Abstract
Background
We aimed to identify the prevalence and predictors of venous thromboembolism (VTE) or mortality in hospitalized coronavirus disease 2019 (COVID-19) patients.
Methods
A ...retrospective cohort study of hospitalized adult patients admitted to an integrated health care network in the New York metropolitan region between March 1, 2020 and April 27, 2020. The final analysis included 9,407 patients with an overall VTE rate of 2.9% (2.4% in the medical ward and 4.9% in the intensive care unit ICU) and a VTE or mortality rate of 26.1%. Most patients received prophylactic-dose thromboprophylaxis. Multivariable analysis showed significantly reduced VTE or mortality with Black race, history of hypertension, angiotensin converting enzyme/angiotensin receptor blocker use, and initial prophylactic anticoagulation. It also showed significantly increased VTE or mortality with age 60 years or greater, Charlson Comorbidity Index (CCI) of 3 or greater, patients on Medicare, history of heart failure, history of cerebrovascular disease, body mass index greater than 35, steroid use, antirheumatologic medication use, hydroxychloroquine use, maximum D-dimer four times or greater than the upper limit of normal (ULN), ICU level of care, increasing creatinine, and decreasing platelet counts.
Conclusion
In our large cohort of hospitalized COVID-19 patients, the overall in-hospital VTE rate was 2.9% (4.9% in the ICU) and a VTE or mortality rate of 26.1%. Key predictors of VTE or mortality included advanced age, increasing CCI, history of cardiovascular disease, ICU level of care, and elevated maximum D-dimer with a cutoff at least four times the ULN. Use of prophylactic-dose anticoagulation but not treatment-dose anticoagulation was associated with reduced VTE or mortality.
IMPORTANCE There is consensus that incorporating clinical decision support into electronic health records will improve quality of care, contain costs, and reduce overtreatment, but this potential has ...yet to be demonstrated in clinical trials. OBJECTIVE To assess the influence of a customized evidence-based clinical decision support tool on the management of respiratory tract infections and on the effectiveness of integrating evidence at the point of care. DESIGN, SETTING, AND PARTICIPANTS In a randomized clinical trial, we implemented 2 well-validated integrated clinical prediction rules, namely, the Walsh rule for streptococcal pharyngitis and the Heckerling rule for pneumonia. INTERVENTIONS AND MAIN OUTCOMES AND MEASURES The intervention group had access to the integrated clinical prediction rule tool and chose whether to complete risk score calculators, order medications, and generate progress notes to assist with complex decision making at the point of care. RESULTS The intervention group completed the integrated clinical prediction rule tool in 57.5% of visits. Providers in the intervention group were significantly less likely to order antibiotics than the control group (age-adjusted relative risk, 0.74; 95% CI, 0.60-0.92). The absolute risk of the intervention was 9.2%, and the number needed to treat was 10.8. The intervention group was significantly less likely to order rapid streptococcal tests compared with the control group (relative risk, 0.75; 95% CI, 0.58-0.97; P = .03). CONCLUSIONS AND RELEVANCE The integrated clinical prediction rule process for integrating complex evidence-based clinical decision report tools is of relevant importance for national initiatives, such as Meaningful Use. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01386047
Currently, chest radiography is the first-line imaging test for identifying pneumonia; chest CT is considered the reference standard. The purpose of this study was to calculate the statistical ...measures of performance of chest radiography for identifying pneumonia when taking into account uncertain results of both chest radiography and CT examinations.
Statistical measures of performance of chest radiography, using CT as the reference standard, were calculated with 95% CIs by varying uncertain radiology report impressions of both chest radiography and CT to all negative or all positive. The resulting scenarios were as follows: scenario 1, uncertain chest radiography and CT impressions are considered positive for pneumonia; scenario 2, uncertain chest radiography impressions are positive but uncertain CT impressions are negative; scenario 3, uncertain chest radiography impressions are negative and uncertain CT impressions are positive; scenario 4, uncertain chest radiography and CT impressions are negative; and scenario 5, uncertain chest radiography and CT impressions are excluded.
