Browsing by Subject "Clinical decision-making"
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Item Association between patient characteristics and HPV vaccination recommendation for postpartum patients: A national survey of Obstetrician/Gynecologists(Elsevier, 2022-04-20) Lake, Paige W.; Head, Katharine J.; Christy, Shannon M.; DeMaria, Andrea L.; Thompson, Erika L.; Vadaparampil, Susan T.; Zimet, Gregory D.; Kasting, Monica L.; Communication Studies, School of Liberal ArtsHuman papillomavirus (HPV) vaccination rates in the U.S. are relatively low. Provider recommendation rates for HPV vaccination often vary by patient age and relationship status. Obstetrician/gynecologists (OB/GYNs) represent a key provider group that can recommend the HPV vaccine. This study examined differences in OB/GYN recommendation of HPV vaccination for inpatient postpartum patients by age, parity, and marital status. Data were collected from OB/GYNs nationally via a cross-sectional survey. Participants were randomized to two vignette groups (23-year-old patient or 33-year-old patient). Within each group, participants received 4 vignettes that were identical except for patient marital status (married/not in a committed relationship) and number of children (first/third child), and were asked to indicate HPV vaccination recommendation likelihood on a scale of 0 (definitely would not) to 100 (definitely would). A 2 × 2 × 2 general linear model with repeated measures was used to examine main and interaction effects of patient age, relationship status, and parity. 207 OB/GYNs were included in the final analyses. Recommendation was high for 23-year-old patients (range: 64.5-84.6 out of 100). When marital status and parity were held constant, recommendation likelihood was higher for the younger vs. older patient and was also higher for patients not in a committed relationship, compared to married patients (all p-values < 0.001). Differences in recommendation exist when considering age and relationship status, which provides insight into OB/GYN clinical decision-making. Findings highlight the need to address barriers to HPV vaccination recommendation, including awareness of risk factors to consider when recommending the vaccine.Item Barriers to and facilitators of effective management of fever episodes in hospitalised Kenyan children with cancer: protocol for convergent mixed methods study(BMJ Publishing, 2023-11-02) Nessle, Charles Nathaniel; Njuguna, Festus; Dettinger, Julia; Koima, Raphael; Nyamusi, Lenah; Kisembe, Evelynn; Kinja, Sarah; Ndung’u, Mercy; Njenga, Dennis; Langat, Sandra; Olbara, Gilbert; Moyer, Cheryl; Vik, Terry; Pediatrics, School of MedicineIntroduction: Febrile neutropenia is an oncological emergency in children with cancer, associated with serious infections and complications. In low-resourced settings, death from infections in children with cancer is 20 times higher than in high-resourced treatment settings, thought to be related to delays in antibiotic administration and management. The barriers to effective management of fever episodes in children with cancer have not previously been described. This convergent mixed-methods study will provide the evidence to develop fever treatment guidelines and to inform their effective implementation in children with cancer at Moi Teaching and Referral Hospital (MTRH), a level 6 referral hospital in western Kenya. Methods and analysis: Prospective data collection of paediatric patients with cancer with new fever episodes admitted to MTRH will be performed during routine treatment. Clinical variables will be collected from 50 fever episodes, including cancer diagnosis and infectious characteristics of the fever episode, and elapsed time from fever onset to various milestones in the management workflow. Semistructured qualitative interviews with healthcare providers (estimated 20 to reach saturation) will explore the barriers to and facilitators of appropriate management of fever episodes in children with cancer. The interview guide was informed by a theoretical framework and Consolidated Framework for Implementation Research. A mixed-methods analysis use of joint display tables and process mapping will link and integrate the two types of data with meta-inferences. Ethics and dissemination: Institutional review board approval was obtained from the MTRH (0004273) and the University of Michigan (HUM0225674), and the study was registered with National Commission for Science Technology and Innovation (P/23/22885). Written consent will be obtained from all participants. Results will be formally shared with local and national policy leadership and local end users, presented at relevant national academic conferences and submitted for publication in a peer-reviewed journal.Item Bias in pain care: What patient variables do providers report as influencing their treatment decisions?