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Month: August 2017

Published on Leave a comment on Acute low back pain: diazepam no better than placebo?
Ameer Khalek

August 20, 2017

Nearly 2.7 million patients present to the emergency department (ED) annually with acute low back pain (LBP). Current medical practice dictates that specific nonsteroidal anti-inflammatory drugs (NSAIDs) are an efficacious first-line therapy. However, uncertainty remains on whether the addition of other classes of medication (i.e., combination therapy) can further improve LBP outcomes. Currently, benzodiazepines (e.g., diazepam) are considered a prescriber favorite to accompany NSAID therapy and are prescribed in 300,000 US ED visits for LBP, annually.[i]

How We Got Here

 In 2014, Williams et al. published a practice-changing study in The Lancet showing that neither regular, nor as-needed acetaminophen dosing affects recovery time when compared with placebo in LBP.[ii] Since then, naproxen has become a standard over-the-counter (OTC) medication for acute LBP. Friedman et al. (2014) added to the evidence surrounding care of acute LBP by showing that under the same presentation, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen therapy does not improve functional outcomes.[iii]  A 2017 study published in Annals of Emergency Medicine by Friedman et al. raises the question:

Will adding a short-term course of diazepam to naproxen yield any additional benefit to functional outcomes at one-week post-discharge from the ED in patients with acute LBP?[iv]

An Urgent Matters podcast with Dr. Friedman details the study as well as how it may or may not change emergency medicine practice.[v] 

Friedman et al. 2017

Dr. Friedman and his team conducted a randomized, double-blind, comparative efficacy clinical trial for adult patients presenting to the ED with acute (onset <2 weeks), atraumatic, non-radicular LBP and functional impairment quantified by a Roland-Morris Disability Questionnaire (RMDQ) greater than 5. The RMDQ is a validated health status measure for LBP in both research and clinical practice consisting of 24 Yes/No statements, each corresponding as one point if marked “Yes,” and no point if marked “No.” Both intervention and control group received a 10-minute LBP educational session and naproxen 500mg PO BID as-needed. The intervention group received either 28 tablets of diazepam 5mg or identical placebo to be taken BID as-needed.

  • Intervention Group: Education + 500mg Naproxen BID (as needed) + 5mg Diazepam BID (as-needed)
  • Control Group: Education + 500mg Naproxen BID (as needed) + Placebo BID (as-needed)

While many outcomes were measured starting at the point of discharge, the primary outcome measured was a change in RMDQ score between ED discharge and one-week follow-up. A decrease of 5 or more points when compared to the other group was considered clinically significant. The secondary outcome measures included pain intensity on a subjective four-point descriptive scale (none, mild, moderate, and severe) at one-week and three-month checkpoints and medication adherence for LBP within 72 hours of ED discharge.  Only 21% (114/545) of the patients screened were included in the study after meeting selection criteria. The mean RMDQ score of both patients randomized to the intervention and control group improved by 11 points. The study found no comparative improvement in functional outcome at one week when diazepam was added to a naproxen regimen. Additionally, pain intensity at one week and three months was no different between the two groups, with similar incidence of adverse events throughout the trial.

While limitations to the study certainly exist, results appear reasonable when taken in context of the reality behind clinical practice. Most noteworthy of the limitations is that the study was conducted in a single urban healthcare system serving a population with predominantly low socioeconomic status (SES). Lower neighborhood median household incomes and higher unemployment rates have been associated with longer length of disability (i.e., longer prognosis), potentially impacting outcome data.[vi] Secondly, in the interest of maintaining cohort homogeneity, researchers excluded many patients secondary to strict entry criteria. Therefore, there is a reasonable index of suspicion about the study’s generalizability to patients with other types of back pain. Anecdotally speaking, often times the onset of radiating pain can serve as the impetus behind seeking emergency care. Finally, it is important to note that while diazepam is also prescribed as an anxiolytic, this would have skewed data in favor of the intervention group in controlling LBP (not the case here). In the future, research should be done on the efficacy of alternative treatments for LBP such as controlled stretching and thermal pack use.

