Algorithms identifying low-acuity emergency department visits: A review and validation study.

OBJECTIVE: To characterize and validate the landscape of algorithms that use International Classification of Disease (ICD) codes to identify low-acuity emergency department (ED) visits. DATA SOURCES: Publicly available ED data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). STUDY DESIGN: We systematically searched for studies that specify algorithms consisting of ICD codes that identify preventable or low-acuity ED visits. We classified ED visits in NHAMCS according to these algorithms and compared agreements using the Jaccard index. We then evaluated the performance of each algorithm using positive predictive value (PPV) and sensitivity, with the reference group specified using low-acuity composite (LAC) criteria consisting of both triage and clinical components. In sensitivity analyses, we repeated our primary analysis using only triage or only clinical criteria for reference. DATA COLLECTION: We used the 2011-2017 NHAMCS data, totaling 163,576 observations before survey weighting and after dropping observations missing a primary diagnosis. We translated ICD-9 codes (years 2011-2015) to ICD-10 using a standard crosswalk. PRINCIPAL FINDINGS: We identified 15 papers with an original list of ICD codes used to identify preventable or low-acuity ED presentations. These papers were published between 1992 and 2020, cited an average of 310 (SD 360) times, and included 968 (SD 1175) codes. Pairwise Jaccard similarity indices (0 = no overlap, 1 = perfect congruence) ranged from 0.01 to 0.82, with mean 0.20 (SD 0.13). When validated against the LAC reference group, the algorithms had an average PPV of 0.308 (95% CI [0.253, 0.364]) and sensitivity of 0.183 (95% CI [0.111, 0.256]). Overall, 2.1% of visits identified as low acuity by the algorithms died prehospital or in the ED, or needed surgery, critical care, or cardiac catheterization. CONCLUSIONS: Existing algorithms that identify low-acuity ED visits lack congruence and are imperfect predictors of visit acuity.

Disruptions in preventive care: Mammograms during the COVID-19 pandemic.

OBJECTIVE: To measure the extent to which the provision of mammograms was impacted by the COVID-19 pandemic and surrounding guidelines. DATA SOURCES: De-identified summary data derived from medical claims and eligibility files were provided by Independence Blue Cross for women receiving mammograms. STUDY DESIGN: We used a difference-in-differences approach to characterize the change in mammograms performed over time and a queueing formula to estimate the time to clear the queue of missed mammograms. DATA COLLECTION: We used data from the first 30 weeks of each year from 2018 to 2020. PRINCIPAL FINDINGS: Over the 20 weeks following March 11, 2020, the volume of screening mammograms and diagnostic mammograms fell by 58% and 38% of expected levels, on average. Lowest volumes were observed in week 15 (April 8 to 14), when screening and diagnostic mammograms fell by 99% and 74%, respectively. Volumes began to rebound in week 19 (May), with diagnostic mammograms reaching levels to similar to previous years' and screening mammograms remaining 14% below expectations. We estimate it will take a minimum of 22 weeks to clear the queue of missed mammograms in our study sample. CONCLUSIONS: The provision of mammograms has been significantly disrupted due to the COVID-19 pandemic.

Patient experiences of decision-making in the treatment of spinal metastases: a qualitative study.

BACKGROUND: In the treatment of spinal metastases the risks of surgery must be balanced against potential benefits, particularly in light of limited life-expectancy. Patient experiences and preferences regarding decision-making in this context are not well explored. PURPOSE: We performed a qualitative study involving patients receiving treatment for spinal metastatic disease. We sought to understand factors that influenced decision-making around care for spinal metastases. STUDY SETTING: Three tertiary academic medical centers. PATIENT SAMPLE: We recruited patients presenting for treatment of spinal metastatic disease at one of three tertiary centers in Boston, MA. OUTCOME MEASURES: We conducted semistructured interviews using a guide that probed participants' experiences with making treatment decisions. METHODS: We performed a thematic analysis that produced a list of themes, subthemes, and statement explaining how the themes related to the study's guiding questions. Patients were recruited until thematic saturation was reached. RESULTS: We interviewed 23 participants before reaching thematic saturation. The enormity of treatment decisions, and of the diagnosis of spinal metastases itself, shaped participant preferences for who should take responsibility for the decision and whether to accept treatments bearing greater risk of complications. Pre-existing participant beliefs about decision-making and about surgery interacted with the clinical context in a way that tended to promote accepting physician recommendations and delaying or avoiding surgery. CONCLUSIONS: The diagnosis of spinal metastatic disease played an outsized role in shaping participant preferences for agency in treatment decision-making. Further research should address strategies to support patient understanding of treatment options in clinical contexts-such as spinal metastases-characterized by ominous underlying disease and high-risk, often urgent interventions.

Ambulatory status after surgical and nonsurgical treatment for spinal metastasis.

BACKGROUND: Decisions for operative or nonoperative management remain challenging for patients with spinal metastases, especially when life expectancy and quality of life are not easily predicted. This study evaluated the effects of operative and nonoperative management on maintenance of ambulatory function and survival for patients treated for spinal metastases. METHODS: Propensity matching was used to yield an analytic sample in which operatively and nonoperatively treated patients were similar with respect to key baseline covariates. The study included patients treated for spinal metastases between 2005 and 2017 who were 40 to 80 years old, were independent ambulators at presentation, and had fewer than 5 medical comorbidities. It evaluated the influence of operative care and nonoperative care on ambulatory function 6 months after presentation as the primary outcome. Survival at 6 months and survival at 1 year were secondary outcomes. RESULTS: Nine hundred twenty-nine individuals eligible for inclusion were identified, with 402 (201 operative patients and 201 nonoperative patients) retained after propensity score matching. Patients treated operatively had a lower likelihood than those treated nonoperatively of being nonambulatory 6 months after presentation (3% vs 16%; relative risk [RR], 0.16; 95% confidence interval [CI], 0.06-0.46) as well as a reduced risk of 6-month mortality (20% vs 29%; RR, 0.69; 95% CI, 0.49-0.98). CONCLUSIONS: These results indicate that in a group of patients with similar demographic and clinical characteristics, those treated operatively were less likely to lose ambulatory function 6 months after presentation than those managed nonoperatively. For patients with spinal metastases, our data can be incorporated into discussions about the treatments that align best with patients' preferences regarding surgical risk, mortality, and ambulatory status.

The TeMPO trial (treatment of meniscal tears in osteoarthritis): rationale and design features for a four arm randomized controlled clinical trial.

BACKGROUND: Meniscal tears often accompany knee osteoarthritis, a disabling condition affecting 14 million individuals in the United States. While several randomized controlled trials have compared physical therapy to surgery for individuals with knee pain, meniscal tear, and osteoarthritic changes (determined via radiographs or magnetic resonance imaging), no trial has evaluated the efficacy of physical therapy alone in these subjects. METHODS: The Treatment of Meniscal Tear in Osteoarthritis (TeMPO) Trial is a four-arm multi-center randomized controlled clinical trial designed to establish the comparative efficacy of two in-clinic physical therapy interventions (one focused on strengthening and one containing placebo) and two protocolized home exercise programs. DISCUSSION: The goal of this paper is to present the rationale behind TeMPO and describe the study design and implementation strategies, focusing on methodologic and clinical challenges. TRIAL REGISTRATION: The TeMPO Trial was first registered at clinicaltrials.gov with registration No. NCT03059004 . on February 14, 2017.