June 2017 – Urgent Matters

Asking about Sexual Orientation in the Emergency Department: An Invasion of Privacy or a Step Toward More Patient-Centered Care 1

Urgent MattersJune 26, 2017June 26, 20171 Comment

Rose Kleiman

June 26, 2017

Is the emergency department (ED) the right place to inquire about a patient’s sexual orientation? A recent study published in JAMA Internal Medicine points toward yes[i].

While lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations often report poorer health and less access to health insurance and health services, lack of data on sexual orientation is a barrier to understanding and addressing these disparities. Recent efforts to capture data on sexual orientation have been made by both the US Department of Health and Human Services and the National Academy of Medicine. Yet, few health systems or emergency departments (EDs) regularly collect data on sexual orientation.

Researchers for the Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity (EQUALITY) Study used a mixed-methods approach to try and understand the willingness of patients to disclose and of providers to collect information on sexual orientation in the ED. The research team conducted in-depth interviews with patients and ED professionals in the Baltimore, Maryland, and Washington, DC, areas and used results from the first, qualitative phase to develop a national survey of patients and ED providers.

Findings from their qualitative interviews (see Table 2 below) highlight the following themes when discussing routine collection of sexual orientation in the ED: Medical relevance, normalization, and recognition.

The qualitative interviews describe the disconnect between patients and providers. Emergency providers felt if sexual orientation was not relevant for a patient’s immediate care plan, it was not necessary to know and thus not important to ask. Patients felt that their sexual orientation was essential information for their overall health and wellness, similar to inquiring about family history of heart disease or exercise habits, and thus should be a routine part of screening. Therefore, the lack of screening on sexual orientation may be a missed-opportunity for providers to build meaningful relationships with patients.

Similar findings were reflected in the quantitative results from the national survey. A total of 80% of emergency providers reported they thought patients would be offended if asked their sexual orientation in the ED, with 78% believing patients would refuse to provide this information. By contrast, only 10% of patients reported they would refuse to provide such information in the ED and only 11% reported that they would be offended if sexual orientation data were routinely collected.

Patients in the survey also emphasized the importance of collecting data on sexual orientation for recognition and normalization of LGBTQ individuals in society. It was expressed that standardizing the collection of this information may help to further promote patient-centered care for all patients.

The research team found that the preferred method of both patients and clinicians for collecting this information was through a nonverbal self-report. The EQUALITY team currently has a trial under way to study the different ways of collecting this information to determine the optimal method.

This study does have some limitations. First, the qualitative interviews were only sampled from one region of the United States; however, the interviews informed the development of the survey, which found similar themes on a national level. In addition, the study did not test how patients actually respond when asked about sexual orientation information in a clinical setting.

While this article highlights the significance of collecting data on sexual orientation, it leads to an important message for emergency providers: patients believe that their sexual orientation is an important component of their overall health and feel that it is necessary information for their providers to know. Whether it is essential to determining an immediate treatment plan or not, querying about a person’s sexual orientation can lead to a more person-centered approach to care.

[i] Haider, Adil H., et al. "Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity: The EQUALITY Study." JAMA Internal Medicine (2017).

Rose Kleiman is a medical student at the GW School of Medicine & Health Sciences

Is IV Contrast for CT Imaging associated with acute kidney injury?

Urgent MattersJune 15, 2017June 20, 2017Leave a comment

Radiographic contrast media is considered a common cause of hospital-acquired renal insufficiency, yet the latest research on contrast-induced nephropathy (CIN) suggests there may be no relationship between contrast use and renal injury^1,2. A recent article by Dr. Hinson et al published in the Annals of Emergency Medicine, found no association between acute kidney injury and IV contrast use. Hinson’s article, a single-center retrospective cohort analysis of 17,934 patients who underwent CT scan with or without contrast, is the largest controlled study of CIN, and may lead to a significant change in practice.

