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Emergency physician describes how to prepare for disasters
, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.
In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.
Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.
In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.
Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.
In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.
Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
REPORTING FROM ACEP18
Pneumonia, COPD most common emergency care–sensitive conditions
SAN DIEGO – Emergency care–sensitive conditions – those for which timely access to high-quality emergency care impact morbidity and mortality—account for 14% of all ED visits, results from a large analysis of national data showed.
In previously published work, an eight-member expert panel identified 51 condition groups as emergency care–sensitive conditions (ECSCs), including asthma, cardiac arrest, cerebral infarction, and pneumonia. The purpose of the current study, published in Annals of Emergency Medicine and presented by Anita Vashi, MD, MPH, at the annual meeting of the American College of Emergency Physicians, was to provide the first national estimates of acute care utilization and the demographic characteristics of adults experiencing ECSCs, compare ECSC and non-ECSC ED visits, and assess patient- and hospital-level characteristics predictive of an ECSC-related ED visit.
Using the Nationwide Emergency Department Sample data set, Dr. Vashi, a physician investigator at the Center for Innovation to Implementation at the VA Palo Alto Health Care System, and her colleagues retrospectively evaluated all ED visits for patients aged 18 years and older from 2009 to 2014. The researchers used summary statistics to compare population characteristics across groups and multivariable logistic regression models to assess the odds of an ECSC-related ED visit with patient- and hospital-level characteristics.
Of the 622,725,542 estimated ED visits evaluated during the study period, 86,577,041 (14%) were ECSCs. Among these ECSC visits, 58% of patients were admitted for an average length of 3.2 days and an average charge of $2,240. The most frequent ECSC-related visits were for pneumonia (9%), chronic obstructive pulmonary disease (9%), asthma (7%), heart failure (7%), and sepsis (5%), but varied by age group.
Dr. Vashi and her colleagues found that ECSCs were more common among older adults, males, those who reside in low-income areas, those who reside in the South, and among metropolitan-based hospitals and nontrauma center hospitals. ECSCs also accounted for about 45% of all inpatient admissions.
Multivariate logistic regression analysis revealed that the odds of having an ECSC-related visit was highest among patients aged 65 years and older (odds ratio, 3.84), those on Medicare (OR, 1.37), those who resided in rural counties (OR, 1.21), and those who reside in the Western portion of the United States (OR, 1.11). Significant hospital-related factors related to ECSC visits included trauma centers (OR, 1.09), nonteaching hospitals (OR, 1.04), and EDs located in the wealthiest counties (OR, 1.02).
The researchers also found that 40% of patients who made ECSC-related ED visits were treated and discharged back to the community. “There is evidence of regional variability, suggesting the need for future research,” said Dr. Vashi, who also holds a faculty position in the department of emergency medicine at Stanford (Calif.) University. “We found no consistent relationship between insurance, income, and ED use for ECSC-related conditions. This suggests that ECSCs are not significantly influenced by socioeconomic factor and can serve as a reliable marker for acuity.”
The next steps in this research area, she added, are to create condition-specific measures related to morbidity, mortality, and posthospital events, as well as to analyze regional and hospital variations including correlation across conditions, and to compare performance across conditions and hospitals.
Dr. Vashi reported having no financial disclosures.
Source: Vashi A et al. Ann Emerg Med. 2018 Oct;72;4:S38. doi. 10.1016/j.annemergmed.2018.08.091.
SAN DIEGO – Emergency care–sensitive conditions – those for which timely access to high-quality emergency care impact morbidity and mortality—account for 14% of all ED visits, results from a large analysis of national data showed.
In previously published work, an eight-member expert panel identified 51 condition groups as emergency care–sensitive conditions (ECSCs), including asthma, cardiac arrest, cerebral infarction, and pneumonia. The purpose of the current study, published in Annals of Emergency Medicine and presented by Anita Vashi, MD, MPH, at the annual meeting of the American College of Emergency Physicians, was to provide the first national estimates of acute care utilization and the demographic characteristics of adults experiencing ECSCs, compare ECSC and non-ECSC ED visits, and assess patient- and hospital-level characteristics predictive of an ECSC-related ED visit.
Using the Nationwide Emergency Department Sample data set, Dr. Vashi, a physician investigator at the Center for Innovation to Implementation at the VA Palo Alto Health Care System, and her colleagues retrospectively evaluated all ED visits for patients aged 18 years and older from 2009 to 2014. The researchers used summary statistics to compare population characteristics across groups and multivariable logistic regression models to assess the odds of an ECSC-related ED visit with patient- and hospital-level characteristics.
Of the 622,725,542 estimated ED visits evaluated during the study period, 86,577,041 (14%) were ECSCs. Among these ECSC visits, 58% of patients were admitted for an average length of 3.2 days and an average charge of $2,240. The most frequent ECSC-related visits were for pneumonia (9%), chronic obstructive pulmonary disease (9%), asthma (7%), heart failure (7%), and sepsis (5%), but varied by age group.
Dr. Vashi and her colleagues found that ECSCs were more common among older adults, males, those who reside in low-income areas, those who reside in the South, and among metropolitan-based hospitals and nontrauma center hospitals. ECSCs also accounted for about 45% of all inpatient admissions.
Multivariate logistic regression analysis revealed that the odds of having an ECSC-related visit was highest among patients aged 65 years and older (odds ratio, 3.84), those on Medicare (OR, 1.37), those who resided in rural counties (OR, 1.21), and those who reside in the Western portion of the United States (OR, 1.11). Significant hospital-related factors related to ECSC visits included trauma centers (OR, 1.09), nonteaching hospitals (OR, 1.04), and EDs located in the wealthiest counties (OR, 1.02).
The researchers also found that 40% of patients who made ECSC-related ED visits were treated and discharged back to the community. “There is evidence of regional variability, suggesting the need for future research,” said Dr. Vashi, who also holds a faculty position in the department of emergency medicine at Stanford (Calif.) University. “We found no consistent relationship between insurance, income, and ED use for ECSC-related conditions. This suggests that ECSCs are not significantly influenced by socioeconomic factor and can serve as a reliable marker for acuity.”
The next steps in this research area, she added, are to create condition-specific measures related to morbidity, mortality, and posthospital events, as well as to analyze regional and hospital variations including correlation across conditions, and to compare performance across conditions and hospitals.
Dr. Vashi reported having no financial disclosures.
Source: Vashi A et al. Ann Emerg Med. 2018 Oct;72;4:S38. doi. 10.1016/j.annemergmed.2018.08.091.
SAN DIEGO – Emergency care–sensitive conditions – those for which timely access to high-quality emergency care impact morbidity and mortality—account for 14% of all ED visits, results from a large analysis of national data showed.
In previously published work, an eight-member expert panel identified 51 condition groups as emergency care–sensitive conditions (ECSCs), including asthma, cardiac arrest, cerebral infarction, and pneumonia. The purpose of the current study, published in Annals of Emergency Medicine and presented by Anita Vashi, MD, MPH, at the annual meeting of the American College of Emergency Physicians, was to provide the first national estimates of acute care utilization and the demographic characteristics of adults experiencing ECSCs, compare ECSC and non-ECSC ED visits, and assess patient- and hospital-level characteristics predictive of an ECSC-related ED visit.
Using the Nationwide Emergency Department Sample data set, Dr. Vashi, a physician investigator at the Center for Innovation to Implementation at the VA Palo Alto Health Care System, and her colleagues retrospectively evaluated all ED visits for patients aged 18 years and older from 2009 to 2014. The researchers used summary statistics to compare population characteristics across groups and multivariable logistic regression models to assess the odds of an ECSC-related ED visit with patient- and hospital-level characteristics.
Of the 622,725,542 estimated ED visits evaluated during the study period, 86,577,041 (14%) were ECSCs. Among these ECSC visits, 58% of patients were admitted for an average length of 3.2 days and an average charge of $2,240. The most frequent ECSC-related visits were for pneumonia (9%), chronic obstructive pulmonary disease (9%), asthma (7%), heart failure (7%), and sepsis (5%), but varied by age group.
Dr. Vashi and her colleagues found that ECSCs were more common among older adults, males, those who reside in low-income areas, those who reside in the South, and among metropolitan-based hospitals and nontrauma center hospitals. ECSCs also accounted for about 45% of all inpatient admissions.
Multivariate logistic regression analysis revealed that the odds of having an ECSC-related visit was highest among patients aged 65 years and older (odds ratio, 3.84), those on Medicare (OR, 1.37), those who resided in rural counties (OR, 1.21), and those who reside in the Western portion of the United States (OR, 1.11). Significant hospital-related factors related to ECSC visits included trauma centers (OR, 1.09), nonteaching hospitals (OR, 1.04), and EDs located in the wealthiest counties (OR, 1.02).
The researchers also found that 40% of patients who made ECSC-related ED visits were treated and discharged back to the community. “There is evidence of regional variability, suggesting the need for future research,” said Dr. Vashi, who also holds a faculty position in the department of emergency medicine at Stanford (Calif.) University. “We found no consistent relationship between insurance, income, and ED use for ECSC-related conditions. This suggests that ECSCs are not significantly influenced by socioeconomic factor and can serve as a reliable marker for acuity.”
The next steps in this research area, she added, are to create condition-specific measures related to morbidity, mortality, and posthospital events, as well as to analyze regional and hospital variations including correlation across conditions, and to compare performance across conditions and hospitals.