Key Takeaways

Diazepam does not have marginal effectiveness when prescribed alongside naproxen for outpatient management of atraumatic, nonradicular LBP following ED discharge when it comes to functional outcomes at one week and pain outcomes at one and three months. Patients should routinely be counseled on the potential for benign symptoms to persist, encouraged to use the recommended dose of naproxen as-needed, and return to the ED with any significant changes.

“Physicians should reassure their patients that acute and subacute low back pain usually improves over time regardless of treatment.” - ACP President Nitin Damle, MD MS

 Barriers to Implementation

The often benign symptoms of acute atraumatic, nonradicular LBP and the subjective nature of reporting pain lead to frustration for both patient and provider. Additionally, clinically irrelevant but psychologically important factors such as patients expectation for prescriptions after physician interaction are detrimental to prescriber stewardship.[vii] Physicians may also feel pressure to order additional testing – for this, the Choosing Wisely initiative is a great resource to aid physicians in identifying patients that warrant further testing.

[i] Friedman BW, Chilstrom M, Bijur PE, Gallagher EJ. Diagnostic testing and treatment of low back pain in US emergency departments. A national perspective. Spine. 2010;35(24):E1406-E1411. doi:10.1097/BRS.0b013e3181d952a5.

[ii] Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial Williams, Christopher M et al. The Lancet , Volume 384 , Issue 9954 , 1586 - 1596

[iii]  Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back PainA Randomized Clinical Trial. JAMA. 2015;314(15):1572–1580. doi:10.1001/jama.2015.13043

[iv] Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain Friedman, Benjamin W. et al. Annals of Emergency Medicine , Volume 70 , Issue 2 , 169 - 176.e1

[v] Pines JM. – Acute Low Back Pain: Diazepam No Better Than Placebo? with Dr. Benjamin Friedman. Urgent Matters Podcast. 2017

[vi] Shraim M, Cifuentes M, Willetts JL, Marucci‐Wellman HR, Pransky G. Regional socioeconomic disparities in outcomes for workers with low back pain in the United States. American Journal of Industrial Medicine. 2017;60(5):472-483. doi:10.1002/ajim.22712.

[vii] Sirota, M., Round, T., Samaranayaka, S., & Kostopoulou, O. Expectations for antibiotics increase their prescribing: Causal evidence about localized impact. Health Psychology, 36(4), 402-409.

Ameer Khalek is a MPH student at the GWU Milken Institute School of Public Health

Published on Leave a comment on Risk Factors for Malpractice

Greg Jasani 

August 14, 2017

Malpractice is a major concern in the specialty of emergency medicine.  Emergency medicine physicians must make quick decisions in the setting of limited time, limited information, and high acuity. EDs are a common source of malpractice liability in the American healthcare system.[i] One study found that the median payout of emergency medicine malpractice claims was $220,000.[ii]  To reduce risks, 9 in 10 physicians report engaging in “defensive medicine”, specifically using tests and/or procedures for the sole purpose of reducing the risk of malpractice liability.[iii]

Malpractice concerns also have adverse effects on the wellness and mental health of emergency medicine physicians. On average, emergency medicine physicians spend 50.7 months of their careers involved in litigation.[iv]  Additionally, over 75% of emergency medicine physicians will be named in a malpractice lawsuit at some point during their careers.[v]  A malpractice claim can have devastating effects on a physician’s well being: “medical malpractice stress syndrome” increases anxiety and depression, and can even lead to thoughts of suicide among providers.[vi]

In a recent article in the Annals of Emergency Medicine, Carlson et al studied physician and hospital factors associated with being named in a malpractice lawsuit.[vii]  They conducted a retrospective cross-sectional study on data collected from a national emergency physician group that managed 87 EDs in 15 states.  The authors looked at data from January 2010 through June 2014.  Physician factors measured were years in practice (excluding residency), board certification, and majority night shift work.  Other factors measured were median monthly RVUs generated per hour, data on patient experience, median monthly physician admission rate, total number of patients treated by a physician, and working in multiple EDs.  The authors chose these variables because they have a conceptual and perceptual links with the risks of malpractice.

