Finding Value in Emergency Care

The Choosing Wisely initiative is, despite its flaws, an necessary cultural shift in medicine towards reducing low-value expenditures.  In a fee-for-service health system, and given the complicated financial framework associated with training and reimbursing physicians, noble endeavors such as these face significant challenges.

Regardless, many specialties – including ACEP – have published at least one “Top 5” list of recommended practices to improve value.  The ACEP Choosing Wisely list, while certainly reflecting sound medical practice, are of uncertain incremental value or applicability over current practice.  Additionally, the methods and stakeholders involved remain opaque.  Luckily, in a coincidental parallel, Partners Healthcare embarked on an unrelated internal process to improve the affordability of healthcare and reduce costs.  This study provides a transparent look at a such a process, as well as the ultimate findings.

Using an expert panel, 64 potential low-value care practices were identified in a brainstorming session, subsequently narrowed down to 17.  Then, 174 physicians and clinical practioners responded to a web-based survey, ranking the value of each.  Based on this feedback, then, the original expert panel voted again on a final “Top 5”:

  • Do not order computed tomography (CT) of the cervical spine for patients after trauma who do not meet the National Emergency X-ray Utilization Study (NEXUS) low-risk criteria or the Canadian C-Spine Rule.
  • Do not order CT to diagnose pulmonary embolism without first risk stratifying for pulmonary embolism (pretest probability and D-dimer tests if low probability). 
  • Do not order magnetic resonance imaging of the lumbar spine for patients with lower back pain without high-risk features. 
  • Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule. 
  • Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (eg, with anticoagulation therapy, clinical coagulopathy).

It always surprises me to see these lists – which, essentially, just constitute sound, evidence-based practice.  That said, given my exposure primarily to an academic, teaching environment, rather than a community hospital environment concerned with expediency and revenue generation, these may be larger problems than I expect.  This list also does not address the estimated cost-savings associated with adherence to these “Top 5” best practices.  While many of these may result in significant cost-savings through reductions in imaging, the yield would be variable based on the quality of care already in place.

Regardless, this list is as much about the derivation process itself, rather than the resulting “Top 5”.  Certainly, the transparency documented in this study is superior to the undocumented process behind ACEP’s contribution.  That said, this list ultimately reflects the biases and practice patterns of a single healthcare network in Massachusetts; your mileage may vary.  Many of the final “Top 5” had overlapping confidence intervals on the Likert Scale for benefit and actionability, suggesting a different survey instrument may have provided better discrimination.  Finally, while we are culturally enamored with “Top 5” lists – all 64 of their original set are important considerations for improving the value of care.

We, and all of medicine, have a long way to go – but these are steps along the right path.  It is also critically important we also (wisely) choose our own destiny – rather than wait for government or insurance administrators to enforce their misguided priorities upon our practice.

“A Top-Five List for Emergency Medicine: A Pilot Project to Improve the Value of Emergency Care”

My ACEP tPA Policy Critique

As some of you are aware, there is controversy regarding the use of tPA for acute ischemic stroke.  To this end, ACEP has opened up public comment for their recent relevant Clinical Policy Statement.