Dr. Vashi reported having no financial disclosures.
Source: Vashi A et al. Ann Emerg Med. 2018 Oct;72;4:S38. doi. 10.1016/j.annemergmed.2018.08.091.
REPORTING FROM ACEP18
Key clinical point: Emergency care–sensitive conditions (ECSCs) make up a significant proportion of ED visits.
Major finding: The most common ECSC-related visits were for pneumonia (9%), chronic obstructive pulmonary disease (9%), and asthma (7%).
Study details: A retrospective cohort study of more than 86.5 million ECSC-related ED visits.
Disclosures: Dr. Vashi reported having no financial disclosures.
Source: Vashi A et al. Ann Emerg Med. 2018 Oct;72;4:S38. doi. 10.1016/j.annemergmed.2018.08.091.
ED clinicians’ confidence in dealing with ICE mixed, survey finds
.
“More robust training and education may improve provider comfort and ability to appropriately balance patients’ rights with law enforcement,” one of the study authors, Charlotte Roy, MD, said at the annual meeting of the American College of Emergency Physicians.
Immigration and Customs Enforcement (ICE) is a federal government agency responsible for the detainment and deportation of immigrants whom they deem to be in violation of federal immigration law. Typically, hospitals have fallen into the category of “sensitive locations,” meaning they are avoided by ICE for enforcement actions, said Dr. Roy, a third-year resident in the department of emergency medicine at University of Chicago Hospital. However, “we’ve seen an increase in the apprehension and removal of illegal immigrants by 30% in 2017 across all locations,” she said.
In an effort to assess provider comfort, knowledge, and previous training on the subject, Dr. Roy and her colleagues administered a 15-question multiple-choice survey to 128 emergency residents, fellows, and attendings at John H. Stroger Jr. Hospital of Cook County and University of Chicago Hospital. Most of the 128 survey participants were residents (70), followed by 54 fellows and 4 attendings. One of the two hospital ED programs offered formal training on the topic, yet only 44% of respondents from that program reported that they participated in the training.
Examples of questions included “Do you know in what circumstances you are required to give protected health information of patients to immigration officers?” “Do you feel confident in your knowledge of which areas of the emergency department ICE agents could enter?” and “Are you confident you can get real-time help to answer questions regarding interactions with immigration officers?”
Among all respondents, 52% said that they would not feel comfortable interacting with immigration officers in the ED, 12% felt confident knowing which areas of the ED immigration officers could freely enter, and 11% were familiar with the designation of “sensitive locations” within their hospital. In addition, 23% of respondents knew that immigration status is protected under the Health Insurance Portability and Accountability Act of 1996 as protected health information, 16% knew in which circumstances they were required to convey immigrant status, and 51% knew a warrant or a court order is required for an immigration office to enter a patient’s room.
“Our conclusion based on these survey results is that there is very limited comfort and knowledge amongst ED providers regarding interactions with ICE officers in the ED,” Dr. Roy said. One resource she recommended is the National Immigration Law Center, which publishes a guide, “What to Do If Immigration Comes to Your Workplace.” The study’s primary author was Joseph Palter, MD. The researchers reported having no financial disclosures.
Source: Palter J et al. Ann Emerg Med. 2018 Oct;72;4:S117. doi. 10.1016/j.annemergmed.2018.08.303.
.
“More robust training and education may improve provider comfort and ability to appropriately balance patients’ rights with law enforcement,” one of the study authors, Charlotte Roy, MD, said at the annual meeting of the American College of Emergency Physicians.
Immigration and Customs Enforcement (ICE) is a federal government agency responsible for the detainment and deportation of immigrants whom they deem to be in violation of federal immigration law. Typically, hospitals have fallen into the category of “sensitive locations,” meaning they are avoided by ICE for enforcement actions, said Dr. Roy, a third-year resident in the department of emergency medicine at University of Chicago Hospital. However, “we’ve seen an increase in the apprehension and removal of illegal immigrants by 30% in 2017 across all locations,” she said.
In an effort to assess provider comfort, knowledge, and previous training on the subject, Dr. Roy and her colleagues administered a 15-question multiple-choice survey to 128 emergency residents, fellows, and attendings at John H. Stroger Jr. Hospital of Cook County and University of Chicago Hospital. Most of the 128 survey participants were residents (70), followed by 54 fellows and 4 attendings. One of the two hospital ED programs offered formal training on the topic, yet only 44% of respondents from that program reported that they participated in the training.
Examples of questions included “Do you know in what circumstances you are required to give protected health information of patients to immigration officers?” “Do you feel confident in your knowledge of which areas of the emergency department ICE agents could enter?” and “Are you confident you can get real-time help to answer questions regarding interactions with immigration officers?”
Among all respondents, 52% said that they would not feel comfortable interacting with immigration officers in the ED, 12% felt confident knowing which areas of the ED immigration officers could freely enter, and 11% were familiar with the designation of “sensitive locations” within their hospital. In addition, 23% of respondents knew that immigration status is protected under the Health Insurance Portability and Accountability Act of 1996 as protected health information, 16% knew in which circumstances they were required to convey immigrant status, and 51% knew a warrant or a court order is required for an immigration office to enter a patient’s room.
“Our conclusion based on these survey results is that there is very limited comfort and knowledge amongst ED providers regarding interactions with ICE officers in the ED,” Dr. Roy said. One resource she recommended is the National Immigration Law Center, which publishes a guide, “What to Do If Immigration Comes to Your Workplace.” The study’s primary author was Joseph Palter, MD. The researchers reported having no financial disclosures.
Source: Palter J et al. Ann Emerg Med. 2018 Oct;72;4:S117. doi. 10.1016/j.annemergmed.2018.08.303.
.
“More robust training and education may improve provider comfort and ability to appropriately balance patients’ rights with law enforcement,” one of the study authors, Charlotte Roy, MD, said at the annual meeting of the American College of Emergency Physicians.
Immigration and Customs Enforcement (ICE) is a federal government agency responsible for the detainment and deportation of immigrants whom they deem to be in violation of federal immigration law. Typically, hospitals have fallen into the category of “sensitive locations,” meaning they are avoided by ICE for enforcement actions, said Dr. Roy, a third-year resident in the department of emergency medicine at University of Chicago Hospital. However, “we’ve seen an increase in the apprehension and removal of illegal immigrants by 30% in 2017 across all locations,” she said.
In an effort to assess provider comfort, knowledge, and previous training on the subject, Dr. Roy and her colleagues administered a 15-question multiple-choice survey to 128 emergency residents, fellows, and attendings at John H. Stroger Jr. Hospital of Cook County and University of Chicago Hospital. Most of the 128 survey participants were residents (70), followed by 54 fellows and 4 attendings. One of the two hospital ED programs offered formal training on the topic, yet only 44% of respondents from that program reported that they participated in the training.
Examples of questions included “Do you know in what circumstances you are required to give protected health information of patients to immigration officers?” “Do you feel confident in your knowledge of which areas of the emergency department ICE agents could enter?” and “Are you confident you can get real-time help to answer questions regarding interactions with immigration officers?”
Among all respondents, 52% said that they would not feel comfortable interacting with immigration officers in the ED, 12% felt confident knowing which areas of the ED immigration officers could freely enter, and 11% were familiar with the designation of “sensitive locations” within their hospital. In addition, 23% of respondents knew that immigration status is protected under the Health Insurance Portability and Accountability Act of 1996 as protected health information, 16% knew in which circumstances they were required to convey immigrant status, and 51% knew a warrant or a court order is required for an immigration office to enter a patient’s room.
“Our conclusion based on these survey results is that there is very limited comfort and knowledge amongst ED providers regarding interactions with ICE officers in the ED,” Dr. Roy said. One resource she recommended is the National Immigration Law Center, which publishes a guide, “What to Do If Immigration Comes to Your Workplace.” The study’s primary author was Joseph Palter, MD. The researchers reported having no financial disclosures.
Source: Palter J et al. Ann Emerg Med. 2018 Oct;72;4:S117. doi. 10.1016/j.annemergmed.2018.08.303.
AT ACEP18
Key clinical point: Emergency physicians’ knowledge of how to interact with immigration agencies is highly variable.
Major finding: More than half of respondents (52%) said that they would not feel comfortable interacting with immigration officers in the ED.
Study details: A survey of 128 emergency medicine physicians.
Disclosures: The researchers reported having no financial disclosures.
Source: Palter J et al. Ann Emerg Med. 2018 Oct;72;4:S117. doi. 10.1016/j.annemergmed.2018.08.303.
Ultrasound excels for assessing shoulder dislocation
SAN DIEGO – Point-of-care ultrasound should be the go-to approach for the routine assessment of suspected shoulder dislocations in the ED, based on data from a prospective, multicenter study presented at the annual meeting of the American College of Emergency Physicians.
In the observational study, the average time needed to diagnose shoulder dislocation using ultrasound was 18 seconds, far faster than time from triage to x-ray, according to Michael Secko, MD, director of the emergency ultrasound division at Stony Brook University (NY).
The results from this study, called MUDDS (Musculoskeletal Ultrasound to Diagnose Dislocated Shoulders), support point-of-care ultrasound as a faster and more readily performed alternative to x-ray. Of the 46 adult patients enrolled so far in the ongoing study, ultrasound’s sensitivity has been 96% and its specificity 100% when validated by x-ray findings.
