Emergency Medicine Literature of Note
Musings on Emergency Medicine, Clinical Informatics, & High-Value Care.
My newest publication, e-published today in the Emergency Medicine Journal of the British Medical Journal.
Currently requires an institutional subscription.
“CT coronary angiography: new risks for low-risk chest pain”
http://emj.bmj.com/content/early/2012/11/07/emermed-2012-201795.abstract
The National Hospital Ambulatory Medical Care Survey is a massive database of abstracted patient records, systematically generated to produce a representative sample of the nation’s Emergency Department visits.
It should come as no surprise that retrospectively abstracted data from the electronic medical record sometimes fails to accurately reflect patient care. The important question, however, is “how often?” This review of NHAMCS by one of the Annals editors looked at a measurement that ought to be pretty obvious – intubation. If you can’t figure out whether a patient has been intubated via chart review, there’s some serious issues with your data sourcing. However, in this review of NHAMCS, the author interprets up to one in four charts as being potentially inaccurate due to inconsistencies between documented intubation and the final disposition of the patient (e.g., non-ICU settings, home, observation status, etc.)
Now, there are some instances in which patients are intubated in the Emergency Department – yet not subsequently dispositioned to a critical care or morgue – but these “temporary” intubations certainly do not constitute 25% of intubations. The author goes on to note that Annals publishes a NHAMCS study at least twice a year – relatively influential towards practice given the Impact Factor – and the flaws in this data should limit the relative weighting of its importance.
“Congruence of Disposition After Emergency Department Intubation in the National Hospital Ambulatory Medical Care Survey”
I work at one of only two trauma centers in a city of four million potential patients, and I have firsthand experience with this issue. The issue is to determine the best management strategy for patients with mild traumatic brain injury and bleeding. We already know what to do with major bleeding – but patients with minor bleeding are a little more of a dilemma. They almost universally do well, but we observe them and repeat tests on nearly all of them.
This is a retrospective review of 36 months of trauma admissions to a level one trauma center in New Jersey, trying to describe the natural progression of mild traumatic intracranial bleeding. Historically, 1/3rd of these patients have bleeding that progresses, but only 1-3% will require neurosurgical intervention. This review found 341 patients with mild injuries and bleeding, and noted that 69% of these patients had no interval change in head CT results when repeated at 24 hours. Of the remaining patients, either no CT was performed (25 patients) because the injury was too insignificant or there was interval progression – including 11 patients who received neurosurgical intervention. But, the point of the article is generally supposed to be shown in Figure 2 – estimating the number of ongoing hemorrhages at each time point in the first 24 hours. Essentially, >80% of the bleeding ceases to expand within the first few hours from injury.
This is a useful jumping off point to perform the sort of work that isn’t featured in this article – characterizing the characteristics of patients and bleeding that progresses. If patients with bleeding unlikely to progress can be safely discharged rather than being observed for interval CT, this is a useful reduction in ED length of stay, observation admissions, or CT use.
“The temporal course of intracranial haemorrhage progression: How long is observation necessary?”
www.ncbi.nlm.nih.gov/pubmed/22658418
This is a survey of the top twelve Emergency Medicine journals, as ranked by impact factor, providing a descriptive analysis of the features of the studies contained within. The authors manually reviewed 330 articles and found a mere 8.8% were randomized studies. Most (65.5%) were cross-sectional studies and 23.6% were cohort studies. 57.3% were prospective, 47.9% were from the U.S., and the minority of studies (31.2%) used informed consent or mentioned waivers of informed consent.
Compared with other fields, the surveyed EM literature was less likely to mention IRB approval, less likely to be prospective, less likely to be blinded and controlled, and enrolled fewer patients per study.
There are many barriers to research in the Emergency Deparment – particularly prospective, randomized, controlled research. However, the establishment of an office for emergency services research at the National Institutes of Health may improve the ability of U.S. researchers to obtain grant funding.
Of course, this will then only exacerbate the bias inherent in the already U.S.-centric published literature.
“Quality of publications in emergency medicine”
This is a lovely feature piece in the BMJ concisely detailing that surging occult demon consuming healthcare resources under the guise of “improved health” – overdiagnosis. It’s really quite lovely to see the cultural changes coming in medicine, where increasing awareness of costs in the face of questionable benefit will reshape our profession in the years to come.
These authors, from Australia, describe twelve categories of “disease” that are expanding without obvious clinical benefit, as well as a brief overview of the sorts of practices that drive overdiagnosis. It’s a bit of a lead-in to next year’s conference, Preventing Overdiagnosis, at Dartmouth University.
The entire article is worth reading, but I thought their table with the drivers of overdiagnosis was a nice summary:
This NEJM study published a couple days ago addresses the effect of funding and methodological rigor on physicians’ confidence in the results. It’s a prospective, mailed and online survey of board-certified Internal Medicine physicians, in which three studies of low, medium, and high rigor were presented with three different funding sources: none, NIH award, or industry funding.