Contrast-induced Nephropathy is a change in creatinine of 25% from baseline, or absolute increase of 0.5 mg/dl 48-72 hours after infusion¹. Early research identified CIN in patients undergoing coronary catheterization, where much larger loads of contrast was used, and before the use of low-osmolar contrast agents³. Other research has found that underlying renal disease, or already impaired renal function, may be the cause of CIN⁴. CIN may be due to many factors other than IV contrast. Patients undergoing a CT with IV contrast followed by a rise in creatinine may have alternative causes which are overlooked, such as nephrotoxic drug use, sepsis, or a range of other causes. The contrast is presumed to be the cause, and much of the research surrounding CIN is hindered by confounding bias due to the exposure itself and the physiology of why the patient is receiving the scan in the first place. Measuring the creatinine level in patients undergoing multiple procedures, nephrotoxic medication use, or requiring CT imaging creates a significant selection bias. When selection bias is accounted for with negative controls, renal injury rates have not been correlated with contrast use, or associated with previous renal injury^5,6.

The most recent study by Hinson sought to clarify the incidence of CIN and utilized two control populations to minimize bias. The paper was a retrospective review of 17,934 patients over a 5-year period, comparing the incidence of AKI in contrast-enhanced CT, non-contrast CT, and no CT imaging, with the primary outcome of incidence of acute kidney injury. Patients were included if they were >18 years-old, received an CT scan either with or without contrast, and had both initial creatinine and 48-72 hour creatinine measurements. A second control group was also included who did not undergo CT imaging, but did have initial and secondary creatinine measurements. Patients were excluded if they already had severe renal injury, a prior renal transplant, recent prior CT imaging, or insufficient creatinine data. The study used both the classic definition of CIN, as well as the Acute Kidney Injury Network/Kidney Disease Improving Global Outcomes (AKIN/KDIGO) guideline to define renal injury as a primary outcome.

The results found that contrast used produced no significant increase in acute renal injury. Using AKIN/KDIGO scoring, the probability of AKI was 6.8% in those with contrast-enhanced CTs, 8.9% in non-contrast CTs, and 8.1% for those without any CT imaging. Classic CIN definitions found the probability of developing AKI in each group was 10.6%, 10.2%, and 10.9%, in contrast-enhanced, non-contrast, and no CT imaging groups respectively. There was also no significant change in the risk for developing chronic kidney disease in 6 months or initiating dialysis between the groups.

Although this study is retrospective and single-center, it represents the largest controlled study of CIN. The inclusion of two control groups reduces the selection bias, and the primary outcome was reported using both AKIN/KDIGO and classic CIN definitions, preventing any under-reporting of renal injury. While the article found no evidence of contrast-induced nephropathy, they do identify some nephroprotective treatment patterns as being potentially responsible. Providers were more likely to provide intravenous fluids and less likely to order contrast-enhanced studies to those with decreased renal function or comorbidities. With these results, the authors are calling for a controlled randomized prospective trial to determine if there is a causative relationship between contrast media and acute renal injury.

1. Hinson JS, Ehmann MR, Fine DM, et al. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Ann Emerg Med 2017;69:577-86 e4.

2. Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis 2002;39:930-6.

3. Daniel J. Pallin M, MPH. Intravenous Contrast May Pose No Risk to Kidneys. 2017.

4. Pickering JW, Blunt IR, Than MP. Acute Kidney Injury and mortality prognosis in Acute Coronary Syndrome patients: A meta-analysis. Nephrology (Carlton) 2016.

5. Contrast-Induced Nephropathy: Confounding Causation - emDOCs.net - Emergency Medicine Education. 2017. at http://www.emdocs.net/contrast-induced-nephropathy-confounding-causation/.)

6. Davenport MS, Khalatbari S, Cohan RH, Dillman JR, Myles JD, Ellis JH. Contrast Material–induced Nephrotoxicity and Intravenous Low-Osmolality Iodinated Contrast Material: Risk Stratification by Using Estimated Glomerular Filtration Rate. Radiology 2013;268:719-28.

