Time-of-day changes in physician clinical decision making: A retrospective study

Background Time of day has been associated with variations in certain clinical practices such as cancer screening rates. In this study, we assessed how more general process measures of physician activity, particularly rates of diagnostic test ordering and diagnostic assessments, might be affected by time of day. Methods We conducted a retrospective chart review of 3,342 appointments by 20 attending physicians at five outpatient clinics, matching appointments by physician and comparing the average diagnostic tests ordered and average diagnoses assessed per appointment in the first hour of the day versus the last hour of the day. Statistical analyses used sign tests, two-sample t-tests, Wilcoxon tests, Kruskal Wallis tests, and multivariate linear regression. Results Examining physicians individually, four and six physicians, respectively, had statistically significant first- versus last-hour differences in the number of diagnostic tests ordered and number of diagnoses assessed per patient visit (p ≤ 0.04). As a group, 16 of 20 physicians ordered more tests on average in the first versus last hour (p = 0.012 for equal chance to order more in each time period). Substantial intra-clinic heterogeneity was found in both outcomes for four of five clinics (p < 0.01). Conclusions There is some statistical evidence on an individual and group level to support the presence of time-of-day effects on the number of diagnostic tests ordered per patient visit. These findings suggest that time of day may be a factor influencing fundamental physician behavior and processes. Notably, many physicians exhibited significant variation in the primary outcomes compared to same-specialty peers. Additional work is necessary to clarify temporal and inter-physician variation in the outcomes of interest.

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Opioid tapering in patients with prescription opioid use disorder: A retrospective study

Scandinavian Journal of Pain ◽

10.1016/j.sjpain.2017.09.005 ◽

2017 ◽

Vol 17 (1) ◽

pp. 167-173 ◽

Cited By ~ 1

Author(s):

Kehua Zhou ◽

Peng Jia ◽

Swati Bhargava ◽

Yong Zhang ◽

Taslima Reza ◽

...

Keyword(s):

Trigger Point ◽

Retrospective Chart Review ◽

Opioid Use Disorder ◽

Prescription Opioid ◽

Office Visits ◽

Opioid Use ◽

Clinical Practices ◽

Medication Assisted Treatment ◽

Opioid Tapering ◽

Prescription Opioid Use

AbstractBackground and aimsOpioid use disorder (OUD) refers to a maladaptive pattern of opioid use leading to clinically significant impairment or distress. OUD causes, and vice versa, misuses and abuse of opioid medications. Clinicians face daily challenges to treat patients with prescription opioid use disorder. An evidence-based management for people who are already addicted to opioids has been identified as the national priority in the US; however, options are limited in clinical practices. In this study, we aimed to explore the success rate and important adjuvant medications in the medication assisted treatment with temporary use of methadone for opioid discontinuation in patients with prescription OUD.MethodsThis is a retrospective chart review performed at a private physician office for physical medicine and rehabilitation. We reviewed all medical records dated between December 1st, 2011 and August 30th, 2016. The initial evaluation of the included patients (N =140) was completed between December 1st, 2011 and December 31st, 2014. They all have concumittant prescription OUD and chronic non-cancer pain. The patients (87 female and 53 male) were 46.7 ± 12.7 years old, and had a history of opioid use of 7.7 ±6.1 years. All patients received the comprehensive opioid taper treatments (including interventional pain management techniques, psychotherapy, acupuncture, physical modalities and exercises, and adjuvant medications) on top of the medication assisted treatment using methadone (transient use). Opioid tapering was considered successful when no opioid medication was used in the last patient visit.ResultsThe 140 patients had pain of 9.6 ± 8.4 years with 8/10 intensity before treatment which decreased after treatment in all comparisons (p < 0.001 for all). Opioids were successfully tapered off in 39 (27.9%) patients after 6.6 ±6.7 visits over 8.8 ±7.2 months; these patients maintained opioid abstinence over 14.3 ± 13.0 months with regular office visits. Among the 101 patients with unsuccessful opioid tapering, 13 patients only visited the outpatient clinic once. Significant differences were found between patients with and without successful opioid tapering in treatment duration, number of clinic visits, the use of mirtazepine, bupropion, topiramate, and trigger point injections with the univariate analyses. The use of mirtazepine (OR, 3.75; 95% CI, 1.48–9.49), topiramate (OR, 5.61; 95% CI, 1.91–16.48), or bupropion (OR, 2.5; 95% CI, 1.08–5.81) was significantly associated with successful opioid tapering. The associations remain significant for mirtazepine and topiramate (not bupropion) in different adjusted models.ConclusionsWith comprehensive treatments, 27.9% of patients had successful opioid tapering with opioid abstinence for over a year. The use of mirtazepine, topiramate, or likely bupropion was associated with successful opioid tapering in the medication assisted treatment with temporary use of methadone. Opioid tapering may be a practical option and should be considered for managing prescription OUD.ImplicationsFor patients with OUD, indefinite opioid maintenance treatment may not be necessary. Considering the ethical values of autonomy, nonmaleficence, and beneficence, clinicians should provide patients with OUD the option of opioid tapering.

