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Self-awareness of computed tomography ordering in the emergency department
- Amjed Kadhim-Saleh, James C. Worrall, Monica Taljaard, Mathieu Gatien, Jeffrey J. Perry
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue 2 / March 2018
- Published online by Cambridge University Press:
- 04 July 2017, pp. 275-283
- Print publication:
- March 2018
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Objectives
Physician variation in the use of computed tomography (CT) is concerning due to the risks of ionizing radiation, cost, and downstream effects of unnecessary testing. The objectives of this study were to describe variation in CT-ordering rates among emergency physicians (EPs), to measure correlation between perceived and actual CT-ordering rates, to assess attitudes that influence decisions to order imaging tests, and to identify EP attitudes associated with higher CT utilization.
MethodsThis study was a retrospective review of imaging and administrative billing records at two emergency department sites of a tertiary care adult teaching hospital. The study also included a cross-sectional survey of EPs at this hospital. We asked physicians about their perceived ordering behaviour, and what factors influenced their decision to order a CT. We examined correlations between perceived and actual CT-ordering rates. We adjusted ordering rates for shift distribution using a logistic regression model and identified outlier physicians whose ordering rate was significantly lower or higher than expected. We used multivariable regression analysis to determine which survey responses predicted higher CT utilization.
ResultsDuring the study period, 59 EPs saw 45,854 patients, and ordered 6,609 CTs — a mean ordering rate of 14.4% (standard deviation (SD)=4.3%). The ordering rate for individual physicians ranged from 5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean perceived ordering rate was 12.6%, and was weakly correlated with actual ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered “about the same” or “fewer” CTs than their peers. Of the 17 EPs in the two highest ordering quintiles, only 3 (18%) knew they were high orderers. In the multivariable analysis, higher ordering was associated with increasing strength of response to the following predictors: medico-legal risk (relative risk [RR]=1.18, 95% CI: 1.03–1.21), risk of contrast (RR=1.14, 95% CI: 1.07–1.22), what colleagues would do (RR=1.09, 95% CI: 0.99–1.19), risk of missing a diagnosis (RR=1.08, 95% CI: 0.98–1.21), and patient wishes (RR=1.07, 95% CI: 0.97–1.17).
ConclusionsThere is large variation in CT ordering among EPs. Physicians’ self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.
WHICH OPTIONS FIT BEST? OPERATIONALIZING THE SOCIO-ECOLOGICAL NICHE CONCEPT
- KATRIEN DESCHEEMAEKER, ESTHER RONNER, MARY OLLENBURGER, ANGELINUS C. FRANKE, CHARLOTTE J. KLAPWIJK, GATIEN N. FALCONNIER, JANNIKE WICHERN, KENNETH E. GILLER
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- Journal:
- Experimental Agriculture / Volume 55 / Issue S1 / June 2019
- Published online by Cambridge University Press:
- 01 August 2016, pp. 169-190
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The large diversity of farms and farming systems in sub-Saharan Africa calls for agricultural improvement options that are adapted to the context in which smallholder farmers operate. The socio-ecological niche concept incorporates the agro-ecological, socio-cultural, economic and institutional dimensions and the multiple levels of this context in order to identify which options fit best. In this paper, we illustrate how farming systems analysis, following the DEED cycle of Describe, Explain, Explore and Design, and embedding co-learning amongst researchers, farmers and other stakeholders, helps to operationalize the socio-ecological niche concept. Examples illustrate how farm typologies, detailed farm characterization and on-farm experimental work, in combination with modelling and participatory approaches inform the matching of options to the context at regional, village, farm and field level. Recommendation domains at these gradually finer levels form the basis for gradually more detailed baskets of options from which farmers and other stakeholders may choose, test and adjust to their specific needs. Tailored options identified through the DEED cycle proof to be more relevant, feasible and performant as compared to blanket recommendations in terms of both researcher and farmer-identified criteria. As part of DEED, on-farm experiments are particularly useful in revealing constraints and risks faced by farmers. We show that targeting options to the niches in which they perform best, helps to reduce this risk. Whereas the conclusions of our work about the potential for improving smallholders’ livelihoods are often sobering, farming systems analysis allows substantiating the limitations of technological options, thus highlighting the need for enabling policies and institutions that may improve the larger-scale context and increase the uptake potential of options.
Sire effect on early and late embryonic death in French Holstein cattle
- D. Ledoux, C. Ponsart, B. Grimard, J. Gatien, M. C. Deloche, S. Fritz, R. Lefebvre, P. Humblot
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We investigated the effect of maternal sire on early pregnancy failure (between D0, day of insemination and D90) in their progeny during the first and second lactations (n=3508) in the Holstein breed. The estimated breeding value (EBV) for cow fertility of 12 bulls (reliability⩾0.95) was used to create the following three groups: low, medium and high EBV (EBV from −0.7 to 1 expressed as genetic standard deviation relative to the mean of the breed). In their daughters (93 to 516 per bull), progesterone measurement was carried out on the day of artificial insemination (AI; D0) to check whether the cows were in the follicular phase and on D18 to 25 to assess non-fertilisation-early embryonic mortality (NF-EEM). Late embryonic mortality (LEM) and early foetal death (FD) were determined by ultrasonography on D45 and D90 and by the return to oestrus after the first AI. Frequencies of NF-EEM, LEM, FD and pregnancy were 33.3%, 11.7%, 1.4% and 48.5% and incidences were 35.1, 19.0, 2.7 and 51.1, respectively. Sire EBV was significantly related to the incidences of pregnancy failure between D0 and D90, fertilisation failure-early embryonic mortality (FF-EEM) and LEM but not to the incidence of FD between D45 and D90 of pregnancy. The relative risk (RR) of FF-EEM was significantly higher (RR=1.2; P<0.05) for the progeny group of low EBV bulls when compared with high EBV bulls. The same effect was observed when comparing LEM of the progeny groups from the low EBV bulls to those from moderate and high EBV bulls (RR, respectively, of 1.3 and 1.4; P<005). The incidence of FF-EEM was significantly higher when cows were inseminated before 80 days postpartum compared with later, and for the extreme values of the difference between milk fat and protein content measured during the first 3 months of lactation. FF-EEM was also significantly related to the year of observation. The incidence of LEM was higher for the highest producing cows and was influenced by interaction between milk yield×lactation rank and milk yield×milk protein content. In conclusion, this study showed large differences in early pregnancy failure between progeny groups and highlights the interest of accurate characterisation of embryonic death in order to identify potential candidate genes for female fertility.