1. Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population
Shanafelt TD, et al. Arch Intern Med. 2012;172(18):1-9.
Background Despite
extensive data about physician burnout, to our knowledge, no national study has
evaluated rates of burnout among US physicians, explored differences by
specialty, or compared physicians with US workers in other fields.
Methods We conducted
a national study of burnout in a large sample of US physicians from all
specialty disciplines using the American Medical Association Physician
Masterfile and surveyed a probability-based sample of the general US population
for comparison. Burnout was measured using validated instruments. Satisfaction
with work-life balance was explored.
Results Of 27 276
physicians who received an invitation to participate, 7288 (26.7%) completed
surveys. When assessed using the Maslach Burnout Inventory, 45.8% of physicians
reported at least 1 symptom of burnout. Substantial differences in burnout were
observed by specialty, with the highest rates among physicians at the front
line of care access (family medicine, general internal medicine, and emergency
medicine). Compared with a probability-based sample of 3442 working US adults,
physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to
be dissatisfied with work-life balance (40.2% vs 23.2%) (P less than .001 for
both). Highest level of education completed also related to burnout in a pooled
multivariate analysis adjusted for age, sex, relationship status, and hours
worked per week. Compared with high school graduates, individuals with an MD or
DO degree were at increased risk for burnout (odds ratio [OR], 1.36; P less
than .001), whereas individuals with a bachelor's degree (OR, 0.80; P = .048),
master's degree (OR, 0.71; P = .01), or professional or doctoral degree other
than an MD or DO degree (OR, 0.64; P = .04) were at lower risk for burnout.
Conclusions Burnout
is more common among physicians than among other US workers. Physicians in
specialties at the front line of care access seem to be at greatest risk.
2. Cardiac Evaluation for Structural
Abnormalities May Not Be Required in Patients Presenting With Syncope and a
Normal ECG Result in an Observation Unit Setting
Anderson KL, et al. Ann Emerg Med. 2012;60: 478-484.e1
Study objective: Patients with syncope are frequently
managed in observation units and receive serial examinations, monitoring for
arrhythmias, and structural analysis of the heart. The primary aim of this
study is to determine the utility of structural analysis of the heart in
syncope patients who are being managed in an observation unit and have a normal
ECG result.
Methods: This is a retrospective, observational chart review
of all consecutive adult patients observed during 18 months at an urban,
academic medical center. A case report form with demographics, ECG
interpretations, and structural analysis of the heart data was generated and
all variables were defined before data extraction. Subjects with an ECG
demonstrating any arrhythmia, premature atrial contraction, premature
ventricular contraction, pacing, second- and third-degree blocks, and left
bundle branch block were excluded from the normal ECG group. An abnormal
cardiac structure was defined as an ejection fraction less than 45%, severe
hypertrophy, or severe valvular abnormality. Ten percent of cases were
evaluated by a second extractor to verify accuracy. Descriptive statistics with
confidence intervals (CIs) and interquartile ranges (IQRs; 25%, 75%) are used.
Results: Three hundred twenty-three subjects were managed in
the observation unit for syncope, 48% were men, and their median age was 66
years (25%, 75% IQR 52, 80). Two of 323 (0.6%; 95% CI 0.2% to 2.2%) had an
arrhythmia; 1 of 323 had a non–ST-segment myocardial infarction (0.3%; 95% CI
0.1% to 1.7%). Of the 323 patients, 267 had a normal ECG result and 235 (88%)
had their cardiac structure evaluated. Forty-eight percent of the normal ECG
group were men, and the median age was 65 years (25%, 75% IQR 52, 79). Zero of
235 patients (0%; 95% CI 0% to 1.6%) had a structural abnormality identified on
evaluation, and 2 of 18 (11%; 95% CI 3.1% to 32.8%) had an abnormal stress
echocardiogram result.
Conclusion: Structural abnormalities are unlikely in syncope
patients with a normal ECG result. Care should focus on excluding arrhythmias
and acute coronary syndrome.
3. Interactive Case
from NEJM: A Complex Cause of Pleuritic Chest Pain
McMahon GT, et al. N Engl J Med 2012; 367:e2.
A 33-year-old man presented with pain on the right side of
his chest that had started 5 days earlier and continued to worsen until the
time of presentation. The pain originated near his right scapula and
progressively radiated throughout his right chest. It did not worsen with
movement of his arm or shoulder but did worsen with deep inspiration and when
he was lying down. The patient . . . .
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4. Dedicated Hospital
Observation Units Could Save $3.1 Billion
Steven Fox. Medscape Medical News. September 28, 2012 —
Maximizing the potential use of dedicated hospital observation units could save
billions of dollars in healthcare resources annually, according to results from
a study published online September 26 and in the October issue of Health
Affairs.
Observation units (OUs) in hospitals provide an alternative
to admitting patients who have received care in emergency departments but
cannot yet be sent home safely. OUs are most often dedicated spaces, within or
adjacent to emergency departments, where patients receive care, usually for
less than 24 hours.
"Observation unit care is an established and
well-studied health care delivery model that is more cost-efficient than
inpatient care for specific patient populations," Christopher W. Baugh,
MD, from the Brigham and Women's Hospital Department of Emergency Medicine,
Boston, Massachusetts, and colleagues write. The researchers note that previous
studies have compared only single-site costs of observational care with routine
inpatient care. "However, we are unaware of any prior attempts to quantify
the potential financial impact of observation unit expansion," they write.
"Our objective was to quantify the potential cost
savings from a decrease in avoidable inpatient admissions that would result
from increasing the use of observation units in eligible hospitals," they
add.
The researchers first conducted a literature review and then
coupled that with national survey data to pinpoint how much money OU care saves
per patient visit. The researchers used a Monte Carlo simulation to quantify
the gap between current use of OUs and potential maximum use of such units. According
to their analysis, OUs saved about $1572 ± $812 per hospital visit, compared
with inpatient care.
Using the Monte Carlo simulation model to extrapolate those
savings out to the national level, the authors estimated that if all hospitals
nationwide set up OUs, the cost savings would be $3.1 billion ± $1.9 billion.
The researchers also estimate that setting up OUs would help
avoid about 2.4 million ± 490,000 inpatient admissions each year.
"For an average hospital with the visit volume to
justify operating an observation unit, the annual direct cost savings would be
$4.6 million (standard deviation: ±$2.9 million) from maximum use, resulting
from about 3,600 (standard deviation: ±740) inpatient admissions avoided each
year," they write.
The researchers emphasize that their study focused on use of
OUs that provide limited lengths of stay (usually less than 24 hours), rather
than OUs that keep patients longer. "Patients are at much lower risk for
excessive out-of-pocket costs when observation is used in this way," they
note.
In conclusion, they write, "Observation units represent
a feasible care innovation worthy of further evaluation. The wider use of
observation units may create cost savings and should be a model for acute care
redesign to increase value in the US health care system."
Baugh CH, et al. Health Aff. Published online September 26,
2012.
