Testing For Pulmonary Embolism is More Harmful Than Helpful

This is, in my opinion, the most conceptually important article I have read in the few months I’ve been posting to this blog.

This is where Dr. Newman and Dr. Schriger, outstanding clinicians and analysts of data, present a compelling case regarding the diagnosis and treatment of pulmonary embolism.  In brief, the authors try to estimate, based on the limited evidence, both the benefits and harm of diagnosis and treatment of pulmonary embolism.  In their review, very few patients were found to benefit from treatment of pulmonary embolism – the existing evidence is weakly supportive of anticoagulation.  Additionally, they show a great many patients were harmed by excessive testing and treatment of clinically unimportant pulmonary embolisms.

This is, while a complicated opinion piece, a lovely summation in a nutshell of the concept that finding more “disease” does not equal better outcomes.  And, depending on the risks of testing and treatment – the barbaric contrast, radiation, and rat poison that diagnosis of PE typically entails – more people would be alive today if we all stopped testing for pulmonary embolism.

This is not unique to pulmonary embolism – this is partly the same issue we encounter with overtesting our low-risk chest pain patients, particularly with CTA.  What this means – and, of course, subject to legal challenge in our bizarre society – is that with our current methods of detection and treatment, society would be better off as a whole if we missed a few pulmonary embolisms in order to find and treat the few clinically relevant ones.  The only shame in this article is that not nearly enough people will read it and take it to heart.

http://www.ncbi.nlm.nih.gov/pubmed/21621091

Liability Protections For Emergency Services

Smart folks at ACEP – tying liability reform to cost savings, which makes liability protection for Emergency Physicians an easier sell.  I have to say, the training environment these days is so skewed, I don’t think anyone graduating now knows how to practice without scanning everyone, as it’s become generally the standard of care.  The “quality of care” argument is a little new to me – but I certainly could move patients through more quickly, have less sign-out liability, etc., if I weren’t tying up beds waiting for scans.

But, the threat of a lawsuit is a big one.  And it’s not just us – so many PMDs refer their patients to the ED for a CT scan – whether the test is indicated, how miserable a malpractice hearing would it be to have testimony from the PMD who thought a CT was indicated after you declined to order it.

Next step beyond liability protection – Press-Ganey protection – for all these patients who expect answers, and CTs at the minimum, and aren’t going to fill out very favorable patient satisfaction surveys without getting what they want….

http://www.acep.org/Content.aspx?id=79958

72-Hour Returns – Fun, But Not Useful

Our EMR lets us generate reports of our 72-hour returns – and it’s a fun toy, but, reading through it is rarely illuminating.  On a rare occasion you see a “true miss”, where one of your colleagues finds something through another line of thinking.  But, mostly, it’s wound checks, admissions for failed outpatient antibiotic therapy for cellulitis, or the town drunk coming back in again.  It is a valuable tool, at least, in the sense that our ED is the only one for 40 miles and is the only tertiary center for 90 miles, so we should get most of our own bouncebacks.

And, this study essentially confirms my anecdotal observations – most people who come back return for non-emergent conditions, do not require significant additional testing, and are no more likely to be admitted.  Their conclusion, then, is that 72-hour returns are of limited utility as a quality measure – something of which I tend to agree…although, if it were, the unintended consequence of discouraging that 2-day wound check/abscess repacking might finally put abscess packing to rest….

http://www.ncbi.nlm.nih.gov/pubmed/21496142

Bypassing The ER With STEMI

This is a paper cited in the most recent ACEP Weekend review that tries to draw more profound conclusions than it probably should.

It’s another piece of the growing body of literature that says “Hurry!  Prehospital activation is all we need in STEMI!”  From Israel, it’s a retrospective review of performance variables and patient outcomes between a cohort that was assessed in the ER and a cohort that went straight to the lab.  They draw a few conclusions, some of which are valid.

First, time.  One of the two “primary” outcome variables is door-to-balloon time.  No argument that skipping steps along the way will save you time.  No study is needed to prove that.

The second “primary” outcome variable is MACE within 30 days – another combined endpoint kludge of death, CHF, reinfarction, CVA, TIA, and urgent revascularization.  This one favored the direct-to-ICCU group, 22% to 30%.  How is 30-day CVA/TIA directly related to the effectiveness of PCI?  Looking at their secondary outcomes – death was not significantly different – but CHF was 8% different, which therefore accounts for essentially the entire difference between groups in this primary outcome.

And the problem?  Well, they also show in a secondary outcome that LVEF >30% was 7% greater in the direct-to-ICCU group…from which it follows there would obviously be less heart failure in that group.  But, in their demographic information, they don’t know the pre-intervention LVEF for their patients – only the Killip class on presentation, which is a measure of the heart failure associated with the acute cardiac event, not their pre-existing LVEF.

So, the only thing they’ve effectively proven in this study is that skipping steps saves time.  And, they don’t comment on the number of false positives in each group, either.

http://www.ima.org.il/imaj/ar11apr-07.pdf

Fluid Boluses Increase Mortality In Children

…or, at least, that’s the gist of the New England Journal Article making rounds in the news.

And, while a close reading of the article doesn’t offer great support for harm, it certainly supports saying that albumin, saline, or nothing were equivalent.

