Emergency Medicine Literature of Note
Musings on Emergency Medicine, Clinical Informatics, & High-Value Care.
Featured today as a guest blog, revisiting the JAMA Clinical Evidence synopsis critiqued last month on this blog, here and here.
It’s rather an experiment in discovering just how influential social media has become – open access, crowdsourced “peer review” – and whether this mechanism for addressing conflict-of-interest in the prominent medical journals is more effective than simply attempting a letter to the editor.
KevinMD.com – “The filtering of medical evidence has clearly failed“
Chest pain observation units run by the Emergency Department are fairly popular – and it’s easy to see why. It eliminates the need to fight a hospitalist for admission, allows for complete coverage of medicolegal liability, captures another set of billing codes for ED revenue, and keeps the cardiologists happy with a steady stream of interpretation and consultation revenue.
Duke University has one of these such chest pain observation units, and this study is a retrospective evaluation of the subgroup of patients aged less than 40 years. Of the 2,231 patients observed for suspected acute coronary syndrome, 362 met eligibility based on age. Of these 362 patients, median age 36, 238 underwent stress testing and the remainder underwent serial enzymes.
From this cohort, there was a single true positive – defined as a patient who underwent a coronary angiogram with an intervention performed.
There were, however, 14 false positives – indeterminate or positive stress tests and one set of positive biomarkers, leading to five negative invasive coronary angiograms.
The authors sum it up quite nicely: “The extremely risk- adverse physician cannot totally exclude the possibility of ACS based on age, but it seems that routine observation for such patients may cause the potential for as much harm as good.”
“Utility of Observation Units For Young Emergency Department Chest Pain Patients”
www.ncbi.nlm.nih.gov/pubmed/22975283
It seems intuitive – if, perhaps, the electronic health record has an updated problem list, and the EHR knows the typical indication of various medications, then the EHR would be able to perform some cursory checks for concordance. If the orders and the problems are not concordant – then, as these authors propose, perhaps the orders are on the wrong patient?
This study is a retrospective analysis of the authors’ EHR, in which they had previously implemented alerts of this fashion in the interests of identifying problem lists that were not current. However, after data mining their 127,320 alerts over a 6-year period, they noticed 32 orders in which the order was immediately cancelled on one patient and re-ordered on another. They then conclude that their problem list alert also has the beneficial side-effect of catching wrong-patient orders.
A bit of a stretch – but, it’s an interesting application of surveillance intelligence. The good news is, at least, that their problem list intervention is successful (pubmed) – because a 0.25 in 1000 patient alert yield for wrong-patient orders would be abysmal!
“Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE)”
www.ncbi.nlm.nih.gov/pubmed/23396543
The state of the art for coronary CT angiograms progressed a great deal in the past year. Four recent studies, CT-STAT, ACRIN-PA, ROMICAT II, and a fourth by Goldstein et al., have added to our knowledge base regarding the performance characteristics of this test.
Overall, by pooling 3,266 patients from these four trials, a couple new features shake out as statistically significant. Specifically, patients undergoing CCTA were significantly more likely (6.3% vs 8.4%) to undergo ICA, and then more likely to receive revascularization (2.6% vs. 4.6%). This adds to what we already knew – CCTA shortens ED length of stay and reduces overall ED costs compared with “usual care”.
But, we still don’t really know if this test is improving important patient-oriented outcomes. These intervention numbers are quite low – meaning a great number of patients simply received expensive diagnostic testing, without any sort of treatment. Then, we don’t even know if these revascularizations are improving (or worsening!) outcomes. Technology keeps blundering forward with its flawed disconnect from rationality – the costs go up and up, but we don’t hardly stop to measure whether we’re actually doing any good….
“Outcomes After Coronary Computed Tomography Angiography in the Emergency Department”
content.onlinejacc.org/article.aspx?articleID=1569168
Mostly unrelated to Emergency Medicine – but an interesting descriptive study of a downstream phenomenon I see on a frequent basis.
For example, I’ll intermittently follow-up a patient to see how they fared as an inpatient. I’ll read the inpatient documentation, consultant reports, etc. – and find the tiny EM HPI perpetuated throughout the chart with minimal modification. This anecdotal experience is backed up by these authors who used text-compare software to identify copied passages in daily progress notes from an ICU setting. In this ICU at MetroHealth in Cleveland, 82% of resident notes copied at least >20% of the text from the previous days’ progress note – and copied 55% of the prior content on average. Attending notes were slightly less frequently copied (74%), but tended to copy more content (61%).
There’s no conclusive data regarding whether this copy/paste practice affects patient outcomes, but it’s an interesting symptom of evolving medical care and documentation in the EHR era. I hope that, as HIT evolves, documentation tools trend towards encouraging concise, effective communication, rather than this sort of (likely ineffective) chart bloat.
“Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes”
www.ncbi.nlm.nih.gov/pubmed/23263617
This short article from JAMA and corresponding study from Archives is concerned with advising practicing clinicians on how to identify which clinical guidelines are “trustworthy”. This is a problem – because most aren’t.
The JAMA article paraphrases the eight critical elements in the 2008 Institute of Medicine report required to generate a “trustworthy” article, such as systematic methodology, appropriate stakeholders, etc. Most prominently, however, several deal specifically with transparency, including this paraphrased bullet point:
The Archives article cited by the JAMA article reviews over 100 published guidelines for compliance with the IOM. The worst performance, by far, was compliance with conflicts of interest, and notes that 71% of committee chairpersons and 90.5% of committee co-chairpersons declared COI – when declarations were explicitly stated at all. Overall, less than half of clinical guidelines met more than half of the IOM recommendations for “trustworthiness”.
Sadly, another dismal addition to the all-too-frequent narrative describing the rotten foundation of modern medical practice.
“How to Decide Whether a Clinical Practice Guideline Is Trustworthy”
www.ncbi.nlm.nih.gov/pubmed/23299601
“Failure of Clinical Practice Guidelines to Meet Institute of Medicine Standards”
www.ncbi.nlm.nih.gov/pubmed/23089902
This study was featured in Academic Emergency Medicine as one of their CME articles – theoretically, an article with additional value presented with incentives to motivate a closer reading of the content. I don’t mean to imply this is somehow a bad article – but it’s just interesting to step back out of the tunnel vision of statistics and boggle at the inadequacy of the current state of medicine.
This is a prospective study of patients evaluated for pulmonary embolism attempting to evaluate how many patients were “inappropriately” scanned. This definition of “inappropriate” scanning was determined by patients who were either PERC negative or had low-risk Wells’ score followed by a negative d-Dimer. Overall, of 152 patients, 11.8% were ultimately diagnosed with PE. However, the authors state that application of the PERC rule might have eliminated 9.2% of these scans while Wells’/d-Dimer would have obviated 13.8%.
While I certainly don’t discount the beneficial effect of even small reductions in the number of individuals evaluated for pulmonary embolism, these are still terrible numbers. 90% of CT scans for PE are negative? And using these decision instruments gets us to ~75% negative scans? This would be comically wasteful performance and innovative performance improvement in any other industry.
We pretty clearly need to do better.
“Overuse of Computed Tomography Pulmonary Angiography in the Evaluation of Patients with Suspected Pulmonary Embolism in the Emergency Department”
www.ncbi.nlm.nih.gov/m/pubmed/23167851/
This is the worst sort of paper – nuggets of truth mired in systematic flaws. There’s certainly no ill intent by the authors to mislead, it’s simply the nature of this sort of retrospective review.
The PROCAT consortium has been publishing studies of their post-arrest protocols for several years. They’re huge proponents of early coronary angiography following resuscitation for out-of-hospital arrest – and this is another in a string of articles demonstrating that patients going to coronary angiography after out-of-hospital arrest have improved outcomes. Of the 1274 patients in their cohort, 745 received early coronary angiography, 447 identified a culprit lesion, and 347 underwent PCI. The survival rate was 46% in patients undergoing PCI.
However, this number is conflated by other confounding variables known to be associated with good outcomes following cardiac arrest – coronary lesions are likely to be associated with VT/VF, which were also associated with good outcomes. Additionally, significantly more survivors received therapeutic hypothermia than non-survivors, illustrating the massive problem with viewing this sort of report with anything other than reasoned curiosity: rampant selection bias. Patients survived because they were selected for interventions based on individualized prognostic features, treatments were not applied evenly across the population.
There is absolutely a subset of OHCA that benefits from early coronary angiography – but this benefit should not be generalized to the inappropriate allocation of resources associated with taking all OHCA to the cath lab after resuscitation.
“Benefit of an early and systematic imaging procedure after cardiac arrest: Insights
This study attempts to address the question we’ve been asking ourselves since the dawn of antibiotics – does this child with a fever have a viral infection, or a bacterial infection? Of course, in reality, we should be asking a more complicated question – does this child have a viral infection, or a bacterial infection for which the increased likelihood of positive outcome with antibiotics outweighs the harms of the antibiotics? But, I digress.
One hypothesis that is bandied about in literature and practice is, if rapid viral testing were available in the Emergency Department, perhaps a positive viral test result would reduce the likelihood of antibiotic usage. These folks from Washington University performed viral PCR for a host of common viruses on 75 children with fever without a source, 15 children with probable bacterial infections, and 115 afebrile children presenting for outpatient surgery. The authors note the patients with bacterial infections were less likely to test positive for a virus – and suggest prospective trials might describe a strategy in which viral testing decreased antibiotic use.
In their cohort, 55% of children aged 2 to 12 months and 39% of those aged 13 to 24 months with no obvious source for fever received antibiotics. This is irresponsible lunacy. However, a much faster, cheaper way to decrease antibiotic use is: to simply return from the abyss of antibiotic overuse to a land of rational practice.
After all, 40% of the bacterial infections and 35% of the outpatient surgical patients tested positive for a virus – clearly indicating the presence of a virus has limited association with acute viral illness or absence of an acute bacterial infection. More tests are not the answer – at least, certainly not this battery of PCR tests.
“Detection of Viruses in Young Children With Fever Without an Apparent Source”
http://www.ncbi.nlm.nih.gov/pubmed/23129086