Self-awareness of computed tomography ordering in the emergency department.

OBJECTIVES: Physician variation in the use of computed tomography (CT) is concerning due to the risks of ionizing radiation, cost, and downstream effects of unnecessary testing. The objectives of this study were to describe variation in CT-ordering rates among emergency physicians (EPs), to measure correlation between perceived and actual CT-ordering rates, to assess attitudes that influence decisions to order imaging tests, and to identify EP attitudes associated with higher CT utilization. METHODS: This study was a retrospective review of imaging and administrative billing records at two emergency department sites of a tertiary care adult teaching hospital. The study also included a cross-sectional survey of EPs at this hospital. We asked physicians about their perceived ordering behaviour, and what factors influenced their decision to order a CT. We examined correlations between perceived and actual CT-ordering rates. We adjusted ordering rates for shift distribution using a logistic regression model and identified outlier physicians whose ordering rate was significantly lower or higher than expected. We used multivariable regression analysis to determine which survey responses predicted higher CT utilization. RESULTS: During the study period, 59 EPs saw 45,854 patients, and ordered 6,609 CTs - a mean ordering rate of 14.4% (standard deviation (SD)=4.3%). The ordering rate for individual physicians ranged from 5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean perceived ordering rate was 12.6%, and was weakly correlated with actual ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered "about the same" or "fewer" CTs than their peers. Of the 17 EPs in the two highest ordering quintiles, only 3 (18%) knew they were high orderers. In the multivariable analysis, higher ordering was associated with increasing strength of response to the following predictors: medico-legal risk (relative risk [RR]=1.18, 95% CI: 1.03-1.21), risk of contrast (RR=1.14, 95% CI: 1.07-1.22), what colleagues would do (RR=1.09, 95% CI: 0.99-1.19), risk of missing a diagnosis (RR=1.08, 95% CI: 0.98-1.21), and patient wishes (RR=1.07, 95% CI: 0.97-1.17). CONCLUSIONS: There is large variation in CT ordering among EPs. Physicians' self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.

Is low-level laser therapy in relieving neck pain effective? Systematic review and meta-analysis.

The aim of this study is to determine the efficacy of low-level laser therapy (LLLT) in reducing acute and chronic neck pain as measured by the visual analog scale (VAS). A systematic search of nine electronic databases was conducted to identify original articles. For study selection, two reviewers independently assessed titles, abstracts, and full text for eligibility. Methodological quality was assessed using the Detsky scale. Data were analyzed using random-effects model in the presence of heterogeneity and fixed-effect model in its absence. Heterogeneity was assessed using Cochran's Q statistic and quantifying I (2). Risk ratios (RR) with 95 % confidence intervals (CI) were reported. Eight randomized controlled trials involving 443 patients met the strict inclusion criteria. Inter-rater reliability for study selection was 92.8 % (95 % CIs 80.9-100 %) and for methodological quality assessment was 83.9 % (95 % CIs 19.4-96.8 %). Five trials included patients with cervical myofascial pain syndrome (CMPS), and three trials included different patient populations. A meta-analysis of five CMPS trials revealed a mean improvement of VAS score of 10.54 with LLLT (95 % CI 0.37-20.71; Heterogeneity I (2 )= 65 %, P = 0.02). This systematic review provides inconclusive evidence because of significant between-study heterogeneity and potential risk of bias. The benefit seen in the use of LLLT, although statistically significant, does not constitute the threshold of minimally important clinical difference.

Validation of the diagnostic algorithms for 5 chronic conditions in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN): a Kingston Practice-based Research Network (PBRN) report.

OBJECTIVE: The objective of this study was to assess the validity of electronic medical records-based diagnostic algorithms for 5 chronic conditions. METHODS: A retrospective validation study using primary chart abstraction. A standardized abstraction form was developed to ascertain diagnoses of diabetes, hypertension, osteoarthritis, chronic obstructive pulmonary disease, and depression. Information about billing, laboratory tests, notes, specialist and hospital reports, and physiologic data was collected. An age-stratified random sample of 350 patient charts was selected from Kingston, Ontario, Canada. Approximately 90% of those charts were allocated to people aged ≥60 years. RESULTS: Three hundred thirteen patient records were included in the study. Patients' mean age was 68 years and 52% were women. High interrater reliability was indicated by 92% complete agreement and a κ statistic of 89.3%. The sensitivities of algorithms were 100% (diabetes), 83% (hypertension), 45% (osteoarthritis), 41% (chronic obstructive pulmonary disease), and 39% (depression). The lowest specificity was 97%, for depression. The positive predictive value ranged from 79% (depression) to 100%, and the negative predictive value ranged from 68% (osteoarthritis) to 100%. CONCLUSIONS: The diagnostic algorithms for diabetes and hypertension demonstrate adequate accuracy, thus allowing their use for research and policy-making purposes. The algorithms for the other 3 conditions require further refinement to attain better sensitivities.

Interprofessional and integrated care of the elderly in a family health team.

PROBLEM ADDRESSED: Family physicians provide most of the care for the frail elderly population, but many challenges and barriers can lead to difficulties with fragmented, ineffective, and inefficient services. OBJECTIVE OF PROGRAM: To improve the quality, efficiency, and coordination of care for the frail elderly living in the community and to enhance geriatric and interprofessional skills for providers and learners. PROGRAM DESCRIPTION: The Seniors Collaborative Care Program used an interprofessional, shared-care, geriatric model. The feasibility of the program was evaluated through a pilot study conducted between November 2008 and June 2009 at Stonechurch Family Health Centre, part of the McMaster Family Health Team. The core team comprised a nurse practitioner, an FP, and a registered practical nurse. Additional team members included a pharmacist, a dietitian, a social worker, and a visiting geriatrician. Twenty-five seniors were evaluated through the pilot program. Patients were assessed within 5 weeks of initial contact. Patients and practitioners valued timely, accessible, preventive, and multidisciplinary aspects of care. The nurse practitioner's role was prominent in the program, while the geriatrician's clinical role was focused efficiently. CONCLUSION: The family health team is ideally positioned to deliver shared care for the frail elderly. Our model allowed for a short referral time and easy access, which might allow seniors to remain in their environment of choice.