Category: Quality

Finding Value in Emergency Care

The Choosing Wisely initiative is, despite its flaws, an necessary cultural shift in medicine towards reducing low-value expenditures.  In a fee-for-service health system, and given the complicated financial framework associated with training and reimbursing physicians, noble endeavors such as these face significant challenges.

Regardless, many specialties – including ACEP – have published at least one “Top 5” list of recommended practices to improve value.  The ACEP Choosing Wisely list, while certainly reflecting sound medical practice, are of uncertain incremental value or applicability over current practice.  Additionally, the methods and stakeholders involved remain opaque.  Luckily, in a coincidental parallel, Partners Healthcare embarked on an unrelated internal process to improve the affordability of healthcare and reduce costs.  This study provides a transparent look at a such a process, as well as the ultimate findings.

Using an expert panel, 64 potential low-value care practices were identified in a brainstorming session, subsequently narrowed down to 17.  Then, 174 physicians and clinical practioners responded to a web-based survey, ranking the value of each.  Based on this feedback, then, the original expert panel voted again on a final “Top 5”:

  • Do not order computed tomography (CT) of the cervical spine for patients after trauma who do not meet the National Emergency X-ray Utilization Study (NEXUS) low-risk criteria or the Canadian C-Spine Rule.
  • Do not order CT to diagnose pulmonary embolism without first risk stratifying for pulmonary embolism (pretest probability and D-dimer tests if low probability). 
  • Do not order magnetic resonance imaging of the lumbar spine for patients with lower back pain without high-risk features. 
  • Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule. 
  • Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (eg, with anticoagulation therapy, clinical coagulopathy).

It always surprises me to see these lists – which, essentially, just constitute sound, evidence-based practice.  That said, given my exposure primarily to an academic, teaching environment, rather than a community hospital environment concerned with expediency and revenue generation, these may be larger problems than I expect.  This list also does not address the estimated cost-savings associated with adherence to these “Top 5” best practices.  While many of these may result in significant cost-savings through reductions in imaging, the yield would be variable based on the quality of care already in place.

Regardless, this list is as much about the derivation process itself, rather than the resulting “Top 5”.  Certainly, the transparency documented in this study is superior to the undocumented process behind ACEP’s contribution.  That said, this list ultimately reflects the biases and practice patterns of a single healthcare network in Massachusetts; your mileage may vary.  Many of the final “Top 5” had overlapping confidence intervals on the Likert Scale for benefit and actionability, suggesting a different survey instrument may have provided better discrimination.  Finally, while we are culturally enamored with “Top 5” lists – all 64 of their original set are important considerations for improving the value of care.

We, and all of medicine, have a long way to go – but these are steps along the right path.  It is also critically important we also (wisely) choose our own destiny – rather than wait for government or insurance administrators to enforce their misguided priorities upon our practice.

“A Top-Five List for Emergency Medicine: A Pilot Project to Improve the Value of Emergency Care”
https://archinte.jamanetwork.com/article.aspx?articleid=1830019

Shared Decision-Making to Reduce Overtesting

Medicine, like life, is full of uncertainty.  Every action or inaction has costs and consequences, both anticipated and unintended.  Permeating through medical culture for many reasons, with the proliferation of tests available, has been a decreased tolerance for this uncertainty and the rise of “zero-miss” medicine.  However, there are some tests that carry with them enough cost and risk, the population harms of the test outweigh the harms of the missed diagnoses.  CTPA for pulmonary embolism is one of those tests.

In this study, these authors attempt to reduce testing for pulmonary embolism by creating a shared decision-making framework to discuss the necessity of testing with patients.  They prospectively enrolled 203 patients presenting to the Emergency Department with dyspnea and, independent of their actual medical evaluation, attempted to ascertain their hypothetical actions were they to be evaluated for PE.  Specifically, they were interested in the “low clinical probability” population whose d-Dimer was elevated above the abnormal threshold – but still below twice-normal the threshold.  For these “borderline” abnormal d-Dimers, the authors created a visual decision tool describing their estimate of the benefit and risk of undergoing CTPA given this specific clinical scenario.

