Category: Quality

ED Recidivism And/Or “Quality”

I’ve only worked in a handful of Emergency Departments – but at each institution, 72-hour Emergency Department recidivism has been tracked.  The simple act of bothering to track such events implies a very simple conclusion: these revisits somehow reflect poor care, missed diagnoses, or other opportunities to prevent return visits.  At a minimum, it’s best not to be an outlier at the high end.

These authors perform a retrospective evaluation of Healthcare Cost and Utilization Project data from New York and Florida, looking specifically at the outcomes of patients returning to the Emergency Department after an index visit.  Based on approximately 9 million Emergency Department visits, these authors found recidivism starting at 8.2% by 7 days and increasing to 16.6% within 30 days.  The proportion of re-visits resulting in an admission to the hospital was stable at ~14.5% across the time period.  Patients with the greatest number of ED visits per year were the most likely to return, and the most likely to be admitted.  Interestingly, only approximately one-quarter of the revisits were identified as for the same condition as their index visit.

The authors’ analysis focuses on comparing the outcomes of patients admitted at an index visit, re-admitted after an ED visit, and those re-admitted after a discharge from the hospital, including ICU admission, length of stay, mortality, and hospital costs.  For what little insight it gives us, these outcomes tended to favor those discharged from the ED – although discharged patients were obviously younger and healthier at baseline than those who were analyzed as hospital readmissions.

These data – given the limitations of their source – do very little to inform any conclusions regarding the underlying processes at work.  And, in essence, by lacking such insight, these data help support the conclusions of the authors: Emergency Department recidivism should not be used as a quality measure.  This level of administrative data whitewashes any clues regarding the etiology of re-visits: are they misdiagnoses?  Are they high healthcare utilizers with chronic problems?  Is system access to primary care inadequate?  Are they scheduled returns for wound care?  Were these patient appropriately given trials of outpatient therapy with an expected failure rate?  Were they simply just very satisfied patients returning to their new favored location for care?  The overall recidivism rate, with all these confounders, is such a poor surrogate for possible missed diagnosis – and whether such missed diagnoses truly represent “low quality” care – that the opacity of the data presented by these authors proves its inadequacy.

Even more importantly, this is excellent context with which to review the proposed Clinical Emergency Data Registry quality measures. Do they accurately reflect the underlying quality of care?  Can they be reliably and accurately measured with little impact on workflow and care delivery?  Capturing data on care delivery is an important part of improving our specialty, but this draft requires substantial feedback.

“In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department”
http://jama.jamanetwork.com/article.aspx?articleid=2491638

Radiation Therapy for the Common Cold

We overuse computed tomography for many things – popular topics in the literature (and on this blog) are mostly minor head injury, renal colic, and CT pulmonary angiograms.  But, it is not simply these modalities that have increased in the preceding decades, as this research letter shows.  CT use has also increased for such apparently benign conditions as non-acute upper respiratory symptoms.

This is a National Hospital Ambulatory Medical Care Survey analysis, with all the sampling limitations inherent to such a data source, evaluating CT usage for upper and lower respiratory complaints between 2001 and 2010.  CT usage in 2001 for such complaints ranged from a 0.5% of visits for non-acute URI, to 3.1% of visits for acute LRTI symptoms.  In 2010, such usage ranged from 3.6% to 12.1%.  Despite all this added cost and extensive evaluation, management of these patients remained unchanged: both antibiotic use and admission rates were steady.

The NHAMCS is an imprecise tool to full discern the reasons for visit on a granular level, but the relative increase in advanced imaging is consistent with increases in CT usage for other indications.  Obviously, the radiation itself has no known therapeutic potential – so, therefore, the clear conclusion is simply the unfortunate presence of additional low-value care.

“Use of Computed Tomography in Emergency Departments in the United States: A Decade of Coughs and Colds”
http://www.ncbi.nlm.nih.gov/pubmed/26720289

The Antibiotic Mandatory Waiting Period?

It has become generally accepted within the medical community the vast majority of cases of pediatric otitis media will resolve without antibiotics.  However, the tradition of treating OM with antibiotics is slow to wane, fueled by momentum and parental expectations.  Some success has been achieved with delayed-prescription strategies, where parents are provided with antibiotics, but encouraged to wait a few days and observe for spontaneous improvement.

