Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review.

BACKGROUND: Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow. METHODS: A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed. RESULTS: The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue". CONCLUSIONS: The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.

How do electronic risk assessment tools affect the communication and understanding of diagnostic uncertainty in the primary care consultation? A systematic review and thematic synthesis.

OBJECTIVES: To conduct a systematic review and synthesise qualitative research of electronic risk assessment tools (eRATs) in primary care, examining how they affect the communication and understanding of diagnostic risk and uncertainty. eRATs are computer-based algorithms designed to help clinicians avoid missing important diagnoses, pick up possible symptoms early and facilitate shared decision-making. DESIGN: Systematic search, using predefined criteria of the published literature and synthesis of the qualitative data, using Thematic Synthesis. Database searches on 27 November 2019 were of MEDLINE, Embase, CINAHL and Web of Science, and a secondary search of the references of included articles. Included studies were those involving electronic risk assessment or decision support, pertaining to diagnosis in primary care, where qualitative data were presented. Non-empirical studies and non-English language studies were excluded. 5971 unique studies were identified of which 441 underwent full-text review. 26 studies were included for data extraction. A further two were found from citation searches. Quality appraisal was via the CASP (Critical Appraisal Skills Program) tool. Data extraction was via line by line coding. A thematic synthesis was performed. SETTING: Primary care. RESULTS: eRATs included differential diagnosis suggestion tools, tools which produce a future risk of disease development or recurrence or calculate a risk of current undiagnosed disease. Analytical themes were developed to describe separate aspects of the clinical consultation where risk and uncertainty are both central and altered via the use of an eRAT: 'Novel risk', 'Risk refinement', 'Autonomy', 'Communication', 'Fear' and 'Mistrust'. CONCLUSION: eRATs may improve the understanding and communication of risk in the primary care consultation. The themes of 'Fear' and 'Mistrust' could represent potential challenges with eRATs. TRIAL REGISTRATION NUMBER: CRD219446.

Parental experiences with their child's eating disorder treatment journey.

BACKGROUND: Parents are integral in the treatment of pediatric eating disorders. The current study was conducted to further understand the barriers and facilitators that parents experience in accessing specialized, tertiary level eating disorder treatment for children and adolescents. The goals of the study were to understand the processes leading to diagnosis and treatment, perceived barriers and facilitators to accessing care, and parents' experiences over the course of their child's eating disorder treatment. METHODS: Ten parents whose children were admitted to a Canadian tertiary level specialized pediatric eating disorders program took part in an exit interview upon their child's completion of treatment in the program. In-depth semi-structured interviews were combined with a visual timeline. Interpretive induction was performed to generate high-level concepts that emerged from the interviews. RESULTS: Five high-level concepts were identified: (1) delays in identifying eating disorder symptoms, (2) challenges in accessing eating disorder services, (3) the right treatment at the right time, (4) emotional impact on parents, and (5) parental expertise and involvement. CONCLUSIONS: Several barriers were identified by parents that interfered with treatment, including system-related challenges when accessing specialized eating disorder treatment, concerns about a lack of appropriate mental health support for their child, and difficulties with transitioning between community and tertiary level care. Negative emotions, including guilt and self-blame, were common early in the treatment journey. Themes of parental involvement throughout treatment, and parents taking charge of their child's recovery, emerged across interviews. The results of this study suggest the importance of early identification of eating disorder symptoms, facilitating smoother transitions between levels of care (e.g., community services and hospital-based eating disorder care), and improving clinical decision-making to ensure children and adolescents with eating disorders receive the most appropriate treatment based on their clinical presentation.

Parents play a central role in pediatric eating disorder treatment. To further understand parents' experiences over the course of their child's eating disorder treatment, interviews were conducted with ten parents whose children were admitted to a specialized pediatric eating disorders program. Five major themes emerged across the interviews with parents: delays in identifying eating disorder symptoms, challenges with accessing eating disorders care, the right treatment at the right time, emotional impact on parents, and parental expertise and involvement. Parents shared several barriers that interfered with their child's treatment, including challenges with transitions between their home community and specialized eating disorder treatment. Parents also commonly spoke about guilt and self-blame when their child was first diagnosed with an eating disorder, though many parents felt relief and improved confidence after being connected with specialized eating disorder treatment. Research is needed to understand how to provide the right treatment at the right time for each child and adolescent with an eating disorder, to ultimately improve clinical care and reduce the barriers experienced by families.

Gender differences in symptom presentation and treatment outcome in children and youths with eating disorders.