The comment form, however, is a bit of an odd and onerous format.  To spark discussion, to provide inspiration – and for public feedback/comment/correction – here are a few points from the initial draft of my response:
Page 225, Line 3, author list:
Area of Content / Concept – Conflict of Interest in Guideline Development Group (GDG)
The Institute of Medicine publishes recommendations regarding the composition and conflict of interest disclosures of a Clinical Practice Guideline (CPG) writing panel.  This tPA policy statement falls short on several accounts, most importantly:
Standard 2.1:  
The disclosures listed by the authors only narrowly address their direct financial relationships, but do not describe non-commercial, intellectual, and patient/public activities pertinent to the scope of the CPG.  For instance, authors do not fully describe their relationships with FERNE, a pharmaceutical-supported organization, nor other indirect and intellectual activities relevant to the CPG.
Standard 2.3:
The recommendation states members of the GDG should not participate in marketing activities or advisory board of entities whose interests are affected by the recommendations.  This standard does not appear to be met.
Standard 2.4:
Whenever possible, GDG members should not have COI.  If this is not possible, members with COIs should represent only a minority.  The chair, or co-chair, should not have COI.  This standard does not appear to have been met.
Standard 3.1:
The GDG should be multidisciplinary with methodological experts, clinicians, and patients.  The GDG members appear to be primarily clinicians and administrators, rather than patients and methodologic experts.
Standard 7:
The external review process is only briefly described, and the guideline was not open to public comment until this 60-day period.
Additional comments on the integrity of CPG come from a recent BMJ article, “Ensuring the integrity of clinical practice guidelines:  a tool for protecting patients.”  The recommendations from this publication are similar to the IOM recommendations, with the addition the GDG members ought to represent diverse viewpoints regarding the topic in question.  It does not appear this CPG represented any point of view other than a pro-tPA viewpoint.  The ACEP tPA clinical policy was evaluated using the “red flag” methodology by this article and found to be lacking.
Based on the COIs identified in this GDG, the output lacks face validity.
Page 227, Line 23:
Area of Content / Concept – Patient Management Recommendations
The guideline specifies offering IV tPA to acute ischemic stroke patients within 3 hours to be a Level A recommendation.  A Level A recommendation, according to the methodology of the CPG, states this indicates “Generally accepted principles for patient management that reflect a high degree of clinical certainty.”
The evidentiary table cites several articles as Class I evidence specifically relevant to the 3 hour timeframe (NINDS, ECASS II, and ATLANTIS B 0-3).  NINDS, by all accounts, shows benefit, while the effect size is debated by many based on the baseline characteristics of the treatment groups.  ECASS II is a negative trial; it is inappropriate to apply a subgroup analysis consisting of the 158 patients treated within 3 hours as the same level of Class I evidence.  The ATLANTIS B publication cited is also a very small subgroup analysis of a heavily modified trial stopped early for futility, and should not be considered the same level of Class I evidence.
Notably missing from this evidentiary table is ATLANTIS Part A – cited in the text, but apparently not considered as contributory to the CPG.  This is randomized, placebo-controlled evidence stopped early due to patient harms in the tPA cohort.  This merits inclusion in the evidentiary table as evidence of the harms of IV tPA.
The Lees meta-analysis, among others performed prior to 2010, is appropriately level II evidence.  However, it should be noted there are significant methodologic concerns associated with performing a meta-analysis that includes trials stopped early by their sponsors for futility or harms alongside trials allowed by their sponsors to run to their conclusion.  The evidentiary table notes “some of the analyzed studies were industry supported.”  To be more precise, all of the listed studies have substantial COI with industry – including employees of the sponsoring corporations listed among study authors – except NINDS, where the COI is minimized.
The remaining observational evidence is not relevant to a Level A recommendation.  The Hill and Wahlgren Phase IV studies are not placebo-controlled and only offer substantially limited, indirect, adjusted comparisons to a non-tPA treated population regarding safety and effectiveness.
My point, therefore, is NINDS is unique in support of tPA.  It is irresponsible to base a Level A treatment recommendation on a single positive study with a disputed effect size, whose results cannot be considered externally valid to current stroke practice.  NINDS – along with most evidence cited here – describes use in controlled trial environments of academic stroke centers supported by stroke neurologists.  There is insufficient evidence to support its general effectiveness, compared with standard treatment, in community Emergency Medicine.  Additionally, the observational evidence cited in the evidentiary table clearly describes a heterogenous acute stroke population, with varying levels of sICH risk, mortality risk, and capacity to benefit.  A CPG should not make a global recommendation for treating such a heterogenous disease without providing tools for physicians to communicate individualized risks and benefits.  Unfortunately, the placebo-controlled data are of insufficient quantity and quality to guide therapy.
A demonstration of the dangers of basing treatment decisions on small trials and small effect sizes is based in statistical theory.  Dr. Ioannidis demonstrates how “Most published research findings are false”, a hypothesis apparently borne out by “A decade of reversal:  an analysis of 146 contradicted medical practice.”
Furthermore, a Level A recommendation constitutes “generally accepted principles” with a “high degree of clinical certainty”.  If this were, indeed, the case, tPA for acute ischemic stroke would not be a controversial therapy 18 years past its introduction.  Respected U.S. Emergency Medicine experts in critical appraisal and knowledge translation, e.g., Jerome Hoffman, David Schriger, David Newman, Anand Swaminathan, and many others feel tPA for stroke remains an unproven and inadequately described therapy for acute ischemic stroke.  Indeed, Dr. Swaminathan ably debates Dr. Jagoda, one of the authors of this Clinical Policy in podcast, hosted by Scott Weingart.


