Publications by authors named "Mathew Mercuri"

75 Publications

Patient participation in the clinical encounter and clinical practice guidelines: The case of patients' participation in a GRADEd world.

Stud Hist Philos Sci 2021 Feb 16;85:192-199. Epub 2020 Nov 16.

Centre for Health Economics and Policy Analysis, Department of Health Research Methods, Evaluation and Impact (formerly, Clinical Epidemiology and Biostatistics), McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada.

It is widely acknowledged that the patient's perspective should be considered when making decisions about how her care will be managed. Patient participation in the decision making process may play an important role in bringing to light and incorporating her perspective. The GRADE framework is touted as an evidence-based process for determining recommendations for clinical practice; i.e. determining how care ought to be managed. GRADE recommendations are categorized as "strong" or "weak" based on several factors, including the "values and preferences" of a "typical" patient. The strength of the recommendation also provides instruction to the clinician about when and how patients should participate in the clinical encounter, and thus whether an individual patient's values and preferences will be heard in her clinical encounter. That is, a "strong" recommendation encourages "paternalism" and a "weak" recommendation encourages shared decision making. We argue that adoption of the GRADE framework is problematic to patient participation and may result in care that is not respectful of the individual patient's values and preferences. We argue that the root of the problem is the conception of "values and preferences" in GRADE - the framework favours population thinking (e.g. "typical" patient "values and preferences"), despite the fact that "values and preferences" are individual in the sense that they are deeply personal. We also show that tying the strength of a recommendation to a model of decision making (paternalism or shared decision making) constrains patient participation and is not justified (theoretically and/or empirically) in the GRADE literature.
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http://dx.doi.org/10.1016/j.shpsa.2020.10.008DOI Listing
February 2021

Anticoagulation for newly diagnosed atrial fibrillation and 90-day rates of stroke and bleeding.

CJEM 2021 May 20;23(3):325-329. Epub 2021 Jan 20.

Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.

Background: Atrial fibrillation increases the risk of stroke, which can be mitigated by anticoagulant prescription. We evaluated local emergency physician anticoagulation practice for patients discharged from the emergency department with atrial fibrillation, along with 90-day incidence of stroke and major bleeding.

Methods: This was a health record review of patients diagnosed with new onset atrial fibrillation in two emergency departments between 2014 and 2017. We collected data on CHADS65 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), systemic embolism or major bleeding within 90 days.

Results: We identified 399 patients, median age 68 (IQR 57-79), 213 (53%) male. Only 299/399 patients had an indication for anticoagulation (CHADS65-positive). Of these 299, 27 had a contraindication to or were already prescribed anticoagulation. 45/272 (17%, 95% confidence interval 12-22%) patients eligible for initiation of anticoagulation left the emergency department with a prescription for anticoagulation. During 90-day follow-up, seven patients had stroke or TIA. Four stroke/TIA patients had been eligible to start an anticoagulant but were not started, two left the emergency department with prescriptions for an anticoagulant and one patient had a contraindication to initiating anticoagulation in the emergency department. There were no major bleeding episodes.

Conclusion: Few eligible patients were prescribed anticoagulation and the 90-day stroke rate was high. Physicians should become familiar with the CAEP Acute AF Best Practices Checklist AF which offers guidance on anticoagulation prescription.
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http://dx.doi.org/10.1007/s43678-020-00054-yDOI Listing
May 2021

Utilization of serum D-dimer assays prior to computed tomography pulmonary angiography scans in the diagnosis of pulmonary embolism among emergency department physicians: a retrospective observational study.

BMC Emerg Med 2021 01 19;21(1):10. Epub 2021 Jan 19.

Division of Emergency Medicine, McMaster University, Hamilton Health Sciences, McMaster Clinic, 2nd floor, 237 Barton Street East, Hamilton, Ontario, Canada.

Background: A variety of evidence-based algorithms and decision rules using D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a pulmonary embolism (PE) in low-risk patients.

Objective: To describe the prevalence of D-Dimer utilization among emergency department (ED) physicians and its impact on positive yields and utilization rates of Computed Tomography Pulmonary Angiography (CTPA).

Methods: Data was collected on all CTPA studies ordered by ED physicians at three sites during a 2-year period. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Secondary analysis was done to examine the impact of D-Dimer testing prior to CTPA on individual physician diagnostic yield or utilization rate.

Results: A total of 2811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer, and 343 (18.7%) underwent a CTPA despite a negative D-Dimer. Those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those ordered without a D-Dimer (9.9% versus 11.3%, p = 0.26). At the individual physician level, no statistically significant relationship was found between D-Dimer utilization and CTPA utilization rate or diagnostic yield.

Conclusion: This study provides evidence of suboptimal adherence to guidelines in terms of D-Dimer screening prior to CTPA, and forgoing CTPAs in patients with negative D-Dimers. However, the lack of a positive impact of D-Dimer testing on either CTPA diagnostic yield or utilization rate is indicative of issues relating to the high false-positive rates associated with D-Dimer screening.
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http://dx.doi.org/10.1186/s12873-021-00401-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814629PMC
January 2021

Worldwide Variation in the Use of Nuclear Cardiology Camera Technology, Reconstruction Software, and Imaging Protocols.

JACC Cardiovasc Imaging 2021 Jan 4. Epub 2021 Jan 4.

Seymour, Paul, and Gloria Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA; Department of Radiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA. Electronic address:

Objectives: This study sought to describe worldwide variations in the use of myocardial perfusion imaging hardware, software, and imaging protocols and their impact on radiation effective dose (ED).

Background: Concerns about long-term effects of ionizing radiation have prompted efforts to identify strategies for dose optimization in myocardial perfusion scintigraphy. Studies have increasingly shown opportunities for dose reduction using newer technologies and optimized protocols.

Methods: Data were submitted voluntarily to the INCAPS (International Atomic Energy Agency Nuclear Cardiology Protocols Study) registry, a multinational, cross-sectional study comprising 7,911 imaging studies from 308 labs in 65 countries. The study compared regional use of camera technologies, advanced post-processing software, and protocol characteristics and analyzed the influence of each factor on ED.

Results: Cadmium-zinc-telluride and positron emission tomography (PET) cameras were used in 10% (regional range 0% to 26%) and 6% (regional range 0% to 17%) of studies worldwide. Attenuation correction was used in 26% of cases (range 10% to 57%), and advanced post-processing software was used in 38% of cases (range 26% to 64%). Stress-first single-photon emission computed tomography (SPECT) imaging comprised nearly 20% of cases from all world regions, except North America, where it was used in just 7% of cases. Factors associated with lower ED and odds ratio for achieving radiation dose ≤9 mSv included use of cadmium-zinc-telluride, PET, advanced post-processing software, and stress- or rest-only imaging. Overall, 39% of all studies (97% PET and 35% SPECT) were ≤9 mSv, while just 6% of all studies (32% PET and 4% SPECT) achieved a dose ≤3 mSv.

Conclusions: Newer-technology cameras, advanced software, and stress-only protocols were associated with reduced ED, but worldwide adoption of these practices was generally low and varied significantly between regions. The implementation of dose-optimizing technologies and protocols offers an opportunity to reduce patient radiation exposure across all world regions.
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http://dx.doi.org/10.1016/j.jcmg.2020.11.011DOI Listing
January 2021

Physician choices in pulmonary embolism testing.

CMAJ 2021 01;193(2):E38-E46

Faculty of Medicine (Zarabi, Varner) and Dalla Lana School of Public Health (Mercuri), University of Toronto, Toronto, Ont.; Faculty of Health Sciences (Chan, Mercuri, Kearon, de Wit), McMaster University, Hamilton, Ont.; Faculty of Medicine (Turcotte, Eagles), University of Ottawa, Ottawa, Ont.; Faculty of Medicine (Grusko), University of Manitoba, Winnipeg, Man.; Faculty of Medicine (Barbic), University of British Columbia, Vancouver, BC; Faculty of Medicine (Bridges), McGill University, Montréal, Que.; Chapel Hill School of Medicine (Houston), University of North Carolina, Chapel Hill, NC

Background: Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians' test choices for PE.

Methods: We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests.

Results: We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE.

Interpretation: Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.
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http://dx.doi.org/10.1503/cmaj.201639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773048PMC
January 2021

Relevance, validity, and evidential reasoning in clinical practice.

J Eval Clin Pract 2020 10 17;26(5):1341-1343. Epub 2020 Sep 17.

The Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1111/jep.13474DOI Listing
October 2020

Canadian emergency physician psychological distress and burnout during the first 10 weeks of COVID-19: A mixed-methods study.

J Am Coll Emerg Physicians Open 2020 Aug 26. Epub 2020 Aug 26.

Department of Medicine McMaster University Hamilton Ontario Canada.

Objectives: The aim of this study was to report burnout time trends and describe the psychological effects of working as a Canadian emergency physician during the first weeks of the coronavirus disease 2019 (COVID-19) pandemic.

Methods: This was a mixed-methods study. Emergency physicians completed a weekly online survey. The primary outcome was physician burnout as measured by the emotional exhaustion and depersonalization items, from the Maslach Burnout Inventory. We captured data on work patterns, aerosolizing procedures, testing and diagnosis of COVID-19. Each week participants entered free text explaining their experiences and well-being.

Results: There were 468 participants who worked in 143 Canadian hospitals. Burnout levels did not significantly change over time (emotional exhaustion = 0.632, depersonalization = 0.155). Three participants were diagnosed with COVID-19. Being tested for COVID-19 (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.1-42.5) and the number of shifts worked (OR 1.3, 95% CI 1.1-1.5 per additional shift) were associated with high emotional exhaustion. Having been tested for COVID-19 (OR 4.3, 95% CI 1.1-17.8) was also associated with high depersonalization. Personal safety, academic and educational work, personal protective equipment, the workforce, patient volumes, work patterns, and work environment had an impact on physician well-being. A new financial reality and contrasting negative and positive experiences affected participants' psychological health.

Conclusion: Emergency physician burnout levels remained stable during the initial 10 weeks of this pandemic. The impact of COVID-19 on the work environment and personal perceptions and fears about the impact on lifestyle have affected physician well-being.
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http://dx.doi.org/10.1002/emp2.12225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461319PMC
August 2020

Worldwide Diagnostic Reference Levels for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging: Findings From INCAPS.

JACC Cardiovasc Imaging 2021 Mar 19;14(3):657-665. Epub 2020 Aug 19.

Seymour, Paul, and Gloria Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA; Department of Radiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA. Electronic address:

Objectives: This study sought to establish worldwide and regional diagnostic reference levels (DRLs) and achievable administered activities (AAAs) for single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI).

Background: Reference levels serve as radiation dose benchmarks to compare individual laboratories against aggregated data, helping to identify sites in greatest need of dose reduction interventions. DRLs for SPECT MPI have previously been derived from national or regional registries. To date there have been no multiregional reports of DRLs for SPECT MPI from a single standardized dataset.

Methods: Data were submitted voluntarily to the INCAPS (International Atomic Energy Agency Nuclear Cardiology Protocols Study), a cross-sectional, multinational registry of MPI protocols. A total of 7,103 studies were included. DRLs and AAAs were calculated by protocol for each world region and for aggregated worldwide data.

Results: The aggregated worldwide DRLs for rest-stress or stress-rest studies employing technetium Tc 99m-labeled radiopharmaceuticals were 11.2 mCi (first dose) and 32.0 mCi (second dose) for 1-day protocols, and 23.0 mCi (first dose) and 24.0 mCi (second dose) for multiday protocols. Corresponding AAAs were 10.1 mCi (first dose) and 28.0 mCi (second dose) for 1-day protocols, and 17.8 mCi (first dose) and 18.7 mCi (second dose) for multiday protocols. For stress-only technetium Tc 99m studies, the worldwide DRL and AAA were 18.0 mCi and 12.5 mCi, respectively. Stress-first imaging was used in 26% to 92% of regional studies except in North America where it was used in just 7% of cases. Significant differences in DRLs and AAAs were observed between regions.

