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Fear of Litigation, Missed Diagnoses Spur Overuse of Imaging in EDs

LOS ANGELES – When emergency physicians order advanced imaging, they may suspect the study is medically unnecessary some of the time but are motivated by fear of missing a diagnosis or being sued, according to a new study.

The report, published recently in the journal Academic Emergency Medicine, points out, “Over-ordering of advanced imaging may be a systemic problem, as many [emergency physicians] believe a substantial proportion of such studies, including some they personally order, are medically unnecessary.”

Solving the problem, according to the study led by researchers from the Robert Wood Johnson Foundation Clinical Scholars Program, the Los Angeles Veterans Affairs Healthcare System and the University of California Los Angeles, will require dealing with “multiple complex factors” that “must be addressed simultaneously to curb over-imaging.”

In initiating the study, researchers sought to determine emergency physician (EP) perceptions regarding the extent to which they order medically unnecessary advanced diagnostic imaging, factors that contribute to the behavior, and proposed solutions for curbing the practice.

As part of a larger study to engage physicians in the delivery of high-value health care, the study team conducted two focus groups to explore the topic of decision-making around resource utilization and then used qualitative analysis to generate survey questions. The survey, which was extensively pilot-tested, focused on advanced diagnostic imaging, i.e., computed tomography [CT] or magnetic resonance imaging [MRI].

With 478 emergency physicians approached, 435 (91%) completed the survey – 68% of the respondents were board-certified, and roughly half worked in academic emergency departments.

More than 85% of respondents said they believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some – an average of 22% – of the advanced imaging studies they personally order are medically unnecessary.

“The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation,” according to the authors.

“Extremely” or “very” helpful possible solutions, according to survey respondents, include:

  • malpractice reform (79%),
  • increased patient involvement through education (70%),
  • shared decision-making (56%),
  • feedback to physicians on test-ordering metrics (55%), and
  • improved education of physicians on diagnostic testing (50%).



Race, Class Biases Exist But Don’t Affect Trauma, Acute-CareELB for ED Push Apr2015

BOSTON – How do unconscious race and social class biases affect care provided by trauma and acute-care clinicians?

While those biases exist, according to a report published online recently by JAMA Surgery, they don’t appear to have much effect on clinical decisions.

Background information in the study, led by researchers from Brigham and Women’s Hospital in Boston, notes that disparities in the quality of care received by minority patients have been reported for decades across multiple conditions, types of care and institutions.

To determine how that affected care, the study conducted a web-based survey among doctors from surgery and related specialties at an academic, level I trauma center.

Using the Implicit Association Test (IAT) for race and class to measure the strength of a person's automatic associations, unconscious attitudes were assessed according to the speed with which respondents pressed computer keys as a way to gauge the ease with which respondents sorted out mental concepts. The study included four race vignettes and four social class vignettes involving patients who were white and black and those of upper and lower social classes.

With 215 clinicians participating – 74 attending surgeons, 32 fellows, 86 residents, 19 interns and four physicians – the study uncovered implicit race and social class biases for most respondents. Average test scores among all clinicians were 0.42 for race, indicating moderate preference, and 0.71 for social class, indicating strong preference. Practitioner specialty, race or age did not appear significant in terms of the results, nor did subtle differences in scores between women and men after further analyses, according to the report.

Some analyses showed possible associations between race and social class biases among participants in three of 27 patient management options in the survey vignettes –respondents being more likely to diagnose a young black woman with pelvic inflammatory disease rather than appendicitis and being less likely to order an MRI of the cervical spine for patients with neck tenderness after a motor vehicle accident if they were of low rather than high socioeconomic status. Those differences were not significant in further analysis.

The study overall found no differential patient treatment related to race or social class biases, according to the authors.

"Although this study of clinicians from surgical and other related specialties did not demonstrate any association between implicit race or social class bias and clinical decision making, existing biases might influence the quality of care received by minority patients and those of lower socioeconomic status in real-life clinical encounters,” the study concludes. “Further research incorporating patient outcomes and data from actual clinical interactions is warranted to clarify the effect of clinician implicit bias on the provision of health care and outcomes.”


Why So Many Kidney Stone Patients End Up Revisiting the ED

DURHAM, NC – When you release a patient with a kidney stone from your emergency department, there is a one in nine chance he or she will be back, according to a new study.

There also may be something you can do about those revisits.

A report published online in the journal Academic Emergency Medicine identifies multiple factors that correlate with repeat ED visits for kidney stones.

