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Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87002/1/j.1747-4949.2011.00586_1.x.pd

Effect of Testing and Treatment on Emergency Department Length of Stay Using a National Database

Objectives:  Testing and treatment are essential aspects of the delivery of emergency care. Recognition of the effects of these activities on emergency department (ED) length of stay (LOS) has implications for administrators planning efficient operations, providers, and patients regarding expectations for length of visit; researchers in creating better models to predict LOS; and policy‐makers concerned about ED crowding. Methods:  A secondary analysis was performed using years 2006 through 2008 of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide study of ED services. In univariate and bivariate analyses, the authors assessed ED LOS and frequency of testing (blood test, urinalysis, electrocardiogram [ECG], radiograph, ultrasound, computed tomography [CT], or magnetic resonance imaging [MRI]) and treatment (providing a medication or performance of a procedure) according to disposition (discharged or admitted status). Two sets of multivariable models were developed to assess the contribution of testing and treatment to LOS, also stratified by disposition. The first was a series of logistic regression models to provide an overview of how testing and treatment activity affects three dichotomized LOS cutoffs at 2, 4, and 6 hours. The second was a generalized linear model (GLM) with a log‐link function and gamma distribution to fit skewed LOS data, which provided time costs associated with tests and treatment. Results:  Among 360 million weighted ED visits included in this analysis, 227 million (63%) involved testing, 304 million (85%) involved treatment, and 201 million (56%) involved both. Overall, visits with any testing were associated with longer LOS (median = 196 minutes; interquartile range [IQR] = 125 to 305 minutes) than those with any treatment (median = 159 minutes; IQR = 91 to 262 minutes). This difference was more pronounced among discharged patients than admitted patients. Obtaining a test was associated with an adjusted odds ratio (OR) of 2.29 (95% confidence interval [CI] = 1.86 to 2.83) for experiencing a more than 4‐hour LOS, while performing a treatment had no effect (adjusted OR = 0.84; 95% CI = 0.68 to 1.03). The most time‐costly testing modalities included blood test (adjusted marginal effects on LOS = +72 minutes; 95% CI = 66 to 78 minutes), MRI (+64 minutes; 95% CI = 36 to 93 minutes), CT (+59 minutes; 95% CI = 54 to 65 minutes), and ultrasound (US; +56 minutes; 95% CI = 45 to 67 minutes). Treatment time costs were less substantial: performing a procedure (+24 minutes; 95% CI = 20 to 28 minutes) and providing a medication (+15 minutes; 95% CI = 8 to 21 minutes). Conclusions:  Testing and less substantially treatment were associated with prolonged LOS in the ED, particularly for blood testing and advanced imaging. This knowledge may better direct efforts at streamlining delivery of care for the most time‐costly diagnostic modalities or suggest areas for future research into improving processes of care. Developing systems to improve efficient utilization of these services in the ED may improve patient and provider satisfaction. Such practice improvements could then be examined to determine their effects on ED crowding.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/92123/1/j.1553-2712.2012.01353.x.pd

Noble gases in deepwater oils of the U.S. Gulf of Mexico

Author Posting. © American Geophysical Union, 2018. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Geochemistry, Geophysics, Geosystems 19(11), (2018): 4218-4235. doi: 10.1029/2018GC007654Hydrocarbon migration and emplacement processes remain underconstrained despite the vast potential economic value associated with oil and gas. Noble gases provide information about hydrocarbon generation, fluid migration pathways, reservoir conditions, and the relative volumes of oil versus water in the subsurface. Produced gas He‐Ne‐Ar‐Kr‐Xe data from two distinct oil fields in the Gulf of Mexico (Genesis and Hoover‐Diana) are used to calibrate a model that takes into account both water‐oil solubility exchange and subsequent gas cap formation. Reconstructed noble gas signatures in oils reflect simple (two‐phase) oil‐water exchange imparted during migration from the source rock to the trap, which are subsequently modified by gas cap formation at current reservoir conditions. Calculated, oil to water volume ratios ( urn:x-wiley:15252027:media:ggge21714:ggge21714-math-0001) in Tertiary‐sourced oils from the Hoover‐Diana system are 2–3 times greater on average than those in the Jurassic sourced oils from the Genesis reservoirs. Higher urn:x-wiley:15252027:media:ggge21714:ggge21714-math-0002 in Hoover‐Diana versus Genesis can be interpreted in two ways: either (1) the Hoover reservoir interval has 2–3 times more oil than any of the individual Genesis reservoirs, which is consistent with independent estimates of oil in place for the respective reservoirs, or (2) Genesis oils have experienced longer migration pathways than Hoover‐Diana oils and thus have interacted with more water. The ability to determine a robust urn:x-wiley:15252027:media:ggge21714:ggge21714-math-0003, despite gas cap formation and possible gas cap loss, is extremely powerful. For example, when volumetric hydrocarbon ratios are combined with independent estimates of hydrocarbon migration distance and/or formation fluid volumes, this technique has the potential to differentiate between large and small oil accumulations.We thank ExxonMobil for funding and providing the samples. In addition, we thank James Scott and two anonymous reviewers for their comprehensive and constructive reviews, as well as Janne Blichert‐Toft for editorial handling.2019-04-1

The accuracy of surrogate decision makers: informed consent in hypothetical acute stroke scenarios

Abstract Background Over one third of stroke patients have cognitive or language deficits such that they require surrogate consent for acute stroke treatment or enrollment into acute stroke trials. Little is known about the agreement of stroke patients and surrogates in this time-sensitive decision-making process. We sought to determine patient and surrogate agreement in 4 hypothetical acute stroke scenarios. Methods We performed face to face interviews with ED patients at an academic teaching hospital from June to August 2011. Patients and the surrogates they designated were asked to make decisions regarding 4 hypothetical stroke scenarios: 2 were treatment decisions; 2 involved enrollment into a clinical trial. Percent agreement was calculated as measures of surrogate predictive ability. Results A total of 200 patient/surrogate pairs were interviewed. Overall patient/surrogate percent agreement was 76.5%. Agreement for clinical scenarios ranged from 87% to 96% but dropped to 49%-74% for research scenarios. Conclusions Surrogates accurately predict patient preferences for standard acute stroke treatments. However, the accuracy decreases when predicting research participation suggesting that the degree of surrogate agreement is dependent on the type of decision being made. Further research is needed to more thoroughly characterize surrogate decision-making in acute stroke situations.http://deepblue.lib.umich.edu/bitstream/2027.42/112377/1/12873_2013_Article_190.pd

Clinical trialist perspectives on the ethics of adaptive clinical trials: a mixed-methods analysis

Abstract Background In an adaptive clinical trial (ACT), key trial characteristics may be altered during the course of the trial according to predefined rules in response to information that accumulates within the trial itself. In addition to having distinguishing scientific features, adaptive trials also may involve ethical considerations that differ from more traditional randomized trials. Better understanding of clinical trial experts’ views about the ethical aspects of adaptive designs could assist those planning ACTs. Our aim was to elucidate the opinions of clinical trial experts regarding their beliefs about ethical aspects of ACTs. Methods We used a convergent, mixed-methods design employing a 22-item ACTs beliefs survey with visual analog scales and open-ended questions and mini-focus groups. We developed a coding scheme to conduct thematic searches of textual data, depicted responses to visual analog scales on box-plot diagrams, and integrated findings thematically. Fifty-three clinical trial experts from four constituent groups participated: academic biostatisticians (n = 5); consultant biostatisticians (n = 6); academic clinicians (n = 22); and other stakeholders including patient advocacy, National Institutes of Health, and U.S. Food and Drug Administration representatives (n = 20). Results The respondents recognized potential ethical benefits of ACTs, including a higher probability of receiving an effective intervention for participants, optimizing resource utilization, and accelerating treatment discovery. Ethical challenges voiced include developing procedures so trial participants can make informed decisions about taking part in ACTs and plausible, though unlikely risks of research personnel altering enrollment patterns. Conclusions Clinical trial experts recognize ethical advantages but also pose potential ethical challenges of ACTs. The four constituencies differ in their weighing of ACT ethical considerations based on their professional vantage points. These data suggest further discussion about the ethics of ACTs is needed to facilitate ACT planning, design and conduct, and ultimately better allow planners to weigh ethical implications of competing trial designs.http://deepblue.lib.umich.edu/bitstream/2027.42/111302/1/12910_2015_Article_22.pd