Conclusions: This study reports reference levels for SPECT MPI for each major world region from one of the largest international registries of clinical MPI studies. Regional DRLs may be useful in establishing or revising guidelines or simply comparing individual laboratory protocols to regional trends. Organizations should continue to focus on establishing standardized reporting methods to improve the validity and comparability of regional DRLs.
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http://dx.doi.org/10.1016/j.jcmg.2020.06.029DOI Listing
March 2021

Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease.

JAMA Netw Open 2020 08 3;3(8):e2012749. Epub 2020 Aug 3.

Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

Importance: Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown.

Objective: To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease.

Design, Setting, And Participants: In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020.

Main Outcomes And Measures: The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist.

Results: Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002).

Conclusions And Relevance: The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.12749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417969PMC
August 2020

When were clinicians ever not competent?

Authors:
Mathew Mercuri

J Eval Clin Pract 2020 08 10;26(4):1067-1069. Epub 2020 Jul 10.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

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http://dx.doi.org/10.1111/jep.13440DOI Listing
August 2020

Guidelines should not recommend the type of decision-making for the medical encounter.

Patient Educ Couns 2020 May 15. Epub 2020 May 15.

Department of Health Research Methods, Evaluation and Impact, McMaster University, Hamilton, Canada.

Clinical practice guidelines (CPGs) often include a recommendation regarding how to approach a clinical encounter and which decision-making model should be used. The GRADE framework, a popular method for developing CPGs, suggests a paternalistic model when recommendations are "strong" and shared decision making (SDM) when recommendations are "weak". Tying the model of decision making and patient participation to the strength of a recommendation is not justified theoretically and/or empirically in the GRADE literature. Thus, why a CPG should offer any advice on which model to use in the clinical encounter is not clear. We argue that including such instruction is not justified and potentially violates the bioethical norms of autonomy and respect for individual choice and may even violate the clinician's legal obligation. Rather, the model to be used is better determined by the participants in the individual encounter during the encounter and not the panel developing the CPG.
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http://dx.doi.org/10.1016/j.pec.2020.05.016DOI Listing
May 2020

Regional needs assessment for emergency physician audit and feedback.

CJEM 2020 07;22(4):542-548

Division of Emergency Medicine, Department of Medicine at McMaster University, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Objectives: Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region.

Methods: We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups.

Results: A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners.

Conclusion: This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.
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http://dx.doi.org/10.1017/cem.2020.348DOI Listing
July 2020

Don't panic, it is only an emergency.

Authors:
Mathew Mercuri

J Eval Clin Pract 2020 06 25;26(3):685-686. Epub 2020 Mar 25.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

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http://dx.doi.org/10.1111/jep.13394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228402PMC
June 2020

Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study.

J Am Geriatr Soc 2020 05 3;68(5):970-976. Epub 2020 Feb 3.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Objectives: Emergency department (ED) visits among older adults are frequently instigated by a fall at home. Some of these patients develop intracranial bleeding. The aim of this study was to identify the incidence of intracranial bleeding and the associated clinical features in older adults who present to the ED after falling.

Design: Prospective cohort study.

Setting: Three Canadian EDs.

Participants: A total of 2 176 patients age 65 years or older who presented to the ED with a fall were assessed, and 1753 were included. Inclusion criteria were a fall on level ground, off a bed, chair, or toilet, or from one or two steps within 48 hours.

Measurements: Emergency physicians recorded predefined clinical findings on initial assessment. The primary outcome was intracranial bleeding, diagnosed either by computed tomography at the index visit or within 42 days. Associations between baseline clinical findings and the presence of intracranial bleeding were assessed with multivariable logistic regression.

Results: A total of 1753 patients (median age = 82 y) were enrolled, of whom 39% were male, 35% were on antiplatelet therapy, and 25% were on an anticoagulant. The incidence of intracranial bleeding was 5.0% (95% confidence interval [CI] = 4.1-6.1). Overall, 76 patients were diagnosed at the index ED visit, and 12 were diagnosed during follow-up. Multivariable regression identified four clinical variables that were independently associated with intracranial bleeding: new abnormalities on neurologic examination (odds ratio [OR] = 4.4; 95% CI = 2.4-8.1), bruise or laceration on the head (OR = 4.3; 95% CI = 2.7-7.0), chronic kidney disease (OR = 2.4; 95% CI = 1.3-4.6), and reduced Glasgow Coma Scale from normal (OR = 1.9; 95% CI = 1.0-3.4).

