Friday, July 15, 2011

Video Education For Emergency Departments

I know you can't get published if you say something like "Our intervention is probably not useful and serves only as a cautionary tale for other wayward sailors", but it still bothers me when you stretch the conclusions out by saying that an intervention that is probably not better than the control group "appears promising".

This is a group that looked at the best way to improve parent education in pediatric asthma encounters in the Emergency Department.  They compared a video-based education program to a written handout and found...it didn't make much difference.  They had two groups of parents, those with "low health literacy" and those with "adequate health literacy".  The low literacy group improved a ton regardless of which educational modality was used.  The adequate literacy group barely budged with written and had a little bit more of bump with video - but the relative change in their level of literacy really wasn't anything to write home about and they don't try to offer an explanation for why intelligent people derive no benefit from written education.

But it doesn't stop them from stating it "appears promising" - which, I suppose, means it's probably better than not educating people at all, or potentially educating the illiterate.

"Parental Health Literacy and Asthma Education Delivery During a Visit to a Community-Based Pediatric Emergency Department."
http://www.ncbi.nlm.nih.gov/pubmed/21629152

Thursday, July 14, 2011

The Diagnose-a-Tron of the Future: FDG-PET

Imagine, if necessary, a case you see every hour in the ED - a child with a fever.  Wave a magic wand in triage, find the source of the fever, and let the doctor pick up the decision-making process advance from there.

This scenario is, of course, totally farfetched - after all, you still need a certain number of HPI and ROS elements before you wave the magic wand to bill at a higher level of service.

But, the principle - this is a fascinating article regarding the workup of "fever of unknown origin" in adults.  These 81 patients had fevers for 3 weeks without a satisfactory explanation, and their cases were retrospectively reviewed following referral to FDG-PET scans.  Essentially, any time this FDG-PET scan localized to an area of high uptake, it provided significant helpful localizing information regarding the underlying disease process.  Examples of diagnoses it identified were infectious endocarditis, tuberculosis, pyogenic spondylitis, graft infections, Takayasu arteritis, and a host of other fascinatingly difficult diseases to identify.

The main diagnostic drawback is that it is mostly only structurally/anatomically specific, not necessarily disease specific, so there is a lot to do in terms of clinical correlation with imaging findings.  And then there is the small issue where it's a nuclear medicine study requiring 5 hours of fasting and an injection of the FDG tracer 1 hour before the study is performed.  But, someday a decade out, the next generations of these devices might be more clinician-friendly....

"FDG-PET for the diagnosis of fever of unknown origin: a Japanese multi-center study."
www.ncbi.nlm.nih.gov/pubmed/21344168

Tuesday, July 12, 2011

5% of Patients Spend 50% of Our Healthcare Dollars

Per-capita spending doubled from 1997 through 2009 from $4100 to $8100 - with 5% of patients spending $35,800 on average annually to account for 47.5% of healthcare spending.  Overall, the five most expensive conditions are heart disease, cancer, trauma, mental disorders, and pulmonary conditions.

Unsurprisingly, people over 55 made up the majority of the high spending groups.  Unhappily enough, the authors note a "flattening" of the distribution of spending, where younger individuals are responsible for a greater proportion of the spending.  This is not due to more cost-effective care in the elderly, it's a result of increasing disease prevalence in the young, primarily attribute to obesity-related diseases such as hypertension, diabetes, hyperlipidemia.

May you live in interesting times, indeed.

"Understanding U.S. Health Care Spending - NIHCM Foundation Data Brief July 2011"
http://www.nihcm.org/images/stories/NIHCM-CostBrief-Email.pdf

Monday, July 11, 2011

Send Children With Negative CTs Home

We should all love PECARN.  I love PECARN (Pediatric Emergency Care Applied Research Network) - and not just because I helped set it up as a research assistant peon before medical school.  I love it because it takes multicenter enrollment cohorts to conduct adequately powered research in a population that is rarely affected by serious morbidity and mortality.

Of 13,543 children with GCS 14 or 15 and a normal CT scan, none needed neurosurgical intervention in their follow-up period.  A small handful of these patients had a repeat CT or MRI for some reason, and between 10-25% of the hospitalized patients and 2-10% of the discharged patients had an abnormal result on repeat imaging.  None led to any intervention...which then, of course, begs the question whether it was appropriate to perform a test that did not result in meaningful change in management.  But, there's not enough patients in this group to draw conclusions as to whether repeat scans should or should not be performed.

My only caveat - when you take an over-utilized test in which nearly all patients are certainly fine and will continue to be fine, you actually dilute its external validity to the patient population that really matters.  However, even in a higher-risk patient population in which CTs are used far more conservatively, the clinically relevant answer is still going to be same - the only reasonable practice is still going to be to discharge these patients home.

"Do children with blunt head trauma and normal cranial tomography scan results require hospitalization for neurologic observation?"
www.ncbi.nlm.nih.gov/pubmed/21683474

Sunday, July 10, 2011

Groomsman Gifts

I bought all my groomsmen whiskey as gifts - at the world's largest liquor store, which is conveniently located 7 blocks from my new home in Houston.

Longrow 14 Year Old Sherry Cask Finish
It's a Campbeltown region Scotch whiskey that's a peatier version of the Springbank that I think is very nice.  Made by the same distillery in a limited run every year.

Suntory Yamazaki 18 Year Old
I posted once upon a time about the 12 year version of this whiskey, which is a Japanese whiskey aged in three types of oak cask.  I really liked the reasonably-priced 12 year, and I hope my best man will enjoy the 18.

Ardbeg Corryvreckan
Named after a famous maelstrom, it's a viscous, peaty Scotch whiskey for my friend who loves all things Islay.

Woodford Reserve Master's Collection
For my bride's brother, who prefers Bourbon whiskey, the seasoned oak finish Master's Collection edition.