Subsequent Encounters Research Articles

Predictors and Consequences of Inappropriate Thyroid Ultrasound in Hypothyroidism.

IntroductionIn 2012, the American Board of Internal Medicine Foundation established the Choosing Wisely® initiative, partnering with specialist societies to promote evidence-based care. Under this program, the Endocrine Society recommends against ordering thyroid ultrasounds in individuals with subclinical or overt hypothyroidism and a normal neck exam. We sought to understand the prevalence, predictors, and consequences of thyroid ultrasound performed at our academic medical center that are not in compliance with this recommendation.MethodsWe conducted a retrospective cohort study of electronic health record data from January 1, 2016 to July 31, 2018. Data were extracted from records of all patients who underwent thyroid ultrasonography. Ultrasounds were considered inappropriate if they were ordered based on hypothyroidism, without other clear indications.ResultsA total of 2,021 patients underwent thyroid ultrasonography, of which 572 (28.3%) were diagnosed with hypothyroidism. Among the patients with hypothyroidism, 40 were identified as having received an inappropriate ultrasound (7.0%). Of those patients who received inappropriate ultrasounds, 42.5% had subsequent medical encounters, with a mean charge of $851 (standard deviation = $271) per patient. Using a multivariable model, the odds of receiving an inappropriate ultrasound were significantly higher for patients younger than 50 years of age (odds ratio: 2.37, 95% confidence interval: 1.01-5.58).ConclusionSeven percent of thyroid ultrasounds were inappropriately ordered in a cohort with hypothyroidism. Patients aged <50 years were at an increased risk of inappropriate ultrasound. Sequelae of inappropriate ultrasound included further medical encounters and financial burdens. Systems to reduce the inappropriate use of thyroid ultrasound may lessen the consequences of unnecessary medical imaging.

Transfer of negative valence in an episodic memory task

Emotion can color what we perceive and subsequently remember in myriad ways. Indeed, it is well established that emotion enhances some aspects of memory, while impairing others. For example, a number of recent episodic memory studies show that emotion—particularly negative emotion—weakens associative memory, including item-item associations. Other literature shows that emotion biases our later attitudes and preferences. That is, the coincident pairing of a negative stimulus with a neutral one can reduce one's preference for that neutral stimulus upon subsequent encounter—a ‘transfer of valence’ effect. In an effort to connect these two phenomena, here we ask if and under what circumstances they co-occur. Across multiple experiments, we show that negative emotion impairs associative memory for item-item pairings, in accordance with prior work. We also show a transfer of valence effect in this paradigm, such that items paired with negative versus neutral stimuli are subsequently rated as less pleasant. Our data further show that transfer of valence is contingent on episodic memory. These findings highlight the complexity and multifaceted nature of emotional effects on memory.

Emergency department visits and readmissions in patients with psychogenic nonepileptic seizures (PNES) at a safety net hospital

IntroductionReadmissions and emergency department (ED) visits after an index admission have been become a quality measure due to associations with poor outcomes and increased healthcare costs. Readmissions and ED encounters have been studied in a variety of conditions including epilepsy but have not been examined exclusively in psychogenic nonepileptic seizures (PNES). In this study we examined the rate of readmissions and ED visits after a discharge from an Epilepsy Monitoring Unit (EMU) in a safety net hospital. We also determined patient phenotypes that are associated with readmissions. Material and methodsThis was a retrospective chart review study with index admission being a discharge from an EMU between January 1 and December 31 2016 with follow-up until August 31 2020. We obtained data regarding demographics, medical and psychiatric history, and social history and treatment interventions. Our outcome variables were both all-cause and seizure-related hospital readmissions and ED visits 30 days following the index discharge and readmissions and ED visits 30 days thereafter. ResultsEleven of 122 patients (9%) had a non-seizure-related ED visit and/or hospitalization within 30 days of index discharge while 45 (37%) had re-contact with the health system thereafter for non-seizure-related issues. Seven of 122 patients (6%) had a seizure-related ED visit or hospital readmission within 30 days of discharge. Twenty-eight (23%) had a seizure-related readmission or ED visit after 30 days. Of these 28, 4 patients had been to an ER within 7 days of EMU discharge. The majority of subsequent encounters with the healthcare system were through the ED (n = 38) as compared to hospital (n = 10) and EMU readmissions (n = 9). On bivariate statistical analysis, charity or self-pay insurance status (p < 0.01), homelessness (p < 0.01), emergent EMU admission on index admission (p < 0.01), history of a psychiatric diagnosis (p < 0.02), and ED encounters 12 months prior to admission (p < 0.01) were significantly associated with readmission; however, on multivariate analysis only charity insurance status was a significant predictor. ConclusionsIn this study of readmissions and ED visits after discharge with a diagnosis of PNES at a safety net hospital, we found a seizure-related readmission rate of approximately 6% in 30 days and 23% thereafter with the majority of re-contact with the hospital being in the ED. On multi-variate analysis insurance status was a significant factor associated with readmission and ED visits. Our future research directions include examining referrals and treatment completion at the hospital’s PNES clinic as well as creating a risk score to better identify patients with PNES at risk of readmission.