5. Non-traumatic SAH in the setting of
negative cranial CT: External validation of a clinical and imaging prediction
rule.
Mark DG, et al, for the Kaiser Permanente CREST Network
Investigators. Ann Emerg Med. 2012 October 1 [Epub ahead of print]
Study objective: Clinical variables can reliably exclude a
diagnosis of nontraumatic subarachnoid hemorrhage in patients with negative
cranial computed tomography (CT) results. We externally validated 2 decision
rules with 100% reported sensitivity for a diagnosis of subarachnoid
hemorrhage, among patients undergoing lumbar puncture after a negative cranial
CT result: (1) clinical rule: presence of any combination of age 40 years and
older, neck pain or stiffness, loss of consciousness, or headache onset during
exertion; and (2) imaging rule: cranial CT performed within 6 hours of headache
onset.
Methods: This was a matched case-control study of patients
presenting to 21 emergency departments between 2000 and 2011. Patients with a
diagnosis of subarachnoid hemorrhage as determined by lumbar puncture after a
negative cranial CT result were screened for inclusion. A matched control
cohort was selected among patients with a diagnosis of headache after negative
cranial CT and lumbar puncture results.
Results: Fifty-five cases of subarachnoid hemorrhage meeting
inclusion criteria were identified, 34 (62%) of which were attributed to
cerebral aneurysms. External validation of the clinical rule demonstrated a
sensitivity of 97.1% (95% confidence interval [CI] 88.6% to 99.7%), a
specificity of 22.7% (95% CI 16.6% to 29.8%), and a negative likelihood ratio
of 0.13 (95% CI 0.03 to 0.61) for a diagnosis of subarachnoid hemorrhage.
External validation of the imaging rule revealed that 11 of 55 subarachnoid
hemorrhage cases (20%) had negative cranial CT results for tests performed
within 6 hours of headache onset.
Conclusion: The clinical rule demonstrated useful Bayesian
test characteristics when retrospectively validated against this patient
cohort. The imaging rule, however, failed to identify 20% of subarachnoid
hemorrhage patients with a negative cranial CT result.
Excerpt from the discussion: Although cranial CT or clinical
prediction rules alone do not clearly and safely achieve these ideal test
performance goals, the combined application of both testing strategies might
offer an improvement. Even with a very conservative estimated subarachnoid
hemorrhage risk of 1.25% (1 of 80 risk) after negative cranial CT, the
application of the 4-item decision rule derived by Perry et al, even with a
negative likelihood ratio as high as 0.13 as reported in this study, can reduce
this incidence to 0.2%, or 1 in 500 patients. Additionally, given that the
specificity for the rule in this study was validated against a population of
patients who uniformly underwent cerebrospinal fluid analysis, application of
the clinical rule after negative cranial CT result has the potential to reduce
rates of lumbar puncture by approximately 25%.
[DRV: Pearl for clinical application: In cases of suspected
SAH, if CT negative, assess for these 4 risk factors:
·
Loss
of consciousness
·
Exertional
onset of headache
·
Age 40 years or older
·
Neck
pain or stiffness
If CT negative and LEAN negative you can safely skip LP in
the work up of suspected atraumatic SAH.]
6. Physicians'
Warnings for Unfit Drivers and the Risk of Trauma from Road Crashes
Redelmeier DA, et al. N Engl J Med 2012; 367:1228-1236.
Background: Physicians' warnings to patients who are
potentially unfit to drive are a medical intervention intended to prevent
trauma from motor vehicle crashes. We assessed the association between medical
warnings and the risk of subsequent road crashes.
Methods: We identified consecutive patients who received a
medical warning in Ontario, Canada, between April 1, 2006, and December 31,
2009, from a physician who judged them to be potentially unfit to drive. We
excluded patients who were younger than 18 years of age, who were not residents
of Ontario, or who lacked valid health-card numbers under universal health
insurance. We analyzed emergency department visits for road crashes during a
baseline interval before the warning and a subsequent interval after the
warning.
Results: A total of 100,075 patients received a medical warning
from a total of 6098 physicians. During the 3-year baseline interval, there
were 1430 road crashes in which the patient was a driver and presented to the
emergency department, as compared with 273 road crashes during the 1-year
subsequent interval, representing a reduction of approximately 45% in the
annual rate of crashes per 1000 patients after the warning (4.76 vs. 2.73, P less
than 0.001). The lower rate was observed across patients with diverse
characteristics. No significant change was observed in subsequent crashes in
which patients were pedestrians or passengers. Medical warnings were associated
with an increase in subsequent emergency department visits for depression and a
decrease in return visits to the responsible physician.
Conclusions: Physicians' warnings to patients who are
potentially unfit to drive may contribute to a decrease in subsequent trauma
from road crashes, yet they may also exacerbate mood disorders and compromise
the doctor–patient relationship. (Funded by the Canada Research Chairs program
and others.)
7. Revisiting a
Prediction Rule for Identifying Children at Low Risk for Appendicitis
Even after refinement, the rule is not sufficient for
excluding this common diagnosis.
A previously published prediction rule developed at a single
center classifies children as having low risk for appendicitis if they meet the
following criteria: absolute neutrophil count 6.75 x 103/µL, absence of nausea,
and absence of maximal tenderness in the right lower quadrant (RLQ). The rule
yielded a sensitivity of 98% and specificity of 32%. Now, the investigators
validated and refined the rule in a prospective cohort of 2625 children (age
range, 3 to 18 years; mean, 11 years) who presented to 9 pediatric emergency
departments during 1 year with abdominal pain of less than 96 hours duration
and suspected appendicitis.
Overall, 1018 patients (39%) were diagnosed with
appendicitis, and of these, 275 (27%) had a perforated appendix. Computed
tomography was performed in 55% of patients, ultrasound in 37%, and both in
12%. The negative appendectomy rate was 9% (95 patients). Had the rule been
applied, 22 unnecessary operations would have been prevented, but 42 patients
with appendicitis would have been missed (sensitivity, 96%; specificity, 36%).
A refined rule, consisting of absolute neutrophil count 6.75 x 103/µL and
either no maximal tenderness in the RLQ or maximal tenderness in the RLQ and no
abdominal pain with walking, jumping, or coughing, identified 400 patients as
having low risk for appendicitis. The refined rule would have missed 19
patients with appendicitis, yielding a sensitivity of 98% and specificity of
24%.
Comment: The investigators failed to compare performance
between these rules and clinical suspicion for appendicitis based on physical
examination alone. Overall clinical gestalt should still be the basis for
identifying children at low risk for appendicitis. When the diagnosis is
uncertain, investigation should begin with ultrasound, followed by computed
tomography if ultrasound is nondiagnostic.
— Katherine Bakes, MD. Published in Journal Watch Emergency
Medicine September 28, 2012. Citation: Kharbanda AB et al. Validation and
refinement of a prediction rule to identify children at low risk for acute
appendicitis. Arch Pediatr Adolesc Med 2012 Aug 1; 166:738.