After viewing the benefits and risks of CTPA, 36% of patients in this study stated they would hypothetically decline testing for PE.  Most of the patients (85%) who planned to follow-through with the CTPA did so because they were concerned regarding a possible missed diagnosis of PE, while the remaining hoped the CT would at least also provide additional information regarding their actual diagnosis.  The authors conclude, based on a base case of 2.6 million possible PE evaluations annually, this strategy might save 100,000 CTPAs.

I think the approach these authors promote is generally on the right track.  The challenge, however, is the data used to discuss risks with patients.  From their information graphics, the risks of CTPA – cancer, IV contrast reaction, kidney injury and false positives – are all fair to include, but can be argued greatly regarding their clinical relevance.  Is a transient 25% increase in serum creatinine in a young, healthy person clinically significant?  Is it the same as a cancer diagnosis?  Is it enough to mention there are false-positives from the CTPA without mentioning the risk of having a severe bleeding event from anticoagulation?  Then, in their risk of not having the CTPA information graphic, they devote the bulk of that risk to a 15% chance of the CT identifying a diagnosis that would have otherwise been missed.  I think that significantly overstates the number of additional, clinically important findings requiring urgent treatment that might be identified.  Finally, the risks presented are for the “average” patient – and may be entirely inaccurate across the heterogenous population presenting for dyspnea.

But, any quibbles over the information graphic, limitations, and magnitude of effect are outweighed by the importance of advancing this approach in our practice.  Paternalism is dead, and new tools for communicating with patients will be critical to the future of medicine.

“Patient preferences for testing for pulmonary embolism in the ED using a shared decision-making model”
http://www.ncbi.nlm.nih.gov/pubmed/24370071

A Rapid Response Fantasyland

Rapid response teams sound good in theory – specifically skilled nurses as back-up providers for floor emergencies, intervening and escalating patients in times of unexpected deterioration.  However, the largest cluster-randomized trial and multiple meta-analyses have failed to show any benefit to rapid response teams.

The response to this high-quality evidence?  Irresponsible conclusions based on low-quality retrospective data.

These authors have so much enthusiasm for their product – a rapid response team that proactively rounds on patients – they’re blind to the most obvious holes in their data.  They try to retrospectively compare pre- and post-RRT implementation outcomes, despite having essentially only data on floor codes.  And, backing up their main conclusion, floor codes are lower post-RRT proactive rounding – of course, floor codes were already trending downwards at the time of implementation.

What happened when the RRT intervened?  The same thing as all other studies show – they moved patients to a higher level of care.  How did patients fare in the ICU?  A third died or were transferred to hospice.  Utterly overlooked in the discussion, in which these authors praise their product and their RRT nurses profusely, is the end result of their RRT product appears to be an unchanged mortality – a simple shuffling around the location of in-hospital deaths.  Their title implies a result that is simply demonstrated nowhere in the article, yet they continue to lavish themselves with accolades right up through the final conclusion:

“Our study demonstrates proactivity and innovation as an overall approach to inpatient cardiac arrests  ….  Innovation stems from a dedicated managerial team who routinely evaluates trends in the code data and creatively seeks ways to prevent cardiac arrest from occurring.”

Managerial buzzword self-aggrandizing nonsense.

“Proactive rounding by the rapid response team reduces inpatient cardiac arrests”
http://www.ncbi.nlm.nih.gov/pubmed/23994805

Sepsis, NHAMCS, and Non-Truths

“… our results provide a worrisome view of the quality of care of septic patients in U.S. EDs.”

Crikey.

This is serious business.  Tell me more.

“Our data suggest that many emergency department patients (31%) with sepsis do not receive antibiotics until they arrive on the inpatient unit.”

This is somewhat concerning data.  Of course, some patients can have sepsis from viremia, and would not warrant antibiotics – but, I think most admitted patients with SIRS and a suspected infectious source ought to receive treatment.

But, unfortunately, for this study, the question is less the quality of ED care, and more the quality of the data source.  The National Hospital Ambulatory Medical Care Survey is a lovely data set, whose quality is only increasing as coding and structured data become more prevalent – but a retrospective analysis of these data is not appropriate substrate to make sweeping generalizations regarding the care in the Emergency Department.