Oral Vancomycin as Secondary Prophylaxis for Clostridioides difficile Infection.

Secondary oral vancomycin prophylaxis (OVP) has been used in adults with a history of Clostridioides difficile infection (CDI) while receiving systemic antibiotics to prevent CDI recurrence. However, this practice has not been studied in pediatric patients. The objective of this study was to assess the utility of secondary OVP in pediatric patients with previous CDI who received subsequent antibiotic exposure. A multicampus, retrospective cohort evaluation was conducted among patients aged ≤18 years with any history of clinical CDI and receiving systemic antibiotics in a subsequent encounter from 2013-2019. Patients who received concomitant OVP with antibiotics were compared with unexposed patients. The primary outcome was CDI recurrence within 8 weeks after antibiotic exposure. Infection with vancomycin-resistant enterococci and risk factors for CDI recurrence were assessed. A total of 148 patients were screened, of which 30 and 44 patients received OVP and no OVP, respectively. Patients who received OVP had greater antibiotic use and hospital lengths of stay. The incidence of CDI recurrence within 8 weeks of antibiotic exposure was significantly lower in patients who received OVP (3% vs 25%; P = .02) despite this group having notably more risk factors for recurrence. There were no vancomycin-resistant enterococci infections in any patients within either group. After adjustment in a multivariable analysis, secondary OVP was associated with less risk of recurrence (odds ratio, 0.10; 95% confidence interval, 0.01-0.86; P = .04). Secondary OVP while receiving systemic antibiotics reduces the risk of recurrent CDI in pediatric patients with a history of CDI.

Repeat exposure to hypercapnic seawater modifies growth and oxidative status in a tolerant burrowing clam.

Although low levels of thermal stress, irradiance and dietary restriction can have beneficial effects for many taxa, stress acclimation remains little studied in marine invertebrates, even though they are threatened by climate change stressors such as ocean acidification. To test the role of life-stage and stress-intensity dependence in eliciting enhanced tolerance under subsequent stress encounters, we initially conditioned pediveliger Pacific geoduck (Panopea generosa) larvae to ambient and moderately elevated PCO2(920 µatm and 2800 µatm, respectively) for 110 days. Then, clams were exposed to ambient, moderate or severely elevated PCO2(750, 2800 or 4900 µatm, respectively) for 7 days and, following 7 days in ambient conditions, a 7-day third exposure to ambient (970 µatm) or moderate PCO2(3000 µatm). Initial conditioning to moderate PCO2stress followed by second and third exposure to severe and moderate PCO2stress increased respiration rate, organic biomass and shell size, suggesting a stress-intensity-dependent effect on energetics. Additionally, stress-acclimated clams had lower antioxidant capacity compared with clams under ambient conditions, supporting the hypothesis that stress over postlarval-to-juvenile development affects oxidative status later in life. Time series and stress intensity-specific approaches can reveal life-stages and magnitudes of exposure, respectively, that may elicit beneficial phenotypic variation.