These authors applied the same school of thought to benign upper respiratory tract infections – sinusitis, pharyngitis, and bronchitis.  They randomized 398 patients with common URTI-spectrum symptoms to one of four treatment strategies:  immediate antibiotic initiation; antibiotics provided immediately, but patient encouraged to wait-and-see a few days for spontaneous improvement; antibiotics available for pick-up three days later, if desired; and no antibiotics.  The primary outcome was duration and severity of symptoms, with various secondary outcomes of absenteeism, satisfaction, and antibiotic utilization.

The results of this study are a little bit mixed.  The patients initiating antibiotics immediately had shorter symptoms duration than any other strategy.  The sample sizes are small, and the standard deviation of symptoms in each cohort is huge, but it’s probably reasonable to estimate antibiotic use truncated moderate or severe symptoms by about a day or a day and a half from a 5-6 day illness duration.  Twelve of 98 randomized to no prescription ultimately crossed over to antibiotics.

But the remainder, despite their randomization to benign neglect, improved regardless, without any detectable difference in safety outcomes.  After all, the majority of these infections are either viral, or self-limited bacterial infections handled by the body’s natural immune system without complications.

The interesting outcomes, however, were the two delayed-antibiotic strategies.  Compared to the 91% antibiotic usage rate of the immediate antibiotic group, the patient-initiated and delayed-collection strategies resulted in 33% and 23% antibiotic usage rates, respectively.  Symptom duration, as to be expected, was mildly attenuated, falling between immediate antibiotic use and no antibiotics.

Is this the happy medium strategy needed to finally divorce ourselves from our addiction to unnecessary care for URTI disease?  “Choosing Wisely” as a general philosophy doesn’t seem to have had the desired effect – how about an executive action to mandate the same waiting period for antibiotics as we have for guns?

“Prescription Strategies in Acute Uncomplicated Respiratory Infections: A Randomized Clinical Trial”
http://www.ncbi.nlm.nih.gov/pubmed/26719947

The Opiate Overdose Train

There is a certain inalterability about trains.  Their travel is predictable and linear.  Slowing and stopping are extended affairs.  It’s hard for a train to make a sharp turn.

Apparently, opiate prescribing is like that.

This study reviewed administrative data from a health insurer to identify patients receiving long-term opiate therapy.  Patients were then included for analysis if they had a visit to an Emergency Department or a hospitalization related to heroin or opiate overdose.  These same patients were then followed for up to 2 years following the index overdose, and their opiate prescribing tracked.

With a median follow-up of 299 days, opiates were dispensed to 91% of patients following opiate overdose – 7% of whom went to to repeated overdose, many of whom had multiple overdose events.  Some patients had their opiate quantities curtailed, but the majority received the same – or even more – opiates after the overdose event.

Certainly, some of this prescribing is still appropriate – our tools for managing severe pain are grossly inadequate, and in hospice settings, inadvertent overdose is an acceptable hazard of control of malignant pain.  But, just as certain, there is a cohort suffering the harms of shocking irresponsibility.

We’ve been getting bombarded with information regarding the harms of opiate prescribing for several years now; why are we still inflicting such great harm on the healthcare-seeking public?

“Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose”
http://annals.org/article.aspx?articleid=2479117

Welcome to Yesterday, Have You Heard of PERC?

I usually like these sorts of articles regarding the yield and utilization of CT pulmonary angiograms.  They’re fun to dissect, useful to marvel at the inefficiency of our usage, and finally to feed my editorial hyperbole.  But, not this time.

This is a retrospective study from the University of Michigan comprising six months of CTPA data from 2013.  These authors reviewed charts on 602 consecutive patients and calculated modified Wells and PERC for each, and describe the appropriateness and yields of various cohorts.

Rather than detail these statistics and outcomes – other than to note their overall yield of 61 positives reported out of 602 scans – I’d rather just focus on the 108 patients scanned who were PERC negative.  PERC has been around since 2004, and it’s been percolating into various guidelines and evidence-based algorithms since.  Hello, it’s 2015: why are almost 20% of CTs at an academic medical center PERC-negative?

The authors state two PERC-negative patients had positive CT findings; given the pretest probability, I wouldn’t be surprised if one or both were ultimately false-positives.  Come on, man.

