Validity of claims-based algorithms to identify neurodevelopmental disorders in children.

PURPOSE: To validate healthcare claim-based algorithms for neurodevelopmental disorders (NDD) in children using medical records as the reference. METHODS: Using a clinical data warehouse of patients receiving outpatient or inpatient care at two hospitals in Boston, we identified children (≤14 years between 2010 and 2014) with at least one of the following NDDs according to claims-based algorithms: autism spectrum disorder/pervasive developmental disorder (ASD), attention deficit disorder/other hyperkinetic syndromes of childhood (ADHD), learning disability, speech/language disorder, developmental coordination disorder (DCD), intellectual disability, and behavioral disorder. Fifty cases per outcome were randomly sampled and their medical records were independently reviewed by two physicians to adjudicate the outcome presence. Positive predictive values (PPVs) and 95% confidence intervals (CIs) were calculated. RESULTS: PPVs were 94% (95% CI, 83%-99%) for ASD, 88% (76%-95%) for ADHD, 98% (89%-100%) for learning disability, 98% (89%-100%) for speech/language disorder, 82% (69%-91%) for intellectual disability, and 92% (81%-98%) for behavioral disorder. A total of 19 of the 50 algorithm-based cases of DCD were confirmed as severe coordination disorders with functional impairment, with a PPV of 38% (25%-53%). Among the 31 false-positive cases of DCD were 7 children with coordination deficits that did not persist throughout childhood, 7 with visual-motor integration deficits, 12 with coordination issues due to an underlying medical condition and 5 with ADHD and at least one other severe NDD. CONCLUSIONS: PPVs were generally high (range: 82%-98%), suggesting that claims-based algorithms can be used to study NDDs. For DCD, additional criteria are needed to improve the classification of true cases.

Anesthesia Type Is Not Associated With Postoperative Complications in the Care of Patients With Lower Extremity Traumatic Fractures.

BACKGROUND: Lower extremity fracture fixation is commonplace and represents the majority of orthopedic trauma surgical volume. Despite this, few studies have examined the use of regional anesthesia or neuraxial anesthesia (RA/NA) versus general anesthesia (GA) in this surgical population. We aimed to determine the overall rates of RA/NA use and whether RA/NA was associated with lower mortality and morbidity versus GA for patients with lower extremity orthopedic trauma. METHODS: We conducted a propensity-matched, retrospective cohort study of hospitalized patients. We used the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) dataset to identify patients undergoing surgical correction of low velocity orthopedic lower extremity traumas between 2011 and 2016. Patients were separated into 2 groups based on anesthesia type (RA/NA versus GA). The primary outcome was 30-day mortality. Secondary outcomes included return to the operating room, failure to wean from the ventilator, intubation, pneumonia, acute kidney injury, myocardial infarction, transfusion, venous thromboembolism (VTE), urinary tract infection, sepsis, length of stay, days from operation to discharge, number of complications, and unplanned readmission. RESULTS: We identified 18,467 patients undergoing surgical repair of lower extremity fractures. Approximately 9.58% had RA/NA and 89.9% had GA as their primary anesthetic. After 1:1 propensity matching, the final cohort had 3254 patients. Our analysis did not find a difference in 30-day mortality between the 2 groups. There were also no significant differences in secondary outcomes. CONCLUSIONS: Despite the potential advantages of RA/NA, utilization for lower extremity trauma was low in our analysis; only 9.58% of patients were in the RA/NA group, with the majority receiving spinal anesthesia. This may be due to surgeon preference to allow for postoperative monitoring for neurologic injury and compartment syndrome or logistical factors given the urgent nature of these trauma cases. No significant differences in 30-day mortality and postoperative complications were found between RA/NA and GA for patients with lower extremity orthopedic fractures. The choice of anesthesia is multifactorial and may be driven by patient and provider preferences in these operations.

Anesthesiology Control Tower-Feasibility Assessment to Support Translation (ACTFAST): Mixed-Methods Study of a Novel Telemedicine-Based Support System for the Operating Room.

BACKGROUND: Despite efforts to improve patient outcomes, major morbidity and mortality remain common after surgery. Health information technologies that provide decision support for clinicians might improve perioperative and postoperative patient care. Evaluating the usability of these technologies and barriers to their implementation can facilitate their acceptance within health systems. OBJECTIVE: This manuscript describes usability testing and refinement of an innovative telemedicine-based clinical support system, the Anesthesiology Control Tower (ACT). It also reports stakeholders' perceptions of the barriers and facilitators to implementation of the intervention. METHODS: Three phases of testing were conducted in an iterative manner. Phase 1 testing employed a think-aloud protocol analysis to identify surface-level usability problems with individual software components of the ACT and its structure. Phase 2 testing involved an extended qualitative and quantitative real-world usability analysis. Phase 3 sought to identify major barriers and facilitators to implementation of the ACT through semistructured interviews with key stakeholders. RESULTS: Phase 1 and phase 2 usability testing sessions identified numerous usability problems with the software components of the ACT. The ACT platform was revised in seven iterations in response to these usability concerns. Initial satisfaction with the ACT, as measured by standardized instruments, was below commonly accepted cutoffs for these measures. Satisfaction improved to acceptable levels over the course of revision and testing. A number of barriers to implementation were also identified and addressed during the refinement of the ACT intervention. CONCLUSIONS: The ACT model can improve the standard of perioperative anesthesia care. Through our thorough and iterative usability testing process and stakeholder assessment of barriers and facilitators, we enhanced the acceptability of this novel technology and improved our ability to implement this innovation into routine practice. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s40814-018-0233-4.

Anesthesiology Control Tower: Feasibility Assessment to Support Translation (ACT-FAST)-a feasibility study protocol.

BACKGROUND: Major postoperative morbidity and mortality remain common despite efforts to improve patient outcomes. Health information technologies have the potential to actualize advances in perioperative patient care, but failure to evaluate the usability of these technologies may hinder their implementation and acceptance. This protocol describes the usability testing of an innovative telemedicine-based intra-operative clinical support system, the Anesthesiology Control Tower, in which a team led by an attending anesthesiologist will use a combination of established and novel information technologies to provide evidence-based support to their colleagues in the operating room. METHODS: Two phases of mixed-methods usability testing will be conducted in an iterative manner and will evaluate both the individual components of the Anesthesiology Control Tower and their integration as a whole. Phase I testing will employ two separate "think-aloud" protocol analyses with the two groups of end users. Segments will be coded and analyzed for usability issues. Phase II will involve a qualitative and quantitative in situ usability and feasibility analysis. Results from each phase will inform the revision and improvement of the Control Tower prototype throughout our testing and analysis process. The final prototype will be evaluated in the form of a pragmatic randomized controlled clinical trial. DISCUSSION: The Anesthesiology Control Tower has the potential to revolutionize the standard of care for perioperative medicine. Through the thorough and iterative usability testing process described in this protocol, we will maximize the usefulness of this novel technology for our clinicians, thus improving our ability to implement this innovation into the model of care for perioperative medicine. TRIAL REGISTRATION: The study that this protocol describes has been registered in clinicaltrials.gov as NCT02830126.