The authors examined over 9,000,000 cases treated by 1,029 different physicians.  During the study time, 90 of the included physicians were named in malpractice suits (98 total).   Of the 9 independent variables analyzed, only increasing years in practice and total patients treated as an attending physician were associated with being named in a malpractice claim.  These results are interesting for several reasons.  Traditionally, many believed that more years in practice would decrease risk of being named in malpractice claim as a physician would be more experienced and less prone to mistakes.  However, this study found that an emergency medicine physician’s risk of being named in a malpractice lawsuit increased 4% every additional year that he or she practiced.  The authors are unable to account for this finding but consider that this could be due to the constantly evolving nature of medicine and the need for providers to receive continuing medical education after residency.  Further studies exploring the associations between years in practice and malpractice, and the possible role of post-residency education, are certainly warranted.

The fact that increased total number of patients treated leads to increased malpractice risk is less surprising.  More patients means more exposure to a clinical outcome that could lead to a malpractice claim.  The fact that patient satisfaction was not related to malpractice risk is also interesting.  Research from other medical specialties has shown that patient complaints about physician communication are related to higher malpractice risk.[viii],[ix]  However this trend does not appear to apply to emergency medicine providers in this study.  The authors posit that this could be due to the brief interactions and lack of relationship building between providers and patients in the emergency department.

This article shows that emergency medicine physicians who have practiced longer and who see more patients are more likely to be named in a malpractice lawsuit.  Malpractice claims are, unfortunately, inevitable due to the environment that emergency medicine physicians operate in.  Malpractice litigation also places a heavy burden on both the health system and the providers.  As with many things in medicine, one of the first steps is identifying who is at risk.  This article helps advance our understanding of which physicians are at a higher risk; knowing this will be invaluable in developing strategies for making the healthcare system safer and hopefully reducing the number of malpractice claims filed.

[i] Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006; 354:2024–33.

[ii] Cohen D, Chan S, Dorfman M. Malpractice claims on emergency physicians: time and     money. J Emerg Med. 2012; 42(1): 22-27

[iii] Bishop T, Federman A, Keyhani S. Physician’s views on defensive medicine: a national survey. Arch Intern Med. 2010; 170: 1081-1083

[iv] Seabury S, Chandra A, Lakdawalla D, et al. On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim.Health Aff (Millwood). 2013; 32: 111-119

[v] Jena A, Seabury S, Lakdawalla D, et al. Malpractice risk according to physician specialty. N Engl J Med. 2011; 365: 629-636

[vi] Sanbar S, Firestone M, Medical malpractice stress syndrome. Available at: https://www.acep.org/uploadedFiles/ACEP/Professional_Development/Faculty_Development/Medical%20Malpractice%20Stress%20Syndrome%20article%20for%20web.pdf.

[vii] Carlson J, Foster K, Pines J, Corbit C, Ward M, Hydari M, et al. Provider and practice    factors associated with emergency physicians’ being named in a malpractice claim. Ann Emerg Med. 2017: 1-8

[viii] Hickson G, Federspiel C, Pitchert J, et al. Patient complaints and malpractice risk. JAMA. 2002; 287: 2951-2957

[ix] Cydulka R, Tamayo-Sarver J, Gage A, et al. Association of patient satisfaction with complaints and risk management among emergency physicians. J Emerg Med. 2011; 41: 401-405

Greg Jasani is a fourth year medical student at the GW School of Medicine & Health Sciences

 

Published on Leave a comment on Health effects of cannabis and cannabinoids: policy outpacing evidence
Ameer Khalek

