Residency Is Thinly Veiled Healthcare Rationing!

Apparently, we’re still $376 million dollars short in funding just to meet the 2003 ACGME work hours regulations, in terms of hiring additional staff, etc.  So, of course, there should be no problem getting the remaining $1.4 billion needed to bring us up to date with the new rules.  And there’s still the matter of these authors saying that’s still not good enough.

They also say, more stick, less carrot.  For patients!  Think of the children!

Of course, they’re probably right.  A lot of EM training is stressful, but it isn’t barbaric.  We have enough off-service rotations to realize we’re one of the relatively coddled residencies in brute terms of sleep deprivation and time away from the hospital.  My sister just finished her PGY-1 in general surgery by going Q2 into the break before 2nd year.  We’re not in compliance, we’re not operating at our peak abilities, and we’re not exhaustively supervised.  Patients are harmed, no doubt.

But that’s the reality of the funding situation and the budgets proscribed by Congress.

Now, if you want go out and inflame a mob, you could invoke this as part of healthcare “rationing”, letting undertrained, barely-doctors practice on the sickest patients because we choose to allow a few people to be harmed to save money.

“Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety.”
http://www.dovepress.com/implementing-the-2009-institute-of-medicine-recommendations-on-residen-peer-reviewed-article-NSS

It’s Not An Abscess (Yes It Is)

These studies pretty much all end up saying the same thing – academic faculty can’t agree on the presence or absence of differentiating characteristics between abscess and cellulitis.  This particular study is in a pediatric population, and, there’s a lot of kappa and absolute agreement to comb through in their tables, but, basically, about 20% of the time two attendings substantially disagreed.  The authors then follow this up by observing that an I&D was performed 75% time, and purulent material was found 92% of the time.

The best conclusion from this might be – if there’s some ambiguity, put a scalpel in it.  I’d say this is reasonable – because we’ve seen a hundred times the child who bounces into the ED on day 3 of cephalexin for cellulitis because what he really had was a MRSA abscess to begin with.

Or, if you have an ultrasound with a high-frequency probe, you might be able to differentiate homogenous hyperemia from fluid collection.

“Interexaminer Agreement in Physical Examination for Children With Suspected Soft Tissue Abscesses”
www.ncbi.nlm.nih.gov/pubmed/21629150

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

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

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

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

Babesiosis – Scourge of the Lower Hudson Valley

Fascinatingly, babesiosis has suddenly become endemic to New York.  From 6 cases per year between 2001-08, it’s now up to 100+ cases per year in the region.  Still nothing compared to the 4600 cases of Lyme disease, but nearly rivaling the 213 cases of ehrlichiosis.

Hospitalized patients had fever and hemolytic anemia, and were treated with azithromycin and atovaquone.  5.6% case-fatality rate, although, the parasitemia in these cases was exacerbated by underlying medical conditions.  Won’t see this down here in Texas, but the public health surveillance responsibility of Emergency Medicine is always important to remember.

“Babesiosis in Lower Hudson Valley, New York, USA.”
www.cdc.gov/eid/content/17/5/pdfs/10-1334.pdf

If You Don’t Reperfuse STEMI, That’s Bad

I’m not sure why this is earthshaking news – other than some good statisticians had access to some good data.  Of course, that’s pretty much what research is about – have data, will travel.

This JAMA article looks at door-in-door-out time for STEMI at transferring hospitals – and they suggest an association between between quicker transfer times and unadjusted mortality.  There is still some debate regarding how much time to primary PCI matters, but, if you say this in-and-out time is a surrogate marker for time to primary PCI, you could presumably support the hypothesis of rapid PCI mattering.

There are a few interesting nuggets of information in the article – particularly looking at patients for whom the transfer time was exceptionally prolonged.  Essentially, left bundle and patients with ambiguous or non-obvious STEMI were delayed.  I.e., when the diagnosis is hard, it’s hard to make the diagnosis.

As usual, time matters to the individual, but system factors affect many patients.  Mortality for STEMI is improved by faster transport, but you still need to consider the consequences of faster transport.  Reckless abandon towards shoving a semi-stable patient out the door won’t always lead to better outcomes, but, then again, I have worked in some of those hospitals….

“Association of Door-In to Door-Out Time With Reperfusion Delays and Outcomes Among Patients Transferred for Primary Percutaneous Coronary Intervention.”
http://www.ncbi.nlm.nih.gov/pubmed/21693742

Electronic Health Records & Patient Safety

Shameless self-promotion, regretfully.

From my other life as a clinical informatician working on patient safety and human factors as it relates to electronic medical records – my commentary on how electronic medical records might be applied to the 2011 JCHAO National Patient Safety Goals was published today in JAMA.

“Application of Electronic Health Records to the Joint Commission’s 2011 National Patient Safety Goals.”
I am also the spotlight author for the current issue, and you can hear my interview at: