Comprehensive Electronic Medical Record Research Articles

Reducing unnecessary preoperative testing through a comprehensive EMR based digital algorithm.

We hypothesised that the implementation of an electronic medical record (EMR) embedded perioperative clinical decision support (CDS) application, Anesthesia Testing Guidelines (ATG), would result in at least a 10% reduction of unnecessary perioperative testing in patients undergoing elective surgeries. The development and implementation of ATG occurred in several phases: 1) team development, 2) development of an embedded EMR application, 3) creation of ATG training and education toolkit, and 4) implementation involving promoting ATG through training and education, addressing challenges, and monitoring compliance. The proportions of patients with any overutilisation across 19 perioperative tests were compared between the baseline cohort and the ATG implementation cohort. The overutilisation of perioperative tests was observed in 77.6% of the baseline cohort (n=59,799) and 68.1% in the ATG cohort (n=132,131), with a significant 12.2% reduction over two years of implementation (p<0.0001). The two tests with the greatest amount of associated cost were reduced by 46% for chest X-rays and 39% for complete metabolic panels. The health system was able to reduce overall costs by 22% from baseline. Interrupted time series analysis estimated an immediate 7.5% decrease in monthly overutilisation when ATG initially launched, and it continued to decrease by 0.24% per month. Our findings suggest CDS ATG is a successful tactic to reduce unnecessary preoperative testing while maintaining quality of care and improving cost avoidance. This type of CDS implementation approach transforms organisational behaviour and medical practices to follow defined guidelines, thereby improving the value of care. CDS ATG was supported by UPMC Department of Anesthesiology and Perioperative Medicine and UPMC Department of Finance.

Mood lability and depression limit oral contraceptive therapy in endometriosis.

To determine the impact of oral contraceptive (OC)-induced mood lability/depression on treatment maintenance in women with endometriosis. Women with endometriosis were retrospectively identified through International Classification of Diseases, 10th Revision, codes, and then a comprehensive electronic medical record review was conducted, identifying mood lability/depression as a reason for treatment discontinuation with the use of combined or progestin-only OCs (POCs). A total of 2,682 women with endometriosis, between the ages of 18 and 45 years treated in a university-affiliated hospital between 2012 and2024. Use of combined or POCs in patients with endometriosis. The primary outcome was OC discontinuation due to mood lability/depression in women with endometriosis. The secondary outcome assessed whether patients with a documented diagnosis of depression were more prone to discontinuing OC use due to mood lability. Mood lability/depression as a side effect of OC use was more common in women with endometriosis and increased the likelihood of discontinuing OCs. Overall, 44.2% of women with endometriosis and treated with OCs discontinued their use. The depression prevalence in our study cohort was 33.6%. Among those who discontinued, 33.9% attributed their discontinuation to mood lability/depression. Of those who discontinued OC use due to mood lability, 52.7% had a diagnosis of depression, a higher rate than those who discontinued OC use for other reasons or did not stop using OCs. There was no difference in OC discontinuation due to side effects comparing combination OCs with POCs. Similarly, the type of progestin prescribed did not influence the OC discontinuation among those who experienced mood lability/depression. Women with endometriosis had an increased incidence of depression and a greater likelihood of discontinuing OCs when they experienced mood lability or depression. Mood lability played a significant role in OC discontinuation. The effect of OC on mood lability/depression did not differ by the type of progestin. In patients with endometriosis at risk of depression or who develop mood changes on OCs, other therapies that are typically considered second line should be considered early in the course of treatment.

Improving Accuracy of Discharge Summary Medication Lists – A Comprehensive Electronic Medical Record Quality Improvement Project

Background: Discharge summaries (DSs) are an important communication tool between hospital and community clinicians however errors in these documents are common. To improve the accuracy of DS information, our health network implemented a suite of quality improvement projects that promoted “More Efficient Documentation (of patient information) for Improved Care” (MEDIC). Objective: The aim of this study was to determine if DSs post-implementation of the MEDIC program of work were associated with lower rates of medication errors. Design: A retrospective pre- (March 2021) post- (March 2022) medical record audit was conducted at five public hospitals. Patients were included chronologically based on discharge date until the target sample size was reached (100 per group). For each patient, the DS medication list was compared to the pharmacy generated patient friendly medication list or interim medication administration chart and any discrepancies were considered errors. Utilisation of electronic Clinical Decision Support (CDS) was evaluated via review of the EMR. Main Outcome Measure: Medication errors Results: The mean number of DS medication errors was lower in the post-intervention group (3.0 vs 1.4, p&lt;0.01). Fewer patients in the post-intervention group had one or more DS medication errors (59% vs 39%, p&lt;0.01). Patients in the post-intervention group were less likely to have one or more high-risk medication errors (20% vs 10% p=0.048). There were 437 individual errors (pre=298, post=139). Omitted medications were less common in the post-intervention group (127 vs 11). Utilisation of EMR home medication CDS was higher in the post-intervention group (54% vs 69%, p=0.005). Pooled data from both groups showed completion of discharge medication reconciliation CDS was associated with a lower number of errors on DSs (mean: 3.7 vs 1.4, p&lt;0.001, DS with one or more errors: 68% vs 39%, p&lt;0.001). Conclusion: The MEDIC program of work was associated with improved DS medication list accuracy.

