Category: Quality

All Hail the Female Resuscitationist

There has been more than one instance recently of observed associations between female gender and improved outcomes. Female physicians have lower rates of 30-day mortality and readmission rates for hospitalized elderly, and have better outcomes among female patients with acute myocardial infarction.

Now, another set of data showing improved survival after in-hospital cardiac arrest.

This is a retrospective review of 1,082 in-hospital cardiac arrests between 2005 and 2017 in which the gender of the code team leader could be ascertained. The minority – 30.2% – were led by a female physician. Location within the hospital, shockable rhythm, time of day, and patient age were similar between the male and female physician-led cardiac arrest cohorts. With male physicians, ROSC was 71.7% and survival to discharge was 29.8%, bested by female physicians with 76.8% ROSC and 37.3% survival. In a sample size this small, there are many potentially unmeasured confounders regarding the underlying health and type of arrest that may have contributed to the baseline likelihood of ROSC and survival – but this is still quite the interesting association.

Unfortunately, this brief analysis cannot tweeze out specifically why the female physician-led cohort had better outcomes. Their data set recorded compression depth and rate, and these were effectively the same – but they do not have medication use, timing, and other relevant attributes for evaluation. They make some further associations between physician and nurse gender, but the confidence intervals simply explode regarding whether any observed survival advantage may have occurred by chance alone.  I expect other inpatient cardiac arrest registries or databases may have more granular data to either confirm or refute this association – and, hopefully, if such an association continues to be observed, to better determine the practice patterns associated with any increased survival.

Lastly, it is reasonable to be concerned regarding publication bias relating to these such reports of gender-based outcomes.  It is probably editorially more interesting – and certainly seems more likely to get picked up by the lay press – to report associations favoring the female gender than the other way around.  Perhaps a bit more research seems warranted before condemning men to the scrap heap of history.  I hope, for my own sake!

“Female Physician Leadership During Cardiopulmonary Resuscitation Is Associated With Improved Patient Outcomes”
https://journals.lww.com/ccmjournal/Abstract/onlinefirst/Female_Physician_Leadership_During_Cardiopulmonary.96124.aspx

Five-Stars is Bad Medicine

In modern medicine, the patient is the customer. Medical services are customer services. Measures of patient – nay, customer – satisfaction are tied to reimbursement and, by association, contracts and employment. We’ve often remarked this perceived or overt emphasis on satisfaction is an incentive for bad medicine – specifically the “Where’s my Z-pack variety?”, and this is one of the few studies to actually show such an effect.

These authors reviewed three years of data from their direct-to-consumer telemedicine program and assessed the correlation between receiving a 5-star patient rating and various physician-related features. There were 85 physicians included across 8,437 patient visits for respiratory tract complaints, mostly sinusitis, but also pharyngitis, bronchitis, and “other” categories. While adjusted ORs showed a variety of small associations with 5-star service just barely clearing statistical significance, there were clear ORs favoring those who gave out candy. Antibiotics were provided in 66% of all visits, and the aOR for a 5-star rating was 3.23 (2.67-3.91) as compared to no antibiotic, and a non-antibiotic prescription bestowed an aOR of 2.21 (1.80-2.71). No other aOR exceeded 1.30, except the “free coupon” visits at 1.58 (1.31-1.90). They also noted it was not possible to be in the 90th percentile for patient satisfaction unless you were basically in the top half of antibiotic prescribing.

There were a couple physicians who were above the 50th percentile for patient satisfaction while maintaining some semblance of antibiotic stewardship. The authors do not provide any qualitative evaluation of those physicians but – thank you good sirs, please share your wisdom with us all.

“Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine”
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2705078

So Many Strokes, Oddly

There a fairly steady stream of occasional articles describing the evolution of stroke care in the U.S. These are typically pieces praising improvements tied to “Get With The Guidlines-Stroke”, describing decreases in overall stroke mortality, and the like. “Never better!” would probably be how most neurologists describe the current state of stroke care.

These impressions might be a bit of a rose-colored view of the elephant. This is just a simple descriptive analysis in trends for stroke, TIA, and ICH care in U.S. emergency departments and hospitals from 2006 until 2014.  A couple things of curiosity and/or concern stand out:

  • Annual in-hospital mortality from stroke has declined from ~5.8% to ~4.4%. This looks good until it’s noted annual total stroke admissions increased from 353,000 to 415,000. So, in an absolute sense, mortality hasn’t changed much – we’ve probably just been adding additional cases that wouldn’t otherwise have been diagnosed as stroke.
  • Costs of hospitalization for all diagnoses have almost doubled. For stroke, hospitalization charges have risen from a mean of $27,000 to $48,000. I’d love to chalk up the cost increase solely to the accompany increased frequency of use of our favorite clot-buster, but the relative cost increases are similar for TIA, as well.

The overall gist I get from these data is the value, overall, of our care for acute neurologic emergencies is diminishing. I’m certain we’re doing a much better job of post-stroke care these days for those who would truly benefit, but clearly we’re also sinking a lot more money into an expanding population where the average benefit is probably lower.  It’s shaping up to be an interesting race to see which aspect of healthcare can bankrupt our economy first.

“National trends in stroke and TIA care in U.S. emergency departments and inpatient hospitalizations”

https://www.ajemjournal.com/article/S0735-6757(18)30648-X/fulltext

Urgent Cares (and Emergency Departments and Medical Offices) Are the Worst!

This small research article has been making the rounds in the news over the last couple days. In theory, these findings supposedly surprising and enlightening – although to anyone in medicine, or who follows this blog, they are hardly profound.

This is a simple retrospective, cohort analysis of the Truven Health MarketScan Commercial Claims and Encounters Database, which pools de-identified data from patients with employed-sponsored health insurance. In this study, they simply chopped up claims for office, urgent care, retail clinics, and emergency department visits. They publish rates of antibiotic use for various coded discharge diagnoses, again, chopped into categories of “antibiotic almost always indicated” (e.g., urinary tract infection), to “antibiotic may be indicated”, to “Antibiotic-inappropriate” (e.g., influenza, bronchitis).

The numbers get ugly in this latter category, and reflect least favorably on urgent care clinics. Rates of antibiotic prescribing for viral upper respiratory infection and bronchitis, for example, were 41.6% and 75.8%, respectively. This is obviously pathetic, and urgent care centers are rightfully taking heat for this, but neither the ED nor the medical offices deserve much credit, either. The ED was at 18.7% and 56.6%, and offices were at 29.9% and 73.1%, for viral URI and bronchitis, respectively. Retail clinics were not great, but certainly better, at 10.5% and 31.1%.

Of course, these are coded diagnoses and do not always fairly reflect the underlying clinical presentation or diagnosis. And then there’s this:

“We used facility codes but could not validate whether facilities were actually urgent care centers, retail clinics, EDs, or medical offices.”

When the crux of the study pits these different types of facilities against each other, that’s probably somewhat important.

“Comparison of Antibiotic Prescribing in Retail Clinics, Urgent Care Centers, Emergency Departments, and Traditional Ambulatory Care Settings in the United States”

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687524

tPA in Under 20 Minutes is Recklessness

In my book, “safe” translates to a lack of attributable harm. Therefore, going as fast as possible while still claiming safety – should mean no excess harms resulting from the rush.

There’s no way to precisely tell whether or not this is the case here in Helsinki, where the stroke neurologists have cut their door-to-needle time for thrombolysis to under 20 minutes. The results as described here, however, are not promising, and the authors agree with my impression:

“Our findings support the safety of highly optimized door-to-needle times.”

Ha ha! Of course they don’t.

This is a retrospective review of 1,015 stroke code patients arriving over a two-year period between 2013 and 2015. This institution, incorporating elements of pre-hospital assessment into their initial evaluation, have had door-to-needle times below 20 minutes since 2011. How do they perform?

Of the 1,015, there were 150 (14.8%) patients with misdiagnosis on the initial assessment. Of these, 90 were ultimately diagnosed with a stroke mimic, 59 were eventually diagnosed with a stroke or TIA, and one small basal ganglia hemorrhage was missed. These initial misdiagnoses led, as you might imagine, to both unnecessary treatment and delays to the correct treatment. The most profound effects of these delays were in the context of stroke mimics, whose median delay until a correct diagnosis was 39 hours. Thirteen stroke mimics received thrombolysis, and diagnostic inertia from the initial misdiagnosis led 13 more to have median delays of up to 56 hours for the initiation of condition-specific treatment.

Now, there are limitations here that likely tilt these statistics in favor of the institution. There is no described standard follow-up evaluation to confirm cerebral ischemia, and likely some of those with TIA (146 patients) or who received tPA (331 patients) and improved could further be lumped in with the stroke mimics based on their clinical evaluation and whether they ever underwent MRI. Conversely, even though these authors are speeding headlong in order to give tPA, we can’t actually attribute all these misdiagnoses to their rushed evaluation. It is likely some of these cases would remain clinically challenging, even with a few extra minutes of careful consideration.

However, if they are trying to prove their implementation is safe, this comparison group is exactly what is necessary. They’ve shown their protocol is results in a substantial number of misdiagnosis and documented patient harms; the onus is on this team to prove their pursuit of a handful fewer minutes to tPA is not a contributing factor.  Finally, any possible advantage to shaving a handful of minutes off door-to0-needle times pales in comparison to these obvious misses.

“Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes”
http://n.neurology.org/content/early/2018/07/11/WNL.0000000000005954

More Snapshots of Awful Antibiotic Use

Is there ever any good news these days? Geopolitical disasters, unwarranted pharmaceutical price increases – and physicians can’t even manage to get the evaluation for group A strep right.

This is a “successful” quality improvement paper wrapped around depressing and embarrassing data from a typical primary care pediatrics practice. These authors, primarily pediatric infectious disease specialists, were dismayed by the rate of guideline-non-compliant group A streptococcal testing and treatment in their group.

How bad?

The base rate of unnecessary GAS testing was 64% of all rapid strep tests performed. The base rate of inappropriate antibiotic prescribing – driven primarily by treating positive results in those who should never have been tested (e.g., likely non-pathogenic colonization) – was 49%.

After their multifaceted year-long intervention, they were able to achieve the amazing results of: 40% unnecessary testing … and the same, inappropriate 49% for antibiotic prescribing. When restricted to selection of antibiotic, at least, first-line antibiotics used 87% of the time.

Is this really the best we can possibly do, even after intent focus on practice improvement? And for a disease entitiy with such limited benefit for antibiotic in most modern settings?

“Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative”
http://pediatrics.aappublications.org/content/early/2018/06/18/peds.2017-2033

Comparing Unnecessary ED Chest Pain Testing

Since my last post regarding the disutility of coronary CT angiograms for the evaluation of acute chest pain in the Emergency Department was so popular, here’s more: a randomized trial testing CCTA versus stress echocardiogram.

The problem: no specific functional or anatomic testing is routinely necessary in the ED.

And, hidden in this comparison are broad results typical of testing in a “low to intermediate” population with a Diamond-Forrester pre-test probability of 28% and a TIMI score of 0 to 1. Effectively, it’s unimportant to describe their comparison because the incidence of their safety outcomes over a median follow-up of 733 days is so low its virtually impossible to detect a difference. Any Major Adverse Cardiovascular Event occurred in only 4.5% of all patients – but, restricted to the endpoints relevant to the testing performed, only 3.0% had a nonfatal myocardial infarction or cardiac arrest. Any differences in throughput and resource utilization between arms will be related to specific process and protocol implementation unique to the trial institution, so even their findings with respect to their primary outcome are not likely to be generalizable.

But, back to the futility of any test – only 10% of those enrolled were referred for cardiac catheterization, and only half of those received an intervention as a result. Another 10% or so received new or increased pharmacotherapy – likely overlapping with the population undergoing catheterization. Therefore, probably 85% of patients enrolled clearly received no specific benefit from these tests, 5% probably had some benefit, 5% were harmed (excess revascularization, serious complications), and 5% are equivocal.

And, all of this on the foundational premise these tests need to be performed widely, and in the ED. True disease is rare in this population, and the timeliness of diagnosis of CAD does not need to be made at the index visit. This is not high-value medical care.

“Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain: A Randomized Controlled Trial”

https://www.ncbi.nlm.nih.gov/pubmed/29909113

Treating Influenza with Antibiotics & Other Stories

Every time I review an article espousing the benefits of a protocol based on the use of procalcitonin to improve antibiotic stewardship, I usually say something along the lines of: “We don’t need this test, it only looks like we need it because our baseline antibiotic prescribing is hysterically shameful.”

Well, here’s another piece of evidence describing the basis for that statement.

This is a secondary analysis of observational data collected from the Influenza Vaccine Effectiveness Network. All patients were eligible for inclusion in the study if they presented with an acute cough of duration fewer than 7 days. Patients all received influenza testing as part of disease surveillance, as well as any other testing indicated.

Of 14,987 patient visits analyzed, 6,136 (41%) were associated with an antibiotic prescription. Of these, 2,494 patients (52%) received diagnoses for “potentially indicated” antibiotics – pharyngitis, sinusitis, and otitis media – while 2,522 (41%) fell into a category of “antibiotics not indicated” – viral upper respiratory infection, bronchitis, allergy or asthma, clinical influenza, or “other”. So, as far as the coded diagnosis is reliable, it is likely half of prescribed antibiotics are simply unnecessary.

Then, of the 14,987 analyzed, 3,381 had laboratory-confirmed influenza. Excluding those receiving a diagnosis of pneumonia, there were 945 who received a prescription for antibiotics. Finally, there were an estimated 860 patients with a diagnosis of pharyngitis and a negative test for Group A Strep, 327 (38%) of whom received antibiotics.

And, let’s not even get into whether patients received an appropriate narrow-spectrum antibiotic (44%).

There are limitations to the precision and clinical context of using diagnosis codes to classify antibiotic prescribing as appropriate or not, but these results are broadly consistent with the prior literature.  Before we start deferring our prescribing decisions to something like a PCT assay, there’s a huge opportunity to simply Do The Right Thing, first. Once the low-hanging fruit has been resolved, then we can worry about tweezing out the uncertain cases in a narrow cohort with potential limited application of PCT or other infectious disease differentiation engine.