“CT Pulmonary Angiography: Using Decision Rules in the Emergency Department”
http://www.ncbi.nlm.nih.gov/pubmed/26435116

You Can Make Unnecessary Care Go Away

Low-value care is such a pervasive problem, ABIM developed the Choosing Wisely initiative.  However, Choosing Wisely is, unfortunately, a disengaged and toothless activity.  And it hasn’t worked.

But, as this study shows, you can eliminate unnecessary care with a more proactive and involved approach.

This is a quality improvement collaborative across 21 hospitals aimed at reducing the use of unnecessary or ineffective care relating to bronchiolitis.  As we’ve seen time and time again, if anything works at all for bronchiolitis, the ambiguity over its effectiveness probably means the effect size is clinically meaningless.  To this end, these hospitals banded together to deploy a QI program targeting reductions in bronchodilator use, steroid use, chest radiography, and other process measures.  Across all measures, the pre- and post-intervention measures demonstrated pooled meaningful and statistically significant improvement.  Bronchodilator use dropped from 46.2% to 32.7%, steroids from 10.9% to 2.2%, and CXRs from 12% to 6.7%.  A secondary effect of these interventions was a reduction in length of stay by 5 hours, from 49.6 to 44.6.

Success!

Of course, the QI intervention did not have the same effect at all participating hospitals.  Some, clearly, were on the ball, and almost entirely eliminated some unnecessary care (steroids).  Others, however, had no change from baseline, or, even, an increase – like two hospitals demonstrating 150%+ increase in bronchodilator use, and three hospitals with 100%+ increases in CXR use.  It would be interesting to see some qualitative analysis regarding the lack of improvement at certain hospitals.

But, in general, widespread improvement in unnecessary care can be realized.  In contrast to Choosing Wisely, it requires motivated agents of change and constant feedback.  The Choosing Wisely lists and their elements, unfortunately, seem adrift.

“A Multicenter Collaborative to Reduce Unnecessary Care in Inpatient Bronchiolitis”

More Futile “Quality”, vis-à-vis, Alert Fatigue

The electronic health record can be a wonderful tool.  As a single application for orders, results review, and integrated documentation storehouse, it holds massive potential.

Unfortunately, much of the currently realized potential is that of unintended harms and inefficiencies.

Even the most seemingly innocuous of checks – those meant to ensure safe medication ordering – have gone rogue, and no one seems capable of restraining them.  These authors report on the real-world effectiveness of adverse drug alerts related to opiates.  These were not public health-related educational interventions, but, simply, duplicate therapy, drug allergy, drug interaction, and pregnancy/lactation safety alerts.  These commonly used medications frequently generate medication safety alerts, and are reasonable targets for study in the Emergency Department.

In just a 4-month study period, these authors retrospectively identified 826 patients for whom an opiate-related medication safety alert was triggered, and these 4,742 alerts constituted the cohort for analysis.  Of these insightful, timely, and important contextual interruptions, these orders were overridden 96.3% of the time.  And, if only physicians had listened, these overridden alerts would have prevented: zero adverse drug events.

In fact, all 8 opiate-related adverse drug events could not have been prevented by alerts – most of which were itching, anyway.  The authors do attribute 38 potentially prevented adverse drug events to the 3.7% of accepted alerts – although, again, these would probably mostly just have been itching.

Thousands of alerts.  A handful of serious events not preventable.  A few episodes of itching averted.  This is the “quality” universe we live in – one in which these alerts paradoxically make our patients less safe due to sheer volume and the phenomenon of “alert fatigue”.

“Clinically Inconsequential Alerts: The Characteristics of Opioid Drug Alerts and Their Utility in Preventing Adverse Drug Events in the Emergency Department”
http://www.ncbi.nlm.nih.gov/pubmed/26553282

The Unintended Harms of “Quality”

Harder!  Better!  Faster!  Stronger!  There is a proliferation of time-based measures in the Emergency Department – the glut of which funds a horde of administrative overhead, and for which the Center for Medicare and Medicaid Services will audit.  These measures must frequently seem relatively benign and commonsense when conceived – but their implementation is anything but.