From the ~400 Emergency Departments providing yearly data to NHAMCS, 0.32% of patients met their definition of sepsis.  That meant these data reflect a sample of 1,141 patients, and the admitted limitation of “studies relying on NHAMCS data are vulnerable to errors of omission in data collection.”  These authors lack information regarding previously administered antibiotics from transferred patients, and admit some patients – those spending <1 hour in the ED – may simply have left the ED before antibiotic administration could be completed.

Quite simply, it’s (mostly) garbage in and (mostly) garbage out.

The authors also attempt an assessment of antibiotic appropriateness from this retrospective chart abstraction.  It is so egregiously flawed it doesn’t even warrant comment.

“Sepsis Visits and Antibiotic Utilization in U.S. Emergency Departments”
http://www.ncbi.nlm.nih.gov/pubmed/24201179

Stepping Up to Choosing Wisely

ACEP recently published their own “Choosing Wisely” campaign contribution – a list of five changes to Emergency Medicine practice that ought be encouraged in the interests of increasing cost-effective care.  While most would agree the ACEP version is reasonable, I think many clinicians hoped for something a little more earth-shattering.

Something like the Pediatric Hospital Medicine list for Choosing Wisely.

These authors specifically looked at the top 10 inpatient diagnoses in terms of volume and aggregate costs, and specifically evaluated components of treatment as candidates for recommendations.  And, even speaking as someone who makes an effort to minimize testing – I find these recommendations take an impressive step in terms of aggressive reduction in resource utilization.

The highlights:
Do not order chest radiographs in children with asthma or bronchiolitis.
Do not use bronchodilators in children with bronchiolitis.
Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection.

How often do you get radiographs in patients with respiratory disease – that get discharged?  How about admitted?  The authors estimate 60% of admitted patients receive radiographs, with fewer than 2% affecting clinical management.

Or, routine bronchodilator therapy – which, frankly, is ordered for a lot of children simply due to a sense we ought to do something.  Both beta-agonist and racemic epinephrine fall under this recommendation, as they’ve not been shown to confer any reliable, clinically meaningful, patient-oriented outcome in bronchiolitis.

Finally – corticosteroids.  Young children, even with albuterol-responsive wheezing, showed no benefit when corticosteroids were added.  These are not harmless interventions, particularly for growing infants, and seems to pre-dispose some folks to subsequent readmission.

With pediatric respiratory season on the horizon, I challenge all of you to use this document as a tool share with colleagues and consultants to decrease unnecessary testing and therapy.

“Choosing Wisely in Pediatric Hospital Medicine: Five Opportunities for Improved Healthcare Value”
http://www.ncbi.nlm.nih.gov/pubmed/23955837

A Snapshot of Chest Pain Waste

The Lown Institute continues their conference today on avoidable care in the U.S., so this study is a lovely glimpse into one of the worst offenders in Emergency Medicine – chest pain.

Coming from the University of Pennsylvania, this is a retrospective review of patients 805 patients for whom an ED observation protocol of rapid rule-out and stress testing was performed.  The supposed point of this article is to demonstrate the potential safety of stress testing after two sets of cardiac troponin 2-hours apart, and, in theory, they do demonstrate this.  Of these 805 patients, 16 patients were diagnosed with acute myocardial infarction on index visit through this protocol – and within 30 days, 1 patient had AMI and 2 received revascularization.

The authors conclusion: “…serial troponins 2 hours apart followed by stress testing is safe and … rapid stress testing represents another option to expedite care of patients with potential ACS”.

789 of 805 patients received serial troponins and a negative stress test to identify a handful of higher than minimal risk folks.  The 16 AMI diagnoses were based on 12 patients with negative troponins and positive stress tests, 1 patient with troponins that rose from <0.02 to 0.16 ng/mL and a negative stress test, and 3 patients with troponins rising from <0.02 to 0.06-0.09 ng/mL and positive stress tests.  But, in order to dredge up these soft diagnoses of ACS, hundreds of thousands of dollars in financial damage were inflicted on the remaining cohort.