8. Ask
Suicide-Screening Questions (ASQ)A Brief Instrument for the Pediatric Emergency
Department
Horowitz LM, et al. Arch Pediatr Adolesc Med. 2012 Oct
1:1-7.
Objective To develop
a brief screening instrument to assess the risk for suicide in pediatric
emergency department patients.
Design A prospective,
cross-sectional instrument-development study evaluated 17 candidate screening
questions assessing suicide risk in young patients. The Suicidal Ideation
Questionnaire served as the criterion standard.
Setting Three urban,
pediatric emergency departments associated with tertiary care teaching
hospitals.
Participants A
convenience sample of 524 patients aged 10 to 21 years who presented with
either medical/surgical or psychiatric chief concerns to the emergency department
between September 10, 2008, and January 5, 2011.
Main Exposures
Participants answered 17 candidate questions followed by the Suicidal
Ideation Questionnaire.
Main Outcome Measures
Sensitivity, specificity, predictive values, likelihood ratios, and area
under the receiver operating characteristic curves of the best-fitting
combinations of screening questions for detecting elevated risk for suicide.
Results A total of
524 patients were screened (344 medical/surgical and 180 psychiatric). Fourteen
of the medical/surgical patients (4%) and 84 of the psychiatric patients (47%)
were at elevated suicide risk on the Suicidal Ideation Questionnaire. Of the 17
candidate questions, the best-fitting model comprised 4 questions assessing
current thoughts of being better off dead, current wish to die, current
suicidal ideation, and past suicide attempt. This model had a sensitivity of
96.9% (95% CI, 91.3-99.4), specificity of 87.6% (95% CI, 84.0-90.5), and
negative predictive values of 99.7% (95% CI, 98.2-99.9) for medical/surgical
patients and 96.9% (95% CI, 89.3-99.6) for psychiatric patients.
Conclusions A
4-question screening instrument, the Ask Suicide-Screening Questions (ASQ),
with high sensitivity and negative predictive value, can identify the risk for
suicide in patients presenting to pediatric emergency departments.
9. IV Dextrose for
Kids with Gastroenteritis and Dehydration?
By Will Boggs, MD. Reuters Health Information. NEW YORK
(Reuters Health) Sep 27 - An initial bolus of 5% dextrose in normal saline does
not reduce hospitalization rates in children with gastroenteritis and
dehydration, but it does reduce serum ketone levels, researchers say. And that
may influence the decision to admit.
"Those kids with low serum bicarbonate (the acidosis from
the high ketones) are the exact ones in which we think the extra glucose can
help," said Dr. Jason A. Levy from Children's Hospital Boston in email to
Reuters Health. "But if they are being admitted because of their low
bicarbonate (even if clinically improved), then we may have been unable to show
a true improvement with our outcome measure."
"We also saw that among the kids with acidosis, those
who received the dextrose bolus required follow-up less than those who received
the normal saline bolus (33% versus 11%)," Dr. Levy said. "Although
this difference was not statistically significant (p=0.09), we feel like these
kids may have benefited from the extra dextrose."
In a randomized trial, Dr. Levy and colleagues compared the
effects of a 20ml/kg infusion of either 5% dextrose in normal saline or normal
saline solution alone on hospitalization rates and serum ketone levels in 188
children, ages six months to six years, who presented to the emergency
department (ED) with gastroenteritis and dehydration. The children could
receive additional oral or IV rehydration therapy at the discretion of the
treating attending physician. Just over half (55%) of the children randomized
to normal saline solution later received some IV dextrose during their ED
visit.
According to results published September 10th online in
Annals of Emergency Medicine, there was no significant difference in the main
outcome: 35% of children assigned to IV dextrose were hospitalized, compared
with 44% of children assigned to IV normal saline. Hospitalization rates were
also similar in the subset of children with acidosis (46% with IV dextrose, 53%
with IV normal saline).
Serum ketone levels, a secondary endpoint, declined by a
significantly greater extent at one hour in the IV dextrose group than in the
IV normal saline group (1.2 vs 0.1 mmol/L decrease). The difference was also
significant at two hours (1.9 vs 0.3 mmol/L, respectively). Children who
received IV dextrose were less likely than children who received IV normal
saline to require unscheduled medical care, but this difference did not reach
statistical significance. Neither group experienced adverse events, according
to the authors.
"I think the studies addressing the efficacy of oral
rehydration therapy (ORT), both with and without ondansetron, have been fairly
conclusive," Dr. Levy said. "Simply put, ORT works and we probably
underutilize it in this country for a variety of reasons (lack of knowledge,
parental and primary care physician expectations, etc)."
"As you can see from our study," he added,
"the jury may still be out on the best way to intravenously rehydrate
these children, both in terms of the solution type and amount, although
dextrose should play a role."
"I still have strong opinions around caring for these
children, which are grounded in both my personal experience and reviews of the
existing literature," Dr. Levy continued. "Looking at our study with
all the existing data - the main message for me - dextrose should clearly be in
the algorithm when treating kids with gastroenteritis and dehydration. By using
IV dextrose, there is a significant decrease in ketones which should make
children feel better. Future studies should determine the optimal regimen with
respect to fluid type and amount."
Levy JA, et al. Ann Emerg Med 2012. [Epub ahead of print
2012 Sept 5] Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22959318
10. 613 cases of
splenic rupture without risk factors or previously diagnosed disease: a
systematic review
FK Aubrey-Bassler and Nicholas Sowers. BMC Emergency Medicine 2012, 12:11
doi:10.1186/1471-227X-12-11
Background: Rupture of the spleen in the absence of trauma
or previously diagnosed disease is largely ignored in the emergency literature
and is often not documented as such in journals from other fields. We have
conducted a systematic review of the literature to highlight the surprisingly
frequent occurrence of this phenomenon and to document the diversity of
diseases that can present in this fashion.
Methods: Systematic review of English and French language
publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011.
Results: We found 613 cases of splenic rupture meeting the
criteria above, 327 of which occurred as the presenting complaint of an
underlying disease and 112 of which occurred following a medical procedure.
Rupture appeared to occur spontaneously in histologically normal (but not
necessarily normal size) spleens in 35 cases and after minor trauma in 23
cases. Medications were implicated in 47 cases, a splenic or adjacent
anatomical abnormality in 31 cases and pregnancy or its complications in 38
cases.
The most common associated diseases were infectious (n =
143), haematologic (n = 84) and non-haematologic neoplasms (n = 48).
Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and
rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n =
87) was the procedure reported most frequently as a cause of rupture. The
anatomic abnormalities associated with rupture include splenic cysts (n = 6),
infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture
include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF
(n = 10). Other causes or associations reported very infrequently include other
endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis,
empyema, remote pancreato-renal transplant, thrombosed splenic vein,
hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol
embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis,
pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma,
afibrinogenemia and ruptured ectopic pregnancy.
