Author: Urgent Matters

A recent article in The British Medical Journal highlights the impact of a web based aid to help in the decision for either admission for observation or referral for outpatient workup in those with chest pain.  Low-risk chest pain patients are frequently admitted for observation and further testing because it is sometimes difficult to predict which patients are at risk for acute coronary syndrome and sudden death.  Sometimes patients are admitted to the hospital even when risk is very low. The article, “Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial” by Hess et al found that when a shared decision aid was used for them to understand this risk and make their own decisions about admission, patients not only had greater knowledge of their risk for acute coronary syndrome and options for care, but also preferred outpatient follow-up to admission¹. Dr. Hess’s results were noted in the most recent SAEM Academic Emergency Medicine Consensus Statement on shared decision making as one of the few ED-based publications on shared decision making².

The study took place in six emergency departments across the US where adult patients presenting with the chief complaint of chest pain were considered for inclusion. Patients were excluded if they had ischemic changes on ECG, an initial troponin greater than the 99^th percentile, had known coronary artery disease, recent cocaine use, or had prior cardiac interventions or admissions. For patients in the treatment group, the treating physician used an online tool to determine the pretest probability of acute coronary syndrome. This web-based tool, previously recognized by in a 2014 Circulation article, utilizes ECGs, troponin results, and the patient’s age, sex, and risk factors to help determine the pretest probability for acute coronary syndrome³. The physician then presented the patient with the decision aid and educated the patient on the test results and potential need for observation or further outpatient workup. Together, a shared decision was made between the patient and physician regarding disposition.

The primary outcome of this study was patient knowledge (tested with knowledge-based questions), while secondary outcomes centered on the degree of uncertainty patients experience when making a choice. This was determined by using a decisional conflict scale, which scores 16 individual items to determine certainty patients feel when deciding which treatment option to take. Overall, 3,236 patients were assessed for eligibility from 2013 to 2015, with a total of 913 patients enrolled, and the authors collected follow-up data for 92.2% of patients.

This study found that those patients presented with the decision aid had greater knowledge (tested by questions about their 45-day risk of ACS and knowledge about ACS) and significantly less decisional conflict. More patients in the decision aid group opted for outpatient testing than the control group (30.2% vs 17.2%). The rate of coronary revascularization, admission to hospital, readmission or repeat emergency department visits did not differ between the groups.

Patient-centered care was first coined in 1988 to emphasize the need to shift the focus of modern medicine aware from disease and back to the patient. Shared decision making provides the patient with better understanding of proposed therapies, while the physician gains insight into the patient’s values and goals. When there are multiple options supported by evidence, shared decision making tools help determine the best option for each patient. In the current medical environment, many physicians may feel pressed to admit patients with what is typically considered “low risk” chest pain because of an assumed patient preference for maximum treatment and intervention. When patients have minimal knowledge about a disease process and physicians are concerned about potential medical and legal effects of a missed diagnosis, there is a lower threshold for further testing and admission. This is estimated to result in approximately $7 billion in unnecessary hospitalizations, false-positive tests, and invasive investigations. Shared decision making tools such as the one tested in this study not only increase patient knowledge and decrease their decisional conflict, but can also decrease admissions and overuse of medical resources. The shift in patient care to better incorporate patient preferences can safely allow for more responsible resource utilization while providing safe and appropriate outpatient follow-up.

References:

1.         Hess EP, Hollander JE, Schaffer JT, et al. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ 2016;355:i6165.

2.         Grudzen CR, Anderson JR, Carpenter CR, Hess EP. The 2016 Academic Emergency Medicine Consensus Conference, Shared Decision Making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda May 10, 2016, New Orleans, LA. Acad Emerg Med 2016;23:1313-9.

3.         Kline JA, Jones AE, Shapiro NI, et al. Multicenter, randomized trial of quantitative pretest probability to reduce unnecessary medical radiation exposure in emergency department patients with chest pain and dyspnea. Circ Cardiovasc Imaging 2014;7:66-73.