These authors feel rapid stress testing is an alternative to CTCA for preventing avoidable admissions.  In the spirit of the Lown Institute, and of Rita Redberg’s NEJM editorial regarding CTCA, the true strategy for preventing an avoidable admission is simply to discharge the majority of these patients.  A less than 2% yield for an expensive observational diagnostic strategy is far more grossly negligent a failure of medicine than an occasional missed minor MI.  We can do nearly as well, for much less cost – but if only we continue to address our “zero-miss” cultural expectations surrounding diagnosis and treatment.

“Safety of a rapid diagnostic protocol with accelerated stress testing”
http://www.ncbi.nlm.nih.gov/pubmed/24211281

Gorging Ourselves to Death on Healthcare

This Harvard Business School paper highlights the nonsensical nature of the United States healthcare system – every advance promises one step forward, yet inevitably results two steps backward.

This is a piece of observational operations research regarding radiology turnaround times.  If you’re involved in your ED’s throughput initiatives in any fashion, I am certain this has been a recurring issue.  Most conversations probably take the form “If only radiology were faster, patients would flow through the department like quicksilver.”  So, what happened in a 100,000-visit academic ED and a 60,000-visit community ED when, through process improvement, an “inefficient” gatekeeping step was eliminated?

Initially, at the hospitals observed, ultrasounds were available only by radiologist approval after 5pm on weekdays and on weekends.  Scans could be performed as needed from a technician on-call, but this inconvenient step alone added 10-15 minutes to the radiology turnaround time for these patients.  After these hospitals added 24/7 technician coverage and eliminated the approval step, two things happened: length of stay for patients receiving an ultrasound on nights and weekends decreased (huzzah), and the number of ultrasounds ordered increased by 11.5% (oh hmm).

Unsurprisingly, as the number of patients receiving ultrasounds increased, the overall average LOS for a patient with an abdominal complaint went up by 26 minutes.  And, with the extra ultrasounds for the radiologists to read, turnaround times for non-ultrasound radiology results were increased by 30 minutes.  Furthermore, CT use in those same time windows also increased by 4.5%, while general CT use in both departments decreased by 10%.  The authors hypothesize incidental findings on ultrasound were prompting subsequent CT use to follow-up suspicious reads, leading to even greater resource utilization.  As you would expect, this congestion extended out to the waiting room, with a predicted increase in time-to-room as well.

So – more tests, more costs, longer waits – no detectable effect on outcomes.

‘Merica.

“Increased Speed Equals Increased Wait: The Impact of a Reduction in Emergency Department Ultrasound Order Processing Time”
http://hbswk.hbs.edu/item/7310.html

Letter in JAMA

A couple months back, JAMA published Jeff Saver’s time-to-tPA association, derived from the Get With the Guidelines-Stroke Registry.  My critique of this article remains essentially the same, but this past issue JAMA published an edited version as a response to Dr. Saver.

While many of you will find the content behind the JAMA paywall, the basic gist of Saver’s response to my letter is:

  • tPA-treated stroke mimics are not included in the GWTG-Stroke registry during the study period.  It is an optional reporting field.
  • The tiny bit of data from original NINDS showed rapidly-improving patients from the placebo group were equally distributed between 59 to 90 minutes and 91 to 180 minutes (3/145 vs. 4/167).
  • The onset-to-treatment-time and outcome association was consistent between NIHSS 0-14 and NIHSS 15-42, and therefore any effects from TIAs must be insignificant.

In summary: they don’t really know how many TIAs/stroke mimics/aborted strokes there were, but they can draw lines around some numbers to support their conclusion.

These are reasonable responses from their standpoint.  I would point out, however, the NINDS group made specific efforts to exclude “rapidly improving” symptoms from inclusion, probably resulting in extreme extra care in preventing enrollment of TIAs.  This population is unlikely to be generalizable to current tPA-happy practice across medicine.  They do not, unfortunately, address the problem of “aborted stroke” coding, which further received a shout-out on Twitter from Dr. Hsia:

@emlitofnote hit the mark in @JAMA_current with citing our averted #stroke paper: #tPA-treated does not equal #stroke http://t.co/6aE7bFlm7k
— Amie Hsia (@DCStrokeDoc) November 8, 2013

I’ll try and get a peek at the GWTG-Stroke data myself, but with the literature documenting anywhere from 2% to 31% stroke mimic treatment rate – with the actual true rate probably exactly in the middle of that range – it’s critically important to uncover risks and costs of inappropriate tPA administration.  If the GWTG-Stroke registry is a true quality device, it needs to do a better job of measuring adverse events.

