for the Critical Care EEG Monitoring Research Consortium IMPORTANCE Periodic and rhythmic electroencephalographic patterns have been associated with risk of seizures in critically ill patients. However, specific features that confer higher seizure risk remain unclear.OBJECTIVE To analyze the association of distinct characteristics of periodic and rhythmic patterns with seizures. DESIGN, SETTING, AND PARTICIPANTSWe reviewed electroencephalographic recordings from 4772 critically ill adults in 3 academic medical centers from February 2013 to September 2015 and performed a multivariate analysis to determine features associated with seizures. INTERVENTIONS Continuous electroencephalography.MAIN OUTCOMES AND MEASURES Association of periodic and rhythmic patterns and specific characteristics, such as pattern frequency (hertz), Plus modifier, prevalence, and stimulation-induced patterns, and the risk for seizures. RESULTSOf the 4772 patients included in our study, 2868 were men and 1904 were women. Lateralized periodic discharges (LPDs) had the highest association with seizures regardless of frequency and the association was greater when the Plus modifier was present (58%; odds ratio [OR], 2.00, P < .001). Generalized periodic discharges (GPDs) and lateralized rhythmic delta activity (LRDA) were associated with seizures in a frequency-dependent manner (1.

IMPORTANCE Continuous electroencephalography (EEG) use in critically ill patients is expanding. There is no validated method to combine risk factors and guide clinicians in assessing seizure risk.OBJECTIVE To use seizure risk factors from EEG and clinical history to create a simple scoring system associated with the probability of seizures in patients with acute illness.

Objective: cEEG is an emerging technology for which there are no clear guidelines for patient selection or length of monitoring. The purpose of this study was to identify subgroups of pediatric patients with high incidence of seizures.Study Design: We conducted a retrospective study on 517 children monitored by cEEG in the intensive care unit (ICU) of a children's hospital. The children were stratified using an age threshold selection method. Using regression modeling, we analyzed significant risk factors for increased seizure risk in younger and older children. Using two alternative correction procedures, we also considered a relevant comparison group to mitigate selection bias and to provide a perspective for our findings.Results: We discovered an approximate risk threshold of 14 months: below this threshold, the seizure risk increases dramatically. The older children had an overall seizure rate of 18%, and previous seizures were the only significant risk factor. In contrast, the younger children had an overall seizure rate of 45%, and the seizures were significantly associated with hypoxic-ischemic encephalopathy (HIE; p = 0.007), intracranial hemorrhage (ICH; p = 0.005), and central nervous system (CNS) infection (p = 0.02). Children with HIE, ICH, or CNS infection accounted for 61% of all seizure patients diagnosed through cEEG under 14 months.Conclusions: An extremely high incidence of seizures prevails among critically ill children under 14 months, particularly those with HIE, ICH, or CNS infection.

Health information exchanges (HIEs) are expected to improve poor information coordination in emergency departments (EDs); however, whether and when HIEs are associated with better operational outcomes remains poorly understood. In this work, we study HIE and length of stay (LOS) relationship using a large dataset from the Healthcare Cost and Utilization Project consisting of about 7.4 million treat‐and‐release visits made to 63 EDs in Massachusetts. Overall, we find that HIE adoption is associated with a 10.2% reduction in LOS and the percentage reduction increases to 14.8% when the hospital is part of an integrated health system or to 21.0% when a patient has a previous visit to an HIE‐carrying hospital. We further find that (i) teaching hospitals benefit more from HIE adoption compared with non‐teaching hospitals, (ii) patients with severe or multiple comorbid conditions spend less time in the ED under HIE presence. Together, these results imply that (i) HIE adoption reduces overall ED LOS, (ii) wider HIE adoption would scale up the benefits for individual hospitals, (iii) magnitude of the association between HIE and LOS is higher when financial incentives for HIE adoption are stronger (e.g., integrated health systems), and (iv) the size of the reduction depends on certain contextual moderating factors. Given that HIEs are a key component of healthcare delivery and ongoing reforms, we believe that our findings have important implications and may inform policymakers regarding the nationwide HIE adoption.

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Problem definition: Under the prevailing fee-for-service (FFS) payments, hospitals receive a fixed payment, whereas physicians receive separate fees for each treatment or procedure performed for a given diagnosis. Under FFS, incentives of hospitals and physicians are misaligned, leading to large inefficiencies. Bundled payments (BP), an alternative to FFS unifying payments to the hospital and physicians, are expected to encourage care coordination and reduce ever increasing healthcare costs. However, as hospitals differ in their relationships with physicians in influencing care (level of physician integration), the expected effects of bundling in hospital systems with a varying level of physician integration remains unclear. Academic/practical relevance: There is a lack of both academic and practical understanding of hospitals’ and physicians’ bundling incentives. Our study builds on and expands the recent operations management literature on alternative payment models. Methodology: We formulate game-theoretic models to study (1) the impact of the level of integration between the hospital and physicians in the uptake of BP and (2) the consequences of bundling with respect to overall care quality and costs/savings across the spectrum of integration levels. Results: We find that (1) hospitals with low to moderate levels of physician integration have more incentives to bundle as compared with hospitals with high physician integration; (2) to engage physicians, hospitals need to financially incentivize them, a mechanism that was not available in traditional FFS-based payment models; (3) when feasible, BP is expected to reduce care intensity, and this reduction in care intensity is expected to result in quality improvement and cost savings in hospital systems with low to moderate level of physician integration; (4) however, when bundling happens in hospital systems with a relatively higher level of physician integration, BP may lead to underprovisioning of care and ultimately quality reduction; (5) in an environment where hospitals are also held accountable for quality, the incentives for bundling will be higher for involved parties, yet quality vulnerabilities due to bundling can be exacerbated. Managerial implications: Our findings have important managerial implications for policy makers, payers such as the Center for Medicare and Medicaid Services, and hospitals: (1) policy makers and payers should be aware of and account for potential negative effects of current BP design on a subset of hospital systems, including a possible quality reduction; (2) in deciding whether to enroll in BP, hospitals should consider their level of physician integration and possible implications for quality. Based on our findings, we expect that a widespread use of BP may trigger further market concentration via hospital mergers or service-line closures. Supplemental Material: The online appendices are available at https://doi.org/10.1287/msom.2023.1187 .

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