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Evan Kuhl, MD

December 4, 2017

More than two thirds of patients seen in an emergency department (ED) leave with instructions to follow-up, often for further diagnosis or treatment of chronic conditions. This practice is supported by numerous guidelines, and many practitioners rely on presumed access to urgent follow-up to safely discharge their patients. Additionally, time-specific discharge instructions have been viewed as a defense against potential litigation, regardless of the patient’s ability to comply. A new article by Chou et al published in the Annals of Emergency Medicine expands on previous research evaluating how often patients are actually able to obtain urgent follow-up, and how insurance status and condition impacts this ability.

To determine if prompt primary care appointments were available and whether this availability differed by insurance type, the researchers performed a “secret shopper” study to make appointments for simulated patients. This follows two previous studies in 1994 and 2005, where similar methods were used to determine insurance type impacted the ability to obtain follow-up. Most recently, the 2005 study by Asplin et al found that only 34% of Medicaid patients could obtain an appointment within 7 days, while privately insured patients were successful in 64% of cases. The new Chou et al study is the first to evaluate access since the passage of the ACA, which provided coverage to approximately 20 million more people, and approximately 241,000 newly insured patients in New Haven, Connecticut where the research data was collected.

In a “secret shopper”, or simulated patient survey, the primary objective to determine the differences in appointment availability and wait time by insurance status.  A primary outcome is the proportion of calls that can obtain an appointment within 7 days. All active primary care practices in New Haven, Connecticut were included in the study, totaling 92 offices. After excluding OB-GYN, Veterans Affairs, HIV/AIDS clinics, student health clinics, and mental health clinics, 53 active practices were included in the simulated patient survey.  The study utilized two scenarios; uncontrolled hypertension and non-traumatic low back pain. Electronic health records were created for each simulated ED visit as most primary care offices would have access to these documents. Two callers were trained to use standardized call scripts to present either of the two scenarios, while altering between commercial insurance, a state exchange plan, or Medicaid. This created 6 different combinations between insurance type and clinical condition. Each practice was called 6 times, once with each combination, between October 2015 and May 2016. The calls were placed into scheduled sets so as to avoid offices from recognizing the callers’ voices, and the order of calling was randomized within each set.

The callers completed 604 calls during the study period, with an adjusted 7-day appointment rate of 30.7% and adjusted overall appointment rate of 68.2%. The overall median wait time was 8 days, with an adjusted mean wait time of 16.4 days. Because the researchers were utilizing the same offices multiple times, they created estimating equation models to calculate mean waiting time and adjusted 7-day appointment rates. The researchers found that Medicaid patients had a lower 7-day appointment rate (25.5% vs 35.7%) and lower overall appointment rate (53.5% vs 77.8%) than commercial insurance. However, there was no significant difference in appointment rates between commercial insurance and state exchange insurance. Although low back pain scenarios had a lower 7-day appointment rate (27.6% vs 33.7%) there was no difference in overall appointment rates.

The most common reason given for declining an appointment overall was that the practice was not accepting new patients (41.9% of all declined requests) while Medicaid patients were most likely to be told their insurance was not accepted (57.4% of declined Medicaid requests). During debriefing, both callers noted anecdotally that they were confronted with more questions about medication use when calling with back pain, and were declined by staff citing they did not provide pain management or back pain care. Although this study was performed in a single city with access to one of the oldest state insurance exchanges and cannot be generalized to many populations, the results are similar to other multi-state studies and provide a comparison to pre-ACA data.

This article provides an interesting and informative perspective on the current state of urgent follow-up availability. When taken in context with the previous research, the Chou et al study shows there is a continued inequality in access to follow-up care, as well as a practical limit to how soon patients are able to obtain an appointment, despite the recommendation of an emergency provider.

Acknowledging the reality that most patients are unable to follow-up within the classically prescribed 2-3 days is an important step in recognizing and understanding the complexities of providing safe transitions from the ED. Furthermore, as the authors highlight, there is a need for improved partnerships between the emergency department and primary care providers to improve primary care access and integration.


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

Evan Kuhl, MD

June 15, 2017

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 injury1,2. 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 injury5,6.

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

Will Denq, MD & Evan Kuhl, MD

May 31, 2017

In 2016, an interesting and potentially practice-changing articles was published: the PESIT trial by Prandoni et al.. The prospective study utilized 11 Italian hospitals and evaluated all patients for pulmonary embolism (PE) who were admitted to the hospital for first-time syncope. The results made for headlines; pulmonary emboli were found in 1 in 6 patients, and was broadcast by major news outlets including NPR and Medscape. With the headlines came a debate amongst physicians about just how useful--if not harmful this study might be.

