Decision support for computed tomography in the emergency department: a multicenter cluster-randomized controlled trial.

OBJECTIVES: Clinical decision support may facilitate evidence-based imaging, but most studies to date examining the impact of decision support have used non-randomized designs which limit the conclusions that can be drawn from them. This randomized trial examines if decision support can reduce computed tomography (CT) utilization for patients with mild traumatic brain injuries and suspected pulmonary embolism in the emergency department. This study was funded by a competitive public research grant and registered on ClinicalTrials.gov (NCT02410941). METHODS: Emergency physicians at five urban sites were assigned to voluntary decision support for CT imaging of patients with either head injuries or suspected pulmonary embolism using a cluster-randomized design over a 1-year intervention period. The co-primary outcomes were CT head and CT pulmonary angiography utilization. CT pulmonary angiography diagnostic yield (proportion of studies diagnostic for acute pulmonary embolism) was a secondary outcome. RESULTS: A total of 225 physicians were randomized and studied over a 2-year baseline and 1-year intervention period. Physicians interacted with the decision support in 38.0% and 45.0% of eligible head injury and suspected pulmonary embolism cases, respectively. A mixed effects logistic regression model demonstrated no significant impact of decision support on head CT utilization (OR 0.93, 95% CI 0.79-1.10, p = 0.31), CT pulmonary angiography utilization (OR 0.98, 95% CI 0.88-1.11, p = 0.74) or diagnostic yield (OR 1.23, 95% CI 0.96-1.65, p = 0.10). However, overall CT pulmonary diagnostic yield (17.7%) was almost three times higher than that reported by a recent large US study, suggesting that selective imaging was already being employed. CONCLUSION: Voluntary decision support addressing many commonly cited barriers to evidence-based imaging did not significantly reduce CT utilization or improve diagnostic yield but was limited by low rates of participation and high baseline rates of selective imaging. Demonstrating value to clinicians through interventions that improve workflow is likely necessary to meaningfully change imaging practices.

RéSUMé: OBJECTIFS: Le soutien à la décision clinique peut faciliter l'imagerie fondée sur des données probantes, mais la plupart des études à ce jour examinant l'impact du soutien à la décision ont utilisé des modèles non randomisés qui limitent les conclusions qui peuvent en être tirées. Cet essai randomisé examine si l'aide à la décision peut réduire l'utilisation de la tomodensitométrie chez les patients présentant des lésions cérébrales traumatiques légères et une embolie pulmonaire présumée au service des urgences. Cette étude a été financée par une subvention de recherche publique compétitive et enregistrée sur ClinicalTrials.gov (NCT02410941). MéTHODES: Les médecins urgentistes de cinq sites urbains ont été assignés à une aide à la décision volontaire pour l'imagerie par tomodensitométrie des patients présentant soit un traumatisme crânien, soit une suspicion d'embolie pulmonaire, selon une conception randomisée en grappes sur une période d'intervention d'un an. Les résultats co-primaires étaient l'utilisation de la tomodensitométrie de la tête et de la tomodensitométrie par angiographie pulmonaire. Le rendement diagnostique de l'angiographie pulmonaire par TDM (proportion d'études diagnostiquant une embolie pulmonaire aiguë) était un résultat secondaire. RéSULTATS: Au total, 225 médecins ont été randomisés et étudiés au cours d'une période de référence de deux ans et d'une période d'intervention d'un an. Les médecins ont interagi avec l'aide à la décision dans 38,0 % et 45,0 % des cas admissibles de blessure à la tête et d'embolie pulmonaire soupçonnée, respectivement. Un modèle de régression logistique à effets mixtes n'a démontré aucun impact significatif de l'aide à la décision sur l'utilisation de la tomodensitométrie de la tête (OR 0,93, IC 95 % 0,79-1,10, p = 0,31), l'utilisation de l'angiographie pulmonaire par tomodensitométrie (OR 0,98, IC 95 % 0,88-1,11, p = 0,74) ou le rendement diagnostique (OR 1,23, IC 95 % 0,96-1,65, p = 0,10). Toutefois, le rendement global du diagnostic pulmonaire par TDM (17,7 %) était près de trois fois supérieur à celui rapporté par une étude récente aux États-Unis, ce qui laisse supposer que l'imagerie sélective était déjà utilisée. CONCLUSIONS: L'aide à la décision volontaire visant à éliminer de nombreux obstacles fréquemment cités à l'imagerie fondée sur des données probantes n'a pas réduit de façon significative l'utilisation de la tomodensitométrie ni amélioré le rendement diagnostique, mais a été limitée par de faibles taux de participation et des taux de base élevés d'imagerie sélective. La démonstration de la valeur pour les cliniciens par des interventions qui améliorent le flux de travail est probablement nécessaire pour changer de manière significative les pratiques d'imagerie.