In the study, adults presenting to the ED are evaluated with point-of-care ultrasound from a posterior approach using either a curvilinear or linear transducer in the transverse plane. About half of the patients enrolled so far had injuries caused by falls, and many of the others had a shoulder complaint related to being pulled. Slightly more than one-third had a previous shoulder dislocation.
When evaluated with point-of-care ultrasound and x-ray, 23 of the 42 evaluable patients had a dislocation. The time from triage to ultrasound evaluation averaged 60 minutes, 40 minutes faster than the average of 100 minutes from triage to x-ray. Both tests were ordered at the same time.
Ultrasound performed less well for the diagnosis of a fracture, with a sensitivity of only 53%. Dr. Secko said the anterior approach would not be expected to provide a comprehensive assessment for fracture. He noted, for example, that there was no attempt in this study to evaluate patients for the presence of Bankart lesions. However, in those found to have a fracture on point-of-care ultrasound, the specificity of this imaging tool was 96%.
Ultimately, a major goal of this study was to determine whether a posterior point-of-care ultrasound could provide a quick answer to the question, “is it in or out?” Although patients are still being enrolled, Dr. Secko believed there is already good evidence that ultrasound is fast and effective for diagnosing dislocations.
Others have addressed this same question. Citing a meta-analysis published last year, Dr. Secko reported that all but one of four studies evaluating ultrasound for shoulder dislocations found a sensitivity and specificity of 100% (Gottlieb M et al. West J Emerg Med. 2017 Aug;18[5]:937-942).
Many centers have already switched to ultrasound for the evaluation of shoulder dislocations, according to Andrew S. Liteplo, MD, who moderated the ACEP session in which Dr. Secko presented his data. “If you are not already doing this for suspected shoulder dislocation, start right away because it is easy and awesome,” said Dr. Liteplo, who is chief of the division of ultrasound in emergency medicine at Massachusetts General Hospital, Boston. He also advised that ultrasound can also can be performed after reduction to confirm the efficacy of treatment.
Dr. Secko reported no financial relationships relevant to this study.
SAN DIEGO – Point-of-care ultrasound should be the go-to approach for the routine assessment of suspected shoulder dislocations in the ED, based on data from a prospective, multicenter study presented at the annual meeting of the American College of Emergency Physicians.
In the observational study, the average time needed to diagnose shoulder dislocation using ultrasound was 18 seconds, far faster than time from triage to x-ray, according to Michael Secko, MD, director of the emergency ultrasound division at Stony Brook University (NY).
The results from this study, called MUDDS (Musculoskeletal Ultrasound to Diagnose Dislocated Shoulders), support point-of-care ultrasound as a faster and more readily performed alternative to x-ray. Of the 46 adult patients enrolled so far in the ongoing study, ultrasound’s sensitivity has been 96% and its specificity 100% when validated by x-ray findings.
In the study, adults presenting to the ED are evaluated with point-of-care ultrasound from a posterior approach using either a curvilinear or linear transducer in the transverse plane. About half of the patients enrolled so far had injuries caused by falls, and many of the others had a shoulder complaint related to being pulled. Slightly more than one-third had a previous shoulder dislocation.
When evaluated with point-of-care ultrasound and x-ray, 23 of the 42 evaluable patients had a dislocation. The time from triage to ultrasound evaluation averaged 60 minutes, 40 minutes faster than the average of 100 minutes from triage to x-ray. Both tests were ordered at the same time.
Ultrasound performed less well for the diagnosis of a fracture, with a sensitivity of only 53%. Dr. Secko said the anterior approach would not be expected to provide a comprehensive assessment for fracture. He noted, for example, that there was no attempt in this study to evaluate patients for the presence of Bankart lesions. However, in those found to have a fracture on point-of-care ultrasound, the specificity of this imaging tool was 96%.
Ultimately, a major goal of this study was to determine whether a posterior point-of-care ultrasound could provide a quick answer to the question, “is it in or out?” Although patients are still being enrolled, Dr. Secko believed there is already good evidence that ultrasound is fast and effective for diagnosing dislocations.
Others have addressed this same question. Citing a meta-analysis published last year, Dr. Secko reported that all but one of four studies evaluating ultrasound for shoulder dislocations found a sensitivity and specificity of 100% (Gottlieb M et al. West J Emerg Med. 2017 Aug;18[5]:937-942).
Many centers have already switched to ultrasound for the evaluation of shoulder dislocations, according to Andrew S. Liteplo, MD, who moderated the ACEP session in which Dr. Secko presented his data. “If you are not already doing this for suspected shoulder dislocation, start right away because it is easy and awesome,” said Dr. Liteplo, who is chief of the division of ultrasound in emergency medicine at Massachusetts General Hospital, Boston. He also advised that ultrasound can also can be performed after reduction to confirm the efficacy of treatment.
Dr. Secko reported no financial relationships relevant to this study.
SAN DIEGO – Point-of-care ultrasound should be the go-to approach for the routine assessment of suspected shoulder dislocations in the ED, based on data from a prospective, multicenter study presented at the annual meeting of the American College of Emergency Physicians.
In the observational study, the average time needed to diagnose shoulder dislocation using ultrasound was 18 seconds, far faster than time from triage to x-ray, according to Michael Secko, MD, director of the emergency ultrasound division at Stony Brook University (NY).
The results from this study, called MUDDS (Musculoskeletal Ultrasound to Diagnose Dislocated Shoulders), support point-of-care ultrasound as a faster and more readily performed alternative to x-ray. Of the 46 adult patients enrolled so far in the ongoing study, ultrasound’s sensitivity has been 96% and its specificity 100% when validated by x-ray findings.
In the study, adults presenting to the ED are evaluated with point-of-care ultrasound from a posterior approach using either a curvilinear or linear transducer in the transverse plane. About half of the patients enrolled so far had injuries caused by falls, and many of the others had a shoulder complaint related to being pulled. Slightly more than one-third had a previous shoulder dislocation.
When evaluated with point-of-care ultrasound and x-ray, 23 of the 42 evaluable patients had a dislocation. The time from triage to ultrasound evaluation averaged 60 minutes, 40 minutes faster than the average of 100 minutes from triage to x-ray. Both tests were ordered at the same time.
Ultrasound performed less well for the diagnosis of a fracture, with a sensitivity of only 53%. Dr. Secko said the anterior approach would not be expected to provide a comprehensive assessment for fracture. He noted, for example, that there was no attempt in this study to evaluate patients for the presence of Bankart lesions. However, in those found to have a fracture on point-of-care ultrasound, the specificity of this imaging tool was 96%.
Ultimately, a major goal of this study was to determine whether a posterior point-of-care ultrasound could provide a quick answer to the question, “is it in or out?” Although patients are still being enrolled, Dr. Secko believed there is already good evidence that ultrasound is fast and effective for diagnosing dislocations.
Others have addressed this same question. Citing a meta-analysis published last year, Dr. Secko reported that all but one of four studies evaluating ultrasound for shoulder dislocations found a sensitivity and specificity of 100% (Gottlieb M et al. West J Emerg Med. 2017 Aug;18[5]:937-942).
Many centers have already switched to ultrasound for the evaluation of shoulder dislocations, according to Andrew S. Liteplo, MD, who moderated the ACEP session in which Dr. Secko presented his data. “If you are not already doing this for suspected shoulder dislocation, start right away because it is easy and awesome,” said Dr. Liteplo, who is chief of the division of ultrasound in emergency medicine at Massachusetts General Hospital, Boston. He also advised that ultrasound can also can be performed after reduction to confirm the efficacy of treatment.
Dr. Secko reported no financial relationships relevant to this study.
REPORTING FROM ACEP18
Key clinical point: Point-of-care ultrasound is accurate, simple, and fast, relative to x-ray, for the evaluation of shoulder dislocation.
Major finding: Based on results from 42 patients, time from triage to ultrasound, which had a sensitivity of 96% and specificity of 100%, was 60 minutes versus 100 minutes for x-ray.
Study details: An ongoing prospective, multicenter, observational study.
Disclosures: Dr. Secko reported no financial relationships relevant to this study.
Most nonemergent diagnoses can’t be predicted at ED presentation
based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.
The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.
“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”
Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.
In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).
Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.
From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.
“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.
Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.
New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.
Dr. Chou reported no financial relationships relevant to this study.
SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.
based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.
The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.
“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”
Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.
In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).
Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.
From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.
“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.
Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.
New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.
Dr. Chou reported no financial relationships relevant to this study.
SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.
based on an analysis of a national health care database presented at the annual meeting of the American College of Emergency Physicians and later published in JAMA Network Open.
The findings have important policy implications, as a large health care insurer recently rolled out a program to deny coverage for ED visits that conclude with a nonemergent diagnosis.
“Nonemergent diagnoses correlate poorly with visit severity and the need for multiple diagnostic tests and hospital care,” Shih-Chuan Chou, MD, of Brigham and Women’s Hospital in Boston, said at the meeting. “Nearly 9 out of 10 ED patients will present with some sort of symptoms that may potentially lead to a nonemergent diagnosis.”
Anthem initiated the decision to deny coverage for nonemergent conditions in 2017. Anthem’s policy is active in six states: Georgia, Indiana, Kentucky, Missouri, New Hampshire, and Ohio. ACEP and the Medical Association of Georgia have filed a federal lawsuit asserting that Anthem Blue Cross/Blue Shield of Georgia is violating the prudent layperson standard, which is a federal law requiring insurance companies to cover the costs of emergency care based on a patient’s symptoms – not their final diagnosis.
