Endovascular Treatment for Acute Stroke Patients With a Pre-stroke Disability: An International Survey

Background: It is unclear what factors clinicians consider when deciding about endovascular thrombectomy (EVT) in acute ischemic stroke patients with a pre-existing disability. We aimed to explore international practice patterns and preferences for EVT in patients with a pre-stroke disability, defined as a modified Rankin score (mRS) ≥ 2.Methods: Electronic survey link was sent to principal investigators of five major EVT trials and members of a professional interventional neurology society.Results: Of the 81 survey-responding clinicians, 57% were neuro-interventionalists and 33% were non-interventional stroke clinicians. Overall, 64.2% would never or almost never consider EVT for a patient with pre-stroke mRS of 4-5, and 49.3% would always or almost always offer EVT for a patient with pre-stroke mRS 2-3. Perceived benefit of EVT (89%) and severity of baseline disability (83.5%) were identified as the most important clinician-level and patient-level factors that influence EVT decisions in these patients.Conclusion: In this survey of 80 respondents, we found that EVT practice for patients with pre-stroke disability across the world is heterogenous and depends upon patient characteristics. Individual clinician opinions substantially alter EVT decisions in pre-stroke disabled patients.

From Bedside to Webside: A Qualitative Study of Pediatric Clinicians’ Use of Telemedicine (Preprint)

BACKGROUND With accelerated use of telemedicine, especially broad adoption with the COVID-19 pandemic, it is essential to maintain care standards and quality through effective communication. Virtual communication or webside manner may require modifications to traditional bedside manner. OBJECTIVE Our aim was to understand how clinicians conduct patient-to-provider virtual visits and communicate with families at a single large-volume children’s hospital to inform program development and training of future clinicians. METHODS Two focus groups of pediatric clinicians performing virtual visits prior to the COVID-19 pandemic, with a range of experience and specialty, were engaged to discuss experiential, implementation, and practice-related issues. Focus groups were facilitated using a semi-structured guide covering general experience, preparedness, rapport strategies, and suggestions. Sessions were digitally recorded and the corresponding transcripts reviewed for data analysis. Transcripts were coded based on the main themes and subthemes identified. Based on higher level analysis of these codes, study authors generated a final set of key themes to describe the collected data. RESULTS Theme consistency was identified across diverse participants, although individual clinician experiences were influenced by their specialty and practice. Three key themes emerged regarding the development of best practices, barriers to scalability, and establishing patient rapport. Issues and concerns related to privacy were salient across all themes. Clinicians felt telemedicine required new skills for patient interaction, and not all were comfortable with their training. CONCLUSIONS Telemedicine provides benefits as well as challenges in healthcare delivery. In interprofessional focus groups, pediatric clinicians emphasized the importance of considering safety and privacy to promote rapport and webside manner when conducting virtual visits. Inclusion of webside manner instruction within training curricula is crucial as telemedicine becomes an established modality for providing healthcare. CLINICALTRIAL n/a

Beyond Notes: Why It Is Time to Abandon an Outdated Documentation Paradigm

Clinicians spend a substantial part of their workday reviewing and writing electronic medical notes. Here we describe how the current, widely accepted paradigm for electronic medical notes represents a poor organizational framework for both the individual clinician and the broader medical team. As described in this viewpoint, the medical chart—including notes, labs, and imaging results—can be reconceptualized as a dynamic, fully collaborative workspace organized by topic rather than time, writer, or data type. This revised framework enables a more accurate and complete assessment of the current state of the patient and easy historical review, saving clinicians substantial time on both data input and retrieval. Collectively, this approach has the potential to improve health care delivery effectiveness and efficiency.

Scoping review: Development and assessment of evaluation frameworks of mobile health apps for recommendations to consumers

Objective The study sought to review the different assessment items that have been used within existing health app evaluation frameworks aimed at individual, clinician, or organizational users, and to analyze the scoring and evaluation methods used in these frameworks. Materials and Methods We searched multiple bibliographic databases and conducted backward searches of reference lists, using search terms that were synonyms of “health apps,” “evaluation,” and “frameworks.” The review covered publications from 2011 to April 2020. Studies on health app evaluation frameworks and studies that elaborated on the scaling and scoring mechanisms applied in such frameworks were included. Results Ten common domains were identified across general health app evaluation frameworks. A list of 430 assessment criteria was compiled across 97 identified studies. The most frequently used scaling mechanism was a 5-point Likert scale. Most studies have adopted summary statistics to generate the total scoring of each app, and the most popular approach taken was the calculation of mean or average scores. Other frameworks did not use any scaling or scoring mechanism and adopted criteria-based, pictorial, or descriptive approaches, or “threshold” filter. Discussion There is wide variance in the approaches to evaluating health apps within published frameworks, and this variance leads to ongoing uncertainty in how to evaluate health apps. Conclusions A new evaluation framework is needed that can integrate the full range of evaluative criteria within one structure, and provide summative guidance on health app rating, to support individual app users, clinicians, and health organizations in choosing or recommending the best health app.