The Stroke Hyperglycemia Insulin Network Effort (SHINE) trial: an adaptive trial design case study

Background: The \u27Adaptive Designs Accelerating Promising Trials into Treatments (ADAPT-IT)\u27 project is a collaborative effort supported by the National Institutes of Health (NIH) and United States Food & Drug Administration (FDA) to explore how adaptive clinical trial design might improve the evaluation of drugs and medical devices. ADAPT-IT uses the National Institute of Neurologic Disorders & Stroke-supported Neurological Emergencies Treatment Trials (NETT) network as a \u27laboratory\u27 in which to study the development of adaptive clinical trial designs in the confirmatory setting. The Stroke Hyperglycemia Insulin Network Effort (SHINE) trial was selected for funding by the NIH-NINDS at the start of ADAPT-IT and is currently an ongoing phase III trial of tight glucose control in hyperglycemic acute ischemic stroke patients. Within ADAPT-IT, a Bayesian adaptive Goldilocks trial design alternative was developed. Methods: The SHINE design includes response adaptive randomization, a sample size re-estimation, and monitoring for early efficacy and futility according to a group sequential design. The Goldilocks design includes more frequent monitoring for predicted success or futility and a longitudinal model of the primary endpoint. Both trial designs were simulated and compared in terms of their mean sample size and power across a range of treatment effects and success rates for the control group. Results: As simulated, the SHINE design tends to have slightly higher power and the Goldilocks design has a lower mean sample size. Both designs were tuned to have approximately 80% power to detect a difference of 25% versus 32% between control and treatment, respectively. In this scenario, mean sample sizes are 1,114 and 979 for the SHINE and Goldilocks designs, respectively. Conclusions: Two designs were brought forward, and both were evaluated, revised, and improved based on the input of all parties involved in the ADAPT-IT process. However, the SHINE investigators were tasked with choosing only a single design to implement and ultimately elected not to implement the Goldilocks design. The Goldilocks design will be retrospectively executed upon completion of SHINE to later compare the designs based on their use of patient resources, time, and conclusions in a real world setting

Risk, Benefit, and Cost Thresholds for Emergency Department Testing: A Cross‐sectional, Scenario‐based Study

BackgroundWhile diagnostic testing is common in the emergency department, the value of some testing is questionable. The purpose of this study was to assess how varying levels of benefit, risk, and costs influenced an individual’s desire to have diagnostic testing.MethodsA survey through Amazon Mechanical Turk presented hypothetical clinical situations: low‐risk chest pain and minor traumatic brain injury. Each scenario included three given variables (benefit, risk, and cost), that was independently randomly varied over four possible values (0.1, 1, 5, and 10% for benefit and risk and $0,$100, $500, and$1,000 for the individual’s personal cost for receiving the test). Benefit was defined as the probability of finding the target disease (traumatic intracranial hemorrhage or acute coronary syndrome).ResultsOne‐thousand unique respondents completed the survey. With an increased benefit from 0.1% to 10%, the percentage of respondents who accepted a diagnostic test went from 28.4% to 53.1%. (odds ratio [OR] = 3.42; 95% confidence interval [CI] = 2.57–4.54). As risk increased from 0.1% to 10%, this number decreased from 52.5% to 28.5%. (OR = 0.33; 95% CI = 0.25–0.44). Increasing cost from $0 to$1,000 had the greatest change of those accepting the test from 61.1% to 21.4%, respectively (OR = 0.15; 95% CI = 0.11–0.2).ConclusionsThe desire for testing was strongly sensitive to the benefits, risks, and costs. Many participants wanted a test when there was no added cost, regardless of benefit or risk levels, but far fewer elected to receive the test as cost increased incrementally. This suggests that out‐of‐pocket costs may deter patients from undergoing diagnostic testing with low potential benefit.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137417/1/acem13148_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137417/2/acem13148.pd

