Implementation of an audit and feedback module targeting low-value clinical practices in a provincial trauma quality assurance program: a cost-effectiveness study.

BACKGROUND: Audit and Feedback (A&F) interventions based on quality indicators have been shown to lead to significant improvements in compliance with evidence-based care including de-adoption of low-value practices (LVPs). Our primary aim was to evaluate the cost-effectiveness of adding a hypothetical A&F module targeting LVPs for trauma admissions to an existing quality assurance intervention targeting high-value care and risk-adjusted outcomes. A secondary aim was to assess how certain A&F characteristics might influence its cost-effectiveness. METHODS: We conducted a cost-effectiveness analysis using a probabilistic static decision analytic model in the Québec trauma care continuum. We considered the Québec Ministry of Health perspective. Our economic evaluation compared a hypothetical scenario in which the A&F module targeting LVPs is implemented in a Canadian provincial trauma quality assurance program to a status quo scenario in which the A&F module is not implemented. In scenarios analyses we assessed the impact of A&F characteristics on its cost-effectiveness. Results are presented in terms of incremental costs per LVP avoided. RESULTS: Results suggest that the implementation of A&F module (Cost = $1,480,850; Number of LVPs = 6,005) is associated with higher costs and higher effectiveness compared to status quo (Cost = $1,124,661; Number of LVPs = 8,228). The A&F module would cost $160 per LVP avoided compared to status quo. The A&F module becomes more cost-effective with the addition of facilitation visits; more frequent evaluation; and when only high-volume trauma centers are considered. CONCLUSION: A&F module targeting LVPs is associated with higher costs and higher effectiveness than status quo and has the potential to be cost-effective if the decision-makers' willingness-to-pay is at least $160 per LVP avoided. This likely represents an underestimate of true ICER due to underestimated costs or missed opportunity costs. Results suggest that virtual facilitation visits, frequent evaluation, and implementing the module in high-volume centers can improve cost-effectiveness.

Development of a Patient-Reported Experience Measure Tool for Ambulatory Patients With Acute Unexpected Needs: The APEX Questionnaire.

Background: The aim of this study was to develop a patient-reported experience measure (PREM) for comparing the experience of care received by ambulatory patients with acute unexpected needs presenting in emergency departments (EDs), walk-in clinics, and primary care practices. Methods: The Ambulatory Patient EXperience (APEX) questionnaire was developed using a 5-phase mixed-methods approach. The questionnaire was pretested by asking potential users to rate its clarity, usefulness, redundancy, content and face validities, and discrimination on a 9-point scale (1 = strongly disagree to 9 = strongly agree). The pre-final version was then tested in a pilot study. Results: The final questionnaire is composed of 61 questions divided into 7 sections. In the pretest (n = 25), median responses were 8 and above for all dimensions assessed. In the pilot study, 63 participants were enrolled. Adjusted results show that access, cleanliness, and feeling treated with respect and dignity by nurses and physicians were significantly better in the clinics than in the ED. Conclusion: We developed a questionnaire to assess and compare experience of ambulatory care in different clinical settings.

Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada.

OBJECTIVE: To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases. DESIGN: A retrospective cohort study. SETTING: This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays. PARTICIPANTS: Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma. MAIN OUTCOME MEASURES: The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients. RESULTS: We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)). CONCLUSIONS: The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

A systematic review of tools for predicting complications in patients with influenza-like illness.

Objective: To identify tools that predict the risk of complications for patients presenting to an outpatient clinic or an emergency department (ED) with influenza-like illness. Methods: We searched Medline, Embase, Cochrane Library and CINAHL from inception to July 2023. We included articles reporting on the derivation or validation of a score or algorithm used to stratify the risk of hospitalization or mortality among patients with influenza-like illness in the ED or outpatient clinic. Results: Twelve articles reporting on eight scores and six predictive models were identified. For predicting the need for hospitalization, the area under the curve (AUC) of the PMEWS and the CURB-65 ranged respectively from 0.76 to 0.94, and 0.65 to 0.88. The Community Assessment Tool had an AUC of 0.62. For predicting inpatient mortality, AUC was 0.66 for PMEWS and 0.79 for CURB-65, 0.79 for the SIRS criteria and 0.86 for the qSOFA score. Two scores were developed without external validation during the Covid-19 pandemic. The CovHos score and the Canadian Covid discharge score had an AUC ranged from 0.70 to 0.91. The predictive models performed adequately (AUC from 0.76 to 0.92) but will require external validation for clinical use. Tool diversity and study population heterogeneity precluded meta-analysis. Conclusion: Although the CURB, PMEWS and qSOFA scores appear to predict accurately the risk of complications of influenza-like illness, none were reliable enough to justify their widespread ED use. Refinement of an existing tool or development of a new tool to optimize the management of these patients is needed.

