Emergency physician gender and head computed tomography orders for older adults who have fallen.

OBJECTIVE: Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS: This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS: There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS: There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

Patterns of multiple chronic conditions in pregnancy: Population-based study using latent class analysis.

BACKGROUND: Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce. OBJECTIVES: To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chronic conditions cluster together among pregnant women with MCC. METHODS: We conducted a population-based cohort study in Ontario, Canada, of all 15-55-year-old women with a recognised pregnancy, from 2007 to 2020. MCC was assessed from a list of 22 conditions, identified using validated algorithms. We estimated the prevalence of MCC. Next, we used latent class analysis to identify classes of co-occurring chronic conditions in women with MCC, with model selection based on parsimony, clinical interpretability and statistical fit. RESULTS: Among 2,014,508 pregnancies, 324,735 had MCC (161.2 per 1000, 95% confidence interval [CI] 160.6, 161.8). Latent class analysis resulted in a five-class solution. In four classes, mood and anxiety disorders were prominent and clustered with one additional condition, as follows: Class 1 (22.4% of women with MCC), osteoarthritis; Class 2 (23.7%), obesity; Class 3 (15.8%), substance use disorders; and Class 4 (22.1%), asthma. In Class 5 (16.1%), four physical conditions clustered together: obesity, asthma, chronic hypertension and diabetes mellitus. CONCLUSIONS: MCC is common in pregnancy, with sub-types dominated by co-occurring mental and physical health conditions. These data show the importance of preconception and perinatal interventions, particularly integrated care strategies, to optimise treatment and stabilisation of chronic conditions in women with MCC.

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen.

BACKGROUND: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

Comparison of Emergency Department Use Between Pregnant People With and Without Disabilities in Ontario, Canada.

Importance: Emergency department (ED) use in pregnancy is common and occurs for a variety of reasons, including obstetrical complications, exacerbated underlying conditions, and inadequate outpatient health care access. People with disabilities have elevated rates of certain medical, psychiatric, and obstetrical conditions as well as inadequate access to prenatal care; their risk of ED use in pregnancy is not known, however. Objective: To compare the risk of ED use in pregnancy among people with physical, sensory, and intellectual or developmental disabilities with those without disabilities. Design, Setting, and Participants: Population-based cohort study leveraging linked administrative health data sets in Ontario, Canada, April 2003 to March 2019. Analysis included all recognized pregnancies to people with a preexisting physical, sensory, intellectual or developmental, or 2 or more (multiple) disabilities, and those without a disability. Data were analyzed from May 2022 to January 2023. Exposure: Disability was ascertained using algorithms applied to 2 or more outpatient physician visits or 1 or more ED visits or hospitalizations before conception. Main outcomes and measures: Modified Poisson regression-generated adjusted relative risks (aRR) and 95% CIs for any ED visit in pregnancy, from the estimated conception date up to the end of the pregnancy, adjusted for age, parity, income quintile, rurality, immigrant status, and preexisting chronic conditions, mental illness, and substance use disorders. Results: The cohort included 2 659 895 pregnant people with physical (221 739 participants; mean [SD] age, 29.8 [6.1] years), sensory (71 891 participants; mean [SD] age, 29.1 [6.4] years), intellectual or developmental (3877 participants; mean [SD] age, 26.1 [6.7] years), and multiple disabilities (14 359 participants; mean [SD] age, 29.5 [6.5] years), and pregnant people without a disability (2 348 023 participants; mean [SD] age, 29.4 [5.9] years). The rate of ED visits in pregnancy was 25.4% in people without a disability (596 771 visits). Relative to these individuals, the aRR for ED use was elevated in people with physical (aRR, 1.26; 95% CI, 1.25-1.27), sensory (aRR, 1.15; 95% CI, 1.14-1.17), intellectual or developmental (aRR, 1.33; 95% CI, 1.28-1.38), and multiple disabilities (aRR, 1.43; 95% CI, 1.40-1.46). Conclusions and Relevance: In this population-based study, people with disabilities were at elevated risk of ED use in pregnancy. This finding underscores the need for research on the benefits of proactive strategies to manage preexisting conditions in these individuals, improve their access to outpatient obstetrical and medical care, and prepare them for when ED visits occur.

Application of the Modified Early Obstetrical Warning System (MEOWS) in postpartum patients in the emergency department.

INTRODUCTION: Over the last two decades, there has been a steady rise in severe maternal morbidity and pregnancy-related deaths in Canada and the USA. The Modified Early Obstetric Warning System (MEOWS) is a risk stratification tool designed to predict severe maternal morbidity and mortality and has been validated for use in obstetrical wards. The objective of this study was to determine if MEOWS could accurately identify patients at risk of severe maternal morbidity and mortality in the ED setting. METHODS: This was a chart review of patients presenting to an academic tertiary care centre (annual ED census 65,000) with a postpartum complaint within 6 weeks of delivery between May 2020 and March 2022. The exposure was the presence of a trigger, defined as one severely abnormal (red) or two mildly abnormal (yellow) physiological measurements during the ED visit. The diagnostic accuracy of the tool to identify patients at risk of severe maternal morbidity severe maternal morbidity or mortality was estimated by calculating the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: Two hundred and sixty-seven patients were included, of which 21 (7.9%) met the criteria for severe maternal morbidity. There were no maternal deaths. Overall, the sensitivity of the MEOWS tool was 85.7% (95% CI 63.7-97.0%), specificity was 67.9% (95% CI 61.7-73.7%), positive predictive value was 18.6% (95% CI 15.1-22.7%), and negative predictive value was 98.2% (95% CI 95.1-99.4%). Severe preeclampsia and eclampsia were the most common outcome category of severe maternal morbidity, representing 16 (76.2%) cases. Most patients (86.5%) were discharged directly from the ED, and 90.0% did not return within 30 days. CONCLUSIONS: This study is the first to explore the utility of MEOWS in postpartum ED patients. The presence of a MEOWS trigger at ED triage or the first ED nursing assessment was associated with severe maternal morbidity. Thus, MEOWS may be a valuable tool to identify postpartum patients at risk of severe outcomes early in an ED visit.

RéSUMé: INTRODUCTION: Au cours des deux dernières décennies, la morbidité maternelle grave et les décès liés à la grossesse ont connu une augmentation constante au Canada et aux États-Unis. Le système d'alerte précoce en obstétrique modifié (Modified Early Obstetric Warning System, MEOWS) est un outil de stratification des risques conçu pour prédire la morbidité et la mortalité maternelles graves. Il a été validé pour être utilisé dans les services d'obstétrique. L'objectif de cette étude était de déterminer si le MEOWS pouvait identifier avec précision les patientes présentant un risque de morbidité et de mortalité maternelles graves dans le contexte des urgences. MéTHODES: Il s'agit d'une étude des dossiers des patientes qui se sont présentées dans un centre de soins tertiaires universitaires (recensement annuel des urgences : 65 000) avec une plainte post-partum dans les six semaines suivant l'accouchement, entre mai 2020 et mars 2022. L'exposition était la présence d'un facteur déclenchant, défini comme une mesure physiologique gravement anormale (rouge) ou deux mesures légèrement anormales (jaune) au cours de la visite au service des urgences. La précision diagnostique de l'outil pour identifier les patientes à risque de morbidité maternelle grave morbidité maternelle grave ou de mortalité a été estimée en calculant la sensibilité, la spécificité, la valeur prédictive positive et la valeur prédictive négative. RéSULTATS: 267 patientes ont été incluses, dont 21 (7,9 %) répondaient aux critères de morbidité maternelle sévère. Il n'y a pas eu de décès maternel. Globalement, la sensibilité de l'outil MEOWS était de 85,7 % (IC 95 % : 63,7 %-97,0 %), la spécificité de 67,9 % (IC 95 % : 61,7 %-73,7 %), la valeur prédictive positive de 18,6 % (IC 95 % : 15,1 %-22,7 %) et la valeur prédictive négative de 98,2 % (IC 95 % : 95,1 %-99,4 %). La pré-éclampsie sévère et l'éclampsie étaient la catégorie d'issue la plus fréquente de la morbidité maternelle sévère, représentant 16 (76,2 %) cas. La plupart des patients (86,5 %) sont sortis directement des urgences et 90,0 % ne sont pas revenus dans les 30 jours. CONCLUSIONS: Cette étude est la première à explorer l'utilité du MEOWS chez les patientes des urgences post-partum. La présence d'un déclencheur MEOWS lors du triage aux urgences ou de la première évaluation infirmière aux urgences était associée à une morbidité maternelle grave. Ainsi, le MEOWS peut être un outil précieux pour identifier les patientes du post-partum qui risquent d'avoir des conséquences graves dès le début d'une visite aux urgences.

