Month: August 2023

End Nail Dogma

In a world of doors, truck beds, furniture, and other finger-crushing nuisances, emergency department visits for injuries involving the distal digits are common. Injuries range from tuft fractures, to degloving injuries, to all manner of nail and nailbed derangement.

Perusing any textbook or online resource will typically advise some manner of repair, including, but not limited to, replacing an avulsed nail back into the proximal nail fold and securing it in place. If the avulsed nail is not available, recommendations include placing a bit of foil into the proximal nail fold. The general idea being that failure to do so will irretrievably scar the germinal matrix, resulting in some disfigured and mutant nail growth.

The NINJA trial tests whether this dogma is valid – and, rather unsurprisingly, finds it is not.

In this trial, children with finger nail and nailbed injuries requiring surgical repair were randomized, at the conclusion of the injury repair, either to replacement of the nail (or foil) into the nail fold, or to discard the nail and simply leave on a non-adherent dressing. The “c0-primary” outcomes were cosmetic appearance of the nail (using the Oxford Fingernail Appearance Score) and surgical-site infection at 1 week follow-up.

The majority of the 451 children involved were aged younger than 6 and most were crush injuries resulting in avulsion of the nail plate. The primary outcomes were no different between groups – 5 and 2 surgical-site infections in the “nail replacement” and “nail discarded” groups, respectively, and median OFNAS score was 5 (the highest score) in each group. Lest the trial be accused of just failing to demonstrate a difference favoring the “nail replacement” group, it was actually the “nail discarded” group having a non-significantly more favorable distribution of cosmetic scores.

When suggesting these results are unsurprising, it’s rather just a perspective many clinical encounters in the emergency department are “over-medicalized”, and receive unnecessary tests or treatment simply due to the spectrum bias associated with acute care. Most healthy human substrate is capable of healing from minor injury in a satisfactory fashion; hopefully, these results further inform the care of children with finger nail injuries, and, may be reasonably generalized to other nails and healthy adults.

“Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial“

The Opiates in Back Pain Conundrum

We do love to give out opiates in the emergency department. Kidney stone? Opiates. Broken arm? Opiates. Gunshot wound? Opiates. Sore throat? Dexamethasone. And opiates.

So of course we’re here with opiates for your back pain.

In this modern day, we are far, far more judicious than in times of yore, back when pharma had lobbied for pain to become the “fifth vital sign”. But, nonetheless, those patients who are struggling to manage despite non-opiate analgesia frequently end up with some sort of small supply to try and resolve an acutely painful condition.

The OPAL trial, published in The Lancet, is yet another in a series of trials decrying the disutility of virtually anything for back pain – in the context of prior work diminishing the efficacy of skeletal muscle relaxants, as well as even acetaminophen added to ibuprofen. In this trial, patients with “acute” low back pain were prescribed an oxycodone-based opiate or matching placebo, and their functional recovery was assessed in follow up. Unfortunately, no advantage was seen for patients randomized to oxycodone, while there were small, but likely real, risks for opiate misuse at later intervals.

However, does this trial apply to the emergency department?

  • Patients were eligible if they had low back pain for up to 3 months. This is not exactly “acute” – especially since early versions of the protocol excluded patients whose back pain had been ongoing for less than 2 weeks.
  • Modified-release oxycodone-naloxone was the opiate of choice in this Australian trial. The naloxone itself does not exert much influence on the analgesic effect, but the preparation itself differs from preparation used commonly in the emergency department.
  • The follow-up interval was at six weeks, a good patient-oriented timeframe for long-term clinical resolution. However, emergency department treatment tends to choose opiate analgesia with the goal of short-term mobilization and return to activity, so 48- or 72- hour relief or functioning may be more relevant.

The most notable problem with this trial is not, in fact, the trial itself. Rather, the issue remains the paucity of true short-term data regarding any added benefit for the minimally effective quantity of opiates usually dispensed from the emergency department. Spring into action, team!

“Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial”

The Cost of “Quality”

In case you missed this beautiful little article, it’s worth re-highlighting regarding the paradoxical “cost” of “quality”.

In theory, high-quality care is its own reward. Timely actions and interventions, thoughtful and thorough evaluations, and appropriate guideline adherence when applicable are all goals with reasonable face validity for healthcare delivery. Competing incentives, however, coupled with time pressures, erode some of the natural inclination towards ideal care. Thus, “quality” metrics and goals, created with the best of intentions to nudge clinicians and health systems towards better care.

Unfortunately, the siren song of “quality” has begat a locust horde of metrics from all manner of organizations. Health care expenditures in the U.S. have grown from 9% of GDP to 20% GDP, and administrative costs are estimated to comprise up to 30% of total national health care spending. To add context to these larger estimates, this little article simply looks within their own institution to evaluate the potential contribution of “quality” measures to those larger sums.

The authors identified, by surveying personnel across their institution, 162 quality metrics reported to 7 measuring organizations, totalling 271 reports (as some required reporting to multiple organizations). The bulk (70%) were publicly reported “quality” measures, while another 27% were related to pay-for-performance programs.

Overall, across surveyed personnel, the authors determined approximately 108,000 person-hours were consumed annually on these reports. Based on the annual salaries of the individuals involved and their time commitment, the total annual cost to the institution was estimated at over USD$5 million. The most expensive metrics were those requiring individual chart abstraction, while those metrics requiring merely electronic data capture required a fraction of the cost.

Multiplied by the 4000+ hospitals in the U.S., suddenly we’re obviously talking about tens of billions of dollars of added administrative overhead. Interestingly enough, and relevant to emergency medicine, one of the worst offenders as far as cost is SEP-1 – the CMS sepsis core measure. Not only is this measure onerous and costly to administer on the institutional side, it results in substantial unmeasured additional work for clinical staff – and I suspect many of these “quality” measures have their cost similarly underestimated.

Administrative costs aside, it is as important to consider whether “quality” metrics actually reflect higher-quality care, or whether the changes in care driven by metrics improve value. What is certain, however, is their proliferation has been clearly nightmarish.

“The Volume and Cost of Quality Metric Reporting”
https://jamanetwork.com/journals/jama/article-abstract/2805705