Angle Kappa Influence on Multifocal IOL Outcomes

Purpose: To characterize angle kappa and study the relationship between preoperative angle kappa and postoperative refractive accuracy, visual outcomes, and patient satisfaction in a large population of eyes with multifocal intraocular lens (MIOL) implantation. Methods: A comprehensive electronic medical record chart review of 26,470 consecutive eyes that underwent immediate sequential bilateral cataract or refractive lens exchange with MIOLs was conducted. The primary outcome measures were postoperative monocular uncorrected distance visual acuity (UDVA), manifest refraction sphere and cylinder, spherical equivalent (SEQ), defocus equivalent (DEQ), subjective quality of vision at near, intermediate, and distance, and the likelihood of recommending the procedure. Relationships between preoperative angle kappa and postoperative outcomes were assessed with Pearson correlations. Results: Angle kappa followed a right-skewed normal distribution ( R 2 = 0.99) with a mean ± standard deviation of 0.64 ± 0.27 mm. No clinically meaningful relationship was found between preoperative angle kappa and postoperative sphere, cylinder, SEQ, and DEQ, all with R 2 ⩽ 0.0005. Similarly, there was no clinically meaningful relationship between preoperative angle kappa and postoperative UDVA ( R 2 = 0.001), postoperative satisfaction for near, intermediate, and distance vision (all R 2 ⩽ 0.0023), or for recommending the MIOL surgery to friends and relatives ( R 2 = 0.0000). Conclusions: Preoperative angle kappa does not have a predictive clinical impact on postoperative MIOL visual outcomes, refractive accuracy, or subjective patient satisfaction. Angle kappa as a single variable cannot be used to determine MIOL candidacy. [ J Refract Surg . 2023;39(12):840–849.]

Demand for oncology visits among low-risk breast cancer survivors.

490 Background: The number of breast cancer (BC) survivors in the United States is large and rapidly growing. An unsustainable number of survivors receive care from oncology providers indefinitely, with a disproportionate number of those being white, high socioeconomic women, potentially contributing to disparities in care. Demand for oncology visits among low-risk BC survivors may decrease access to care for more complex, vulnerable survivors and new cancer patients and increase costs without improving quality of care, but has not been quantified. Our study's objective was to quantify demand for oncology visits among low-risk survivors. Methods: We utilized Atrium Health Wake Forest Baptist Comprehensive Cancer Center cancer registry data and electronic medical record data to identify BC survivors with scheduled appointments with an oncology physician from 7/1/2023 to 7/1/2024, excluding patients with Stage IV disease. We defined low-risk BC survivors as those with ductal carcinoma in situ (DCIS) or Stage I BC &gt;5 years from diagnosis, or any survivor &gt;10 years from diagnosis without evidence of recurrence. We used descriptive statistics to quantify demand for oncology visits among low-risk survivors. Results: We identified 877 BC survivors with a scheduled oncology appointment. Of those, 128 (14.5%), were classified as low-risk and possibly transition-eligible, including 50 with DCIS and 66 with Stage I BC &gt;5 years from diagnosis and 57 who were &gt;10 years post-diagnosis. Conclusions: We developed an efficient method to identify low-risk BC survivors actively receiving oncology physician care. While there are limitations, such as incomplete data and lack of analytic support at smaller institutions, this is an adoptable approach to identify survivors eligible for transition of care to an oncology advanced practice provider or primary care provider. Interventions to improve transitions, and thus increase access and quality of oncologic care, must be prioritized in the face of growing numbers of survivors, rapid therapeutic advances, and oncology physician burnout.[Table: see text]

Unmet informatics needs of nurses regarding the use of personal smartphones in the workplace.

