A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care

Head computerized tomography in emergency department evaluation of the geriatric patient with generalized weakness

Objective

Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients.

Methods

This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention.

Results

Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation.

Conclusion

Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

Reducing unnecessary testing in the emergency department: The case for INR and aPTT

Objective

Routine coagulation testing is rarely indicated in the emergency department. Our goal is to determine the combined effects of uncoupling routine coagulation testing (i.e., international normalized ratio [INR]; activated partial thromboplastin time [aPTT]), disseminating an educational module, and implementing a clinical decision support system (CDSS) on coagulation testing rates in two academic emergency departments.

Methods

A prospective pre-post study of INR-aPTT uncoupling, educational module distribution, and CDSS implementation in two academic emergency departments. All patients ages 18 years and older undergoing evaluation and treatment during the period of August 1, 2015, to November 30, 2017, were included. Primary outcome was coagulation testing utilization during the emergency department encounter. Secondary outcomes included associated costs, frequency of downstream testing, and frequency of blood transfusions.

Results

Uncoupling INR-aPTT testing combined with educational module distribution and CDSS implementation resulted in significantly decreased coupled INR-aPTT testing, with significantly increased selective INR and aPTT testing. Overall, the aggregate rate of coagulation testing declined for both INR and aPTT testing (48 tests/100 patients/day to 26 tests/100 patients/day). There was a significant decrease in associated daily costs (median cost per day: $1048.32 v. $601.68), realizing estimated annual savings of $163,023 Canadian dollars (CAD). There was no signal of increased downstream testing or patient blood product requirements.

Conclusion

Compared to baseline practice patterns, our multimodal initiative significantly decreased coagulation testing, with meaningful cost savings and without evidence of patient harm. Clinicians and administrators now have a growing toolkit to target the plethora of low-value tests and treatments in emergency medicine.

A new clinical score for cranial CT in ED non-trauma patients: Definition and first validation

INTRODUCTION

Well recognized guidelines are available for the use of cranial computed tomography (CCT) in traumatic patients, while no definitely accepted standards exists to for CCT in patients without history of head injury. The aim of this study is to propose an easy clinical score to stratify the need of CCT in emergency department (ED) patients with suspect non-traumatic intracranial pathology.

METHODS

We retrospectively evaluated patients presenting to the ED for neurological deficit, postural instability, acute headache, altered mental status, seizures, confusion, dizziness, vertigo, syncope, and pre-syncope. We build a score for positive CCT prediction by using a logistic regression model on clinical factors significant at univariate analysis. The score was validated on a population of prospectively observed patients.

RESULTS

We reviewed clinical data of 1156 patients; positivity of CCT was 15.2%. Persistent neurological deficit, new onset acute headache, seizures and/or altered state of consciousness, and transient neurological disorders were independent predictors of positive CCT. We observed 508 patients in a validation prospective cohort; CCT was positive in 11.3%. Our score performed well in validation population with a ROC AUC of 0.787 (CI 95% 0.748-0.822). Avoiding CT in score 0 patients would have saved 82 (16.2%) exams. No patients with score 0 had a positive CCT findings; score sensitivity was 100.0 (CI 95% 93.7-100.0).

CONCLUSIONS

A score for risk stratification of patients with suspect of intra-cranial pathology could reduce CT request in ED, avoiding a significant number of CCT while minimizing the risk of missing positive results.

Lean Management to support Choosing Wisely in healthcare: the first evidence from a systematic literature review

Purpose

Choosing Wisely (CW) is an emergent approach to identify and reduce unnecessary care, such as tests and treatments that do not add value for patients and may even cause harm. The purpose of this paper is to investigate whether and how Lean Healthcare Management (LHM) can support CW objectives, focusing on customer needs and on waste elimination.

Data sources

A systematic literature review has been performed in Scopus, PubMed and Web of Science.

Study selection

Peer reviewed articles published in English language have been selected. Papers were considered if they regarded LHM and its possible support for achieving CW objectives. Data extraction. The links between the LHM purposes of adoption and the pursued CW objectives were investigated. Moreover, LHM tools, practices and interventions to support CW were grasped.

Results of data synthesis

Sixteen articles were included in the analysis. Links between the identified LHM purposes of adoption and CW objectives were discovered: through process understanding, optimization, evaluation and control, LHM contributes to the reduction of overuses in healthcare, but also to the delivery of a more effective and evidence-based care (EBC). Moreover, it provides an objective approach useful for choosing the most cost-effective solution among different alternatives.

Conclusions

Results highlight how LHM, and with which tools and practices, can be adopted to enhance the healthcare appropriateness pursued by CW, paving the way for interesting future research about this emerging topic.