Prior to the PESIT trial, there was scant data on the prevalence of PE in patients admitted for syncope. The authors created a multicenter, cross-sectional study with 11 hospitals in Italy to evaluate the frequency of PEs in patients admitted for syncope. Each patient was risk stratified with a Simplified Wells Score (see Table 1) Those with a score greater than 4 or with a positive D-dimer underwent CT angiography or V/Q scan to evaluate for pulmonary emboli.

Of 2,584 patients who were evaluated by the Emergency Department for syncope, 560 patients were included in the study. Of these, 230 patients received CTA or V/Q scans, and 97 patients were found to have PEs.

The Objective Results:

  1. 2584 patients assessed
    1. 560 included (Mean age = 76 )
    2. 1867 patients discharged and therefore excluded
    3. 157 inpatients further excluded
      1. Prior episodes of syncope, anticoagulated, pregnant excluded
  2. 97/560 (17.3%) were found to have PE
    1. 230/560 were high risk -> CTA or V/Q scan
    2. 180 had CTA, 1 had autopsy
      1. 73/180 had PE
        1. 49/73 (67%) had a main pulmonary artery or lobar artery PE
        2. 19/73 (26%) had segmental PE
        3. 5/73 (7%) had subsegmental PE
    3. 49 had V/Q
  3. 330/560 were low risk -> no imaging

The result of this study carries a bold statement. 1 in 6 of patients hospitalized for syncope have a PE, therefore perhaps we should consider testing syncope patients for PE even when we think the symptoms are caused by something else given the high prevalence of disease.  However, without reading the paper in detail may result in lowering the threshold to test for PE and potentially an overutilization of D-dimer, CTA, and/or V/Q scans. Below,we present the pros and cons of this paper to better inform whether to consider PE in your next syncope patient.

Practice Changing:

Bottom Line: The PESIT trial is a well designed study that should increase our consideration of PE during syncope workups, especially in the geriatric population. When a pulmonary embolism causes syncope, a missed diagnosis may cause significant complications and patient safety issues.

Although we are getting better at catching PEs, they can often be subtle and difficult to diagnose. If a casual reader were to browse through the abstract or to base their judgement on a tertiary news source, they would miss the true value behind this study. It actually calls for a closer examination of PE in older patients that are admitted for first-time syncope, not for testing everyone. Those who are low risk and considered safe for discharge were not included in this study, and this study should not impact our practice in these patients. Those at high enough risk to warrant admission may need a second look. In those with prior PEs, undetermined cause of syncope, or clinical features of PE (respiratory distress, tachycardia, hypotension, or signs of DVT) we should have an increased suspicion of pulmonary embolism.

This conclusion results from the question of, how exactly do we translate an inpatient study and apply it to the ED setting? What population of syncope seen in the ED do we even consider PE in? Based on the population you see and ED you work in, admission criteria for syncope is likely to differ. For appropriate reasons, there wasn’t a standard for syncope admission in this study. However, if we refer to Table 1 of the article, a useful data point is the age of the study population. Not so surprisingly, the mean and median age of the study population was 76 and 80, respectively. It makes sense. Geriatric patients tend to have higher admission rates since they have more comorbidities, less reserve, and a larger number of possible etiologies for their symptoms.

Although there is a different discussion to be had about the causality, it is still standard of care to treat PE even if it exists as a non-etiologic diagnosis for their syncope admission. 67% of patients with a CT positive for PE had a significant embolus that could be related to the syncope they experienced. Only 7% of CT-PE positive patients had subsegmental PEs. The best we can take from this data is to consider PE as an association in the geriatric population that presents as first-time syncope.

Not so fast:

Bottom Line: This inpatient study has the dangerous implication of resource overutilization and the results are difficult to translate to other countries and the ED.

There are radiation and potential contrast risks, workflow, and healthcare costs to consider especially if patients or providers do not understand the implications behind this study. The study does not imply that 1 in 6 patients syncopized because of a PE. It just reports that of the patients admitted for syncope, 1 in 6 were found to have a PE. Association, but not causality is what this is. 12.7% of those found to have pulmonary emboli had already been given an alternative diagnosis.  Many of these patients may have presented to the ED with an emboli, and others may have been asymptomatic as the clinical significance of these findings is not known.