Or, you could end up like Houston Texans’ coach Gary Kubiak, who received tPA last week for a stroke mimic (currently reported as having had a TIA – which I find dubious, but I have no personal knowledge of the case).

“Acute Ischemic Stroke and Timing of Treatment”
http://www.ncbi.nlm.nih.gov/pubmed/24193085

Yet More Unnecessary Antibiotics

One would think educational efforts regarding the inefficacy of antibiotics for viruses would at some point take root.  I’m pretty sure it’s explicitly covered in our medical school curriculum that antibiotics are indicated specifically to treat infection caused by bacteria.  Despite this, however, the overwhelming evidence is that clinicians have somehow forgotten these basic fundamentals of medicine.
This is a research letter reviewing the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (NAMCS,NHAMCS) databases for visits to primary care or Emergency Departments for code 1455: “sore throat”.  Considering the prevalence of group A strep infection is about 10%, and a small number of additional cases are pathogenic bacterial infections requiring acute treatment, I suppose you would expect the rate of antibiotic prescribing to be quite low?
Is 60% the number you had in mind?
U.S. physicians have been prescribing antibiotics at a mostly steady rate of 60% of visits for sore throat for over a decade.  Not only are they prescribing antibiotics, almost half of prescriptions are for non-ß-lactam antibiotics – including a huge proportion of azithromycin, as if there weren’t enough macrolide-resistant streptococci out there.  Beyond that, a full 15% were not even close to options on the recommended list for acute sore throat, such as fluoroquinolones.
When smart folks like David Newman are calling for the end of routine treatment of strep throat, certainly we are way off base with a 60% rate of treatment.  Forget about OP-15 – we should have a quality measure based on rates of antibiotic prescription for sore throat and ear pain.
“Antibiotic Prescribing to Adults With Sore Throat in the United States, 1997-2010”

Which Pulmonary Emboli Are Missed?

Apparently, as many as one-third of them!

This is a retrospective study from a Spanish hospital evaluating all patients presenting through the Emergency Department who subsequently received a chest CTA revealing pulmonary embolism.  These diagnoses were further classified as having received the diagnosis of PE on initial presentation, during hospitalization, or on a return visit to the Emergency Department.  66% of patients diagnosed with PE were diagnosed on the initial visit, while 22% were diagnosed only after hospital admission, and 12% on Emergency Department revisit.  This leads to the authors conclusions that delayed diagnosis of acute PE is frequent despite current diagnostic strategies.

While it’s only a single center study, and the frequency of missed diagnoses may not be generalizable, it’s still a reasonable investigation.  The characteristics of patients with missed PE fit the typical spectrum from other, prior studies: confounding comorbidities and diagnostic findings.  Patients with delayed diagnosis had fewer typical features, were more likely to have COPD or asthma, more likely to have fever, and more likely to have pulmonary infiltrates.  The authors state there were no mortality differences between early and delayed PE diagnosis, but the study is too small and heterogenous to truly put much faith in this observation.  Of note, 41% of patients who were initially discharged from the ED had unilateral subsegmental clot, a far greater proportion than either other diagnostic group.

It certainly makes sense that patients with dyspnea and other potential causes will have their diagnosis delayed until their lack of response to therapy results in reassessment.  These authors suggest we ought to be more aggressive in our evaluation for PE in the Emergency Department; I tend to feel the delayed diagnosis in confounding situations is appropriate, and suspect some of these represent subclinical disease.  “Zero-miss” is only appropriate if the harms from the disease outweigh the harms of testing and treatment – and follow-up re-evaluation or additional testing during acute hospitalization are reasonable pathways to diagnosis in a subset of patients.

“Clinical features of patients inappropriately undiagnosed of pulmonary embolism”
http://www.ncbi.nlm.nih.gov/pubmed/24060320