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Tag Archives: Medical Studies

Sending Home the LOL who DFO

The Journal of the American College of Cardiology presented the ROSE study for triaging patients with syncope in the emergency department. No, ROSE isn’t some LOL that the study was named after. ROSE is an acronym standing for “Risk Stratification of Syncope in the Emergency Department.” They just left out a few letters because an acronym of “RSOSITED” just isn’t quite as catchy. Maybe SOS-ED would have been cooler, but ROSE it is. Anyway, the study looked at what factors were likely to be present in patients who passed out and who had a “serious outcome” or death in the following month. Serious outcomes or death occurred in 7% of all patients who passed out in this study. They found that positive fecal occult blood, low hemoglobin levels, low oxygen saturation, and Q waves on the EKG were all predictive of worse prognosis for patients with syncope. In addition, a BNP (brain natriuretic peptide) level greater than 300 was present in 36% of syncopal patients who later suffered serious cardiovascular events and in 89% of syncopal patients who later died. More than 98% of patients who had none of these risk factors also had no serious outcome or death in the subsequent month after their syncopal event. So check the BNP on syncope patients and get out those rubber gloves, ladies and gents. Add syncope to the list of patient complaints for which rectal exams may be indicated. After all this, if you’re still wondering what “LOL who DFO” means, then you have to read this religious post.

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Regulating Radiation

A recent article in the New England Journal of Medicine touches off another salvo about how nonclinicians have no problems judging the abilities of clinicians in the world of medicine. The article begins by presenting the case of a woman who awoke with facial paralysis and then went to the emergency department. On arrival, she received CT scans and MRI scans of her brain. When those were normal, she was diagnosed as having Bells Palsy. Two weeks later, she developed hair loss and other symptoms and it was found that during her first ED visit, the radiology department mistakenly exposed her to 100 times the normal dose of radiation for a brain CT scan. She now has a federal class action suit pending against the CT scanner manufacturer and a medical malpractice lawsuit pending against the treating physicians. It appears that the case cited may be this one. More information here. The author of this article then uses her own calculations to conclude that the “risk of cancer from a single CT scan could be as high as 1 in 80 — unacceptably high.” The study she cites shows that radiation doses for the same tests vary – as they should. Giving the same dose of radiation to a 90 pound grandma and a 500 pound grandson would result in at least one uninterpretable study. Based on the 4 hospitals they studied, they disputed the risk of cancer being 1 in 2000 from a CT scan and stated that the risk to a 20 year old woman from a single chest CT or single multiphase abdomen and pelvis CT could be as high as 1 in 80. The paper advocates lessening and standardizing radiation doses for examinations, noting that the improved image quality obtained with higher radiation doses often has no change in clinical outcomes. Diagnostic accuracy would not be affected if the radiation dose were reduced by 50%. The paper also suggests tracking a patient’s dose of radiation over time and including that measurement in the medical records. Great idea, but how is a radiation dose from someone living in California going to help me when the patient has a potential cervical spine injury in my town while she’s on vacation? Finally, the author suggests that we need to reduce the number of CT scans being performed. Each year 10% of the population receives a CT scan and 75 million scans are conducted each year – with the rate growing more than 10% annually. At the heart of the increased number of scans is “increasing ownership of machines by nonradiologists” and the resulting “self-referral” which increases the use of the scanners. Those bastard non-radiologists. Only radiologists should be able to self-refer and get away with it. In general, I think that Dr. Smith-Bindman is on point with her suggestions. It would be great if patients’ total radiation doses could be tracked throughout their lives. However, assuming that could happen, would a high dose of radiation make any difference in determining whether an 80 year old lady with abdominal pain got a CT scan? How about in determining whether a hypotensive unconscious 50 year old trauma victim should undergo CT scanning? What about deciding whether the obese 30 year old complaining of severe difficulty breathing should get a chest CT to rule out a pulmonary embolism? Can we reduce radiation dose at the sacrifice of less clear scans? That’s a radiologist’s call. Is Dr. Smith-Bindman following her own suggestions? If we missed a small nodule that later became metastatic cancer, would the defense that “at least the patient didn’t get ...

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Will Insurance Deny Payment if You Leave AMA?

Fifty seven percent of all health care providers (and probably just as many patients) believe that if you leave the hospital or the emergency department against medical advice, insurance companies will not pay for the visit. Half of doctors surveyed have told or would tell patients that insurance would not pay the bill if they left AMA. With 1 in 70 of all discharges in the US being against medical advice, such a policy would have a significant effect on finances for both patients and hospitals (if patients are unable to pay for denied coverage). Enter a study in last month’s Annals of Emergency Medicine titled “Insurance Companies Refusing Payment for Patients Who Leave the Emergency Department Against Medical Advice is a Myth” Several researchers reviewed 104 AMA discharges in a suburban hospital emergency department and queried 19 insurance companies including HMOs, PPOs, Medicare, Medicaid, and worker’s compensation. Out of 104 AMA discharges, each and every visit was fully reimbursed by the  insurance companies. Now that the cat is out of the bag, will insurers change their tunes? May not be a bad idea to find out what your policy covers before you have to make a decision to leave AMA.