(2024-10) Rose-McCandlish, Margaret; Hirsh, Adam; Mosher, Catherine; Stewart, JesseRacialized and low socioeconomic status (SES) patients are often under-treated for chronic pain, despite reporting more pain on average. This disparity is likely due to multiple systemic factors, including healthcare provider bias. Providers often treat patients differently for chronic pain depending on the patient’s race and SES, but little is known about providers’ awareness of the extent to which patient demographic variables influence their pain treatment decisions. The present study examined the variables that providers report as influencing their pain treatment decisions, whether these variables group together to form distinct factors, and whether providers who demonstrate racial or socioeconomic bias in their treatment decisions report different patient variables or factors as influencing their treatment decisions compared to providers who did not demonstrate biases. Four hundred thirty-two United States-based physician residents and fellows (“providers”) made treatment decisions for 12 computer-simulated patients with chronic pain who varied by race (Black/White) and SES (high/low). Providers then rated the level to which 15 different variables influenced their treatment decision-making. Robust repeated measures ANOVAs indicated that providers rated patient sex/gender, age, and race as the least influential variables in their pain treatment decisions for the simulated patients. For the factor analysis, I sequentially omitted variables to achieve proper model fit and reliability and arrived at a three-factor solution; I labelled these factors Demographic, Biomedical, and Psychosocial, according to the variables’ conceptual overlap. Robust repeated measures ANOVAs found that reported use of variables did not differ between the providers who demonstrated bias and those who did not demonstrate bias, nor did factor scores for the three factors. The present study suggests that providers have low awareness of the extent to which patient race and SES may influence their clinical decision-making in pain care. Results can help inform future research to improve interventions to reduce the impact of racial and socioeconomic bias on providers’ treatment decisions for patients with chronic pain.Item Clinical Decision Making in Inflammatory Bowel Disease Mimics: Practice Management from Inflammatory Bowel Disease LIVE(Oxford University Press, 2024-04-11) Fiske, Hannah W.; Ward, Christopher; Shah, Samir A.; Holubar, Stefan D.; Al-Bawardy, Badr; Barnes, Edward L.; Binion, David; Bohm, Matthew; Brand, Myron; Clarke, Kofi; Cohen, Benjamin L.; Cross, Raymond K.; Dueker, Jeffrey; Engels, Michael; Farraye, Francis A.; Fine, Sean; Forster, Erin; Gaidos, Jill; Ginsburg, Philip; Goyal, Alka; Hanson, John; Herfath, Hans; Hull, Tracy; Kelly, Colleen R.; Lazarev, Mark; Levy, L. Campbell; Melia, Joanna; Philpott, Jessica; Qazi, Taha; Siegel, Corey A.; Watson, Andrew; Wexner, Steven D.; Williams, Emmanuelle D.; Regueiro, Miguel; Medicine, School of MedicineBackground: Since 2009, inflammatory bowel disease (IBD) specialists have utilized "IBD LIVE," a weekly live video conference with a global audience, to discuss the multidisciplinary management of their most challenging cases. While most cases presented were confirmed IBD, a substantial number were diseases that mimic IBD. We have categorized all IBD LIVE cases and identified "IBD-mimics" with consequent clinical management implications. Methods: Cases have been recorded/archived since May 2018; we reviewed all 371 cases from May 2018-February 2023. IBD-mimics were analyzed/categorized according to their diagnostic and therapeutic workup. Results: Confirmed IBD cases made up 82.5% (306/371; 193 Crohn's disease, 107 ulcerative colitis, and 6 IBD-unclassified). Sixty-five (17.5%) cases were found to be mimics, most commonly medication-induced (n = 8) or vasculitis (n = 7). The evaluations that ultimately resulted in correct diagnosis included additional endoscopic biopsies (n = 13, 21%), surgical exploration/pathology (n = 10, 16.5%), biopsies from outside the GI tract (n = 10, 16.5%), genetic/laboratory testing (n = 8, 13%), extensive review of patient history (n = 8, 13%), imaging (n = 5, 8%), balloon enteroscopy (n = 5, 8%), and capsule endoscopy (n = 2, 3%). Twenty-five patients (25/65, 38%) were treated with biologics for presumed IBD, 5 of whom subsequently experienced adverse events requiring discontinuation of the biologic. Many patients were prescribed steroids, azathioprine, mercaptopurine, or methotrexate, and 3 were trialed on tofacitinib. Conclusions: The diverse presentation of IBD and IBD-mimics necessitates periodic consideration of the differential diagnosis, and reassessment of treatment in presumed IBD patients without appropriate clinical response. The substantial differences and often conflicting treatment approaches to IBD versus IBD-mimics directly impact the quality and cost of patient care.Item Comparison of Troponin Elevation, Prior Myocardial Infarction, and Chest Pain in Acute Ischemic Heart Failure(Elsevier, 2020-05) Freitas, Cassandra; Wang, Xuesong; Ge, Yin; Ross, Heather J.; Austin, Peter C.; Pang, Peter S.; Ko, Dennis T.; Farkouh, Michael E.; Stukel, Therese A.; McMurray, John J.V.; Lee, Douglas S.; Emergency Medicine, School of MedicineBackground: Patients with heart failure (HF) with concomitant ischemic heart disease (IHD) have not been well characterized. We examined survival of patients with ischemic HF syndrome (IHFS), defined as presentation with acute HF and concomitant features suggestive of IHD. Methods: Patients were included if they presented with acute HF to hospitals in