Thankfully, physicians were less confident and less likely to prescribe the study drug for studies that were of low methodological quality and were funded by industry. Or, so I think. The study authors – and the accompanying editorial – take issue with the harshness with which physicians judge industry funded trials. They feel that, if a study is of high methodological quality, the funding source should not be relevant, and we should “Believe the Data“. Considering how easy it is to exert favorable effects on study outcomes otherwise invisible to ClincalTrials.gov and the “data”, I don’t think it is safe or responsible to be less skeptical of industry-funded trials.
Entertainingly, their study probably doesn’t even meet their definition of high rigor, considering the 50% response rate and small sample size….
“A Randomized Study of How Physicians Interpret Research Funding Disclosures”
www.ncbi.nlm.nih.gov/pubmed/22992075
Falling into the “well, duh” sort of category that cuts through the dogmatic haze, this article examines the ordering of post-reduction radiographs in the Emergency Department.
Specifically, this group of orthopedists from New York City looks at X-ray utilization and length-of-stay after consultation and management of minimally displaced, minimally angulated extremity fractures. They note that, of 342 fractures meeting study criteria, 204 of them subsequently received post-splinting radiography. They note that none of the patients receiving post-reduction radiography had any change in alignment or change in splint application, and this practice resulted in significantly longer ED length-of-stay.
This leads them to their conclusion that minimally displaced, minimally angulated extremity fractures that do not receive manipulation when splinting should not be re-imaged after splint application. And, this seems like a fairly reasonable conclusion. It’s retrospective, the outcomes are surrogates for patient oriented-outcomes, etc., and it would be reasonable to re-evaluate this conclusion in a prospective trial – but if your practice is already to not routinely re-image, this supports continuing your entirely reasonable clinical decision-making.
“Post-Splinting Radiographs of Minimally Displaced Fractures: Good Medicine or Medicolegal Protection?”
http://jbjs.org/article.aspx?articleid=1356145
This article made the rounds a couple weeks ago in the news media, probably based on the conclusion from the abstract stating “efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population.”
They base this statement off a retrospective review of prospectively gathered standardized data from in-hospital cardiac arrests. Comparing 31,000 patients with ROSC following an initial episode of cardiac arrest with a cohort of 33,000 who did not have ROSC – the authors found that patients who arrested at hospitals with higher median resuscitation times were more likely to have ROSC. Initial ROSC was tied to survival to discharge, where hospitals with the shortest median resuscitation time having a 14.5% adjusted survival compared to 16.2% at hospitals with the longest resuscitations.
Now, if you’re a glass half-full sort of person, “could improve survival” sounds like an endorsement. However, when we’re conjuring up hypotheses and associations from retrospective data, it’s important to re-read every instance of “could” and “might” as “could not” and “might not”. They also performed a horde of patient-related covariates, which gives some scope of the difficulty of weeding out a significant finding from the confounders. The most glaring difference in their baseline characteristics was the 6% absolute difference in witnessed arrest – which if not accounted for properly could nearly explain the entirety of their outcomes difference.
It’s also to consider the unintended consequences of their statement. What does it mean to continue resuscitation past the point it is judged clinically appropriate? What sort of potentially well-meaning policies might this entail? What are the harms to other patients in the facility if nursing and physician resources are increasingly tied up in (mostly) futile resuscitations? How much additional healthcare costs will result from additional successful ROSC – most of whom are still not neurologically intact survivors?
“Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study“
www.thelancet.com/journals/lancet/article/PIIS0140…9/abstract
In a survey of U.S. physicians, published in Archives of Internal Medicine, Emergency Physicians hold the dubious honor of being the most “burned out” specialty. This estimation of burnout is based on survey questions regarding emotional exhaustion, depersonalization, and personal accomplishment. Unsurprisingly, dermatology was not a terribly burned out specialty – likely because they also ranked quite highly in time for personal and family life. Surgical specialties, despite ranking at the bottom for family life, were only in the middle of the road for burnout – probably indicating the nature of the work plays a role in the strain. Self-selection bias always plays a role in these surveys, of course, considering the response rate was only 26%.
Compared with the employed general population, physicians were more burned out and had less time for family – which may or may not be related to the 25% more hours per week worked, although, there were many differences between the physician cohort surveyed and the comparison.
The New York Times discusses this article and uses a vignette of a “missed diagnosis” as symptomatic of the disruption of quality of care due to burnout. While it may be true that burnout relates to healthcare quality, the specific case presented seems to fall more into a category of reasonable conservative management of the most likely condition, with appropriate further enquiry made at a re-visit due to persistent symptoms.
“Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population”
http://archinte.jamanetwork.com/article.aspx?articleid=1351351
Jeremiah Schuur, featured on EM Lit of Note for his timely critique of the inadequacy of the “quality” measure for non-contrast head CT, passes along a notification of a pre-ACEP conference in ED infection control practices.
Sponsored by AHRQ, ACEP, and infection control societies, find more information about the conference here: