Health Care Disparities and the Emergency Management of Postpartum Patients with Cardiovascular Complaints.

OBJECTIVE: This study aimed to determine health care disparities in evaluation and admission among underserved racial and ethnic minority groups presenting with cardiovascular complaints during the first postpartum year according to patient and provider demographics. STUDY DESIGN: A retrospective cohort study was performed on all postpartum patients who sought emergency care between February 2012 and October 2020 in a large urban care center in Southeastern Texas. Patient information was collected according to International Classification of Diseases 10th Revision codes and individual chart analysis. Race, ethnicity, and gender information were self-reported for both patients on hospital enrollment forms and emergency department (ED) providers on their employment records. Statistical analysis was performed with logistic regression and Pearson's chi-square test. RESULTS: Of 47,976 patients who delivered during the study period, 41,237 (85.9%) were black, Hispanic, or Latina and 490 (1.1%) presented to the ED with cardiovascular complaints. Baseline characteristics were similar between groups; however, Hispanic or Latina patients were more likely to have had gestational diabetes mellitus during the index pregnancy (6.2 vs. 18.3%). There was no difference in hospital admission between groups (17.9% black vs. 16.2% Latina or Hispanic patients). There was no difference in the hospital admission rate by provider race or ethnicity overall (p = 0.82). There was no difference in the hospital admission rate when a patient was evaluated by a provider of a different race or ethnicity (relative risk [RR] = 1.08, CI: 0.6-1.97). There was no difference in the rate of admission according to the self-reported gender of the provider (RR = 0.97, CI: 0.66-1.44). CONCLUSION: This study illustrates that disparities did not exist in the management of racial and ethnic minority groups who presented to the ED with cardiovascular complaints during the first postpartum year. Patient-provider discordance in race or gender was not a significant source of bias or discrimination during the evaluation and treatment of these patients. KEY POINTS: · Adverse postpartum outcomes disproportionately affect minorities.. · There was no difference in admissions between minority groups.. · There was no difference in admissions by provider race and ethnicity..

Performance evaluation and acceptability of point-of-care Trichomonas vaginalis testing in adult female emergency department patients.

We evaluated the accuracy and perception of a patient self-administered, tablet-facilitated rapid Trichomonas vaginalis (TV) point-of-care (POC) test in adult female emergency department (ED) patients.ED patients undergoing gynecologic examination were eligible. Each consented participant self-collected a vaginal swab, performed a tablet-facilitated TV rapid test using the OSOM® Trichomonas Rapid Test, and completed pre- and post-test self-surveys. After the self-test, the clinician collected one standard-of-care (SOC) vaginal swab for wet-mount testing and two for research. The research coordinator performed the TV rapid test using the clinician-collected swab, and reported the results to the clinician and patient. If the self- and coordinator-performed results were discordant, a TV nucleic acid amplification test (NAAT) was performed in a clinical laboratory. A survey was later administered to providers to assess their perceptions of the utility of the POC TV test.Of the 136 participants, 134 (98.5%) completed self-testing; two had invalid results. Comparing coordinator-performed TV rapid test adjudicated with NAAT, the sensitivity and specificity of self-administered test was 96.0% and 100%, respectively. The wet mount had a sensitivity of 52.0% and specificity of 100%. TV detection increased from 9.6% with wet mount to 18.4% with the TV rapid test. Most women (82.0%) stated self-testing was "not at all hard" (versus 66.2% before testing, p < 0.001). Clinicians indicated the TV rapid test affected their clinical management in 48.5% of cases, including 82.6% of positive cases and 41.6% of negative cases.ED patients were able to reliably collect, perform, and interpret their own POC TV test using tablet instructions. Both participants and providers reported high levels of acceptability of POC TV testing, which nearly doubled rates of TV detection.

Advanced liver fibrosis and care continuum in emergency department patients with chronic hepatitis C.