A retrospective analysis of 2411 patient visits revealed the prevalence of uncertain radiology report impressions to be 31.8% for chest radiography and 21.7% for CT. Scenario 1 yielded the following performance values: sensitivity, 51.9%; specificity, 71.3%; PPV, 59.4%; and NPV, 64.5%. Scenario 2 produced the following performance values: sensitivity, 59.6%; specificity, 67.1%; PPV, 59.6%; and NPV, 67.1%. Scenario 3 showed the following performance values: sensitivity, 13.4%; specificity, 97.7%; PPV, 82.6%; and NPV, 58.1%. Scenario 4 yielded the following performance values: sensitivity, 19.6%; specificity, 96.4%; PPV, 81.6%; and NPV, 59.5%. Scenario 5 produced the following performance values: sensitivity, 32.7%; specificity, 96.8%; PPV, 89.2%; and NPV, 63.8%.
Uncertain chest radiography results for the evaluation of pneumonia are prevalent. A chest radiography impression using the strongest language in support of a pneumonia diagnosis is useful to rule in pneumonia radiographically, but a negative result performs poorly at ruling out disease.
Highlights ► This study successfully combined “think-aloud” protocol analysis with “near-live” clinical simulations in a usability evaluation of a new primary care CDS tool. ► These two forms of ...usability evaluation provided complementary observations on problems with the new tool and were used to refine both its usability and workflow integration. ► Their synergistic use provided a robust assessment of how CDS tools would interact in live clinical environments and allowed for enhanced early redesign to augment clinician utilization. ► These findings suggest the importance of using complementary testing methods before releasing CDS for live use.
Objective:In recent years there has been a greater appreciation of the elevated prevalence of cardiovascular risk factors in the schizophrenia population and the liability some treatments have for ...their development. These vascular risk factors are in turn important risk factors in the development of dementia and more subtle cognitive impairments. However, their impact on the cognitive functions of patients with schizophrenia remains underexplored. The authors investigated whether vascular risk factors influence the cognitive impairments of schizophrenia and whether their effects on cognition in schizophrenia are different from those observed in nonpsychiatric comparison subjects.
Method:The authors compared 100 patients with schizophrenia and 53 comparison subjects on cognitive test performance in 2×2 matrices composed of individual vascular risk factors and group (schizophrenia patients and comparison subjects).
Results:Hypertension exerted a significant negative effect on immediate delayed and recognition memory in both groups. Patients with schizophrenia and hypertension were adversely affected in recognition memory, whereas comparison subjects were not. A body mass index above 25 was associated with negative effects on delayed memory in both groups, although the association fell short of statistical significance.
Conclusions:Given that patients with schizophrenia have a higher prevalence of vascular risk factors than the general population and are undertreated for them, treatment of these risk factors may significantly improve cognitive outcome in schizophrenia.
Depression is the leading cause of disability and a major cause of morbidity worldwide, with societal costs now upwards of 1 trillion dollars across the globe. Hence, extending current efforts to ...augment prevention outcomes is consistent with global public health interests. Although many prevention programs have been developed and have demonstrated efficacy, studies have yet to demonstrate that CBT is effective in preventing symptoms in populations at risk for developing depression induced by pharmacological substances. Using a randomized, controlled design, this pilot study reports on the feasibility and preliminary effects of a novel, guided symptom exposure augmented cognitive behavioral prevention intervention (GSE-CBT) in a sample diagnosed with Hepatitis C at risk for developing medication induced depression. Results demonstrated that the guided symptom exposure augmented CBT (GSE-CBT) was feasible in this population and was delivered with high integrity. Although not statistically different, we observed a pattern of lower depression levels in the GSE-CBT group versus those in the control group throughout. This pilot study demonstrates that a psychosocial prevention intervention is feasible for use in patients at risk for developing pharmacologically induced depression and that a guided symptom exposure augmented CBT protocol has the potential to prevent symptoms of depression that develop as a side effect to taking these medications. Results are preliminary and future studies should use larger samples and test the intervention in other populations.