Maternal Emergency Department Use Before Pregnancy and Infant Emergency Department Use After Birth.

Importance: Maternal emergency department (ED) use before or during pregnancy is associated with worse obstetrical outcomes, for reasons including preexisting medical conditions and challenges in accessing health care. It is not known whether maternal prepregnancy ED use is associated with higher use of the ED by their infant. Objective: To study the association between maternal prepregnancy ED use and risk of infant ED use in the first year of life. Design, Setting, and Participants: This population-based cohort study included all singleton livebirths in all of Ontario, Canada, from June 2003 to January 2020. Exposures: Any maternal ED encounter within 90 days preceding the start of the index pregnancy. Main Outcomes and Measures: Any infant ED visit up to 365 days after the index birth hospitalization discharge date. Relative risks (RR) and absolute risk differences (ARD) were adjusted for maternal age, income, rural residence, immigrant status, parity, having a primary care clinician, and number of prepregnancy comorbidities. Results: There were 2 088 111 singleton livebirths; the mean (SD) maternal age was 29.5 (5.4) years, 208 356 (10.0%) were rural dwelling, and 487 773 (23.4%) had 3 or more comorbidities. Among singleton livebirths, 206 539 mothers (9.9%) had an ED visit within 90 days before the index pregnancy. ED use in the first year of life was higher among infants whose mother had visited the ED before pregnancy (570 per 1000) vs those whose mother had not (388 per 1000) (RR, 1.19 [95% CI, 1.18-1.20]; ARD, 91.1 per 1000 [95% CI, 88.6-93.6 per 1000]). Compared with mothers without a prepregnancy ED visit, the RR of infant ED use in the first year was 1.19 (95% CI, 1.18-1.20) if its mother had 1 prepregnancy ED visit, 1.18 (95% CI, 1.17-1.20) following 2 visits, and 1.22 (95% CI, 1.20-1.23) after at least 3 maternal visits. A low-acuity maternal prepregnancy ED visit was associated with an adjusted odds ratio (aOR) of 5.52 (95% CI, 5.16-5.90) for a low-acuity infant ED visit, which was numerically higher than the pairing of a high-acuity ED use between mother and infant (aOR, 1.43, 95% CI, 1.38-1.49). Conclusions and Relevance: In this cohort study of singleton livebirths, prepregnancy maternal ED use was associated with a higher rate of ED use by the infant in the first year of life, especially for low-acuity ED use. This study's results may suggest a useful trigger for health system interventions aimed at reducing some ED use in infancy.

Point-of-care ultrasound for evaluation of vaginal bleeding or abdominal pain in early pregnancy: Use by family physicians following focused training and certification.