While the authors focus on the number of patients admitted, they do not account for the 2584 patients screened in the ED. Additionally, many of the patients found to have PEs showed clear evidence of DVT and would have a high Well’s score, which should be identified in the ED prior to admission. When all 2584 patients are taken into consideration, you see a much more typical rate of PEs that many of us are more used to seeing, near 5-10%. It is difficult to translate the algorithm and results of the study across the world from Italy to the US. Do we also discharge 72% of our first time syncope patients? Do we D-dimer all of our syncope patients? The clear answer is no. Despite the authors’ claim that the “standardized protocol” for the diagnostic workup of syncope was based on international guidelines - there is no mention in either guideline about the use of D-dimer or even Well’s in the initial consideration for syncope (1,2).

Summary:

Bottom Line: This study is not practice-changing, but it should increase our awareness for the prevalence of PE in the geriatric population that presents with first-time syncope. If you decide to change your practice, consider the downstream consequences.

There may be some benefit in considering PE in the differential in the admitted geriatric patient with first-time syncope. However, the guidelines (1,2) from both cardiology societies in the United States and Europe do not even discuss the use of D-dimer or Well’s criteria in the initial workup for syncope. Although these tools are an acceptable method for ruling out PE, PE may not even be on the differential for a first-time syncope patient.

This study potentially opens a can of worms. If we start to screen the geriatric population more for PEs, what are the downstream consequences? We will begin to adopt age-adjusted D-dimers more? Will we seen an increase in V/Q scans in patients with kidney disease? Will we see an increase in kidney disease from the contrast used in CTAs? What is the appropriate management for the subsegmental PEs that we find? Will we see an increase in bleeding complications such as GI bleeds or head bleeds in the fall-prone geriatric population? What implications will this have for ER workflow? This article, like many others, is merely a beginning step towards more inquiry. It is not practice-changing, but should increase awareness for the prevalence of PE especially in our geriatric population.

What this paper does do is to open an avenue to have discussions with patients. In the world of the internet and immediate access to information, patients come with new expectations. While we may see an increase in patients or other physicians requesting CT scans and D dimer testing, we have the opportunity to better inform our patients. Identifying your patient’s concerns and addressing them with evidence-based medicine should be the foundation of our practice. Being able to translate the evaluation for DVT and PE for a lay person can be difficult, but may produce a more informed and empowered patient. This paper, and the media attention it received, is a launch point for a larger discussion we should all be having with our patients.

  1. Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology, European Heart Rhythm Association, Heart Failure Association, Heart Rhythm Society. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30:2631-2671
  2. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 2006;113:316-327

 

Will Denq, MD & Evan Kuhl, MD are both Emergency Medicine Residents at The George Washington University Hospital

Evan Kuhl, MD

April 4, 2017

I thought I had caught him. Logging onto our prescription monitoring system, I found recently filled prescriptions for hundreds of doses of Oxycodone, Morphine, and Hydromorphone from multiple emergency departments and pain management specialists, all under my patient’s name.

“He’s not an addict, if that’s what you’re looking for” said his mother, scowling at me from across the hall. “He has real pain, and you doctors never believe him.” She had a point. Her son’s recent imaging showed severe intra-abdominal pathology treated in emergency departments, operating rooms, and pain management offices over the past year without relief. Her son had become dependent on substantial amounts of narcotics not only to treat his pain, but to treat a burgeoning addiction. Unfortunately, his story is not unique, and as an emergency provider I may be part of the problem.

...continue reading "New Data: Linking prescribing practices of emergency physicians with long-term opioid use"

Evan Kuhl, MD

January 30, 2017

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 99th 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

Evan Kuhl, MD

November 2, 2016

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, 1st, 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

Evan Kuhl, MD

October 13, 2016

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.

 

Overall, this decrease in prescription drug utilization saved approximately $165.2 million in Medicare funds in 2013 alone.

 

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.


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

Evan Kuhl, MD

July 8, 2016

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

Evan Kuhl, MD

June 24, 2016

In the latest volume of the Annals of Emergency Medicine, two articles discuss one of the most prominent complaints in any emergency department; pain. Pain is both difficult to evaluate and treat; numeric scoring of pain is frequently inaccurate, and the amount of medication required varies between individuals, leading to ineffective treatment and decreased patient satisfaction.

Dr. Chang et al.’s article Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query takes the discussion of pain management back to the basics.(1)  Although useful for research and utilized to meet standards set by The Joint Commission, numeric pain scoring has been found to be inaccurate and does not identify if a patient requires further analgesia. In this study, the practice of numeric scoring for pain reassessment was replaced with a simple question; “Do you want more pain medication?” Over four hours, a maximum of 4 doses of 1mg hydromorphone were given depending on patient response. 55% of study participants received only one dose of medication, and 97% of study participants were either very satisfied or satisfied with their pain treatment. While concerns for drug-seeking behavior are valid, only 3% of patients requested all four doses, and only 1% of the patients requested more than four doses of medication.