August 7, 2017

There has been a significant and steady increase in cannabis (i.e., marijuana) use in the U.S. between 2002 and 2015.[i] California was the first state to allow for medical use of cannabis after Proposition 215 in 1996. Currently, 29 states, the District of Columbia, Guam, and Puerto Rico have legalized cannabis for medical use, eight of which have also legalized recreational use. Results from a 2015 nationwide survey indicate that over 22 million Americans (>12 years) reported using cannabis within 30 days of the survey.[ii] Despite increases in use, there is a dearth of conclusive evidence around the harms and benefits of cannabis. This not only makes the topic difficult to discuss in a healthcare setting, but also contributes to a significant public health concern for at-risk populations. Recently on the Urgent Matters Podcast, Dr. Esther Choo (an emergency physician at Oregon State Health & Science University) spoke about her experiences working with a population that has access to legal recreational marijuana use.[iii] When asked if she includes marijuana use as a part of her social history she stated:

“The policy has outpaced our evidence base… We ask, and then what are we going to say?”

Dr. Choo highlights a thought-provoking dilemma that physicians face. The culture behind marijuana use is supported by public sentiments of both its health benefits as well as potential harms.  However, physicians are not equipped with the evidence base to either endorse or recommend against it. As more states legalize marijuana, evidence around both short- and long-term health outcomes is needed to better inform patient-physician interaction and accurately evaluate the public health impact of marijuana use. So, how close are we to having a pragmatic discussion centered around cannabis with our patients?

The Evidence Base Around Cannabis and Cannabinoids

A 2017 report from the National Academies of Sciences, Engineering, and Medicine offers an extensive review of relevant scientific literature surrounding the health effects of cannabis and cannabinoids published after 1999.[iv]  While there is an abundance of information available in the 468-page report, some key conclusions that I find most informative with potential to impact clinical practice are listed below. I encourage you to at least read through the annex of the report for a summary of evidence-based recommendations on cannabis/cannabinoids and their impact on various cases such as cancer, cardiometabolic risk, respiratory disease, immunity, and mental health.

There is conclusive/substantial evidence that cannabis/cannabinoids are effective for:

  1. Chronic pain in adults (cannabis)
  2. Chemotherapy-induced nausea & vomiting (oral cannabinoid)
  3. Patient-reported multiple sclerosis spasticity symptoms (oral cannabinoid)

There is limited evidence that cannabis/cannabinoids are effective for:

  1. Clinician-measured multiple sclerosis spasticity symptoms (oral cannabinoid)
  2. Anxiety symptoms in individuals with social anxiety disorder (cannabidiol)
  3. Posttraumatic stress disorder (nabilone)

There is no or insufficient evidence to support or refute the conclusion that cannabis or cannabinoids are an effective treatment for:

  1. Cancers, including glioma (cannabinoids)
  2. Symptoms of irritable bowel syndrome (dronabinol)
  3. Epilepsy (cannabinoids)
  4. Dystonia (nabilone and dronabinol)
  5. Abstinence in the use of addictive substances (cannabinoids)

There is substantial evidence of a statistical association between cannabis smoking and:

  1. Worse respiratory symptoms and more frequent chronic bronchitis episodes
  2. Development of schizophrenia or other psychoses

Barriers & Future Direction

The National Academies of Sciences, Engineering, and Medicine report outlines many barriers to conducting research on the health effects of cannabis and cannabinoids. Any research around cannabis, a Schedule I substance, faces strict regulatory barriers. Additionally, researchers are often unable to obtain the quantity, quality, and type of cannabis needed to address specific research questions and draw scientific conclusions. If a physician is to prescribe cannabis, their patient should be well informed (i.e., starting dose, CBD vs. THC concentration, how to escalate safely, medication interaction, etc…). While we will have to wait for more evidence to make informed decisions on cannabis use, what about the legalization of recreational use? Does it impact healthcare? A 2017 study published in Preventive Medicine by Wang et al. raises the question:

Does the legalization of medical and recreational marijuana have an impact on hospitalizations, emergency department (ED) visits, and regional poison center (RPC) calls in Colorado?[v]

Wang et al. 2017

Dr. Wang and his team conducted a retrospective review of data collected from the Colorado Hospital Association (CHA) Discharge Databank and National Poison Data System (NPDS) data repository. The primary objective was to compare rates of hospitalizations and ED visits with marijuana-related billing codes and RPC calls with mention of marijuana. The secondary objective was to compare the primary diagnosis categories of hospitalizations and ED visits with marijuana-related billing codes to those without.

