Constance McAneney

Automated clinical trial eligibility prescreening: increasing the efficiency of patient identification for clinical trials in the emergency department

Objectives (1) To develop an automated eligibility screening (ES) approach for clinical trials in an urban tertiary care pediatric emergency department (ED); (2) to assess the effectiveness of natural language processing (NLP), information extraction (IE), and machine learning (ML) techniques on real-world clinical data and trials. Data and methods We collected eligibility criteria for 13 randomly selected, disease-specific clinical trials actively enrolling patients between January 1, 2010 and August 31, 2012. In parallel, we retrospectively selected data fields including demographics, laboratory data, and clinical notes from the electronic health record (EHR) to represent profiles of all 202795 patients visiting the ED during the same period. Leveraging NLP, IE, and ML technologies, the automated ES algorithms identified patients whose profiles matched the trial criteria to reduce the pool of candidates for staff screening. The performance was validated on both a physician-generated gold standard of trial–patient matches and a reference standard of historical trial–patient enrollment decisions, where workload, mean average precision (MAP), and recall were assessed. Results Compared with the case without automation, the workload with automated ES was reduced by 92% on the gold standard set, with a MAP of 62.9%. The automated ES achieved a 450% increase in trial screening efficiency. The findings on the gold standard set were confirmed by large-scale evaluation on the reference set of trial–patient matches. Discussion and conclusion By exploiting the text of trial criteria and the content of EHRs, we demonstrated that NLP-, IE-, and ML-based automated ES could successfully identify patients for clinical trials.

Emergency Department Management of Bronchiolitis in the United States.

Objective The aim of this study was to examine differences between general and pediatric emergency departments (PEDs) in adherence to the American Academy of Pediatrics bronchiolitis management guidelines. Methods We conducted a nationally representative study of ED visits by infants younger than 24 months with bronchiolitis from 2002 to 2011 using the National Hospital Ambulatory Medical Care Survey. Diagnostic testing (complete blood counts, radiographs) and medication use (albuterol, corticosteroids, antibiotics and intravenous fluids) in general emergency departments (GEDs) were compared with those in PEDs before and after 2006 American Academy of Pediatrics guideline publication. Weighted percentages were compared, and logistic regression evaluated the association between ED type and resource use. Results Of more than 2.5 million ED visits for bronchiolitis from 2002 to 2011, 77.3% occurred in GEDs. General emergency departments were more likely to use radiography (62.7% vs 42.1%; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4–4.1), antibiotics (41.3% vs 18.8%; aOR, 2.8; 95% CI, 1.5–5.2), and corticosteroids (24.3% vs 12.5%; aOR, 2.1; 95% CI, 1.0–4.5) compared with PEDs. Compared with preguideline, after guideline publication PEDs had a greater decrease in radiography use (−19.7%; 95% CI, −39.3% to −0.03%) compared with GEDs (−12.2%; 95% CI, −22.3% to −2.1%), and PEDs showed a significant decline in corticosteroid use (−12.4%; 95% CI, −22.1% to −2.8%), whereas GEDs showed no significant decline (−4.6%; 95% CI, −13.5% to 4.3%). Conclusions The majority of ED visits for bronchiolitis in the United States occurred in GEDs, yet GEDs had increased use of radiography, corticosteroids, and antibiotics and did not show substantial declines with national guideline publication. Given that national guidelines discourage the use of such tests and treatments in the management of bronchiolitis, efforts are required to decrease ED use of these resources in infants with bronchiolitis, particularly in GEDs.

Essentials of Pediatric Emergency Medicine Fellowship: Part 1: An Overview.

This article is the first in a 7-part series (Table 1) that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated on program completion. This overview article provides a framework for the series.

Essentials of Pediatric Emergency Medicine Fellowship: Part 3: Clinical Education and Experience.

Abstract This article is the third in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on the clinical aspects of fellowship training including the impact of the clinical environment, modalities for teaching and evaluation, and threats and opportunities in clinical education.

Is pediatric emergency department utilization by pregnant adolescents on the rise

Objectives This study evaluates trends of pregnant adolescents’ utilization of pediatric emergency departments (PEDs), describes patient demographics, and reviews common pregnancy-related conditions seen in the PED. Methods This was a retrospective cross-sectional study of a large pediatric emergency medicine research network database including 11 freestanding PEDs, 3 separate PEDs from a site with a general ED, and 8 general EDs that see pediatric patients. Pediatric patients (<19 years old) were identified from January 1, 2003, to December 31, 2007, by any International Classification of Diseases, Ninth Revision pregnancy or pregnancy-related condition diagnosis code. Demographic information (age, race, payer type) and disposition (admit, discharge home, transfer) were recorded. Results There were 15,190 unique pregnancy-related visits with an overall annual growth rate of 2.8% (P = 0.03). There was a statistically significant increase in visits to freestanding PEDs (P = 0.02) and separate PED from a site with a general ED (P = 0.03), but there was not in the general EDs (P = 0.16). The 3 most common pregnancy-related conditions were abdominal pain, genitourinary infection, and hemorrhage in early pregnancy. Conclusions Pregnant adolescents make up a small (<1%) but growing proportion of overall visits to PEDs. Future direction should include an evaluation of the educational opportunities provided during pediatric residency and pediatric emergency medicine fellowship training and, if inadequacies exist, work to develop an innovative curriculum for this particular patient population.

Essentials of Pediatric Emergency Medicine Fellowship: Part 6: Program Administration.

This article is the sixth in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article provides a broad overview of administering and supervising a PEM fellowship program. It explores 3 topics: the principles of program administration, committee management, and recommendations for minimum time allocated for PEM fellowship program directors to administer their programs.

Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities

Abstract This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.