Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries

Boutis, Kathy; Grootendorst, Paul; Willan, Andrew R.; Plint, Amy C.; Babyn, Paul; Brison, Robert J.; Sayal, Arun; Parker, Melissa; Mamen, Natalie; Schuh, Suzanne; Grimshaw, Jeremy; Johnson, David H.; Narayanan, Unni G.

doi:10.1503/cmaj.122050

Cited by 43 publications

(55 citation statements)

References 26 publications

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“…37,38 Funded studies are prominent in the articles highlighted for superior methodology (86%). 12,21,23,30,34,36 This is consistent with findings by Reed et al, 53 who noted that funded studies were more likely to have been of higher quality as assessed on a validated scale.…”

Section: Trends In Medical Education Research In 2013supporting

confidence: 86%

“…Fourteen (32.5%) studies were funded. 10,12,15,19,[21][22][23]30,33,34,[36][37][38]44 Funding sources included federal grants, 12,21 institutional or specialty organization support, 10,22,23,33,34,36,44 foundations, 15,19,30 and industry. 37,38 Funded studies are prominent in the articles highlighted for superior methodology (86%).…”

Section: Trends In Medical Education Research In 2013mentioning

confidence: 99%

“…10,16,22,23,25,37,44 Fourteen studies (33%) employed rigorous experimental or quasi-experimental methodologies, 10,12,15,18,21,24,30,31,34,36,38,41,47,48 including five (71%) of the featured articles. 10,21,30,34,36 Outcome measures in all studies reviewed ranged from learner satisfaction (Kirkpatrick level I) to improved performance (Kirkpatrick level 3). 54 Although the outcome measures for the highest Kirkpatrick level (level 4) are difficult to study and focus on tangible patient outcome results after training, they are what education research studies should build toward.…”

Section: Trends In Medical Education Research In 2013mentioning

confidence: 99%

“…Six quantitative studies met a priori criteria as methodologically superior publications in education research, with a range of mean scores from 16.5 to 21.2 (maximum 25 points). 12,20,21,30,34,36 One qualitative study received the highest score of 16.0 (maximum 25 points). 23 The six highest ranking quantitative studies are presented in alphabetical order by the surname of the first author, followed by the one highest-ranked qualitative study.…”

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confidence: 99%

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Critical Appraisal of Emergency Medicine Education Research: The Best Publications of 2013

Farrell

Kuhn

Coates

et al. 2014

Academic Emergency Medicine

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Objectives: The objective was to critically appraise and highlight methodologically superior medical education research articles published in 2013 whose outcomes are pertinent to teaching and education in emergency medicine (EM).Methods: A search of the English-language literature in 2013 querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 251 EM-related studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. Six reviewers then independently scored the remaining 43 publications using either a qualitative a or quantitative scoring system, based on the research methodology of each article. Each scoring system consisted of nine criteria. Selected criteria were based on accepted educational review literature and chosen a priori. Both scoring systems used parallel scoring metrics and have been used previously within this annual review.Results: Forty-three medical education research papers (37 quantitative and six qualitative studies) met the a priori criteria for inclusion and were reviewed. Six quantitative and one qualitative study were scored and ranked most highly by the reviewers as exemplary and are summarized in this article.Conclusions: This annual critical appraisal article aims to promote superior research in EM-related education, by reviewing and highlighting seven of 43 major education research studies, meeting a priori criteria, and published in 2013. Common methodologic pitfalls in the 2013 papers are noted, and current trends in medical education research in EM are discussed.ACADEMIC EMERGENCY MEDICINE 2014;21:1274-1283 by the Society for Academic Emergency Medicine Q uality, hypothesis-driven education research is necessary to promote evidence-based decisions about effective ways to teach the physicians of tomorrow. Education research has gained increasing support and prominence in emergency medicine (EM) academia, with available grant opportunities from the Society of Academic Emergency Medicine and the Council of Emergency Medicine Residency Directors. Furthermore, the 2012 Academic Emergency Medicine consensus conference focused on the theme "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" to promote a national initiative to advance the field of education research. 1 In this sixth installment of the annual critical appraisal series, the same six reviewers used previously published criteria 2 to critically analyze and rank the EM education research from 2013. The focus of this article is to review and highlight the methodologically superior studies that are pertinent to teaching and education in EM. Trends in EM education research over the past 6 years, as they can be inferred from this review, are summarized. It is METHODS Article IdentificationThe previously described methodology to search for relevant publications was used. 2 Publications...