Quantifying The Costs of Creating and Maintaining Hemodialysis Access in An All-Payer Rate-Controlled Health System

The creation and maintenance of durable hemodialysis access is critically important for reducing patient morbidity and controlling overall costs within health systems. Our objective was to quantify the costs associated with hemodialysis access creation and its maintenance over time within a rate-controlled health system where charges equate to payments. The Maryland Health Services Cost Review Commission administrative claims database was used to identify patients who underwent first-time access creation from 2012-2020. Patients were identified using CPT codes for access creation, and costs were accrued for the initial encounter and all subsequent outpatient access-related encounters. T-tests and Wilcoxon tests were used to compare reinterventions and access-related costs ($USD) between arteriovenous fistulae (AVF) and arteriovenous grafts (AVG). Multivariable modeling was used to quantify the association of access type with charge variation. Overall, 12,716 patients underwent first-time access creation (69.3% AVF vs. 30.7% AVG). There was no difference in freedom from reintervention between the two access types at any point following creation (HR: 1.03, 95%CI: 0.97-1.10); however, AVF were associated with a lower number of cumulative reinterventions (1.50 vs. 2.24) compared to AVG (P<0.0001). AVF was associated with lower overall costs in the year of creation ($9,388 vs. $13,539, P<0.0001), a difference that remained significant over the subsequent 3 years. The lower costs associated with AVF were present both in the costs associated with creation and subsequent maintenance. On multivariable analysis, AVF was associated with a $3,557 reduction in total access-related costs versus AVG (95%CI -$3828, -3287). AVF require fewer interventions and are associated with lower costs at placement and over the first three years of maintenance compared to AVG. The use of AVF for first-time hemodialysis access represents an opportunity for healthcare savings in appropriately selected patients with a high preoperative likelihood of AVF maturation.

Emergency Department-initiated Buprenorphine and Referral to Follow-up Addiction Care: A Program Description.

Emergency department (ED) initiated opioid use disorder (OUD) care is effective; however, real-world predictors of patient engagement are lacking. This program evaluation examined predictors of ED-based OUD treatment and subsequent engagement. Program evaluation in Boston, MA. Adult patients who met criteria for OUD during an ED visit in 2019 were included. Patients were included if a diagnosis of OUD or opioid-related overdose was associated with the ED visit or if they met previously validated criteria for OUD within the previous 12 months. We assessed predictors of ED-OUD treatment receipt and subsequent engagement, using Healthcare Effectiveness Data and Information Set definition of initial encounter within 14 days of discharge and either 2 subsequent encounters or a subsequent buprenorphine prescription within 34 days of the initial encounter. We used generalized estimating equations for panel data. During 2019, 1946 patients met criteria for OUD. Referrals to Bridge Clinic were made for 207 (11%), buprenorphine initiated for 106 (5%), and home induction buprenorphine kits given to 56 (3%). Following ED discharge, 237 patients (12%) had a visit within 14 days, 122 (6%) had ≥2 additional visits, and 207 (11%) received a subsequent buprenorphine prescription. Young, White, male patients were most likely to receive ED-OUD care. Patients who received ED-OUD care were more likely to have subsequent treatment engagement (adjusted rate ratio: 2.30, 95% confidence intervals: 1.62-3.27). Referrals were made less often than predicted for Black (-49%) or Hispanic/Latinx (-25%) patients. Initiating treatment for OUD in the ED was associated with increased engagement in outpatient addiction care.

Characteristics and retention of emergency department patients who left without being seen (LWBS).

A retrospective observational study was conducted for patients 18 years or older presenting to a Midwestern emergency department (ED) in the United States during February 2019–January 2020 to characterize associated subsequent care utilization in patients who left the ED without being seen. Patients were classified as left without being seen (LWBS) based on documented ED disposition. The healthcare system’s records were reviewed for any associated utilizations within 3 weeks following the initial ED encounter. During the study period, 45,456 patients presented to the ED, with 2269 (5.0%) classified as LWBS. The median documented time until patients left the ED was 112 min. Of these patients, 1257 (55.4%) had a subsequent encounter within the health system within 3 weeks and 920 (73.2%) of these visits were determined to be related to the LWBS chief complaint. These visits included 67.5% of patients returning to ED or hospital, 27.5% to primary care or an urgent care clinic, and 5.0% to a specialty or other provider appointment. Of patients returning to ED, 78.1% did so within 72 h. Patients without a subsequent health system associated encounter tended to be younger, female, non-White, and present with possible lower-acuity chief complaints. At least one-half of LWBS patients sought care related to the concerns by a health system provider within 3 weeks of the initial encounter within the same system. The high prevalence of ED returns within a narrow turnaround window highlights a missed opportunity to provide services to these patients during their initial encounter.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11739-021-02775-z.