This study aimed to investigate the differences in practices, policies, and perceptions of nurses regarding work-related utilization of smartphones in acute-care settings. Mobile devices utilizing emerging technology are widely used in acute-care settings; however, concerns such as potential distraction, improper use, and negative impact on the nursing image in clinical practice remain valid. Nurse managers (n=8) and nurses (n=181) were enrolled from eight academic tertiary hospitals that have comprehensive electronic medical record systems and mobile versions. Between October 2018 and February 2019, participants completed a questionnaire designed to explore their use of smartphones. The reporting guide for self-administered surveys of clinicians was applied. Approximately 80% of nurses carried personal smartphones while working, with 70% using their devices for work. The prevalence of work-related smartphone use ranged from 3% to 43% by functionality, which was lower than that estimated by managers. Frequent uses included taking pictures/videos and internet browsing. Nurses were more positive than managers about the benefits of smartphone use and less burdened by related concerns. Novice and junior nurses were more optimistic than senior nurses. Only one hospital had a policy on nurses' use of personal devices at work. Two unmet needs in the current clinical information system were identified: information supporting task-related knowledge at the bedside and security of data capture and communication. The unintended perception gaps between nurses and managers regarding work-related smartphone use can be closed by nursing leadership. Unmet nursing informatics, particularly for information-seeking purposes, can be addressed in the context of quality assurance. Nurse leaders can advocate secure and proper use of smartphones in clinical practice.

Comanagement of Rashes by Primary Care Providers and Dermatologists: A Retrospective Study

There is a high demand for managing skin disease, and dermatologists are in short supply. To better understand how rashes and other specific skin conditions are co-managed by primary care providers (PCPs) and dermatologists, we estimated the frequency with which PCPs sought consultation with or referral to dermatology and the proportion of patients who had a follow-up dermatology office visit in the following 90 days. The retrospective longitudinal study included 106,459 patients with a skin condition diagnosed by 3,830 PCPs, from January 2017 to March 2017. Comprehensive electronic medical record data with generalized linear mixed modeling accounted for patient factors including diagnosis and clustering by medical center and PCP. PCPs escalated 9% of patients to dermatology through consultation or referral, while 5% required a follow-up dermatology office visit within 90 days. Patients with bullous, hair, or pigment conditions or psoriasis were most likely to be escalated. Clustering of escalation and follow-up visits was minimal in relation to medical center (intraclass correlation, 0.04 for both outcomes) or PCP (escalation, intraclass correlation, 0.16; follow-up visits, 0.09). Improving primary care education in skin disease and, for certain skin conditions, standardizing approaches to workup, treatment, and escalation may further streamline care and reduce pressure on the dermatologist workforce. PCPs managed 91% of rashes without consultation or referral to dermatology, and the frequency of patients scheduled for dermatology office visits after primary care was similar from one PCP to another.

REAL-WORLD OUTCOMES IN TREATMENT OF HIGHLY CALCIFIED CORONARY LESIONS WITH INTRAVASCULAR SHOCKWAVE LITHOTRIPSY

<h3>BACKGROUND</h3> Intravascular lithotripsy (IVL) has emerged as a novel modality for treatment of highly-calcified coronary lesions. However, real-world data regarding the efficacy and safety of IVL are lacking, particularly for high-risk or complicated coronary lesions. We conducted a study to determine real-world outcomes of IVL in a high-risk population. <h3>METHODS AND RESULTS</h3> A retrospective review of consecutive patients who underwent IVL at a tertiary care center between Sep 1, 2019 and Jan 31, 2021 was undertaken. A comprehensive electronic medical record and centralized cardiac catheterization database were used to ascertain clinical and procedural characteristics and outcomes of the patients. The primary outcome was major adverse cardiac events (MACE), defined as death, myocardial infarction, or unplanned target vessel revascularization. Secondary outcomes included angiographic success and freedom from angina. 50 patients, totalling 64 lesions, underwent IVL during the study period. 3 patients suffered in-hospital mortality unrelated to the IVL; there was no other occurrence of MACE in hospital or at 30 days. Angiographic success was near universal (98% of patients with residual stenosis < 50%, and 96% of patients with TIMI 3 flow) and periprocedural complication was very rare. Among patients undergoing IVL of in-stent restenosis (ISR) (n=13) or left main coronary artery (LMCA) (n=12) lesions, angiographic success was universal and there was no occurrence of periprocedural complication or 30-day MACE. <h3>CONCLUSION</h3> In a high-risk real-world cohort, including patients with acute coronary syndrome and those undergoing PCI of the LMCA and ISR lesions, IVL was a highly safe and effective treatment for highly-calcified coronary lesions.

Decreased in-hospital mortality rate following implementation of a comprehensive electronic medical record system.