Transfusions in patients with iron deficiency anemia following release of Choosing Wisely Guidelines.

BACKGROUND: In 2016, based on recommendations of the American Association of Blood Banks (AABB), Choosing Wisely Canada released transfusion guidelines for patients with Iron Deficiency Anemia. The goal of the present study was to examine the number of transfusions given in Calgary emergency departments (EDs) before and after the release of these guidelines. METHODS: We analyzed 11,786 anemia encounters from January 2014 to December 2019. A transfusion was considered potentially avoidable if the patient's hemoglobin was > 70 g/L and if the patient was hemodynamically stable. We used time-series analyses to examine change in rate of total and potentially avoidable transfusions quarterly over the total and pre and post intervention periods. RESULTS: In total, 1409/11,786 (12.0%) of the encounters received transfusions; 80.0% (1127/1409) were indicated while 19.9% (281/1409) were potentially avoidable. In the pre-intervention period, the rate of potentially avoidable transfusions was 21.5% (133/618) and in the post-intervention period, the rate of potentially avoidable transfusions was 18.7% (148/791). The rate of potentially avoidable transfusions decreased quarterly at a rate of 0.3% which did not reach statistical significance (p = 0.06). DISCUSSION: Our data suggest that the number of potentially avoidable transfusions has not decreased since the release of Choosing Wisely Canada guidelines and local educational initiatives. This may be due to the fact that there is a pre-existing down trend in the number of transfusions provided.

RéSUMé: CONTEXTE: En 2016, sur la base des recommandations de l'AABB (Association américaine des banques de sang) Choisir avec soin Canada a publié des directives sur la pratique transfusionnelle pour les patients atteints d'anémie ferriprive. Le but de la présente étude était d'examiner le nombre de transfusions administrées dans les services d'urgence (SU) de Calgary avant et après la publication de ces directives. MéTHODES: Nous avons analysé 11 786 cas d'anémie entre janvier 2014 et décembre 2019. Une transfusion était jugée comme potentiellement évitable si l'hémoglobine du patient était > 70 g/L et si le patient était stable sur le plan hémodynamique. Nous avons utilisé des analyses de séries chronologiques pour examiner trimestriellement le changement du taux de transfusions totales et potentiellement évitables au cours de l'ensemble des périodes, y compris avant et après l'intervention. RéSULTATS: Au total, 1409/11786 (12.0%) des cas ont reçu des transfusions ; 80.0% (1127/1409) ont été indiqués tandis que 19.9 % (281/1409) étaient potentiellement évitables. Pendant la période précédant l'intervention, le taux de transfusions potentiellement évitables était de 21.5 % (133/618) et dans la période postérieur à l'intervention, le taux de transfusions potentiellement évitables était de 18,7 % (148/791). Le taux de transfusions potentiellement évitables a diminué chaque trimestre à un taux de 0,3 % qui n'a pas atteint la signification statistique (p = 0,06). DISCUSSION: Nos données suggèrent que le nombre de transfusions potentiellement évitables n'a pas diminué depuis la publication des directives de Choisir avec soin Canada et des initiatives éducatives locales. Cela peut être dû au fait qu'il existe une tendance à la baisse préexistante du nombre de transfusions fournies.