From 2000 to 2015, hospitalization rates with marijuana-related billing codes increased from 274 to 593 per 100,000. Interestingly, the prevalence of mental illness among ED visits with marijuana-related codes was 5x higher than the prevalence without – potentially due to the subsection of patients often receiving more detailed assessment around substance abuse habits, or having a greater number of visits to the ED. RPC calls remained constant from 2000 to 2009, but upon the legalization of medical marijuana in 2010 the number increased from 42 to 93. After recreational legalization in 2014, RPC calls increased from 123 to 221.

Figure 1: Rates of hospitalizations and ED visits with marijuana-related billing codes in the first three diagnosis codes in CO

Figure 2: Annual RPC human exposure calls related to marijuana in CO, by age group

Overall, legalization of both medical and recreational marijuana in Colorado is associated with an increase in hospitalizations, ED visits, and RPC calls. Since the study was conducted in a state with legalized recreational marijuana, the findings are likely generalizable to states with similar laws. However, as expected in such complex area, limitations do exist. Researchers relied solely on ICD codes and drug screens without conducting full chart reviews. Marijuana use cannot be viewed as the direct cause of most ED visits, hospitalizations, or RPC calls, as the effects are often short-lasting and not clinically relevant. The data provided does not establish causality between hospitalizations or ED visits secondary to marijuana exposure, and future research in this area should emphasize the importance of not overestimating the healthcare burden related to marijuana use. While researchers did well to establish an association between legalization of marijuana and increased healthcare utilization, there is still much work to be done in this area.

Key Terms

  • Marijuana: colloquial term for the flowering plant intended for consumption. Used in discussion of Wang et al. to align with manuscript terminology.
  • Cannabis: also known as marijuana, is the science-based term of flowering plant intended for consumption.
  • Cannabinoid: a single class of diverse chemical compounds that act on cannabinoid receptors in the brain. The most notable cannabinoid is tetrahydrocannabinol (THC), the primary psychoactive compound in cannabis.
  • Dronabinol: the international nonproprietary name (INN) for a pure isomer of THC, often used to treat anorexia in patients with HIV/AIDS as well as for refractory nausea and vomiting in people undergoing chemotherapy.
  • Nabilone: a synthetic cannabinoid that mimics THC and is often used as an antiemetic and adjunct analgesic for neuropathic pain.

[i] CBHSQ (Center for Behavioral Health Statistics and Quality). 2016. Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). 

[ii] NCSL (National Conference of State Legislatures). 2016. State medical marijuana laws.

[iii] Pines JM. – Cannabis in the Emergency Department: policy vs. evidence with Dr. Esther Choo. Urgent Matters Podcast. 2017

[iv] National Academies of Sciences, Engineering, and Medicine. 2017. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press. doi:https://doi.org/10.17226/24625.

[v] Wang GS, Hall K, Vigil D, Banerji S, Monte A, VanDyke M. Marijuana and acute health care contacts in Colorado. Prev Med. 2017 Mar 30. pii: S0091-7435(17)30120-2. doi: 10.1016/j.ypmed.2017.03.022.

Ameer Khalek is a MPH student at the GWU Milken Institute School of Public Health

Published on Leave a comment on Identifying Low-Risk Febrile Neutropenic Patients in the ED

Greg Jasani

August 2, 2017

Febrile neutropenia is a well known side effect of chemotherapy and patients with it often present to emergency departments.  Standard of care has been to admit these patients for aggressive IV antibiotics. However, recent research has suggested that a certain subset of these patients can be considered low risk and managed as outpatients[1],[2].  Two risk stratification tools, the Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, have been proposed to identify these low risk patients[3].  While these scores have been studied and validated in the inpatient setting, there has been no research about whether these risk stratification tools are valid in the emergency department.  A recent article in Annals of Emergency Medicine by Coyne et al examined whether these scores could be used to accurately identify low-risk febrile neutropenic patients in the emergency department.

