Category: Policy

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”
http://www.bmj.com/content/347/bmj.f6867 (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”
http://www.ncbi.nlm.nih.gov/pubmed/23955837

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”
http://www.bmj.com/content/346/bmj.f3830?tab=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”
www.ncbi.nlm.nih.gov/pubmed/23550214

Too Much Admission Rate Variation

Anyone and everyone who works in the Emergency Department is aware there is a spectrum of individual practice.  Certainly, any resident currently in training frustratingly knows this all too well, and can easily predict the prevailing culture of their shift in advance depending on their supervising attending.

So, it comes as no surprise this review of 389,120 Emergency Department visits in a three hospital, single-system review shows substantial variation in admission rate.  There was, obviously, variation between hospitals – expected as different hospitals may have variable patient demographics.  But, within hospitals – and across all three sites – there was up to a 2.3-fold (21% to 49%) variation in admission rate.  As with all retrospective, observational studies, there are limitations inherent in the data set.  However, the authors attempted adjustments based on several factors without substantially altering the outcomes.

There is no data on patient outcomes – particularly as relevant to those discharged by physicians with the lowest admission rates.  Considering our culture of over-diagnosis and over-treatment, I expect, with further prospective or cross-sectional study, we would find the physicians with the lowest admission rates to have indistinguishable health outcomes from their peers.  The factors that contribute to this variation – as well as interventions to reduce the variation – require further study.

“Emergency Department Physician-Level and Hospital-Level Variation in Admission Rates”
www.ncbi.nlm.nih.gov/pubmed/23415741‎

ED Physicians are Clueless on Cost

Not a day goes by, it seems, the New York Times or some other equally prominent journalistic source publishes a scathing invective regarding the irresponsible cost of healthcare in the U.S.  In this context, it is equal parts highly entertaining and appalling to measure how ignorant Emergency Physicians are regarding the cost of the care they provide.

This single-center study performed in Philadelphia gives results similar to prior work in the same vein.  23 attending physicians and 21 residents were surveyed regarding estimates of cost of care for 102 of their patients discharged from the Emergency Physician.  Each estimate for the total cost of care was compared with the actual final charges billed to the patient or their insurance carrier.

Median estimated charge:  $1,268
Median actual charge:  $2,175

There was no difference between attending and resident performance.

Not an encouraging result – particularly as patients are likely going to be burdened with ever-increasing portions of their healthcare costs, and we ought to be able to communicate with them the cost of care as part of shared decision-making in the Emergency Department.

“Emergency physicians’ knowledge of the total charges of medical care”
www.ncbi.nlm.nih.gov/pubmed/23685055