Emergency physician gender and head computed tomography orders for older adults who have fallen.

OBJECTIVE: Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS: This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS: There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS: There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

Patterns of multiple chronic conditions in pregnancy: Population-based study using latent class analysis.

BACKGROUND: Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce. OBJECTIVES: To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chronic conditions cluster together among pregnant women with MCC. METHODS: We conducted a population-based cohort study in Ontario, Canada, of all 15-55-year-old women with a recognised pregnancy, from 2007 to 2020. MCC was assessed from a list of 22 conditions, identified using validated algorithms. We estimated the prevalence of MCC. Next, we used latent class analysis to identify classes of co-occurring chronic conditions in women with MCC, with model selection based on parsimony, clinical interpretability and statistical fit. RESULTS: Among 2,014,508 pregnancies, 324,735 had MCC (161.2 per 1000, 95% confidence interval [CI] 160.6, 161.8). Latent class analysis resulted in a five-class solution. In four classes, mood and anxiety disorders were prominent and clustered with one additional condition, as follows: Class 1 (22.4% of women with MCC), osteoarthritis; Class 2 (23.7%), obesity; Class 3 (15.8%), substance use disorders; and Class 4 (22.1%), asthma. In Class 5 (16.1%), four physical conditions clustered together: obesity, asthma, chronic hypertension and diabetes mellitus. CONCLUSIONS: MCC is common in pregnancy, with sub-types dominated by co-occurring mental and physical health conditions. These data show the importance of preconception and perinatal interventions, particularly integrated care strategies, to optimise treatment and stabilisation of chronic conditions in women with MCC.

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen.

BACKGROUND: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

Comparison of Emergency Department Use Between Pregnant People With and Without Disabilities in Ontario, Canada.

Importance: Emergency department (ED) use in pregnancy is common and occurs for a variety of reasons, including obstetrical complications, exacerbated underlying conditions, and inadequate outpatient health care access. People with disabilities have elevated rates of certain medical, psychiatric, and obstetrical conditions as well as inadequate access to prenatal care; their risk of ED use in pregnancy is not known, however. Objective: To compare the risk of ED use in pregnancy among people with physical, sensory, and intellectual or developmental disabilities with those without disabilities. Design, Setting, and Participants: Population-based cohort study leveraging linked administrative health data sets in Ontario, Canada, April 2003 to March 2019. Analysis included all recognized pregnancies to people with a preexisting physical, sensory, intellectual or developmental, or 2 or more (multiple) disabilities, and those without a disability. Data were analyzed from May 2022 to January 2023. Exposure: Disability was ascertained using algorithms applied to 2 or more outpatient physician visits or 1 or more ED visits or hospitalizations before conception. Main outcomes and measures: Modified Poisson regression-generated adjusted relative risks (aRR) and 95% CIs for any ED visit in pregnancy, from the estimated conception date up to the end of the pregnancy, adjusted for age, parity, income quintile, rurality, immigrant status, and preexisting chronic conditions, mental illness, and substance use disorders. Results: The cohort included 2 659 895 pregnant people with physical (221 739 participants; mean [SD] age, 29.8 [6.1] years), sensory (71 891 participants; mean [SD] age, 29.1 [6.4] years), intellectual or developmental (3877 participants; mean [SD] age, 26.1 [6.7] years), and multiple disabilities (14 359 participants; mean [SD] age, 29.5 [6.5] years), and pregnant people without a disability (2 348 023 participants; mean [SD] age, 29.4 [5.9] years). The rate of ED visits in pregnancy was 25.4% in people without a disability (596 771 visits). Relative to these individuals, the aRR for ED use was elevated in people with physical (aRR, 1.26; 95% CI, 1.25-1.27), sensory (aRR, 1.15; 95% CI, 1.14-1.17), intellectual or developmental (aRR, 1.33; 95% CI, 1.28-1.38), and multiple disabilities (aRR, 1.43; 95% CI, 1.40-1.46). Conclusions and Relevance: In this population-based study, people with disabilities were at elevated risk of ED use in pregnancy. This finding underscores the need for research on the benefits of proactive strategies to manage preexisting conditions in these individuals, improve their access to outpatient obstetrical and medical care, and prepare them for when ED visits occur.

Application of the Modified Early Obstetrical Warning System (MEOWS) in postpartum patients in the emergency department.

INTRODUCTION: Over the last two decades, there has been a steady rise in severe maternal morbidity and pregnancy-related deaths in Canada and the USA. The Modified Early Obstetric Warning System (MEOWS) is a risk stratification tool designed to predict severe maternal morbidity and mortality and has been validated for use in obstetrical wards. The objective of this study was to determine if MEOWS could accurately identify patients at risk of severe maternal morbidity and mortality in the ED setting. METHODS: This was a chart review of patients presenting to an academic tertiary care centre (annual ED census 65,000) with a postpartum complaint within 6 weeks of delivery between May 2020 and March 2022. The exposure was the presence of a trigger, defined as one severely abnormal (red) or two mildly abnormal (yellow) physiological measurements during the ED visit. The diagnostic accuracy of the tool to identify patients at risk of severe maternal morbidity severe maternal morbidity or mortality was estimated by calculating the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: Two hundred and sixty-seven patients were included, of which 21 (7.9%) met the criteria for severe maternal morbidity. There were no maternal deaths. Overall, the sensitivity of the MEOWS tool was 85.7% (95% CI 63.7-97.0%), specificity was 67.9% (95% CI 61.7-73.7%), positive predictive value was 18.6% (95% CI 15.1-22.7%), and negative predictive value was 98.2% (95% CI 95.1-99.4%). Severe preeclampsia and eclampsia were the most common outcome category of severe maternal morbidity, representing 16 (76.2%) cases. Most patients (86.5%) were discharged directly from the ED, and 90.0% did not return within 30 days. CONCLUSIONS: This study is the first to explore the utility of MEOWS in postpartum ED patients. The presence of a MEOWS trigger at ED triage or the first ED nursing assessment was associated with severe maternal morbidity. Thus, MEOWS may be a valuable tool to identify postpartum patients at risk of severe outcomes early in an ED visit.

RéSUMé: INTRODUCTION: Au cours des deux dernières décennies, la morbidité maternelle grave et les décès liés à la grossesse ont connu une augmentation constante au Canada et aux États-Unis. Le système d'alerte précoce en obstétrique modifié (Modified Early Obstetric Warning System, MEOWS) est un outil de stratification des risques conçu pour prédire la morbidité et la mortalité maternelles graves. Il a été validé pour être utilisé dans les services d'obstétrique. L'objectif de cette étude était de déterminer si le MEOWS pouvait identifier avec précision les patientes présentant un risque de morbidité et de mortalité maternelles graves dans le contexte des urgences. MéTHODES: Il s'agit d'une étude des dossiers des patientes qui se sont présentées dans un centre de soins tertiaires universitaires (recensement annuel des urgences : 65 000) avec une plainte post-partum dans les six semaines suivant l'accouchement, entre mai 2020 et mars 2022. L'exposition était la présence d'un facteur déclenchant, défini comme une mesure physiologique gravement anormale (rouge) ou deux mesures légèrement anormales (jaune) au cours de la visite au service des urgences. La précision diagnostique de l'outil pour identifier les patientes à risque de morbidité maternelle grave morbidité maternelle grave ou de mortalité a été estimée en calculant la sensibilité, la spécificité, la valeur prédictive positive et la valeur prédictive négative. RéSULTATS: 267 patientes ont été incluses, dont 21 (7,9 %) répondaient aux critères de morbidité maternelle sévère. Il n'y a pas eu de décès maternel. Globalement, la sensibilité de l'outil MEOWS était de 85,7 % (IC 95 % : 63,7 %-97,0 %), la spécificité de 67,9 % (IC 95 % : 61,7 %-73,7 %), la valeur prédictive positive de 18,6 % (IC 95 % : 15,1 %-22,7 %) et la valeur prédictive négative de 98,2 % (IC 95 % : 95,1 %-99,4 %). La pré-éclampsie sévère et l'éclampsie étaient la catégorie d'issue la plus fréquente de la morbidité maternelle sévère, représentant 16 (76,2 %) cas. La plupart des patients (86,5 %) sont sortis directement des urgences et 90,0 % ne sont pas revenus dans les 30 jours. CONCLUSIONS: Cette étude est la première à explorer l'utilité du MEOWS chez les patientes des urgences post-partum. La présence d'un déclencheur MEOWS lors du triage aux urgences ou de la première évaluation infirmière aux urgences était associée à une morbidité maternelle grave. Ainsi, le MEOWS peut être un outil précieux pour identifier les patientes du post-partum qui risquent d'avoir des conséquences graves dès le début d'une visite aux urgences.