Feasibility of Emergency Department–initiated, Mobile Health Blood Pressure Intervention: An Exploratory, Randomized Clinical Trial

ObjectivesWe aimed to assess the feasibility of a text messaging intervention by determining the proportion of emergency department (ED) patients who responded to prompted home blood pressure (BP) self‐monitoring and had persistent hypertension. We also explored the effect of the intervention on systolic blood pressure (sBP) over time.MethodsWe conducted a randomized, controlled trial of ED patients with expected discharge to home with elevated BP. Participants were identified by automated alerts from the electronic health record. Those who consented received a BP cuff to take home and enrolled in the 3‐week screening phase. Text responders with persistent hypertension were randomized to control or weekly prompted BP self‐monitoring and healthy behavior text messages.ResultsAmong the 104 patients enrolled in the ED, 73 reported at least one home BP over the 3‐week run‐in (screening) period. A total of 55 of 73 reported a home BP of ≥140/90 and were randomized to SMS intervention (n = 28) or control (n = 27). The intervention group had significant sBP reduction over time with a mean drop of 9.1 mm Hg (95% confidence interval = 1.1 to 17.6).ConclusionsThe identification of ED patients with persistent hypertension using home BP self‐monitoring and text messaging was feasible. The intervention was associated with a decrease in sBP likely to be clinically meaningful. Future studies are needed to further refine this approach and determine its efficacy.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149295/1/acem13691.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149295/2/acem13691_am.pd

Patient Preferences for Diagnostic Testing in the Emergency Department: A Crossâ sectional Study

BackgroundDiagnostic testing is common during emergency department (ED) visits. Little is understood about patient preferences for such testing. We hypothesized that a patient’s willingness to undergo diagnostic testing is influenced by the potential benefit, risk, and personal cost.MethodsWe conducted a cross sectional survey among ED patients for diagnostic testing in two hypothetical scenarios: chest pain (CP) and mild traumatic brain injury (mTBI). Each scenario defined specific risks, benefits, and costs of testing. The odds of a participant desiring diagnostic testing were calculated using a series of nested multivariable logistic regression models.ResultsParticipants opted for diagnostic testing 68.2% of the time, including 69.7% of CP and 66.7% of all mTBI scenarios. In the CP scenario, 81% of participants desired free testing versus 59% when it was associated with a $100 copay (difference = 22$100 copayment (difference = 17%, 95% CI = 11% to 24%). Benefit and risk had mixed effects across the scenarios. In fully adjusted models, the association between cost and desire for testing persisted in the CP (odds ratio [OR] = 0.33, 95% CI = 0.23 to 0.47) and adult mTBI (OR = 0.47, 95% CI = 0.33 to 0.67) scenarios.ConclusionsIn this EDâ based study, patient preferences for diagnostic testing differed significantly across levels of risk, benefit, and cost of diagnostic testing. Cost was the strongest and most consistent factor associated with decreased desire for testing.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/144652/1/acem13404.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144652/2/acem13404_am.pd

The S troke H yperglycemia I nsulin N etwork E ffort ( SHINE ) trial protocol: a randomized, blinded, efficacy trial of standard vs. intensive hyperglycemia management in acute stroke

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102726/1/ijs12045.pd