Drs. Green and Baruch dive deeper with a discussion of the history of pain scales as a way to meet Joint Commission mandates for pain screening. As most practitioners are aware, pain scales vary wildly between patients and are not predictive of a patient's analgesia requirements. In many cases, Green writes, it is more helpful to have a description of pain and inquire about analgesia needs, more so than to improve a surrogate number.

While Dr. Chang's study did not specifically identify causes of pain within the study population, it broaches important questions about how we are treating pain. With the current national epidemic of opioid abuse, physicians are in the unenviable position of both treating pain while preventing overuse. As discussed by Dr. Green, numeric pain scoring can lead to increased administration of analgesics, while many patients are willing to forgo opioid pain medications.  These articles show asking a simple question can help adequately control pain and increase satisfaction.

Sources:

-Chang A.K., Bijur P.E., Holden L., et al: Efficacy of an acute pain titration protocol driven by patient response to a simple query: Do you want more pain medication? Ann Emerg Med 2016; 67: pp. 565-572

-Green SM, Krauss BS, The Numeric Scoring of Pain: This Practice Rates a Zero Out of Ten. Ann Emerg Med 2016; 67(5):573-5. doi:10.1016/j.annemergmed.2015.06.002.


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

Evan Kuhl, MD

June 9, 2016

During my undergraduate education, I worked nights and weekends as an ED tech and frequently I would walk into work with a full waiting room and grease board, eventually leading the ED to go on ‘Diversion’. At the time, my understanding of diversion was something that made the patients stop coming and the nurses start celebrating. To me, it seemed like a good idea; have EMS take patients to other hospitals to give us a chance to decrease our own patient load. Moving into medical school, it seemed to become a point of pride that the ED would rarely—if ever—go on diversion. Now, the culture is starting to shift with many states and regions moving to diversion bans to prevent hospitals from not accepting EMS patients. Massachusetts became the first state to enact a ban in 2009, and a new brief in Health Affairs discusses the most recent research and debate about hospital diversion.

Ambulance diversion was first cited in 1990, when it was viewed as an option to be used rarely, such as during a crisis or disaster when a large number of patients could potentially overwhelm an ER’s ability to function. As the new HA brief states, by the early 2000’s, 45% of EDs had gone on diversion within a year, with 70% of urban hospitals having diverted in the same time frame. EDs have utilized diversion because it works; in the short term, individual EDs are able to process the overflow of patients and return to normal function. The secondary effects, however, are bringing about regional and state bans on the practice. Once diversion is initiated, surrounding hospitals must bear the brunt of these displaced patients, potentially triggering additional diversion statuses, prolonging EMS transport times, and leading to delays in patient care. What was once considered a crisis response tool has become a frequently used means with dubious outcomes.

As a result of diversion bans, systems have seen no increase in length of stay for discharged patients, decreased length of stay for admitted patients, and faster ambulance turn-around times. As a prior ED tech, most surprising to me was that ED clinicians and administrators strongly support the diversion ban.  With diversion seemingly on the way out, other approaches to ED crowding are taking the spotlight. Recently, the Urgent Matters Podcast discussed the Advance Resource Medic (ARM) with Rick Lewis, EMT-P EMS chief for South Metro Fire Rescue. The ARM utilizes an advanced practice paramedic and nurse practitioner to provide on-scene care for non-life threatening calls, and was first piloted in 2013.

Looking toward the future, ED crowding will continue to be an issue as utilization of emergency departments increases, and new policies to increase patient flow and department decompression will be required to treat the higher number of patients.

Read the complete Health Policy Brief on ambulance diversion.

Sources:

 "Health Policy Brief: Ambulance Diversion," Health Affairs, June 2, 2016. http://www.healthaffairs.org.proxygw.wrlc.org/healthpolicybriefs/brief.php?brief_id=158

Kincaid, Cynthia. "Use the ARM." JEMS. N.p., 21 Feb. 2014. Web. 7 June 2016. http://www.jems.com/articles/2014/02/use-arm-2013.html

Urgent Matters Podcast. An Urgent Care Clinic on Wheels. Rec. 26 May 2016. N.d. MP3. https://itunes.apple.com/us/podcast/urgent-care-clinic-on-wheels/id92638...

Catherine W. Burt, Linda F. McCaig, and Roberto H. Valverde, "Analysis of Ambulance Transports and Diversions among US Emergency Departments,"Annals of Emergency Medicine 47, no. 4 (2006): 317-26.


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