Copy & Paste Medicine

Mostly unrelated to Emergency Medicine – but an interesting descriptive study of a downstream phenomenon I see on a frequent basis.  

For example, I'll intermittently follow-up a patient to see how they fared as an inpatient.  I'll read the inpatient documentation, consultant reports, etc. – and find the tiny EM HPI perpetuated throughout the chart with minimal modification.  This anecdotal experience is backed up by these authors who used text-compare software to identify copied passages in daily progress notes from an ICU setting.  In this ICU at MetroHealth in Cleveland, 82% of resident notes copied at least >20% of the text from the previous days' progress note – and copied 55% of the prior content on average.  Attending notes were slightly less frequently copied (74%), but tended to copy more content (61%).

There's no conclusive data regarding whether this copy/paste practice affects patient outcomes, but it's an interesting symptom of evolving medical care and documentation in the EHR era.  I hope that, as HIT evolves, documentation tools trend towards encouraging concise, effective communication, rather than this sort of (likely ineffective) chart bloat.

"Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes"
www.ncbi.nlm.nih.gov/pubmed/23263617

New ACEP tPA Clinical Policy

If you're still skeptical about the use of tPA in stroke patients – too bad.  If you're not on the bus, it would seem now you're under it.  ACEP has published their new Clinical Policy regarding tPA use in the most recent issue of Annals of Emergency Medicine.  tPA should be offered to folks in the 0-3 hour window who meet NINDS criteria as a Level A recommendation.  This is based on the following Class I evidence:

• Two studies that are negative for benefit (ECASS, ATLANTIS)
• The post-hoc analysis of ATLANTIS B with 61 patients,
• NINDS

The Level B recommendation is that tPA be considered for use off-label in the 3-4.5 hour window, based on ECASS III.

If you'll travel backwards in time a couple days (by scrolling down), you'll see I did a quick review of two articles concerning the "trustworthiness" of clinical practice guidelines.  The Institute of Medicine names eight criteria – and, for the most part, this guideline does OK.  It does, unfortunately, fare less well at the conflict of interests declared:

• Dr. Smith – Served on scientific advisory board for Genentech.
• Dr. Gronseth – Speakers' bureau for, and honoraria from, Boehringer Ingelheim.
• Dr. Messe – Former speakers' bureau for Boehringer Ingelheim.

Three out of eight guideline writers directly involved with the pharmaceutical manufacturer.   As far as indirect support, however, if they wanted to be more transparent, Dr. Edlow, Dr. Jagoda, Dr. Stead, Dr. Wears, and Dr. Decker also ought to have disclosed their association with the Foundation for Education and Research in Neurologic Emergencies – supported by multitudinous pharmaceutical manufacturers, including Genentech.

If you're irritated that pharmaceutical manufacturers are helping write our clinical guidelines, make your voice heard.

"Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department"

http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064412017362.pdf

What Are "Trustworthy" Clinical Guidelines?

This short article from JAMA and corresponding study from Archives is concerned with advising practicing clinicians on how to identify which clinical guidelines are "trustworthy".  This is a problem – because most aren't.  

The JAMA article paraphrases the eight critical elements in the 2008 Institute of Medicine report required to generate a "trustworthy" article, such as systematic methodology, appropriate stakeholders, etc.  Most prominently, however, several deal specifically with transparency, including this paraphrased bullet point:

• Conflicts of interest:  Potential guideline development group members should declare conflicts. None, or at most a small minority, should have conflicts, including services from which a clinician derives a substantial proportion of income. The chair and co-chair should not have conflicts. Eliminate financial ties that create conflicts.

The Archives article cited by the JAMA article reviews over 100 published guidelines for compliance with the IOM.  The worst performance, by far, was compliance with conflicts of interest, and notes that 71% of committee chairpersons and 90.5% of committee co-chairpersons declared COI – when declarations were explicitly stated at all.  Overall, less than half of clinical guidelines met more than half of the IOM recommendations for "trustworthiness".

Sadly, another dismal addition to the all-too-frequent narrative describing the rotten foundation of modern medical practice.

"How to Decide Whether a Clinical Practice Guideline Is Trustworthy"
www.ncbi.nlm.nih.gov/pubmed/23299601

"Failure of Clinical Practice Guidelines to Meet Institute of Medicine Standards"
www.ncbi.nlm.nih.gov/pubmed/23089902