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Distinguishing Admissions Specifically for COVID-19 From Incidental SARS-CoV-2 Admissions: National Retrospective Electronic Health Record Study

Klann, Jeffrey G; Strasser, Zachary H; Hutch, Meghan R; Kennedy, Chris J; Marwaha, Jayson S; Morris, Michele; Samayamuthu, Malarkodi Jebathilagam; Pfaff, Ashley C; Estiri, Hossein; South, Andrew M; Weber, Griffin M; Yuan, William; Avillach, Paul; Wagholikar, Kavishwar B; Luo, Yuan; Omenn, Gilbert S; Visweswaran, Shyam; Holmes, John H; Xia, Zongqi; Brat, Gabriel A; Murphy, Shawn N
BACKGROUND:Admissions are generally classified as COVID-19 hospitalizations if the patient has a positive SARS-CoV-2 polymerase chain reaction (PCR) test. However, because 35% of SARS-CoV-2 infections are asymptomatic, patients admitted for unrelated indications with an incidentally positive test could be misclassified as a COVID-19 hospitalization. Electronic health record (EHR)-based studies have been unable to distinguish between a hospitalization specifically for COVID-19 versus an incidental SARS-CoV-2 hospitalization. Although the need to improve classification of COVID-19 versus incidental SARS-CoV-2 is well understood, the magnitude of the problems has only been characterized in small, single-center studies. Furthermore, there have been no peer-reviewed studies evaluating methods for improving classification. OBJECTIVE:The aims of this study are to, first, quantify the frequency of incidental hospitalizations over the first 15 months of the pandemic in multiple hospital systems in the United States and, second, to apply electronic phenotyping techniques to automatically improve COVID-19 hospitalization classification. METHODS:From a retrospective EHR-based cohort in 4 US health care systems in Massachusetts, Pennsylvania, and Illinois, a random sample of 1123 SARS-CoV-2 PCR-positive patients hospitalized from March 2020 to August 2021 was manually chart-reviewed and classified as "admitted with COVID-19" (incidental) versus specifically admitted for COVID-19 ("for COVID-19"). EHR-based phenotyping was used to find feature sets to filter out incidental admissions. RESULTS:EHR-based phenotyped feature sets filtered out incidental admissions, which occurred in an average of 26% of hospitalizations (although this varied widely over time, from 0% to 75%). The top site-specific feature sets had 79%-99% specificity with 62%-75% sensitivity, while the best-performing across-site feature sets had 71%-94% specificity with 69%-81% sensitivity. CONCLUSIONS:A large proportion of SARS-CoV-2 PCR-positive admissions were incidental. Straightforward EHR-based phenotypes differentiated admissions, which is important to assure accurate public health reporting and research.
PMID: 35476727
ISSN: 1438-8871
CID: 5297142

Distinguishing Admissions Specifically for COVID-19 from Incidental SARS-CoV-2 Admissions: A National EHR Research Consortium Study [PrePrint]

Klann, Jeffrey G; Strasser, Zachary H; Hutch, Meghan R; Kennedy, Chris J; Marwaha, Jayson S; Morris, Michele; Samayamuthu, Malarkodi Jebathilagam; Pfaff, Ashley C; Estiri, Hossein; South, Andrew M; Weber, Griffin M; Yuan, William; Avillach, Paul; Wagholikar, Kavishwar B; Luo, Yuan; Omenn, Gilbert S; Visweswaran, Shyam; Holmes, John H; Xia, Zongqi; Brat, Gabriel A; Murphy, Shawn N
Admissions are generally classified as COVID-19 hospitalizations if the patient has a positive SARS-CoV-2 polymerase chain reaction (PCR) test. However, because 35% of SARS-CoV-2 infections are asymptomatic, patients admitted for unrelated indications with an incidentally positive test could be misclassified as a COVID-19 hospitalization. EHR-based studies have been unable to distinguish between a hospitalization specifically for COVID-19 versus an incidental SARS-CoV-2 hospitalization. From a retrospective EHR-based cohort in four US healthcare systems, a random sample of 1,123 SARS-CoV-2 PCR-positive patients hospitalized between 3/2020â€"8/2021 was manually chart-reviewed and classified as admitted-with-COVID-19 (incidental) vs. specifically admitted for COVID-19 (for-COVID-19). EHR-based phenotyped feature sets filtered out incidental admissions, which occurred in 26%. The top site-specific feature sets had 79-99% specificity with 62-75% sensitivity, while the best performing across-site feature set had 71-94% specificity with 69-81% sensitivity. A large proportion of SARS-CoV-2 PCR-positive admissions were incidental. Straightforward EHR-based phenotypes differentiated admissions, which is important to assure accurate public health reporting and research.
PMID: 35350202
ISSN: n/a
CID: 5297132

Are there variations in timing to tracheostomy in a tertiary academic medical center?

Gillis, Andrea; Pfaff, Ashley; Ata, Ashar; Giammarino, Alexa; Stain, Steven; Tafen, Marcel
BACKGROUND:It is unclear what drives variation in timing to tracheostomy among different patients. METHODS:Age, ethnicity, admission service, and income were retrospectively collected for patients undergoing tracheostomy in a Level 1 trauma center from 2007 to 2017. The primary outcome was time to tracheostomy with early tracheostomy (ET) or late tracheotomy (LT) defined as 3-7 or ≥ 10 days post-intubation, respectively. Secondary outcomes included length of stay (LOS), ventilator associated pneumonia, and mortality. RESULTS:Among 1,640 patients, more men had ET compared to women (30% vs 28%; p = 0.05). The mean time to tracheostomy was 11.2 ± 7.7 days. Neurology and trauma patients had significantly shorter time to tracheostomy compared to other services. Age, ethnicity, and income showed no differences in timing to tracheostomy. Patients who underwent LT had a longer LOS (46 vs 32 days, p < 0.01) and higher mortality (19% vs 13% p < 0.01). CONCLUSIONS:There were no disparities in timing to tracheostomy based on age, ethnicity, or income. We detected a hesitation in performing tracheostomies by certain providers with shorter LOS and improved mortality in ET.
PMID: 32005496
ISSN: 1879-1883
CID: 5297122

Impact of blunt pulmonary contusion in polytrauma patients with rib fractures

Miller, Claire; Stolarski, Allan; Ata, Ashar; Pfaff, Ashley; Nadendla, Pallavi; Owens, Kimberly; Evans, Lauren; Bonville, Daniel; Rosati, Carl; Stain, Steven C; Tafen, Marcel
BACKGROUND:We investigated the impact of blunt pulmonary contusion (BPC) in patients with rib fractures. METHODS:Adult patients with rib fractures caused by blunt mechanisms were enrolled over 3 years at a Level 1 trauma center. BPC was defined according to percentage of lung affected as: moderate (1-19% contusion) or severe (≥20% contusion). RESULTS:In total, 1448 of the 7238 admitted patients had rib fractures. Of these, 321 (22.2%) had BPC: 236 moderate and 85 severe. Patients with BPC were more likely to be admitted to the ICU (moderate: OR 1.55, 95% CI 1.10-2.19; severe: OR 2.74, 95% CI 1.41-5.32). Significantly increased rates of pneumonia (OR 2.52, 95% CI 1.43-4.90) and empyema (OR 4.80, 95% CI 1.07-21.54) were found for moderate and severe BPC, respectively. CONCLUSIONS:ICU admission and infectious pulmonary complications were more likely with BPC. The presence of BPC on admission CT is also prognostic of increased resource utilization.
PMID: 30791991
ISSN: 1879-1883
CID: 5297112

Impact of a Comprehensive Multidisciplinary Rib Fracture Treatment Protocol on Patient Outcomes at a Level I Trauma Center [Meeting Abstract]

Pfaff, Ashley C.; Miller, Claire P.; Ata, Ashar; Stolarski, Allan E.; Evans, Lauren; Johnson, Matthew; Bartscherer, Ashley; Rosati, Carl; Stain, Steven C.; Tafen, Marcel
ISI:000492740900585
ISSN: 1072-7515
CID: 5297162

Variability in orthopedic surgeon treatment preferences for nondisplaced scaphoid fractures: A cross-sectional survey

Paulus, Megan Carroll; Braunstein, Jake; Merenstein, Daniel; Neufeld, Steven; Narvaez, Michael; Friedland, Robert; Bruce, Katherine; Pfaff, Ashley
PURPOSE/OBJECTIVE:The absence of a best practice treatment standard contributes to clinical variation in medicine. Often in the absence of evidence, a standard of care is developed and treatment protocols are implemented. The purpose of this study was to examine whether the standard of care for the treatment of nondisplaced scaphoid fractures is uniform among orthopedic surgeons. METHODS:A survey of orthopedic surgeons actively practicing in the US or abroad was conducted to elicit preferred treatment strategies for nondisplaced scaphoid fractures. The surgeons were recruited at orthopedic conferences, clinical visits, and via email. The survey included demographic questions along with a short clinical vignette. The option for fracture management included surgical versus nonsurgical treatment. For those who chose nonsurgical treatment, type/duration of immobilization was recorded. Cost analysis was performed to estimate direct and indirect costs of various treatment options. RESULTS:A total of 494 orthopedic surgeons completed the survey. The preference for surgical treatment was preferred in 13% of respondents. Hand/upper extremity specialists were significantly more likely to operate compared with generalists (p = 0.0002). Surgeons younger than forty-five were nearly twice as likely to choose surgery (p = 0.01). There was no clear consensus on duration of immobilization as 30% of surgeons chose 6 weeks, 33% selected 8 weeks, and 27% opted for 12 weeks. Total cost of surgery was 49% greater than that of nonoperative treatment. With each additional week of immobilization for nonoperative treatment, the total costs of surgical treatment near that of nonoperative treatment. CONCLUSION/CONCLUSIONS:There exist clear trends in how specific demographic groups choose to treat the nondisplaced scaphoid fracture. Whether these trends are the result of generational gaps or additional subspecialty training remains difficult to determine, but there is need to pursue a more consistent approach that benefits the patients and the health care system as a whole.
PMCID:4939409
PMID: 27436923
ISSN: 0972-978x
CID: 5297102