"Choosing Wisely" Imaging Recommendations: Initial Implementation in New England Emergency Departments

Introduction

In June 2016, the American College of Emergency Physicians (ACEP) Emergency Quality Network began its Reduce Avoidable Imaging Initiative, designed to “reduce testing and imaging with low risk patients through the implementation of Choosing Wisely recommendations.” However, it is unknown whether New England emergency departments (ED) have already implemented evidence-based interventions to improve adherence to ACEP Choosing Wisely recommendations related to imaging after their initial release in 2013. Our objective was to determine this, as well as whether provider-specific audit and feedback for imaging had been implemented in these EDs.

Methods

This survey study was exempt from institutional review board review. In 2015, we mailed surveys to 195 hospital-affiliated EDs in all six New England states to determine whether they had implemented Choosing Wisely-focused interventions in 2014. Initial mailings included cover letters denoting the endorsement of each state’s ACEP chapter, and we followed up twice with repeat mailings to non-responders. Data analysis included descriptive statistics and a comparison of state differences using Fisher’s exact test.

Results

A total of 169/195 (87%) of New England EDs responded, with all individual state response rates >80%. Overall, 101 (60%) of responding EDs had implemented an intervention for at least one Choosing Wisely imaging scenario; 57% reported implementing a specific guideline/policy/clinical pathway and 28% reported implementing a computerized decision support system. The most common interventions were for chest computed tomography (CT) in patients at low risk of pulmonary embolism (47% of EDs) and head CT in patients with minor trauma (45% of EDs). In addition, 40% of EDs had implemented provider-specific audit and feedback, without significant interstate variation (range: 29–55%).

Conclusion

One year after release of the ACEP Choosing Wisely recommendations, most New England EDs had a guideline/policy/clinical pathway related to at least one of the recommendations. However, only a minority of them were using provider-specific audit and feedback or computerized decision support. Few EDs have embraced the opportunity to implement the multiple evidence-based interventions likely to advance the national goals of improving patient-centered and resource-efficient care.

Early death after discharge from emergency departments: analysis of national US insurance claims data

OBJECTIVE

 To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.

DESIGN

 Retrospective cohort study.

SETTING

 Claims data from the US Medicare program, covering visits to an emergency department, 2007-12.

PARTICIPANTS

 Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.

MAIN OUTCOME MEASURE

 Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.

RESULTS

 Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)-3.4 times higher than hospitals in the highest fifth (0.08%)-despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).

CONCLUSIONS

 Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.

The 2016 Academic Emergency Medicine Consensus Conference, "Shared Decision Making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda" Diagnostic Testing Breakout Session Report

Diagnostic testing is an integral component of patient evaluation in the emergency department (ED). Emergency clinicians frequently use diagnostic testing to more confidently exclude "worst-case" diagnoses rather than to determine the most likely etiology for a presenting complaint. Increased utilization of diagnostic testing has not been associated with reductions in disease-related mortality but has led to increased overall healthcare costs and other unintended consequences (e.g., incidental findings requiring further workup, unnecessary exposure to ionizing radiation or potentially nephrotoxic contrast). Shared decision making (SDM) presents an opportunity for clinicians to discuss the benefits and harms associated with diagnostic testing with patients to more closely tailor testing to patient risk. This article introduces the challenges and opportunities associated with incorporating SDM into emergency care by summarizing the conclusions of the diagnostic testing group at the 2016 Academic Emergency Medicine Consensus Conference on SDM. Three primary domains emerged: 1) characteristics of a condition or test appropriate for SDM, 2) critical elements of and potential barriers to SDM discussions on diagnostic testing, and 3) financial aspects of SDM applied to diagnostic testing. The most critical research questions to improve engagement of patients in their acute care diagnostic decisions were determined by consensus.

The Association Between Physician Empathy and Variation in Imaging Use

BACKGROUND

Variation in emergency physician computed tomography (CT) imaging utilization is well described, but little is known about what drives it. Physician empathy has been proposed as a potential characteristic affecting CT utilization.

OBJECTIVES

The objective was to describe empathy in a cohort of emergency physicians and evaluate its association with CT utilization. We also sought to compare emergency physician performance on an empathy psychometric test with performance on other psychometric tests previously proposed as predictors of CT utilization.

METHODS

This cross-sectional study included two parts: 1) a secondary analysis of emergency department (ED) CT imaging utilization data in a large health system from July 2013 to June 2014 and 2) a survey study of the cohort of physicians responsible for this imaging using four psychometric scales: the Jefferson Scale of Empathy (JSE), a risk-taking subset of the Jackson Personality Index (RTS), the Stress from Uncertainty Scale (SUS), and the Malpractice Fear Scale (MFS). The study included data and physicians from four EDs: one urban, academic ED, two community, and one free-standing. A hierarchical, mixed-effects regression model was used to evaluate the association between emergency physician performance on the four scales and risk-adjusted CT imaging utilization. The model incorporated physician-specific CT utilization rates adjusted for propensity scores that were calculated using over 500 patient-level variables via random forest methods, physician demographics, and a random provider effect to account for the clustering of observations.