Ontario, Canada. IHD was defined by any of the following criteria: angina/chest pain, prior myocardial infarction (MI), or troponin elevation that was above the upper limit of normal (mild) or suggestive of cardiac injury. Deaths were determined after hospital presentation. Results: Of 5353 patients presenting with acute HF, 4088 (76.4%) exhibited features of IHFS. Patients with IHFS demonstrated a higher rate of 30-day (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.33-2.68) and 1-year death (HR, 1.16, 95% CI, 1.00-1.35) compared with those with nonischemic HF. Troponin elevation demonstrated the strongest association with mortality. Mildly elevated troponin was associated with increased hazard over 30-day (HR, 1.77; 95% CI, 1.12-2.81) and 1-year (HR, 1.63; 95% CI, 1.38-1.93) mortality. Troponins indicative of cardiac injury were associated with increased hazard of death over 30 days (HR, 2.33; 95% CI, 1.63-3.33) and 1 year (HR, 1.40; 95% CI, 1.21-1.61). The association between elevated troponin and higher mortality at 30 days was similar in left ventricular ejection fraction subcategories of HF with reduced ejection fraction, HF with mildly reduced ejection fraction, or HF with preserved ejection fraction (P interaction = 0.588). After multivariable adjustment, prior MI and angina were not associated with higher mortality risk. Conclusions: In acute HF, elevated troponin, but not prior MI or angina, was associated with a higher risk of 30-day and 1-year mortality irrespective of left ventricular ejection fraction.Item Current State of Pediatric Reference Intervals and the Importance of Correctly Describing the Biochemistry of Child Development: A Review(American Medical Association, 2022) Lyle, Alicia N.; Pokuah, Fidelia; Dietzen, Dennis J.; Wong, Edward C. C.; Pyle-Eilola, Amy L.; Fuqua, John S.; Woodworth, Alison; Jones, Patricia M.; Akinbami, Lara J.; Garibaldi, Luigi R.; Vesper, Hubert W.; Pediatrics, School of MedicineImportance: Appropriately established pediatric reference intervals are critical to the clinical decision-making process and should reflect the physiologic changes that occur during healthy child development. Reference intervals used in pediatric care today remain highly inconsistent across a broad range of common clinical biomarkers. Observations: This narrative review assesses biomarker-specific pediatric reference intervals and their clinical utility with respect to the underlying biological changes occurring during development. Pediatric reference intervals from PubMed-indexed articles published from January 2015 to April 2021, commercial laboratory websites, study cohorts, and pediatric reference interval books were all examined. Although large numbers of pediatric reference intervals are published for some biomarkers, very few are used by clinical and commercial laboratories. The patterns, extent, and timing of biomarker changes are highly variable, particularly during developmental stages with rapid physiologic changes. However, many pediatric reference intervals do not capture these changes and thus do not accurately reflect the underlying biochemistry of development, resulting in significant inconsistencies between reference intervals. Conclusions and relevance: There is a need to correctly describe the biochemistry of child development as well as to identify strategies to develop accurate and consistent pediatric reference intervals for improved pediatric care.Item Decision Fatigue in Hospital Settings: A Scoping Review(Wiley, 2024-11-11) Perry , Kelsey; Jones , Sarah; Stumpff, Julia C.; Kruer, Rachel; Czosnowski, Lauren; Kashiwagi, Deanne; Kara, AreebaBACKGROUND: ‘Decision Fatigue’ (DF) describes the impaired ability to make decisions because of repeated acts of decision-making. We conducted a scoping review to describe DF in inpatient settings. METHODS: To be included, studies should have explored a clinical decision, included a mechanism to account for the order of decision making, published in English in or after the year 2000. Six data bases were searched. Retrieved citations were screened and retained studies were reviewed against inclusion criteria. References of included studies were manually searched, and forward citation searches were conducted to capture relevant sources. RESULTS: The search retrieved 12,781 citations of which 41 were retained following screening. Following review, sixteen studies met inclusion criteria. Half were conference abstracts and no studies examined hospitalists. Emergency medicine and intensive care settings were the most frequently studied clinical environments (n=13, 81%). All studies were observational. The most frequently examined decisions were about resource utilization (n=8, 50%), however only half of these examined downstream clinical outcomes. Decision quality against prespecified standards was examined in four (25%) studies. Work environment and patient attributes were often described but not consistently accounted for in analyses. Clinician attributes were described in four (25%) investigations. Findings were inconsistent: both supporting and refuting DF’s role in the outcome studied. CONCLUSIONS: The role of clinician, patient and work environment attributes in mediating DF is understudied. Similarly, the contexts surrounding the decision