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Necrotizing fasciitis: presentation, microbiology and outcomes in a community hospital

International Surgery Journal ◽

10.18203/2349-2902.isj20203225 ◽

2020 ◽

Vol 7 (8) ◽

pp. 2471

Author(s):

Mercy N. Jimenez ◽

Emily S. Seltzer ◽

Bhavana Devanabanda ◽

Martine Louis ◽

Nageswara Mandava

Keyword(s):

New York ◽

Necrotizing Fasciitis ◽

Clinical Decision Making ◽

Community Hospital ◽

Average Length ◽

Retrospective Chart Review ◽

Patient Characteristics ◽

Clinical Decision ◽

Blood Cultures ◽

Average Length Of Stay

Background: Necrotizing fasciitis (NF) is an aggressive and often fatal, soft tissue infection. Delayed surgical therapy leads to worsened outcomes. This study evaluates the mortality, outcomes, and characteristics of patients with NF in a diverse New York City Community Hospital Network.Methods: Retrospective chart review from 2012 to 2019 using ICD-9 and ICD-10 codes of gas gangrene, Fournier’s gangrene, and necrotizing fasciitis was done. Of the 297 patients reviewed 28 met inclusion criteria of imaging findings, operative reports, and clinical diagnosis of NF by an attending surgeon.Results: On average patients in ER were seen by the surgical team within less than 12 hours. Most patients were debrided within 10 hours of surgical consultation and on average received 2.2 procedures. Of the wound cultures obtained 65.38% were polymicrobial in nature. The average length of stay was 17.4 days and 32% of patients required ICU admission. The surgical mortality rate was 7.61%.Conclusions: Necrotizing fasciitis is a rare entity and increasing provider knowledge on patient characteristics as well as the complexity of these patients and the types and number of procedures they require may help guide clinical decision making. We identified that while most of our patients had negative blood cultures on admission, those that had positive blood cultures had multiple organisms growing. Knowing that these patients are complex and likely require multiple procedures, prompt operative intervention is key.

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Abstract WP330: Process Measures and Outcomes in Defuse 3 Trial by Day and Week Time Patterns

Stroke ◽

10.1161/str.51.suppl_1.wp330 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Michael Mlynash ◽

Maarten G Lansberg ◽

Stephanie Kemp ◽

Soren Christensen ◽

Michael P Marks ◽

...

Keyword(s):