Lack of Agreement on Distal Radius Fracture Treatment

Bruce, Katherine K; Merenstein, Daniel J; Narvaez, Michael V; Neufeld, Steven K; Paulus, Megan J; Tan, Tina P; Braunstein, Jake R; Pfaff, Ashley C; Huang, Chun-Chih; Friedland, Robert B
INTRODUCTION/BACKGROUND:Variation in clinical practice resulting from the absence of evidence-based treatment protocols has negative implications on both the cost and the quality of medical care. The objective of this study was to assess whether a standard of care for the treatment of extra-articular nondisplaced distal radius fracture has developed despite the lack of a conclusive recommendation from the American Academy of Orthopaedic Surgeons. METHODS:A case-vignette survey was conducted. Treatment type and duration of casting selections were analyzed. The cost implications of responses were assessed. Participants were practicing orthopedists primarily in the mid-Atlantic region of the United States. Orthopedists (n = 494) were recruited via E-mail and at the American Academy of Orthopaedic Surgeons Annual Meeting held in Chicago in March 2013. Inclusion criteria required that participants be graduates of an accredited medical school and be practicing orthopedists at the time of survey distribution. The main outcome measure was surgical or nonsurgical intervention. RESULTS:Nonsurgical treatment was selected by 60% of respondents, with surgery preferred by 37%. Duration of casting responses varied from 2 to 12 weeks. Among nonsurgical responses, 69% indicated 6 weeks as their preferred duration of casting (95% confidence interval, 64.9-73.1%). Surgery imposes a 76% greater total cost to society than nonsurgical treatments. CONCLUSIONS:Our findings suggest the absence of a consensus strategy for the treatment of extra-articular nondisplaced distal radius fractures. Implications of variance in treatment on cost and quality support the need for established, evidence-based guidelines or further clinical trials to assist in the management of this common fracture.
PMID: 26957378
ISSN: 1558-7118
CID: 5297092

Increased working memory-related brain activity in middle-aged women with cognitive complaints

Dumas, Julie A; Kutz, Amanda M; McDonald, Brenna C; Naylor, Magdalena R; Pfaff, Ashley C; Saykin, Andrew J; Newhouse, Paul A
Individuals who report subjective cognitive complaints but perform normally on neuropsychological tests might be at increased risk for pathological cognitive aging. The current study examined the effects of the presence of subjective cognitive complaints on functional brain activity during a working memory task in a sample of middle-aged postmenopausal women. Twenty-three postmenopausal women aged 50-60 completed a cognitive complaint battery of questionnaires. Using 20% of items endorsed as the threshold, 12 women were categorized as cognitive complainers (CC) and 11 were noncomplainers (NC). All subjects then took part in a functional magnetic resonance imaging scanning session during which they completed a visual-verbal N-back test of working memory. Results showed no difference in working memory performance between CC and NC groups. However, the CC group showed greater activation relative to the NC group in a broad network involved in working memory including the middle frontal gyrus (Brodmann area [BA] 9 and 10), the precuneus (BA 7), and the cingulate gyrus (BA 24 and 32). The CC group recruited additional regions of the working memory network compared with the NC group as the working memory load and difficulty of the task increased. This study showed brain activation differences during working memory performance in a middle-aged group of postmenopausal women with subjective cognitive complaints but without objective cognitive deficit. These findings suggest that subjective cognitive complaints in postmenopausal women might be associated with increased cortical activity during effort-demanding cognitive tasks.
PMCID:3540200
PMID: 23036586
ISSN: 1558-1497
CID: 5297082

Estradiol Treatment Increased Cortical Gray Matter In Healthy Postmenopausal Women [Meeting Abstract]

Newhouse, Paul A.; Kutz, Amanda; Pfaff, Ashley; McDonald, Brenna; Saykin, Andrew; West, John; Casson, Peter; Devins, Robert; Dumas, Julie A.
ISI:000302466001185
ISSN: 0006-3223
CID: 5297152