“Outpatient Antibiotic Prescribing for Acute Respiratory Infections
During Influenza Seasons”
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2683951

That Time Dermatology Saved the Day!

Thanks to the insightful teaching of Seinfeld, we know dermatology’s scope exceeds that of “Pimple Popper, MD“. However, when an article published reviewed the rate of misdiagnosis of cellulitis in the hospital, pegged the costs half a billion dollars per year, and suggested a dermatologist be involved in every case where the skin ain’t look right – I was skeptical.

This publication details the results of a trial in which patients admitted with a diagnosis of cellulitis were randomized to either consultation of with a dermatologist within 24-hour of admission or to routine medical care. And, by consultation with a dermatologist – actually just one dermatologist, the senior author on the paper. Over the five year-study period, this dermatologist screened 1,300 patients for potential inclusion, yielding 175 for randomization. The primary outcome, a little unclear from the clinicaltrials.gov registration, is either antibiotic usage or inpatient length-of-stay.

Regardless, the dermatology consultation appeared to improve medical care, although the magnitude of the benefit is more difficult to pin down. The dermatologist identified approximately an excess of one-quarter of the cases to be “pseudocellulitis” – venous stasis dermatitis, erythema migrans, contact dermatitis, or some such ilk – leading to changes in therapy based on misdiagnosis.  Both length-of-stay and antibiotic-free days displayed modest absolute gains in those evaluated by dermatology. The author further tabulated her other recommendations for treatment, including wound care, steroid treatment, and additional testing, and suggests there are many peripheral benefits to specialist involvement.

This is all fairly reasonable at face validity, although it is nearly impossible to generalize this single-institution, single-dermatologist, low-enrollment study to general practice. Given the scarcity of dermatology specialists in many settings, it would take some substantial innovation to find a cost-effective and high-value protocol for utilization.

“Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis”
https://jamanetwork.com/journals/jamadermatology/fullarticle/2672582

Anti-Calcitonin

The use of procalcitonin to guide antibiotic therapy has been gradually increasing over the past several years – driven, in no small part, by increased recognition of the harms of antibiotic overuse. However, what evidence we have regarding its utility is primarily derived from manufacturer-sponsored trials – including virtual carpet-bombing of the literature by their sponsored representatives.

So, what happens when the manufacturer isn’t part of the trial?

No benefit.

This is the ProACT trial, an individual-randomized comparison between a procalcitonin-guided arm and “usual care” in patients with suspected lower respiratory tract infection for whom the indication for antibiotics is unclear. Physicians caring for patients randomized to the procalcitonin arm were provided results tied to antibiotic use recommendations – “strongly discouraged”, “discouraged”, “encouraged”, “strongly encouraged” – on initial presentation in the Emergency Department, and then in serial fashion for those admitted to the hospital. In those in the “usual care” arm, procalcitonin results were obtained, but not provided to the treating clinicians.

Then: Across 14 hospitals and 1,656 patients, there were no statistically significant differences between antibiotic-free days or adverse outcomes between the two arms. Done? Done.

Except, as skeptical as I might be regarding procalcitonin-guided therapy, there are big holes in these data as the definitive word on its disutility. Unlike other trials, these centers provided only passive guidance to clinicians regarding the procalcitonin algorithm. This resulted in only 72.9% of physicians adhering to protocol, with the greatest numbers of violations being antibiotic use in patients for whom it were discouraged, including 30% of those for whom antibiotic use was “strongly discouraged”:

Even though the “per-guideline” analysis also shows no difference, this is mostly because the bulk of the procalcitonin “per-guideline” population were those who appropriately received antibiotics – effectively eliminating the possibility of showing a difference in antibiotic use.

There are a few signals within these data reflecting the potential advantages of a procalcitonin-guided algorithm, should the protocol actually be followed. There were small differences in prescribing favoring the procalcitonin arm for almost every final clinical diagnosis – excepting about 15% absolute advantages for “acute bronchitis” and for those with non-specific diagnoses. It is likely these represented the cases for which the appropriateness of antibiotics was lowest, and probably also represent the majority of protocol violations. That said, one could easily make the argument this advantage only exists as a result of culturally-ingrained poor antibiotic prescribing habits for these sorts of borderline cases.

In short, these data clearly show there is no advantage to introducing procalcitonin into practice specifically in the fashion demonstrated here – but these cannot be generalized to say a different implementation or application of procalcitonin has no value.  On the flip side, however, places that have implemented procalcitonin-driven stewardship programs also struggle with inappropriate and high-volume test ordering.  There is work yet to be done for both proponents and skeptics of its value.

“Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection”
https://www.nejm.org/doi/full/10.1056/NEJMoa1802670