Category: Quality

Big Pharma Is Behind The Money Hemorrhage

This is a research letter from the Archives of Internal Medicine that received a good deal of press recently, examining exactly where in the health system we were wasting money.

They focused on the ambulatory setting, used the NAMCS/NHAMCS database, and evaluated for the activities identified in the “Good Stewardship Working Group” identified by consensus to be low-yield and unnecessary.  They considered this to include antibiotics for afebrile/non-strep pharyngitis, routine EKGs, CT and MRI for uncomplicated low back pain, DEXA scans for young women, etc.  And they found – and this is where the big story comes in – $6.7 billion in these consensus not-recommended activities.

Fortunately for our Internal Medicine and Family Medicine colleagues, they actually weren’t ordering a lot of unnecessary tests – $175 million for low back pain and $527 million for DEXA are a lot of money, but still a drop in the bucket.  The majority of the unnecessary activities, $5.8 billion of the total $6.7 billion, was writing for a brand-name statin (atorvastatin or rosuvastatin) instead of one of the generics.

Certainly just the tip of the iceberg.  Drug reps are more than earning their salaries, apparently.

“‘Top 5’ Lists Top $5 Billion”
http://www.ncbi.nlm.nih.gov/pubmed/21965814

Computers – Probably Better Doctors for UTI

Uncomplicated urinary tract infections are probably one of the diagnoses that Emergency Physicians handle the worst – if they come to the ER, they’re likely to get some sort drawn-out testing, whereas, if they went to their regular physician or called the nurse hotline, there would be antibiotics waiting for them at the pharmacy before they finished talking.

This is a prospective study in which patients with possible UTI were referred to a triage kiosk to complete a standardized computer questionnaire.  624 patients with possible UTI interacted with the kiosk – and unfortunately, only 103 qualified for the study by having enough features of typical, low-risk illness.  Patients were then randomized to protocolized antibiotic prescription as reviewed by a triage physician or usual care.

The good news – the kiosk saved a lot of time (89 minutes vs. 146 minutes).  The bad news – there were only 41 patients  followed-up in the intervention group and 26 followed-up in the control group, so we end up with only a tiny number of patients in each arm.  The kiosk group received more antibiotics for negative urine cultures than the control group (93% vs. 67%), so there is some additional element of harm secondary to antibiotic exposure – and, with a limited protocol, there are potential misses – and this study isn’t large enough to identify them.

But, really, uncomplicated, typical UTI symptoms in women shouldn’t be rocket science – and you shouldn’t necessarily be doing any testing.  I would say the computer is a better physician – except, it would be absolutely simple for a physician to simply narrow their approach to match the efficiency of the kiosk with, in theory, some added skill.

“A Randomized Trial of Computer Kiosk–expedited Management of Cystitis in the Emergency Department”

Predicting Deterioration After Admission

This is a decidedly unsexy topic that I guarantee your Medical Director or QI committee cares about a lot.  Particularly where I work, we occasionally have a prolonged boarding event, the patient isn’t reassessed in a certain time frame, the patient is transported out of the ED – and they arrive on the floor or step-down and Rapid Response is called for an unanticipated escalation in care.

This is apparently a bigger deal in the United Kingdom, because it is recommended by their government hospital body to employ a risk-stratification system to predict patient deterioration.  These two articles discuss the derivation in the UK and the validation in Canada of the “ViEWS” score, which is named in part by from their electronic health record that stores their physiologic data.  The general gist of the system is that the authors of the first article derived a score incorporating pulse, respiratory rate, temperature, systolic BP, O2 saturation, whether patient was on oxygen, and a measure of CNS alertness.  They then compare it do several other scoring systems and amazingly enough, the scoring system they derive – using the system from the company the authors’ wives work for and in which they own shares of stock – works better than the other systems.

An abbreviated version of this is put into validation at a Canadian hospital that does not use any of the equipment, or have any financial conflict of interests.  They found equally good results – which, in summation they give as four risk-stratification groups:
 – < 3 points: 65% of all patients, only 0.02% died within 48 hrs.
 – 3-6 points: 28% of all patients, 0.41% died within 48 hrs.
 – 7-10 points: 6% of all patients, 3% died within 48 hrs.
 – >11 points: 0.7% of all patients, 13.8% died within 48 hrs.

So, yes, we all can probably look at the patients scoring >11 and know they’re sick without a scoring system.  However, this might be a model to look at with nursing staff to help change the parameters for floor beds or to reassess which patients can be downgraded in order to free up more intensive resources upstairs.  Just don’t necessarily buy the product being hawked by the original authors.

“ViEWS—Towards a national early warning score for detecting adult inpatient deterioration.”
www.ncbi.nlm.nih.gov/pubmed/20637974

“Validation of an abbreviated VitalpacTM Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian Regional Hospital”
www.ncbi.nlm.nih.gov/pubmed/21907689

Medication Errors During Resuscitation

According to previous literature from 2002, up to 19% of medication doses are administered in error to hospitalized patients.  Presumably, we’ve improved.