OBJECTIVE: To evaluate the use of point-of-care ultrasound (POCUS) for the assessment of patients experiencing first-trimester bleeding or abdominal pain by family physicians working in family medicine clinics following first-trimester POCUS training and certification. DESIGN: Multisite, retrospective chart review. SETTING: Two hospital-affiliated academic family medicine clinics in Toronto, Ont. PARTICIPANTS: Twelve family physicians who completed a first-trimester POCUS training and certification course. MAIN OUTCOME MEASURES: The primary outcome was the proportion of family physicians using POCUS during their evaluations of patients in the first trimester of pregnancy in the 6 months following the FPs' successful completion of the Family Medicine Obstetrical Ultrasound (FaMOUS) course. Secondary outcomes included indications for POCUS use, diagnostic accuracy of POCUS compared with radiologist-interpreted ultrasound, pregnancy outcomes, and emergency department visits within 10 days of the index family medicine clinic visit. RESULTS: Of the 12 certified family physicians, 7 (58.3%) used POCUS during their assessments of first-trimester patients during the study period. The FPs used POCUS with 56 patients for the following indications: 11 (19.6%) had only vaginal bleeding, 5 (8.9%) had only abdominal pain, and 8 (14.3%) had both vaginal bleeding and abdominal pain; the indication for 32 patients (57.1%) was unclear. Forty-six patients (82.1%) underwent a subsequent radiologist-interpreted ultrasound within 10 days of the index POCUS test. Compared with radiologist-interpreted ultrasound, POCUS had a sensitivity of 91.3% (95% CI 79.2% to 97.6%) for documenting intrauterine pregnancy and a sensitivity of 81.4% (95% CI 66.6% to 91.6%) for documenting the presence of fetal cardiac activity. CONCLUSION: Following a first-trimester POCUS certification course, family physicians used POCUS for the assessment of first-trimester patients with varying frequency and for indications other than vaginal bleeding or abdominal pain. Further study is needed to assess the clinical impact of office-based POCUS, unforeseen barriers and facilitators to its use, and patient and provider preferences.

Prepregnancy Emergency Department Use and Risks of Severe Maternal and Neonatal Morbidity in Canada.

Importance: Emergency department (ED) use during pregnancy may be associated with worse obstetrical outcomes, possibly because of differences in access to health care. It is not known whether ED use before pregnancy is associated with serious adverse maternal and perinatal outcomes. Objective: To study the association between prepregnancy ED use and adverse maternal and perinatal outcomes. Design, Setting, and Participants: This population-based cohort study was conducted in Ontario, Canada, and included all livebirths and stillbirths from April 2003 to January 2020. Exposures: Main exposure was any ED encounter within 90 days preceding the start of the index pregnancy. Main Outcomes and Measures: Primary outcome was a composite of severe maternal morbidity (SMM) from 20 weeks' gestation to 42 days' post partum. Secondary outcomes included severe neonatal morbidity (SNM) from 0 to 27 days, neonatal death, and stillbirth. Relative risks (RRs) were adjusted for maternal age, income, and rurality. Results: Of 2 130 245 births, there were 2 119 335 livebirths (99.5%) and 10 910 stillbirths (0.5%). The mean (SD) maternal age was 29.6 (5.4) years, 212 478 (9.9%) were rural dwelling, and 498 219 (23%) had 3 or more comorbidities. Among all births, 218 011 (9.7%) had a prepregnancy ED visit. The rate of SMM was higher among women with a prepregnancy ED visit than those without (22.3 vs 16.5 per 1000 births), with an RR of 1.34 (95% CI, 1.30-1.38) and an adjusted RR (aRR) of 1.37 (95% CI, 1.33-1.42). Compared with no prepregnancy ED visit, the aRR was higher in those with 1 (1.29; 95% CI, 1.24-1.34), 2 (1.51; 95% CI, 1.42-1.61), and 3 or more (1.74; 95% CI, 1.61-1.90) ED visits. Prepregnancy ED visits for a hematological (aRR, 13.60; 95% CI, 10.48-17.64), endocrine (aRR, 4.96; 95% CI, 3.72-6.62), and circulatory (aRR, 2.27; 95% CI, 1.68-3.07) conditions were associated with the highest aRRs for SMM. The rate of SNM was higher among newborns whose mother visited the ED within 90 days before pregnancy (68.2 vs 55.4 per 1000 births; aRR, 1.24; 95% CI, 1.22-1.26) as was the risk of neonatal death (aRR, 1.26; 95% CI, 1.16-1.37) and stillbirth (aRR, 1.18; 95% CI, 1.11-1.25). Conclusions and Relevance: In this study, ED use was common before pregnancy. These findings suggest that ED use may not only reflect a woman's access to prepregnancy care but also higher future risk of severe maternal and perinatal morbidity, potentially offering a useful trigger for health system interventions to decrease adverse pregnancy outcomes.