The AAP Policy on Firearm Safety

Might not it be helpful if, coincidentally, the Council on Injury, Violence, and Poison Prevention for the American Academy of Pediatrics had just updated their policy statement regarding firearm-related injuries?  Indeed, just two months ago, the AAP published an update, featuring a mere 66 citations worth of evidence, rather than politicized talking points.

A couple interesting statistics from their summary:
 – The firearm-associated death rate among youth ages 15 to 19 has fallen from its peak of 27.8 deaths per 100 000 in 1994 to 11.4 per 100 000 in 2009.
 – However, of all injury deaths of individuals younger than 20 years, still 1 in 5 were firearm related.
 – For youth 15 to 24 years of age, firearm homicide rates were 35.7 times higher than in other high-income countries.
 – For children 5 to 14 years of age, firearm suicide rates were 8 times higher, and death rates from unintentional firearm injuries were 10 times higher in the United States than other high-income countries. 
 – The difference in rates is postulated to the ease of availability of guns in the United States compared with other high-income countries.

Their recommendations section seems quite straightforward:
 – The most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.
 – Health care professionals should counsel the parents of all adolescents to remove guns from the home or restrict access to them.
 – Trigger locks, lock boxes, gun safes, and safe storage legislation are encouraged by the AAP.
 – Other measures aimed at regulating access of guns should include legislative actions, such as mandatory waiting periods, closure of the gun show loophole, mental health restrictions for gun purchases, and background checks.
 – The AAP recommends restoration of the ban on the sale of assault weapons to the general public.

Any chance policymakers might listen to the society of physicians “Dedicated to the health and well-being of infants, children, adolescents and young adults”?

Firearm-Related Injuries Affecting the Pediatric Population”
www.ncbi.nlm.nih.gov/pubmed/10742344

Reducing ED Overcrowding Reduces Mortality


In Western Australia, in 2008, a mandate was undertaken in which Emergency Departments were to implement processes requiring patients to be discharged or admitted within four hours of presentation.  These rules phased in through 2009 in the tertiary hospitals, and then in 2010 in the secondary hospitals.

Of course, with an arbitrary mandate to simply “work faster,” the concerns were that this would have adverse effects on mortality.  Rather, the overall mortality of patients admitted through the Emergency Department tended to decrease during this time period.  Each of the hospitals spent less time of ED diversion (“access block”) as well.

The article doesn’t mention specifically what process changes were implemented, but it does allude to and likely understates the resistance met while making ED overcrowding a problem for the entire hospital.  Authors report that shifting patients out of the Emergency Department led to a greater proportion of the initial investigations being performed on the inpatient wards, leading to some professional stress.

Regardless, this article seems to suggest that it is feasible, in a culture accepting of change in practice pattern, to decrease the amount of time patients spend in the Emergency Department.  It also seems to demonstrate it is, at least, potentially safe.  That being said, it would be quite a feat to accomplish something similar here in the U.S., given the various warring incentives at work in our highly dysfunctional system.

Emergency department overcrowding, mortality and the 4-hour rule in Western Australia”
www.ncbi.nlm.nih.gov/pubmed/22304606

How Medical Students Choose Residencies

Turns out, it’s only mildly earthshaking – for some students, location is more important.  For other students, the program “fit” is more important.

The article goes on to evaluate whether there are specific factors that residency directors can influence in terms of attracting the right candidates and, obviously, none of the location-based factors are easily influenced by program leadership.  The top location-based factor was simply the attractiveness of a particular geographic location, with proximity to family being the next most important factor.

Drilling into the features of individual programs that residency directors can modify, it seems as though candidates base their decision mostly on “gut feeling” – coming down to how well they clicked during the interview session or when meeting with current residents.  After “fit” characteristics, then factors such as curriculum, length of program, and reputation came into play.  Relatively unimportant features were compensation, program size, and websites/social media run by a program.

Unfortunately, the article does not delve into what specific program characteristics residents were looking for – presumably 3-year programs were preferred to 4-year, and one of the popular curriculum questions during visits is regarding the presence of “floor” months.  However, it is an interesting overview of how candidates self-report the importance of their ranking influences.

Factors That Influence Medical Student Selection of an Emergency Medicine Residency Program: Implications for Training Programs”

The Future of Medicine…is Defensive

At Northwestern University in Chicago, anyway – and probably externally valid to other institutions, as well.

This is a survey of 194 fourth-year medical students and 141 third-year residents regarding whether they observed or encountered “assurance” practice (extra testing of minimal clinical value) or “avoidance” practice (withholding services from patients perceived as high risk).  65% of medical students and 54% of residents completed the survey – decent numbers, but low enough to introduce sampling bias.

The numbers, of course, are grim – 92% of medical students and 96% of residents reported encountering “assurance” practice at least “sometimes” or “often”, while 34% of medical students and 43% of residents had encountered “avoidance” practice at least “sometimes” or “often” – nearly all of those being “sometimes”.  These behaviors are apparently learned from their superiors – approximately 40% of medical students and 55% of residents were explicitly taught to consider practicing defensive medicine.

Interestingly, medical students, internal medicine residents, and surgical residents all reported nearly identical levels of “often”/”sometimes”/”rarely” regardless of the behavior sampled – although surgical residents were more frequently taught to be defensive than medicine residents.

Must be a tough legal quagmire up in Chicago.

“Medical Students’ and Residents’ Clinical and Educational Experiences With Defensive Medicine”
http://www.ncbi.nlm.nih.gov/pubmed/22189882

Safety-Nets & ED Length of Stay

This is a relatively intriguing public policy article in JAMA following up in a timely fashion regarding the new CMS Emergency Department quality measures.  These new measures include various time-to-X measures, including length of stay, length of time to admission from bed request, etc.  There is some concern that these quality measures may be tied to federal funding, unfairly targeting “safety-net” hospitals that are not at baseline provided with the resources to address patient flow issues.

This article is a review of the NHAMCS database, a national probability sample survey of patient visits, looking at independent predictors of increased length of stay in patients admitted and discharged from the Emergency Department.  Based on the review of this sample, they do not see a significant difference in ED length of stay – and conclude that these quality measures should not be of concern to “safety net” EDs.  However, these general time-based measures mask most of the problems encountered in “safety net” institutions.
There are some baseline differences in patient characteristics between the safety-net and non-safety-net hospitals in their sample, and they tend to work in favor of safety-net hospitals.  The safety net hospitals in this sample tended to have younger patients with lower triage acuities, which should work in favor of reduced ED overall average length of stay.  My anecdotal experience suggests that, once the quality measures track more detailed ED transit times, I believe we will see more significant deficiencies drop out in the safety-net group.
“Association of Emergency Department Length of Stay With Safety-Net Status”

Big Pharma Is Behind The Money Hemorrhage

This is a research letter from the Archives of Internal Medicine that received a good deal of press recently, examining exactly where in the health system we were wasting money.

They focused on the ambulatory setting, used the NAMCS/NHAMCS database, and evaluated for the activities identified in the “Good Stewardship Working Group” identified by consensus to be low-yield and unnecessary.  They considered this to include antibiotics for afebrile/non-strep pharyngitis, routine EKGs, CT and MRI for uncomplicated low back pain, DEXA scans for young women, etc.  And they found – and this is where the big story comes in – $6.7 billion in these consensus not-recommended activities.

Fortunately for our Internal Medicine and Family Medicine colleagues, they actually weren’t ordering a lot of unnecessary tests – $175 million for low back pain and $527 million for DEXA are a lot of money, but still a drop in the bucket.  The majority of the unnecessary activities, $5.8 billion of the total $6.7 billion, was writing for a brand-name statin (atorvastatin or rosuvastatin) instead of one of the generics.

Certainly just the tip of the iceberg.  Drug reps are more than earning their salaries, apparently.

“‘Top 5’ Lists Top $5 Billion”
http://www.ncbi.nlm.nih.gov/pubmed/21965814

Predicting Poor-Performing Residents

This is an entertaining look into the residency training experience in the United States, which is renowned for its brutality in certain specialities.  As far as sleep-deprivation goes, it ranks right up there with some of the lowest quality of life professional jobs.

This is, basically, the quality-of-life information from the Internal Medicine in-service training examination, as reported in JAMA.  The authors have linked it to in-training examination results for the, probably predictable, association of poor work/life balance and poor in-training scores.

Interesting tidbits I noticed:
 – 15.3% of residents stated that life was as good as it could be.
 – PGY-1 and PGY-2 residents had nearly equal poor quality-of-life and work/life balance – which improves significantly PGY-3.
 – Over 40% of residents have >$100,000 in debts – and that was associated with poorer quality-of-life scores.
 – Improvements in quality-of-life for PGY-3 was mirrored by a corresponding increase in depersonalization.
Not a healthy experience, by a longshot.  Pity those whose residencies are longer than the bare minimum of 3 years.
“Quality of Life, Burnout, Educational Debt, and Medical Knowledge Among Internal Medicine Residents.”

Malpractice Risk in Emergency Medicine

I was actually surprised by these statistics – I expected Emergency Medicine to be higher.  After all, we’re meeting people with potentially unrealistic expectations, suffering long wait times, without continuity of care, and potential bad outcomes lurking everywhere.

But, really, our claims against and claims with payout are really pretty much average across specialties.  Neurosurgery and Thoracic Surgery are the nightmare specialties, where nearly a 5th of physicians practicing in those specialties has a claim filed against them each year.  Another interesting statistic was that Gynecology, only a little above average in claims filed against, has the highest percentage of payouts.

Neurosurgery, Neurology, and Internal Medicine lead the way in median payout, but Pediatrics, Pathology, and Ob/Gyn lead the way in mean payout – apparently skewed by the occasional massive award.

Given the legislation pending in many states these days giving additional protections to Emergency Physicians and physicians on-call to Emergency Departments, it’s really not a bad time to be in EM, from a liability standpoint.

“Malpratice Risk According to Physician Specialty”
www.ncbi.nlm.nih.gov/pubmed/21848463

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

Ambulance Diversion Kills People? Maybe?

This article got a ton of press – but it tries to take far too simple an approach to far too complicated an issue.  I’ve done research like this, where you use zip code centroids and calculated distances to nearest hospitals, and it’s just one way a blind man describes an elephant.

These authors look retrospectively at all the acute MIs in four California counties, then looked at hospital daily diversion logs for each day from each of those hospitals – and tried to merge them together to prove that if your nearest hospital was on diversion for a lot of the day you had your acute MI, you had worse outcomes.

Their final analysis says, basically, there’s a 3-5% difference in 30-day, 90-day, and 1-year mortality if your nearest hospital is on diversion >12 hours in a day vs. if your nearest hospital is on diversion <6 hours per day.  The between 6-12 hour diversion cohort performed identically to the <6 hour per day cohort.  So, I don’t know exactly what to make of this.  Their 95% CI almost crosses zero.  Something magical happens at 12 hours that changes your acute MI mortality risk.  So, yes, what the authors are trying to prove is probably true – but this article’s data mining and massage can only hypothesize the association, and doesn’t prove anything.

“Association Between Ambulance Diversion and Survival Among Patients With Acute Myocardial Infarction.”
http://www.ncbi.nlm.nih.gov/pubmed/21666277