Showing papers by "Thomas McGinn published in 2019"

Screening for Social Determinants of Health: The Known and Unknown.

Abstract: In the age of precision medicine and genomics, screening for social determinants of health in a clinical setting is relatively simple. This screening may be as or more effectivethangeneticscreeninginimprovingpatienthealthand aiding risk stratification. Universal screening for social determinants of health by clinicians is now either recommended or being actively considered for recommendation by many professional societies and national organizations, including the American Academy of Pediatrics,AmericanAcademyofFamilyPhysicians,andAmerican College of Obstetricians and Gynecologists. Substantial evidence highlights ways to integrate addressing patients’ social determinants and social service needs into clinical care. Thus, now is an opportune time to review various practices for clinical screening and referrals. However, identifying and addressing patients’ social determinants will only be successful if these clinical practices occur with broad structural, community, and societal changes to the determinants that currently perpetuate poor health.

The Clinical Utility of Chest Radiography for Identifying Pneumonia: Accounting for Diagnostic Uncertainty in Radiology Reports.

Abstract: OBJECTIVE. 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. MATERIALS AND METHODS. 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. RESULTS. 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%. CONCLUSION. 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.

Improving Provider Adoption With Adaptive Clinical Decision Support Surveillance: An Observational Study

Abstract: Background: Successful clinical decision support (CDS) tools can help use evidence-based medicine to effectively improve patient outcomes. However, the impact of these tools has been limited by low provider adoption due to overtriggering, leading to alert fatigue. We developed a tracking mechanism for monitoring trigger (percent of total visits for which the tool triggers) and adoption (percent of completed tools) rates of a complex CDS tool based on the Wells criteria for pulmonary embolism (PE). Objective: We aimed to monitor and evaluate the adoption and trigger rates of the tool and assess whether ongoing tool modifications would improve adoption rates. Methods: As part of a larger clinical trial, a CDS tool was developed using the Wells criteria to calculate pretest probability for PE at 2 tertiary centers’ emergency departments (EDs). The tool had multiple triggers: any order for D-dimer, computed tomography (CT) of the chest with intravenous contrast, CT pulmonary angiography (CTPA), ventilation-perfusion scan, or lower extremity Doppler ultrasound. A tracking dashboard was developed using Tableau to monitor real-time trigger and adoption rates. Based on initial low provider adoption rates of the tool, we conducted small focus groups with key ED providers to elicit barriers to tool use. We identified overtriggering of the tool for non-PE-related evaluations and inability to order CT testing for intermediate-risk patients. Thus, the tool was modified to allow CT testing for the intermediate-risk group and not to trigger for CT chest with intravenous contrast orders. A dialogue box, “Are you considering PE for this patient?” was added before the tool triggered to account for CTPAs ordered for aortic dissection evaluation. Results: In the ED of tertiary center 1, 95,295 patients visited during the academic year. The tool triggered for an average of 509 patients per month (average trigger rate 2036/30,234, 6.73%) before the modifications, reducing to 423 patients per month (average trigger rate 1629/31,361, 5.22%). In the ED of tertiary center 2, 88,956 patients visited during the academic year, with the tool triggering for about 473 patients per month (average trigger rate 1892/29,706, 6.37%) before the modifications and for about 400 per month (average trigger rate 1534/30,006, 5.12%) afterward. The modifications resulted in a significant 4.5- and 3-fold increase in provider adoption rates in tertiary centers 1 and 2, respectively. The modifications increased the average monthly adoption rate from 23.20/360 (6.5%) tools to 81.60/280.20 (29.3%) tools and 46.60/318.80 (14.7%) tools to 111.20/263.40 (42.6%) tools in centers 1 and 2, respectively. Conclusions: Close postimplementation monitoring of CDS tools may help improve provider adoption. Adaptive modifications based on user feedback may increase targeted CDS with lower trigger rates, reducing alert fatigue and increasing provider adoption. Iterative improvements and a postimplementation monitoring dashboard can significantly improve adoption rates.

Adaptive design of a clinical decision support tool: What the impact on utilization rates means for future CDS research.

Abstract: OBJECTIVEWe employed an agile, user-centered approach to the design of a clinical decision support tool in our prior integrated clinical prediction rule study, which achieved high adoption rates. T...

Live Usability Testing of Two Complex Clinical Decision Support Tools: Observational Study

Abstract: Background: Potential of the electronic health records (EHR) and clinical decision support (CDS) systems to improve the practice of medicine has been tempered by poor design and the resulting burden they place on providers. CDS is rarely tested in the real clinical environment. As a result, many tools are hard to use, placing strain on providers and resulting in low adoption rates. The existing CDS usability literature relies primarily on expert opinion and provider feedback via survey. This is the first study to evaluate CDS usability and the provider-computer-patient interaction with complex CDS in the real clinical environment. Objective: This study aimed to further understand the barriers and facilitators of meaningful CDS usage within a real clinical context. Methods: This qualitative observational study was conducted with 3 primary care providers during 6 patient care sessions. In patients with the chief complaint of sore throat, a CDS tool built with the Centor Score was used to stratify the risk of group A Streptococcus pharyngitis. In patients with a chief complaint of cough or upper respiratory tract infection, a CDS tool built with the Heckerling Rule was used to stratify the risk of pneumonia. During usability testing, all human-computer interactions, including audio and continuous screen capture, were recorded using the Camtasia software. Participants’ comments and interactions with the tool during clinical sessions and participant comments during a postsession brief interview were placed into coding categories and analyzed for generalizable themes. Results: In the 6 encounters observed, primary care providers toggled between addressing either the computer or the patient during the visit. Minimal time was spent listening to the patient without engaging the EHR. Participants mostly used the CDS tool with the patient, asking questions to populate the calculator and discussing the results of the risk assessment; they reported the ability to do this as the major benefit of the tool. All providers were interrupted during their use of the CDS tool by the need to refer to other sections of the chart. In half of the visits, patients’ clinical symptoms challenged the applicability of the tool to calculate the risk of bacterial infection. Primary care providers rarely used the incorporated incentives for CDS usage, including progress notes and patient instructions. Conclusions: Live usability testing of these CDS tools generated insights about their role in the patient-provider interaction. CDS may contribute to the interaction by being simultaneously viewed by the provider and patient. CDS can improve usability and lessen the strain it places on providers by being short, flexible, and customizable to unique provider workflow. A useful component of CDS is being as widely applicable as possible and ensuring that its functions represent the fastest way to perform a particular task.

Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings.

Abstract: Background Effective implementation of technologies into clinical workflow is hampered by lack of integration into daily activities. Normalisation process theory (NPT) can be used to describe the kinds of ‘work’ necessary to implement and embed complex new practices. We determined the suitability of NPT to assess the facilitators, barriers and ‘work’ of implementation of two clinical decision support (CDS) tools across diverse care settings. Methods We conducted baseline and 6-month follow-up quantitative surveys of clinic leadership at two academic institutions’ primary care clinics randomised to the intervention arm of a larger study. The survey was adapted from the NPT toolkit, analysing four implementation domains: sense-making, participation, action, monitoring. Domains were summarised among completed responses (n=60) and examined by role, institution, and time. Results The median score for each NPT domain was the same across roles and institutions at baseline, and decreased at 6 months. At 6 months, clinic managers’ participation domain (p=0.003), and all domains for medical directors (p Conclusions This study employed NPT to longitudinally assess the implementation barriers of new CDS. The consistency of results across participant roles suggests similarities in the work each role took on during implementation. The decline in engagement over time suggests the need for more frequent contact to maintain momentum. Using NPT to evaluate this implementation provides insight into domains which can be addressed with participants to improve success of new electronic health record technologies. Trial registration number NCT02534987.

Feasibility and impact of a guided symptom exposure augmented cognitive behavior therapy protocol to prevent symptoms of pharmacologically induced depression: A pilot study.

Abstract: 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.

The high cost of low value care.

Abstract: The main focus of this study is bridging the "evidence gap" between frontline decision-making in health care and the actual evidence, with the hope of reducing unnecessary diagnostic testing and treatments. From our work in pulmonary embolism (PE) and over ordering of computed tomography pulmonary angiography, we integrated the highly validated Wells' criteria into the electronic health record at two of our major academic tertiary hospitals. The Wells' clinical decision support tool triggered for patients being evaluated for PE and therefore determined a patients' pretest probability for having a PE. There were 12,759 patient visits representing 11,836 patients, 51% had no D-dimer, 41% had a negative D-dimer, and 9% had a positive D-dimer. Our study gave us an opportunity to determine which patients were very low probabilities for PE, with no need for further testing.