A quantitative approach for the analysis of clinician recognition of acute respiratory distress syndrome using electronic health record data

English version

Autoři: Meagan A. Bechel ^aff001; Adam R. Pah ^aff003; Hanyu Shi ^aff005; Sanjay Mehrotra ^aff006; Stephen D. Persell ^aff007; Shayna Weiner ^aff009; Richard G. Wunderink ^aff010; Luís A. Nunes Amaral ^aff003; Curtis H. Weiss ^aff012
Působiště autorů: Medical Scientist Training Program, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America ^aff001; Department of Biomedical Engineering, Northwestern University, Evanston, IL, United States of America ^aff002; Northwestern Institute on Complex Systems, Northwestern University, Evanston, IL, United States of America ^aff003; Kellogg School of Management, Northwestern University, Evanston, IL, United States of America ^aff004; Department of Chemical and Biological Engineering, Northwestern University, Evanston, IL, United States of America ^aff005; Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, IL, United States of America ^aff006; Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America ^aff007; Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America ^aff008; Michigan Oncology Quality Consortium, Ann Arbor, MI, United States of America ^aff009; Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America ^aff010; Department of Physics and Astronomy, Northwestern University, Evanston, IL, United States of America ^aff011; Division of Pulmonary, Critical Care, Allergy, and Immunology, NorthShore University HealthSystem, Evanston, IL, United States of America ^aff012
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
prolekare.web.journal.doi_sk: https://doi.org/10.1371/journal.pone.0222826

Souhrn

Importance

Despite its efficacy, low tidal volume ventilation (LTVV) remains severely underutilized for patients with acute respiratory distress syndrome (ARDS). Physician under-recognition of ARDS is a significant barrier to LTVV use. We propose a computational method that addresses some of the limitations of the current approaches to automated measurement of whether ARDS is recognized by physicians.

Objective

To quantify patient and physician factors affecting physicians’ tidal volume selection and to build a computational model of physician recognition of ARDS that accounts for these factors.

Design, setting, and participants

In this cross-sectional study, electronic health record data were collected for 361 ARDS patients and 388 non-ARDS hypoxemic (control) patients in nine adult intensive care units at four hospitals between June 24 and December 31, 2013.

Methods

Standardized tidal volumes (mL/kg predicted body weight) were chosen as a proxy for physician decision-making behavior. Using data-science approaches, we quantified the effect of eight factors (six severity of illness, two physician behaviors) on selected standardized tidal volumes in ARDS and control patients. Significant factors were incorporated in computational behavioral models of physician recognition of ARDS.

Results

Hypoxemia severity and ARDS documentation in physicians’ notes were associated with lower standardized tidal volumes in the ARDS cohort. Greater patient height was associated with lower standardized tidal volumes (which is already normalized for height) in both ARDS and control patients. The recognition model yielded a mean (99% confidence interval) physician recognition of ARDS of 22% (9%-42%) for mild, 34% (19%-49%) for moderate, and 67% (41%-100%) for severe ARDS.

Conclusions and relevance

In this study, patient characteristics and physician behaviors were demonstrated to be associated with differences in ventilator management in both ARDS and control patients. Our model of physician ARDS recognition measurement accounts for these clinical variables, providing an electronic approach that moves beyond relying on chart documentation or resource intensive approaches.

Klíčová slova:

Biology and life sciences – Research and analysis methods – Database and informatics methods – Neuroscience – Cognitive science – Cognitive psychology – Psychology – Social sciences – People and places – Population groupings – Professions – Computer and information sciences – Medicine and health sciences – Physiology – Physiological parameters – Critical care and emergency medicine – Health care – Health care providers – Medical doctors – Physicians – Medical personnel – Body weight – Pulmonology – Health informatics – Cognition – Pulmonary function – Surgical and invasive medical procedures – Data visualization – Infographics – Decision making – Charts – Tidal volume – Acute respiratory distress syndrome – Respiratory failure – Intubation – Electronic medical records

Zdroje

1. Balas E, Boren S. Managing clinical knowledge for health care improvement. Yearb Med Informatics 2000. 2000;65–70.

2. Adler-Milstein J, Holmgren AJ, Kralovec P, Worzala C, Searcy T, Patel V. Electronic health record adoption in US hospitals: The emergence of a digital “advanced use” divide. J Am Med Informatics Assoc. 2017;24(6):1142–8.