Conclusions: Emergency physicians should be attuned to the
fact that rupture of the spleen can occur in the absence of major trauma or
previously diagnosed splenic disease. The occurrence of such a rupture is
likely to be the manifesting complaint of an underlying disease. Furthermore,
colonoscopy should be more widely documented as a cause of splenic rupture.
Provisional Full-text (free): http://www.biomedcentral.com/content/pdf/1471-227X-12-11.pdf
11. Small-bore
catheter versus chest tube drainage for pneumothorax
Contou D, et al. Amer J Emerg Med 2012;30:1407-1413.
Study Objective: The aim of the study was to compare the
effectiveness of drainage via a single-lumen (5F catheter) central venous
catheter (CVC) to a conventional (14-20F catheter) chest tube (CT) for the
management of pneumothoraces, including primary spontaneous pneumothorax (PSP),
secondary spontaneous pneumothorax (SSP), and traumatic and iatrogenic
pneumothoraces.
Patients: All consecutive patients admitted to the
intermediate intensive care unit of a university hospital for pneumothorax were
retrospectively screened over an 8-year period. Patients were preferentially
treated using CT from 2003 to 2007 and using CVC from 2008 to 2010. Drainage
failure was defined as the need for a second drainage procedure or for surgery.
Results: Of 212 patients included, 117 (55%) had PSP, 28
(13%) had SSP associated with chronic obstructive pulmonary disease, 19 (9%)
had traumatic pneumothorax, and 48 (23%) had iatrogenic pneumothorax. The
failure rate was 23% in PSP, 36% in SSP, 16% in traumatic pneumothorax, and only
2% in iatrogenic pneumothorax. After adjustment, iatrogenic pneumothorax was
the only factor that had an influence on drainage failure. The failure rate was
similar between the 112 patients treated using CVC and the 100 patients treated
using CT (18% vs 21%, P = .60). However, the durations of drainage (3.3 ± 1.9
vs 4.6 ± 2.6 days, P less than .01) and of hospital stay were significantly
shorter in patients treated using CVC as compared with CT.
Conclusion: Our findings suggest that drainage via a
catheter or via a CT is similarly effective in the management of pneumothorax.
We recommend considering drainage via a small-bore catheter as a first-line
treatment in patients with pneumothorax, whatever its cause.
12. Intraaortic
Balloon Support for MI with Cardiogenic Shock
Thiele H, et al. for the IABP-SHOCK II Trial Investigators.
N Engl J Med 2012; 367:1287-1296
In this trial, patients with acute MI and cardiogenic shock
who were expected to undergo coronary revascularization were randomly assigned
to receive or not to receive intraaortic balloon support. Balloon support had
no effect on 30-day mortality.
Background: In current international guidelines, intraaortic
balloon counterpulsation is considered to be a class I treatment for
cardiogenic shock complicating acute myocardial infarction. However, evidence
is based mainly on registry data, and there is a paucity of randomized clinical
trials.
Methods: In this randomized, prospective, open-label,
multicenter trial, we randomly assigned 600 patients with cardiogenic shock
complicating acute myocardial infarction to intraaortic balloon
counterpulsation (IABP group, 301 patients) or no intraaortic balloon counterpulsation
(control group, 299 patients). All patients were expected to undergo early
revascularization (by means of percutaneous coronary intervention or bypass
surgery) and to receive the best available medical therapy. The primary
efficacy end point was 30-day all-cause mortality. Safety assessments included
major bleeding, peripheral ischemic complications, sepsis, and stroke.
Results: A total of 300 patients in the IABP group and 298
in the control group were included in the analysis of the primary end point. At
30 days, 119 patients in the IABP group (39.7%) and 123 patients in the control
group (41.3%) had died (relative risk with IABP, 0.96; 95% confidence interval,
0.79 to 1.17; P=0.69). There were no significant differences in secondary end
points or in process-of-care measures, including the time to hemodynamic
stabilization, the length of stay in the intensive care unit, serum lactate
levels, the dose and duration of catecholamine therapy, and renal function. The
IABP group and the control group did not differ significantly with respect to
the rates of major bleeding (3.3% and 4.4%, respectively; P=0.51), peripheral
ischemic complications (4.3% and 3.4%, P=0.53), sepsis (15.7% and 20.5%,
P=0.15), and stroke (0.7% and 1.7%, P=0.28).
Conclusions: The use of intraaortic balloon counterpulsation
did not significantly reduce 30-day mortality in patients with cardiogenic
shock complicating acute myocardial infarction for whom an early
revascularization strategy was planned. (Funded by the German Research Foundation
and others; IABP-SHOCK II)
Editorial (subscription only): O'Connor SM, et al. Evidence
for Overturning the Guidelines in Cardiogenic Shock. N Engl J Med 2012;
367:1349-1350
13. Risk factors for
unplanned transfer to intensive care within 24 hours of admission from the ED
in an integrated healthcare system
Delgado MK, et al. J Hosp Med 2012 Sept 28 [Epub ahead of
print]
BACKGROUND: Emergency department (ED) ward admissions
subsequently transferred to the intensive care unit (ICU) within 24 hours have
higher mortality than direct ICU admissions.
DESIGN, SETTING, PATIENTS: Describe risk factors for
unplanned ICU transfer within 24 hours of ward arrival from the ED.
METHODS: Evaluation of 178,315 ED non-ICU admissions to 13
US community hospitals. We tabulated the outcome of unplanned ICU transfer by
patient characteristics and hospital volume. We present factors associated with
unplanned ICU transfer after adjusting for patient and hospital differences in
a hierarchical logistic regression.
RESULTS: There were 4252 (2.4%) non-ICU admissions
transferred to the ICU within 24 hours. Admitting diagnoses most associated
with unplanned transfer, listed by descending prevalence were: pneumonia (odds
ratio [OR] 1.5; 95% confidence interval [CI] 1.2–1.9), myocardial infarction
(MI) (OR 1.5; 95% CI 1.2–2.0), chronic obstructive pulmonary disease (COPD) (OR
1.4; 95% CI 1.1–1.9), sepsis (OR 2.5; 95% CI 1.9–3.3), and catastrophic
conditions (OR 2.3; 95% CI 1.7–3.0). Other significant predictors included: male
sex, Comorbidity Points Score above 145, Laboratory Acute Physiology Score ≥7,
arriving on the ward between 11 PM and 7 AM. Decreased risk was found with
admission to monitored transitional care units (OR 0.83; 95% CI 0.77–0.90) and
to higher volume hospitals (OR 0.94 per 1,000 additional annual ED inpatient
admissions; 95% CI 0.91–0.98).
CONCLUSIONS: ED patients admitted with respiratory
conditions, MI, or sepsis are at modestly increased risk for unplanned ICU
transfer and may benefit from better triage from the ED, earlier intervention,
or closer monitoring to prevent acute decompensation. More research is needed
to determine how intermediate care units, hospital volume, time of day, and sex
affect unplanned ICU transfer.