Parents' perspective on pediatric emergency department visits for low-acuity conditions before and during the COVID-19 pandemic: a cross-sectional bicentric study.

OBJECTIVES: The primary objective of this study was to describe and compare the motivation of parents/guardians to bring children with low-acuity conditions to a tertiary-care pediatric emergency department (ED) versus a clinic before and after the pandemic. The secondary objectives were to describe and compare the demographic and clinical characteristics of the population studied and the impact of the pandemic on their access to primary care services. METHODS: This is a cross-sectional study based on a survey administered to parents/guardians of patients presenting with low-acuity conditions at one of two EDs. RESULTS: The respondents numbered 659. Children were brought to a pediatric ED generally because of the perceived urgency of the condition, the presumed resource availability in the pediatric ED and the unavailability of the primary care physician. However, most respondents (n = 438, 66.5%) indicated preference for a clinic. More respondents before than during the pandemic reported they had been unable to find a doctor outside the ED (48.6% before COVID vs 26.8% during COVID, p < 0.001) but patients during the pandemic were less likely to seek care in a primary care practice or walk-in clinic (30.0% during COVID vs 48.6% before COVID, p < 0.001). In addition, the number of respondents presenting with symptoms of infection decreased by more than half after the pandemic began while the proportion of musculoskeletal and psychiatric complaints doubled. CONCLUSION: Although the pandemic has altered the landscape of presenting complaints and pediatric healthcare-seeking behaviors, most respondents indicated they would prefer to receive care in a clinic. This finding contradicts the view that most pediatric ED visits for low-acuity conditions are by choice rather than perceived necessity. Prioritizing improved access to primary care resources would better address the preferences and expectations of parents/guardians.

ABSTRAIT: OBJECTIFS: L'objectif principal de cette étude était de décrire et de comparer la motivation des parents/tuteurs à amener des enfants présentant des troubles de faible sévérité à un service d'urgence (SU) pédiatrique de soins tertiaires par rapport à une clinique avant et après la pandémie. Les objectifs secondaires étaient de décrire et de comparer les caractéristiques démographiques et cliniques de la population étudiée et l'impact de la pandémie sur leur accès aux services de soins primaires. MéTHODES: Il s'agit d'une étude transversale fondée sur une enquête menée auprès de parents/tuteurs de patients présentant des problèmes de faible sévérité à l'un des deux SU. RéSULTATS: Les répondants étaient au nombre de 659. Les enfants ont été amenés à un SU pédiatrique généralement en raison de l'urgence perçue de la condition, de la disponibilité présumée des ressources dans le SU pédiatrique et de l'indisponibilité du médecin de soins primaires. Cependant, la plupart des répondants (n = 438, 66,5%) ont indiqué une préférence pour une clinique. Plus de répondants avant que pendant la pandémie ont déclaré qu'ils avaient été incapables de trouver un médecin à l'extérieur de l'urgence (48,6% avant la COVID-19 contre 26,8% pendant la COVID-19, p < 0,001), mais les patients pendant la pandémie étaient moins susceptibles de solliciter des soins dans une clinique de soins primaires ou une clinique sans rendez-vous. (30,0% pendant la COVID-19 contre 48,6% avant la COVID-19, p < 0,001). De plus, le nombre de répondants présentant des symptômes d'infection a diminué de plus de la moitié après le début de la pandémie, tandis que la proportion de plaintes musculosquelettiques et psychiatriques a doublé. CONCLUSION: Bien que la pandémie ait modifié le portrait des raisons et des habitudes de consultation dans les urgences pédiatriques, la plupart des répondants ont indiqué qu'ils préféreraient recevoir des soins dans une clinique. Cette constatation contredit le point de vue selon lequel la plupart des visites aux urgences pédiatriques pour des problèmes de faible sévérité se font par choix plutôt que par nécessité perçue. Donner la priorité à l'amélioration de l'accès aux ressources de soins primaires permettrait de mieux répondre aux préférences et aux attentes des parents/tuteurs.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review.

STUDY OBJECTIVE: Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. METHODS: We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. RESULTS: We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. CONCLUSIONS: We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Postpandemic Evaluation of the Eco-Efficiency of Personal Protective Equipment Against COVID-19 in Emergency Departments: Proposal for a Mixed Methods Study.

BACKGROUND: The COVID-19 pandemic has had a profound impact on emergency department (ED) care in Canada and around the world. To prevent transmission of COVID-19, personal protective equipment (PPE) was required for all ED care providers in contact with suspected cases. With mass vaccination and improvements in several infection prevention components, our hypothesis is that the risks of transmission of COVID-19 will be significantly reduced and that current PPE use will have economic and ecological consequences that exceed its anticipated benefits. Evidence is needed to evaluate PPE use so that recommendations can ensure the clinical, economic, and environmental efficiency (ie, eco-efficiency) of its use. OBJECTIVE: To support the development of recommendations for the eco-efficient use of PPE, our research objectives are to (1) estimate the clinical effectiveness (reduced transmission, hospitalizations, mortality, and work absenteeism) of PPE against COVID-19 for health care workers; (2) estimate the financial cost of using PPE in the ED for the management of suspected or confirmed COVID-19 patients; and (3) estimate the ecological footprint of PPE use against COVID-19 in the ED. METHODS: We will conduct a mixed method study to evaluate the eco-efficiency of PPE use in the 5 EDs of the CHU de Québec-Université Laval (Québec, Canada). To achieve our goals, the project will include four phases: systematic review of the literature to assess the clinical effectiveness of PPE (objective 1; phase 1); cost estimation of PPE use in the ED using a time-driven activity-based costing method (objective 2; phase 2); ecological footprint estimation of PPE use using a life cycle assessment approach (objective 3; phase 3); and cost-consequence analysis and focus groups (integration of objectives 1 to 3; phase 4). RESULTS: The first 3 phases have started. The results of these phases will be available in 2023. Phase 4 will begin in 2023 and results will be available in 2024. CONCLUSIONS: While the benefits of PPE use are likely to diminish as health care workers' immunity increases, it is important to assess its economic and ecological impacts to develop recommendations to guide its eco-efficient use. TRIAL REGISTRATION: PROSPERO CRD42022302598; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=302598. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50682.

Post-COVID-19 Condition in Children 6 and 12 Months After Infection.

Importance: There is a need to understand the long-term outcomes among children infected with SARS-CoV-2. Objective: To quantify the prevalence of post-COVID-19 condition (PCC) among children tested for SARS-CoV-2 infection in pediatric emergency departments (EDs). Design, Setting, and Participants: Multicenter, prospective cohort study at 14 Canadian tertiary pediatric EDs that are members of the Pediatric Emergency Research Canada network with 90-day, 6-month, and 12-month follow-up. Participants were children younger than 18 years who were tested for SARS-CoV-2 infection between August 2020 and February 2022. Data were analyzed from May to November 2023. Exposure: The presence of SARS-CoV-2 infection at or within 14 days of the index ED visit. Main Outcomes and Measures: Presence of symptoms and QoL reductions that meet the PCC definition. This includes any symptom with onset within 3 months of infection that is ongoing at the time of follow-up and affects everyday functioning. The outcome was quantified at 6 and 12 months following the index ED visit. Results: Among the 5147 children at 6 months (1152 with SARS-CoV-2 positive tests and 3995 with negative tests) and 5563 children at 12 months (1192 with SARS-CoV-2 positive tests and 4371 with negative tests) who had sufficient data regarding the primary outcome to enable PCC classification, the median (IQR) age was 2.0 (0.9-5.0) years, and 2956 of 5563 (53.1%) were male. At 6-month follow-up, symptoms and QoL changes consistent with the PCC definition were present in 6 of 1152 children with positive SARS-CoV-2 tests (0.52%) and 4 of 3995 children with negative SARS-CoV-2 tests (0.10%; absolute risk difference, 0.42%; 95% CI, 0.02% to 0.94%). The PCC definition was met at 12 months by 8 of 1192 children with positive SARS-CoV-2 tests (0.67%) and 7 of 4371 children with negative SARS-CoV-2 tests (0.16%; absolute risk difference, 0.51%; 95% CI, 0.06 to 1.08%). At 12 months, the median (IQR) PedsQL Generic Core Scale scores were 98.4 (90.0-100) among children with positive SARS-CoV-2 tests and 98.8 (91.7-100) among children with negative SARS-CoV-2 tests (difference, -0.3; 95% CI, -1.5 to 0.8; P = .56). Among the 8 children with SARS-CoV-2 positive tests and PCC at 12-month follow-up, children reported respiratory (7 of 8 patients [88%]), systemic (3 of 8 patients [38%]), and neurologic (1 of 8 patients [13%]) symptoms. Conclusions and Relevance: In this cohort study of children tested for SARS-CoV-2 infection in Canadian pediatric EDs, although children infected with SARS-CoV-2 reported increased chronic symptoms, few of these children developed PCC, and overall QoL did not differ from children with negative SARS-CoV-2 tests.

Lack of association between four biomarkers and persistent post-concussion symptoms after a mild traumatic brain injury.

Approximately 15 % of individuals who sustained a mild Traumatic Brain Injury (TBI) develop persistent post-concussion symptoms (PPCS). We hypothesized that blood biomarkers drawn in the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and PPCS at 90 days post mild TBI. We conducted a prospective cohort study in seven Canadian EDs. Patients aged ≥ 14 years presenting to the ED within 24 h of a mild TBI who were discharged were eligible. Clinical data and blood samples were collected in the ED, and a standardized questionnaire was administered 90 days later to assess the presence of symptoms. The following biomarkers were analyzed: S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial Fibrillary Acidic Protein (GFAP). The primary outcome measure was the presence of PPCS at 90 days after trauma. Relative risks and Areas Under the Curve (AUC) were computed. A total of 595 patients were included, and 13.8 % suffered from PPCS at 90 days. The relative risk of PPCS was 0.9 (95 % CI: 0.5-1.8) for S100B ≥ 20 pg/mL, 1.0 (95 % CI: 0.6-1.5) for NSE ≥ 200 pg/mL, 3.4 (95 % CI: 0.5-23.4) for GFAP ≥ 100 pg/mL, and 1.0 (95 % CI: 0.6-1.8) for C-Tau ≥ 1500 pg/mL. AUC were 0.50, 0.50, 0.51 and 0.54, respectively. Among mild TBI patients, S100B protein, NSE, c-Tau or GFAP do not seem to predict PPCS. Future research testing of other biomarkers is needed to determine their usefulness in predicting PPCS.

Integration of primary contact physiotherapists in the emergency department for individuals presenting with minor musculoskeletal disorders: Protocol for an economic evaluation.

OBJECTIVES: 1) To compare the average cost of an emergency department (ED) visit for various minor musculoskeletal disorders between two models of care (physiotherapist and ED physician or ED physician alone); 2) To evaluate the incremental cost-effectiveness ratio (ICER) of these two models of care over a 3-month period post-initial visit; and 3) To estimate the ICER of three ED models of care (physiotherapist and ED physician, ED physician alone, physiotherapist alone) over a two-year period. METHODS: Obj.1: The costs incurred by participants in the two groups during their ED visit will be calculated using the Time-Driven Activity-Based Costing (TDABC) method. These costs will be compared using generalized linear models. Obj. 2: The ICER of the two models will be evaluated over three months via a cost-utility analysis that will combine costs and effectiveness data (quality-adjusted life years) using both Health system and Societal perspectives (patient + health system costs). Obj. 3: The 2-year ICER of the three above-mentioned models will be estimated using a mathematical model including a decision tree (0-3 months post-visit) and a Markov model (3-24 months post-visit), also using both Health system and Societal perspectives. Data to answer the three objectives will come from data collected during a randomized clinical trial (n = 78, CHU de Québec)which will be supplemented with data obtained via some of the CHU de Québec administrative databases (nominative data; SIURGE (ED management software), Cristal-Net (patient electronic record), and the ED's pharmacy transactions directory; administrative data: drug costs repository), the literature, and public cost repositories. CONCLUSION: This study will help to determine which model of care is most efficient for the management of individuals who come to the ED with minor musculoskeletal disorders. The increased involvement of various health professionals in the management of patients in the ED paves the way for the development of new avenues of practice and more efficient organization of services.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

BACKGROUND: Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. METHODS: We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. RESULTS: We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. CONCLUSIONS: We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. LEVEL OF EVIDENCE: Level II-therapeutic study.

Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial.

