Diagnostic patterns and stress testing trends after implementing high-sensitivity troponin assay.

OBJECTIVES: High-sensitivity troponin T (hsTnT) testing was approved in the United States to better facilitate diagnosis of acute coronary syndrome (ACS). Although hsTnT has been widely studied internationally, the impact of hsTnT on discharge diagnoses and health care utilization within the United States is less known. We sought to evaluate the effects of implementing hsTnT on diagnosis patterns and stress testing utilization. STUDY DESIGN: We performed a retrospective cohort analysis consisting of patients with suspected ACS undergoing either conventional troponin I (n = 14,631) or hsTnT (n = 7237) testing between January 2016 and February 2019. METHODS: Log-binomial regression with interrupted time series modeled diagnosis patterns, and logistic regression with segmented time trends modeled stress testing rates. Observed trends were compared with expected trends using average marginal effect (AME). RESULTS: Rates of acute myocardial infarction-related diagnoses were similar in the post-hsTnT period (AME, -0.6%; P = .065). Post hsTnT introduction, patients were more likely to receive a diagnosis of heart failure (2.1%; P < .001) or atrial fibrillation/flutter (0.9%; P < .001) and less likely to receive a diagnosis of hypertensive heart disease (-10.2%; P < .01) or hypertensive heart disease with chronic kidney disease (-3.7%; P < .001). Likelihood of receiving stress testing increased after hsTnT implementation (2.3%; P < .001). CONCLUSIONS: Variations in discharge diagnosis patterns and increases in stress test utilization were observed following hsTnT implementation. Hospitals can expect similar changes, which may have long-term implications on health care utilization, cost, and hospital reimbursement.

Evidence-Based Practices for Acute Respiratory Failure and Acute Respiratory Distress Syndrome: A Systematic Review of Reviews.

BACKGROUND: The recent pandemic highlights the essential nature of optimizing the use of invasive mechanical ventilation (IMV) in complex critical care settings. This review of reviews maps evidence-based practices (EBPs) that are associated with better outcomes among adult patients with acute respiratory failure or ARDS on the continuum of care, from intubation to liberation. RESEARCH QUESTION: What EPBs are recommended to reduce the duration of IMV and mortality rate among patients with acute respiratory failure/ARDS? STUDY DESIGN AND METHODS: We identified an initial set of reports that links EBPs to mortality rates and/or duration of IMV. We conducted a review of reviews, focusing on preappraised guidelines, meta-analyses, and systematic reviews. We searched Scopus, CINAHL, and PubMed from January 2016 to January 2019 for additional evidence that has not yet been incorporated into current guidelines. RESULTS: Our initial search produced 61 publications that contained 42 EBPs. We excluded 42 manuscripts during the data extraction process, primarily because they were not associated with improved patient outcomes. The remaining 19 preappraised guidelines, meta-analyses, and systematic reviews met our full inclusion criteria and spanned the continuum of IMV care from intubation to liberation. These contained 20 EBPs, a majority of which were supported with moderate levels of evidence. Of these, six EBPs focused on intubation and escalation of care, such as ventilator management and synchrony; ten EBPs reduced complications associated with IMV, which included spontaneous awakening and breathing trials and early mobility protocols; and four EBPs promoted timely extubation and postextubation recovery. INTERPRETATION: This review describes EBPs that are associated with fewer ventilator days and/or lower mortality rates among patients who received IMV for acute respiratory failure/ARDS. Many of these EBPs are connected across the care continuum, which indicates the need to promote and assess effective implementation jointly, rather than individually.

A Rapid Process for Identifying and Prioritizing Technology-Based Tools for Health System Implementation.

BACKGROUND: Health system decisions to put new technologies into clinical practice require a rapid and trustworthy decision-making process informed by best evidence. OBJECTIVE: This study aimed to present a rapid evidence review process that can be used to inform health system leaders and clinicians seeking to implement new technology tools to improve patient-clinician decision making and patient-oriented outcomes. METHODS: The rapid evidence review process we pioneered involved 5 sequential subprocesses: (1) environmental scan, (2) expert panel recruitment, (3) host evidence review panel, (4) analysis, and (5) local validation panel. We conducted an environmental scan of health information technology (IT) literature to identify relevant digital tools in oncology care. We synthesized the recent literature using current evidence review methods, creating visual summaries for use by a national panel of experts. Panelists were taken through a 6-hour modified Delphi process to prioritize tools for implementation. Findings from the rapid evidence review panel were taken to a local validation panel for further rapid review during a 3-hour session. RESULTS: Our rapid evidence review process shows promise for informing decision making by reducing the amount of time and resources needed to identify and prioritize adoption of IT tools. Despite evidence of improved patient outcomes, panelists had substantial concerns about implementing patient-reported outcome tracking tools, voicing concerns about liability, lack of familiarity with new technology, and additional time and workflow changes such tools would require. Instead, clinicians favored technologies that did not require clinician involvement. CONCLUSIONS: Health system leaders can use the rapid evidence review process presented here to usefully inform local technology adoption, implementation, and use in practice.