14. BMJ Meta-analysis Suggests Progesterone
Level May ID Nonviable Pregnancies
By Todd Neale, Senior Staff Writer, MedPage Today. September
27, 2012
Among women who have bleeding or pain and an inconclusive
ultrasound scan in early pregnancy, a single serum progesterone test may be
able to identify those who are likely to miscarry or who have an ectopic
pregnancy, a meta-analysis showed.
In a pooled analysis, a single test with a threshold of 3.2
to 6 ng/mL predicted a nonviable pregnancy with a sensitivity of 74.6% and a
specificity of 98.4%, according to Ioannis Gallos, MD, of the University of
Oxford in England, and colleagues. The risk of a nonviable pregnancy was 99.2%
when progesterone levels were below the cutoff and 44.8% when they were above
the cutoff, the researchers reported online in BMJ.
The progesterone test could not, however, distinguish
between an ectopic pregnancy and a miscarriage. Serial serum β human chorionic
gonadotropin measurements are needed for that purpose.
The researchers said that a progesterone test could serve in
a complementary role for women presenting with pain or bleeding early in
pregnancy. "This test could be added to the existing algorithms for
evaluation of early pregnancy, and its effect should be evaluated through a
randomized trial comparing algorithms with and without serum
progesterone," they wrote.
Vaginal bleeding and abdominal pain are common early in
pregnancy, with about 30% of women reporting those symptoms in the first
trimester. Most women with those symptoms will undergo a transvaginal
ultrasound to explore the problem, but that might not be enough to determine
whether the pregnancy is viable.
A progesterone test has been proposed to help make the
diagnosis because low levels are associated with miscarriages and ectopic
pregnancies. To assess the diagnostic accuracy of such a test, the researchers
reviewed data from 26 cohort studies that included a total of 9,436 women with
a pregnancy of less than 14 weeks gestation; seven of the studies included
women with pain or bleeding plus an inconclusive ultrasound result and 19
included women with the symptoms alone. Meta-analysis revealed a high degree of
accuracy for a single serum progesterone test to rule out a viable pregnancy in
women with symptoms and an inconclusive ultrasound result.
Diagnostic accuracy, however, was not as high among the
women with symptoms alone. In those women, the progesterone test -- using a
cutoff of 10 ng/mL -- predicted nonviable pregnancies with a pooled sensitivity
of 66.5%, and a specificity of 96.3%.
The median prevalence of nonviable pregnancy was 62.9%, a
rate that increased to 96.8% when the progesterone level was below 10 ng/mL and
dropped to 37.2% when the progesterone level was above the cutoff.
Verhaegen J, et al. Accuracy of single progesterone test to
predict early pregnancy outcome in women with pain or bleeding: meta-analysis
of cohort studies. BMJ 2012; DOI: 10.1136/bmj.e6077. Full-text: http://www.bmj.com/content/345/bmj.e6077
15. Inviting Patients
to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead
Delbanco T, et al. Ann Intern Med. 2 October
2012;157(7):461-470
Background: Little information exists about what primary
care physicians (PCPs) and patients experience if patients are invited to read
their doctors' office notes.
Objective: To evaluate the effect on doctors and patients of
facilitating patient access to visit notes over secure Internet portals.
Design: Quasi-experimental trial of PCPs and patient
volunteers in a year-long program that provided patients with electronic links
to their doctors' notes.
Setting: Primary care practices at Beth Israel Deaconess
Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in
Pennsylvania, and Harborview Medical Center (HMC) in Washington.
Participants: 105 PCPs and 13 564 of their patients who had
at least 1 completed note available during the intervention period.
Measurements: Portal use and electronic messaging by
patients and surveys focusing on participants' perceptions of behaviors,
benefits, and negative consequences.
Results: 11 797 of 13 564 patients with visit notes
available opened at least 1 note (84% at BIDMC, 92% at GHS, and 47% at HMC). Of
5391 patients who opened at least 1 note and completed a postintervention
survey, 77% to 87% across the 3 sites reported that open notes helped them feel
more in control of their care; 60% to 78% of those taking medications reported
increased medication adherence; 26% to 36% had privacy concerns; 1% to 8%
reported that the notes caused confusion, worry, or offense; and 20% to 42%
reported sharing notes with others. The volume of electronic messages from
patients did not change. After the intervention, few doctors reported longer
visits (0% to 5%) or more time addressing patients' questions outside of visits
(0% to 8%), with practice size having little effect; 3% to 36% of doctors
reported changing documentation content; and 0% to 21% reported taking more
time writing notes. Looking ahead, 59% to 62% of patients believed that they
should be able to add comments to a doctor's note. One out of 3 patients
believed that they should be able to approve the notes' contents, but 85% to
96% of doctors did not agree. At the end of the experimental period, 99% of
patients wanted open notes to continue and no doctor elected to stop.
Limitations: Only 3 geographic areas were represented, and
most participants were experienced in using portals. Doctors volunteering to
participate and patients using portals and completing surveys may tend to offer
favorable feedback, and the response rate of the patient surveys (41%) may
further limit generalizability.
Conclusion: Patients accessed visit notes frequently, a
large majority reported clinically relevant benefits and minimal concerns, and
virtually all patients wanted the practice to continue. With doctors
experiencing no more than a modest effect on their work lives, open notes seem
worthy of widespread adoption.
Primary Funding Source: The Robert Wood Johnson Foundation,
the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation,
and the National Cancer Institute.
Full-text (free): http://annals.org/article.aspx?articleid=1363511
See also Meltsner M. A Patient's View of OpenNotes. Ann
Intern Med 2012;157(7):523-524.
16. Bilateral
Anterior Dislocation of the Shoulder: Review of Seventy Cases and Proposal of a
New Etiological-mechanical Classification
Ballesteros R, et al. J Emerg Med. 2012; in press
Background: Although anterior shoulder dislocation is common
in everyday practice in Emergency Departments, bilateral presentation is a rare
entity.
Objectives: The aim of this article is to report two
additional cases of this rare injury and to introduce a new mechanism that can
produce it. We made an exhaustive review of the literature and found 68 cases
in printed publications. Also, we analyzed the mechanism of injury and the
presence of predisposing factors, and propose a new etiological-mechanical
classification.
Case Report: One case occurred after a trivial fall, and the
other was produced by a mechanism not previously reported: the patient pushed
strongly forward, expecting a resistance and finding none, his arms kept the
forward movement and the shoulders dislocated.
Discussion: This lesion has a bimodal distribution,
affecting mainly men (70%) with a mean age of 33.5 years, whereas in women, the
average age is 57 years. The most common cause is trauma (50%), followed by
muscle contractions (37%) due to seizures of different causes (epileptic, hypoglycemia,
toxic, or hypoxic) or electrocution. In 15.7% of the cases, the diagnosis of
bilateral anterior dislocation was not acute (less than 3 weeks), and in
virtually all of these cases it was not traumatic.
Conclusion: The bilateral anterior shoulder dislocation may
not be as rare as previously thought and must be taken into account in
emergency services. The authors propose a new etiological-mechanical
classification. Also, the importance of radiologic diagnosis must be
highlighted.