Apparently, we haven’t.  This is a prospective observational study by pharmacists in Pittsburgh who observed the inpatient Medical Emergency Team in operation – which in this instance, was a physician-led team with “full” critical care capabilities, as opposed to their non-physician Rapid Response Team.  They observed medication administration during 50 of these calls and found that there were 1.6 errors per medication administration.  Yes, they really observed more than one error per dose – but 66% of those issues involved aseptic technique.  Subtracting those, they observed an error merely every other dose.  46% were prescribing errors, 28% administration technique, 14% mislabeling, 10% preparation, and 2% improper doses.  The authors eventually conclude that 14% of the total non-aseptic errors were truly harmful, not just “errors”.

Despite the small sample size, I think it’s a fair assessment that “medical emergency” situations can be chaotic and error-prone – and we still have a ways to go to implement systemic changes to prevent errors.

In the end, the pharmacists’ solution is – more pharmacists.  Hmmm….

“Medication Errors During Medical Emergencies in a Large, Tertiary Care, Academic Medical Center”
www.ncbi.nlm.nih.gov/pubmed/22001000

Do/Don’t Scan the Trauma Patient

In a study attempting to build consensus, they discovered philosophical differences between the trauma team and the emergency physician.

This is a prospective observational study in which 701 blunt trauma activations at LAC-USC were enrolled, with the EP and the trauma team each giving an opinion on which CT studies were necessary.  The authors then reviewed which scans were obtained, sorted out the scans that were undesired by one or both physicians, and determined whether any injuries would be missed.

Bafflingly, 7% of the 2,804 scans obtained during the study period were deemed unnecessary by both the emergency physician and the trauma attending – yet were still performed.  The remaining 794 undesired scans were desired by the trauma team but not the emergency physician.  Their question – would anything of significance been missed if the scans had been more selectively ordered?

The answer is – yes and no.  The trauma surgeon authors state yes, and justify that by saying that many of the abnormalities missed on CT required closer monitoring – just because none of the missed injuries deteriorated during the study period does not mean they were not significant.  The emergency physician authors point to a 56% reduction in pan-scanning, the benefits of radiation and cost reductions, and hang their hats on the fact that none of the hypothetically missed injuries changed management.

So, who is right?  Both, and neither, of course.  Emergency physicians and trauma teams should work on developing evidence-based clinical decision rules to support selective scanning in blunt trauma – and then try this study again to see if they can generate results they can agree on.

Definitely a fun read.

As far as medical literature goes, of course.

“Selective Use of Computed Tomography Compared With Routine Whole Body Imaging in Patients With Blunt Trauma.”
www.ncbi.nlm.nih.gov/pubmed/21890237

EMS Blood Pressures Aren’t Unreliable

Ever since a trauma patient billed as normotensive with stable vital signs rolled off the elevator with CPR in progress having “just lost pulses”, I’ve been somewhat skeptical of my prehospital report, including vital signs.  This study, at least, supports a position that, barring untruthfulness, EMS providers vital signs are usually not clinically significantly different than vital signs obtained on arrival to the Emergency Department – even if observed techniques for EMS providers weren’t perfect.

The first phase study looked at 100 patients arriving in the Emergency Department.  BP measurements were obtained within 5 minutes of arrival, and compared to the reported measurement from EMS.  There was approximately a 17mmHg +/- spread to the systolic pressures measured by EMS compared to the first BP in the Emergency Department.

The second phase of the study had observers riding with EMS and documenting the technique at which they used to find vital signs – and then having the research assistants performing the same measurement in the field as well.    In this phase, EMS providers systolic pressure was only a 10.1mmgHg +/- spread away from the research assistant – despite having ideal technique deficiencies and a terminal digit preference for numbers ending in zero.

The article concludes that EMS providers measurements had poor agreement with subsequent measurements, and that the differences were clinically significant.  However, based on the distribution of error in their Bland-Altman plots, I disagree that assessment, as most of the variability occurred throughout a range of inconsequential systolic pressures between 120 and 170.  They unfortunately had very few patients with clinically important hypo- or hypertension, so the question really remains unanswered whether EMS measurements at the clinically important extremes are reliable.

I do find it rather entertaining that their methods included a “specially trained research assistant” to measure blood pressure, referred to in the title as an “expert”.  You can be an “expert” in anything nowadays, apparently.

“Agreement between emergency medical services and expert blood pressure measurements.”
www.ncbi.nlm.nih.gov/pubmed/21982624

Stroke After-Care Is Far More Important

Somewhere in the rush to but up billboards and focus the medical establishment on experimental revascularization interventions for acute stroke (e.g., time is brain), we’ve overlooked what truly matters – follow-up care after the ischemic event.  This is a lovely study that reminds us of what we probably knew once, but have forgotten – that even in the absence of acute therapy, simple protocols to prevent fever, prevent hyperglycemia, and prevent aspiration pneumonia lead to profound differences in the number of patients with zero or minimal disability after stroke.

This is a prospective interventional study in which acute stroke units in New South Wales Australia were randomized to either no protocolized intervention, or an intervention with nursing protocols named above.  At the end of the three-year intervention period, 42% of the control group had mRS 0 or 1 at 90 days, and 58% of the intervention group had mRS 0 or 1 at 90 days.  There were small differences in the type of stroke, education level, and prior ability to work that probably favored the intervention group, but the differences at baseline were far smaller than the magnitude of the treatment effect.  In short, a basic nursing protocol intervention improved outcomes more than any other intervention for acute stroke.

“Implementation of evidence-based treatment protocols to manage fever, hyperglycemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial.”
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61485-2/fulltext

Lack of IV Access, Harbinger of Death

Interesting observational study of 56,332 patients picked up in an EMS system in King County, looking at IV access and outcomes.

For reasons they don’t look into in this study, they find that IV access is an independent predictor of decreased in-hospital mortality.  Not for the less-acute patients, but for patients of high-acuity, lack of IV access shows a pretty significant trend towards poor outcomes.  They don’t look at fluid therapy, medication therapy, etc. as confounding variables – so we don’t know what it is specifically about IV access that confers a survival advantage.

They do a brief breakdown of the systolic blood pressure and the percentage of patients receiving IV access, and, as expected, more IVs are attempted at the extremes.  This leads me to believe there are patients who were high acuity, required IV access, but had failed IV access attempts – but there’s no data on that either.

This is a study that could end up telling us something, or nothing.  Interesting, nonetheless.

“Intravenous Access During Out-of-Hospital Emergency Care of Noninjured Patients: A Population-Based Outcome Study”
http://www.ncbi.nlm.nih.gov/pubmed/21872970

We’re Covered in Filth

This is not the first study showing physician white coats and nursing uniforms are colonized with bacteria, nor that may of those bacteria are pathogenic and multi-drug resistant.  In the past, this has been used as a call for the abolishment of physician white coats, ties, and all long-sleeved apparel.

This study, however, shows that short-sleeved nursing uniforms were just as likely to be coated with bacteria – 49% to 54%.  Interestingly, even “changing uniform daily” still resulted in colonization with pathogenic bacteria.  The authors speculate the main issues are that all textiles easily transmit bacteria, and that hand hygiene might be more critical than uniforms in prevent transmission from patients to physician clothing.

This study also, like the many before it, doesn’t demonstrate anything but colonization – not documented patient-to-patient transmission via healthcare worker clothing or any specific outcome measures.  However, I am a believer that white coats are fomites and medical relics that should go the way of bloodletting and golden elixirs. The studies in support of white coats cite patient satisfaction and ease of identification of roles – which, while important, could be mitigated by new interventions for identification of healthcare providers.  Even though we yet have no evidence of harms from this colonization with pathogenic bacteria, it’s essentially a zero-cost intervention to stop wearing white coats and ties – so even if the number needed to treat to prevent a transmissible infection is immense, it’s a free way to protect our patients as best we can.

“Nursing and Physician Attire as Possible Source of Nosocomial Infections.”
www.ncbi.nlm.nih.gov/pubmed/21864762

CMS ED Quality Measures Are Coming

When the government is the largest healthcare payor, you pay attention when they start measuring “quality” – because it’s usually not long after that payments are tied to “quality”.

This is an Annals study looking at the pilot reporting program from CMS, which includes seven metrics that hospitals are going to have report in the next two years.  These metrics are:
 – Throughput time for admitted patients.
 – Throughput time for discharged patients.
 – Admit order to bed placement for admitted patients.
 – Time to pain management for long bone fractures (discharged and admitted)
 – Time to chest x-ray after order placed (discharged and admitted)

I love the pain management metric.  The literature that supports how poorly ED physicians manage pain is extensive.  Not a day goes by where have a resident trying to give a 2 milligram dose of morphine to treat acute pain.  The other metrics – well, so, faster is more and more is better, so therefore more, faster is “quality”, right?  Well, there are some studies that show improved outcomes when patients reach the floor more rapidly, so, perhaps that’s what they’re getting at.  I don’t know if we’ll ever really know how improving these measures affects quality, because there are so many other confounding variables affecting these issues.

What is good about these metrics is that it should make a lot of EDs re-examine their processes and see how they can maximize the resources they have.  But, after the low-hanging fruit, you run up against issues of physical and financial resources – many of which are hospital-wide issues.  It will be interesting to see how our workplace changes in response to this.  Unsurprisingly, academic centers and busy EDs had the worst throughput statistics; not sure about magical solutions there.

“A Field-Test of Time-Based Emergency Department Quality Measures.”
www.ncbi.nlm.nih.gov/pubmed/21868129