Lest ACEP consider these objections simply a vocal minority or lunatic fringe, it should be noted active debate continues in the international literature as well.  Just last year, the BMJ posted a “Head to Head” debate regarding the proven efficacy of tPA in acute ischemic stroke.  An unscientific poll accompanying the article reported a slim majority of respondents did not feel tPA was proven effective.


Additionally, there remains disagreement between international professional societies regarding the use of tPA in acute ischemic stroke.  While several countries endorse its use, others, such as Australia and New Zealand, remain concerned the strength of the evidence does not support widespread use.


In summary, the evidence does not support a Level A recommendation for tPA for ischemic stroke within 3 hours.

There is no reasonable justification for anything higher than a Level B recommendation – and even then, a caveat stating this has never been demonstrated as efficacious compared to usual therapy outside of controlled clinical trial environments.  Physicians may consider offering this therapy based on comfort, diagnostic certainty, supporting resources, and institutional commitment, but it should not be considered the standard of care.

Page 227, Line 28:
Area of Content / Concept – Patient Management Recommendations
The Level B recommendation given to IV tPA is inappropriate given the lack of unbiased evidence in support of treatment beyond the 3 hour time window.  This therapy is not approved in the U.S. and the Class I evidence regarding the 3-4.5 hour time window is conflicting.  ECASS, ECASS II, and ECASS III are manufacturer-sponsored studies of which only ECASS III demonstrated benefit.  ATLANTIS, also manufacturer-sponsored, enrolled patients similar to the NINDS criteria and showed harms beyond 5 hours, futility in the 3-5 hour window, and no usable insights in the 0-3 hour timeframe.  As Clark and Madden note, “Keep the three hour tPA window: the lost study of Atlantis” – ECASS III alone is not enough to refute prior evidence of either futility or harm.  There is a reason why the FDA still has not approved IV tPA beyond 3 hours.
ECASS III is also flawed regarding a baseline imbalance of prior stroke included in the placebo arm.  The absolute difference in percentage of patients with prior stroke is identical to the effect size offered by IV tPA.  Even more concerning regarding the internal validity of the findings, ECASS III offers this COI statement:
Supported by Boehringer Ingelheim.
Dr. Hacke reports receiving consulting, advisory board, and lecture fees from Paion, Forest Laboratories, Lundbeck, and Boehringer Ingelheim and grant support from Lundbeck; Dr. Brozman, receiving consulting and lecture fees from Sanofi- Aventis and consulting fees and grant support from Boehringer Ingelheim; Dr. Davalos, receiving consulting fees from Boeh- ringer Ingelheim, the Ferrer Group, Paion, and Lundbeck and lecture fees from Boehringer Ingelheim, Pfizer, Ferrer Group, Paion, and Bristol-Myers Squibb; Dr. Kaste, receiving consulting and lecture fees from Boehringer Ingelheim; Dr. Larrue, receiv- ing consulting fees from Pierre Fabre; Dr. Lees, receiving con- sulting fees from Boehringer Ingelheim, Paion, Forest, and Lund- beck, lecture fees from the Ferrer Group, and grant support from Boehringer Ingelheim; Dr. Schneider, receiving consulting fees from the Ferrer Group, D-Pharm, BrainsGate, and Stroke Treat- ment Academic Industry Round Table (STAIR) and lecture fees from Boehringer Ingelheim and Trommsdorff Arzneimittel; Dr. von Kummer, receiving consulting fees from Boehringer Ingel- heim and Paion and lecture fees from Boehringer Ingelheim and Bayer Schering Pharma; Dr. Wahlgren, receiving consulting fees from ThromboGenics, lecture fees from Ferrer and Boehringer Ingelheim, and grant support from Boehringer Ingelheim; Dr. Toni, receiving consulting fees from Boehringer Ingelheim and lecture fees from Boehringer Ingelheim, Sanofi-Aventis, and Novo Nordisk; and Drs. Bluhmki, Machnig, and Medeghri, being employees of Boehringer Ingelheim.
As I did not mention it previously, the meta-analysis by Lees also supplies this relevant COI statement:
KRL, RvK, DT, MK, and WH report honoraria from Boehringer Ingelheim for their roles in conduct of the ECASS trials. KRL reports honoraria from Lundbeck and Thrombogenics. DT reports honoraria from Novo-Nordisk, Pfizer, Sanofi-Aventis, and Boehringer Ingelheim. EB is an employee of Boehringer Ingelheim. RvK and JCG report being consultants to Lundbeck. GWA reports being a consultant to Lundbeck and Boehringer Ingelheim. SMD reports honoraria from Boehringer Ingelheim.
Confident translation in policy of clinical trial evidence having this level of COI is simply not reasonable.

Finally, it should also be noted the updated meta-analysis by Wardlaw accompanying the publication of IST-3 no longer shows a statistically significant benefit for alive and independent for the 3-6h time frame – moving from OR 1.17 (1.00 – 1.36) to OR 1.07 (0.96 – 1.20).  This ought to be viewed as regression to the mean as the sample size continues to increase.  Considering thrombolytic trials for myocardial infarction enrolled 140,000 patients, rather than the ~3500 tPA patients from the trials included in the Wardlaw meta-analysis, this should serve as a warning regarding the inadequacy of current evidence.

In summary, treatment beyond 3 hours can only be recommended based on “expert” (e.g., the sponsored mouthpieces of industry) opinion, should be considered only as part of prospective research, and absolutely not be recommended or implied to be standard of care.
Page 232, Line 28:
Area of Content / Concept – NINDS Exclusion Criteria
There is no mention of oral anticoagulation in these treatment recommendations, other than reference to the NINDS exclusion criteria regarding PTT and PT.
The safety of tPA given concomitant use of coumadin and the novel oral anticoagulants (direct thrombin inhibitors, factor Xa inhibitors) is not established.  Contradictory findings from meta-analyses and systematic reviews suggest increased risk of bleeding, even with INR <1.6.  Any CPG recommending offering IV tPA is remiss in excluding mention of these commonly prescribed medications in the population most at risk for stroke.
tPA cannot yet be considered safe when considered in the setting of anticoagulation, despite the NINDS inclusion criteria, in the absence of high-quality data on the subject.

Can We Escape Antibiotics in Sore Throat?

Yes.  And no.

It is well-established complications of acute sore throat are incredibly rare.  The likelihood of a patient developing the most concerning of suppurative complications – a peritonsillar abscess or “quinsy” – is less than a fraction of a percent.  Rheumatic fever is virtually eliminated in the United States.  Yet, as we see from this British cohort, over half of patients visiting primary care received a prescription for antibiotics.

