Back in 2011, there was an article in Annals of Emergency Medicine discussing what a fantastic job we were doing in diagnosing stroke and avoiding administering tPA to “stroke mimics”. They reported a rate of 1.4% administration to stroke mimics – none of whom had bleeds. The problem I pointed out, both on my blog and in a response letter to Annals, was that the authors invented a new category called “neuroimaging negative” acute stroke – which was probably actually all stroke mimics. This would have changed the rate of tPA administration to stroke mimics from 1.4% to 29.3%. The authors, having financial conflict of interest with the manufacturers of tPA, disagreed.
This study, part of the “Lesion Evolution in Stroke and Ischemia On Neuroimaging” project, evaluated the progression of lesions on MRI following tPA administration. These authors found 231 patients with acute stroke who were initially screened by MRI prior to tPA administration and had evidence of infarction on diffusion weighted imaging. They found that, following tPA administration, only 2 patients had resolution of an MRI DWI lesion. They therefore conclude that “Patients with a stroke are unlikely to have complete DWI lesion reversal within 24 hours after IV tPA treatment,” and patients with no DWI lesion following tPA administration should be considered to have a diagnosis other than acute stroke.
Thus, this confirms my conclusion that the 27.9% of patients from the prior study with “neuroimaging negative” acute stroke ought to universally be considered to have had a diagnosis other than acute stroke. The reality is that we are likely treating an ever-greater number of acute ischemic strokes – and further efforts to push Emergency Physicians to treat additional patients more quickly are certainly going to expose additional patients to avoidable harms.
“Negative Diffusion-Weighted Imaging After Intravenous Tissue-Type Plasminogen Activator Is Rare and Unlikely to Indicate Averted Infarction”
http://www.ncbi.nlm.nih.gov/pubmed/23572476
Category: Policy
Don’t Get Sick on the Weekend
Quite bluntly, you’re more likely to die.
These authors analyzed the 2008 Nationwide Emergency Department Sample, using 4,225,973 patient encounters as the basis of their observational analysis. The absolute mortality differences between weekday emergency department presentations and weekend emergency department presentations is tiny – about 0.2% difference. However, this difference is very consistent across type of insurance, teaching hospital status, and hospital funding source.
The NEDS sample did not offer these authors any specific explanation of the “weekend effect”, but they expect it is due to decreased resource availability on weekends. The authors note specific systems in place (e.g., trauma centers, PICU, stroke centers) where weekend staffing is unchanged have demonstrated the ability to eliminate such weekend phenomena. However, it’s probably never going to be the case that weekend shifts are less desirable – so we’re probably stuck with this slight mortality bump on weekends.
“Don’t get sick on the weekend: an evaluation of the weekend effect on mortality for
The Boondoggle of Step 2 CS
Recent medical school graduates are familiar with the Step 2 Clinical Skills examination, a day-long charade of simulated clinical encounters intended to screen out medical students who are incapable of functioning in a clinical setting. This test was adapted from the ECFMG Clinical Skills Assessment, intended essentially to screen out foreign medical graduates with inadequate communication skills to safely practice medicine in the United States.
However, U.S. and Canadian medical school graduates pass this test 98% of the time on the first attempt, and 91% of the time on a re-attempt. This means each year $20.4 million are expended in test fees – and probably half again that amount in travel expenses – to identify 30-odd medical school graduates who are truly non-functional. The authors of this brief letter in the NEJM suggest, with interest compounding secondary to medical school debt repayments, it costs over a million dollars per failed student.
Clearly, some medical students are not capable of functioning as physicians. However, clinical skills teaching, evaluation, and remediation ought to be part of the purview of the medical school training program that has multi-year longitudinal experience with the student, not a one-day simulation. I’m sure some of the few who fail Step 2 CS twice are capable of safely practicing medicine, and certainly many who pass Step 2 CS still require additional teaching. I agree with these authors that this test is an expensive and ineffective farce.
Then again, as this NYTimes vignette points out, medical schools are having a tough time failing folks for poor clinical skills. However, the solution is not to pass the buck along to the NBME.
“The Step 2 Clinical Skills Exam — A Poor Value Proposition”
www.nejm.org/doi/full/10.1056/NEJMp1213760
Saving Lives Through More Sleep
Or, at least, that’s the theory. Ever since the infamous Libby Zion case – surely exemplar of similar occurrences throughout medicine training programs – institutional focus on resident workload and wellness has been emphasized as a surrogate marker for patient safety. Better-rested residents, working fewer hours, will have fewer misses and derive more substantial benefit from their educational opportunities.
This randomized trial from the University of Pennsylvania evaluating the performance of the new protected sleep time afforded to interns under ACGME rules. These authors used wrist-based sleep activity monitors to measure the cumulative sleep time on-shift for interns randomized to either traditional 30-hour blocks or blocks with a nap period between 12:30am and 5:30am. The primary outcome was sleep obtained on shift, with secondary outcomes being total hours of sleep during a call cycle, and post-call scores on the Karolinska Sleepiness Scale.
Well, protected sleep time works – 2.86 vs. 1.98 hours of sleep at the VA hospital, and 3.04 vs. 2.04 at the University hospital, with significantly fewer no-sleep nights as well. And, the Karolinska Sleepiness Scale means also favored the nap-time group 7.10 vs. 6.65 at the VA and 6.79 vs 5.91 at the University.
But, as I said before, these are surrogate markers for patient safety. One extra hour of sleep? Less than a full point on the KSS? Let’s look specifically at the subjective self-reported meaning of the KSS in the range these physicians were reporting:
• 5 = neither alert nor sleepy
• 6 = some signs of sleepiness
• 7 = sleepy, but no effort to keep awake
• 8 = sleepy, some effort to keep awake
Regardless of intervention group, they’re … pretty much a little sleepy, but not generally struggling to stay awake. I remain a little skeptical this will account for a substantial improvement in patient safety – at least, at this single-residency experience.
“Effect of a Protected Sleep Period on Hours Slept During Extended Overnight In-hospital Duty Hours Among Medical Interns”
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