes (P = 0.51). In conclusion, DM was a risk factor for death in Maryland TB patients. There was a trend toward increased time to culture conversion; two-month culture conversion proportions, however, were similar.

First case of infant botulism caused by Clostridium baratii type F in California.

In late 2003 a severely hypotonic neonate, just 38 h old at onset of illness, was found to have infant botulism caused by neurotoxigenic Clostridium baratii type F. Environmental investigations failed to identify a source of this strain. This is the youngest patient reported to have infant botulism and the fifth instance of infant botulism caused by C. baratii type F.