3. Gattinoni L, Haren F Van, Larsson A, Mcauley DF, Ranieri M. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. 2016; doi: 10.1001/jama.2016.0291 26903337

4. Rubenfeld GD, Caldwell E, Peabody E, Weaver J, Martin DP, Neff M, et al. Incidence and outcomes of acute lung injury. N Engl J Med 2005; 353:1685–1693 doi: 10.1056/NEJMoa050333

5. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA [Internet]. 2012 Jun 20 [cited 2014 Jul 10];307(23):2526–33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22797452 doi: 10.1001/jama.2012.5669 22797452

6. Matthay MA, Zemans RL, Zimmerman GA, Arabi YM, Beitler JR, Mercat A, et al. Acute respiratory distress syndrome. Nat Rev Dis Prim [Internet]. Springer US; 2019; Available from: http://dx.doi.org/10.1038/s41572-019-0069-0

7. Matthay and Hopkins. Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. N Engl J Med. 2000;342(18):1301–8. doi: 10.1056/NEJM200005043421801 10793162

8. Fan E, Del Sorbo L, Goligher EC, Hodgson CL, Munshi L, Walkey AJ, et al. An official American Thoracic Society/European Society of intensive care medicine/society of critical care medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;195(9):1253–63. doi: 10.1164/rccm.201703-0548ST 28459336

9. Needham DM, Colantuoni E, Mendez-Tellez P a, Dinglas VD, Sevransky JE, Dennison Himmelfarb CR, et al. Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study. BMJ [Internet]. 2012 Jan [cited 2014 Sep 8];344(April):e2124. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3320566&tool=pmcentrez&rendertype=abstract

10. Needham DM, Yang T, Dinglas VD, Mendez-Tellez PA, Shanholtz C, Sevransky JE, et al. Timing of low tidal volume ventilation and intensive care unit mortality in acute respiratory distress syndrome:A Prospective Cohort Study. Am J Respir Crit Care Med. 2015;191(2):177–85. doi: 10.1164/rccm.201409-1598OC 25478681

11. Young MP, Manning HL, Wilson DL, Mette S a., Riker RR, Leiter JC, et al. Ventilation of patients with acute lung injury and acute respiratory distress syndrome: Has new evidence changed clinical practice?*. Crit Care Med [Internet]. 2004 Jun [cited 2014 Sep 8];32(6):1260–5. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003246-200406000-00003 doi: 10.1097/01.ccm.0000127784.54727.56 15187503

12. Checkley W, Brower R, Korpak A, Thompson BT. Effects of a clinical trial on mechanical ventilation practices in patients with acute lung injury. Am J Respir Crit Care Med. 2008;177(11):1215–22. doi: 10.1164/rccm.200709-1424OC 18356562

13. Kalhan R, Mikkelsen M, Dedhiya P, Christie J, Gaughan C, Lanken PN, et al. Underuse of lung protective ventilation: Analysis of potential factors to explain physician behavior*. Crit Care Med [Internet]. 2006 Feb [cited 2014 Sep 8];34(2):300–6. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003246-200602000-00003 doi: 10.1097/01.ccm.0000198328.83571.4a 16424706

14. Chen YF, Lim CK, Ruan SY, Jerng JS, Lin JW, Kuo PH, et al. Factors associated with adherence to low-tidal volume strategy for acute lung injury and acute respiratory distress syndrome and their impacts on outcomes: An observational study and propensity analysis. Minerva Anestesiol. 2014;80(11):1158–68. 24569355

15. Umoh NJ, Fan E, Mendez-Tellez P a, Sevransky JE, Dennison CR, Shanholtz C, et al. Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury. Crit Care Med [Internet]. 2008;36(5):1463–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18434907 doi: 10.1097/CCM.0b013e31816fc3d0 18434907

16. Weiss CH, Baker DW, Weiner S, Bechel M, Ragland M, Rademaker A, et al. Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome. Crit Care Med [Internet]. 2016;V:1–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27035237

17. Spece LJ, Mitchell KH, Caldwell ES, Gundel SJ, Jolley SE, and Hough CL. Rate of Low Tidal Volume Ventilation Use Remains Low in Patients with Acute Respiratory Distress Syndrome Despite Improvement Efforts at a Single Center. J Crit Care. 2019;(206):72–6.

