Health Information Exchanges Might Save Money

Though, from this data, it’s not clear through what mechanism.

This is an retrospective billing database evaluation of Memphis Emergency Department visits between 2007 and 2008.  In Memphis, 12 EDs participate in an online data repository, which may be accessed by secure web connection.  The authors compared patients presenting to the Emergency Department for whom this medical record was accessed to patients for whom this record was not.

There were no baseline differences between the demographics of the study groups, although, this retrospective evaluation cannot account for the factors contributing to why physicians chose to access the information exchange for individual patients.

The results are rather odd.  The authors cite cost savings as a result of an OR of 0.27 for inpatient hospitalization after accessing the information exchange.  However, the frequency of basically every other type of activity stayed flat or increased – in fact, the OR for Head CT was 5.0 and a chest x-ray was 4.3 if information exchange records were accessed.

More tests?  Fewer admissions?  I’m not sure it’s practical to generalize the effects of an information exchange on medical decision making in a retrospective fashion such as this.

“The financial impact of health information exchange on emergency department care.”
www.ncbi.nlm.nih.gov/pubmed/22058169

Skipping the LP in Infants 30-90 Days – Eh.

This is another one of those “practice-changing” types of articles, where the authors try to debunk some specific aggressive diagnostic or therapeutic modality that is over-utilized in a low-prevalence, high-risk population.  This article, which you may have already seen, is regarding the need for a lumbar puncture in infants between 30 and 90 days.

They perform a retrospective review of nonconsecutive infants between 30 and 90 days of age who presented to the Emergency Department and received the “septic workup” – urinalysis/culture, blood culture, and lumbar puncture/CSF culture.  They analyze a data set of 392 infants, the overwhelming majority of which are completely culture negative.  52 of them are culture positive on their urinalysis, 13 are culture positive in the blood, and 4 are CSF culture positive.  The authors note that only one patient who had a positive urinalysis also had a positive CSF fluid culture – and that infant did not qualify as a low-risk infant by the Rochester criteria – so a well-appearing infant with a positive urinalysis need not undergo LP.

So, essentially, this study tells us only that meningitis is rare and that UTIs are common.  The authors attempt to make the flawed logical argument against LP in their discussion by emphasizing the negative predictive value for meningitis in the setting of an abnormal UA is 98.2%.  However, they erroneously discount the negative likelihood ratio of 0.87 (95% CI, 0.5–1.5).  Therefore, statistically speaking, based on their results, repeating this study 100 times could lead to nearly half the study results showing a positive urinalysis favored concomitant meningitis.

Now, in a clinical sense, the authors are likely correct.  An infant who looks well, meets the Rochester criteria, has an identified source for fever, and will be receiving antibiotics is at low risk for meningitis – by prevalence alone, not by anything this study shows – and is probable to have a good clinical outcome since they’re receiving antibiotics (in the event that same organism is resulting in a well-appearing, subclinical systemic and cerebrospinal bacteremia).  The argument should not be that you can generate a zero-risk population with their combination of +UA and Rochester, but that the risk of bad outcome may be similar to the risk of harms associated with the lumbar puncture, false positives, and follow-on treatment/testing.

“Is a Lumbar Puncture Necessary When Evaluating Febrile Infants (30 to 90 Days of Age) With an Abnormal Urinalysis?”

ED Nursing Hand-Offs & Stroke Outcomes

Yet again, in the “little things matter more” series of dull, but important, Emergency Department literature.  TPA or no, what matters more in terms of their ultimate outcome is everything that happens down the line.

This is a retrospective review of consecutively-collected prospective registry data for acute ischemic stroke patients in Louisiana, looking at patients who were present in the ED during shift change.  They simply reviewed and compared the outcomes of 366 consecutive patients, looking at good outcome, neurologic worsening, discharge status, and development of pneumonia.

There are, unfortunately, huge, irreconcilable differences between the shift-change and non-shift change groups – the group that was in the ED had milder strokes and was less likely to have TPA 9.5% vs. 4.5% – but still ended up developing more pneumonia.  After their mathematical adjustments for various baseline differences, being present during shift change ended up with a five-fold increased odds of developing pneumonia, resulting in decreased likelihood of discharge to home or rehab.  The authors attribute this primarily to non-adherence with stroke unit dysphagia precautions, which is probably reasonable.  This is just retrospective and observational, but it probably identifies an important operations issue for the Emergency Department.

So, perhaps it does matter whether you give TPA or not – if TPA gets them out of the ED faster, that will help more than anything.

“Emergency Department Shift Change Is Associated With Pneumonia in Patients With Acute Ischemic Stroke”
http://stroke.ahajournals.org/content/42/11/3226.short

The Cure For Bleeding is More Bleeding?