Paediatrics, ethics, and the law

Treating sick children creates a range of ethical and legal considerations that are different from adult medicine. Paediatrics adapts as children develop cognitively, physically, and in autonomy. The introduction of new vaccines, therapies, and technology has improved the outcome for many conditions, including preterm birth, CHD, and oncology. At the same time as improvements in medicine and technology has come increased societal expectation, the impact of social media, and the rise of obesity in childhood. There are complex and blurred lines to be negotiated in parental, individual clinician, and institutional responsibility, especially when things go wrong. Paediatrics involves complex cases of neglect and abuse of children that have occurred in all societies and cultures. In this chapter, some of these aspects are discussed, including an outline of ethical principles that allow us to frame decision-making, how the law in the United Kingdom has evolved, and some of the principles of the Children Act 1989 and the Human rights Act 1998.

134. Derivation of novel phenotypes of outpatient pediatrician prescribing patterns

Background Antibiotics are the most commonly prescribed drugs for children with estimates that 30%-50% of outpatient antibiotic prescriptions are inappropriate. Most analyses of outpatient antibiotic prescribing practices do not examine patterns within individual clinicians’ prescribing practices. We sought to derive unique phenotypes of outpatient antibiotic prescribing practices using an unsupervised machine learning clustering algorithm. Methods We extracted diagnoses and prescribing data on all problem-focused visits with a physician or nurse practitioner between 6/11/2018 – 12/11/2018 for a state-wide association of pediatric practices across Massachusetts. Clinicians with fewer than 100 encounters were excluded. The proportion of encounters resulting in an antibiotic prescription were calculated. Proportions were stratified by diagnoses: otitis media (OM), pharyngitis, pneumonia (PNA), sinusitis, skin & soft tissue infection (SSTI), and urinary tract infection (UTI). We then applied consensus k-means clustering, a form of unsupervised machine learning, across all included clinicians to create clusters (or phenotypes) based on their prescribing rates for these 6 conditions. A scree plot was used to determine the optimal number of clusters. Results A total of 431 clinicians at 77 practices with 234,288 problem-focused visits were included (Table 1). Overall, 42,441 visits (18%) resulted in an antibiotic prescription. Individual clinician prescribing proportions ranged from 5% of visits up to 44%. The optimal number of clusters was determined to be four (designated alpha, beta, gamma, delta). Antibiotic prescribing rates were similar for each phenotype across AOM, pharyngitis, and pneumonia but differed substantially for sinusitis, SSTI, and UTI (Figure 1). The beta phenotype had the highest median rates of prescribing across all conditions while the delta phenotype had the lowest median prescribing rates except for UTI. Table 1. Patient demographics and clinician characteristics Figure 1. Novel phenotypes of antibiotic prescribing practices across six common conditions Conclusion Antibiotic prescribing varies by both condition and individual clinician. Clustering algorithms can be used to derive phenotypic antibiotic prescribing practices. Antimicrobial stewardship efforts may have a higher impact if tailored by antibiotic prescribing phenotype. Disclosures All Authors: No reported disclosures

Beyond Notes: Why It Is Time to Abandon an Outdated Documentation Paradigm (Preprint)

UNSTRUCTURED Clinicians spend a substantial part of their workday reviewing and writing electronic medical notes. Here we describe how the current, widely accepted paradigm for electronic medical notes represents a poor organizational framework for both the individual clinician and the broader medical team. As described in this viewpoint, the medical chart—including notes, labs, and imaging results—can be reconceptualized as a dynamic, fully collaborative workspace organized by topic rather than time, writer, or data type. This revised framework enables a more accurate and complete assessment of the current state of the patient and easy historical review, saving clinicians substantial time on both data input and retrieval. Collectively, this approach has the potential to improve health care delivery effectiveness and efficiency.