In the study reported by Dr. Chou, the impact of the change in reimbursement was applied to ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED).
Of the 29.6 million adult ED visits by commercially insured patients in the NHAMCS-ED database over the study period, 15.7%, or approximately 4.6 million visits, would have been denied reimbursement based on the new Anthem policy. Of these, 24.5% of the visits were initially triaged by the ED staff as urgent or emergent. Another 26% of the visits resulted in two or more diagnostic tests, suggesting that ED staff were concerned that the underlying disease was potentially serious.
From another perspective, 87.9% of patients with a diagnosis that met criteria for reimbursement had symptoms similar to those of patients who would have been denied reimbursement. In other words, according to Dr. Chou, neither patients nor ED staff would likely be able to distinguish on the basis of symptoms alone which patients would ultimately be diagnosed with a disease that was or was not eligible for reimbursement.
“If commercial insurers begin adopting similar policies and retrospectively deny coverage for ED visits using discharge diagnoses, patients will be forced to weigh the odds of foregoing potentially necessary care against the risk of facing a significant financial burden if they guessed wrong,” Dr. Chou said.
Such policies are “likely to disproportionally impact low income populations,” he added, noting that many patient advocacy groups, as well as the American Medical Association, have expressed opposition to Anthem’s approach.
New strategies are needed to reduce reliance on ED visits for acute but nonemergent diseases, Dr. Chou said, but the data argue against denial of reimbursement as a method consistent with delivery of good health care.
Dr. Chou reported no financial relationships relevant to this study.
SOURCE: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.
REPORTING FROM ACEP18
Key clinical point: A program to deny coverage for nonemergent visits to the ED is likely to have an adverse impact on patient care.
Major finding: Of patients with serious diseases eligible for reimbursement, 87.9% also have symptoms associated with nonurgent diseases.
Study details: An analysis of 29.6 million adult ED visits by commercially insured patients in the National Hospital Ambulatory Medical Care Survey.
Disclosures: Dr. Chou reported no financial relationships relevant to this study.
Source: Chou S-C et al. JAMA Netw Open. 2018 Oct 19. doi: 10.1001/jamanetworkopen.2018.3731.
High ED recidivism seen in disadvantaged populations with chest pain
SAN DIEGO – After implementation of a new chest pain protocol in the emergency department, a greater proportion of patients with low-risk chest pain were discharged, yet a higher rate of ED recidivism was observed, results from a single-center study in Detroit showed.
While the precise cause of this finding is unclear, it may stem from factors affecting socioeconomically disadvantaged populations, Eric M. Blake, one of the study authors, said at the annual meeting of the American College of Emergency Physicians. “Recurrent ED visits are associated with social determinants of health, including race and economic status,” said Mr. Blake, a second-year student at Wayne State University School of Medicine, Detroit. “Socioeconomically disadvantaged patients often lack the transportation and monetary resources to follow up at an outpatient clinic. Detroit is an example of this type of a community; 83% of our population is African American, 36% of people live below the poverty line, and Detroit has an illiteracy rate of 47% in its adult population.”
He and his colleagues hypothesized that implementation of a standardized chest pain protocol in Detroit Receiving Hospital would safely reduce the number of hospital inpatient admissions and ED recidivism rates. Implemented on Nov. 1, 2012, the protocol uses the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography, and contemporary sensitivity troponin I to triage patients into low-, intermediate-, and high-risk categories. Low-risk patients were discharged and asked to follow up with a cardiologist within 48 hours. For the current study, the researchers retrospectively analyzed patients older than age 18 who presented with low-risk chest pain in the six months before the protocol was implemented and six months after.
A total of 3,613 patients were studied: 1,837 in the pre-protocol group and 1,776 in the post-protocol group. Their mean age was 47 years, 82% were African American, and 53% were male. No differences were observed between the pre- and post-protocol groups in terms of race (P = .280) or sex (P = .497). There was no statistical difference in the proportion of patients deemed at low risk in the pre- vs. post-protocol periods (P = .167). Significantly more low-risk patients were discharged in the post-protocol group, , compared with the pre-protocol group (55% vs. 44%; P less than .001), however. ED recidivism was also significantly greater in the post-protocol vs. pre-protocol group (3% vs. 1.6%; P = .0035).
“These findings may reflect an embedded racial mistrust of the medical system by certain minority groups,” Mr. Blake said. “Due to an extensive history of racism and segregation, a community like Detroit may have reservations when it comes to medical follow-up at outpatient clinics. Difficulty assessing outpatient follow-up for a variety of logistical and monetary reasons common among underprivileged communities may also be reflected in the increased recidivism rates.”
He concluded that administrators and clinicians in EDs nationwide “need to better understand the needs of underprivileged patients. A reduction in resource expenditures when a patient is discharged must be balanced with the cost of a recidivism in vulnerable populations like Detroit.”
To address poor cardiac outpatient follow-up rates, he and his colleagues are conducting a prospective randomized controlled trial investigating the use of motivational interviewing techniques with these patients.
The study’s senior author was Vijaya “Arun” Kumar, MD of Wayne State University School of Medicine. Mr. Blake reported having no financial disclosures.
SOURCE: Kumar VA et al. Ann Emerg Med. 2018 Oct;72;4:S117-18. doi. 10.1016/j.annemergmed.2018.08.304.
SAN DIEGO – After implementation of a new chest pain protocol in the emergency department, a greater proportion of patients with low-risk chest pain were discharged, yet a higher rate of ED recidivism was observed, results from a single-center study in Detroit showed.
While the precise cause of this finding is unclear, it may stem from factors affecting socioeconomically disadvantaged populations, Eric M. Blake, one of the study authors, said at the annual meeting of the American College of Emergency Physicians. “Recurrent ED visits are associated with social determinants of health, including race and economic status,” said Mr. Blake, a second-year student at Wayne State University School of Medicine, Detroit. “Socioeconomically disadvantaged patients often lack the transportation and monetary resources to follow up at an outpatient clinic. Detroit is an example of this type of a community; 83% of our population is African American, 36% of people live below the poverty line, and Detroit has an illiteracy rate of 47% in its adult population.”
He and his colleagues hypothesized that implementation of a standardized chest pain protocol in Detroit Receiving Hospital would safely reduce the number of hospital inpatient admissions and ED recidivism rates. Implemented on Nov. 1, 2012, the protocol uses the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography, and contemporary sensitivity troponin I to triage patients into low-, intermediate-, and high-risk categories. Low-risk patients were discharged and asked to follow up with a cardiologist within 48 hours. For the current study, the researchers retrospectively analyzed patients older than age 18 who presented with low-risk chest pain in the six months before the protocol was implemented and six months after.
A total of 3,613 patients were studied: 1,837 in the pre-protocol group and 1,776 in the post-protocol group. Their mean age was 47 years, 82% were African American, and 53% were male. No differences were observed between the pre- and post-protocol groups in terms of race (P = .280) or sex (P = .497). There was no statistical difference in the proportion of patients deemed at low risk in the pre- vs. post-protocol periods (P = .167). Significantly more low-risk patients were discharged in the post-protocol group, , compared with the pre-protocol group (55% vs. 44%; P less than .001), however. ED recidivism was also significantly greater in the post-protocol vs. pre-protocol group (3% vs. 1.6%; P = .0035).
“These findings may reflect an embedded racial mistrust of the medical system by certain minority groups,” Mr. Blake said. “Due to an extensive history of racism and segregation, a community like Detroit may have reservations when it comes to medical follow-up at outpatient clinics. Difficulty assessing outpatient follow-up for a variety of logistical and monetary reasons common among underprivileged communities may also be reflected in the increased recidivism rates.”
He concluded that administrators and clinicians in EDs nationwide “need to better understand the needs of underprivileged patients. A reduction in resource expenditures when a patient is discharged must be balanced with the cost of a recidivism in vulnerable populations like Detroit.”
To address poor cardiac outpatient follow-up rates, he and his colleagues are conducting a prospective randomized controlled trial investigating the use of motivational interviewing techniques with these patients.
The study’s senior author was Vijaya “Arun” Kumar, MD of Wayne State University School of Medicine. Mr. Blake reported having no financial disclosures.
SOURCE: Kumar VA et al. Ann Emerg Med. 2018 Oct;72;4:S117-18. doi. 10.1016/j.annemergmed.2018.08.304.
SAN DIEGO – After implementation of a new chest pain protocol in the emergency department, a greater proportion of patients with low-risk chest pain were discharged, yet a higher rate of ED recidivism was observed, results from a single-center study in Detroit showed.
While the precise cause of this finding is unclear, it may stem from factors affecting socioeconomically disadvantaged populations, Eric M. Blake, one of the study authors, said at the annual meeting of the American College of Emergency Physicians. “Recurrent ED visits are associated with social determinants of health, including race and economic status,” said Mr. Blake, a second-year student at Wayne State University School of Medicine, Detroit. “Socioeconomically disadvantaged patients often lack the transportation and monetary resources to follow up at an outpatient clinic. Detroit is an example of this type of a community; 83% of our population is African American, 36% of people live below the poverty line, and Detroit has an illiteracy rate of 47% in its adult population.”