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

Last month, Health Affairs published new research on hepatitis C treatment in American prisons. Hepatitis C is a liver disease and the most common bloodborne pathogen in the United States, infecting approximately 1 percent of the general population.(1) Within the prison population, however, the prevalence of hepatitis C is higher: 17 percent. Prisoners are a key demographic to decrease the spread of hepatitis C, which is spread through IV drug abuse because approximately 20-55 percent of inmates have used IV drugs in the past.

The article is the most recent investigation to identify the number of inmates with hepatitis C, and identify how these people are being treated. This is important now because today hepatitis C is treatable through direct-acting antivirals (DAAs). Treatment is important because hepatitis C can lead to cirrhosis, portal hypertension and chronic liver failure requiring liver transplant. The DAAs are very expensive with a 12-week course costing $43,418-$94,500. Yet 90% of the time, the treatment is curative, preventing the morbidity associated with chronic hepatitis.

The main finding of the article was that despite the drugs being available and effective, less than 1 percent of known infected inmates actual receive treatment. This is despite US Supreme Court rulings that prison officials must provide adequate medical care of inmates, and the Federal Bureau of Prisons’ Clinical Practice Guidelines recommend the use of DAAs. Currently, prisoners in Massachusetts are suing the state for withholding treatment.(2) On average, each state spent about 6 percent of their annual drug budget on hepatitis C medications: $39.8 million annually. This is despite the fact that many states actually negotiate lower prices.

Clearly, cost plays a major role in this failure to treat inmates with DAAs. However, other reasons cited by the authors include outdated treatment guidelines which do not take into account DAA availability.  As of January, 1^st, 2016, Tennessee’s treatment guidelines did not recommend DAA medications, and only recommended hepatitis C testing for inmates meeting certain indications, unless specifically requested by an inmate. In addition, state protocols only recommend treatment for those with more severe disease, including cirrhosis.

In the Health Affairs article, the authors describe several ways to increase treatment and decrease costs. First, the federal 340B Drug Discount Program allows health institutions to partner with prisons and provide healthcare services including hepatitis C treatment, a system being used by three of the four departments paying the least for DAAs. Pooled procurement of DAAs is also recommended, as currently many departments negotiate independently for drug prices. Finally, increased federal involvement and funding is needed help treat inmates. Once inmates are released, the federal government bears a significant proportion of the cost of hepatitis C, which is much higher if it’s untreated. Treatment in an institutional setting may provide greater savings and more effective treatment, while treating those at the highest risk of spreading the disease. This article is a first step towards understanding the burden and availability of effective treatment for one of the most high-risk populations in the United States.

1. Beckman AL, Bilinski A, Boyko R, et al. New Hepatitis C Drugs Are Very Costly And Unavailable To Many State Prisoners. Health Aff (Millwood) 2016;35:1893-901.

2. Loftus P. Prisoners Sue Massachusetts for Withholding Hepatitis C Drugs. The Wall Street Journal 2016 Jun 11, 2015.

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

New data published this summer studies medical marijuana trends in the United States. Specifically, one article published in Health Affairs and written by Ashley and David Bradford of the University of Georgia reviews how medical marijuana availability has impacted other prescriptions filled by Medicare Part D enrollees¹. The study, also noted in the BMJ, found there were several categories where prescriptions where reduced². On average, states with medical marijuana saw a 20% decrease in prescription medications for spasticity, and an 8-13% decrease in medications for anxiety, depression, nausea, psychosis, and sleep disorders. The decrease in prescription drug use saved an estimated $165.2 million in Medicare funds in 2013 alone. If medical marijuana was available nationwide, the authors estimated that Medicare could see a 0.5% reduction of the program’s nation-wide spending.

While the Bradford study shows that marijuana appears to be replacing several other medications, the question is whether marijuana actually as effective as other drugs? The answer is that several randomized clinical trials data support the effectiveness of marijuana , some researchers question the standards used to evaluate how well it really works. For example, research has examined how marijuana helps gastrointestinal conditions, such as Crohn’s disease³.  Yet, most of this research evaluates subjective responses to marijuana, and do not focus on objective disease markers such as intestinal inflammation or C-reactive protein levels.  Therefore, even if patients using marijuana note pleasurable side-effects of the drug as effective treatment, it may not directly impact the disease process itself.  Dartmouth Drs. Koliani-Pace and Siegel co-authored an article calling for increasing the quality control of marijuana research. They wrote: “If marijuana can meet all of the FDA requirements, including efficacy data, evidence of safety, and a meticulous quality control program, then the medicinal use of marijuana could be supported”³. Besides objective outcome data, other major concerns still left unanswered include the untoward respiratory side effects of marijuana smoke, as well as the co-use of marijuana and tobacco, with some research showing that marijuana use can increase tobacco use and dependence⁴.