This is study reports on a combination of several, prospectively gathered cohorts presenting with acute sore throat to British primary care practices.  Comprising 14,610 adults, only 5,243 escaped the physicians office without an antibiotic prescription, while the remainder received immediate or delayed antibiotics.  Suppurative complications across all cohorts – peritonsillar abscess, sinusitis, otitis media, and cellulitis – ranged from 0.1% to 0.6%.

Unfortunately, this is not a randomized trial – the patients who were given antibiotics by their physician had much more severe initial clinical presentations.  This means, unfortunately, there is no information in this data set describing the actual protective effect of antibiotics without making statistical contortions.  The main value, however, is in describing the futility of clinical judgement for selecting patients for antibiotics.  Of all the various clinical features recorded prospectively for each patient, only severe ear pain and severely inflamed tonsils were significant predictors of suppurative complications – with ORs of 3.02 and 1.92, respectively.  However, these still constituted hundreds of patients with symptoms who otherwise did not progress.  High scores on the Centor and FeverPAIN criteria were similarly, minimally predictive.

In the end, it is ultimately apparent antibiotics confer some protective effect.  The absolute benefit, however, will represent just a handful of patients out of thousands.  The authors sum it up just as nicely as I might:

“Since a policy of liberal antibiotic prescription for sore throat to prevent complications is highly unlikely to be cost effective, and clinicians cannot rely on clinical targeting to predict most complications, clinicians will need to rely on strategies such as safety netting or delayed prescription in managing the low risk of suppurative complications.”

“Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study” (open access)

ACEP Clinical Policy on tPA Up For Comment

At ACEP13, the Council voted to reconsider the clinical policy statement regarding tPA for acute ischemic stroke.  As part of that resolution, the policy was to be opened up for a sixty-day public comment period.
And, the moment you’ve all been waiting for – it’s up!  Follow this link to read more, download the clinical policy statement, and leave your comments:

Follow the Money

The sun is coming up – in 2014 the Sunshine Act will further illuminate just how much money is being hemorrhaged in healthcare to support the profit motives of pharmaceutical and device providers.  However, increased transparency has become more prevalent – including a few companies posting grant award registries to their websites.  These 14 companies, and their distribution of funds in 2010, are the focus of this brief report in JAMA.

Considering this is just a subset of a little more than half the top drug companies in sales from 2010, the numbers are more than a little staggering: $657M distributed, with over $100M from Roche/Genentech alone.  Medical communication companies received 26%, followed by academic medical centers with 21%, then disease-targeted advocacy organizations with 15%.  But, this report focuses only on the MCCs – considering their role in knowledge translation to the average clinician and consumer.

The largest beneficiary/offender?  Medscape/WebMD.  $20M in grant awards from just this subset of 14 drug companies – suggesting pharmaceutical corporation “donations” represent a significant portion of their $500M annual revenue.  It might be most appropriate to label every news post on their site as “sponsored content” or “special advertising section”.  This brief report further evaluates the privacy policies of these MCCs, and determines physician behavior collected by their sites is likely redistributed for profit back to various industry players.

Pharmaceutical and device manufacturers are not charities.  Executives from these companies, despite what their public relations department would have you believe, are not sitting in strategy meetings discussing altruistic giving for the good of health.  These financial outlays are investments in marketshare and mindshare, and ought to be viewed for what they are – corrupting influences contributing to the degradation of cost-effective care.

“Medical Communication Companies and Industry Grants”

Stepping Up to Choosing Wisely

ACEP recently published their own “Choosing Wisely” campaign contribution – a list of five changes to Emergency Medicine practice that ought be encouraged in the interests of increasing cost-effective care.  While most would agree the ACEP version is reasonable, I think many clinicians hoped for something a little more earth-shattering.

Something like the Pediatric Hospital Medicine list for Choosing Wisely.

These authors specifically looked at the top 10 inpatient diagnoses in terms of volume and aggregate costs, and specifically evaluated components of treatment as candidates for recommendations.  And, even speaking as someone who makes an effort to minimize testing – I find these recommendations take an impressive step in terms of aggressive reduction in resource utilization.