under study require further explication and when assessing resource use and decision quality, adjudication should be made against prespecified standards.Item Decisional Informatics for Psychosocial Rehabilitation: A Feasibility Pilot on Tailored and Fluid Treatment Algorithms for Serious Mental Illness(Wolters Kluwer, 2017-11) Choi, Jimmy; Lysaker, Paul H.; Bell, Morris D.; Dixon, Lisa; Margolies, Paul; Gold, Matthew; Golden-Roose, Elizabeth; Thime, Warren; Haber, Lawrence C.; Dewberry, Michael J.; Stevens, Michael; Pearlson, Godfrey D.; Fiszdon, Joanna M.; Medicine, School of MedicineThis study introduces a computerized clinical decision-support tool, the Fluid Outpatient Rehabilitation Treatment (FORT), that incorporates individual and ever-evolving patient needs to guide clinicians in developing and updating treatment decisions in real-time. In this proof-of-concept feasibility pilot, FORT was compared against traditional treatment planning using similar behavioral therapies in 52 adults with severe mental illness attending community-based day treatment. At posttreatment and follow-up, group differences and moderate-to-large effect sizes favoring FORT were detected in social function, work readiness, self-esteem, working memory, processing speed, and mental flexibility. Of participants who identified obtaining a General Education Diploma as their goal, 73% in FORT passed the examination compared with 18% in traditional treatment planning. FORT was also associated with higher agency cost-effectiveness and a better average benefit-cost ratio, even when considering diagnosis, baseline symptoms, and education. Although the comparison groups were not completely equivalent, the findings suggest computerized decision support systems that collaborate with human decision-makers to personalize psychiatric rehabilitation and address critical decisions may have a role in improving treatment effectiveness and efficiency.Item Editorial. Pediatric neurosurgery along with Children's Hospitals' innovations are rapid and uniform in response to the COVID-19 pandemic(American Association of Neurological Surgeons, 2020-04) Weiner, Howard L.; Adelson, P. David; Brockmeyer, Douglas L.; Maher, Cormac O.; Gupta, Nalin; Smyth, Matthew D.; Jea, Andrew; Blount, Jeffrey P.; Riva-Cambrin, Jay; Lam, Sandi K.; Ahn, Edward S.; Albert, Gregory W.; Leonard, Jeffrey R.; Neurological Surgery, School of MedicineThe COVID-19 pandemic is an unprecedented international crisis, with enormous health, economic, and social consequences, the likes of which have not been experienced in recent human history. The global medical community is facing historic practical and ethical challenges that require an urgent response. This situation has necessitated swift decision-making in the neurosurgery community. An inspiring and consistent message emerged from the resultant conversation, demonstrating our discipline’s response to this tragedy, which was strikingly rapid, uniform, and thoughtful across the many centers represented. Not surprisingly, pediatric neurosurgeons are able to lead their teams through this unprecedented time with creative decision-making and a razor-sharp focus on the health of both patients and colleagues. At the time of this writing, each center reported either no or only a small number of COVID-19–positive cases at their pediatric hospital, among either patients or staff, and a range of documented coronavirus community transmissions. Several notably consistent themes emerged from this exchange among the 13 members of the Journal of Neurosurgery: Pediatrics Editorial Board, the common concept being that decision-making remains dynamic and is modified as needed on a daily basis.Item Impact of bedside lung ultrasound on physician clinical decision-making in an emergency department in Nepal(BMC, 2020) House, Darlene R.; Amatya, Yogendra; Nti, Benjamin; Russell, Frances M.; Emergency Medicine, School of MedicineBackground Lung ultrasound is an effective tool for the evaluation of undifferentiated dyspnea in the emergency department. Impact of lung ultrasound on clinical decisions for the evaluation of patients with dyspnea in resource-limited settings is not well-known. The objective of this study was to evaluate the impact of lung ultrasound on clinical decision-making for patients presenting with dyspnea to an emergency department in the resource-limited setting of Nepal. Methods A prospective, cross-sectional study of clinicians working in the Patan Hospital Emergency Department was performed. Clinicians performed lung ultrasounds on patients presenting with dyspnea and submitted ultrasounds with their pre-test diagnosis, lung ultrasound interpretation, post-test diagnosis, and any change in management. Results Twenty-two clinicians participated in the study, completing 280 lung ultrasounds. Diagnosis changed in 124 (44.3%) of patients with dyspnea. Clinicians reported a change in management based on the lung ultrasound in 150 cases (53.6%). Of the changes in management, the majority involved treatment (83.3%) followed by disposition (13.3%) and new consults (2.7%). Conclusions In an emergency department in Nepal, bedside lung ultrasound had a significant impact on physician clinical decision-making, especially on patient diagnosis and treatment.