BACKGROUND: FIB-4, a non-invasive serum fibrosis index (which includes age, ALT, AST, and platelet count), is frequently available during ED visits. Our objective was to define 1-year HCV-related care outcomes of ED patients with known HCV, for the overall group, and both those with and without advanced fibrosis. METHODS: As part of an ongoing HCV linkage-to-care (LTC) program, HCV-infected ED patients were identified retrospectively via medical record review. Components of FIB-4 were abstracted, and patients with an FIB-4 > 3.25 were classified with advanced fibrosis and characterized with regards to downstream HCV care continuum outcomes at one-year after enrollment. RESULTS: Of the 113 patients with known HCV, 38 (33.6%) had advanced fibrosis. One-year outcomes along the HCV care continuum after ED encounter for 'all' 113, 75 'without advanced fibrosis', and 38 'advanced fibrosis' patients, respectively, were as follows: agreeing to be linked to care [106 (93.8%), 72 (96.0%), 34 (89.5%)]; LTC [38 (33.6%), 21 (28.0%), 17 (44.7%)]; treatment initiation among those linked [16 (42.1%), 9 (42.9%), 7 (41.2%)]; sustained virologic response 4 weeks post-treatment among those treated [15 (93.8%), 9 (100.0%), 6 (85.7%)]; documented all-cause mortality [10 (8.8%), 3 (4.0%), 7 (18.4%)]. Notably, 70% of those who died had advanced fibrosis. For those with advanced liver fibrosis, all-cause mortality was significantly higher, than those without (18.4% versus 4.0%, p = 0.030). CONCLUSIONS: Over one-third of HCV-infected ED patients have advanced liver fibrosis, incomplete LTC, and higher mortality, suggesting this readily-available FIB-4 might be used to prioritize LTC services for those with advanced fibrosis.

Cervical ribs: identification on MRI and clinical relevance.

To determine the prevalence of cervical ribs on cervical spine MRI and clinical relevance, we reviewed 2500 studies for cervical ribs and compression of neurovascular structures and compared to CT, when available. Brachial plexus or subclavian artery contact by cervical rib was identified on MRI and/or CT in 12 cases with diagnosis of thoracic outlet syndrome in one. Cervical ribs were identified on 1.2% (25/2083) of examinations, lower than on CT (2%), but MRI may offer equivalent anatomic explanation for patient symptoms.

Reporting of critical findings in neuroradiology.

OBJECTIVE: The objective of our study was to assess compliance among academic neuroradiologists in reporting institutionally derived critical findings. MATERIALS AND METHODS: We analyzed 3054 neuroradiology CT and MRI reports generated in 1 month. Reports were categorized by whether or not they contained a critical finding based on a previously established list. The reports were subcategorized by whether the reporting neuroradiologist flagged the report as containing a critical finding and whether the radiologist verbally communicated the critical finding to the referring clinician. Reports were divided into day or night categories and the frequency of critical findings for each time period was calculated. RESULTS: Of the 3054 reports included in this study, 301 (9.9%) had critical findings. Of those 301 reports, 233 (77.4%) were flagged and the referring clinician was called. Of the remaining 68 reports with critical findings, the reporting radiologist did not call the clinician about 35.3% of them (24/68). Of the 2753 reports without critical findings, 2658 (96.5%) were appropriately not flagged and the clinician was not called. However, radiologists called clinicians about 3.5% (95/2753) of the reports without critical findings and erroneously flagged 68.4% (65/95) of those reports as critical. A majority of the cases with critical findings were reported at night (55.1%) despite the fact that 67.2% of the studies occurred during the day. CONCLUSION: Compliance with reporting and communicating critical findings must be monitored. Calling clinicians to report noncritical findings may result in unnecessary interruptions in work flow for radiologists and referring health care providers.

Determination and communication of critical findings in neuroradiology.

PURPOSE: The aims of this study were to analyze reporting of critical findings among neuroradiologists in a university setting and to revise a list of critical findings reflecting an academic clinical practice as part of a practice quality improvement project. MATERIALS AND METHODS: Neuroradiologic studies performed between January 1 and February 28, 2011, containing "critical finding" notations were searched. Reports were matched with an institutionally approved list of critical findings. These findings and unlisted items that were labeled critical were analyzed for frequency, clinical severity, and diagnosis category. The list was revised on the basis of frequency and severity results. RESULTS: A total of 12,607 reports contained 871 critical findings, 608 of which (69.8%) matched the preexisting list. One-third of the findings (263 of 871) labeled critical were not found on the list. Facial, spinal, and calvarial fractures (76 of 263 [28.9%]) and neurovascular injuries (38 of 263 [14.4%]) were the most frequent unlisted findings. A revised list encompassed 86.7% of all communicated neuroradiologic critical findings. CONCLUSIONS: Clinician-approved and neuroradiologist-approved standardized sets of critical findings can facilitate the communication of important results without "overcalling" and decreasing efficiency. Physician judgment of what constitutes a critical finding supersedes any such list, as clinical scenarios are highly variable from patient to patient. Critical findings lists require intermittent revision to reflect practice patterns and changing incidence of disease. Such a review can constitute a practice quality improvement initiative.