Sunday, October 14, 2012

Lit Bits: Oct 14, 2012

From the recent medical literature...

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 . . . . 

About Interactive Medical Cases 

Each interactive case presents an evolving patient history and a series of questions and exercises designed to test your diagnostic and therapeutic skills. You will receive immediate feedback on your answers and treatment choices, along with the opportunity to compare your final score with those of your peers. Video, animation, and interactive content allow you to learn more about mechanisms, diagnostic tests, and treatments.
·         Signing in at the beginning of the case allows you to save your progress and resume later. Work by users who are not signed in will not be saved.
·         A link at the end of the case leads to a CME examination; you can claim up to 2 AMA PRA Category 1 Credits™ for participating.
·         Please share your opinions about the case by taking our survey. 

Pilot Phase: For a limited time, the Interactive Medical Cases will be in a pilot phase, during which this content and service will be available free. Your feedback is welcome and will be used to improve the interface and functionality of future Interactive Medical Cases. 

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:  

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.  

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:  

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. 

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:  
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:  

What are the significant findings and what is the differential diagnosis? 

Discussion (requires subscription): First page here: 

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.