Conclusion: The incidence of intracranial bleeding in our study was 5.0%. We found significant associations between intracranial bleeding and four simple clinical variables. We did not find significant associations between intracranial bleeding and antiplatelet or anticoagulant use. J Am Geriatr Soc 68:970-976, 2020.
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http://dx.doi.org/10.1111/jgs.16338DOI Listing
May 2020

Publishing your work: An editor's perspective.

Authors:
Mathew Mercuri

J Eval Clin Pract 2020 02;26(1):3-6

Department of Medicine, McMaster University, Hamilton, Canada.

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http://dx.doi.org/10.1111/jep.13342DOI Listing
February 2020

Making Decisions in the Era of the Clinical Decision Rule: How Emergency Physicians Use Clinical Decision Rules.

Acad Med 2020 08;95(8):1230-1237

K. de Wit is assistant professor, Division of Emergency Medicine, Department of Medicine, and associate professor, Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.

Purpose: Physicians are often asked to integrate clinical decision rules (CDRs) with their own cognitive processes to reach a diagnosis. Clinicians, researchers, and educators must understand these cognitive processes to evaluate and improve the diagnostic process. The authors sought to explore emergency physicians' diagnostic processes and to examine how they integrated CDRs into their reasoning using simulated cases (with chest pain or leg pain).

Method: From August 2015 to July 2016, 16 practicing emergency physicians from 3 teaching hospitals associated with McMaster University, Ontario, Canada, were interviewed via a novel "teach aloud" protocol. Six videos of simulated patients with chest pain, breathlessness, or leg discomfort were used as prompts for the physicians to demonstrate their diagnostic thinking. Using a constructivist grounded theory analysis, 3 investigators independently reviewed the interview transcripts, meeting regularly to discuss identified themes and subthemes until sufficiency was reached.

Results: A model to describe how clinicians integrate their own decision making with CDRs was developed, showing that physicians engage in an iterative diagnostic process that repeatedly refines the differential diagnosis list. The steps in the diagnostic process were: refinement of the differential diagnosis, ordering a hierarchy of risk, the decision to test, choosing the tests, and interpreting test results. Physicians applied CDRs when they had already decided to test.

Conclusions: To date, CDRs assume a static, linear model of clinical decision making. Findings demonstrate that participants engaged in iterative and dynamic decision-making processes that changed throughout their patient encounter, contingent on multiple contextual features. Understanding these processes could inform future development of CDRs and educational strategies around these decision aids.
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http://dx.doi.org/10.1097/ACM.0000000000003098DOI Listing
August 2020

Variability in practice patterns among emergency physicians in the evaluation of patients with a suspected diagnosis of pulmonary embolism.

Emerg Radiol 2020 Apr 21;27(2):127-134. Epub 2019 Nov 21.

Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.

Purpose: To describe the inter-physician variability in the utilisation rate and diagnostic yield of computed tomography pulmonary angiography (CTPA) among a group of emergency department (ED) physicians working in a similar clinical environment.

Methods: We collected data on all CTPA studies ordered by ED physicians at three affiliated sites during a 2-year period between January 1, 2016, and December 31, 2017. For each physician, we calculated individual CTPA utilisation rate (total number of CTPAs ordered per 1000 ED visits) and diagnostic yield (percentage of CTPAs that were positive for PE). Additional analysis was carried out in order to identify the highest orderers of CTPA and their diagnostic yield.

Results: Seventy-seven ED physicians who collectively ordered a total of 2788 CTPAs were included in the study. Utilisation rates ranged from 1.1 to 22.2 CTPA per 1000 ED visits (median: 5.2 CTPA/1000 ED visits; 25%ile: 3.6 CTPA/1000 ED visits; 75%ile: 7.9 CTPA/1000 ED visits) and the CTPA diagnostic yields ranged from 0% to 33% (median: 9.1%; 25%ile: 5.2%; 75%ile: 16.1%). Those physicians in the lower quartile for ordering rate had a higher mean diagnostic yield when compared to the higher quartiles.