17. Sepsis Update:
Management of Severe Sepsis and Septic Shock In The ED After The Withdrawal Of
Xigris
Green RS, et al. CJEM 2012;14(5):265-266
Xigris, a systemic anticoagulant used for the management of
patients with severe sepsis and septic shock, has recently been removed from
the market. Also known as drotrecogin alfa (activated) or activated protein C,
this medication is no longer available for use. Recommendations and guidelines
(including the Canadian Association of Emergency Physicians [CAEP] sepsis
guidelines1) require revision to reflect this important development.1
The story of Xigris serves as a cautionary tale, which has
both advanced and distracted the care of patients with severe sepsis/septic
shock. Few emergency physicians may be aware of the history of this medication,
the controversy surrounding it, and evidence leading to its use and subsequent
termination as a treatment option.
The remainder of the essay: http://www.cjem-online.ca/v14/n5/p265
18. Cochrane Review
Says Topical NSAIDs a Better Choice for Elderly with OA
Janis C. Kelly. Medscape Medical News. September 18, 2012 —
Topical diclofenac is about as effective as oral diclofenac in knee and hand
osteoarthritis (OA), is probably as effective as other oral NSAIDs, and might
be a safer choice for elderly patients and others at risk for gastrointestinal
adverse effects, according to an intervention review published online September
12 in the Cochrane Database of Systematic Reviews.
Sheena Derry, PhD, and colleagues from the University of
Oxford in the United Kingdom based their conclusions about topical NSAIDs on a
review of randomized, double-blind studies with placebo or active comparators
in which at least a single treatment was a topical NSAID used to treat chronic
pain caused by OA, and in which treatment lasted at least 2 weeks. The analysis
included data from 7688 participants in 34 studies, 23 of which compared a
topical NSAID with placebo.
"Topical NSAIDs were significantly more effective than
placebo for reducing pain due to chronic musculoskeletal conditions," the
authors conclude. "Direct comparison of topical NSAID with an oral NSAID
did not show any difference in efficacy." Topical NSAIDs were associated
with more local adverse events, such as mild rash, but with fewer
gastrointestinal adverse events than oral NSAIDs.
For topical diclofenac, the number needed to treat (NNT) for
at least 50% pain relief vs placebo was 6.4 for diclofenac solution and 11 for
diclofenac gel formulation. There were insufficient data to calculate NNTs for
other individual topical NSAIDs.
"The results presented here show clearly that high
quality large studies demonstrate efficacy of topical NSAIDs in 12 week
studies, with NNTs similar to those of oral NSAIDs," the authors write.
Coauthor R. Andrew Moore, from the Pain Research Unit at
Oxford University, told Medscape Medical News that in view of the low NNT for
diclofenac solution, it would be reasonable for clinicians to view that
formulation as good first-line therapy for hand or knee OA, especially in
elderly patients. "It is what [the National Institute for Health and
Clinical Excellence] in the UK suggest in their excellent OA guideline,"
Dr. Moore said. "This [is] nothing new for us, but then we have been
looking at the evidence on topical NSAIDs for almost 20 years.... [And] what we
said then is true now. Truer, perhaps."
Experimental data suggest that creams are generally less
effective than gels or sprays, according to the authors. "One of the
features of topical NSAIDs is that formulation has the potential to play a big
part in efficacy," Dr. Moore said.
The authors write, "It is probable that topical NSAIDs
exert their action both by local reduction of symptoms arising from
periarticular structures, and by systemic delivery to intracapsular structures.
Tissue levels of NSAIDs applied topically certainly reach levels high enough to
inhibit cyclooxygenase-2. Plasma concentrations found after topical
administration, however, are only a fraction (usually much less than 5%) of the
levels found in plasma following oral administration. Topical application can
potentially limit systemic adverse events by increasing local effects, and
minimizing systemic concentrations of the drug. We know that upper
gastrointestinal bleeding is low with chronic use of topical NSAIDs."
Roy Altman, MD, professor emeritus, Division of
Rheumatology, University of California, Los Angeles, reviewed the study for
Medscape Medical News. "I think this Cochrane review was well done and
carefully reported," Dr. Altman said. "The data are convincing. Their
results are concordant with our results from the literature and consistent with
our recommendations of the American College of Rheumatology guidelines
published earlier this year. I suspect topical NSAIDs will eventually be
approved for over-the-counter use, as they are in Europe. That will
dramatically increase their use."
Derry S, et al. Cochrane Database Syst Rev. Published online
September 12, 2012
19. Suicides More
Common than Traffic Deaths
By Crystal Phend, Senior Staff Writer, MedPage Today,
September 25, 2012
Suicide has overtaken traffic accidents as the leading cause
of injury deaths in the U.S., a national study found. The suicide rate rose 15%
over the past decade, while unintentional motor vehicle crashes fell 25%, Ian
R.H. Rockett, PhD, MPH, of the West Virginia University School of Public Health
in Morgantown, and colleagues found.
Deaths from poisoning and falls also rose substantially from
2000 through 2009, the group reported online in the American Journal of Public
Health.
"Comprehensive and sustained traffic safety measures
have apparently substantially diminished the motor vehicle traffic mortality
rate, and similar attention and resources are needed to reduce the burden of
other injury," they wrote. Eliminating fatal injuries might raise the
national life expectancy by 1 to 2 years, "but it would extend the mean
length of life of those whose deaths were averted by a projected 3
decades," they added.
The researchers analyzed data on cause of death from the
CDC's National Center for Health Statistics for patterns and trends in fatal
injury from 2000 through 2009. Overall, combined unintentional and intentional
injury mortality rose 10% over this period from 53 to 56 per 100,000 population
after adjustment for trends in age. The adjusted total injury death rate fell
78% in the youngest age group -- those 14 and under, while the 75 and older
group had a 2.8-fold increase. Total injury death rates rose more among females
and whites than among other groups.
The five leading causes of injury deaths accounted for an
increasing proportion, up from 77% to 82% over the study period.
Shifts occurred within the list as well. Suicide took over
from motor vehicle accidents as the leading cause of injury death in 2009, with
an age-adjusted rate of 12 per 100,000 population in that year. Motor vehicle
crashes remained in second place with an age-adjusted rate of 11 per 100,000. "Our
finding that suicide now accounts for more deaths than do traffic crashes
echoes similar findings for the European Union, Canada, and China,"
Rockett's group noted.
Poisoning rose the most among the injury-related causes of
death. The 128% increase from 2000 to 2009 bumped homicide out of third place
in 2003. These deaths were largely accounted for by overdoses of prescription
drugs, particularly opioid analgesics.
Tackling fatal overdoses may take a multi-pronged approach,
the investigators noted. "Several promising prevention and control
strategies have recently been implemented, including Prescription Drug
Monitoring Programs, the Food and Drug Administration's Opioid Drugs and Risk
Evaluation and Mitigation Strategies, provider prescribing guidelines, and
single provider-single pharmacist 'lock-in' programs," they wrote.