Currently, 39 states now allow medical marijuana despire still being listed as a Schedule 1 drug by the Federal government. Although individual state regulations vary, every program requires a physician to prescribe the use of marijuana or marijuana-derived substances. As the policies and regulations regarding marijuana continue to change, it will be essential to continue researching both the efficacy of marijuana treatment and the impact on healthcare utilization.  As providers, it is important to understand the impact these policies on our patients. The research and experience of providers is an important part of creating safe and viable policies to protect and treat our patients.

1.         Bradford AC, Bradford WD. Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D. Health Aff (Millwood)                     2016;35:1230-6.

2.         Dyer O. US states that allow medical marijuana see drop in prescriptions for other drugs, study finds. BMJ 2016;354:i3942.

3.         Koliani-Pace J, Siegel CA. Is the Hype of Medical Marijuana All Smoke and Mirrors? Am J Gastroenterol 2016;111:161-2.

4.         Wang JB, Ramo DE, Lisha NE, Cataldo JK. Medical marijuana legalization and cigarette and marijuana co-use in adolescents and                       adults. Drug Alcohol Depend 2016;166:32-8.

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

Elderly patients have the highest rate of ED usage amongst all adult populations as well as the highest return rate.  Despite this increased burden on the healthcare system, it is difficult to predict poor outcomes after discharge. We all want to treat each patient “as if they were my grandfather/grandmother” yet we still cannot prevent many catastrophic outcomes. Of course we know that many chronic diseases increase the risk of readmission, and the 1-year mortality of many injuries are very well studied—but translating these risks into improvement of patient care is difficult, and many patients don’t fall so neatly into these boxes. There is still a need to identify risk factors to help providers identify patients at high risk of poor or catastrophic outcomes.

A new article by Dr. Gelareh Gabayan et. Al takes a new perspective on this problem. Instead of identifying historical information, type of injury, or other clinical data that is classically used to highlight at-risk patients, the team instead looked at process-of-care factors which occurred during the ER visit. What are we doing during a visit that can raise a red flag? Their study generated 300 case-control visit pairs of patients >65 years old who were treated in their ED system, and either died or was admitted to the ICU within 7 days of discharge. The chart review matched 300 patients who experienced such an outcome with 300 case control patients who did not, then compared the charts to identify predictors for ICU admission and/or death. Read more about their methods of exclusion, randomization, and measurement in their article, here. The article identifies many characteristics as having an increased adjusted odds ratio for death or ICU admission, including Asian/Pacific islander, Hispanic, or black ethnicity, hypotension, tachycardia, and mental status changes.

Most interesting, however is that changing the disposition of a patient (or noting the consideration of admission) was found to be associated with a greater likelihood of death or an ICU admission. Change in disposition was the only association that was not a hard number. In fact, it’s the only association that we actively play a role in as physicians. Interestingly, Dr. Gabayan’s paper finds that when a change in disposition was related to specialty consultation, there was no longer an increase in risk. It appears these consults were able to provide services or follow-up care outside of an emergency physician’s scope of practice. Per the article; “Our findings, coupled with that of other studies, suggest that regardless of the initiating event causing the change in disposition status, the emergency providers’ clinical judgment about the disposition (admit versus discharge) of the patient should be given special attention by both the care team and the patient.”  Next time you consider your disposition of an elderly patient, take a moment and consider their next 7 days.

Interested in more? This month’s Annals of Emergency Medicine included several articles regarding the care of our elderly patients, including two other very interesting articles: Dr. Fassier’s article explores the attitudes of EM physicians regarding critically ill elderly patients, while Drs. LeFebvre and Platts-Mills provide an editorial to the article, including discussing the frustrations many EM physicians have when it comes to both the patient and family.

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