Test results pending at discharge among emergency department patients experiencing homelessness.

BACKGROUND: Persons experiencing homelessness (PEH) are vulnerable emergency department (ED) patients due to high rates of multi-comorbidity and mortality, as well as a lack of follow up care. Communication of test results pending at discharge (TPAD) is an important area of post-ED follow up care. We examined phone access, successful contact, and change in treatment among PEH and non-PEH with TPAD from the ED. METHODS: We performed a retrospective cohort study and included all abnormal TPAD and patient telephone notes regarding TPAD over 7 months extracted from the electronic health record of a single, high-volume, urban, safety-net hospital in Denver, Colorado. Two investigators reviewed all data to determine phone access, successful contact, and recommended treatment change. Descriptive statistics were calculated for all variables and compared between PEH and non-PEH. We assessed associations between homelessness and successful contact and phone access while adjusting for age and sex using multivariable logistic regression. RESULTS: A total of 940 patient encounters with TPAD were included. 142 telephone notes regarding abnormal TPAD were included, of which 33 (23 %) were to PEH. Compared to PEH, housed patients were significantly more likely to have access to a phone (+31 %, 95 % CI: 14-48 %), have an active phone (+46 %, 95 % CI: 29-64 %), and be successfully contacted (+42 %, 95 % CI: 24-60 %), but were less likely to have a recommended change in treatment (-14 %, 95 % CI: -24 to -5 %). Homelessness was significantly associated with decreased successful contact (odds ratio [OR] 0.16, 95 % CI: 0.07-0.38) and decreased phone access (OR 0.11, 95 % CI: 0.04-0.33) after adjusting for age and sex. In the subgroup of patients with phone access (n = 124), homelessness was significantly associated with decreased successful contact (OR 0.26, 95 % CI: 0.10-0.70) after adjusting for age and sex. CONCLUSION: PEH are less likely to have phone access and be successfully contacted regarding TPAD, resulting in untreated or improperly treated infectious disease. Thus, EDs and hospital systems should explore innovative communication solutions, such as shared responsibility models and partnerships with shelters and healthcare for the homeless clinics to improve successful contact with PEH regarding TPAD.

Cost-Effectiveness of HIV Screening in Emergency Departments: Results From the Pragmatic Randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments Trial.

STUDY OBJECTIVE: Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial. METHODS: This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed. RESULTS: The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests. CONCLUSION: Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

Practical Guide to Survey Research in Surgical Education.

This Guide to Statistics and Methods describes aspects of methods of survey research in surgical education, important considerations, and pitfalls and limitations.

Practical Guide to Pragmatic Clinical Trials in Surgical Education Research.

This Guide to Statistics and Methods provides an overview of the key features of pragmatic trials within the context of surgical education research using examples from the Flexibility in Duty-Hour Requirements for Surgical Trainees trial.

Practical Guide to Education Program Evaluation Research.

This Guide to Statistics and Methods describes common methods for building evidence of validity for a program within health professional education and provides a framework for program evaluation.

Adding age-adjusted shock index to the American College of Surgeons' trauma team activation criteria to predict severe injury in children.

BACKGROUND: The American College of Surgeons (ACS) requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation. Our goal was to evaluate the effect of adding age-adjusted shock index (SI) to the ACS-6 for the prediction of severe injury among pediatric trauma patients with the hypothesis that SI would significantly improve sensitivity with an acceptable decrease in specificity. METHODS: We performed a secondary analysis of prospectively collected EMS and trauma registry data from two urban pediatric trauma centers. Age-adjusted SI thresholds were calculated as heart rate divided by systolic blood pressure using 2020 Pediatric Advanced Life Support SI vital sign ranges and previously published Shock Index, Pediatric Adjusted (SIPA) thresholds. The primary outcome was a composite of emergency operative (within 1 hour of arrival) or emergency procedural intervention (EOPI) or Injury Severity Score (ISS) greater than 15. Sensitivities, specificities, and 95% CIs were calculated for the ACS-6 alone and in combination with age-adjusted SI. RESULTS: There were 8,078 patients included; 20% had an elevated age-adjusted SI and 17% met at least one ACS minimum criterion; 1% underwent EOPI; and 17% had ISS >15. Sensitivity and specificity of the ACS-6 for EOPI or ISS > 5 were 45% (95% confidence interval [CI], 41-50%) and 89% (95% CI, 81-96%). Inclusion of Pediatric Advanced Life Support-SI and SIPA resulted in sensitivities of 51% (95% CI, 47-56%) and 69% (95% CI, 65-72%), and specificities of 80% (95% CI, 71-89%) and 60% (95% CI, 53-68%), respectively. Similar trends were seen for each secondary outcome. CONCLUSION: In this cohort of pediatric trauma registry patients, the addition of SIPA to the ACS-6 for trauma team activation resulted in significantly increased sensitivity for EOPI or ISS greater than 15 but poor specificity. Future investigation should explore using age-adjusted shock index in a two-tiered trauma activation system, or in combination with novel triage criteria, in a population-based cohort. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level II.