RESULTS

CT variation analysis included 113,517 patients seen during the study period by the 74 eligible emergency physician survey respondents; 20,972 (18.5%) of these patients had at least one CT. The survey response rate was 74 of 82 (90.2%). Correlation coefficients between JSE and the other scales were not statistically significant. In subset analysis, there was a trend toward a physician's number of years in practice and RTS score contributing to CT utilization for traumatic head CT. There were no significant associations between performance on any of the psychometric scales and CT utilization.

CONCLUSIONS

Performance on the JSE, RTS, SUS, or MFS was not predictive of risk-adjusted CT utilization in the ED. The underlying physician-based factors that mediate interphysician variation remain to be clearly identified.

Risk of Delayed Intracerebral Hemorrhage in Anticoagulated Patients after Minor Head Trauma: The Role of Repeat Cranial Computed Tomography

CONTEXT

Patients receiving anticoagulant medications who experience minor head injury are at increased risk of an intracerebral hemorrhage (ICH) developing, even after an initial computed tomography (CT) scan of the brain yields normal findings. Conflicting evidence exists regarding the frequency at which delayed bleeding occurs.

OBJECTIVE

To identify the frequency of delayed traumatic ICH in patients receiving warfarin or clopidogrel.

DESIGN

We performed a retrospective observational study of adult trauma encounters for anticoagulated patients undergoing head CT at 1 of 13 Kaiser Permanente Southern California Emergency Departments (EDs) between 2007 and 2011. Encounters were identified using structured data from electronic health and administrative records, and then records were individually reviewed for validation of results.

MAIN OUTCOME MEASURES

The primary outcome measure was ICH within 60 days of an ED visit with a normal head CT result.

RESULTS

Our sample included 443 (260 clopidogrel and 183 warfarin) eligible ED encounters with normal findings of initial head CT. Overall, 11 patients (2.5%, 95% confidence interval [CI] = 1.4%-4.4%) had a delayed ICH, and events occurred at similar rates between the clopidogrel group (6/260, 2.3%, CI 1.1%-5.0%) and warfarin group (5/183, 2.7%, CI 1.2%-6.2%).

CONCLUSION

Trauma patients in the ED who are receiving warfarin or clopidogrel have approximately a 2.5% risk of delayed ICH after an initial normal finding on a head CT.

Choosing Wisely in Emergency Medicine: A National Survey of Emergency Medicine Academic Chairs and Division Chiefs

OBJECTIVES

The Choosing Wisely campaign was launched in 2011 to promote stewardship of medical resources by encouraging patients and physicians to speak with each other regarding the appropriateness of common tests and procedures. Medical societies including the American College of Emergency Physicians (ACEP) have developed lists of potentially low-value practices for their members to address with patients. No research has described the awareness or attitudes of emergency physicians (EPs) regarding the Choosing Wisely campaign. The study objective was to assess these beliefs among leaders of academic departments of emergency medicine (EM).

METHODS

This was a Web-based survey of emergency department (ED) chairs and division chiefs at institutions with allopathic EM residency programs. The survey examined awareness of Choosing Wisely, anticipated effects of the program, and discussions of Choosing Wisely with patients and professional colleagues. Participants also identified factors they associated with the use of potentially low-value services in the ED. Questions and answer scales were refined using iterative pilot testing with EPs and health services researchers.

RESULTS

Seventy-eight percent (105/134) of invited participants responded to the survey. Eighty percent of respondents were aware of Choosing Wisely. A majority of participants anticipate the program will decrease costs of care (72% of respondents) and use of ED diagnostic imaging (69%) but will have no effect on EP salaries (94%) or medical-legal risks (65%). Only 45% of chairs have ever addressed Choosing Wisely with patients, in contrast to 88 and 82% who have discussed it with faculty and residents, respectively. Consultant-requested tests were identified by 97% of residents as a potential contributor to low-value services in the ED.

CONCLUSIONS

A substantial majority of academic EM leaders in our study were aware of Choosing Wisely, but only slightly more than half could recall any ACEP recommendations for the program. Respondents familiar with Choosing Wisely anticipated generally positive effects, but chairs reported only infrequently discussing Choosing Wisely with patients. Future research should identify potentially low-value tests requested by consultants and objectively measure the utility and cost of these tests among ED patient populations.

Research Priorities in the Utilization and Interpretation of Diagnostic Imaging: Education, Assessment, and Competency

The appropriate selection and accurate interpretation of diagnostic imaging is a crucial skill for emergency practitioners. To date, the majority of the published literature and research on competency assessment comes from the subspecialty of point-of-care ultrasound. A group of radiologists, physicists, and emergency physicians convened at the 2015 Academic Emergency Medicine consensus conference to discuss and prioritize a research agenda related to education, assessment, and competency in ordering and interpreting diagnostic imaging. A set of questions for the continued development of an educational curriculum on diagnostic imaging for trainees and competency assessment using specific assessment methods based on current best practices was delineated. The research priorities were developed through an iterative consensus-driven process using a modified nominal group technique that culminated in an in-person breakout session. The four recommendations are: 1) develop a diagnostic imaging curriculum for emergency medicine (EM) residency training; 2) develop, study, and validate tools to assess competency in diagnostic imaging interpretation; 3) evaluate the role of simulation in education, assessment, and competency measures for diagnostic imaging; 4) study is needed regarding the American College of Radiology Appropriateness Criteria, an evidence-based peer-reviewed resource in determining the use of diagnostic imaging, to maximize its value in EM. In this article, the authors review the supporting reliability and validity evidence and make specific recommendations for future research on the education, competency, and assessment of learning diagnostic imaging.

Overtesting and the Downstream Consequences of Overtreatment: Implications of "Preventing Overdiagnosis" for Emergency Medicine

Overtesting, the downstream consequences of overdiagnosis, and overtreatment of some patients are topics of growing debate within emergency medicine (EM). The "Preventing Overdiagnosis" conference, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, with sponsorship from consumer organizations, medical journals, and academic institutions, is evidence of an expanding interest in this topic. However, EM represents a compellingly unique environment, with increased decision density tied to high stakes for patients and providers with missed or delayed diagnoses in a professional atmosphere that does not tolerate mistakes. This article reviews the relevance of this reductionist paradigm to EM, provides a first-hand synopsis of the first "Preventing Overdiagnosis" conference, and assesses barriers to moving the concept of less test ordering to reality.

Clinical scoring system may improve yield of head CT of non-trauma emergency department patients

The positive rate of head CT in non-trauma patients presenting to the emergency department (ED) is low. Currently, indications for imaging are based on the individual experience of the treating physician, which contributes to overutilization and variability in imaging utilization. The goals of this study are to ascertain the predictors of positive head CT in non-trauma patients and demonstrate feasibility of a clinical scoring algorithm to improve yield. We retrospectively reviewed 500 consecutive ED non-trauma patients evaluated with non-contrast head CT after presenting with headache, altered mentation, syncope, dizziness, or focal neurologic deficit. Medical records were assessed for clinical risk factors: focal neurologic deficit, altered mental status, nausea/vomiting, known malignancy, coagulopathy, and age. Data was analyzed using logistic regression and receiver operator characteristic (ROC) curves and three derived algorithms. Positive CTs were found in 51 of 500 patients (10.2 %). Only two clinical factors were significant: focal neurologic deficit (adjusted odds ratio (OR) 20.7; 95 % confidence interval (CI) 9.4-45.7) and age >55 (adjusted OR 3.08; CI 1.44-6.56). Area under the ROC curve for all three algorithms was 0.73-0.83. In proposed algorithm C, only patients with focal neurologic deficit (major risk factor) or ≥2 of the five minor risk factors (altered mental status, nausea/vomiting, known malignancy, coagulopathy, and age) would undergo CT imaging. This may reduce utilization by 34 % with only a small decrease in sensitivity (98 %). Our simple scoring algorithm utilizing multiple clinical risk factors could help to predict the non-trauma patients who will benefit from CT imaging, resulting in reduced radiation exposure without sacrificing sensitivity.

Emergency care and the national quality strategy: highlights from the Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) of the US Department of Health and Human Services seeks to optimize health outcomes by leading clinical quality improvement and health system transformation through a variety of activities, including quality measure alignment, prioritization, and implementation. CMS manages more than 20 federal quality measurement and public reporting programs that cover the gamut of health care providers and facilities, including both hospital-based emergency departments (EDs) and individual emergency physicians. With more than 130 million annual visits, and as the primary portal of hospital admission, US hospital-based EDs deliver a substantial portion of acute care to Medicare beneficiaries. Given the position of emergency care across clinical conditions and between multiple settings of care, the ED plays a critical role in fulfilling all 6 priorities of the National Quality Strategy. We outline current CMS initiatives and future opportunities for emergency physicians and EDs to effect each of these priorities and help CMS achieve the triple aim of better health, better health care, and lower costs.