Arrival Time ◽

Stroke Care ◽

Mortality Rates ◽

Temporal Variations ◽

Time Of Day ◽

Process Measures ◽

Time Period ◽

Time Patterns ◽

Time Of Admission

Introduction: Several studies identified temporal variations in stroke care and suggested that quality of care declines during off-hours and on weekends. Methods: We specified 2 time definitions: a) 8-hour blocks: night (midnight – 7:59), day (8:00 – 15:59), evening (16:00-23:59); b) weekday vs. weekend. We compared process measures and outcomes of the EVT-treated DEFUSE 3 patients based on these definitions. To assign patients to time-blocks, we used date and time of admission to hospital that performed EVT. Results: 92 patients were randomized to EVT treatment: 30% arrived to the treating hospital at night, 49% at day, 21% at evening. Mean age by arrival time 71±14, 70±12, 63±15 (p=0.09); NIHSS 17±5, 15±6, 15±8 (p=0.40); female 39%, 51%, 63% (p=0.27). Weekend admission occurred in 21%. Weekday vs weekend mean age 68±14 vs 72±11 (p=0.19); female 53% vs 37% (p=0.20), higher weekend NIHSS 15±6 vs 18±6 (p=0.04). Onset to arrival at the EVT center varied by time of day: (hrs:mins) 7:04±2:43 night, 8:05±3:01 day, 4:51±2:30 evening, p<0.001. However, day admissions tended to be wake-up/not witnessed strokes more often: 76% vs. 47% evening and 64% night, p=0.09. Transfer times for 57 transfer patients were similar: mean 3:06, 3:09, 3:38. Time from arrival at the treating hospital to groin puncture varied by presenting times: 2:28±1:11 night, 1:45±0:46 day, 2:36±2:32 evening (p=0.02). Time-metrics for weekday vs weekend were similar. Rates of successful reperfusion, 90-day mRS and mRS=0-2 did not differ by time of day or week. There was higher 90-day mortality (32% vs 10%, p=0.02) and in-hospital mortality (21% vs. 4%, p=0.03) on weekend. Symptomatic ICH also occurred more commonly in weekend admits (21% vs 3%, p=0.01). However, after adjustment for age and NIHSS, presenting on weekend was not independently associated with mortality, p=0.13. Conclusions: DEFUSE 3 patients admitted during the day had the longest time from last known well to arrival at the study site due to the high percentage of wake-up strokes admitted during this time period, however, these patients had the shortest arrival to groin puncture times. Although mortality rates were higher for patients who presented on weekends, this may be explained by the fact that these patients were older and had higher NIHSS.

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Relationships Across Clinical Measures of Vocal Quality and Functioning and Their Relationship With Patient Perception

American Journal of Speech-Language Pathology ◽

10.1044/2021_ajslp-21-00128 ◽

2021 ◽

pp. 1-13

Author(s):

Nichole Houle ◽

Aaron M. Johnson

Keyword(s):

Principal Components ◽

Clinical Decision Making ◽

Principal Component ◽

Retrospective Chart Review ◽

Voice Disorder ◽

Initial Assessment ◽

Linear Regression Models ◽

Perceived Severity ◽

Vocal Quality ◽

Clinical Measures

Purpose The purpose of this study was to investigate the relationships among subjective auditory-perceptual ratings of vocal quality, objective acoustic and aerodynamic measures of vocal function, and patient-perceived severity of their vocal complaint. Method This study was a retrospective chart review of adult patients evaluated at a single outpatient center over a 1.5-year time period. Twenty-two clinical objective and subjective measures of voice were extracted from 676 charts (310 males, 366 females). To identify the underlying concepts addressed in an initial voice assessment, principal component analyses were conducted for males and females to account for sex differences. Linear regression models were conducted to examine the relationship between the principal components and patient perceived severity. Results Seven principal components were identified for both sexes and accounted for 75% and 71% of the variance in the clinical measures, respectively. Of these seven principal components, only two predicted male patient perceived severity, which accounted for 22% of the variance. In contrast, four principal components predicted female patient perceived severity of their voice disorder and accounted for 19% of the variance. Conclusions The results highlight the underlying aspects of vocal quality and functioning that are evaluated during an initial assessment. Male and female patients differ in which of these components may contribute self-perceived severity of a voice disorder. Identifying these underlying components may support clinical decision making when developing a clinical protocol and highlights the overlap between patient concerns and clinical measures. Supplemental Material https://doi.org/10.23641/asha.16879603

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Evaluating Diagnostic Tests

Advances in Dental Research ◽

10.1177/08959374930070021701 ◽

1993 ◽

Vol 7 (2) ◽

pp. 66-69 ◽

Cited By ~ 18

Author(s):

C.W. Douglass

Keyword(s):