The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial: rationale and design of an emergency department-based randomized clinical trial of linkage-to-care strategies for hepatitis C.

BACKGROUND: Hepatitis C (HCV) poses a major public health problem in the USA. While early identification is a critical priority, subsequent linkage to a treatment specialist is a crucial step that bridges diagnosed patients to treatment, cure, and prevention of ongoing transmission. Emergency departments (EDs) serve as an important clinical setting for HCV screening, although optimal methods of linkage-to-care for HCV-diagnosed individuals remain unknown. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial. METHODS: The DETECT Hep C Linkage-to-Care Trial will be a single-center prospective comparative effectiveness randomized two-arm parallel-group superiority trial to test the effectiveness of linkage navigation and clinician referral among ED patients identified with untreated HCV with a primary hypothesis that linkage navigation plus clinician referral is superior to clinician referral alone when using treatment initiation as the primary outcome. Participants will be enrolled in the ED at Denver Health Medical Center (Denver, CO), an urban, safety-net hospital with approximately 75,000 annual adult ED visits. This trial was designed to enroll a maximum of 280 HCV RNA-positive participants with one planned interim analysis based on methods by O'Brien and Fleming. This trial will further inform the evaluation of cost effectiveness, disparities, and social determinants of health in linkage-to-care, treatment, and disease progression. DISCUSSION: When complete, the DETECT Hep C Linkage-to-Care Trial will significantly inform how best to perform linkage-to-care among ED patients identified with HCV. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04026867 Original date: July 1, 2019 URL: https://clinicaltrials.gov/ct2/show/NCT04026867.

Practical Guide to Surgical Clinical Trial Implementation, Oversight, and Regulatory Aspects.

This Guide to Statistics and Methods describes the steps necessary for a successful trial implementation that can safeguard credible results and conclusions while minimizing potential harm.

Practical Guide to Clinical Trial Publication.

This Guide to Statistics and Methods describes the process for publishing about a clinical trial by planning its clinical relevance, knowing the audience, and following reporting guidelines.

Practical Guide to Adjuncts to Clinical Trials in Surgery.

This Guide to Statistics and Methods discusses adjunct outcome parameters that optimize patient-centered, timely, efficient, and equitable components in randomized clinical trials.

Practical Guide to Design Choice of Randomized Clinical Trials in Surgery.

This Guide to Statistics and Methods provides an overview of the strengths and weaknesses of several randomized clinical trial design options.

Development of a clinical prediction instrument to estimate risk of initial violent injury.

BACKGROUND: Interpersonal violent injury is a public health crisis, disproportionately affecting young people of color. We aimed to evaluate associations between sociobehavioral predictors and first-time violent injury, and to develop a predictive risk score for violent injury. METHODS: We performed a retrospective case-cohort study of adolescents aged 12-18 years. Multivariable logistic regression was used to estimate associations between 35 candidate variables and interpersonal first-time violent injury resulting in an emergency department (ED) visit. Multiple imputation was used to account for missing values and a risk score was developed by multiplying regression coefficients by 10 to generate a composite tool to predict initial violent injury (IVI). Discrimination and calibration were assessed using 10-fold cross validation. RESULTS: 19,210 adolescents were included, 276 (1.4%) as victims of IVI. The final model, the Initial Violent Injury Risk Prediction Tool (IVI-RPT), included: age, fight within the prior year, trouble with the law, and alcohol use. IVI-RPT scores were categorized as: 0-7 (low risk), 8-16 (moderate), and 17-26 (high), and IVI prevalence was 0.8% (95% confidence interval [CI]: 0.6%, 0.9%), 2.5% (95% CI: 1.9%, 3.1%), and 5.3% (95% CI: 4.1%, 6.6%), respectively. The area under the receiver operating characteristic curve was 0.70 (95% CI: 0.66, 0.73), while the slope of the calibration curve was 1.1 (95% CI: 0.9, 1.2). CONCLUSIONS: We developed a promising clinical prediction instrument, the IVI-RPT, that categorizes individuals into risk groups with increasing probabilities of violent injury. External validation of this tool is required prior to clinical practice implementation.