To evaluate changes in in-hospital mortality rate following implementation of a comprehensive electronic medical record (EMR) system. Before and after study of 355,709 hospital discharges, over an 8-year period, at a paediatric teaching hospital. The major outcome measures were crude number of in-hospital deaths, deaths per 1000 discharges, and standardised mortality ratio. Primary analysis of data from 2 years before and 2 years after EMR go-live showed a reduction in absolute mortality of 33 deaths, a reduction in the mortality rate of 0.48 per 1000 discharges (95% CI 0.09, 0.88 per 1000): and a relative 22% decrease (95% CI: 4%, 36%, P= 0.02) in deaths per 1000 discharges from 2.20 to 1.72. There was also a reduction in standardised mortality ratio of 47% (95% CI: 18%, 66%, P= 0.004). Post-hoc analysis of mortality rates for an additional 2-year pre-intervention period indicated that these changes in the mortality rate were not part of a pre-existing downward trend. Further analysis of an additional 20-month post-intervention period suggests that the reduced mortality rate has been sustained. We documented evidence of a clinically important decrease in in-hospital mortality rate following the implementation of a modern comprehensive EMR system in an Australian paediatric teaching hospital. The study does not prove a causal relationship, and it is possible that other factors explain some, or all, of this difference, but no changes in the hospital population or other major interventions were identified as alternative explanations for this observed change.

The Impact of Upgrade towards Comprehensive Electronic Medical Record System on Hospital Performance: A Single Tertiary Care Center Experience in Saudi Arabia

In line with the global trend, hospitals in the Kingdom of Saudi Arabia, including tertiary medical care centers, have increasingly adopted comprehensive electronic medical record (EMR) systems in the past twenty years. However, knowledge of these systems and the extent of their impact on performance is still limited in the Kingdom due to the lack of studies researching in this field. Accordingly, this study aims to investigate the impact of implementing a comprehensive EMR system in King Abdullah Medical City (KAMC) on hospital performance and to test the assumed hypotheses which propose that implementing a comprehensive EMR significantly improves the clinical effectiveness, patient-centeredness, patients’ safety and production efficiency in an advanced tertiary care setting in Saudi Arabia. To achieve this, a quantitative cross-sectional survey was conducted, using a valid questionnaire, on a random representative sample of 150 participants from healthcare professionals working in KAMC who experienced the upgrade towards the comprehensive EMR. The data collected was analyzed and the results showed the existence of statistically significant relationships between the implementation of comprehensive EMR as an independent variable and the four investigated dependent variables which are clinical effectiveness, patient-centeredness, patients’ safety and production efficiency in an advanced tertiary care setting in Saudi Arabia at significance level p=0.000 < 0.05. The study concluded the necessity of implementing comprehensive EMR to the point where tertiary care hospitals should pay attention to the application of such advanced electronic system because of their role in improving health care performance. Eventually, the study recommends the need to build an integrated EMR system at the level of the Kingdom that ensures the safe exchange of information between hospitals and health national centers which would enhance the provision of more distinguished health service for each patient, increase administrative efficiency and reduce the use of traditional means of recording like paper.

Development of an Electronic Medical Record for Extracorporeal Membrane Oxygenation and Its Role in a Multidisciplinary Team.

As the extracorporeal membrane oxygenation (ECMO) program at our institution has grown and our staffing model has evolved into a multidisciplinary team, our method of ECMO charting has also evolved, using an electronic medical record (EMR) with electronic checklists, progress notes, and remote access. Using our EPIC charting platform, version 1 of our EMR was implemented in 2015. It has been revised three times, and remote access deemed necessary to properly support our staff and patients. Our current, yet still evolving, remotely accessible, ECMO EMR incorporates hourly charting and protocol-based checklists for procedures such as initiation of support, shift handoffs, circuit checks, and patient transport. Perfusionists are required to fill out thrice daily progress notes, notes for bedside/operating room procedures, and patient transport. We present a format for centers looking to implement a comprehensive EMR for ECMO patients. An expanding ECMO program required a change to our staffing model, and an EMR with electronic checklists and remote access facilitated the transition to a multidisciplinary team. Protocol-based checklists ensure consistency during procedures, transports, and shift changes. The remote access and required progress notes create a safer team approach and keep our perfusionists engaged when specialists are sitting ECMO.

Development of an Electronic Medical Record for Extracorporeal Membrane Oxygenation and Its Role in a Multidisciplinary Team

As the extracorporeal membrane oxygenation (ECMO) program at our institution has grown and our staffing model has evolved into a multidisciplinary team, our method of ECMO charting has also evolved, using an electronic medical record (EMR) with electronic checklists, progress notes, and remote access. Using our EPIC charting platform, version 1 of our EMR was implemented in 2015. It has been revised three times, and remote access deemed necessary to properly support our staff and patients. Our current, yet still evolving, remotely accessible, ECMO EMR incorporates hourly charting and protocol-based checklists for procedures such as initiation of support, shift handoffs, circuit checks, and patient transport. Perfusionists are required to fill out thrice daily progress notes, notes for bedside/operating room procedures, and patient transport. We present a format for centers looking to implement a comprehensive EMR for ECMO patients. An expanding ECMO program required a change to our staffing model, and an EMR with electronic checklists and remote access facilitated the transition to a multidisciplinary team. Protocol-based checklists ensure consistency during procedures, transports, and shift changes. The remote access and required progress notes create a safer team approach and keep our perfusionists engaged when specialists are sitting ECMO.