Conclusion: The findings of this study demonstrate variability in CTPA ordering patterns and diagnostic yields among physicians working within the same clinical environment. There is some suggestion that those physicians who order disproportionately higher numbers of CTPAs have lower diagnostic yields.
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http://dx.doi.org/10.1007/s10140-019-01740-wDOI Listing
April 2020

The ever-shifting source of authority on what works in clinical medicine.

Authors:
Mathew Mercuri

J Eval Clin Pract 2019 10 16;25(5):703-705. Epub 2019 Aug 16.

Journal of Evaluation in Clinical Practice, Canada.

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http://dx.doi.org/10.1111/jep.13259DOI Listing
October 2019

What counts as evidence in an evidence-based world?

J Eval Clin Pract 2019 08 3;25(4):533-535. Epub 2019 Jul 3.

Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1111/jep.13220DOI Listing
August 2019

The "problem(s)" with quality improvement in health care.

Authors:
Mathew Mercuri

J Eval Clin Pract 2019 06 1;25(3):355-357. Epub 2019 May 1.

Department of Medicine, McMaster University, Hamilton, Canada.

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http://dx.doi.org/10.1111/jep.13154DOI Listing
June 2019

Examining Canada's return visits to the emergency department after a concussion.

CJEM 2019 11;21(6):784-788

Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON.

Objectives: The purpose of this study was to identify 1) the proportion of patients discharged from the emergency department (ED) with a diagnosis of concussion and return within 14 days, and 2) the characteristics that prompt a return.

Methods: A health records review was conducted on adult patients with a discharge diagnosis of a concussion who accessed care through Hamilton Health Sciences EDs and Urgent Care Centre in 2016. Subsequent data were collected from those who returned to the ED within 14 days. Clinical characteristics of returners were compared to those of non-returners.

Results: Of the 389 patients included in the study, 38 (10%) returned within 14 days. Patients who sustained a concussion in a sport-related context or were referred to a specialized clinic were less likely to return (p = 0.03). Those who suffered an assault-related concussion were more likely to return (p = 0.01). Of those who did return, 42% received a CT scan with normal results, and 42% were given new discharge instructions.

Conclusions: Approximately 10% of patients diagnosed with a concussion in a Canadian hospital setting returned to the ED within 14 days of their index visit. Our study suggests the opportunity to reduce this burden to both the healthcare system and the patient through careful discharge instructions outlining anticipated symptoms following a concussion (specifically, headache) or referral to a concussion clinic.
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http://dx.doi.org/10.1017/cem.2019.22DOI Listing
November 2019

Time of Transfer of Admitted Patients from the ED: A Contributor to ED Boarding in High-Volume Community Hospitals.

Healthc Q 2019 Jan;21(4):48-53

Appointed in the Division of Emergency Medicine, Department of Medicine, McMaster University, ON.

The twin challenges of bed boarding and "hallway medicine" have emerged in recent years as key healthcare issues. Many hospitals, challenged with increasing demand and limited resources, have tried to find efficiencies within their operations. One such strategy is that of early morning discharges and expedited bed turnaround times. We conducted a retrospective study within three high-volume hospitals in the Greater Toronto Area looking at discharge times of in-patients and transfer times of admitted, Emergency Department (ED)-boarded patients. We discovered a consistent pattern of late-in-the-day discharges, and even later-in-the-day transfers of boarded ED patients, indicating that this may be a potential source of increased efficiency for overburdened hospitals.
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http://dx.doi.org/10.12927/hcq.2019.25740DOI Listing
January 2019

Humility in the face of uncertainty.

Authors:
Mathew Mercuri

J Eval Clin Pract 2019 04 20;25(2):173-175. Epub 2019 Feb 20.

Department of Medicine, McMaster University, Hamilton, Canada.

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http://dx.doi.org/10.1111/jep.13116DOI Listing
April 2019

Good drivers: Achieving dose reduction across a health care system through implementation of multiple radiation-sparing practices.

J Nucl Cardiol 2020 06 7;27(3):795-797. Epub 2019 Feb 7.