Predictive Value ◽

Diagnostic Tests ◽

Clinical Decision Making ◽

New Technologies ◽

Clinical Decision ◽

Future Research ◽

Scientific Support ◽

Body Of Knowledge ◽

Efficacy Parameters ◽

Sensitivity Specificity

The presentations at this conference will discuss new technologies and rapid scientific developments that have resulted in new diagnostic tests for periodontal disease, musculoskeletal imaging, temporomandibular joint dysfunctions, and incipient coronal and root dental caries. However, for many of these claims, there has been insufficient scientific support regarding the sensitivity and specificity of the tests, or their ability to predict the percent of cases in which the disease or condition progresses to the next state of development. Research is needed that will yield the basic diagnostic parameters of new diagnostic tests, i.e., their accuracy, precision, sensitivity, specificity, positive predictive value, and negative predictive value. The purpose and methods for calculating each of these measures are described in this paper. Five questions are then presented that will need to be addressed in future research regarding new diagnostic tests: (1) Does the scientific theory of the test fit with our current body of knowledge? (2) Have the efficacy parameters of the test been reliably determined? (3) How does the test affect clinical decision-making? (4) Does using the test improve the patient's health? and (5) Is the added expense of the test justified by increased effectiveness or by avoiding other health expenditures?

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Assessing the quality of medication documentation: development and feasibility of the MediDocQ instrument for retrospective chart review in the hospital setting

BMJ Open ◽

10.1136/bmjopen-2019-034609 ◽

2019 ◽

Vol 9 (11) ◽

pp. e034609 ◽

Cited By ~ 3

Author(s):

Antje Hammer ◽

Anke Wagner ◽

Monika A Rieger ◽

Tanja Manser

Keyword(s):

Development Process ◽

Chart Review ◽

Clinical Decision Making ◽

Hospital Setting ◽

Retrospective Chart Review ◽

Medication Administration ◽

Patient Records ◽

Mean Values ◽

Medication Documentation

ObjectiveThe medication process requires clear and transparent documentation in patient records. Incomplete or incorrect medication documentation may contribute to inappropriate clinical decision-making and adverse events. To comprehensively assess the quality of in-hospital medication documentation, we developed a retrospective chart review (RCR) instrument. We report on the development process, the feasibility of the instrument and describe our application of the instrument to a sample of patient records.DesignCross-sectional study using an RCR instrument to evaluate paper-based, non-standardised prescription and medication administration charts (MediDocQ).SettingTwo German university hospitals.ParticipantsRecords from 1361 patients admitted between April and July 2015 were evaluated.MethodsThe MediDocQ development process comprised six consecutive stages: focused literature review, web-based search, initial patient record screening, review by project advisory board, focus groups with professionals and pilot testing. The final 54-item RCR instrument covers three key components of medication documentation: (1) completeness of documented information (including prescription, medication administration and pro re nata (PRN) medication), (2) quality of transcriptions and (3) compliance with chart structure, legibility, handling of deletions and chart corrections. Descriptive statistics are presented as mean values, SD, median and interquartile ranges for individual items.ResultsOverall, 33 out of 54 items resulted in mean values above 0.75, indicating high-quality medication documentation. Documentation quality was particularly compromised for verbal and PRN orders (which involve more steps than standard orders) and when documentation was not completed at the same time as medication administration.ConclusionsMediDocQ is a patient safety instrument that can be used to evaluate the quality of medication documentation and identify components of the process where intervention is required. In our setting, standardisation of medication documentation, particularly regarding medication administration and PRN medication is a priority.

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Appropriateness of Tympanostomy Tubes in the Boston Metropolitan Area: Are the AAO-HNSF Guidelines Being Met?

Otolaryngology ◽

10.1177/0194599817721454 ◽

2017 ◽

Vol 157 (6) ◽

pp. 1041-1047 ◽

Cited By ~ 4

Author(s):

Amy L. Hughes ◽

David Roberson ◽

Cassandra Bannos ◽

Emily K. Trudell ◽

Louis Vernacchio

Keyword(s):