18. Dennison CR, Mendez-Tellez P a, Wang W, Pronovost PJ, Needham DM. Barriers to low tidal volume ventilation in acute respiratory distress syndrome: survey development, validation, and results. Crit Care Med [Internet]. 2007;35(12):2747–54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17901838 doi: 10.1097/01.CCM.0000287591.09487.70 17901838

19. Rubenfeld GD, Cooper C, Carter G, Thompson BT, Hudson LD. Barriers to providing lung-protective ventilation to patients with acute lung injury. Crit Care Med [Internet]. 2004 Jun [cited 2014 Sep 8];32(6):1289–93. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003246-200406000-00008 doi: 10.1097/01.ccm.0000127266.39560.96 15187508

20. Mikkelsen ME, Dedhiya PM, Kalhan R, Gallop RJ, Lanken PN, Fuchs BD. Potential reasons why physicians underuse lung-protective ventilation: a retrospective cohort study using physician documentation. Respir Care [Internet]. 2008;53(4):455–61. Available from: http://rc.rcjournal.com/content/53/4/455.short 18364057

21. Han S, Martin GS, Maloney JP, Shanholtz C, Barnes KC, Murray S, et al. Short women with severe sepsis-related acute lung injury receive lung protective ventilation less frequently: an observational cohort study. Crit Care [Internet]. BioMed Central Ltd; 2011;15(6):R262. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3388675&tool=pmcentrez&rendertype=abstract doi: 10.1186/cc10524 22044724

22. Owyang CG, Kim JL, Loo G, Ranginwala S, Mathews KS. The effect of emergency department crowding on lung-protective ventilation utilization for critically ill patients. J Crit Care [Internet]. Elsevier Inc.; 2019;52:40–7. Available from: doi: 10.1016/j.jcrc.2019.03.008 30954692

23. Fletcher RH, Fletcher SW, Fletcher GS. Measuring Exposure. In: Clinical Epidemiology: The Essentials, 5e. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 97–8.

24. Fletcher RH, Fletcher SW, Fletcher GS. Hawthorne Effect. In: Clinical Epidemiology: The Essentials, 5e. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 131.

25. Parkin M. Priming. In: Encyclopedia of Survey Research Methods. Thousand Oaks, CA: SAGE Publications; 2008. p. 611–2.

26. Colquhoun D. An investigation of the false discovery rate and the misinterpretation of P values. R Soc Open Sci. 2014;1–15.

27. Walkey AJ, Wiener RS. Risk factors for underuse of lung-protective ventilation in acute lung injury. J Crit Care [Internet]. Elsevier Inc.; 2012 Jun [cited 2014 Sep 8];27(3):323.e1–9. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3223550&tool=pmcentrez&rendertype=abstract

28. Tenney SM, Bartlett D. Comparative Quantitative Morphology of the Mammalian Lung: Trachea. Nature. 1967;3(May):130–5.

29. Gilovich T, Griffin D, Kahneman D, editors. Heuristics and Biases in Application. In: Heuristics and Biases. New York: Cambridge University Press; 2012. p. 559–81.

30. Sasko B, Thiem U, Christ M, Trappe H, Ritter O, Pagonas N. Size matters: An observational study investigating estimated height as a reference size for calculating tidal volumes if low tidal volume ventilation is required. 2018;v:1–14.

31. Aynes RBRH, Aplan BOK. Clinical Decision Support Systems for the Practice of Evidence-based Medicine. 2001;8(6):527–34. doi: 10.1136/jamia.2001.0080527 11687560

32. David W, Gilad J, Bates DW, Kuperman GJ, Wang S, Gandhi T, et al. Ten commandments for effective clinical decision support: Making the. J Am Med Informatics Assoc [Internet]. 2003;10(6):523–30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12925543

33. Lorenzi NM, Novak LL, Weiss JB, Gadd CS, Unertl KM. Crossing the Implementation Chasm: A Proposal for Bold Action. J Am Med Informatics Assoc. 2008;15(3):290–6.