Department of Medicine, Division of Cardiology, and Department of Radiology, Columbia University Irving Medical Center and New York-Presbyterian Hospital, PH 10-203, New York, NY, USA.

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http://dx.doi.org/10.1007/s12350-019-01609-yDOI Listing
June 2020

From the (new) editor's desk.

Authors:
Mathew Mercuri

J Eval Clin Pract 2019 02;25(1):3-4

Division of Emergency Medicine, McMaster University, Hamilton General Hospital, McMaster Wing, Rm 242, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.

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http://dx.doi.org/10.1111/jep.13089DOI Listing
February 2019

Rock Climber Self-Rescue Skills.

Wilderness Environ Med 2019 Mar 5;30(1):44-51. Epub 2019 Jan 5.

Division of Emergency Medicine, University of Utah, Salt Lake City, UT.

Introduction: Rock climbing involves some inherent danger, and rock climbers should be able to carry out basic rescue techniques for their own safety. This study seeks to assess such abilities by examining self-rescue skills in a cohort of rock climbers.

Methods: Climbers who participate in multipitch sport or traditional climbing styles were recruited via posters at a local climbing gym and on social media. Participants completed a survey assessing climbing history and confidence in their rescue skills and then were evaluated on 3 rescue scenarios in an indoor, standardized setting. Scenario pass rates were calculated and compared with rescue skill confidence on the survey.

Results: Twenty-five climbers participated in the study. Mean confidence in rescue skills varied from 4 to 4.5 (on a 7-point scale). The pass rates for the 3 scenarios were 28%, 68%, and 52%. Only 24% of climbers passed all 3 scenarios. Surveyed confidence in rescue skills and pass rate statistically correlated in only 1 scenario.

Conclusions: Self-rescue skills were generally lacking in our study population. Climber confidence, experience, training, and climbing frequency did not appear to be associated with a higher level of rescue skills. Self-rescue skills should be emphasized in climbing instruction and courses to increase overall safety.
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http://dx.doi.org/10.1016/j.wem.2018.10.005DOI Listing
March 2019

Treating real people: Science and humanity.

J Eval Clin Pract 2018 10 30;24(5):919-929. Epub 2018 Aug 30.

Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand.

Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, overdiagnosis, co-morbidity, and multi-morbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, and health and social care are being revised and their relationships reconsidered: Boundaries are indeed being redrawn; reasoning is being made "fit for practice." Ideas like "person-centred care" are no longer phrases with potential to be helpful in some yet-to-be-clarified way: Theorists and practitioners are working in collaboration to give them substantive import and application.
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http://dx.doi.org/10.1111/jep.13024DOI Listing
October 2018

The evolution of GRADE (part 3): A framework built on science or faith?

J Eval Clin Pract 2018 10 31;24(5):1223-1231. Epub 2018 Jul 31.

Centre for Health Economics and Policy Analysis, Department of Health Research Methods, Evaluation and Impact (formerly, Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, Canada.

Rationale, Aims, And Objectives: The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework has undergone several modifications since it was first presented as a method for developing clinical practice recommendations. In the previous two articles of this series, we showed that absent, in the first three versions of GRADE, is a justification (theoretical and/or empirical) for why the presented criteria for determining the quality of evidence and the components for determining the strength of a recommendation were included (and others not included) in the framework. Furthermore, it was often not clear how to operationalize and integrate the criteria/components when using the framework. In part 3 of this series, we examine the literature since version 3 to see if the GRADE working group has provided an overall justification scheme for GRADE or clear instruction on how to operationalize and integrate the criteria/components in the framework.

Methods: Narrative review.

Results: GRADE has undergone further modification since the last version was presented. In the recent literature, we see additional shifts in terminology (eg, "quality of evidence" is now "certainty of evidence"), clarification on the construct of certainty of evidence, continued emphasis on "transparency" and new emphasis on "trustworthiness," the addition of health equity as a component for determining strength of a recommendation, and the development of the Evidence to Decision frameworks. However, these modifications have done little to improve the justification scheme that sustains GRADE or clarify how to operationalize the criteria/components.