Clinical experience provides clinicians with an intuitive sense of which
findings on history, physical examination, and investigation are critical
in making an accurate diagnosis, or an accurate ...assessment of a patient's
fate. A clinical decision rule (CDR) is a clinical tool that quantifies the
individual contributions that various components of the history, physical
examination, and basic laboratory results make toward the diagnosis, prognosis,
or likely response to treatment in a patient. Clinical decision rules attempt
to formally test, simplify, and increase the accuracy of clinicians' diagnostic
and prognostic assessments. Existing CDRs guide clinicians, establish pretest
probability, provide screening tests for common problems, and estimate risk.
Three steps are involved in the development and testing of a CDR: creation
of the rule, testing or validating the rule, and assessing the impact of the
rule on clinical behavior. Clinicians evaluating CDRs for possible clinical
use should assess the following components: the method of derivation; the
validation of the CDR to ensure that its repeated use leads to the same results;
and its predictive power. We consider CDRs that have been validated in a new
clinical setting to be level 1 CDRs and most appropriate for implementation.
Level 1 CDRs have the potential to inform clinical judgment, to change clinical
behavior, and to reduce unnecessary costs, while maintaining quality of care
and patient satisfaction.
Clinical prediction rules (CPRs) represent well-validated but underutilized evidence-based medicine tools at the point-of-care. To date, an inability to integrate these rules into an electronic ...health record (EHR) has been a major limitation and we are not aware of a study demonstrating the use of CPR's in an ambulatory EHR setting. The integrated clinical prediction rule (iCPR) trial integrates two CPR's in an EHR and assesses both the usability and the effect on evidence-based practice in the primary care setting.
A multi-disciplinary design team was assembled to develop a prototype iCPR for validated streptococcal pharyngitis and bacterial pneumonia CPRs. The iCPR tool was built as an active Clinical Decision Support (CDS) tool that can be triggered by user action during typical workflow. Using the EHR CDS toolkit, the iCPR risk score calculator was linked to tailored ordered sets, documentation, and patient instructions. The team subsequently conducted two levels of 'real world' usability testing with eight providers per group. Usability data were used to refine and create a production tool. Participating primary care providers (n = 149) were randomized and intervention providers were trained in the use of the new iCPR tool. Rates of iCPR tool triggering in the intervention and control (simulated) groups are monitored and subsequent use of the various components of the iCPR tool among intervention encounters is also tracked. The primary outcome is the difference in antibiotic prescribing rates (strep and pneumonia iCPR's encounters) and chest x-rays (pneumonia iCPR only) between intervention and control providers.
Using iterative usability testing and development paired with provider training, the iCPR CDS tool leverages user-centered design principles to overcome pervasive underutilization of EBM and support evidence-based practice at the point-of-care. The ongoing trial will determine if this collaborative process will lead to higher rates of utilization and EBM guided use of antibiotics and chest x-ray's in primary care.
ClinicalTrials.gov Identifier NCT01386047.
Purpose
Blacks have a higher mortality rate than whites from esophageal cancer, but the reasons underlying this disparity remain unclear. In this study, we used a national sample of patients with ...resectable esophageal cancer to assess the extent to which racial inequalities in care can explain outcome disparities.
Methods
We identified all non-Hispanic white and black patients diagnosed with T0–T2, node-negative esophageal cancer between 1988 and 2003 from the Surveillance, Epidemiology, and End Results registry. Racial differences in esophageal-specific survival were assessed using the Kaplan-Meier method. We performed Cox regression to test for racial differences in survival after adjusting for potential confounders and to assess the extent to which disparities can be explained by later diagnosis or treatment inequalities.
Results
A total of 1522 patients were included in the study. Blacks had worse esophageal-specific survival rates than whites (37% vs 60% 5-year survival;
P
< .0001). Blacks were more likely to be diagnosed at a more advanced stage and to have squamous cell tumors, but were less likely to undergo surgery. In multivariate regression controlling for age, sex, marital status, histology, and tumor location, black race was associated with worse survival. When tumor status, surgery, and radiotherapy were added to the model, race was no longer significantly associated with survival.
Conclusion
These data suggest that blacks are at greater risk of death from esophageal cancer. While the disparity is due in part to differences in tumor histology, diagnosis at an earlier stage and higher rates of surgery among blacks could reduce this survival disparity.
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