Veterans on anticancer medications in rural and community environment support (VA CARES) program: A pharmacist-led telemedicine medication management program for veterans receiving oral antineoplastic therapies through the MISSION Act.

1545 Background: Cancer therapies are leveraging oral targeted treatments over traditional cytotoxic chemotherapy (CT) at an increasing rate. Compared to CT, use of oral antineoplastic treatments (OATs) shift some of the burden of medication management onto patients. To address these challenges, several health systems have developed multidisciplinary OAT management teams or ‘clinics’ whereby an Oncology Clinical Pharmacist (OCP) collaborates with oncology teams to ensure optimal use of these agents. Through the VA MISSION Act of 2018, Veterans can be prescribed treatments in the community which are dispensed by VA. These Veterans often live in rural areas and may lack access to comprehensive medication management resources. Methods: The VA CARES Program is a telemedicine medication management ‘clinic’ and care delivery model for patients receiving OATs leveraging custom designed health information technology (HIT) tools to remotely coordinate OAT related care. Veterans are automatically enrolled in the program if they have OATs prescribed by community providers which are to be dispensed by VA. An OCP provides telemedicine medication management services. The OCP performs a screening assessment, ensures appropriate indication and dosing, reviews baseline laboratory results, and performs a thorough drug-drug interaction analysis. The OCP then provides OAT education. Throughout the duration of therapy the OCP ensures necessary therapeutic monitoring, and regularly follows up with the Veterans. Subsequent encounters are to assess knowledge, adherence, toxicities, new drug-drug interactions, and need for OAT refills. The outcome measures for the VA CARES Program include safety (number and type of pharmacist interventions), economic benefits (cost savings or cost avoidance), and patient satisfaction. Results: In the initial 13 months, the VA CARES Program screened N = 78 and enrolled N = 64 (82%) Veterans from three VA medical facilities in VISN-19 from January 2020 to January 2021. The CPS performed n = 342 telemedicine visits and n = 80 interventions leading to improved safety, effectiveness, and/or an economical benefit. The most common interventions included detection and/or prevention of drug-drug interactions (n = 45) and adverse events (n = 18), drug not indicated (n = 13), alternative therapy suggested (n = 7), and limited-quantity dispensed (n = 7). The CPS interventions saved an estimated $210,864 in medication-related costs or avoidance. The Veterans surveyed were highly satisfied with the program services. Conclusions: Telemedicine delivery of oncology medication management by an OCP across systems is feasible, and provides clinical and economic benefits.

A unified framework for joint patient-physician collaboration: The colorectal cancer screening problem

As patients have become more active in their medical decisions, healthcare providers have increasingly emphasized patient-centred care. To deliver such care, providers must respect patients’ needs and preferences and ensure that patients’ values are a centrepiece of clinical decisions. This research proposes a framework for shared decision-making, capable of analytically incorporating patients’ preferences and physicians’ expertise into a joint patient-physician (JPP) model to overcome the barriers encountered in clinical patient-centred care. The JPP framework combines patient’s wishes and physician’s judgments coherently and transparently and generates user-friendly guidance for discussion in a subsequent medical encounter. We examine the impact of integrating patient’s preferences with physician’s expertise for preventive healthcare in the case of choosing an appropriate colorectal cancer screening option. Our results indicate that two possible scenarios might be encountered: (a) the patient-preference-only model and the JPP model do not result in the same screening alternative, and (b) the two models agree in their recommendation. We identify the structural differences in the two models associated with both scenarios. The results show that clinically the proposed JPP model has the capability of providing a transparent starting point for discussions between the patient and the physician.