Surveying perceptions of the early impacts of an integrated electronic medical record across a hospital and healthcare service.

Objective This study provides insights into the reported early impacts of the digital transformation of a large Australian hospital and healthcare service (HHS) by surveying staff perceptions of an integrated electronic medical record (ieMR). Methods The information systems success model was used as a tool to evaluate perceptions of system quality, information quality, individual benefits and expected organisational benefits of the ieMR soon after its introduction at the HHS. A questionnaire was distributed to staff in all five hospitals in the HHS immediately after implementation. Overall staff perceptions were examined, in addition to how perceptions differed by site and profession. Results Overall, staff held mildly positive early perceptions of system quality, information quality, individual benefits and expected organisational benefits. These views were largely consistent across sites. In terms of professions, allied health held more positive perceptions, followed by administrative and nursing professionals. Medical professionals held negative perceptions, but were neutral regarding their future expectations. Conclusion On average, staff viewed the ieMR mildly positively immediately after implementation (despite significant changes to work practices), but differences exist across professional groups. What is known about the topic? Hospitals globally are in the midst of a digital transformation. Yet, reported impacts are mixed and there have been few studies of the effects of comprehensive electronic medical record (EMR) implementations. What does this paper add? This paper evaluates a comprehensive EMR immediately after go-live. We found positive early perceptions of system quality, information quality, individual benefits and expected organisational benefits. We also found that perceptions of medical professionals were largely negative, but they were neutral in terms of their future expectations. What are the implications for practitioners? Health services may be unsure of the effect of implementing a comprehensive EMR because of conflicting reports in the literature, some touting major benefits, others stressing major costs. Our results paint a middle-ground picture immediately after implementation. Staff perceptions are mildly positive on average, which is reassuring given the results were obtained during the early disruptive period after implementation.

Impact of Neurocognitive Dysfunction in a Veteran Population Undergoing First Outpatient Autologous Hematopoietic Stem Cell Transplantation for Multiple Myeloma

INTRODUCTION Older adults (age &gt; 70 years) with multiple myeloma (MM) are at higher risk of early mortality partly due to age-related factors, including impairments of cognition and function. To date, few studies have investigated the prevalence of neurocognitive impairment prior to autologous hematopoietic stem cell transplantation (ASCT) and its impact on post-transplant outcomes. We hypothesize, for patients with MM undergoing first outpatient ASCT, age &gt;70 years or the presence of comorbid neurocognitive dysfunction decreases the time to first unplanned hospitalization occurring within 30 days post ASCT, and increases the overall length of stay (LOS) on the transplant service. METHODS We conducted a retrospective cohort study of 76 consecutive patients who underwent first ASCT at the Puget Sound Veterans Health Administration, for MM between January 2017 and December 2018. Patients with the following were excluded: amyloidosis, anaplastic plasmacytoma, and POEMS. Comprehensive psychological evaluations performed within 30 days prior to ASCT included: cognitive screening [Montreal Cognitive Assessment (MOCA)], depression [Patient Health Questionnaire-9 (PHQ-9)], and anxiety [General Anxiety Disorder- 7 (GAD-7)]. Functional status was assessed by activities of daily living (ADLS) and instrumental activities of daily living (IADLS). Data sources for table 1, included the institutional stem cell transplant database, and comprehensive electronic medical record review for each patient. This included vital status as of 7/15/19. Total LOS on the transplant service was measured as the time from arrival until discharge post-engraftment. For eligible patients, all portions of ASCT, including, stem cell collection, conditioning and stem cell infusion were completed as an outpatient. Statistical analyses were performed using SAS version 9.4. Kaplan Meier curves were generated to explore the association of cognitive scores and 1) time until first unplanned hospitalization within 30 days post-ASCT and 2) outpatient LOS on the stem cell transplant service. RESULTS Of the 76 patients undergoing ASCT, median age was 67 (range 40-79), 29% (22/76) were ≥ 70 years old . 67% (51/76) underwent ASCT within 1 year from diagnosis. The majority (73/76) scored ≥ 70 on a provider-assessed Karnofsky performance scale. Of those with MOCA scores available (n=64), impairments in cognition ranged from suspected mild cognitive impairment (MOCA 20-25) to probable cognitive impairment (MOCA 15-19), in 50% (32/64) and 6%( 8/64) of patients respectively. Those with MOCA scores&lt; 26 were more likely to have ≥ 1 IADL impairment compared to those with scores ≥ 26 (Fisher Exact p=0.014). A total of 19 patients underwent planned hospitalization for conditioning followed by stem cell rescue, and therefore were not included in our analysis of unplanned hospitalization. Of the 57% (33/59) of patients with an unplanned inpatient admission within 30 days post-ASCT, the median time to first admission was 11 days. A total of 61% (17/28) and 53%(10/19) patients with MOCA &lt;26 and ≥26, respectively, required hospitalization post-ASCT (log-rank p-value=0.70). There was no difference in the time to first unplanned hospitalization by age (&lt;70, ≥70 years; log-rank p-value 0.58). Median time spent on the transplant service was 78 days (range 30 - 118). Suspected cognitive impairment did not influence time on the outpatient transplant service (median: 79 days MOCA &lt;26 and 77 days MOCA ≥ 26, log-rank p-value=0.38). Median number of days on the transplant service differed by age group (log-rank p-value=0.02),) 76 vs 79 days in those age &lt;70 and ≥70 respectively. CONCLUSION We found a high prevalence of cognitive impairment in MM patients undergoing first ASCT. However, we found no significant association between cognitive impairment or age and 30-day unplanned hospitalization. Older age (&gt;70 years) was associated with a longer transplant service LOS. Thus, select older patients may have higher utilization of hospital resources post-ASCT compared to their younger counterparts. However confounding variables and selection bias may have influenced these preliminary results and additional analyses are ongoing. Future studies will evaluate the impact of age and pre-transplant neurocognitive function on additional outcomes, including longitudinal neurocognitive deterioration and impact on long-term morbidity and mortality. Disclosures Graf: TG Therapeutics: Research Funding; AstraZeneca: Research Funding; BeiGene: Research Funding.

Primary Umbilical Hernia Repair: A Large-Volume Single-Surgeon Study

There are conflicting views regarding techniques for repair of small umbilical hernias (UHs). Here, we compare the recurrence rate in primary repair with that reported for mesh repair by examining a single surgeon's practice at a large medical center with a comprehensive electronic medical record. A six-year retrospective review of primary UH repairs between January 2012 and December 2017 at Kaiser Permanente Los Angeles Medical Center was undertaken. Patients were identified through a database search of the electronic medical record. The primary endpoint of UH recurrence was examined; median follow-up was 3.4 years. Primary, elective UH repair was performed in 244 patients; 71 per cent of hernias were small (<2 cm). The total number of recurrences was seven (3%). The t test analysis showed significant differences in the average size of hernia defects between those with recurrences (2 cm) and those without (1.4 cm), P < 0.05. Primary repair affords low infection and recurrence rates, comparable to those reported for mesh repair. Our single-surgeon/large-volume study contributes to the evidence that primary UH repair is a safe and durable method, with low risk of recurrence. The use of absorbable monofilament suture, and selection for lower BMI and smaller hernia sizes proved to be effective.

Outcomes Following ACL Reconstruction Using Patellar Tendon Versus Hamstring Tendon Autograft In Adolescent Athletes: An Age, Sex, And Bmi-matched Comparative Cohort Study