The study was a retrospective cohort study conducted in the emergency departments of two academic hospitals.  It examined the medical records of all patients who presented with febrile neutropenia to the two emergency departments between June 2012 and January 2015.  Inclusion criteria for the study were a fever of greater than 100.4F and an absolute neutrophil count of less than 1,000.  Only patients with febrile neutropenia believed to be secondary to chemotherapy were included.  In total, the authors reviewed 230 charts in their final analysis.  The primary outcomes of the study were inpatient length of stay, level of care, clinical deterioration, clinical deterioration, positive blood cultures, and death.  For the purposes of the study, the authors considered patients who did not experience any negative outcomes during their admission to be truly low risk.

Source: Coyne et al.  Application of the MASCC and CISNE risk-stratification scores to identify low-risk febrile febrile neutropenic patients in the emergency department. Ann Emerg Med.  2017; 69(6): 755-764

For every patient, the authors calculated both the CISNE and MASCC scores to determine which was more accurate in identifying low-risk patients (See the Figure for details on how to calculate these scores).  Ultimately, they found that the CISNE score was more accurate in identifying febrile neutropenic patients in the ED did not have an adverse event while hospitalized.  The score was 100% specific in identifying all negative outcomes except for positive blood cultures for which the specificity was 97.4%.  The positive predictive value of the CISNE score in the identification of low risk patients was found to be 98.1%.  The MASCC score was less accurate at identifying low risk patients.  The specificity for identifying low risk patients was only 54.2% and the positive predictive value was 84%.

This study provides evidence that the CISNE score can be used to accurately identify low-risk febrile neutropenic patients in the emergency department.  The CISNE score was also found to be superior to the MASCC score.  Although this study was a retrospective chart review, it provides evidence that the CISNE score may be helpful in determining which patients are at low risk of having adverse outcomes associated with their condition.  There is growing evidence to suggest that these patients can be managed successfully as outpatients[4],[5].  Managing them as outpatients would not only save hospital resources but prevent exposing these patients to potentially harmful hospital acquired infections.  While this paper is not enough justification to discharge these patients directly from the emergency department it does show that further research into this area is warranted and provides a potentially helpful risk stratification tool for emergency medicine physicians to help guide clinical decision making.

[1] Cooksley, T., Holland, M., and Klastersky, J. Ambulatory outpatient management of patients with   low risk febrile neutropaenia. Acute Med. 2015; 14: 178–181

[2] Gea-Banacloche, J. Evidence-based approach to treatment of febrile neutropenia in hematologic malignancies. Hematol Am Soc Hematol Educ Program. 2013; 2013: 414–422

[3] Coyne C, Le V, Brennan J, Castillo E, Shatsky R, Ferran K, et al.  Application of the MASCC and CISNE risk-stratification scores to identify low-risk febrile febrile neutropenic patients in the emergency department. Ann Emerg Med.  2017; 69(6): 755-764

[4] Flowers, C.R. and Karten, C. Communicating safe outpatient management of fever and neutropenia. J Oncol Pract. 2013; 9: 207–210

[5] Pherwani, N., Ghayad, J.M., Holle, L.M. et al. Outpatient management of febrile neutropenia associated with cancer chemotherapy: risk stratification and treatment review. Am J Health Syst Pharm. 2015; 72: 619–631

Greg Jasani is a fourth year medical student at the GW School of Medicine & Health Sciences

Unless otherwise indicated, the content and opinions expressed on this web site are those of the author(s). They are not endorsed by and do not necessarily reflect the views of the George Washington University.
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