The study authors, led by Duke University researchers, suggest that the results could help physicians improve care for the condition, which can be both painful and costly.

“This is the first study that has looked at what happens to a large group of patients after they leave the emergency department,” said lead author Charles Scales, MD, assistant professor of surgery at Duke University School of Medicine. “Prior work in this area has really only looked at the processes of care during an emergency department visit, but not outcomes after patients go home.”

Background information in the article notes that more than a million people visit EDs annually because of kidney stones and the number is rising.

“The prevalence of kidney stones has nearly doubled in the past 15 years,” Scales pointed out. “This is likely related to the increasing obesity rates in the U.S. population and the diet and lifestyle of Americans today.”

For the retrospective study, researchers looked at medical records of all patients in California initially treated and released from EDs for kidney stones between February 2008 and November 2009. The primary outcome was a second ED visit within 30 days of the initial discharge from emergent care.

Results indicate that, among 128,564 patients discharged from EDs, 13,684 (11%) had at least one additional emergency visit for treatment of their kidney stone. Among those patients, nearly one in three required hospitalization or an urgent temporizing procedure at the second visit.

The study finds that being on Medicaid vs. having private insurance increased the risk of an ED visit. Greater access to urologic care, meanwhile, was associated with lower odds. Performance of a complete blood count also was associated with a decreased risk of a revisit, the authors point out.

Symptoms that led patients to return to the ED included uncontrolled pain, severe vomiting leading to dehydration, or infections that coincide with kidney stones.

The researchers also examined whether the care patients received was associated with the risk of revisits. Patients who received lab testing to assess for systemic infection were less likely to return to the emergency department.

“Although requiring further investigation, this finding suggests that the quality of care at that first visit may influence the risk of a second emergency department visit,” Scales said.

“Overall, our aim is to find ways to improve care for patients facing the excruciating pain of passing a kidney stone," he added. "One solution may be better coordination between primary care and urology to treat patients so they do not have to seek care in a high-expense, high-acuity setting like the emergency department.”


Clinical Decision Tool Shows Promise in Reducing Pneumonia Deaths

SALT LAKE CITY – Use of an advanced clinical decision tool potentially could reduce mortality for the 1.1 million patients treated for pneumonia in the United States each year.

That’s according to a new study, published recently in Annals of Emergency Medicine.

Researchers from Intermountain Medical Center in Salt Lake City report that a tool they developed saved up to 12 lives in hospitals where it was used, compared to routine care standards. Currently, more than 50,000 Americans die each year from pneumonia.

According to the report, the advanced computer program combines a patient's personal medical information and risk factors in real time to alert emergency department physicians to the possibility of a pneumonia diagnosis.

Once pneumonia is confirmed by the physician, the tool automatically provides a calculated severity assessment as well as management recommendations, which include diagnostic testing and antibiotic selection, based on current North American pneumonia treatment guidelines.

"Because of the complexity of pneumonia, physicians can't easily make consistent decisions that follow current treatment recommendations," explained lead author Nathan Dean, MD, a pulmonologist and chief of critical care medicine at Intermountain Medical Center.

In the prospective, controlled trial in seven Intermountain Healthcare hospital EDs in urban areas in Utah, the researchers looked at patients diagnosed with pneumonia from December 2009 through November 2010, prior to introduction of the tool, and December 2011 through November 2012, after the tool was deployed.

The study compared 30-day, all-cause mortality adjusted for illness severity at the four intervention EDs, which began using the tool in May 2011, to three EDs providing usual care.

Of 4,758 ED pneumonia patients, 14% of whom had healthcare-associated pneumonia, median age was 58, 53% were female and 59% were admitted to the hospital.

With the tool used in 62.6% of intervention ED study patients, no difference was detected in severity-adjusted mortality between intervention and usual care EDs’ post–tool deployment. Post hoc analysis, however, indicated that patients with community-acquired pneumonia experienced significantly lower mortality, whereas mortality was unchanged among patients with healthcare–associated pneumonia. Tool recommendations were followed more by patients discharged from EDs post-deployment, according to the researchers.

"This tool doesn't take over for doctors, but it does assemble the needed information, calculates the patients' severity of illness and likelihood of infection with resistant bacteria, and presents recommendations to help doctors make better decisions,” Dean said. “It's all about giving local doctors tools to be more consistent, objective, and focused on best practices."


The Top Ten Issues in Emergency Medicine Today

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