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The Institute for Healthcare Improvement's 4-Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4-Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4-Ms.Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media.Sixty-six respondents from all geographic segments of the U.S. (n = 62) and non-U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4-Ms, and creating age-specific best practice alerts.The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4-Ms in EHRs.

Sepsis is a life-threatening condition with high in-hospital mortality rate. The timing of antibiotic (ATB) administration poses a critical problem for sepsis management. Existing work studying antibiotic timing either ignores the temporality of the observational data or the heterogeneity of the treatment effects. In this paper, we propose a novel method to estimate TreatmenT effects for Time-to-Treatment antibiotic stewardship in sepsis (T4). T4 estimates individual treatment effects (ITEs) by recurrently encoding temporal and static variables as potential confounders, and then decoding the outcomes under different treatment sequences. We propose a mini-batch balancing matching that mimics the randomized controlled trial process to adjust the confounding. The model achieves interpretability through a global-level attention mechanism and a variable-level importance examination. Meanwhile, we incorporate T4 with uncertainty quantification to help prevent overconfident recommendations. We demonstrate that T4 can identify effective treatment timing with estimated ITEs for antibiotic stewardship on two real-world datasets. Moreover, comprehensive experiments on a synthetic dataset exhibit the outstanding performance of T4 compared to the state-of-the-art models on ITE estimation.

Women comprise 28% of faculty in academic departments of emergency medicine (EM) and 11% of academic chairs. Professional development programs for women are key to career success and to prevent pipeline attrition. Within emergency medicine, there is a paucity of outcomes-level data for such programs.We aim to measure the impact of a novel structured professional development curriculum and mentorship group (Resident and Faculty Female Tribe, or RAFFT) within an academic department of EM.This prospective single-center curriculum implementation and evaluation was conducted in the academic year 2020-2021. A planning group identified potential curricular topics using an iterative Delphi process. We developed a 10-session longitudinal curriculum; a postcurriculum survey was conducted to assess the perceived benefit of the program in four domains.A total of 76% of 51 eligible women attended at least one session; for this project we analyzed the 24 participants (47%) who attended at least one session and completed both the pre- and the postsurvey. The majority of participants reported a positive benefit, which aligned with their expectations in the following areas: professional development (79.2%), job satisfaction (83.3%), professional well-being (70.8%), and personal well-being (79.2%). Resident physicians more often reported less benefit than expected compared to fellow/faculty physicians. Median perceived impact on career choice and trajectory was positive for all respondents.Success of this professional development program was measured through a perceived benefit aligning with participant expectations, a positive impact on career choice and career trajectory for participants in each career stage, and a high level of engagement in this voluntary program. Recommendations for the successful implementation of professional development programs include early engagement of stakeholders, the application of data from a program-specific needs assessment, early dissemination of session dates to allow for protected time off, and structured discussions with appropriate identification of presession resources.

The aim of this study was to describe the 1-year direct and indirect transition probabilities to premature discontinuation of statin therapy after concurrently initiating statins and CYP3A4-inhibitor drugs.A retrospective new-user cohort study design was used to identify (N = 160 828) patients who concurrently initiated CYP3A4 inhibitors (diltiazem, ketoconazole, clarithromycin, others) and CYP3A4-metabolized statins (statin DDI exposed, n = 104 774) vs. other statins (unexposed to statin DDI, n = 56 054) from the MarketScan commercial claims database (2012-2017). The statin DDI exposed and unexposed groups were matched (2:1) through propensity score matching techniques. We applied a multistate transition model to compare the 1-year transition probabilities involving four distinct states (start, adverse drug events [ADEs], discontinuation of CYP3A4-inhibitor drugs, and discontinuation of statin therapy) between those exposed to statin DDIs vs. those unexposed. Statistically significant differences were assessed by comparing the 95% confidence intervals (CIs) of probabilities.After concurrently starting stains and CYP3A, patients exposed to statin DDIs, vs. unexposed, were significantly less likely to discontinue statin therapy (71.4% [95% CI: 71.1, 71.6] vs. 73.3% [95% CI: 72.9, 73.6]) but more likely to experience an ADE (3.4% [95% CI: 3.3, 3.5] vs. 3.2% [95% CI: 3.1, 3.3]) and discontinue with CYP3A4-inhibitor therapy (21.0% [95% CI: 20.8, 21.3] vs. 19.5% [95% CI: 19.2, 19.8]). ADEs did not change these associations because those exposed to statin DDIs, vs. unexposed, were still less likely to discontinue statin therapy but more likely to discontinue CYP3A4-inhibitor therapy after experiencing an ADE.We did not observe any meaningful clinical differences in the probability of premature statin discontinuation between statin users exposed to statin DDIs and those unexposed.

OBJECTIVES: Emergency medicine (EM) residents take the In‐Training Examination (ITE) annually to assess medical knowledge. Question content is derived from the Model of Clinical Practice of Emergency Medicine (EM Model), but it is unknown how well clinical encounters reflect the EM Model. The objective of this study was to compare the content of resident patient encounters from 2016–2018 to the content of the EM Model represented by the ITE Blueprint. METHODS: This was a retrospective cross‐sectional study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS). Reason for visit (RFV) codes were matched to the 20 categories of the American Board of Emergency Medicine (ABEM) ITE Blueprint. All analyses were done with weighted methodology. The proportion of visits in each of the 20 content categories and 5 acuity levels were compared to the proportion in the ITE Blueprint using 95% confidence intervals (CIs). RESULTS: Both resident and nonresident patient visits demonstrated content differences from the ITE Blueprint. The most common EM Model category were visits with only RFV codes related to signs, symptoms, and presentations regardless of resident involvement. Musculoskeletal disorders (nontraumatic), psychobehavioral disorders, and traumatic disorders categories were overrepresented in resident encounters. Cardiovascular disorders and systemic infectious diseases were underrepresented. When residents were involved with patient care, visits had a higher proportion of RFV codes in the emergent and urgent acuity categories compared to those without a resident. CONCLUSIONS: Resident physicians see higher acuity patients with varied patient presentations, but the distribution of encounters differ in content category than those represented by the ITE Blueprint.

The epidemiology and presence of pediatric medical emergencies and injury prevention practices in Kenya and resource-limited settings are not well understood. This is a barrier to planning and providing quality emergency care within the local health systems. We performed a prospective, cross-sectional study to describe the epidemiology of case encounters to the pediatric emergency unit (PEU) at Kenyatta National Hospital in Nairobi, Kenya; and to explore injury prevention measures used in the population.Patients were enrolled prospectively using systematic sampling over four weeks in the Kenyatta National Hospital PEU. Demographic data, PEU visit data and lifestyle practices associated with pediatric injury prevention were collected directly from patients or guardians and through chart review. Data were analyzed with descriptive statistics with stratification based on pediatric age groups.Of the 332 patients included, the majority were female (56%) and 76% were under 5 years of age. The most common presenting complaints were cough (40%) fever (34%), and nausea/vomiting (19%). The most common PEU diagnoses were upper respiratory tract infections (27%), gastroenteritis (11%), and pneumonia (8%). The majority of patients (77%) were discharged from the PEU, while 22% were admitted. Regarding injury prevention practices, the majority (68%) of guardians reported their child never used seatbelts or car seats. Of 68 patients that rode bicycles/motorbikes, one reported helmet use. More than half of caregivers cook at potentially dangerous heights; 59% use ground/low level stoves.Chief complaints and diagnoses in the PEU population were congruent with communicable disease burdens seen globally. Measures for primary injury prevention were reported as rarely used in the sample studied. The epidemiology described by this study provides a framework for improving public health education and provider training in resource-limited settings.