Improving care for residents in long term care facilities experiencing an acute change in health status.

BACKGROUND: Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community. METHODS/DESIGN: We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care. DISCUSSION: This study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.

A Systematic Review Protocol to Determine the Most Effective Strategies to Reduce Computed Tomography Usage in the Emergency Department.

This study describes the protocol for a systematic review and meta-analysis. The primary objective of the review is to identify experimental studies assessing the effectiveness of interventions that aim to reduce the proportion of computed tomography (CT) in emergency departments (EDs). Data permitting, our secondary objectives will be to assess the impact of reduction in CT utilization on the length of stay, admission to hospital, and uptake/satisfaction with the intervention. When available, balancing measures such as readmission to hospital or ED revisit rates will be included. Pre-defined subgroup analyses include patient populations (adult or pediatric), type of ED, and the nature of the intervention. Through this review, the research team aims to inform knowledge translation initiatives aimed at lowering CT usage in the ED by identifying the most effective interventions to safely improve CT resource stewardship.

A Patient-focused Information Design Intervention to Support the Minor Traumatic Brain Injuries (mTBI) Choosing Wisely Canada Recommendation.

Introduction The first Choosing Wisely Canada (CWC) recommendation for Emergency Medicine states: "Don't order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule)". In order to provide patients with information on the risks and benefits of computed tomography (CT) scans in minor traumatic brain injuries (mTBI) and to encourage discussions between patients and their doctor, we designed a patient-focused mTBI infographic for the emergency department (ED). Methods Stakeholders worked with content experts to co-design the infographic, which was posted in two emergency department (ED) waiting rooms. A survey was administered to evaluate whether the infographic influenced patient beliefs about the risks and benefits of CT scans and to gauge patient willingness to have a discussion with their doctor about the necessity of a scan. Results One hundred fifteen patients completed the survey. Prior to participating, 38% of patients thought a CT after an mTBI was always a good idea and 60% thought it was sometimes a good idea. After viewing the poster, 87% of respondents stated they better understood when a CT scan may be appropriate, 93% felt they better understood the risks of CT scans, and 76% understood that their doctor can often rule out serious illness without a CT scan. Only 19% of patients still felt that a CT was always necessary after an mTBI. Conclusions The mTBI infographic changed patient perceptions regarding the need for CT scans and increased awareness of the indications and risks of CT scans. This study demonstrates that targeted patient education materials can help support CWC recommendations.

Age-adjusted D-dimer thresholds in the investigation of suspected pulmonary embolism: A retrospective evaluation in patients ages 50 and older using administrative data.

OBJECTIVES: D-dimer testing is an important component of the workup for pulmonary embolism (PE). However, age-related increases in D-dimer concentrations result in false positives in older adults, leading to potentially unnecessary imaging utilization. The objective of this study was to quantify the test characteristics of an age-adjusted D-dimer cut-off for ruling out PE in older patients investigated in actual clinical practice. METHODS: This observational study used administrative data from four emergency departments from July 2013 to January 2015. Eligible patients were ages 50 and older with symptoms of PE who underwent D-dimer testing. The primary outcome was 30-day diagnosis of PE, confirmed by imaging reports. Test characteristics of the D-dimer assay were calculated using the standard reference value (500 ng/ml), the local reference value (470 ng/ml), and an age-adjusted threshold (10 ng/ml × patient's age). RESULTS: This cohort includes 6,655 patients ages 50 and older undergoing D-dimer testing for a possible PE. Of these, 246 (3.7%) were diagnosed with PE. Age-adjusted D-dimer cut-offs were more specific than standard cut-offs (75.4% v. 63.8%) but less sensitive (90.3% v. 97.2%). The false-negative risk in this population was 0.49% using age-adjusted D-dimer cut-offs compared with 0.15% with traditional cut-offs. CONCLUSION: Age-adjusted D-dimer cut-offs are substantially more specific than traditional cut-offs and may reduce CT utilization among older patients with suspected PE. We observed a loss of sensitivity, with an increased risk of false-negatives, using age-adjusted cut-offs. We encourage further evaluation of the safety and accuracy of age-adjusted D-dimer cut-offs in actual clinical practice.

