Elizabeth S. Chen

Bio: Elizabeth S. Chen is an academic researcher from Brown University. The author has contributed to research in topics: Informatics & Family history. The author has an hindex of 20, co-authored 98 publications receiving 1387 citations. Previous affiliations of Elizabeth S. Chen include Harvard University & Federal University of São Paulo.

Just-in-Time to Save Lives: A Pilot Study of Layperson Tourniquet Application.

Abstract: Objectives The objective was to determine whether just-in-time (JiT) instructions increase successful tourniquet application by laypersons. Methods This was a randomized pilot study conducted in August 2014. The study occurred at the Uniformed Services University campus in Bethesda, Maryland. A total of 194 volunteers without prior military service or medical training completed the study. The participant stood in front of a waist-down mannequin that had an exposed leg. An observer read a scenario card aloud that described a mass casualty event. The observer then asked the participant to apply a Combat Application Tourniquet (C-A-T) to the mannequin. Test participants received a 4 × 6-inch card, with JiT instructions, in addition to their C-A-T; controls received no instructions. Participants were randomized in a 3:1 ratio of instructions to no instructions. The study's primary outcome was the proportion of successfully applied tourniquets by participants receiving JiT instructions compared to participants not receiving instructions. Secondary outcomes included the time for successful tourniquet placement, reasons for failed tourniquet application, and participants' self-reported willingness and comfort using tourniquets in real-life settings. Results Just-in-time instructions more than doubled successful tourniquet placement. Participants supplied with JiT instructions placed a tourniquet successfully 44.14% of the time, compared to 20.41% of the time for controls without instructions (risk ratio = 2.16; 95% confidence interval = 1.21 to 3.87; p = 0.003). Conclusions Just-in-time instructions increase laypeople's successful application of C-A-T. This pilot study provides evidence that JiT instructions may assist the lay public in providing effective point-of-injury hemorrhage control. Resumen Justo a Tiempo Para Salvar Vidas: Estudio Piloto de la Aplicacion de Torniquete por un Lego Objetivos Determinar si las instrucciones “justo a tiempo” (JAT) incrementan la aplicacion de forma exitosa de un torniquete por legos. Metodologia Estudio piloto aleatorizado llevado a cabo en agosto del 2014. El estudio tuvo lugar en el campus de la Uniformed Services University (USU) en Bethesda, Maryland. Ciento noventa y cuatro voluntarios sin servicio militar o formacion medica previos completaron el estudio. El participante estuvo frente a un maniqui sin ropa por debajo de la cintura y tenia una pierna expuesta. Un observador leyo en voz alta una tarjeta del escenario que describio un acontecimiento con multiples victimas. El observador posteriormente ordeno al participante aplicar un torniquete de accion de combate (TAC) al maniqui. Los participantes recibieron una tarjeta 4x6 pulgadas, con las instrucciones JAT, ademas de su TAC; los controles no recibieron ninguna instruccion. Los participantes se aleatorizaron en una proporcion 3:1 a instrucciones frente no instrucciones. El resultado principal del estudio fue la proporcion de torniquetes aplicados de forma exitosa por los participantes que recibieron las instrucciones del JAT en comparacion con los participantes que no recibieron instrucciones. Los resultados secundarios incluyeron el tiempo para la aplicacion del torniquete de forma exitosa, las razones para el fallo en la aplicacion del torniquete, y la disposicion autoreportada de los participantes y su comodidad en el uso de torniquetes en escenarios de la vida real. Resultados El grupo de las instrucciones del grupo JAT aplicaron torniquetes de forma exitosa en mas del doble de los casos. Los participantes con las instrucciones JAT proporcionaron un torniquete de forma exitosa en enl 44,14% de casos, en comparacion con un 20,41% de los participantes control sin instrucciones (riesgo relatico [RR] 2,16; IC95% = 1,21 a 3,87; p = 0,003). Conclusiones Las instrucciones JAT incrementan la aplicacion de TAC de forma exitosa por legos. Este estudio piloto proporciona evidencia que las instrucciones JAT pueden ayudar a los legos a proporcionar de forma efectiva un control de la hemorragia en el lugar de la lesion.

Decision aids for people facing health treatment or screening decisions

Abstract: Background Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty. Objectives To assess the effects of decision aids for people facing treatment or screening decisions. Search methods For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008). Selection criteria We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions. Data collection and analysis Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were: A) 'choice made' attributes; B) 'decision-making process' attributes. Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model. Main results This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each. Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies). A) Criteria involving 'choice made' attributes: Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13). B) Criteria involving 'decision-making process' attributes: Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18); b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); and c) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18). Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice. C) Secondary outcomes Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable. The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive. Authors' conclusions There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values. New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.

Mining electronic health records: towards better research applications and clinical care

Abstract: The adoption of electronic health records will provide a rich resource for biomedical researchers. This Review discusses the potential for their use in informed decision making in the clinic, for a finer understanding of genotype–phenotype relationships and for selection of research cohorts, along with the current challenges for their mining and use. Clinical data describing the phenotypes and treatment of patients represents an underused data source that has much greater research potential than is currently realized. Mining of electronic health records (EHRs) has the potential for establishing new patient-stratification principles and for revealing unknown disease correlations. Integrating EHR data with genetic data will also give a finer understanding of genotype–phenotype relationships. However, a broad range of ethical, legal and technical reasons currently hinder the systematic deposition of these data in EHRs and their mining. Here, we consider the potential for furthering medical research and clinical care using EHR data and the challenges that must be overcome before this is a reality.

The effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis.

Abstract: Caroline Free and colleagues systematically review controlled trials of mobile technology interventions to improve health care delivery processes and show that current interventions give only modest benefits and that high-quality trials measuring clinical outcomes are needed.