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Section: Trends In Medical Education Research In 2013supporting

confidence: 86%

Section: Trends In Medical Education Research In 2013mentioning

confidence: 99%

Section: Trends In Medical Education Research In 2013mentioning

confidence: 99%

mentioning

confidence: 99%

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Critical Appraisal of Emergency Medicine Education Research: The Best Publications of 2013

Farrell

Kuhn

Coates

et al. 2014

Academic Emergency Medicine

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“…Cost data identified a pre-post reduction in costs from $2010 to $1174 per patient [20]. Further evidence to support cost reduction through standardization across multiple sites was reported based on use of the Low Risk Ankle Rule, an algorithm shown to reduce radiographs for children without fractures or clinically unimportant ankle fractures [21]. The rule was implemented in three Canadian emergency departments with costs compared to three sites not using the rule to assess possible fractures.…”

Section: Standardization In Networkmentioning

confidence: 99%

Reducing Cost Through Standardization

Friedman

Fulton

2016

Curr Treat Options Peds

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Opinion statementThe drive for standardization of care within pediatrics based on medical evidence is gaining momentum among hospitals and providers. Initiated by care guidelines with origins in specialty societies, adoption of pathways is now being implemented in many settings. The keys to success of these algorithms in narrowing practice variation and their potential contribution to reducing utilization of unnecessary resources are not uniformly addressed in advance. Clinical guidelines are often not updated frequently to incorporate new evidence from the literature. Education of providers about the goals and process of pathways in advance may not be sufficient depending on the commitment of the clinical champions of the algorithms. Anticipatory modeling to identify potential barriers in the workflow that interfere with proper implementation of pathways is beneficial with the opportunity to refine the algorithm where appropriate. In order to confirm cost reduction, economic data points need to be defined in advance for comparisons between preimplementation and post-implementation periods. It is possible that improved outcomes from narrowed practice variation may not always lead to cost reduction which should be reconciled by analysis of the data. Our experience with these limitations motivated our Department of Cardiology to seek a different approach to care pathways, standardized clinical and management pathways (SCAMPs) which engender algorithm design informed by existing evidence and experience of clinicians coupled with targeted questions that can be addressed by active data collection. Providers are free to depart from recommendations in the algorithm but must explain their reasons, an option that promotes participation. Data analysis combined with new medical evidence leads to iterative changes, greater standardization, and reduction of cost.

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Radiograph-Negative Lateral Ankle Injuries in Children

et al. 2016

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IMPORTANCE Lateral ankle injuries without radiographic evidence of a fracture are a common pediatric injury. These children are often presumed to have a Salter-Harris type I fracture of the distal fibula (SH1DF) and managed with immobilization and orthopedic follow-up. However, previous small studies suggest that these injuries may represent ankle sprains rather than growth plate fractures. OBJECTIVES To determine the frequency of SH1DF using magnetic resonance imaging (MRI) and compare the functional recovery of children with fractures identified by MRI vs those with isolated ligament injuries. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study was conducted between September 2012 and August 2014 at 2 tertiary care pediatric emergency departments. We screened 271 skeletally immature children aged 5 to 12 years with a clinically suspected SH1DF; 170 were eligible and 140 consented to participate. INTERVENTIONS Children underwent MRI of both ankles within 1 week of injury. Children were managed with a removable brace and allowed to return to activities as tolerated. MAIN OUTCOMES AND MEASURES The proportion with MRI-confirmed SH1DF. A secondary outcome included the Activity Scale for Kids score at 1 month. RESULTS Of the 135 children who underwent ankle MRI, 4 (3.0%; 95% CI, 0.1%-5.9%) demonstrated MRI-confirmed SH1DF, and 2 of these were partial growth plate injuries. Also, 108 children (80.0%) had ligament injuries and 27 (22.0%) had isolated bone contusions. Of the 108 ligament injuries, 73 (67.6%) were intermediate to high-grade injuries, 38 of which were associated with radiographically occult fibular avulsion fractures. At 1 month, the mean (SD) Activity Scale for Kids score of children with MRI-detected fibular fractures (82.0% [17.2%]) was not significantly different from those without fractures (85.8% [12.5%]) (mean difference, −3.8%; 95% CI, −1.7% to 9.2%). CONCLUSIONS AND RELEVANCE Salter-Harris I fractures of the distal fibula are rare in children with radiograph fracture-negative lateral ankle injuries. These children most commonly have ligament injuries (sprains), sometimes associated with radiographically occult avulsion fractures. Children with fractures detectable only by MRI had a comparable recovery with those with sprains when treated with a removable ankle brace and self-regulated return to activities. This work has the potential to simplify the care of these common injuries, safely minimizing the inconveniences and costs of overtreatment.

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Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries

Cited by 43 publications

References 26 publications

Critical Appraisal of Emergency Medicine Education Research: The Best Publications of 2013

Critical Appraisal of Emergency Medicine Education Research: The Best Publications of 2013

Reducing Cost Through Standardization

Radiograph-Negative Lateral Ankle Injuries in Children

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