He and his colleagues hypothesized that implementation of a standardized chest pain protocol in Detroit Receiving Hospital would safely reduce the number of hospital inpatient admissions and ED recidivism rates. Implemented on Nov. 1, 2012, the protocol uses the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography, and contemporary sensitivity troponin I to triage patients into low-, intermediate-, and high-risk categories. Low-risk patients were discharged and asked to follow up with a cardiologist within 48 hours. For the current study, the researchers retrospectively analyzed patients older than age 18 who presented with low-risk chest pain in the six months before the protocol was implemented and six months after.
A total of 3,613 patients were studied: 1,837 in the pre-protocol group and 1,776 in the post-protocol group. Their mean age was 47 years, 82% were African American, and 53% were male. No differences were observed between the pre- and post-protocol groups in terms of race (P = .280) or sex (P = .497). There was no statistical difference in the proportion of patients deemed at low risk in the pre- vs. post-protocol periods (P = .167). Significantly more low-risk patients were discharged in the post-protocol group, , compared with the pre-protocol group (55% vs. 44%; P less than .001), however. ED recidivism was also significantly greater in the post-protocol vs. pre-protocol group (3% vs. 1.6%; P = .0035).
“These findings may reflect an embedded racial mistrust of the medical system by certain minority groups,” Mr. Blake said. “Due to an extensive history of racism and segregation, a community like Detroit may have reservations when it comes to medical follow-up at outpatient clinics. Difficulty assessing outpatient follow-up for a variety of logistical and monetary reasons common among underprivileged communities may also be reflected in the increased recidivism rates.”
He concluded that administrators and clinicians in EDs nationwide “need to better understand the needs of underprivileged patients. A reduction in resource expenditures when a patient is discharged must be balanced with the cost of a recidivism in vulnerable populations like Detroit.”
To address poor cardiac outpatient follow-up rates, he and his colleagues are conducting a prospective randomized controlled trial investigating the use of motivational interviewing techniques with these patients.
The study’s senior author was Vijaya “Arun” Kumar, MD of Wayne State University School of Medicine. Mr. Blake reported having no financial disclosures.
SOURCE: Kumar VA et al. Ann Emerg Med. 2018 Oct;72;4:S117-18. doi. 10.1016/j.annemergmed.2018.08.304.
AT ACEP18
Key clinical point:
Major finding: Following implementation of a new chest pain protocol, significantly more low-risk patients were discharged (55% vs. 44%; P less than .001).
Study details: A retrospective analysis of 3,613 adults who presented with low-risk chest pain.
Disclosures: The researchers reported having no financial disclosures.
Source: Kumar VA et al. Ann Emerg Med. 2018 Oct;72;4:S117-18. doi. 10.1016/j.annemergmed.2018.08.304.
Transition to high-sensitivity troponin T assay helped boost ED discharge rates
SAN DIEGO – After transitioning to using the high-sensitivity troponin T assay for patients over the age of 35 years who presented to the ED with chest pain or tightness, an increased number of patients were discharged, yet no impact was observed on the time to admission and/or observation, according to a study conducted at two Philadelphia-based hospitals.
“Biomarkers have been a cornerstone of evaluating patients who present with chest pain,” Frederick T. Randolph, MD, said at the annual meeting of the American College of Emergency Physicians. “Recently in the United States, fifth-generation or high-sensitivity troponin [assays] have been approved for use. Our institution made the plan to transition to utilization of high-sensitivity troponins. At that time, we were aware of European studies that they were able to discharge a higher percentage of patients from the ED. There have been no prior studies of the clinical impact of transition to high-sensitivity troponin [assays] in the U.S.”
Dr. Randolph, director of the Chest Pain Center at Thomas Jefferson University, Philadelphia, and his colleagues performed a before and after study assessing all patients over age 35 years who presented to two hospitals with chest pain or tightness and who received a troponin assay draw in the ED. They conducted two town halls, in-services with cardiology and emergency medicine, and distributed a slide set to all providers. “There was no guidance as to who to order the troponin on,” said Dr. Randolph, who is also vice chief of emergency medicine at the university. “Essentially, the recommendation was, ‘Keep using troponins the same way you’ve been using troponins for years.’ The education was centered on how frequently we were going to order repeat troponins and how to interpret those results.”
The researchers used a 0- and 2-hour sampling strategy (unless the first value was less than 6 ng/L) and used a cut-point of 19 ng/L to define “ruled out” and a cut-point of 53 ng/L to define “consistent with acute myocardial infarction.” Indeterminate values were repeated every 2 hours. Dr. Randolph and his associates collected data for 1 year prior to transition to high-sensitivity troponins in 4,295 patients, and 2 months post transition in 769 patients. The primary outcome was discharge rate from the ED. Secondary outcome was time from presentation to admission/observation decision.
There were no statistically significant differences between the pre- and posttransition groups in the percentage of those aged 36-64 years (74% vs. 76%, respectively) or in the percentage of those who were nonwhite (61% vs. 59%). The only statistically significant difference was a higher percentage of females in the preimplementation group (49% vs. 46%; P = .02).
In all, the researchers were able to discharge 45.2% of all patients during the pretransition period, compared with 58.7% of patients in the posttransition period, for an absolute increase of 13% (P less than .001). There was no difference between the two groups in time to decision to admit or to observe (a mean of 199.1 vs. 192.2 minutes, respectively; P = .96). “Areas of future study would be to evaluate those patients who were discharged and monitor them for any changes in outcomes, to see if there is any increase in morbidity or complications,” said Dr. Randolph. “An additional research curiosity would be the downstream consequences on cost or revenue to the institution given the increased number of admissions and the decreased use of diagnostic testing such as coronary computed tomography angiography and stress testing.”
Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi. 10.1016/j.annemergmed.2018.08.009.
SAN DIEGO – After transitioning to using the high-sensitivity troponin T assay for patients over the age of 35 years who presented to the ED with chest pain or tightness, an increased number of patients were discharged, yet no impact was observed on the time to admission and/or observation, according to a study conducted at two Philadelphia-based hospitals.
“Biomarkers have been a cornerstone of evaluating patients who present with chest pain,” Frederick T. Randolph, MD, said at the annual meeting of the American College of Emergency Physicians. “Recently in the United States, fifth-generation or high-sensitivity troponin [assays] have been approved for use. Our institution made the plan to transition to utilization of high-sensitivity troponins. At that time, we were aware of European studies that they were able to discharge a higher percentage of patients from the ED. There have been no prior studies of the clinical impact of transition to high-sensitivity troponin [assays] in the U.S.”
Dr. Randolph, director of the Chest Pain Center at Thomas Jefferson University, Philadelphia, and his colleagues performed a before and after study assessing all patients over age 35 years who presented to two hospitals with chest pain or tightness and who received a troponin assay draw in the ED. They conducted two town halls, in-services with cardiology and emergency medicine, and distributed a slide set to all providers. “There was no guidance as to who to order the troponin on,” said Dr. Randolph, who is also vice chief of emergency medicine at the university. “Essentially, the recommendation was, ‘Keep using troponins the same way you’ve been using troponins for years.’ The education was centered on how frequently we were going to order repeat troponins and how to interpret those results.”
The researchers used a 0- and 2-hour sampling strategy (unless the first value was less than 6 ng/L) and used a cut-point of 19 ng/L to define “ruled out” and a cut-point of 53 ng/L to define “consistent with acute myocardial infarction.” Indeterminate values were repeated every 2 hours. Dr. Randolph and his associates collected data for 1 year prior to transition to high-sensitivity troponins in 4,295 patients, and 2 months post transition in 769 patients. The primary outcome was discharge rate from the ED. Secondary outcome was time from presentation to admission/observation decision.
There were no statistically significant differences between the pre- and posttransition groups in the percentage of those aged 36-64 years (74% vs. 76%, respectively) or in the percentage of those who were nonwhite (61% vs. 59%). The only statistically significant difference was a higher percentage of females in the preimplementation group (49% vs. 46%; P = .02).
In all, the researchers were able to discharge 45.2% of all patients during the pretransition period, compared with 58.7% of patients in the posttransition period, for an absolute increase of 13% (P less than .001). There was no difference between the two groups in time to decision to admit or to observe (a mean of 199.1 vs. 192.2 minutes, respectively; P = .96). “Areas of future study would be to evaluate those patients who were discharged and monitor them for any changes in outcomes, to see if there is any increase in morbidity or complications,” said Dr. Randolph. “An additional research curiosity would be the downstream consequences on cost or revenue to the institution given the increased number of admissions and the decreased use of diagnostic testing such as coronary computed tomography angiography and stress testing.”
Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi. 10.1016/j.annemergmed.2018.08.009.
SAN DIEGO – After transitioning to using the high-sensitivity troponin T assay for patients over the age of 35 years who presented to the ED with chest pain or tightness, an increased number of patients were discharged, yet no impact was observed on the time to admission and/or observation, according to a study conducted at two Philadelphia-based hospitals.
“Biomarkers have been a cornerstone of evaluating patients who present with chest pain,” Frederick T. Randolph, MD, said at the annual meeting of the American College of Emergency Physicians. “Recently in the United States, fifth-generation or high-sensitivity troponin [assays] have been approved for use. Our institution made the plan to transition to utilization of high-sensitivity troponins. At that time, we were aware of European studies that they were able to discharge a higher percentage of patients from the ED. There have been no prior studies of the clinical impact of transition to high-sensitivity troponin [assays] in the U.S.”
Dr. Randolph, director of the Chest Pain Center at Thomas Jefferson University, Philadelphia, and his colleagues performed a before and after study assessing all patients over age 35 years who presented to two hospitals with chest pain or tightness and who received a troponin assay draw in the ED. They conducted two town halls, in-services with cardiology and emergency medicine, and distributed a slide set to all providers. “There was no guidance as to who to order the troponin on,” said Dr. Randolph, who is also vice chief of emergency medicine at the university. “Essentially, the recommendation was, ‘Keep using troponins the same way you’ve been using troponins for years.’ The education was centered on how frequently we were going to order repeat troponins and how to interpret those results.”
The researchers used a 0- and 2-hour sampling strategy (unless the first value was less than 6 ng/L) and used a cut-point of 19 ng/L to define “ruled out” and a cut-point of 53 ng/L to define “consistent with acute myocardial infarction.” Indeterminate values were repeated every 2 hours. Dr. Randolph and his associates collected data for 1 year prior to transition to high-sensitivity troponins in 4,295 patients, and 2 months post transition in 769 patients. The primary outcome was discharge rate from the ED. Secondary outcome was time from presentation to admission/observation decision.
There were no statistically significant differences between the pre- and posttransition groups in the percentage of those aged 36-64 years (74% vs. 76%, respectively) or in the percentage of those who were nonwhite (61% vs. 59%). The only statistically significant difference was a higher percentage of females in the preimplementation group (49% vs. 46%; P = .02).
In all, the researchers were able to discharge 45.2% of all patients during the pretransition period, compared with 58.7% of patients in the posttransition period, for an absolute increase of 13% (P less than .001). There was no difference between the two groups in time to decision to admit or to observe (a mean of 199.1 vs. 192.2 minutes, respectively; P = .96). “Areas of future study would be to evaluate those patients who were discharged and monitor them for any changes in outcomes, to see if there is any increase in morbidity or complications,” said Dr. Randolph. “An additional research curiosity would be the downstream consequences on cost or revenue to the institution given the increased number of admissions and the decreased use of diagnostic testing such as coronary computed tomography angiography and stress testing.”
Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi. 10.1016/j.annemergmed.2018.08.009.
AT ACEP18
Key clinical point: .
Major finding: After conversion to using the high-sensitivity troponin T assay, the ED discharge rate increased to 58.7%, from 45.2% (P less than 0.001).
Study details: A before and after study of 5,064 patients aged 35 and older who presented to the ED with chest pain or tightness.
Disclosures: Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi: 10.1016/j.annemergmed.2018.08.009.
About 20% of penalties from EMTALA violations linked to psychiatric emergencies
SAN DIEGO – Between 2002 and April 2018, about one in five civil monetary penalty payments linked to Emergency Medical Treatment and Labor Act (EMTALA) violations involved psychiatric emergencies, an analysis of national data found.
“Penalties were twice as high for psychiatric cases as for nonpsychiatric cases, with failure to stabilize being more common,” Sophie Terp, MD, MPH, said at the annual meeting of the American College of Emergency Physicians. “Recent large penalties suggest the need to improve care for psychiatric emergencies.”
In an effort to characterize U.S. Office of Inspector General (OIG) penalties resulting from EMTALA violations involving psychiatric emergencies, Dr. Terp, of the department of emergency medicine at the University of Southern California, Los Angeles, and her colleagues reviewed all OIG penalties between 2002 and April 2018. Characteristics of penalties involving psychiatric emergencies were described and compared with other penalties.
Of the 229 civil monetary penalties levied during the study period, 44 (19%) were related to psychiatric emergencies and the average fine was $85,488, which was significantly higher than the average fine of $32,042 for nonpsychiatric-related civil monetary penalties (P = .004). The three largest penalties during the study period were all related to psychiatric emergencies, including one for $360,000 in 2012, one for $1,295,000 in 2017, and one for $200,000 in 2018.
“Settlements have been particularly high in recent years,” Dr. Terp said. By comparison, the largest civil monetary penalty for a nonpsychiatric case was $170,000.
Failure to provide a medical screening exam was the most common reason for civil monetary settlements in both psychiatric and nonpsychiatric cases (84% vs. 74%; P = .147), but “failure to stabilize” occurred in a significantly greater proportion of psychiatric versus nonpsychiatric cases (68% vs. 51%; P = .041). About one-third of all psychiatric cases occurred in Centers for Medicare & Medicaid Services Region 4, “which is a region known to have a very high rate of EMTALA enforcement overall,” Dr. Terp said. “About half of those cases occurred in Florida, and another 20% occurred in South Carolina. About 20% occurred in CMS Region 6, and about half of those were in Texas. But the overall proportions of psychiatric versus nonpsychiatric cases that distributed over the CMS regions did not significantly differ.”
Dr. Terp reported having no financial disclosures.
SOURCE: Terp S et al. ACEP18, Abstract 46.
SAN DIEGO – Between 2002 and April 2018, about one in five civil monetary penalty payments linked to Emergency Medical Treatment and Labor Act (EMTALA) violations involved psychiatric emergencies, an analysis of national data found.
“Penalties were twice as high for psychiatric cases as for nonpsychiatric cases, with failure to stabilize being more common,” Sophie Terp, MD, MPH, said at the annual meeting of the American College of Emergency Physicians. “Recent large penalties suggest the need to improve care for psychiatric emergencies.”
In an effort to characterize U.S. Office of Inspector General (OIG) penalties resulting from EMTALA violations involving psychiatric emergencies, Dr. Terp, of the department of emergency medicine at the University of Southern California, Los Angeles, and her colleagues reviewed all OIG penalties between 2002 and April 2018. Characteristics of penalties involving psychiatric emergencies were described and compared with other penalties.
Of the 229 civil monetary penalties levied during the study period, 44 (19%) were related to psychiatric emergencies and the average fine was $85,488, which was significantly higher than the average fine of $32,042 for nonpsychiatric-related civil monetary penalties (P = .004). The three largest penalties during the study period were all related to psychiatric emergencies, including one for $360,000 in 2012, one for $1,295,000 in 2017, and one for $200,000 in 2018.
“Settlements have been particularly high in recent years,” Dr. Terp said. By comparison, the largest civil monetary penalty for a nonpsychiatric case was $170,000.
Failure to provide a medical screening exam was the most common reason for civil monetary settlements in both psychiatric and nonpsychiatric cases (84% vs. 74%; P = .147), but “failure to stabilize” occurred in a significantly greater proportion of psychiatric versus nonpsychiatric cases (68% vs. 51%; P = .041). About one-third of all psychiatric cases occurred in Centers for Medicare & Medicaid Services Region 4, “which is a region known to have a very high rate of EMTALA enforcement overall,” Dr. Terp said. “About half of those cases occurred in Florida, and another 20% occurred in South Carolina. About 20% occurred in CMS Region 6, and about half of those were in Texas. But the overall proportions of psychiatric versus nonpsychiatric cases that distributed over the CMS regions did not significantly differ.”
Dr. Terp reported having no financial disclosures.
SOURCE: Terp S et al. ACEP18, Abstract 46.
SAN DIEGO – Between 2002 and April 2018, about one in five civil monetary penalty payments linked to Emergency Medical Treatment and Labor Act (EMTALA) violations involved psychiatric emergencies, an analysis of national data found.
“Penalties were twice as high for psychiatric cases as for nonpsychiatric cases, with failure to stabilize being more common,” Sophie Terp, MD, MPH, said at the annual meeting of the American College of Emergency Physicians. “Recent large penalties suggest the need to improve care for psychiatric emergencies.”
In an effort to characterize U.S. Office of Inspector General (OIG) penalties resulting from EMTALA violations involving psychiatric emergencies, Dr. Terp, of the department of emergency medicine at the University of Southern California, Los Angeles, and her colleagues reviewed all OIG penalties between 2002 and April 2018. Characteristics of penalties involving psychiatric emergencies were described and compared with other penalties.
Of the 229 civil monetary penalties levied during the study period, 44 (19%) were related to psychiatric emergencies and the average fine was $85,488, which was significantly higher than the average fine of $32,042 for nonpsychiatric-related civil monetary penalties (P = .004). The three largest penalties during the study period were all related to psychiatric emergencies, including one for $360,000 in 2012, one for $1,295,000 in 2017, and one for $200,000 in 2018.
“Settlements have been particularly high in recent years,” Dr. Terp said. By comparison, the largest civil monetary penalty for a nonpsychiatric case was $170,000.
Failure to provide a medical screening exam was the most common reason for civil monetary settlements in both psychiatric and nonpsychiatric cases (84% vs. 74%; P = .147), but “failure to stabilize” occurred in a significantly greater proportion of psychiatric versus nonpsychiatric cases (68% vs. 51%; P = .041). About one-third of all psychiatric cases occurred in Centers for Medicare & Medicaid Services Region 4, “which is a region known to have a very high rate of EMTALA enforcement overall,” Dr. Terp said. “About half of those cases occurred in Florida, and another 20% occurred in South Carolina. About 20% occurred in CMS Region 6, and about half of those were in Texas. But the overall proportions of psychiatric versus nonpsychiatric cases that distributed over the CMS regions did not significantly differ.”
Dr. Terp reported having no financial disclosures.
SOURCE: Terp S et al. ACEP18, Abstract 46.
REPORTING FROM ACEP18
Key clinical point: Nearly one in five settlements related to Emergency Medical Treatment and Labor Act violations involved psychiatric emergencies.
Major finding: Of the civil monetary penalties levied during the study period, 19% were related to psychiatric emergencies and the average fine was $85,488.
Study details: An analysis of 229 civil monetary penalties levied by the Office of Inspector General related to violations of EMTALA between 2002 and April 2018.
Disclosures: Dr. Terp reported having no financial disclosures.
Source: Terp S et al. ACEP18, Abstract 46.
Blood test may obviate need for head CTs in brain trauma evaluation
SAN DIEGO – A biomarker test based on the presence of two proteins in the blood appears to be suitable for ruling out significant intracranial injuries in patients with a history of mild traumatic brain injury (TBI) without the need for a CT head scan, according to data presented at the annual meeting of the American College of Emergency Physicians.
according to Jeffrey J. Bazarian, MD, professor of emergency medicine, University of Rochester (New York).
In the ALERT-TBI study, which evaluated the biomarker test, 1,959 patients with suspected TBI at 22 participating EDs in the United States and Europe were enrolled and available for analysis. All had mild TBI as defined as a Glasgow Coma Scale (GCS) score of 13-15.
The treating ED physician’s decision to order a head CT scan was the major criterion for study entry. All enrolled patients had their blood drawn within 12 hours in order to quantify two biomarkers, C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP).
The biomarker test for TBI was negative when the UCH-L1 value was less than 327 pg/mL and the GFAP was less than 22 pg/mL; the test was positive if either value was at this threshold or higher. To evaluate the sensitivity and specificity of this dual-biomarker test, results were correlated with head CT scans read by two neurologists blinded to the biomarker values.
The mean age of the study population was 48.8 years and slightly more than half were male. About half of the suspected TBI in these patients was attributed to falls and about one third to motor vehicle accidents.
Typical of TBI with GCS scores in the mild range, only 6% of the patients had a positive CT head scan. Of the 125 positive CT scans, the most common injury detected on CT scan was subarachnoid hemorrhage followed by subdural hematoma.
Of the 671 negative biomarker tests, 668 had normal head CT scans. Of the three false positives, one included a cavernous malformation that may have been present prior to the TBI. The others were a small subarachnoid hemorrhage and a small subdural hematoma. Overall the negative predictive value was 99.6% and the sensitivity was 97.6%.
Although the biomarker specificity was only 36% with an even-lower positive predictive value, the goal of the test was to rule out significant TBI to avoid the need for CT scan. On this basis, the biomarker test, which is being developed under the proprietary name Banyan BTI, appears to be promising. The data, according to Dr. Bazarian, have been submitted to the Food and Drug Administration.
“Head CT scans are the current standard for evaluating intracranial injuries after TBI, but they are overused, based on the high proportion that do not show an injury,” said Dr. Bazarian. Although he does not know the disposition of the FDA application, he said, based on these data, “I would definitely be using this test if it were available.”
SAN DIEGO – A biomarker test based on the presence of two proteins in the blood appears to be suitable for ruling out significant intracranial injuries in patients with a history of mild traumatic brain injury (TBI) without the need for a CT head scan, according to data presented at the annual meeting of the American College of Emergency Physicians.
according to Jeffrey J. Bazarian, MD, professor of emergency medicine, University of Rochester (New York).
In the ALERT-TBI study, which evaluated the biomarker test, 1,959 patients with suspected TBI at 22 participating EDs in the United States and Europe were enrolled and available for analysis. All had mild TBI as defined as a Glasgow Coma Scale (GCS) score of 13-15.
The treating ED physician’s decision to order a head CT scan was the major criterion for study entry. All enrolled patients had their blood drawn within 12 hours in order to quantify two biomarkers, C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP).
The biomarker test for TBI was negative when the UCH-L1 value was less than 327 pg/mL and the GFAP was less than 22 pg/mL; the test was positive if either value was at this threshold or higher. To evaluate the sensitivity and specificity of this dual-biomarker test, results were correlated with head CT scans read by two neurologists blinded to the biomarker values.
The mean age of the study population was 48.8 years and slightly more than half were male. About half of the suspected TBI in these patients was attributed to falls and about one third to motor vehicle accidents.
Typical of TBI with GCS scores in the mild range, only 6% of the patients had a positive CT head scan. Of the 125 positive CT scans, the most common injury detected on CT scan was subarachnoid hemorrhage followed by subdural hematoma.
Of the 671 negative biomarker tests, 668 had normal head CT scans. Of the three false positives, one included a cavernous malformation that may have been present prior to the TBI. The others were a small subarachnoid hemorrhage and a small subdural hematoma. Overall the negative predictive value was 99.6% and the sensitivity was 97.6%.
Although the biomarker specificity was only 36% with an even-lower positive predictive value, the goal of the test was to rule out significant TBI to avoid the need for CT scan. On this basis, the biomarker test, which is being developed under the proprietary name Banyan BTI, appears to be promising. The data, according to Dr. Bazarian, have been submitted to the Food and Drug Administration.
“Head CT scans are the current standard for evaluating intracranial injuries after TBI, but they are overused, based on the high proportion that do not show an injury,” said Dr. Bazarian. Although he does not know the disposition of the FDA application, he said, based on these data, “I would definitely be using this test if it were available.”
SAN DIEGO – A biomarker test based on the presence of two proteins in the blood appears to be suitable for ruling out significant intracranial injuries in patients with a history of mild traumatic brain injury (TBI) without the need for a CT head scan, according to data presented at the annual meeting of the American College of Emergency Physicians.
according to Jeffrey J. Bazarian, MD, professor of emergency medicine, University of Rochester (New York).
In the ALERT-TBI study, which evaluated the biomarker test, 1,959 patients with suspected TBI at 22 participating EDs in the United States and Europe were enrolled and available for analysis. All had mild TBI as defined as a Glasgow Coma Scale (GCS) score of 13-15.
The treating ED physician’s decision to order a head CT scan was the major criterion for study entry. All enrolled patients had their blood drawn within 12 hours in order to quantify two biomarkers, C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP).
The biomarker test for TBI was negative when the UCH-L1 value was less than 327 pg/mL and the GFAP was less than 22 pg/mL; the test was positive if either value was at this threshold or higher. To evaluate the sensitivity and specificity of this dual-biomarker test, results were correlated with head CT scans read by two neurologists blinded to the biomarker values.
The mean age of the study population was 48.8 years and slightly more than half were male. About half of the suspected TBI in these patients was attributed to falls and about one third to motor vehicle accidents.
Typical of TBI with GCS scores in the mild range, only 6% of the patients had a positive CT head scan. Of the 125 positive CT scans, the most common injury detected on CT scan was subarachnoid hemorrhage followed by subdural hematoma.
Of the 671 negative biomarker tests, 668 had normal head CT scans. Of the three false positives, one included a cavernous malformation that may have been present prior to the TBI. The others were a small subarachnoid hemorrhage and a small subdural hematoma. Overall the negative predictive value was 99.6% and the sensitivity was 97.6%.
Although the biomarker specificity was only 36% with an even-lower positive predictive value, the goal of the test was to rule out significant TBI to avoid the need for CT scan. On this basis, the biomarker test, which is being developed under the proprietary name Banyan BTI, appears to be promising. The data, according to Dr. Bazarian, have been submitted to the Food and Drug Administration.
“Head CT scans are the current standard for evaluating intracranial injuries after TBI, but they are overused, based on the high proportion that do not show an injury,” said Dr. Bazarian. Although he does not know the disposition of the FDA application, he said, based on these data, “I would definitely be using this test if it were available.”
FROM ACEP 2018
Key clinical point: In patients with mild head trauma, a simple blood test may eliminate need and cost for routine CT scans.
Major finding: In patients a history of head trauma, the biomarker test had a 99.6% negative predictive value in ruling out injury.
Study details: Prospective, controlled registration study.
Disclosures: Dr. Bazarian reported no financial relationships relevant to this study, which was in part funded by Banyan Biomarkers.
Survey sheds light on fellows’ perceptions of health care disparities
SAN DIEGO – About 25% of Fellows of the American College of Emergency Physicians acknowledged that health care disparities exist in their practices, according to a survey completed by 945 ACEP fellows in 36 states.
In conjunction with the American College of Emergency Physicians, Cheryl K. Zogg, MSPH, MHS, and her colleagues surveyed a nationally representative subset of ACEP fellows between September and December of 2017 to determine the extent to which emergency medicine physicians perceive that various forms of disparities exist and that there is “strong evidence” to support the existence of disparities.
The results were reported in an abstract presented during the annual meeting of the American College of Emergency Physicians.
“The existence of disparities in medicine has been widely acknowledged,” she said. “A lot of the modern conversation began in 2002, when the Institute of Medicine published its now-famous report, ‘Unequal Treatment.’ Since that time, a growing body of literature has discussed the existence of disparities in various medical fields and related to a number of factors including but not limited to race and ethnicity.”
The survey contained questions about perceptions of disparities related to insurance status, type of insurance, ability to speak English, educational attainment, race/ethnicity, sexual identity, and sexual orientation as well as the perceived strength of the evidence to support the existence of disparities in medicine in general and in emergency medicine specifically.
Ms. Zogg, an MD-PhD candidate at Yale University, New Haven, Conn., found that disparities of insurance status (85.6%) and type of insurance (81.3%) were the most widely acknowledged, followed by variations in care as a result of patients’ ability to speak English (73.7%) and level of educational attainment (61.5%).