This is a retrospective quality evaluation from the Christiana Health System, looking at their door-to-balloon time metric for STEMI.  Faster is better – of course – so, in 2009, an aggressive quality improvement intervention was performed to decrease delays and obstacles to cardiac catheterization.  As described in the article, this mostly seemed to consist of exhorting each step the process to be performed more rapidly, and providing additional feedback during the QI initiative.

And, it worked!  Median door-to-ballon time sank from 76 minutes to 61 minutes by 2010.

Unfortunately, this came at a cost: false-positive activations more than doubled.  Furthermore, the mortality rate of false-positive activations jumped from 5.6% to 21.6%.  The fatal alternative diagnoses included massive PE, intracranial hemorrhage, severe sepsis, and aortic dissection.

The authors go on further to describe a follow-up QI intervention of education and feedback regarding the missed diagnoses, and, over time, the mortality rate has improved.  However, false positives persist around 20% of activations – triple the original rate.

So, they’ve saved 15 minutes of door-to-balloon time – a probably clinically insignificant amount – at the cost of scads new false-positives and at least one substantial bump in mortality.  And, you know this is but _one_ of many time-based metrics invading – and harming patients in – the Emergency Department.

Will the madness ever stop?

“Aggressive Measures to Decrease “Door to Balloon” Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement”
http://www.ncbi.nlm.nih.gov/pubmed/26549506

The Best Defense is … Overtesting?

In a much–hyped study, these authors attempt to address the important mythology of “defensive medicine”.  As the self-preservationists have taught us, there’s nothing to be gained from judicious use of resources – particularly in any sense that outweighs the patient satisfaction and perceived diagnostic certainty resulting from overtesting.

But … is it true?  Does healthcare spending at an individual level really equate to fewer lawsuits?

Maybe.

These authors looked just at the state of Florida, and looked specifically at the costs accumulated for the hospital discharges.  Then, they correlated this data with closed malpractice claims, and broke it all down by clinician specialty.  Impressively, the lowest quintile of spending was less than half the highest quintile.  Then, when comparing clinicians with the lowest levels of hospital spending to those with the highest, the malpractice claim rate steadily decreased for each specialty involved.

Unfortunately, all this depends on the black box of statistical adjustment:

“We accounted for differences in patient characteristics and admission diagnoses between physicians by estimating a patient level multivariable linear model of total hospital charges during the hospital stay as a function of patient age, sex, race, diagnosis related group, indicator variables for Charlson-Deyo comorbid conditions, and year and physician indicators.”

One bit I do think quite strong in this paper is the dramatic association between caesarean delivery rates and diminished malpractice risk.  However – is it all “defensive”?  Or is there just a level of appropriate vigilance that avoids poor outcomes?  Regardless, the trend is quite pronounced.

There is some bit of a leap to associated increased expenditures with defensive medicine, particularly given the various statistical adjustments for disease severity and patient characteristics.  Whether defensive or not, however, the interaction between spending and litigation is quite consistent.  I do think these data indicate what they are supposed to show, but it’s not as airtight as the hype.

“Physician spending and subsequent risk of malpractice claims: observational study”
http://www.bmj.com/content/351/bmj.h5516-0

Ah, Is Choosing Wisely Futile?

… or is it just too early to tell?

Announced with much pomp, the ABIM Choosing Wisely campaign was picked up by many specialties.  Each chose at least 5 “low value” tests reflective of unnecessary resource utilization, and such have been disseminated via press release, social medial, and web presence.  The Annals of Internal Medicine further supports the endeavour by publishing original research in the same vein.

This retrospective analysis of patients enrolled in Anthem health plans evaluated the utilization trend for seven of these services over the past 3 years.  And, ultimately, the conclusion is: nothing has reliably changed.  Two of seven “low value” services had decreasing trends on the order of a fraction of a percentage, while two more had increasing trends on the order of a fraction of a percentage.  Just to tie in with one of my all-time favorite themes, antibiotics for acute sinusitis remained stable between 84.5% and 83.7%.

So, the early report is: no one’s making wise choices.

What’s the solution?  If you look around medicine for initiatives with the most robust implementation, it seems tied to either reimbursement or public shaming via quality scorecard.  Is it time for a value-based care rating?  Can we take all the resources devoted to Press-Ganey and repurpose them for good instead of evil?

“Early Trends Among Seven Recommendations From the Choosing Wisely Campaign”
http://www.ncbi.nlm.nih.gov/pubmed/26457643