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As the new medical-academic year begins, I'm guessing a bunch of new interns will learn about how great FOAM is, and at the same time,...

November 14, 2017

On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at best, a misguided effort:

1) Great overview of many systemic issues which funnel patients to emergency departments, by Annals of Emergency Medicine Editor in Chief Mike Callaham*:
The Prudent Layperson’s Complicated and Uncertain Road to Urgent Care

2) We can't discern low acuity diagnoses from chief complaints, by Maria Raven, Robert Lowe, Judith Maselli, and Renee Hsia in JAMA:
Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department Visits

3) Low acuity ED visits is just not where the money is, by Peter Smulowitz, Leah Honigman and Bruce Landon, in Annals of EM:
A novel approach to identifying targets for cost reduction in the emergency department.

4) EDs aren't overcrowded because of low acuity patients; we are busy because of boarding -- patients we have seen & admitted in the ED and are waiting for their inpatient beds. (tons on this, here's one on how boarding-> crowding in Annals by Brent Asplin et al A conceptual model of emergency department crowding, and 2 of my blog posts 4A) here and 4B) here).

5) And for those who suggest higher patient copays for low acuity ED visits, the famous RAND HIE, which shows that patients who have to spend more out of pocket decrease *all* care, both appropriate & inappropriate care (which isn't surprising, given Raven's study, above):

Here are a few studies that show that retail clinics tend to *increase* rather than decrease overall utilization (suggesting something like supply induced demand) and fail to lower (and probably increase!) ED use:
6) Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care by Jesse Pines in Annals
7) Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending by J Scott Ashwood, Martin Gaynor, Claude Setodji, Rachel Reid, Ellerie Weber, and Ateev Mehrotra in Health Affairs. From what I hear from people who run EDs which opened urgent cares etc, the same holds true, but I don't have great data on that.

UPDATE 12/5/2017
8) Surprise! Uninsured people don't use the ED any more than those with insurance; rather, they use it the same. But, they use other health care less. By Ruohua Annetta Zhou, Katherine Baicker, Sarah Taubman, and Amy Finkelstein in Health Affairs:
The Uninsured Do Not Use The Emergency Department More—They Use Other Care Less

UPDATE 12/18/2017
9) Another great new paper from Maria Raven and Faye Steiner: 1 in 4 patients in the ED were referred from an outpatient provider (and they're more likely to be admitted than other ED patients):
A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization

10) and while finding (9) I found this great review by Raven et al in Annals showing ED visit reduction programs generally don't work:
The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review

11) This great episode of EM Over Easy on fundamental attribution error
12) David Foster Wallace's This Is Water.
The basic idea: when I cut someone off in traffic, I make excuses for myself (I'm late to work, the light is changing, etc etc) but when someone cuts me off, of course I think they're just a jerk. The less I judge patients for being in the ED, the less stress I have.

13) And here are my 2 blog posts on crowding:
A Spoon in the Bucket?
Empty the Dishwasher

*COI: I am Social Media Editor for Annals which makes Mike my boss.

November 28, 2016

It's the Medicaid Expansion, Stupid

I came across this nice post:

My initial reactions: hmm, some of this looks like lack of Medicaid expansion, some might be from a combination of too-high premiums/insufficient subsidies/ignorance of subsidies etc on the exchanges.
But wait, "childless adults"? That sounds familiar!

"Childless adults, most uninsured under traditional Medicaid." For those who have studied health policy, it's a stimulus-response, like "chloramphenicol, grey baby" and "dental plan, Lisa needs braces."

I followed the link and noticed the normal, understated citation at the bottom of the post:
Source: Kaiser Family Foundation: Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?
The title on KFF's page is, not surprisingly:

Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?

This reminds me of the famous desaturation curve which appears in every airway lecture, as mandated by CMS due to Obamacare:

Note the title of the source of this familiar graph: Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine.

(Benumof, Dagg, Benumof. Anesthesiology. 1997 Oct;87(4):979-82.)

How often are these graphs shared without noting their expressed purpose? 

October 21, 2016

PE in Syncope: An External Validation of the Wells Score

I'm not going to reinvent the wheel -- see some of the fantastic analyses of PESIT (in no particular order) at:

St. Emlyns - Simon Carley
EM Lit of Note - Ryan Radecki
EMNerd at EMCrit - Rory Spiegel

One common thread is that the patients who had PEs seemed to be patients who we would think had PEs, rather than some occult finding we need to hunt for in all of our syncope patients.

Just look at Table 2, emphasis mine, which looks a lot like their Table 1, which is (gasp!) the Wells Score:

Sure, prolonged immobility and recent trauma/surgery don't reach frequentist significance, but they're close, and there just aren't a lot of people in either of those groups.

Literally the only non-Wells factors they find are tachypnea and hypotension.

You cannot make this up:

July 25, 2016

So You've Decided to Tweet

As the new medical-academic year begins, I'm guessing a bunch of new interns will learn about how great FOAM is, and at the same time, get an orientation lecture on "threats to professionalism." Obviously I think there is a ton of potential benefit to using social media as a medical professional, and here are some of the ways I "maintain professionalism" (read: keep myself out of trouble).

One of my big keys is to not try to "not violate HIPAA" – that's easy and too low of a bar.
The real key is to not piss off the carpetwalkers: I don't want to have to defend myself in a meeting with Risk Management. Instead, I want to maintain a general profile I can defend to my dean and my department chair (and maybe someday to the promotion & tenure committee).

Twitter is a Giant Elevator
My big overall philosophy is that social media is like talking on an elevator. But: my mom, department chair, medical school dean, the patients' family, and a million other people are in the elevator. Obviously that doesn't mean that I'm always banal and polite. Rather, I recognize that people will see what I write and it is always tied to me.

Patient Privacy
Easy version: never talk about real patients.

Slightly tougher but still easy: if I do want to talk about real patients, I change enough of the details so that if the actual patient were to see it, the patient wouldn't recognize that it was them.

Two mistakes people make: date of service and age over 90 are HIPAA-protected PHI. The number one thing I do if I am referencing something that happened to a real patient is that I don't do it the same day (or even the same week).

I never even reference "oh look what happened on my drive to work today" so there can't be a real connection between anything I say and a real patient. And I don't share pictures from work or of patients without all of my ducks in a row (if at all).

On Anonymity
I'm not opposed to being anonymous, but I'm very much intentionally not. This is partially as a check on myself -- I know whatever I say is tied to me. A big part of it is to avoid the fear of people discovering my secret identity.

I'm not recommending anyone be anonymous on social media, but if I were, I would tell all my relevant bosses (e.g. program director, chair). If something serious "goes down," i.e. there's some sort of scandal, and it's a total surprise and secret to everyone, I imagine that there will likely be a big sense of betrayal.

But I don't want to be anonymous, it means you are giving up a lot of the upside. I imagine the benefits are possible but a lot harder if anonymous. Because the bottom line is that there are legitimate career, academic, and potentially financial benefits to being active on social media as a medical professional.