Evan Kuhl, MD is an Emergency Medicine Resident at The George Washington University Hospital

Efficacy of Prescription Guidelines on Opioid Prescriptions in the ED 1

Urgent MattersJune 7, 2017June 20, 20171 Comment

As described in a previous Urgent Matters blog post, opioid prescriptions in the emergency department (ED) have the potential to cause long-term opioid use (defined as 180 days or more of opioids within 12 months of the index ED visit). Further, prescription opioids continue to be the number one cause of drug overdose deaths in the US.[1] These trends indicate a dire need for effective interventions to curb unnecessary opioid prescriptions and prevent opioid abuse by patients.

A recent study in the Annals of Emergency Medicine examines the effects of one such intervention: opioid prescribing guidelines. Specifically, the study examined opioid prescription rates by ED physicians in Ohio, comparing pre and post guideline data.[2] The goal was to determine whether the implementation of Ohio’s April 2012 opioid prescription guidelines for ED physicians reduced the number of opioid prescriptions by ED physicians.

Researchers utilized data from Ohio’s prescription drug monitoring program from 2010 – 2014, and conducted an interrupted time series analysis. Ohio’s Prescription Drug Monitoring Program includes all prescriptions for schedule II to IV medications dispensed by a pharmacy within the state. Prescriptions written in Ohio but dispensed outside the state were not included. The 5 most commonly prescribed opioids (hydrocodone, oxycodone, tramadol, codeine, and hydromorphone) were examined in this study, and prescriptions counted were limited to those prescribed by physicians with a primary specialty of emergency medicine, pediatric emergency medicine, and sports medicine. Orthopedic surgery opioid prescriptions were utilized as a control against confounding variables, primarily from opioid-related interventions initiated in parallel with the new guidelines.

Three measurements were followed in the study: 1) Total opioid prescriptions in Ohio per month by ED physicians 2) Total morphine milligram equivalents contained in these monthly prescription totals 3) Number of opioid prescriptions greater than 3 days’ duration (specifically discouraged by guidelines). The data in January of 2010 showed that total opioid prescriptions dispensed by all ED physicians in Ohio declined by 0.31% per month, which than changed to a 11.98% decrease per month after guideline implementation, starting April of 2012. Total morphine milligram equivalents improved from a 0.29% decrease per month to 17.36% decrease per month. Opioid prescriptions greater than 3 days’ duration improved from 0.04% per month to 11.2% per month. Further, the rate of decline in all three of these measures continued to decline at approximately 0.9% per month. The graphs below depict total prescription trends when stratified into the 5 most commonly prescribed opioids. A, B, C, D, and E represent Hydrocodone, Oxycodone, Tramadol, Codeine, and Hydromorphone, respectively.

SOURCE: Scott G. Weiner et al., “The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio,” Annals of Emergency Medicine, May 2017, doi:10.1016/j.annemergmed.2017.03.057.

As demonstrated by the downward shift after the May 2012 time point, all five opioids displayed a reduction in number of prescriptions after the guidelines were implemented. The steeper slopes also demonstrate an increased rate of decline in opioid prescriptions post-guidelines.

There were several limitations to this study, including possible data entry errors, a focus on a specialty representing only 5% of total opioid prescriptions, and limited generalizability as a statewide study. However, this research suggests promise for using guidelines, both within and outside the specialty of emergency medicine, as one effective tool for combating the opioid epidemic.

[1] Rose A. Rudd, “Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015,” MMWR. Morbidity and Mortality Weekly Report 65 (2016), doi:10.15585/mmwr.mm655051e1.

[2] Scott G. Weiner et al., “The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio,” Annals of Emergency Medicine, May 2017, doi:10.1016/j.annemergmed.2017.03.057.

Austin Wu is a medical student at the GW School of Medicine & Health Sciences

Month: June 2017

Asking about Sexual Orientation in the Emergency Department: An Invasion of Privacy or a Step Toward More Patient-Centered Care 1

Is IV Contrast for CT Imaging associated with acute kidney injury?

Efficacy of Prescription Guidelines on Opioid Prescriptions in the ED 1

SOURCE: Scott G. Weiner et al., “The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio,” Annals of Emergency Medicine, May 2017, doi:10.1016/j.annemergmed.2017.03.057.

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