Falls also surpassed homicide in 2004 to become the fourth
most common cause of injury deaths at a rate of 7 per 100,000 in 2009, which
reflected a 54% increase since 2000. The increase in fall-related deaths was
greater with older age and disproportionately affected men and whites. Homicide
ended up as the fifth leading cause of injury deaths, with an 8% decline to an
age-adjusted rate of 5 per 100,000 in 2009.
Limitations of the study were largely due to the quality of
the information recorded on the death certificate, which could have been
influenced by differential reporting stemming from "variable training,
resources, philosophies, procedures, and practices of medical examiners and
coroners," Rockett's group cautioned. Distinguishing intentional from
unintentional injury is also a challenge, they noted.The study was supported in
part by grants from the CDC and the National Institute on Alcohol Abuse and
Alcoholism.
Rockett IRH, et al. Leading causes of unintentional and
intentional injury mortality: United States, 2000–2009. Am J Public Health 2012
Nov;102(11):e84-e92.
20. Kaiser study finds efficacy of DTaP vaccine
is short-lived
A Kaiser Permanente study found that the diphtheria and
tetanus toxoids and acellular pertussis adsorbed, or DTaP, vaccine had a short
efficacy span in preventing pertussis and that protection declined quickly
after the fifth and final dose. Researchers said preventing future whooping
cough outbreaks may require new vaccines or reformulating existing ones to
provide longer immunity. The study was reported in the New England Journal of
Medicine.
21. Infecting the Electrocardiogram
Fredrickson M, et al. Arch Intern Med. 2012 Oct 1:1. doi:
10.1001/archinternmed.2012.3740a. [Epub ahead of print]
A 60-year-old man with no known medical history was admitted
to our emergency department following an episode of syncope. The patient was at
work when he suddenly developed tunnel vision and lightheadedness followed by
loss of consciousness for 10 seconds. There was no chest pain, shortness of
breath, or palpitations. His blood pressure was 118/37 mm Hg, with a heart rate
of 38 beats/min. He was alert and oriented. Heart sounds were normal with an
irregular rate, no murmurs or gallop, and symmetric pulses. An initial
electrocardiogram (ECG) was obtained (Figure 1: http://archinte.jamanetwork.com/article.aspx?articleid=1368354).
What are the significant findings and what is the
differential diagnosis?
Discussion (requires subscription): First page here: http://archinte.jamanetwork.com/article.aspx?articleid=1368355
Invited commentary (free full-text): http://archinte.jamanetwork.com/article.aspx?articleid=1368356
22. Readers Beware: 'Spinning' Study Results
Happens at All Levels
By Cole Petrochko, Associate Staff Writer, MedPage Today.
September 11, 2012
The positive "spin" that study abstracts and press
releases put on research outcomes can distort -- and possibly misinform --
media coverage of those studies, researchers found.
Spin in a study press release was significantly associated
with spin in news reports on that study (P less than 0.001), which was then
significantly associated with an overestimation of study benefits compared with
media stories without spin (P=0.009), according to Isabelle Boutron, PhD, of
the Institut National de la Santé et de la Recherche Médicale in Paris, and
colleagues.
In addition, spin -- defined as reporting that emphasized
"the beneficial effects of the experimental (new) treatment" -- was
nearly six times more likely to be found in a press release if the conclusion
of the abstract also was "spun" (RR 5.6, 95% CI 2.8 to 11.1, P less
than 0.001), Boutron and co-authors wrote online in PLoS Medicine.
"'Spin' can distort the transposition of research into
clinical practice and, when reproduced in the mass media, it can give patients
unrealistic expectations about new treatments," the authors added.
Boutron and colleagues studied the presence of spin in press
releases and news coverage and whether the presence of spin leads to
misrepresentation of study findings in those releases. The authors found 70
studies with associated press releases, as well as 41 news stories based on the
press releases.
Studies were evaluated for whether the researched treatment
was beneficial to patients. A press release or news article was considered to
misrepresent a study if the benefit of the treatment was overestimated or if adverse
effects were underestimated.
Just under half (49%) of the studies had statistically
significant findings, while just over a third (34%) had no statistically
significant primary outcomes. Still, 40% of the articles had some kind of spin
in the abstract conclusion, including:
·
No acknowledgement of nonstatistically
significant primary outcomes (20%)
·
Establishing P-values larger than 0.05 as
equivalent (7%)
·
Inappropriate extrapolation (9%)
·
Focusing on significant results in subgroup
analyses (6%), within-group comparisons (9%), and secondary outcomes (4%)
·
Inadequate claims of safety (6%)
Additionally, 47% of the press releases and 51% of the news
stories contained spin.
Studies that were spun in news coverage were more likely to
be published in a specialty journal rather than a general one (67% versus 35%,
P=0.04), to have a small sample size versus a large one (68% versus 32%,
P=0.02), and to be based on studies with spin in the abstract or press release
versus no spin (100% versus 5% and 100% versus 13%, respectively, P less than 0.001
for both).
News reports also were significantly more likely to
overestimate study benefit when the study had a small versus large sample size
(41% versus 5%, P less than 0.01) or if the news story contained spin on the
study findings (43% versus 5%, P=0.009).
Spin was significantly more likely to appear in studies with
a small sample size versus a large sample size (63% versus 31%, P=0.008) and in
studies with spin in the abstract conclusion versus articles without any (93%
versus 17%, P less than 0.001). Similarly, risk of spin in the press release
was significantly associated with spin in the abstract conclusion (RR 5.6, 95%
CI 2.8 to 11, P less than 0.001).
In a comparison of results based on press release data
versus the study's full text, 79% of treatments were considered beneficial in
press releases versus 54% in the full text, 3% were of neutral benefit versus
26%, and 18% were not beneficial versus 20%.
Factors significantly associated with misinterpreted study
outcomes included publication in a specialized versus general journal (45%
versus 6%, P less than 0.001), small versus large sample size (46% versus 9%, P
less than 0.001), and presence of spin in the press release versus no spin (48%
versus 8%, P less than 0.001). Data in studies with nonstatistically
significant versus significant primary outcomes also were misrepresented more
often (42% versus 20%, P=0.05).
The authors noted that spin, in conjunction with other
biases in reporting, "may be responsible for an important gap between the
public perception of the beneficial effect and the real effect of the treatment
studied."
They added that, although press releases are meant to
summarize and contextualize findings rather than detail the complete study, use
of spin in press releases can be problematic if it "modifies readers'
interpretation of research findings." And they noted that the findings
"raise the issue of the quality of the peer review process and highlight
the importance of this process for disseminating accurate research
results."
Boutron and colleagues said their research was limited by
their use of studies reported in English with releases housed in a single
source and within a 4-month period, and that the single source did not reflect
on all press releases or news reports. They also did not search for spin in the
article bodies and recognized their analyses and interpretations were based on
subjective measures.
The authors declared no conflicts of interest.