Chart Review ◽

Clinical Decision Making ◽

Retrospective Chart Review ◽

Clinical Decision ◽

Neck Surgery ◽

Middle Ear Effusion ◽

Tympanostomy Tubes ◽

Risk Patients ◽

Speech Learning ◽

Ear Effusion

Introduction Otitis media (OM) is the most common reason children receive general anesthesia, with bilateral tympanostomy tube (TT) insertion the second most common surgery in children. Prior research suggests overuse of TT. As part of a project designed to improve appropriateness of OM referrals, we evaluated appropriateness of TT insertion in a patient cohort. Methods Patients younger than 9 years with initial otolaryngology (ORL) visits in academic and private office settings for OM from January 1, 2012, to August 31, 2013, were identified through claims database. A detailed retrospective chart review of patients undergoing TT insertion was performed to determine appropriateness of TT insertion per the 2013 American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) guidelines. Results A total of 120 patients undergoing TT insertion were randomly chosen for detailed chart review; 32 patients were excluded. Sixty-six (75%) of 88 patients available for analysis met AAO-HNSF guidelines for TT. Recurrent acute OM with middle ear effusion was the most common indication (56%). Other indications included chronic OME and TT in at-risk patients with speech, learning, or behavioral delays. Of the 22 patients undergoing TT insertion not meeting AAO-HNSF guidelines, 11(50%) had abnormal exams, but were 1 to 2 infections short of meeting guidelines; 7 (33%) had normal exams but met criteria for number of infections. Discussion Contrary to prior publications, 75% of patients undergoing TT insertion had an appropriate indication per AAO-HNSF guidelines. In only 5% was TT insertion a substantial departure from guidelines. Implications for Practice The study outcomes suggest appropriate clinical decision making, improved guideline adherence, and better guideline applicability from the previously published 1994 and 2004 guidelines.

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A software tool for calculating the uncertainty of diagnostic accuracy measures

10.21203/rs.3.rs-34357/v1 ◽

2020 ◽

Author(s):

Theodora Chatzimichail ◽

Aristides T. Hatjimihail

Keyword(s):

Decision Making ◽

Diagnostic Accuracy ◽

Diagnostic Tests ◽

Clinical Decision Making ◽

Single Point ◽

Population Sample ◽

Medical Decision ◽

Interactive Program ◽

Diagnostic Threshold ◽

Accuracy Measures

Abstract Background: Screening and diagnostic tests are used to classify people with and without a disease. Although diagnostic accuracy measures are used to evaluate the correctness of a classification in clinical research and practice, there has been limited research on their uncertainty. The objective for this work is to develop a tool for calculating the uncertainty of diagnostic accuracy measures, as diagnostic accuracy is fundamental to clinical decision-making.Results: For this reason, a freely available interactive program has been developed in Wolfram Language. The program provides six modules with nine submodules, for calculating and plotting the standard and expanded uncertainty and the resultant confidence intervals of various diagnostic accuracy measures of screening or diagnostic tests, which measure a normally distributed measurand, applied at a single point in time in non-diseased and diseased populations. This is done for differing population sample sizes, mean and standard deviation of the measurand, diagnostic threshold and standard measurement uncertainty of the test.The application of the program is illustrated with a case study of glucose measurements in diabetic and non-diabetic populations, that demonstrates the calculation of the uncertainty of diagnostic accuracy measures.Conclusion: The presented interactive program is user-friendly and can be used as a flexible educational and research tool in medical decision making, to calculate and explore the uncertainty of diagnostic accuracy measures.

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Nurses' Finnegan Scoring of Newborns with Neonatal Abstinence Syndrome Not Affected by Time or Day of the Week

American Journal of Perinatology ◽

10.1055/s-0039-1698458 ◽

2019 ◽

Vol 37 (02) ◽

pp. 224-230 ◽

Cited By ~ 2

Author(s):

Alla Kushnir ◽

Jennifer L. Bleznak ◽

Judy G. Saslow ◽

Gary Stahl

Keyword(s):