BACKGROUND: While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care. METHODS: We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios. DISCUSSION: On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm. TRIAL REGISTRATION: This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).

Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review.

BACKGROUND: Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs. METHODS: We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria. RESULTS: We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries. CONCLUSION: We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level III.

Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review.

OBJECTIVE: To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps. BACKGROUND: Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care. METHODS: We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II." RESULTS: We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning. CONCLUSIONS: We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

Up-to-date on cancer screening among Ontario patients seen by walk-in clinic physicians: A retrospective cohort study.

Walk-in clinics are typically viewed as high-volume locations for managing acute issues but also may serve as a location for primary care, including cancer screening, for patients without a family physician. In this population-based cohort study, we compared breast, cervical and colorectal cancer screening up-to-date status for people living in the Canadian province of Ontario who were formally enrolled to a family physician versus those not enrolled but who had at least one encounter with a walk-in clinic physician in the previous year. Using provincial administrative databases, we created two mutually exclusive groups: i) those who were formally enrolled to a family physician, ii) those who were not enrolled but had at least one visit with a walk-in clinic physician from April 1, 2019 to March 31, 2020. We compared up to date status for three cancer screenings as of April 1, 2020 among screen-eligible people. We found that people who were not enrolled and had seen a walk-in clinic physician in the previous year consistently were less likely to be up to date on cancer screening than Ontarians who were formally enrolled with a family physician (46.1% vs. 67.4% for breast, 45.8% vs. 67.4% for cervical, 49.5% vs. 73.1% for colorectal). They were also more likely to be foreign-born and to live in structurally marginalized neighbourhoods. New methods are needed to enable screening for people who are reliant on walk-in clinics and to address the urgent need in Ontario for more primary care providers who deliver comprehensive, longitudinal care.

Walk-in clinic patient characteristics and utilization patterns in Ontario, Canada: a cross-sectional study.

BACKGROUND: Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment. METHODS: We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits. RESULTS: Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients' homes than enrolling physicians' offices (0 to < 3 km: 32% v. 22%, SMD 0.21). INTERPRETATION: Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.

A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments.

OBJECTIVES: Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease. METHODS: A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health's perspectives using time-driven activity-based costing. RESULTS: The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6-8.6) and 2.7 (1.9-3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3-125.7) in the ED vs. 62.5 (57.7-67.3) in the walk-in clinic (mean difference of 56.4 (45.7-67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01-0.6). CONCLUSIONS: This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.

RéSUMé: OBJECTIFS: Notre objectif était de comparer certains des résultats sanitaires et des coûts associés à la valeur des soins dans les services d'urgence et les cliniques sans rendez-vous pour les patients ambulatoires souffrant d'une maladie respiratoire aiguë. MéTHODES: Une revue des dossiers médicaux a été réalisée d'avril 2016 à mars 2017 dans un service d'urgence et une clinique sans rendez-vous. Les critères d'inclusion étaient les suivants : (i) patients ambulatoires âgés d'au moins 18 ans, (ii) renvoyés chez eux avec un diagnostic d'infection des voies respiratoires supérieures (IVRS), de pneumonie, d'asthme aigu ou d'exacerbation aiguë de la maladie pulmonaire obstructive chronique. Le résultat primaire était la proportion de patients retournant à un service d'urgence ou à une clinique sans rendez-vous dans les trois et sept jours suivant la visite de référence. Les résultats secondaires étaient le coût moyen des soins et l'incidence de la prescription d'antibiotiques pour les patients atteints d'IVRS. Le coût des soins a été estimé à partir des perspectives du ministère de la santé, en utilisant la méthode de calcul des coûts par activité en fonction du temps. RéSULTATS: Le groupe des urgences comprenait 170 patients et le groupe des cliniques sans rendez-vous 326 patients. Les incidences des visites de retour à trois et sept jours étaient respectivement de 25,9 % et 38,2 % dans le service des urgences contre 4,9 % et 14,7 % à la clinique sans rendez-vous (risque relatif ajusté (arr) de 4,7 (IC à 95 % 2,6 à 8,6) et 2,7 (1,9-3,9)). Le coût moyen ($CAN) de la visite de référence était de 116,0 (106,3-125,7) aux urgences contre 62,5 (57,7-67,3) dans la clinique sans rendez-vous (différence moyenne de 56,4 (45,7-67,1)). La prescription d'antibiotiques pour l'IVRS était de 5,6 % aux urgences contre 24,7 % dans la clinique sans rendez-vous (arr 0,2, 0,01-0,6). CONCLUSIONS: Cette étude est la première d'un programme de recherche plus vaste visant à comparer la valeur des soins entre les cliniques sans rendez-vous et les urgences. Les avantages potentiels des cliniques sans rendez-vous par rapport aux services d'urgence (coûts moindres, incidence plus faible des visites de retour) pour les patients ambulatoires souffrant de maladies respiratoires devraient être pris en compte dans la planification des soins de santé.