Boutron I, et al. Misrepresentation of randomized controlled
trials in press releases and news coverage: a cohort study. PLoS Med 2012;
9(9): e1001308.
23. U.S.
Warning to Hospitals on Medicare Bill Abuses
By Reed Abelson and Julie Creswell. New York
Times September 24, 2012
Saying there are “troubling indications” of abuse in the way
hospitals use electronic records to bill forMedicare and Medicaid reimbursement,
the Obama administration warned on Monday that it would not tolerate what
it called attempts to “game the system” and vowed to vigorously prosecute
doctors and hospitals implicated in fraud.
The strongly worded letter, signed by the attorney
general, Eric H. Holder Jr., and the secretary of health and human
services, Kathleen Sebelius, said that “electronic health records have the
potential to save money and save lives.”
But the letter continued: “There are troubling indications that
some providers are using this technology to game the system, possibly to obtain
payments to which they are not entitled. False documentation of care is
not just bad patient care; it’s illegal.”
“Obviously, we are very concerned” that the adoption of electronic
health records “could lead to coding inappropriately,” an administration
official said. While aggressively looking for any providers who are
committing fraud, the administration will also consider whether it needs to
make changes in the way it pays for care.
The letter, sent to five major hospital trade associations,
cited possible abuses including “cloning” of medical records, where information
about one patient is repeated in other records, to inflate reimbursement.
“There are also reports that some hospitals may be using
electronic health records to facilitate ‘upcoding’ of the intensity of care or
severity of patients’ condition as a means to profit with no commensurate
improvement in the quality of care,” the letter said.
The letter was sent two days after a front-page
article in The New York Times detailed the ways in which the greater use
of electronic records by hospitals and doctors might be contributing to a
rise in Medicare billing. Much of the higher billing is taking place in hospital
emergency rooms, where hospitals are classifying many more patients as
sicker and needing more care.
Hospitals received $1 billion more in Medicare
reimbursements in 2010 than they did five years earlier, at least in part by
changing the billing codes they assign to patients in emergency rooms,
according to an analysis by The Times of Medicare data from the American
Hospital Directory. Regulators also say physicians have changed the way
they bill for office visits similarly, increasing their payments by billions
of dollars.
Regulators, including the Office of Inspector General for
Health and Human Services, are concerned about the increase in billing for the
most expensive evaluation services by hospitals, in the emergency room,
and by doctors in their offices. Private insurers have also expressed concern
about the higher level of billing.
The Centers for Medicare and Medicaid Services is conducting
audits to prevent improper billing. The agency is also starting more extensive
medical reviews of billing practices that will identify those hospitals or
doctors that are billing for much more expensive services than their peers,
according to the letter. While not unprecedented, the letter is especially
blunt.
The issue of Medicare costs is a contentious one in the
presidential campaign and has been a centerpiece of the Obama administration.
As part of a push that began under the Bush administration, government
officials are spending tens of billions of dollars to encourage hospitals and
doctors to use electronic records as a way to reduce costs and improve
care.
“This letter underscores our resolve to ensure payment
accuracy and to prevent and prosecute health care fraud,” the letter said. The
letter reminded hospitals that a patient’s medical information “must be
verified individually to ensure accuracy: it cannot be cut and pasted from a
different record of the patient, which risks medical errors as well
as overpayments.”
The five hospital associations receiving the letter were the
American Hospital Association, the Federation of American Hospitals, the
Association of Academic Health Centers, the Association of American
Medical Colleges and the National Association of Public Hospitals and Health
Systems. The associations, in turn, will notify their member hospitals
about the administration’s concerns. Many hospitals and doctors argue that the
new systems allow them to more accurately record information about their
patients, leading to higher payments for the services they provide. They
say the paper records often did not reflect how sick the patients they were
treating were and how much time hospitals and doctors were spending during
a visit.
Rich Umbdenstock, the chief executive of the American
Hospital Association, which represents more than 5,000 member hospitals, responded
to the administration’s letter, saying hospitals “take seriously their
obligation to properly bill for the services they provide to Medicare and
Medicaid beneficiaries.”
“We agree that the alleged practices described in your
letter, such as so-called ‘cloning’ of medical records and ‘upcoding’ of the
intensity of care, should not be tolerated,” he wrote in a letter. The
letter also called for Medicare to develop clear national guidelines for the
billing of hospital emergency room and clinic visits.
Some experts have criticized federal officials for not
providing more guidance to the software companies developing the electronic
records or to hospitals and doctors about what is and what is not allowed.
Officials say they are considering whether they need to take additional steps
to clarify the rules and educate hospitals and doctors. “Those are steps
we could consider in the future,” said the administration official. The letter
from Ms. Sebelius and Mr. Holder said, “As we phase in electronic health
records, though, we ask for your help in ensuring these tools are not misused
or abused.”
The administration said it had undertaken record-high
collections and prosecutions against fraud, contending that prosecutions in
2011 were 75 percent higher than in 2008. In a report last February
about the administration’s efforts, officials said the federal government had
received about $2.4 billion in fiscal 2011 from health care
fraud settlements and judgments.
24. Largest Study
Ever Links Electronic Health Records with Improved Patient Outcome
Zina Moukheiber, Forbes. October 3, 2012
A study conducted at HMO giant Kaiser Permanente involving
nearly 170,000 patients with diabetes found that use of electronic health
records helped significantly reduce A1c levels (average blood glucose over the
previous three months) and LDL cholesterol in patients with the highest levels,
indicating better monitoring and treatment. Those with lower A1c and LDL values
experienced incremental improvements. Since their target levels were under
control, they underwent less testing, suggesting electronic health records
could actually reduce overtesting.
The study, which appears tomorrow in Annals of Internal
Medicine, was conducted between 2004 and 2009 at 17 medical centers in Northern
California. During that period, Kaiser Permanente was making the transition
from a patchwork of health IT systems and paper charts to Epic Systems at a
cost of $4 billion—the largest implementation of a commercial electronic health
record. The National Institute of Diabetes and Digestive and Kidney Diseases
funded the study.
Patients who were tracked had been Kaiser members since
2003. “We wanted to determine whether an EHR had a positive or negative impact
on diabetes patients,” says Marc Jaffe, an endocrinologist at Kaiser, and an
author of the study. “It [use of EHRs] helps us target patients.”
Jaffe and his colleagues, including lead author and research
scientist Mary Reed, looked at blood tests taken at intervals recommended by
the American Diabetes Association, and drug prescriptions. They excluded
patients on insulin, because intake was more difficult to gauge, and the bulk
of diabetes patients in the registry were on pills. Jaffe posits that the drop
in A1c and LDL levels was not only due to a readjustment in dosage or a switch
in medication, but also possibly to better compliance to existing medication in
patients with the most elevated levels.
At the very least, electronic health records didn’t harm
patients. “Skeptics who say the effort and energy that go into implementing an
EHR detract from care have clearly been disproved,” says Jaffe. Hopefully,
those kinds of promising results can be replicated elsewhere.