Immunisation with the BCG and DTPw vaccines induces different programs of trained immunity in mice

In addition to providing pathogen-specific immunity, vaccines can also confer nonspecific effects (NSEs) on mortality and morbidity unrelated to the targeted disease. Immunisation with live vaccines, such as the BCG vaccine, has generally been associated with significantly reduced all-cause infant mortality. In contrast, some inactivated vaccines, such as the diphtheria, tetanus, whole-cell pertussis (DTPw) vaccine, have been controversially associated with increased all-cause mortality especially in female infants in high-mortality settings. The NSEs associated with BCG have been attributed, in part, to the induction of trained immunity, an epigenetic and metabolic reprograming of innate immune cells, increasing their responsiveness to subsequent microbial encounters. Whether non-live vaccines such as DTPw induce trained immunity is currently poorly understood. Here, we report that immunisation of mice with DTPw induced a unique program of trained immunity in comparison to BCG immunised mice. Altered monocyte and DC cytokine responses were evident in DTPw immunised mice even months after vaccination. Furthermore, splenic cDCs from DTPw immunised mice had altered chromatin accessibility at loci involved in immunity and metabolism, suggesting that these changes were epigenetically mediated. Interestingly, changing the order in which the BCG and DTPw vaccines were co-administered to mice altered subsequent trained immune responses. Given these differences in trained immunity, we also assessed whether administration of these vaccines altered susceptibility to sepsis in two different mouse models. Immunisation with either BCG or a DTPw-containing vaccine prior to the induction of sepsis did not significantly alter survival. Further studies are now needed to more fully investigate the potential consequences of DTPw induced trained immunity in different contexts and to assess whether other non-live vaccines also induce similar changes.

Telemedicine visits generate accurate surgical plans across orthopaedic subspecialties.

IntroductionThe role of telemedicine is rapidly evolving across medical specialties and orthopaedics. The utility of telemedicine to identify operative candidates and determine surgical plans has yet to be demonstrated. We sought to assess whether surgical plans proposed following telemedicine visits changed after subsequent in-person interaction across orthopaedic subspecialties.Materials and methodsWe identified all elective telemedicine encounters across two academic institutions from March 1, 2020 to July 31, 2020. We identified patients indicated for surgery with a specific surgical plan during the virtual visit. The surgical plans delineated during the telemedicine encounter were then compared to final pre-operative plans documented following subsequent in-person evaluation. Changes in the surgical plan between telemedicine and in-person encounters were defined using a standardised schema. Regression analysis was used to evaluate factors associated with a change in surgical plan between visits across specialties, including the number of virtual examination manoeuvres performed.ResultsWe identified 303 instances of a patient being indicated for orthopaedic surgery during a telemedicine encounter. In 11 cases (4%), the plan was changed between telemedicine and subsequent in-person encounter. No plans were changed amongst patients indicated for joint arthroplasty and foot and ankle surgery, whilst 4% of plans were changed amongst sports surgery and upper extremity/shoulder surgery. Surgical plans had the highest rate of change amongst spine surgery patients (8%). There was notable variability in the conduct of virtual examinations across subspecialties.ConclusionOur results demonstrate the capability of telemedicine to support development of accurate surgical plans for orthopaedic patients across several subspecialties. Our findings also highlight the substantial variation in the utilisation of physical examination manoeuvres conducted via telemedicine across institutions, subspecialties, and providers.Description of study typeLevel IV, retrospective cohort study.

Combining proximate with online learning in real-time: ambidextrous teaching and pathways towards inclusion during COVID-19 restrictions and beyond

ABSTRACT COVID-19 forced universities to engage in rapid improvisation and adoption of online learning and teaching. This paper explores “real-time blended” learning in which online students are taught simultaneously with students who are experiencing proximate learning. Two cliques could develop with those learning online becoming observers rather than participants in an active learning process. This paper is based on action-based research to develop an inclusive approach to simultaneous teaching of proximate and online students. This approach includes alterations in classroom layout, the equipment used, facilitating varying modes of social interaction and the role of communication. Effective teaching requires continual minor modifications to teaching design and delivery. This represents an ambidextrous approach to teaching in which teachers focus on the immediate co-creation of student experiences, but also identify cues which are used to adjust the ways in which they engage with a student cohort over the course of delivering a module. Module evaluation becomes an ongoing process in which alterations are made in real-time and to subsequent learning encounters with students. The paper evaluates student performance and concludes that the approach went some way towards ensuring equality of the student experience between those learning online and those proximate with the lecturer.

Characteristics of hospital encounters and associated economic burden of patients with major depressive disorder and acute suicidal ideation or behavior

ABSTRACT Objectives Relatively little is known about the hospital experience among patients with major depressive disorder (MDD) and acute suicidal ideation or behavior (MDSI). The objectives of this study were to examine hospital encounter characteristics, including the associated economic burden and risk of subsequent hospital encounters of patients with MDSI in the US. Methods In this retrospective analysis, patients ≥18 years of age with a hospital encounter (emergency department [ED] visit or inpatient admission) were selected from the de-identified Premier Hospital database between 1 January 2017 and 30 September 2018. Patients were required to have MDD as the primary and acute suicidal ideation or behavior as a secondary discharge diagnosis or vice versa. Patient demographics and characteristics of hospital encounters were examined. Rates and costs of subsequent all-cause and MDD-related hospital encounters 6 months following initial discharge were also evaluated. Results The study population consisted of 123,179 patients with a hospital encounter for MDSI (mean age: 38 years, 50.9% female, 74.6% White); 50.2% were treated in the ED only (mean ± standard deviation cost: $693±$630), while 49.8% were admitted as inpatients ($6,478±$7,001). Among those with ED visits, very few (7.0%) received an antidepressant (AD). Among those with an inpatient admission, 87.2% received ≥1 AD and 39.0% received AD augmentation. Overall rates and costs of subsequent all-cause and MDD-related hospital encounters were 22.3% ($5,136±$11,791) and 12.0% ($3,722±$9,621), respectively; nearly half of subsequent encounters (41.3% and 44.3%, respectively) occurred in the first month following initial discharge. Conclusions This analysis of patients with MDSI presenting to US hospitals shows heterogeneity in treatment and a concentration of costly subsequent hospital encounters within 1-month post discharge, suggesting that healthcare systems may benefit from examination of current care pathways for this vulnerable patient population.

Descriptive exploration of overdose codes in hospital and emergency department discharge data to inform development of drug overdose morbidity surveillance indicator definitions in ICD-10-CM

BackgroundIn October 2015, discharge data coding in the USA shifted to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), necessitating new indicator definitions for drug overdose morbidity. Amid...

The Efficacy of Orthopedic Telemedicine Encounters During the COVID-19 Crisis.

Telemedicine technology was rapidly and widely adopted during the early phase of the coronavirus disease 2019 (COVID-19) response, and its efficacy in orthopedic surgery is still undetermined. The objective of this study was to determine the efficacy of new patient orthopedic surgery ambulatory encounters performed using telemedicine during the early phase of the COVID-19 crisis. Failure of the telemedicine encounter was assessed in this study by 2 separate criteria: (1) an unplanned visit to the emergency department (ED) within 6 weeks of the telemedicine encounter and (2) a planned subsequent in-person encounter for inability to formulate a complete diagnosis virtually. The authors retrospectively identified all new patient orthopedic surgery ambulatory encounters performed using telemedicine in the orthopedic surgery department of an academic tertiary care center during the first 6 weeks of the COVID-19 response, from March 16, 2020, to April 26, 2020. The study cohort included 298 new patients treated by 41 providers. The mean age of the 298 patients was 48 years, and 59% were women. Two hundred encounters were performed with video, and 98 were performed with telephone only. Three (1%) patients presented to the ED within 6 weeks of their new patient telemedicine encounter, and 8 (3%) patients presented for a planned in-person encounter. The authors concluded that new patient orthopedic surgery ambulatory encounters performed using telemedicine were able to effectively direct patients to a variety of treatments and dispositions, with a low rate of unplanned presentation to the ED or need for supplementary in-person assessment. [Orthopedics. 2021;44(2):e211-e214.].

Methodologies for Validation of Diagnoses in Real-World Data: BONES-A Case Study.

The accuracy of any claim-based study is dependent on the quality of real-world coding of the condition of interest. This retrospective, administrative claims analysis presents a method for using a real-world data source to evaluate the accuracy of coding for nonunion of a fifth metatarsal fracture. Patients 21-80 years old with a diagnosis of a fifth metatarsal fracture between January 1, 2016, and October 31, 2016, and a nonunion of the fifth metatarsal fracture within the next 9 months were identified in the MarketScan Databases. Patient health care claims in the 12 months after the nonunion diagnosis were examined for health care encounters and pharmaceutical treatments considered indicative of treatment for nonunion, such as claims for bone growth stimulation or a second claim with a diagnosis of nonunion. Of the 230 patients who had at least one health care encounter attributable to a nonunion of the fifth metatarsal, 95.2% had at least one subsequent health care encounter confirming nonunion diagnosis. The mean number of supporting health care claims was 5.8, and the mean time between nonunion and first confirmatory claim was 33 days. This analysis demonstrated a method for evaluating the quality of coding for a specific condition when a traditional medical chart comparison is not feasible.

Defining indicators for drug overdose emergency department visits and hospitalisations in ICD-10-CM coded discharge data

IntroductionThe drug overdose epidemic has worsened over the past decade; however, efforts have been made to better understand and track nonfatal overdoses using various data sources including emergency department and...

Non-transport after Prehospital Naloxone Administration Is Associated with Higher Risk of Subsequent Non-fatal Overdose

Objective: U.S. opioid overdoses increased nearly sixfold from 1999 to 2018, and greater than 1% of all emergency medical services (EMS) encounters now involve naloxone administration. While “treat and release” protocols may have low short-term mortality, the risk of subsequent non-fatal overdoses is not known. This study compares the risk of repeat overdose encounters between patients transported to an emergency department (ED) and those who refused transport after prehospital naloxone administration. Methods: All EMS charts within a large single-tier fire-based urban EMS system between January 1 and August 31, 2018 were reviewed if either naloxone administration or a clinical impression related to opioid overdose was documented. Charts were excluded if there was no documented evidence of an opioid toxidrome (respiratory depression or altered mental status), if there was another clear explanation for the symptoms (e.g., hypoglycemia), or if naloxone was not administered. Ten percent of charts were reviewed by a second author to assess reliability. Cox regression (survival analysis) was used to estimate the risk of a subsequent EMS encounter with naloxone administration following an index encounter with naloxone administration. Results: Of the 2143 charts reviewed, 1311 unique patients with 1600 overdose encounters involving naloxone administration were identified. Inter-rater reliability for chart inclusion was strong [κ = 0.83 (95% CI: 0.72–0.90)]. Police/bystanders administered naloxone in 208/1600 (13.0%) encounters. A substantial proportion of encounters resulted in transport refusal (674/1600, 42.1%). The final Cox model included only refusal vs. acceptance of transport to an ED during the index EMS encounter. Patient age, gender, and naloxone administration prior to EMS arrival were not statistically significant in univariate or multivariable analyses, nor were they significant confounders. Refusal of transport was associated with a hazard ratio of 1.66 (95% CI: 1.23–2.23) for subsequent EMS encounters with naloxone administration. Conclusions: Non-transport after prehospital naloxone administration is associated with an increased risk of subsequent non-fatal overdose requiring EMS intervention. Limitations include the use of a single EMS agency as patients may have had uncaptured overdose encounters in neighboring municipalities.

Diagnostic Errors Induced by a Wrong a Priori Diagnosis: A Prospective Randomized Simulator-Based Trial.

Preventive strategies against diagnostic errors require the knowledge of underlying mechanisms. We examined the effects of a wrong a priori diagnosis on diagnostic accuracy of a focussed assessment in an acute myocardial infarction scenario. One-hundred-and-fifty-six medical students (cohort 1) were randomized to three study arms differing in the a priori diagnosis revealed: no diagnosis (control group), myocardial infarction (correct diagnosis group), and pulmonary embolism (wrong diagnosis group). Forty-four physicians (cohort 2) were randomized to the control group and the wrong diagnosis group. Primary endpoint was the participants’ final presumptive diagnosis. Among students, the correct diagnosis of an acute myocardial infarction was made by 48/52 (92%) in the control group, 49/52 (94%) in the correct diagnosis group, and 14/52 (27%) in the wrong diagnosis group (p < 0.001 vs. both other groups). Among physicians, the correct diagnosis was made by 20/21 (95%) in the control group and 15/23 (65%) in the wrong diagnosis group (p = 0.023). In the wrong diagnosis group, 31/52 (60%) students and 6/23 (19%) physicians indicated their initially given wrong a priori diagnosis pulmonary embolism as final diagnosis. A wrong a priori diagnosis significantly increases the likelihood of a diagnostic error during a subsequent patient encounter.