Conclusions: If we desire that our clinical recommendations be based on scientific teaching rather than faith-based preaching, then the GRADE framework should be justified theoretically and/or empirically. Until such time that the working group provides a theoretical justification that the use of the GRADE framework should produce valid recommendations, and/or empirical evidence to support that it does, enthusiasm for the framework should be tempered.
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http://dx.doi.org/10.1111/jep.13016DOI Listing
October 2018

The evolution of GRADE (part 2): Still searching for a theoretical and/or empirical basis for the GRADE framework.

J Eval Clin Pract 2018 10 17;24(5):1211-1222. Epub 2018 Jul 17.

Centre for Health Economics and Policy Analysis, Department of Health Research Methods, Evaluation and Impact (formerly, Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, Canada.

Rationale, Aims, And Objectives: The GRADE framework has been widely adopted as the preferred method for developing clinical practice recommendations. In the first article of our three part series examining the evolution of GRADE, we showed an absence (in the first two versions of GRADE) of a theoretical basis and/or empirical data to support why the presented criteria for determining the quality of evidence regarding the effect estimate and the components under consideration for determining the strength of the recommendation were included and other criteria/components excluded. Furthermore, often, it was not clear how to operationalize the included criteria/components (and integrate them) when using the framework. In part 2 of this series, we examine if version 3 of GRADE offered improvements on previous versions with respect to a justification scheme and how to operationalize the framework's criteria/components.

Methods: Narrative review.

Results: Our examination suggests that version 3 has done little to improve on the justification scheme that sustains GRADE. Still absent is a justification (theoretical and/or empirical) for why the criteria/components were chosen. Likewise, version 3 is still lacking clarity regarding how to implement and integrate the criteria/considerations in the framework (ie, operationalize the framework) when determining the quality of evidence or strength of recommendation. Transparency is now emphasized as the merit of GRADE. However, we are offered no theoretical justification for how the use of GRADE should achieve transparency or empirical evidence to support that transparency is achieved.

Conclusions: While version 3 reveals acknowledgement by the authors of GRADE that the framework is a work in progress, it still lacks a justification scheme (theoretical and/or empirical) to sustain it and clarity in its criteria/components to operationalize it. As was suggested in part 1, such issues limit one's ability to scientifically assess the appropriateness of GRADE for its stated purpose.
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http://dx.doi.org/10.1111/jep.12997DOI Listing
October 2018

The evolution of GRADE (part 1): Is there a theoretical and/or empirical basis for the GRADE framework?

J Eval Clin Pract 2018 10 16;24(5):1203-1210. Epub 2018 Jul 16.

Centre for Health Economics and Policy Analysis, Department of Health Research Methods, Evaluation and Impact (formerly, Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, ON, Canada.

Rationale, Aims, And Objectives: The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework has been presented as the best method available for developing clinical recommendations. GRADE has undergone a series of modifications. Here, we present the first part of a three article series examining the evolution of GRADE. Our purpose is to explore if (and if so, how) GRADE provides: (1) a justification (ie, theoretical and/or empirical) for why the criteria/components under consideration in the system are included (and other factors excluded), as well as why some criteria/components where added/modified in the evolution process, (2) clear and functional (ie, how to operationalize them) definitions of the included criteria/components, and (3) instruction and justification for how all the criteria/components are to be integrated when determining a recommendation. In part 1 of the series, we examine the first two versions of GRADE.

Methods: Narrative review.

Results: The justification scheme that sustains GRADE is not articulated in the first two versions of the framework. Why some criteria/components were included, and others excluded, is not justified theoretically nor is empirical support provided to suggest that the framework as presented includes that which is needed to produce valid recommendations. The first two versions of GRADE show a lack of clear instruction on how to operationalize the criteria for assessing the quality of evidence and the components for making a recommendation (including how to integrate the criteria/components at each step), which leaves substantial room for judgement on the part of the user of GRADE for guideline development.

Conclusions: This article revealed an absence of a justification (theoretical and/or empirical) to support important aspects of the GRADE framework, as well as a lack of clear instruction on how to operationalize the criteria and components in the framework. These issues limit one's ability to scientifically assess the appropriateness of GRADE for determining clinical recommendations.
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http://dx.doi.org/10.1111/jep.12998DOI Listing
October 2018