Reverse stress testing interbank networks.

We reverse engineer dynamics of financial contagion to find the scenario of smallest exogenous shock that, should it occur, would lead to a given final systemic loss. This reverse stress test can be used to identify the potential triggers of systemic events, and it removes the arbitrariness in the selection of shock scenarios in stress testing. We consider in particular the case of distress propagation in an interbank market, and we study a network of 44 European banks, which we reconstruct using data collected from banks statements. By looking at the distribution across banks of the size of smallest exogenous shocks we rank banks in terms of their systemic importance, and we show the effectiveness of a policy with capital requirements based on this ranking. We also study the properties of smallest exogenous shocks as a function of the parameters that determine the endogenous amplification of shocks. We find that the size of smallest exogenous shocks reduces and that the distribution across banks becomes more localized as the system becomes more unstable.

Knowledge Translation and Barriers to Imaging Optimization in the Emergency Department: A Research Agenda.

Researchers have attempted to optimize imaging utilization by describing which clinical variables are more predictive of acute disease and, conversely, what combination of variables can obviate the need for imaging. These results are then used to develop evidence-based clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the validation of these results in subsequent studies, with some demonstrating improved outcomes, their actual use is often limited. This article outlines a research agenda to promote the dissemination and implementation (also known as knowledge translation) of evidence-based interventions for emergency department (ED) imaging, i.e., clinical pathways, clinical decision instruments, and clinical practice guidelines. We convened a multidisciplinary group of stakeholders and held online and telephone discussions over a 6-month period culminating in an in-person meeting at the 2015 Academic Emergency Medicine consensus conference. We identified the following four overarching research questions: 1) what determinants (barriers and facilitators) influence emergency physicians' use of evidence-based interventions when ordering imaging in the ED; 2) what implementation strategies at the institutional level can improve the use of evidence-based interventions for ED imaging; 3) what interventions at the health care policy level can facilitate the adoption of evidence-based interventions for ED imaging; and 4) how can health information technology, including electronic health records, clinical decision support, and health information exchanges, be used to increase awareness, use, and adherence to evidence-based interventions for ED imaging? Advancing research that addresses these questions will provide valuable information as to how we can use evidence-based interventions to optimize imaging utilization and ultimately improve patient care.

Living with inflammatory bowel disease: A Crohn's and Colitis Canada survey.

BACKGROUND: Despite improvements in therapies for inflammatory bowel diseases (IBDs), patient quality of life continues to be significantly impacted. OBJECTIVE: To assess the impact of IBD on patients and families with regard to leisure, relationships, mental well-being and financial security, and to evaluate the quality and availability of IBD information. METHODS: An online survey was advertised on the Crohn's and Colitis Canada website, and at gastroenterology clinics at the University of Alberta Hospital (Edmonton, Alberta) and University of Calgary Hospital (Calgary, Alberta). RESULTS: The survey was completed by 281 IBD patients and 32 family members. Among respondents with IBD, 64% reported a significant or major impact on leisure activities, 52% a significant or major impact on interpersonal relationships, 40% a significant or major impact on financial security, and 28% a significant or major impact on planning to start a family. Patient information needs emphasized understanding disease progression (84%) and extraintestinal symptoms (82%). There was a strong interest in support systems such as health care insurance (70%) and alternative therapies (66%). The most common source of information for patients was their gastroenterologist (70%); however, most (70%) patients preferred to obtain their information from the Crohn's and Colitis Canada website. CONCLUSIONS: The impact of IBD on interpersonal relationships and leisure activities was significant among IBD patients and their families. Understanding the disease, but also alternative treatment options, was of high interest. Currently, there is a discrepancy between interest in information topics and their availability. Respondents reported a strong desire to obtain information regarding disease progression, especially extraintestinal symptoms.