Objectives: The purpose of this study is to compare the re-tear rates and medium-term functional outcomes in matched cohorts of adolescent athletes who underwent primary anterior cruciate ligament reconstruction (ACLR) with patellar tendon/bone-tendon-bone autograft (BTB) versus hamstring tendon autograft (HS). Methods: An initial cohort of 731 patients, aged 13-19 years, who underwent ACLR-BTB or ACLR-HS between 2003-2015 at a pediatric tertiary care hospital by one of 5 surgeons, was identified through a comprehensive electronic medical record database query. Propensity score matching was performed through a logistic regression model, based on characteristics frequently used by some surgeons to guide graft selection: age, sex, and body mass index (BMI). The resultant cohort of 269 patients allowed for a 1:2 (BTB: HS, 83:186) match. A chart review was performed to identify patient demographics, surgical data, and post-operative outcomes, including ACL re-tear and length of clinical follow-up. Patients were additionally contacted to obtain longer term sport participation and re-injury data that may have been investigated or addressed at outside institutions, as well as to obtain patient reported outcomes (PRO) using validated knee function and activity questionnaires (Pedi-IKDC and HSS-Pedi FABS). Individual questions from the Pedi-IKDC that related to anterior knee pain or kneeling pain were specifically investigated to assess the potential effect of these factors, commonly cited aspects of donor site morbidity associated with BTB grafts, on overall scores within this adolescent population. Results: No significant differences were seen in demographic and clinical characteristics of the two matched graft-based cohorts (overall mean clinical follow-up: 54 months), as listed in Table 1. In the sub-population providing PROs (52% response rate, mean PRO follow up: 81 months), no significant differences were seen in activity level, median Pedi-IKDC scores, or knee pain. BTB patients demonstrated superior scores regarding ability to kneel than HS patients. Rates of ACL graft re-tear were not significantly different between groups, both when calculated based on all possible follow-up methods (ACLR-BTB: 11%; ACLR-HS: 12%; p: 0.72), or amongst patients responding to long-term follow up. Conclusion: Despite previous studies, including large, multi-country registry-based analyses, demonstrating lower re-tear rates following ACLR-BTB than ACLR-HS, the current study, focused exclusively on adolescent cohorts matched for age, sex, and BMI, showed no difference in graft re-tear rates between the two cohorts at medium-term follow-up. Moreover, activity scores and overall functional knee outcome scores appear to be equivalent between these younger graft-based populations, with no suggestion of increased donor site morbidity with BTB autograft, as it relates to knee pain or kneeling ability. For skeletally mature adolescents, graft choice may not influence outcome following ACL reconstruction. Consistent with previous studies, the current study reveals relatively high ACL re-tear rates in adolescents, the sub-population most affected by this common injury. [Table: see text]

OUTCOMES FOLLOWING ACL RECONSTRUCTION USING PATELLAR TENDON VERSUS HAMSTRING TENDON AUTOGRAFT IN ADOLESCENT ATHLETES: AN AGE-MATCH, SEX-MATCHED, AND BODY MASS INDEX-MATCHED COHORT STUDY

Background: Anterior cruciate ligament reconstruction (ACLR) remains one of the most commonly performed orthopaedic surgeries in adolescents and young adults. However, selection of the optimal graft for the individual patient remains controversial, considering multiple graft options, subtle technique differences, and wide-ranging bodies of evidence for each graft option in largely adult populations. However, multiple epidemiologic studies clearly demonstrate adolescents as the most greatly affected age-based sub-population, with the highest rates of re-tear and global morbidity, due to psychological and physical effects of long absences from athletic activity. Nevertheless, methodologically rigorous comparative studies specific to the adolescent athlete are largely absent from the literature. The purpose of the current study is to therefore investigate the outcomes of ACLR in adolescents receiving either patellar tendon/bone-tendon-bone (BTB) autograft (ACLR-BTB) or hamstring tendon autograft (ACLR-HS), using retrospective propensity score matching techniques to generate comparable cohorts. Methods: The study was designed as a retrospective chart review, with collection of cross-sectional data from a single pediatric tertiary care center over a thirteen year period (2003-2015). An initial cohort of patients, aged 13-19 years at time of primary ACLR-BTB or primary ACLR-HS by one of 5 surgeons, was identified through a comprehensive electronic medical record database query. Propensity score matching of ACLR-BTB and ACLR-HS subjects through a logistic regression model, with caliper restriction of 0.1 standard deviations, was then applied, based upon specific baseline characteristics that are frequently used by some surgeons to guide graft selection: age, sex, and body mass index (BMI). The resultant cohort of patients obtained a 1:2 (ACLR-BTB: ACLR-HS, 83 patients:186 patients) match. A chart review was performed to identify patient demographics, surgical data, and post-operative outcomes including graft rupture/re-tear and length of clinical follow-up. Patients were additionally contacted to obtain longer term sport participation and re-injury data that may have been investigated or addressed at outside institutions, as well as to obtain functional outcomes using region-specific questionnaires (Pedi-IKDC and HSS-Pedi FABS), which are validated for both this younger population and adult populations. Due to previous literature-based reports on greater anterior knee pain following ACLR-BTB, compared to ACL-HS, scores from the questions specific to knee pain or kneeling pain were extracted from the Pedi-IKDC results and analyzed to assess the potential influence of anterior knee pain on overall scores within this adolescent population. Results: At time of ACLR, the mean age and BMI of the matched ACLR-BTB patients were 17.1 years (sd: +/-1.14 years) and 25.8 (sd: +/-5.04), compared to 16.9 years (sd: +/- 1.38, p: 0.18) and 24.9 (sd: +/- 5.01, p: 0.18) for matched ACLR-HS patients, with similar male preponderance (ACLR-BTB: 77%, ACLR-HS: 72%, p: 0.47) and mean length of follow-up (ACLR-BTB: 42.9 months; ACLR-HS: 43.3 months). While mean Pedi-IKDC scores were slightly higher in the ACLR-BTB group (88.8; sd: +/-10.2, range: 56.5-100) than the ACLR-HS group (85.2; sd: +/- 16.1, range: 23.9-100), this difference was not statistically different (p: 0.50). When scores on questions regarding knee pain and kneeling difficulty were analyzed, no differences were seen between graft cohorts (ACLR-BTB: median knee pain score: 4, ACLR-HS: 4 p: 0.73; ACLR-BTB median kneeling difficulty score: 4, ACLR-HS: 4, p: 0.21). Activity level, based on the HSS-Pedi FABS score, was also similar (ACLR-BTB: 16, range: 3-29 vs. ACLR-HS: 17, range: 0-30; p: 0.96). Rates of ACL graft re-tear were not significantly different between groups, both when calculated based all possible follow-up methods (ACLR-BTB: 11%, ACLR-HS: 11%, p: 0.91), or when those patients responding to long-term follow up questionnaires were isolated (ACLR-BTB: 15%, ACLR-HS: 16%, p: 0.85). Conclusion/Significance: Despite previous studies, including large, multi-country registry-based analyses, demonstrating lower re-tear rates following ACLR-BTB than ACLR-HS, the current study, focused exclusively on adolescent cohorts matched for age, sex, and BMI, showed no difference in graft re-tear rates between the two cohorts at medium-term follow-up. Moreover, activity scores and functional knee outcome scores appear to be equivalent between these younger graft-based populations. In contrast to previous studies associating BTB autograft with greater long term anterior knee pain, adolescents appear to have equal degrees of knee pain or kneeling pain, regardless of graft choice, which may stem from greater healing and biologic remodeling capacity at graft harvest sites than adults or more modern techniques of patellar bone grafting and paratenon closure. Given the consistently high adolescent ACL re-tear rates in this and other studies, continued focus on ACL prevention programs and optimizing the timing and safety of return to play remains critical.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population

