Friday, August 5, 2011

Physicians Will Test For PE However They Damn Well Please

Another decision-support in the Emergency Department paper.

Basically, in this study, an emergency physician considered the diagnosis of pulmonary embolism - and a computerized intervention forced the calculation of a Wells score to help guide further evaluation.  Clinicians were not bound by the recommendations of the Wells calculator to guide their ordering.  And they sure didn't.  There were 229 patients in their "post-intervention" group, and 26% of their clinicians said that evidence-based medicine wasn't for them, and were "non-compliant" with their testing strategy.

So, did the intervention help increase the number of positive CTAs for PE?  Officially, no - their trend from 8.3% positive to 12.7% positive didn't meet significance.  Testing-guideline complaint CTA positivity was 16.7% in the post-intervention group, which, to them, validated their intervention.

It is interesting that a low-risk Wells + positive d-Dimer or high-risk Wells cohort had only a 16% positive rate on a 64-slice CT scanner - which doesn't really match up with the original data.  So, I'm not sure exactly what to make of their intervention, testing strategy, or ED cohort.  I think the take home point is supposed to be, if you you can get evidence in front of clinicians, and they do evidence-based things, outcomes will be better - but either this just was too complex a clinical problem to tackle to prove it, or their practice environment isn't externally valid.

Thursday, August 4, 2011

Should Rural Health Care Be Equivalent?

"All residents in the United States should have access to safe, high-quality health care and should have confidence in the health care system regardless of where they live."

That is the final statement of the accompanying editorial to the JAMA article documenting superiority in outcomes in urban hospitals vs. critical care access rural hospitals for acute MI, CHF, and pneumonia.  The acute MI study population is slightly more ill at baseline in the rural hospital sample, but the groups are otherwise similar.  Raw mortality is higher for AMI (26.1% vs 23.9% adjusted), CHF (13.4% vs. 12.5%) and pneumonia (13.0% vs. 12.5% [not significant]) favoring urban hospitals.

The key feature - critical access hospitals were less likely to have ICUs, cardiac cath, surgical capabilities, and had reduced access to specialists.  Is it any wonder their outcomes are worse?  As someone who moonlit in one of these hospitals as a resident, I can guarantee the standard of care in a rural setting is lower.

But, coming back to the original supposition - is it realistic to dedicate the funding and resources to bring rural hospitals up to the standard?  To equip far-flung hospitals with the same standard of care as urban settings to cover the remaining 20% of the population is likely simply an unfeasible proposition.  Living in rural areas is simply going to come with the risks associated with unavoidable delays in care and reduced access to specialists and technology.

"Quality of Care and Patient Outcomes at Critical Access Rural Hospitals"
www.ncbi.nlm.nih.gov/pubmed/21730240
"Critical Access Hospitals and the Challenges to Quality Care"
www.ncbi.nlm.nih.gov/pubmed/21730248

Tuesday, August 2, 2011

It's Impossible To Catch All Pediatric Pneumonia

Another glass half-full vs half-empty, depending on how you read it.  Their editor capsule summary says "Children without hypoxia, fever, and ausculatory findings are low risk."  The numbers say - in the absence of hypoxia, fever, or focal ausculatory findings, radiographic pneumonia was seen in 7.6% (CI 5.3-10.0).  Interesting numbers that, to me, say that pediatric pneumonia is still a black box of uncertainty.

However, what the authors call "definite" pneumonia was only 2.9% in the absence of those findings, and the editor's capsule conclusion is that low-risk patients are best served by follow-up rather than radiology.  And, this is where the half-full/half-empty comes in - because a lot of EPs don't want to the guy that sends home pneumonia even in a "low risk" situation, given than 30% of their pneumonia diagnoses required admission.  I'd rather take the half-full approach - recognizing that the majority of radiographic pneumonias are viral anyway, and, if the patient has adequate follow-up and tunes up nicely, do my best to avoid unnecessary testing in a low pretest probability setting that will end up with more false positives and unnecessary antibiotics.

"Prediction of Pneumonia in a Pediatric Emergency Department"

Monday, August 1, 2011

Does EHR Decision Support Make You More Liable?

That's the question these JAMA article authors asked themselves, and they say - probably.  The way they present it, it's probably true - using the specific example of drug-drug interactions.  If you put an anticoagulated elderly person on TMP-SMX and they come back a few days later bleeding with an INR of 7, you might be in trouble for clicking away the one important drug alert out of the one hundred you're inundated on your shift.  The authors note how poorly designed the alerts are, how few are relevant, and "alert fatigue" - but really, if you're getting any kind of alerts or have any EHR tools available to you during your practice, each time you dismiss one, someone could turn it around against you.

The authors potential solutions are an "expert" drug-drug interaction list or legislative legal safe harbors.

"Clinical Decision Support and Malpractice Risk."
www.ncbi.nlm.nih.gov/pubmed/21730245