Saturday, December 3, 2011

Physician Profiteering From Self-Referral

Unfortunately, another distasteful – and likely more common than the authors estimate – assessment of the unethical behavior of physicians.

This is from JAMA.  It's a health-insurance carrier records review regarding differences in rate of ordering nuclear stress testing and stress echocardiography depending on the cardiologist financial conflict-of-interest.  Basically, they were asking the question – if the ordering cardiologist had a financial interest in the imaging performance and interpretation, would they order more tests?

Sadly, as you might imagine, the answer is yet.  If the physician billed technical and professional fees for the nuclear stress, the adjusted OR for ordering a nuclear stress was 2.3 compared to physicians who had no financial interests in the nuclear stress.  For stress echocardiography, the adjusted OR was 12.6.

I have no doubt the same sort of thing happens with neurologists who own their own MRI facilities, etc.  Money corrupts physicians just the same as any other human being.

"Association Between Physician Billing and Cardiac Stress Testing Patterns Following Coronary Revascularization"
jama.ama-assn.org/content/306/18/1993

Thursday, December 1, 2011

C1-Esterase Inhibitor Might Improve Some Sepsis Outcomes

...or it might not.  This is a tiny study using a very expensive medication that probably works only on a few patients, but it's interesting nonetheless.

As part of the inflammatory cascade, C1-esterase inhibitor (C1INH) modulates the coagulation cascade, impacts leukocyte activation, enhances bactericidal activity, and prevents endotoxin shock in sepsis models.  So, sounds like a good thing - let's give it to patients and see what happens!

This was an open-label, randomized, controlled study in Moscow and St. Petersburg with 62 ICU patients - 20 controls and 42 treatment patients - that met inclusion criteria.  There were, unfortunately, a lot of differences between the control group and the treatment group.  These differences included a lot more post-operative patients, much more pneumonia, and more on the ventilator, and probably favored the treatment group.  The mortality is way better for the treatment group - 12% dead versus 45% - but it's simply impossible to attribute all the effects to C1INH with all the other confounding differences.

That being said, this study is consistent the effects from other small studies.  Therefore, we will likely hear more about C1INH after larger, manufacturer-sponsored trials also undoubtedly find a way to spin positive results.

"C1-esterase inhibitor infusion increases survival rates for patients with sepsis"
www.ncbi.nlm.nih.gov/pubmed/22080632

Wednesday, November 30, 2011

ED Blood Pressure Management In Acute Stroke Is Terrible

This is a non-TPA article regarding the medical management of hypertension in acute ischemic stroke in the Emergency Department.

The authors remind us that for every 10 mmHg drop in SBP <150 mmHg, there is a 17.9% increase in risk for death at 14 days.  They additionally remind us that antihypertensive therapy is only recommended for BP >220/120 mmHg, with a 15-25% goal decrease in the first 24 hours.

This is a retrospective review of cases from 16 Cincinnati region hospitals looking at the blood pressure observed in the ED along with any treatment.  They found 1739 cases, 1520 of whom did not receive treatment and 219 who did.  It turned out that 2.6% of the non-treated patients should have had some blood pressure lowering - oops.  But, amazingly even worse, only 31.5% of patients who did receive treatment actually required lowering.

Of the 217 patients that were treated, 52 of them had greater than a 20% drop in blood pressure in the Emergency Department.  So, we treat a lot of blood pressure that shouldn't be treated - and when we treat it, it is not uncommon to treat it too aggressively.

Stop it!

"Emergency Department Adherence to American Heart Association Guidelines for Blood Pressure Management in Acute Ischemic Stroke"
http://www.ncbi.nlm.nih.gov/pubmed/22033993

Monday, November 28, 2011

Computer Reminders For Pain Scoring Improve Treatment

This is a paper on an important topic - considering the CMS quality measures coming up that will track time to pain medication for long bone fractures - that demonstrates a mandatory computer reminder improved pain treatment more than an educational campaign did.

This is a prospective study of 35,628 patients visiting an Australian emergency department in which they went through several phases of intervention, the most salient in their minds was requiring assessment of a pain score at triage.  They started by simply observing their performance, then they altered their electronic medical record with a mandated input of the pain score at triage.  After the mandated scoring, time to analgesia went from median of 123 minutes to 95 minutes.  After the mandate phase, the ED staff underwent an education program regarding pain management in the ED - and the time to analgesia didn't improve any further.

So, it is reasonable to infer that mandating the pain score at triage had the desired effect on decreasing time to analgesia.  However, 95 minutes until analgesia is still terrible.  It would be far more interesting of an article if it truly broke down all the times - such as time to triage, time to room, time to physician, time to analgesia order, etc., because there are a lot more data points to gather.

Additionally, it seems it might simply be higher yield if - in addition to asking pain in triage - they had a triage protocol to treat the pain immediately at that point, rather than later downstream.

"Mandatory Pain Scoring at Triage Reduces Time to Analgesia"
www.ncbi.nlm.nih.gov/pubmed/21908072

Sunday, November 27, 2011

False-Negative Abdominal CTs

This is an article from the radiology literature that essentially tries to say that CT is not the imaging modality of choice for upper abdominal pain.

It's a retrospective review of 235 patients over a four-year period who had CTs of the abdomen reported as "normal" or "non-diagnostic" in the setting of upper abdominal pain.  They determine false-negative studies if another diagnostic modality eventually provided a definitive diagnosis for the patient's symptoms.  Out of the 235, 81 were lost to follow-up and 27 were excluded for other reasons.  Of the remaining 127, 46 were classified as false-negative and 81 were classified as true-negative.

The misses?  23 cases of pancreaticobiliary disease (biliary colic, cholecystitis, choledocholithiasis), 12 cases of gastritis/gastric ulcer disease, and 6 miscellaneous cases that included Mediterranean fever and prosthetic valve endocarditis.

So, yes, there is some inkling that CT of the upper abdomen is going to miss a segment of pathology.  On the other hand, this paper presents incomplete data regarding the true positives and false positives - making evaluation of this specific imaging indication incomplete other than to remind clinicians that the evaluation may need to continue in the setting of a negative CT.

"Negative predictive value of intravenous contrast-enhanced CT of the abdomen for patients presenting to the emergency department with undifferentiated upper abdominal pain"
www.ncbi.nlm.nih.gov/pubmed/22072086