This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

Frequency that Laboratory Tests Influence Medical Decisions.

Among the variables that influence medical decisions, laboratory tests are considered to be among the most important and frequently used. The influence of laboratory tests on medical decisions has been difficult to estimate. The goal of this study was to estimate the number of patient encounters that included a laboratory test. We extracted information for 72196 patient encounters from 1-week intervals each quarter of a year from our comprehensive academic medical center electronic medical record. The patients examined represent a comprehensive range of clinical conditions and medical services. We determined for which encounters laboratory and other orders existed. Overall 35% of encounters had 1 or more laboratory tests ordered. However, the percent varied markedly with patient care areas. For inpatient, emergency department, and outpatient populations, 98%, 56%, and 29%, respectively, had 1 or more laboratory tests ordered. Our observations support that it is not possible to use a single number to categorize the frequency with which laboratory tests occur in patient encounters. Utilization of laboratory tests varied with type of medical service with almost all inpatients, approximately half of emergency department patients, and nearly one-third of outpatients having laboratory tests during their healthcare visit.

Mapping clinical journeys of Asian patients presenting to the Emergency Department with syncope: Strict adoption of international guidelines does not reduce hospitalisations

Limited data exists about management of syncope in Asia. The American College of Emergency Physicians (ACEP) and European Society of Cardiology (ESC) guidelines have defined the high-risk syncope patient. This study aims to determine the effectiveness of managing syncope in an Asian healthcare system and whether strict adherence of international guidelines would reduce hospitalizations. Patients attending the Emergency Department of a Singaporean tertiary hospital with syncope were identified. Clinical journeys of all patients were meticulously mapped by interrogation of a comprehensive electronic medical record system and linkages with national datasets. Primary endpoint was hospitalization. Secondary endpoints were recurrent syncope within 1year and all-cause mortality. Expected admission rates based on application of ACEP/ESC guidelines were calculated. 638 patients (43.8±22.4years, 49.0% male) presented with syncope. 48.9% were hospitalized for 2.9±3.2days. Yields of common investigations ranged from 0 to 11.5% and no diagnosis was reached in 51.5% of patients. Diuretics use (HR 5.1, p=0.01) and prior hospitalization for syncope (HR 6.9, p<0.01) predicted recurrent syncope. Over 2.8 SD 0.3years of follow-up, 40 deaths occurred. 24 patients who died within 12months of presentation were admitted or had a firm diagnosis upon discharge. Application of guidelines did not significantly reduce hospitalisations, with limited agreement which patients warrant admission. (Actual 376, ACEP 354, ESC 391 admissions, p=NS). Unstructured management of syncope results in nearly half of patients being admitted and substantial healthcare expenditures, yet with limited diagnostic yield. Strict adoption of ACEP or ESC guidelines does not reduce admissions.