Exploring paramedic perceptions of feedback using a phenomenological approach

Objectives: Despite widespread advocacy of a feedback culture in healthcare, paramedics receive little feedback on their clinical performance. Provision of ‘outcome feedback’, or information concerning health-related patient outcomes following incidents that paramedics have attended, is proposed, to provide paramedics with a means of assessing and developing their diagnostic and decision-making skills. To inform the design of feedback mechanisms, this study aimed to explore the perceptions of paramedics concerning current feedback provision and to discover their attitudes towards formal provision of patient outcome feedback.Methods: Convenience sampling from a single ambulance station in the United Kingdom (UK) resulted in eight paramedics participating in semi-structured interviews. Interpretative phenomenological analysis was employed to generate descriptive and interpretative themes related to both current and potential feedback provision.Results: The perception that only exceptional incidents initiate feedback, and that often the required depth of information supplied is lacking, resulted in some participants describing an isolation of their daily practice. Barriers and limitations of the informal processes currently employed to access feedback were also highlighted. Formal provision of outcome feedback was anticipated by participants to benefit the integration and progression of the paramedic profession as a whole, in addition to facilitating the continued development and well-being of the individual clinician. Participants anticipated feedback to be delivered electronically to minimise resource demands, with delivery initiated by the individual clinician. However, a level of support or supervision may also be required to minimise the potential for harmful consequences.Conclusions: Establishing a just feedback culture within paramedic practice may reduce a perceived isolation of clinical practice, enabling both individual development and progression of the profession. Carefully designed formal outcome feedback mechanisms should be initiated and subsequently evaluated to establish resultant benefits and costs.

Quality in the Context of Value: Reliability of Quality Metrics in an Academic Health System Shifting Toward Value-Based Payments

Quality metrics are fundamental to value-based payment reforms. Because metrics are key components used to drive performance, health care organizations participating in payment reforms should consider metric reliability—a measure of true performance versus statistical “noise.” This cross-sectional study examined reliability, variation from patient and clinician characteristics, and volume thresholds for 9 ambulatory quality metrics in a health system engaged in value-based payment reforms. Hierarchical mixed models were used to analyze data from 276 316 patients attributed to 4373 clinicians in 31 primary care clinics from 2015 to 2017. Reliability was lower for all metrics at the clinician level (range 6%-64%) than at the clinic level (84%-99%), with little variation related to patient or clinician characteristics. Few clinicians, but the majority of clinics, contributed sufficient volumes of patient encounters to meet a 70% reliability threshold. These findings suggest that clinic-level performance measurement may be more appropriate than individual clinician-level measurement, particularly in low-volume contexts.

An Electronic Medical Record-Derived Individualized Performance Metric to Measure Risk-Adjusted Adherence with Perioperative Prophylactic Bundles for Health Care Disparity Research and Implementation Science

Background Health care disparity persists despite vigorous countermeasures. Clinician performance is paramount for equitable care processes and outcomes. However, precise and valid individual performance measures remain elusive. Objectives We sought to develop a generalizable, rigorous, risk-adjusted metric for individual clinician performance (MIP) derived directly from the electronic medical record (EMR) to provide visual, personalized feedback. Methods We conceptualized MIP as risk responsiveness, i.e., administering an increasing number of interventions contingent on patient risk. We embedded MIP in a hierarchical statistical model, reflecting contemporary nested health care delivery. We tested MIP by investigating the adherence with prophylactic bundles to reduce the risk of postoperative nausea and vomiting (PONV), retrieving PONV risk factors and prophylactic antiemetic interventions from the EMR. We explored the impact of social determinants of health on MIP. Results We extracted data from the EMR on 25,980 elective anesthesia cases performed at Penn State Milton S. Hershey Medical Center between June 3, 2018 and March 31, 2019. Limiting the data by anesthesia Current Procedural Terminology code and to complete cases with PONV risk and antiemetic interventions, we evaluated the performance of 83 anesthesia clinicians on 2,211 anesthesia cases. Our metric demonstrated considerable variance between clinicians in the adherence to risk-adjusted utilization of antiemetic interventions. Risk seemed to drive utilization only in few clinicians. We demonstrated the impact of social determinants of health on MIP, illustrating its utility for health science and disparity research. Conclusion The strength of our novel measure of individual clinician performance is its generalizability, as well as its intuitive graphical representation of risk-adjusted individual performance. However, accuracy, precision and validity, stability over time, sensitivity to system perturbations, and acceptance among clinicians remain to be evaluated.