Slightly more than half of respondents (51.9%) acknowledged the existence of disparities based on race/ethnicity in United States, but only 20.9% believe that such disparities exist in their hospitals and even fewer (3.9%) believe that they exist in their own personal practices. At the same time, more than one-third of respondents (40.6%) acknowledged the existence of disparities based on gender identity in the United States, but 22.4% believe that such disparities exist in their hospitals and even fewer (5.7%) believe that they exist in their own practices. Similar percentages were observed when respondents were asked about issues of sexual orientation (33.7%, 10.6%, and 2.3%, respectively).
Perceived strength of the evidence supporting the existence of disparities followed a similar trend. Between 74.7% and 82.2% of respondents believe there is strong evidence in medicine to support the existence of racial disparities in insurance status and insurance type, respectively. However, between 47% and 49.4% of respondents rated such evidence as strong in emergency medicine, and between 25.9% and 26.5% rated such evidence as strong in their own personal practices.
“While acknowledgment of disparities in the U.S. was strongly associated with perceived strength of the evidence in medicine in general (P less than .001), acknowledgment of disparities in one’s own practice was not associated with perceived strength of evidence in emergency medicine or with medicine in general,” Ms. Zogg said. “As evidence documenting disparities continues to increase, action is needed to address disparities in emergency care. This is important because as frontline providers of care, emergency physicians often act as the first point of contact for these patients within the U.S. health system. Ultimately, despite recognition of health care providers as a contributing factor to the existence of disparities and evidence to suggest the presence of disparities in emergency medicine, only one-fourth of FACEP openly acknowledge the potential for disparities in their personal practice.”
Ms. Zogg is supported by a National Institutes of Health Medical Scientist Training Program grant. The study was supported in part by a grant from the Emergency Medicine Foundation and the Society for Academic Emergency Medicine.
SOURCE: Zogg C et al. Ann Emerg Med. 2018 Oct;72(4):S118-9. doi: 10.1016/j.annemergmed.2018.08.306.
SAN DIEGO – About 25% of Fellows of the American College of Emergency Physicians acknowledged that health care disparities exist in their practices, according to a survey completed by 945 ACEP fellows in 36 states.
In conjunction with the American College of Emergency Physicians, Cheryl K. Zogg, MSPH, MHS, and her colleagues surveyed a nationally representative subset of ACEP fellows between September and December of 2017 to determine the extent to which emergency medicine physicians perceive that various forms of disparities exist and that there is “strong evidence” to support the existence of disparities.
The results were reported in an abstract presented during the annual meeting of the American College of Emergency Physicians.
“The existence of disparities in medicine has been widely acknowledged,” she said. “A lot of the modern conversation began in 2002, when the Institute of Medicine published its now-famous report, ‘Unequal Treatment.’ Since that time, a growing body of literature has discussed the existence of disparities in various medical fields and related to a number of factors including but not limited to race and ethnicity.”
The survey contained questions about perceptions of disparities related to insurance status, type of insurance, ability to speak English, educational attainment, race/ethnicity, sexual identity, and sexual orientation as well as the perceived strength of the evidence to support the existence of disparities in medicine in general and in emergency medicine specifically.
Ms. Zogg, an MD-PhD candidate at Yale University, New Haven, Conn., found that disparities of insurance status (85.6%) and type of insurance (81.3%) were the most widely acknowledged, followed by variations in care as a result of patients’ ability to speak English (73.7%) and level of educational attainment (61.5%).
Slightly more than half of respondents (51.9%) acknowledged the existence of disparities based on race/ethnicity in United States, but only 20.9% believe that such disparities exist in their hospitals and even fewer (3.9%) believe that they exist in their own personal practices. At the same time, more than one-third of respondents (40.6%) acknowledged the existence of disparities based on gender identity in the United States, but 22.4% believe that such disparities exist in their hospitals and even fewer (5.7%) believe that they exist in their own practices. Similar percentages were observed when respondents were asked about issues of sexual orientation (33.7%, 10.6%, and 2.3%, respectively).
Perceived strength of the evidence supporting the existence of disparities followed a similar trend. Between 74.7% and 82.2% of respondents believe there is strong evidence in medicine to support the existence of racial disparities in insurance status and insurance type, respectively. However, between 47% and 49.4% of respondents rated such evidence as strong in emergency medicine, and between 25.9% and 26.5% rated such evidence as strong in their own personal practices.
“While acknowledgment of disparities in the U.S. was strongly associated with perceived strength of the evidence in medicine in general (P less than .001), acknowledgment of disparities in one’s own practice was not associated with perceived strength of evidence in emergency medicine or with medicine in general,” Ms. Zogg said. “As evidence documenting disparities continues to increase, action is needed to address disparities in emergency care. This is important because as frontline providers of care, emergency physicians often act as the first point of contact for these patients within the U.S. health system. Ultimately, despite recognition of health care providers as a contributing factor to the existence of disparities and evidence to suggest the presence of disparities in emergency medicine, only one-fourth of FACEP openly acknowledge the potential for disparities in their personal practice.”
Ms. Zogg is supported by a National Institutes of Health Medical Scientist Training Program grant. The study was supported in part by a grant from the Emergency Medicine Foundation and the Society for Academic Emergency Medicine.
SOURCE: Zogg C et al. Ann Emerg Med. 2018 Oct;72(4):S118-9. doi: 10.1016/j.annemergmed.2018.08.306.
SAN DIEGO – About 25% of Fellows of the American College of Emergency Physicians acknowledged that health care disparities exist in their practices, according to a survey completed by 945 ACEP fellows in 36 states.
In conjunction with the American College of Emergency Physicians, Cheryl K. Zogg, MSPH, MHS, and her colleagues surveyed a nationally representative subset of ACEP fellows between September and December of 2017 to determine the extent to which emergency medicine physicians perceive that various forms of disparities exist and that there is “strong evidence” to support the existence of disparities.
The results were reported in an abstract presented during the annual meeting of the American College of Emergency Physicians.
“The existence of disparities in medicine has been widely acknowledged,” she said. “A lot of the modern conversation began in 2002, when the Institute of Medicine published its now-famous report, ‘Unequal Treatment.’ Since that time, a growing body of literature has discussed the existence of disparities in various medical fields and related to a number of factors including but not limited to race and ethnicity.”
The survey contained questions about perceptions of disparities related to insurance status, type of insurance, ability to speak English, educational attainment, race/ethnicity, sexual identity, and sexual orientation as well as the perceived strength of the evidence to support the existence of disparities in medicine in general and in emergency medicine specifically.
Ms. Zogg, an MD-PhD candidate at Yale University, New Haven, Conn., found that disparities of insurance status (85.6%) and type of insurance (81.3%) were the most widely acknowledged, followed by variations in care as a result of patients’ ability to speak English (73.7%) and level of educational attainment (61.5%).
Slightly more than half of respondents (51.9%) acknowledged the existence of disparities based on race/ethnicity in United States, but only 20.9% believe that such disparities exist in their hospitals and even fewer (3.9%) believe that they exist in their own personal practices. At the same time, more than one-third of respondents (40.6%) acknowledged the existence of disparities based on gender identity in the United States, but 22.4% believe that such disparities exist in their hospitals and even fewer (5.7%) believe that they exist in their own practices. Similar percentages were observed when respondents were asked about issues of sexual orientation (33.7%, 10.6%, and 2.3%, respectively).
Perceived strength of the evidence supporting the existence of disparities followed a similar trend. Between 74.7% and 82.2% of respondents believe there is strong evidence in medicine to support the existence of racial disparities in insurance status and insurance type, respectively. However, between 47% and 49.4% of respondents rated such evidence as strong in emergency medicine, and between 25.9% and 26.5% rated such evidence as strong in their own personal practices.
“While acknowledgment of disparities in the U.S. was strongly associated with perceived strength of the evidence in medicine in general (P less than .001), acknowledgment of disparities in one’s own practice was not associated with perceived strength of evidence in emergency medicine or with medicine in general,” Ms. Zogg said. “As evidence documenting disparities continues to increase, action is needed to address disparities in emergency care. This is important because as frontline providers of care, emergency physicians often act as the first point of contact for these patients within the U.S. health system. Ultimately, despite recognition of health care providers as a contributing factor to the existence of disparities and evidence to suggest the presence of disparities in emergency medicine, only one-fourth of FACEP openly acknowledge the potential for disparities in their personal practice.”
Ms. Zogg is supported by a National Institutes of Health Medical Scientist Training Program grant. The study was supported in part by a grant from the Emergency Medicine Foundation and the Society for Academic Emergency Medicine.
SOURCE: Zogg C et al. Ann Emerg Med. 2018 Oct;72(4):S118-9. doi: 10.1016/j.annemergmed.2018.08.306.
AT ACEP18
Key clinical point: As evidence documenting disparities continues to increase, action is needed to address disparities in EM care.
Major finding: Only one-fourth of ACEP fellows openly acknowledge the potential for disparities in their practices.
Study details: A survey of 945 ACEP fellows in 36 states.
Disclosures: Ms. Zogg is supported by a National Institutes of Health Medical Scientist Training Program grant. The study was supported in part by a grant from the Emergency Medicine Foundation and the Society for Academic Emergency Medicine.
Source: Zogg C et al. Ann Emerg Med. 2018 Oct;72(4):S118-9. doi: 10.1016/j.annemergmed.2018.08.306.