Neonatal Intensive Care ◽

Chart Review ◽

Retrospective Chart Review ◽

Time Of Day ◽

Behavioral Changes ◽

Neonatal Abstinence Syndrome ◽

Abstinence Syndrome ◽

Institutional Review ◽

Day Of The Week ◽

Scoring Tool

Abstract Objective Newborns exposed to drugs in utero are at risk of developing neonatal abstinence syndrome (NAS), characterized by behavioral changes and physiologic instability. Finnegan scoring tool quantifies severity of symptoms and guides treatment. This article evaluates whether time of day and the number of shift hours affects modified Finnegan scores, and the subjective component of these scores. Study Design Institutional review board-approved, retrospective chart review of newborns admitted to neonatal intensive care or transitional nursery from 2011 to 2014. Inclusion criteria: > 35 weeks' gestation, known maternal substance use, positive maternal or newborn urine, or meconium drug screen, NAS treatment. Results A total of 101 charts were evaluated. Mean treatment duration was 31.8 days (standard deviation ±18.3). There was no significant relationship between observer shift hour and high scores (> 8) (p = 0.83). Highest scores occurred in the afternoon, decreased at night (p = 0.03), and throughout admission (p < 0.0001). Weekend and weekday scores were similar (p = 0.4). The objective component of the scores remained similar throughout the day (p = 0.91) and week (p = 0.52). Conclusion Finnegan scores given by nurses were not influenced by shift hour. Time of day did not influence overall high scores or the proportion of objective to total Finnegan score. Inter-rater reliability was maintained regardless of time of day or day of the week.

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4 The Effects of Rapid Rewarming on Tissue Salvage in Severe Frostbite Injury

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.008 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S6-S6

Author(s):

Charlotte Rogers ◽

Frederick W Endorf ◽

Gopal Punjabi ◽

Jon Gayken ◽

Angela Whitley ◽

...

Keyword(s):

Limb Salvage ◽

Specific Treatment ◽

Retrospective Chart Review ◽

Treatment Modalities ◽

Risk Scores ◽

High Morbidity ◽

Body Parts ◽

Clinical Practices ◽

Burn Centers ◽

Significant Difference

Abstract Introduction Frostbite is a high morbidity, high cost injury caused by soft tissue freezing, which can lead to digit or limb necrosis requiring amputation. Many severe frostbite injuries are initially assessed at healthcare facilities outside of dedicated burn centers. Rapid rewarming is the widely accepted first line treatment and is typically performed by placing the affected body parts in a 40–42 C water bath for 15–30 minutes. The aim of this study is to ascertain the clinical practices at the referring facilities before transferring patients with severe frostbite to regional burn centers, as well as any impact on clinical outcomes. Methods Upon IRB approval, retrospective chart review identified severe frostbite patients admitted to our ABA verified burn center between 2014 and 2019. Records were reviewed to identify initial rewarming strategy from referring facilities. Time to thrombolytics after initial admission was also noted. Amputation and salvage rates were calculated. Results Seventy-four severe frostbite patients presented to outside facilities and 96 were direct admissions (N=170). There was no significant difference in age, gender, social and comorbid characteristics between transfer and direct admit groups. We found that a significantly greater number of transfer patients received tPA versus direct admit patients (82.4% v 66.7%, P=0.023). On average, tPA was given 1.5 hours earlier in the direct admit patients (5.8 vs 7.3 hours, P=0.004). There was no significant difference in tissue at risk scores (10.2 v 9.1, P=0.465), percentage of patients requiring amputation (35.1% v 24.0%, P=0.126), or tissue salvage rates (76.8 v 84.2, P=0.207) between the two groups. In the cohort of patients presenting to outside hospitals, 66% received rapid rewarming. Other warming modalities at referring centers included warm intravenous fluids, heated blankets, heated oxygen, catheter-based warming, bladder irrigation, and heat packs. On regression analysis, the use of rapid rewarming was not a significant predictor for poor outcomes for limb salvage (P=0.578). The early use of thrombolytics had a positive outcome on limb salvage (P=0.013). Conclusions Initial rewarming practices for frostbite vary dramatically at outside centers. While rapid rewarming was not statistically associated with improved outcomes, variations in specific treatment modalities and limited sample size decrease the likelihood of identifying differences in a retrospective study. Outreach efforts are needed to educate outside centers about the importance of rapid rewarming and early transfer of severe frostbite patients to burn centers for thrombolytic therapy. Applicability of Research to Practice This study shows the need for outreach and education of frostbite management for non-burn centers.

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