The highlights:
Do not order chest radiographs in children with asthma or bronchiolitis.
Do not use bronchodilators in children with bronchiolitis.
Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection.

How often do you get radiographs in patients with respiratory disease – that get discharged?  How about admitted?  The authors estimate 60% of admitted patients receive radiographs, with fewer than 2% affecting clinical management.

Or, routine bronchodilator therapy – which, frankly, is ordered for a lot of children simply due to a sense we ought to do something.  Both beta-agonist and racemic epinephrine fall under this recommendation, as they’ve not been shown to confer any reliable, clinically meaningful, patient-oriented outcome in bronchiolitis.

Finally – corticosteroids.  Young children, even with albuterol-responsive wheezing, showed no benefit when corticosteroids were added.  These are not harmless interventions, particularly for growing infants, and seems to pre-dispose some folks to subsequent readmission.

With pediatric respiratory season on the horizon, I challenge all of you to use this document as a tool share with colleagues and consultants to decrease unnecessary testing and therapy.

“Choosing Wisely in Pediatric Hospital Medicine: Five Opportunities for Improved Healthcare Value”

ACEP/AAN Guideline Writers Respond

Some of the authors of the new ACEP/AAN clinical policy have responded to the BMJ report discussing conflict-of-interest in guidelines, focusing on the science behind the tPA portion.

If you haven’t already visited, it’s truly a star-studded sort of discussion, with David Newman, Jerome Hoffman, Robert Solomon, Jeffrey Saver, Stephen Messe, Peter Sandercock, and James Grotta, among others.

Continuing Debate Over Thrombolysis

The debate spurred by Jeanne Lenzer’s report on conflicts of interest by guideline writers continues.

Drs. Grotta, Hoffman, Saver, Newman, Solomon, Klauer, Marchidann, Sandercock, Quinn and myself all contribute to the back-and-forth regarding the future of tPA in stroke, while Dr. Geisler and Bracken respond regarding the data for use of steroids in spinal cord trauma.  Some truly amazing responses by leading physicians on both sides of the issues.
“Why we can’t trust clinical guidelines”

BMJ Rapid Responses

The BMJ article highlighting conflict-of-interest in medical guidelines has a thriving Rapid Response section – including responses from Michael Bracken, Peter Sandercock, Fred Geisler, and David Newman.  A fascinating microcosm of sorts of some of the recent controversies in Emergency Medicine!

“Why we can’t trust clinical guidelines – Rapid Responses”

Does Funding Source Influence Guidelines?

There’s been a little hullabaloo recently regarding the influence of financial conflicts-of-interest on guidelines – the result of a recent BMJ investigative report.  But, what effect do these conflicts truly have?  Is there any way to compare, side-by-side, a conflicted guideline with a non-conflicted guideline?

Why – yes!

In the very popular American Journal of Medical Quality comes this tiny gem, a comparison between two guidelines written just over a year apart.  Both guidelines describe treatment options for Primary Immune Thrombocytopenia, and were both published in the same journal.  One guideline was written by a financially untarnished societal group, while the other guideline was written by sponsored experts.  In addition, the sponsored guideline had supplemental assistance by a professional scientific writing group funded by pharma.

Table 4 is a lovely, side by side comparison of the major treatment recommendations.  Unsurprisingly, various thrombopoietin-receptor agonists and anti-D immunoglobulin received top billing in the sponsored guideline, while more conventional therapies were recommended in the non-sponsored guideline.

This article was, however, written by members of the non-conflicted guideline group – so, perhaps there’s some ulterior motive at work.  Regardless, at least, it’s a fascinating look at the tangible effects of financial conflicts-of-interest.

“Conflicts of Interest and Clinical Recommendations: Comparison of Two Concurrent Clinical Practice Guidelines for Primary Immune Thrombocytopenia Developed by Different Methods”