Prospective cost implications with a clinical decision support system for pediatric emergency head computed tomography.

BACKGROUND: Unnecessary imaging is a potential cost driver in the United States health care system. OBJECTIVE: Using a clinical decision support tool, we determined the percentage of low-utility non-contrast head computed tomography (CT) examinations on emergency patients and calculated the prospective cost implications of providing low-value imaging using time-driven activity-based costing at an academic quaternary pediatric hospital. MATERIALS AND METHODS: A clinical decision support tool for imaging, CareSelect (National Decision Support Co., Madison, WI), was integrated in silent mode into the electronic health record from September 2018 through August 2019. Each non-contrast head CT order received a score from the clinical decision support tool based on the American College of Radiology Appropriateness Criteria. Descriptive statistics for all levels of appropriateness scores were compiled with an emphasis on low-utility exams. A micro-costing assessment was conducted using time-driven activity-based costing on head CT without contrast examinations. RESULTS: Within the 11-month time period, 3,186 head CT examinations without contrast were ordered for emergency center patients. Among these orders, 28% (896/3,186) were classified as low-utility studies. The base case CT pathway time was 43 min and base case total cost was $193.35. The base case opportunity cost of these low-utility exams extrapolated annually amounts to $188,902 for our institution. CONCLUSION: Silent mode implementation of a clinical decision support tool resulted in 28% of head CT non-contrast exams on emergency patients being graded as low-utility studies. Prospective cost implications resulted in an annual base case cost of $188,902 to Texas Children's Hospital.

Characteristics of the gait initiation phase in older adults with diabetic peripheral neuropathy compared to control older adults.

BACKGROUND: Gait is deteriorated in older adults with diabetic peripheral neuropathy; however, too little is known about the gait initiation phase. We aimed to determine if gait initiation variables are more sensitive in identifying the extent to which diabetic peripheral neuropathy impacts gait. METHODS: We examined steps, distance, speed and dynamic balance in the gait initiation phase using a validated algorithm based on wearable sensors in 38 older adults with diabetic peripheral neuropathy and 33 non-diabetic, non-neurologic, non-orthopedic control older adults (≥65 years) under single-task and dual-task gait conditions. FINDINGS: During the single-task gait condition, the largest differences between the two groups were found in gait initiation steps and dynamic balance (66.7% more steps and 57.2% poorer balance for the diabetic group; effect size = 1.08 and 1.11, respectively; all p < 0.05), while gait speed had a medium effect (10.9% slower for the diabetic group; effect size = 0.54; p < 0.05). Although gait deteriorated for both groups during the dual-task gait condition compared to the single-task gait condition, effect sizes of the between-group differences remained similar. The differences in gait initiation steps and dynamic balance between the two groups were independent of gait speed. INTERPRETATION: Gait initiation steps and dynamic balance may be more sensitive than gait speed for detecting gait deterioration due to diabetic peripheral neuropathy. Given the association between gait initiation and risk for fall, our findings suggest that gait initiation variables may be important outcomes for clinical management of diabetic peripheral neuropathy.