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Add Another Thing to the List

In addition to calling it the “ER,” using cell phones in said “ER,” and engaging in baby talk, we can now add “scientific studies” like this to the list of things that drive me friggin batty. The American College of Radiology published this study that purported to analyze the “appropriateness” of outpatient CT and MRI scans ordered from primary care clinics at an academic medical center. In the study, researchers at the University of Washington used “appropriateness criteria from a radiology benefit management company” to determine whether CT scans and MRIs ordered by the lowly primary care physicians met “criteria for approval.” Then researchers compared studies that did meet “criteria for approval” with those that did not meet “criteria for approval” and found that 26% of the studies ordered were considered “inappropriate.” The authors listed several examples of “inappropriate” studies such as obtaining a brain CT for chronic headache, obtaining a lumbar spine MR for acute back pain, ordering knee or shoulder MRI in patients with osteoarthritis, and ordering a CT for hematuria during a urinary tract infection. Here’s the thing, though. The study states that “only” 24% of the “inappropriate studies” had positive results and affected patient management. In other words, if the researchers had not performed the “inappropriate studies”, they would have missed clinically significant findings in a quarter of patients. The conclusion of the “study” is that because the sensitivity of appropriate studies is higher than that of inappropriate studies, primary care physicians need help to “improve the quality of their imaging decision requests.” Want some help? Here’s some help for you: Stop the Monday morning quarterbacking and create a policy at your academic institutions so that none of the lowly primary care physicians can obtain a diagnostic radiology test without the esteemed radiologist’s approval. Lowly family practitioners can order the tests and you researchers just veto them when they cross your desk. Think of all the money and wasted testing you’ll save. Oh yeah … then you can be legally liable for the bad patient outcomes when you don’t allow the test. Why doesn’t one of you suggest that as an official ACR policy at your annual meeting in April? Those tests don’t look quite so “inappropriate” when you don’t have the benefit of a retrospectoscope, do they? P.S. Have family practitioners ever done a study to determine how many of the additional radiographic tests recommended in a radiologist report (i.e. “hip fracture present, cannot rule out pathologic fracture, recommend MRI and bone scan”) were retrospectively “appropriate”?

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Reducing Bloodstream Infections

There’s this light on my way to work that is just a royal pain. It’s set up so that you have to wait for the arrow to make a left hand turn. The intersection is busy, especially in the mornings, and the arrow only stays lit for about 13 seconds. So you end up waiting five minutes or more – through several light cycles – to make the turn. OR … you can go straight through the intersection, turn left into McDonald’s parking lot, pull out of the parking lot, come back to the intersection from the other direction, and make a right turn, saving yourself 4 minutes and 30 seconds. Now mind you that drivers who choose the latter route are, in effect, going through a red turn arrow – they’re just taking a bunch of extra steps to make sure that they are complying with all of the traffic laws in the process. You’re probably wondering what a traffic light has to do with bloodstream infections. I’ll get to that later. This month, Consumer Reports published a well-written article about reducing hospital infections, and a lot of the take-home messages are good ones. The Consumer Reports article focuses on blood stream infections – also known as “septicemia“. Consumer Reports compared central line infection data for intensive care units at 926 hospitals in 43 states. Hospitals voluntarily submit such information to the Leapfrog Group, a nonprofit organization based in Washington, D.C. and Consumer Reports obtained the data from Leapfrog. As many people realize, septicemia and sepsis can lead to significant mortality in patients. Approximately 20–35% of patients with severe sepsis and 40–60% of patients with septic shock die within 30 days. Anything that we can do to prevent bloodstream infections will be a net positive for patient care. So it was interesting to read the data Consumer Reports collected regarding central line-related bloodstream infections. In every state, hospitals significantly decreased the number of central line infections that occurred. In fact, many hospitals – several with more than 6,000 central line days – reported ZERO central line-related blood infections. You read that right. ZERO. Zilch. Nada. Absolutely no incidents of central line-related bloodstream infections. The prevention in central line-related infections is credited to a simple five step checklist that was developed by Peter Pronovost, a Johns Hopkins critical care specialist. He felt that public disclosure of infection rates was a powerful motivator for hospitals to reduce the incidence of infections. I agree, to a point, but there is a bigger motivator out there, though. Cold hard cash. Under Section 5001(c) of the Deficit Reduction Act, the Centers for Medicare and Medicaid Services was required to select diagnosis codes that “have a high cost or high volume”, results in higher payment, and “could reasonably be prevented using evidence-based guidelines.” Bloodstream infections related to catheters was chosen as one of these codes and eventually became known as a “never event” – at least alluding to the notion that such infections should “never” happen and making a firm statement that the government would “never” pay for care related to such infections. In law, the concept of incurring liability for the occurrence of an event, regardless of whether that event is within one’s control is called strict liability. Here are come comments I previously made about strict liability in medicine. Faced with public scrutiny and the possibility of being held liable for providing significant amounts of uncompensated care to sepsis patients, hospitals needed to make changes … and they did. So first I’d like to start by congratulating the hospitals in Pennsylvania that made ...

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Contrast Allergy and Shellfish

A recent EMedHome Clinical Pearl sheds some light on the alleged relationship between “allergies” to radiocontrast/iodine and seafood allergies. The pearl noted that iodine is found throughout our bodies and is added to most kinds of table salt used in the United States. Our thyroid glands need iodine to function properly. While seafood contains iodine, the allergies to seafood are due to muscle proteins, not to the iodine. Because reactions to IV contrast are not IgE-mediated, they are not considered “anaphylactic” or “allergic.” Sensitization does not occur since the reactions are not immune-mediated. In other words, your immune system won’t “remember” a prior reaction to contrast material. Administration of steroids has no effect on whether a severe reaction will occur. Since the reaction is not “allergic”, Benadryl probably won’t have any effect, either – although this was not specifically stated in the study. Severe reactions to contrast media occur in 0.02-0.5% of cases and deaths occur in 0.0006-0.006% of patients (something else to consider when deciding whether to undergo repeated CT scans), but serious reactions and death are not related to allergies to iodine/seafood or to prior reactions to contrast media. One recently-published study used to create the pearl dispels this “medical myth” quite nicely.

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