Identifying incarceration status in the electronic health record using large language models in emergency department settings.

Background: Incarceration is a significant social determinant of health, contributing to high morbidity, mortality, and racialized health inequities. However, incarceration status is largely invisible to health services research due to inadequate clinical electronic health record (EHR) capture. This study aims to develop, train, and validate natural language processing (NLP) techniques to more effectively identify incarceration status in the EHR. Methods: The study population consisted of adult patients (≥ 18 y.o.) who presented to the emergency department between June 2013 and August 2021. The EHR database was filtered for notes for specific incarceration-related terms, and then a random selection of 1,000 notes was annotated for incarceration and further stratified into specific statuses of prior history, recent, and current incarceration. For NLP model development, 80% of the notes were used to train the Longformer-based and RoBERTa algorithms. The remaining 20% of the notes underwent analysis with GPT-4. Results: There were 849 unique patients across 989 visits in the 1000 annotated notes. Manual annotation revealed that 559 of 1000 notes (55.9%) contained evidence of incarceration history. ICD-10 code (sensitivity: 4.8%, specificity: 99.1%, F1-score: 0.09) demonstrated inferior performance to RoBERTa NLP (sensitivity: 78.6%, specificity: 73.3%, F1-score: 0.79), Longformer NLP (sensitivity: 94.6%, specificity: 87.5%, F1-score: 0.93), and GPT-4 (sensitivity: 100%, specificity: 61.1%, F1-score: 0.86). Conclusions: Our advanced NLP models demonstrate a high degree of accuracy in identifying incarceration status from clinical notes. Further research is needed to explore their scaled implementation in population health initiatives and assess their potential to mitigate health disparities through tailored system interventions.

Disparities Associated With Electronic Behavioral Alerts for Safety and Violence Concerns in the Emergency Department.

STUDY OBJECTIVE: Although electronic behavioral alerts are placed as an alert flag in the electronic health record to notify staff of previous behavioral and/or violent incidents in emergency departments (EDs), they have the potential to reinforce negative perceptions of patients and contribute to bias. We provide characterization of ED electronic behavioral alerts using electronic health record data across a large, regional health care system. METHODS: We conducted a retrospective cross-sectional study of adult patients presenting to 10 adult EDs within a Northeastern United States health care system from 2013 to 2022. Electronic behavioral alerts were manually screened for safety concerns and then categorized by the type of concern. In our patient-level analyses, we included patient data at the time of the first ED visit where an electronic behavioral alert was triggered or, if a patient had no electronic behavioral alerts, the earliest visit in the study period. We performed a mixed-effects regression analysis to identify patient-level risk factors associated with safety-related electronic behavioral alert deployment. RESULTS: Of the 2,932,870 ED visits, 6,775 (0.2%) had associated electronic behavioral alerts across 789 unique patients and 1,364 unique electronic behavioral alerts. Of the encounters with electronic behavioral alerts, 5,945 (88%) were adjudicated as having a safety concern involving 653 patients. In our patient-level analysis, the median age for patients with safety-related electronic behavioral alerts was 44 years (interquartile range 33 to 55 years), 66% were men, and 37% were Black. Visits with safety-related electronic behavioral alerts had higher rates of discontinuance of care (7.8% vs 1.5% with no alert; P<.001) as defined by the patient-directed discharge, left-without-being-seen, or elopement-type dispositions. The most common topics in the electronic behavioral alerts were physical (41%) or verbal (36%) incidents with staff or other patients. In the mixed-effects logistic analysis, Black non-Hispanic patients (vs White non-Hispanic patients: adjusted odds ratio 2.60; 95% confidence interval [CI] 2.13 to 3.17), aged younger than 45 (vs aged 45-64 years: adjusted odds ratio 1.41; 95% CI 1.17 to 1.70), male (vs female: adjusted odds ratio 2.09; 95% CI 1.76 to 2.49), and publicly insured patients (Medicaid: adjusted odds ratio 6.18; 95% CI 4.58 to 8.36; Medicare: adjusted odds ratio 5.63; 95% CI 3.96 to 8.00 vs commercial) were associated with a higher risk of a patient having at least 1 safety-related electronic behavioral alert deployment during the study period. CONCLUSION: In our analysis, younger, Black non-Hispanic, publicly insured, and male patients were at a higher risk of having an ED electronic behavioral alert. Although our study is not designed to reflect causality, electronic behavioral alerts may disproportionately affect care delivery and medical decisions for historically marginalized populations presenting to the ED, contribute to structural racism, and perpetuate systemic inequities.

Use of Point-of-Care Ultrasound in the Emergency Department: Insights From the 2012 Medicare National Payment Data Set.

OBJECTIVES: Point-of-care ultrasound is a valuable tool with potential to expedite diagnoses and improve patient outcomes in the emergency department. However, little is known about national patterns of adoption. This study examined nationwide point-of-care ultrasound reimbursement among emergency medicine (EM) practitioners and examined regional and practitioner level variations. METHODS: Data from the 2012 Center for Medicare and Medicaid Services Fee-for-Service Provider Utilization and Payment Data include all practitioners who received more than 10 Medicare Part B fee-for-service reimbursements for any Healthcare Common Procedure Coding System code in 2012. Odds ratios (ORs) and descriptive statistics were calculated to assess relationships between ultrasound reimbursement and practice location, nearby presence of an EM residency, and time elapsed since practitioner graduation. RESULTS: Of 52,928 unique EM practitioners, 391 (0.7%) received limited ultrasound reimbursements for a total of 16,389 scans in 2012. Urban counties had an OR of 5.4 (95% confidence interval, 3.8-7.8) for receiving point-of-care ultrasound reimbursements compared to rural counties. Counties with an EM residency had an OR of 84.7 (95% confidence interval, 42.6-178.8) for reimbursement compared to counties without. The OR for receiving reimbursement was independent of medical school graduation year (P = .83); however, recent graduates performed more scans (P = .02). CONCLUSIONS: A small minority of EM practitioners received reimbursements for point-of-care ultrasound from Medicare beneficiaries. These practitioners were more likely to reside in urban and academic settings. Future efforts should assess the degree to which our findings reflect either low point-of-care ultrasound use or low rates of billing for ultrasound examinations that are performed.

Cost-effectiveness of the Cardiac Component of the Focused Assessment of Sonography in Trauma Examination in Blunt Trauma.

BACKGROUND: Blunt cardiac injury severe enough to require surgical intervention (sBCI) is an exceedingly rare event occurring in approximately 1 out of every 1600 trauma patients. While performing the cardiac component of the Focused Assessment of Sonography in Trauma (cFAST) exam is effective in penetrating trauma, it is unclear whether it is of value in blunt trauma given the low prevalence of sBCI, the imperfect test characteristics of the FAST exam, and the rate of incidental pericardial effusion. OBJECTIVE: The objective was to determine through decision analysis whether performing the cFAST exam is cost-effective in the evaluation of hypotensive and normotensive blunt trauma patients. METHODS: We created two decision analytic models using commercially available software (TreeAgePro2011) to evaluate the cost-effectiveness of the cFAST in hypotensive (systolic blood pressure <90 mm Hg) and normotensive blunt trauma patients. Clinical probabilities were obtained from published data. Costs were estimated from Medicare reimbursement and charge data. The willingness-to-pay threshold was $50,000/quality-adjusted life-years (QALYs). Sensitivity analyses were performed over plausible ranges using available literature. RESULTS: In hypotensive patients, for the base case scenario of a 34-year-old with blunt trauma, the cFAST strategy had a cost of $42,882.70 and an effectiveness of 25.3597 QALYs, whereas the no cFAST strategy had a cost of $42,753.52 and an effectiveness of 25.3532 QALYs. The incremental cost-effectiveness ratio (ICER) was $19,918/QALY. For normotensive patients the cFAST strategy had a cost of $18,331.03 and an effectiveness of 23.2817 QALYs, whereas the no cFAST strategy had a cost of $18,207.58 and an effectiveness of 23.2814 QALYs. The ICER was $465,867/QALY. In the sensitivity analyses, age, probability of death from sBCI with prompt treatment, and probability of sBCI were the main drivers of variability in the model outcomes. CONCLUSIONS: The cFAST for blunt trauma is cost-effective for hypotensive but not for normotensive patients. The ICER for hypotensive patients was more than 20 times higher than the ICER for normotensive patients. Our results suggest that performing the cFAST exam may not be an effective use of resources in normotensive blunt trauma patients.

Redefining Overuse to Include Costs: A Decision Analysis for Computed Tomography in Minor Head Injury.

BACKGROUND: A study was conducted to (1) determine the testing threshold for head computed tomography (CT) in minor head injury in the emergency department using decision analysis with and without costs included in the analysis, (2) to determine which variables have significant impact on the testing threshold, and (3) to compare this calculated testing threshold to the pretest risk estimate previously reported when the Canadian CT Head Rule (CCHR) was applied. It was hypothesized that the CCHR might not identify all patients above the testing threshold. METHODS: A decision analytic model was constructed using commercially available software and data from published literature. Outcomes were assigned values on the basis of quality-adjusted life-years (QALYs) and cost. Two testing thresholds were calculated, the first based only on the effectiveness of either strategy, the second on the overall net monetary benefit. Two-way sensitivity analyses were performed to determine which variables most affected the testing threshold. RESULTS: When only effectiveness (QALYs) was considered, the testing threshold for obtaining head CT was 0.039%. This threshold increased to 0.421% when the net monetary benefit was considered in lieu of QALYs. Age, probability of lesion on CT requiring neurosurgery, and cost of CT were the main drivers of the model. CONCLUSION: If only effectiveness is considered, current clinical decision rules might not provide a sufficient degree of certainty to ensure identification of all patients for whom the benefits of CT outweigh its risks. However, inclusion of cost in the analysis increases the testing threshold by an order of magnitude and well outside the range of uncertainty of current clinical decision rules. These results suggest that the term overuse should be redefined to include the provision of medical services with no benefits or for which harms including cost outweigh benefits.

