Clinical Decision Support for Surgery: A Mixed Methods Study on Design and Implementation Perspectives From Urologists.

OBJECTIVE: To assess urologist attitudes toward clinical decision support (CDS) embedded into the electronic health record (EHR) and define design needs to facilitate implementation and impact. With recent advances in big data and artificial intelligence (AI), enthusiasm for personalized, data-driven tools to improve surgical decision-making has grown, but the impact of current tools remains limited. METHODS: A sequential explanatory mixed methods study from 2019 to 2020 was performed. First, survey responses from the 2019 American Urological Association Annual Census evaluated attitudes toward an automatic CDS tool that would display risk/benefit data. This was followed by the purposeful sampling of 25 urologists and qualitative interviews assessing perspectives on CDS impact and design needs. Bivariable, multivariable, and coding-based thematic analysis were applied and integrated. RESULTS: Among a weighted sample of 12,366 practicing urologists, the majority agreed CDS would help decision-making (70.9%, 95% CI 68.7%-73.2%), aid patient counseling (78.5%, 95% CI 76.5%-80.5%), save time (58.1%, 95% CI 55.7%-60.5%), and improve patient outcomes (42.9%, 95% CI 40.5%-45.4%). More years in practice was negatively associated with agreement (P <.001). Urologists described how CDS could bolster evidence-based care, personalized medicine, resource utilization, and patient experience. They also identified multiple implementation barriers and provided suggestions on form, functionality, and visual design to improve usefulness and ease of use. CONCLUSION: Urologists have favorable attitudes toward the potential for clinical decision support in the EHR. Smart design will be critical to ensure effective implementation and impact.

Pregnancy and Emergency Department Utilization in North Carolina, 2016-2021: A Population-Based Surveillance Study.

Introduction: Pregnancy-associated complaints are a common reason for emergency department visits for women of reproductive age. Emergency department utilization during pregnancy is associated with worse birth outcomes for both mothers and infants. We used statewide North Carolina emergency department surveillance data between 2016 and 2021 to describe the sociodemographic factors associated with the use of emergency department for pregnancy-associated problems and subsequent hospital admission. Methods: North Carolina Disease Event Tracking and Epidemiologic Collection Tool is a syndromic surveillance system that includes all emergency department encounters at civilian acute-care facilities in North Carolina. We analyzed all emergency department visits between January 1, 2016 and December 31, 2021 for female patients aged 15-44 years residing in North Carolina with at least 1 ICD-10-CM code (analysis occurred in July 2021-October 2022). Each emergency department visit was categorized as pregnancy-associated if assigned ICD-10-CM code(s) indicated pregnancy. We stratified visits by age, race, ethnicity, county of residence, and insurance and compared them with estimated pregnant population proportions using 1-sample t-tests. We used multivariable logistic regression to determine whether pregnancy-associated visits were more likely to be associated with hospital admission and then to determine sociodemographic predictors of admission among pregnancy-associated emergency department visits. Results: More than 6.4 million emergency department visits were included (N=6,471,197); 10.1% (n=655,476) were pregnancy-associated, significantly higher than the proportion of women estimated to be pregnant at any given time in North Carolina (4.6%, p<0.0001) and increased over time (8.6% in 2016 vs 11.1% in 2021, p<0.0001). Pregnancy-associated visits were lower than expected for ages 25-44 years and higher than expected for those aged 15-24 years, for those of Black race, and for patients residing in rural or suburban areas. The proportion admitted was higher for pregnancy-associated emergency department visits than for nonpregnancy associated (15.6% vs 7.0%, AOR=3.06 [95% CI=3.03, 3.09]). Pregnancy-associated emergency department visits for patients of Black race had 0.58 times (95% CI=0.57, 0.59) the odds of admission compared with White patients. Conclusions: Emergency department utilization during pregnancy is common. The proportion of pregnancy-associated emergency department visits among reproductive-age women is increasing, as are inpatient admissions from the emergency department for pregnancy-associated diagnoses. Use of public health surveillance databases such as the North Carolina Disease Event Tracking and Epidemiologic Collection Tool may help identify opportunities for improving disparities in maternal health care, especially related to access to care.