Death or revascularization among nonadmitted ED patients with low-positive vs negative troponin T results.

STUDY OBJECTIVE: Compare outcomes among emergency department (ED) patients with low-positive (0.01-0.02 ng/mL) vs negative troponin T. METHODS: Retrospective cohort study of nonadmitted ED patients with troponin testing at a tertiary-care hospital. Trained research assistants used a structured tool to review charts from all nonadmitted ED patients with troponin testing, 12/1/2009 to 11/30/2010. Outcomes of death and coronary revascularization were assessed at 30 days and 6 months via medical record review, Social Security Death Index searches, and patient contact. RESULTS: There were 57596 ED visits; with 33388 (58%) discharged immediately, 6410 (11%) assigned to the observation unit, and 17798 (31%) admitted or other. Troponin was measured in 2684 (6.7%) of the nonadmitted cases. Troponin was negative in 2523 (94.0%), low positive in 78 (2.9%), and positive (≥0.03 ng/mL) in 83 (3.1%). Of troponin-negative cases, 0.8% (95% CI, 0.4-1.1%) died or were revascularized by 30 days, vs 2.8% (95% CI, 0.0-6.7%) of low-positive cases (risk difference [RD], 2.0%; 95% CI, -1.8 to 5.9%). At 6 months, the rates were 1.7% (95% CI, 1.1-2.2%) and 12.9% (95% CI, 5.0-20.7%) (RD, 11%; 95% CI, 3.3-19.1%). Death alone at 30 days occurred in 0.4% (95% CI, 0.1-0.6%) vs 1.3% (95% CI, 0.0-3.8%) (RD, 0.9%; 95% CI, -1.6 to 3.4%). Death at 6 months occurred in 1.2% (95% CI, 0.8-1.6%) vs 11.7% (95% CI, 4.5-18.9%) (RD, 10%; 95% CI, 3.3-17.7%). CONCLUSION: Among patients not initially admitted, rates of death and coronary revascularization differed insignificantly at 30 days but significantly at 6 months. Detailed inspection of our results reveals that the bulk of the added risk at 6 months was due to non-cardiac mortality.

The impact of clinical decision support systems on provider behavior in the inpatient setting: A systematic review and meta-analysis.

BACKGROUND: Clinical decision support systems (CDSS) are used to improve processes of care. CDSS proliferation may have unintended consequences impacting effectiveness. OBJECTIVE: To evaluate the effectiveness of CDSS in altering clinician behavior. DESIGN: Electronic searches were performed in EMBASE, PubMed, and Cochrane Central Register of Control Trials for randomized controlled trials testing the impacted of CDSS on clinician behavior from 2000-2021. Extracted data included study design, CDSS attributed and outcomes, user characteristics, settings, and risk of bias. Eligible studies were analyzed qualitatively to describe CDSS types. Studies with sufficient outcome data were included in the meta-analysis. SETTING AND PARTICIPANTS: Adult inpatients in the United States. INTERVENTION: Clinical decision support system versus non-clinical decision support system. MAIN OUTCOME AND MEASURE: A random-effects model measured the pooled risk difference (RD) and odds ratio of clinicians' adherence to CDSS; subgroup analyses tested differences in CDSS effectiveness over time and by CDSS type. RESULTS: Qualitative synthesis included 22 studies. Eleven studies reported sufficient outcome data for inclusion in the meta-analysis. CDSS did not result in a statistically significant increase in clinician adoption of desired practicies (RD = 0.04 [95% confidence interval {CI} 0.00, 0.07]). CDSS from 2010-2015 (n = 5) did not increase clinician adoption of desired practice [RD -0.01, (95% CI -0.04, 0.02)].CDSS from 2016-2021 (n = 6) were associated with an increase in targeted practices [RD 0.07 (95% CI0.03, 0.12)], pInteraction = 0.004. EHR [RD 0.04 (95% CI 0.00, 0.08)] vs. non-EHR [RD 0.01 (95% CI -0.01, 0.04)] based CDSS interventions did not result in different adoption of desired practices (pInteraction = 0.27). The meta-analysis did not find an overall positive impact of CDSS on clinician behavior in the inpatient setting.

Patient preferences and acceptable risk for computed tomography in trauma.

BACKGROUND: Rising use of computed tomography (CT) to evaluate patients with trauma has increased both patient costs and risk of cancer from ionizing radiation, without demonstrable improvements in outcome. Patient-centred care mandates disclosure of the potential risks, costs and benefits of diagnostic testing whenever possible. OBJECTIVE: We sought to determine (1) patient preferences regarding emergency department (ED) real-time discussions of risks and costs of CT during their trauma evaluations; and (2) whether varying levels of odds of detection of life-threatening injury (LTI) were associated with changes in patient preferences for CT. METHODS: Excluding patients already receiving CT and patients with altered mental status, we surveyed adult, English-speaking patients at four Level I verified trauma centres. After informing subjects of cancer risks associated with chest CT, we used hypothetical scenarios with varying LTIs to assess patients' preferences regarding CT. RESULTS: Of 941 patients enrolled, 50% were male and their mean age was 42 years. Most patients stated they would prefer to discuss CT radiation risks (73.5%, 95% CI [66.1-80.8]) and costs (53.2%, 95% CI [46.1-60.4]) with physicians. As the odds of detecting LTI decreased, preferences for receiving CT decreased accordingly: LTI 25% (desire 91.2%, 95% CI [89.4-93.1]), LTI 10% (desire 79.3%, 95% CI [76.7-81.9]), LTI 5% (desire 69.1%, 95% CI [66.1-72.1]) and LTI <2% (desire 53.8%, 95% CI [50.6-57.0]). If the LTI was <2% and subjects were required to pay $1000 out-of-pocket, only 34.5% (95% CI 31.4-37.5) would opt for CT. CONCLUSION: Most non-critically injured patients prefer to discuss radiation risks and costs of CT prior to receiving imaging. As the odds of detecting LTI decrease, fewer patients prefer to have CT; at an LTI threshold of 2%, approximately half of patients would prefer to forego CT. Adding out-of-pocket costs reduced this proportion to one-third of patients.