Intraventricular TPA for intraventricular hemorrhage – I wouldn’t call it counter-intuitive, but I would certainly call it unusual.
This is a small placebo-controlled, randomized, blinded, prospective trial enrolling 48 patients with intraventricular hemorrhage requiring placement of an intraventricular catheter for CSF drainage.  They were testing the theory that low-dose TPA would assist in clot breakdown, thus speeding recovery.  There are probably not significant differences between groups – although the placebo group was oddly mostly women.  Also fascinatingly, the predicted mortality of each group was ~74% – and ended up being 23% in the placebo group and 19% in the TPA group.  Serious adverse events including 61% in the TPA group and 36% in the TPA group.  Due to the small sample size of the cohort, none of these differences reached statistical significance.
Unfortunately, the screaming major flaw in this study is that they do not truly have a control group – a true control would be standard care without the use of placebo administration through the intraventricular catheter.  Their rate of ventriculitis (8% and 9%) is higher than the typically expected rate for intraventricular catheter placement (probably below 5%), and is consistent with prior studies that showed increased incidence of ventriculitis when the catheter is used for administration of drugs or irrigation.  So, the safety profile and minimal outcome trend in favor of the TPA group can’t truly be evaluated because it isn’t being compared to the current standard of care, which is leaving the catheter alone for drainage only.
The authors conclude these results support further evaluation – which is already ongoing in the CLEAR III trial – and that the treatment met their pre-defined safety profile cut-offs.  Unfortunately, yet again, propagating their skew on the data is motivated by financial interests – Johns Hopkins has applied for a use patent and Genentech is behind the rtPA licensing and funding.  
“Low-Dose Recombinant Tissue-Type Plasminogen Activator Enhances Clot Resolution in Brain Hemorrhage”

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

When Parents Refuse a Septic Workup

This is a brief commentary and discussion regarding the implications of parental refusal of hospitalization and evaluation of a potentially septic neonate.  It is absolutely an issue we all hope to never face, but probably will at some point in our careers.

Two pediatricians offer differing opinions on the extent to which social work and child protective services need be involved, raising such issues as the threshold percentage for likelihood of serious bacterial infection/bacteremia should be for “imminent harm” to the child, and the perceived benefits of therapy.  No specific answers are gleaned from the article, but it is worth reading and thinking through the discussions you would have in a similar situation.

“When Parents Refuse a Septic Workup for a Newborn”
www.ncbi.nlm.nih.gov/pubmed/22025599

Ethanol – Miracle Drug (For Stroke)

From China, in Stroke, an animal model (poor rats, as usual) of MCA ischemia, collagenase-induced ICH, and post-TPA ICH.  Rats received either 0.5 mg/kg, 1.0 mg/kg, or 1.5 mg/kg ethanol after two hours of MCA occlusion.  Performance on various foot, balance, and parallel behavioral testing significantly favored the ethanol treatment group with initial and sustained reduction in errors as compared to the no-treatment group.

No difference was found between groups in induced ICH volume, and in their (small) series, no increase in ICH after TPA administration.  A transient increase in expression of hypoxia-inducible factor 1-alpha favoring ethanol was seen at 3 hours after reperfusion, gone by 24 hours.

I cannot wait to see the day where we give IV ethanol for acute stroke.

“Beer, the cause and solution to all the world’s problems.”

“Neuroprotective Effect of Acute Ethanol Administration in a Rat With Transient Cerebral Ischemia”

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”

Conflict of Interest in TPA Literature

Another tiny bit of self-promotion – a new publication published today.  Stems essentially from a literature review I did after clawing through ECASS-III and noting that 12 of the 14 investigators were paid, sponsored, or employed by the manufacturers of alteplase – which muddied my estimation of the reliability of the conclusions.  Turns out, ECASS-III wasn’t the only one….

“Pharmaceutical Sponsorship Bias Influences Thrombolytic Literature in Acute Ischemic Stroke”

Resident Productivity Does Not Predict ABEM Scores

Simple, single-institution study of 11 years of resident in-service scores, patients-per-hour, and ABEM qualifying examination scores – and, as previously shown, only PGY-3 in-service examination scores predicted ABEM oral and written examination scores.
Simulated oral board examination scores did not correlate with ABEM oral examination scores, and the relative number of patients-per-hour had no significant correlations between any testing.
I would say that bears out my observational experience – doing more has no bearing on whether you might be doing more incorrectly.
“Outcome Measures for Emergency Medicine Residency Graduates: Do Measures of Academic and Clinical Performance During Residency Training Correlate With American Board of Emergency Medicine Test Performance?”
www.ncbi.nlm.nih.gov/pubmed/21999560

Good luck to everyone taking their ABEM exam today!