The absolute difference in survival was 3% – and, looking at the demographic breakdown, there were 2-3% differences or trends in favor of the control group regarding dehydration, acidemia, base-deficit, and bacteremia.  Enough that it lets me cling in denial to standard practice and teaching here in the U.S., in addition to whatever you want to say about external validity of a study in resource-poor settings in Africa.

It is an odd and unexpected finding, so say the least.  The authors attribute at least part of the unusual discovery to the high percentage of malaria cases they treated, and that fluid resuscitation in malaria is controversial – but regardless, this is going to be a frequently discussed study on the Pediatric Critical Care side of things for some time.  I also expect follow-up confirmatory studies to be a tough sell to U.S. IRBs.

http://www.nejm.org/doi/full/10.1056/NEJMoa1101549

Red Cell Distribution Width… Means What Now?

“Red cell distribution width is a robust predictor of… all-cause patient mortality.”

I saw this article when I was browsing abstracts, and I thought, “Huh!  That sounds interesting, though, probably not relevant.”

So, yes, increasing red cell distribution width is associated with increased mortality.  However – and this is something I’ve never seen before in an article – looking at the table describing the differences between their various divisions of RDW% – every other descriptive statistic is different between groups.  More septic patients with high RDW%.  More renal failure.  Differences in hematocrit.  More organ failure.  They claim by statistical multivariate massage, that RDW shakes out as an independent factor, but, sheesh…it’s almost like saying decrease in temperature is highly associated with death, when they’re cold because the blood isn’t circulating, the breathing has stopped, the brain has shut down, etc….

Another fine example of where reading the abstract is absolutely no replacement for perusing the article.

http://www.ncbi.nlm.nih.gov/pubmed/21532476

Pediatric Septic Shock Protocol

Another sort of goal-directed sepsis study, this time in Pediatrics at Primary Children’s.  They implemented a protocolized triage system in their ED designed explicitly identify more cases of sepsis – which led to increased percentages getting early fluid resuscitation, early lactate level measurements, and more frequently antibiotics in the first three hours.

But the net effect of all these interventions…the only detectable difference in their 345 patient cohort was improved length-of-stay for survivors, from IQR 103-328 hours pre-intervention to IQR 86-214 post-intervention.  Total hospital costs were not significantly different.  No change in mortality – which was already low at 7%.
So, yet again – adherence to “quality measures” has debatable clinical significance.

Procalcitonin Misleads Antibiotic Therapy In Sepsis

An important negative study of an inflammatory biomarker that’s been getting a fair amount of push.

It is absolutely true that procalcitonin levels may be elevated in an inflammatory states such as sepsis.  This group tried to make a clinically relevant protocol for procalcitonin trends by saying, if the procalcitonin level is not decreasing with current therapy, then antibiotic coverage should be expanded and aggressive testing should be undertaken to evaluate for missed source control.

Unfortunately, in the treatment arm where procalcitonin was used in clinical decision making, there was extensively greater broad-spectrum and multiple-antibiotic utilization without any demonstrated mortality benefit.  In addition, LOS and ventilator-depended days were longer in the procalcitonin arm.

There were very minor differences between the two groups, probably favoring the control, but not nearly enough to suggest that procalcitonin has any value in assessing failure of current therapy.

http://www.ncbi.nlm.nih.gov/pubmed/21572328

Massachusetts Health Reform Is “Working”

By some measures, at least, you can claim that the Health Reform is working.  I’ve seen a few articles out there saying it failed, because ED visits continue to rise.  But, if this study is reliable, the increases in ED utilization are a result in increased illness severity, not inability to access a physician.

Non-acute visits for the uninsured/low-income cohort in Massachusetts went down, from 43.8% to 41.2% – a greater decrease as compared to their “control” group of private insurance that is supposedly unaffected by health reform, which decreased from 35.7% to 34.9%.  So, one way to interpret this is that increased access has kept some of the non-urgent uninsured out of the ED.

…but they’re still seeing, by their definition, a solid nearly 40% of patients in our EDs that have less than a 25% of requiring true Emergency Department care.  So things have incrementally improved – but the problem is not simply that a patient has nominal access to a PMD, they actually need to be able to access that PMD on a semi-urgent basis to truly reduce ED utilization…and that PMD needs to be more than simply a revolving door back to the ED.

http://www.ncbi.nlm.nih.gov/pubmed/21570157

Early Antibiotics Show No Benefit in Sepsis

Interesting analysis of the EMSHOCKNET cohort, looking to see if there was any association between time to antibiotic administration and survival benefit in septic shock.

And, no.  Earlier antibiotic administration, as measured by arrival time in the the ED, showed no significant impact.

They do another secondary analysis where they try to say, well, if the patient received antibiotics before they met criteria for septic shock – then they had a 2.59 (1.17 – 5.74) OR for survival.  I’m not sure how to interpret this finding – perhaps because they looked at 10 different cut-off points for antibiotic administration, they found one that favored antibiotics by chance.

Or, perhaps antibiotics really aren’t the lynchpin in treating sepsis – if you can give antibiotics ahead of SIRS, perhaps you have a milder case – but once you have end-organ dysfunction, the interventions that target improving the physiologic changes of sepsis are more important.

http://www.ncbi.nlm.nih.gov/pubmed/21572327