Limited evidence that emergency department care is more costly than other outpatient settings for low-acuity conditions: a systematic review.

PURPOSE: Caring for patients with low-acuity conditions in Emergency Departments (ED) is often thought to cost more than treating those patients in other ambulatory settings. Understanding the relative cost of care between settings has critical implications for healthcare policy and system design. METHODS: We conducted a systematic review of papers comparing the cost of care for low-acuity and ambulatory care sensitive conditions in ED and other outpatient settings. We searched PubMed, EMBASE, CINAHL, and Web of Science for peer reviewed papers, plus Google for grey literature. We conducted duplicate screening and data extraction, and quality assessment of included studies using an adapted SIGN checklist for economic studies. We calculated an unweighted mean charge ratio across studies and summarized our findings in narrative and tabular format. RESULTS: We identified one study comparing costs. 18 studies assessed physician or facility charges, conducted in the United States, United Kingdom, and Canada, including cohort analyses (5), charge analyses (5), survey (1), and database searches (5) assessing populations ranging from 370 participants to 60 million. Charge ratios ranged from 0.60 to 13.45 with an unweighted mean of 4.20. Most (12) studies were of acceptable quality. CONCLUSION: No studies since 2001 assess the comparative costs of ED versus non-ED care for low-acuity ambulatory conditions. Physician and facility charges for ED care are higher than in other ambulatory settings for low-acuity conditions. Empirical evidence is lacking to support that ED care is more costly than similar care in other ambulatory settings.

RéSUMé: OBJECTIFS: La prise en charge des patients souffrant d'affections de faible gravité dans les services d'urgence est souvent considérée comme plus coûteuse que la prise en charge de ces mêmes patients dans d'autres structures ambulatoires. Comprendre le coût relatif des soins entre les différents environnements a des implications cruciales pour la politique des soins de santé et la conception des systèmes. MéTHODES: Nous avons procédé à un examen systématique des documents comparant le coût des soins pour les affections à faible gravité et les affections sensibles aux soins ambulatoires dans les services d'urgence et dans d'autres établissements de soins ambulatoires. Nous avons effectué des recherches dans PubMed, EMBASE, CINAHL et Web of Science pour les articles évalués par des pairs, ainsi que dans Google pour la littérature grise. Nous avons procédé à une double sélection et à une extraction des données, ainsi qu'à une évaluation de la qualité des études incluses à l'aide d'une liste de contrôle SIGN adaptée aux études économiques. Nous avons calculé un ratio moyen non pondéré pour l'ensemble des études et avons résumé nos conclusions sous forme de texte et de tableau. RéSULTATS: Nous avons identifié une étude comparant les coûts. 18 études ont évalué les frais des médecins ou des établissements, menées aux États-Unis, au Royaume-Uni et au Canada, y compris des analyses de cohortes (5), des analyses de frais (5), des enquêtes (1) et des recherches dans des bases de données (5) évaluant des populations allant de 370 participants à 60 millions de personnes. Les taux d'imputation allaient de 0,60 à 13,45, avec une moyenne non pondérée de 4,20. La plupart des études (12) étaient de qualité acceptable. CONCLUSION: Depuis 2001, aucune étude n'a évalué les coûts comparatifs des soins aux urgences par rapport aux soins hors urgences pour les affections ambulatoires de faible gravité. Les honoraires des médecins et des établissements pour les soins aux urgences sont plus élevés que dans d'autres structures ambulatoires pour les affections de faible gravité. Il n'existe pas de données empiriques permettant d'affirmer que les soins aux urgences sont plus coûteux que des soins similaires dispensés dans d'autres structures ambulatoires.

Comparison of Symptoms Associated With SARS-CoV-2 Variants Among Children in Canada.

Importance: Clinical manifestations of SARS-CoV-2 variants have not been systematically compared in children. Objective: To compare symptoms, emergency department (ED) chest radiography, treatments, and outcomes among children with different SARS-CoV-2 variants. Design, Setting, and Participants: This multicenter cohort study was performed at 14 Canadian pediatric EDs. Participants included children and adolescents younger than 18 years (hereinafter referred to as children) tested for SARS-CoV-2 infection in an ED between August 4, 2020, and February 22, 2022, with 14 days of follow-up. Exposure(s): SARS-CoV-2 variants detected on a specimen collected from the nasopharynx, nares, or throat. Main Outcomes and Measures: The primary outcome was presence and number of presenting symptoms. The secondary outcomes were presence of core COVID-19 symptoms, chest radiography findings, treatments, and 14-day outcomes. Results: Among 7272 participants presenting to an ED, 1440 (19.8%) had test results positive for SARS-CoV-2 infection. Of these, 801 (55.6%) were boys, with a median age of 2.0 (IQR, 0.6-7.0) years. Children with the Alpha variant reported the fewest core COVID-19 symptoms (195 of 237 [82.3%]), which were most often reported by participants with Omicron variant infection (434 of 468 [92.7%]; difference, 10.5% [95% CI, 5.1%-15.9%]). In a multivariable model with the original type as the referent, the Omicron and Delta variants were associated with fever (odds ratios [ORs], 2.00 [95% CI, 1.43-2.80] and 1.93 [95% CI, 1.33-2.78], respectively) and cough (ORs, 1.42 [95% CI, 1.06-1.91] and 1.57 [95% CI, 1.13-2.17], respectively). Upper respiratory tract symptoms were associated with Delta infection (OR, 1.96 [95% CI, 1.38-2.79]); lower respiratory tract and systemic symptoms were associated with Omicron variant infection (ORs, 1.42 [95% CI, 1.04-1.92] and 1.77 [95% CI, 1.24-2.52], respectively). Children with Omicron infection most often had chest radiography performed and received treatments; compared with those who had Delta infection, they were more likely to have chest radiography performed (difference, 9.7% [95% CI, 4.7%-14.8%]), to receive intravenous fluids (difference, 5.6% [95% CI, 1.0%-10.2%]) and corticosteroids (difference, 7.9% [95% CI, 3.2%-12.7%]), and to have an ED revisit (difference, 8.8% [95% CI, 3.5%-14.1%]). The proportions of children admitted to the hospital and intensive care unit did not differ between variants. Conclusions and Relevance: The findings of this cohort study of SARS-CoV-2 variants suggest that the Omicron and Delta variants were more strongly associated with fever and cough than the original-type virus and the Alpha variant. Children with Omicron variant infection were more likely to report lower respiratory tract symptoms and systemic manifestations, undergo chest radiography, and receive interventions. No differences were found in undesirable outcomes (ie, hospitalization, intensive care unit admission) across variants.

A systematic review of tools for predicting complications in patients with acute infectious diarrhea.

OBJECTIVE: To identify tools that predict the risk of complications in patients presenting to outpatient clinics or emergency departments (ED) with acute infectious diarrhea. METHODS: Medline, Embase, Cochrane Library, Web of Science and CINAHL were searched from inception to July 2021. Articles reporting on the derivation or validation of a score to stratify the risk of intravenous rehydration or hospitalization among patients with acute infectious diarrhea in the ED or outpatient clinic were retained for analysis. RESULTS: Five articles reporting on two different tools were identified. Developed to assess the risk of hospitalization of children, the EsVida scale has not been externally validated. Developed originally to assess the level of dehydration in children, the Clinical Dehydration Scale (CDS) was evaluated as a risk stratification tool. For predicting intravenous rehydration, a CDS score ≥ 1 showed a sensitivity between 0.73 and 0.88 and specificity between 0.38 and 0.69, whereas a CDS score ≥ 5 showed a sensitivity between 0.06 and 0.32 and specificity between 0.94 and 0.99. For predicting hospitalization, a CDS score ≥ 1 showed a sensitivity between 0.74 and 1.00 and specificity between 0.34 and 0.38, whereas a CDS score ≥ 5 showed a sensitivity between 0.26 and 0.62 and specificity between 0.66 and 0.96. High heterogeneity among studies and unclear risk of bias precluded meta-analysis. CONCLUSION: As a risk-stratification tool, the CDS has been validated only for children. Further research is needed to develop and validate a tool suitable for adults in the ED.