BACKGROUND: To address the gaps in the literature examining eating disorders among males and gender minority youths, a prospective study was designed to assess gender differences in eating disorder symptom presentation and outcomes. Muscularity concerns may be particularly relevant for male youths with eating disorders, and were included in assessment of eating disorder symptom presentation. METHODS: All cisgender male youths who presented for specialized eating disorder treatment at one of two sites were invited to participate, along with a group of matched cisgender females, and all youths who did not identify with the sex assigned to them at birth. Youths completed measures of eating disorder symptoms, including muscularity concerns, and other psychiatric symptoms at baseline and end of treatment. RESULTS: A total of 27 males, 28 females and 6 trans youths took part in the study. At baseline, Kruskal-Wallis tests demonstrated that trans youths reported higher scores than cisgender male and female youths on measures of eating pathology (Eating disorder examination-questionnaire (EDE-Q) and the body fat subscale of the male body attitudes scale (MBAS)). These analyses demonstrated that there were no differences between cisgender male and female youths on eating disorder symptoms at baseline. However, repeated measures ANOVA demonstrated that males had greater decreases in eating pathology at discharge than did females, based on self-reported scores on the EDE-Q, MBAS, and Body Change Inventory. CONCLUSIONS: Gender differences in eating pathology appeared at baseline, with trans youths reporting higher levels of eating pathology than cisgender youths, though no differences between cisgender males and females emerged at baseline for eating disorder symptom presentation. Contrary to expectations, there were no gender differences in measures of muscularity concerns. Males demonstrated greater eating disorder symptom improvements than females, suggesting that male adolescents may have better treatment outcomes than females in some domains.

Research in the field of eating disorders has focused on females, and less is known about the symptom presentation and treatment outcomes in males and gender minority youths. This prospective study set out to assess gender differences in eating pathology and treatment outcomes. Muscularity concerns may be particularly relevant for male youths with eating disorders, yet there is limited research on gender differences in muscularity concerns in treatment-seeking youths with eating disorders. Participants include cisgender male youths, matched cisgender females, and gender diverse youths who did not identify with the sex assigned to them at birth. Youths completed measures of eating disorder symptoms, including muscularity concerns, and other psychiatric symptoms at baseline and end of treatment. Some gender differences in eating pathology appeared at baseline, with trans youths reporting higher levels of eating pathology than cisgender youths. There were no differences between cisgender males and females in eating disorder symptom presentation at baseline, and contrary to expectations, there were no gender differences in measures of muscularity concerns. However, males demonstrated greater eating disorder symptom improvements than females.

Eating disorders in biological males: clinical presentation and consideration of sex differences in a pediatric sample.

BACKGROUND: The growing body of research on eating disorders among male adolescents reveals some sex differences in clinical presentation. The current study set out to replicate and extend recent research on the clinical and medical characteristics of male youth with eating disorders, and examine sex differences between biological males and females in a tertiary pediatric eating disorder treatment setting. METHODS: A retrospective chart review was conducted with all biological males who were admitted to the Eating Disorders Programs at British Columbia Children's Hospital (2003-2015) or the Looking Glass Residence (2011-2015). Clinical data, including demographics, percentage of median body mass index (% mBMI), and psychiatric diagnoses, were recorded along with medical data (i.e., vital signs, basic biochemistry investigations, and bone mineral density). A comparison group of females with eating disorders who received treatment at British Columbia Children's Hospital in the inpatient or outpatient streams (2010-2015) were included, to examine sex differences with males who were admitted during the same period. RESULTS: A total of 71 male youth were included in the chart review. Males had significant medical complications, with 26.5% of the sample presenting with a heart rate of less than 50 beats per minute and 31.4% presenting with a bone mineral density z-score for the lumbar spine ≤ - 1. Sex differences between the subset of males who were treated between 2010 and 2015 (n = 41) and the females (n = 251) were examined. Females were more likely than were males to have a diagnosis of anorexia nervosa or bulimia nervosa, and to be underweight (< 95% mBMI) at admission. Males were younger than females, but no differences emerged in the duration of the eating disorder symptoms. No sex differences emerged relating to medical instability (e.g., bradycardia). CONCLUSIONS: A large proportion of male children and youth with eating disorders are medically compromised at admission. Males were younger than females, and were less likely than females to have a diagnosis of anorexia nervosa or bulimia nervosa. Males who were underweight at admission had also lost a lower percentage of body weight in comparison to females. The current study replicates previous sex differences reported in pediatric samples.

Hypoplastic left heart syndrome: knowledge discovery with a data mining approach.

Hypoplastic left heart syndrome (HLHS) affects infants and is uniformly fatal without surgical palliation. Post-surgery mortality rates are highly variable and dependent on postoperative management. A data acquisition system was developed for collection of 73 physiologic, laboratory, and nurse-assessed parameters. The acquisition system was designed for the collection on numerous patients. Data records were created at 30s intervals. An expert-validated wellness score was computed for each data record. To efficiently analyze the data, a new metric for assessment of data utility, the combined classification quality measure, was developed. This measure assesses the impact of a feature on classification accuracy without performing computationally expensive cross-validation. The proposed measure can be also used to derive new features that enhance classification accuracy. The knowledge discovery approach allows for instantaneous prediction of interventions for the patient in an intensive care unit. The discovered knowledge can improve care of complex to manage infants by the development of an intelligent bedside advisory system.