A decision analysis to determine a testing threshold for computed tomographic angiography and D-dimer in the evaluation of aortic dissection.

OBJECTIVE: The objective of this study is to determine at what probability of thoracic aortic dissection (TAD) to use a computed tomographic angiography (CTA) or a d-dimer test. METHODS: We used decision analysis software to determine the testing threshold (TT) for 3 hypothetical decisions when evaluating for TAD: (1) no testing vs CTA, (2) no testing vs D-dimer, and (3) CTA vs D-dimer. One- and 2-way sensitivity analyses were performed to determine which variables were drivers of the TTs. RESULTS: We found TTs of 0.03%, 0.013%, and 0.6% for decisions 1, 2, and 3, respectively. For all 3 decisions, patient age and the annual rate of cancer were major drivers of the TT. In decisions 1 and 2, the probability of acute renal failure requiring renal replacement therapy was a major driver, whereas d-dimer sensitivity was a major driver for decision 3. CONCLUSION: The TTs for TAD are low and reflect the large mortality benefit from diagnosis and treatment when compared with the small risks of CTA. However, given the low prevalence of TAD (~0.05% among emergency department patients presenting with symptoms previously attributed to TAD), our results suggest that without high-risk features, clinicians should not order a CTA test for TAD. Depending on age, CTA should be considered for those patients with a disease probability greater than 0.3% to 2.1%, whereas d-dimer testing is appropriate in the range of pretest probabilities from 0.01% to 0.6%. Future studies should focus on clinical decision rules that place disease probabilities below, between, and above the calculated TTs.

Point-of-care focused cardiac ultrasound for the assessment of thoracic aortic dimensions, dilation, and aneurysmal disease.

OBJECTIVES: Thoracic aortic aneurysm and thoracic aortic dissection are related and potentially deadly diseases that present with nonspecific symptoms. Transthoracic echocardiography (TTE) may detect thoracic aortic pathology and is being increasingly performed by the emergency physician at the bedside; however, the accuracy of point-of-care (POC) focused cardiac ultrasound (FOCUS) for thoracic aortic aneurysm and thoracic aortic dissection has not been studied. The objective of this pilot study was to explore the agreement, sensitivity, and specificity of FOCUS for thoracic aortic dimensions, dilation, and aneurysm compared with CT angiography (CTA) as the reference standard. METHODS: This study was a retrospective pilot analysis of image and chart data on consecutive patients presenting to an urban, academic emergency department (ED) between January 2008 and June 2010, who had both a FOCUS and a CTA for suspicion of thoracic aorta pathology. Thoracic aorta dimensions were measured from recordings by three ultrasound-trained emergency physicians blinded to any initial FOCUS and CTA results. CTA measurements were obtained by a radiologist blinded to the FOCUS results. Using cutoffs of 40 and 45 mm, we calculated the sensitivity and specificity of FOCUS for aortic dilation and aneurysm with the largest measurement on CT as the reference standard. Bland-Altman plots with 95% limits of agreement were used to demonstrate agreement for aortic measurements, kappa statistics to assess the degree of agreement between tests for aortic dilation, and intraclass correlation for interobserver and intraobserver variability. RESULTS: Ninety-two patients underwent both FOCUS and CTA during the study period. Ten FOCUS studies had inadequate visualization for all measurements areas. Eighty-two patients were included in the final analysis. Mean (±SD) age was 58.1 (±16.6) years and 58.5% were male. Sensitivity, specificity, and the observed kappa value (95% confidence interval [CI]) between FOCUS and CTA for the presence of aortic dilation at the 40-mm cutoff were 0.77 (95% CI = 0.58 to 0.98), 0.95 (95% CI = 0.84 to 0.99), and 0.74 (95% CI = 0.58 to 0.90), respectively. The mean difference (95% limits of agreement) for the Bland-Altman plots was 0.6 mm (-5.3 to 6.5) for the sinuses of Valsalva, 4 mm (-2.7 to 10.7) for the sinotubular junction, 1.5 mm (-5.8 to 8.8) for the ascending aorta, and 2.2 mm (-5.9 to 10.3) for the descending aorta. CONCLUSIONS: In this retrospective pilot study, FOCUS demonstrated good agreement with CTA measurements of maximal thoracic aortic diameter. FOCUS appears to be specific for aortic dilation and aneurysm when compared to CTA, but requires further prospective study.