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From practice variability to EHR adoption, the top studies that should change your practice.

I often get asked to give presentations on what I think are the most important articles of the year. Clearly, one’s perspective regarding what is important varies from individual to individual, however, I tend to gravitate to articles that look at systems issues and those that I think can have a major impact on how we practice clinically. For this month’s column, I’m digging deep to find what I think should be articles that really impact what we do.

I say “should impact” with substantial reservations since getting physicians to become involved in change processes is really tough – not because they are not interested but because most physicians are so busy just maintaining the status quo. Unfortunately, many physicians just don’t have the time to volunteer to take on issues that really require physician leadership.

One of my major interests is looking at the variability that exists in physician practice. I see narrowing variability through the use of evidence-based medicine as a way to improve the quality of care patients receive while substantially decreasing costs.

Every practicing physician in emergency medicine knows the physician in their practice who is the biggest user of lab and imaging studies; who has the highest admission percentage and is the most afraid of being sued. Although physicians have an intuition of the magnitude of this variability, there’s evidence that, most likely, their estimates will be way low.

There are lots of examples demonstrating the huge variability in physician practice – go to DartmouthAtlas.org and you’ll see, on their home page, a map of the U.S. demonstrating the incredible variation in patients readmitted within 30 days of being discharge from a hospital following a medical admission – the range is two fold depending on the location!!

But until recently, I was not aware of any article drilling down to variability in the practice of emergency medicine. Clearly, demonstrating variation is a courageous endeavor because fundamentally it is pointing out differences in practices than cannot be defended -- practices that cost patients and their insurance companies serious dollars without delivering any measurable improvement in care.

Seems every doctor gets to practice the way they want with little scrutiny. Why, because physicians don’t want their work to be scrutinized and to approach this difficult task requires unassailable data – which is often very difficult to obtain. The implications of quantifying variability suggest that some providers are grossly more efficient than others while, at the same time, not getting into trouble with bad outcomes, patient complaints, malpractice suits or other markers of poor performance.

So here is the study that I think is extraordinarily telling -- and courageous – and which should be a wake-up call to all of us. It compared practices in two pediatric emergency departments in Atlanta. The abstract makes it clear that the variation in individual physician practice was embarrassingly huge and medically indefensible. Furthermore, the study’s methodology is fairly rigorous with large numbers of visits being compared so the variation demonstrated was real and not just a fluke.

Check out the variation in admission rates between individual doctors at one ED – eight fold! Although unfortunately not noted in the abstract, the ordering of head CTs varied five-fold between doctors in the same practice!! No other service business would tolerate such variability, however, in the practice of medicine we get to hide behind calling it “practicing the art” of medicine. BS. Congratulations to Dr. Jain and colleagues for helping to point out the tremendous opportunity that exists to do better.  
 
PHYSICIAN PRACTICE VARIATION IN THE PEDIATRIC EMERGENCY DEPARTMENT AND ITS IMPACT ON RESOURCE USE AND QUALITY OF CARE
Jain, S., et al, Ped Emerg Care 26(12):902, December 2010

BACKGROUND: Previous studies of variation in medical practice have generally compared practice patterns in different geographical regions and between physicians with different levels of training.

METHODS: This study, from Emory University in Atlanta, compared the care provided in three resource categories by attending physicians practicing in the EDs of two tertiary care children’s hospitals in the same city (one academic and one nonacademic). The study included 163,669 visits managed by 36 physicians in ED1 and 289,199 visits managed by 45 physicians in ED2 in 2003 through 2006.

RESULTS: The hospital admission rate was 13.3% in ED1 and 12.1% in ED2, but there was a nearly three-fold variation in admission rates between physicians practicing in ED1 and an eight-fold variation in ED2. For patients discharged from the ED, utilization of laboratory tests was relatively similar. Although overall imaging rates were similar (14.4% vs. 15.4%), there was a two-fold variation between physicians in ED2. The overall use of IV fluids and antibiotics for discharged patients was about 7% in both EDs but the interindividual rates varied two-fold in ED1 and three-fold in ED2. The mean length of stay was longer at ED2 by 10 minutes, and there was more variation between physicians in this facility than in ED1. Rates of return ED visits at 72 hours were similar in the two EDs. In ED1, there was a two- to three-fold difference between physicians in the minimum and maximum observed-to-expected ratios in the utilization of imaging, lab testing and IV therapy, and higher than expected utilization was associated with a longer than expected ED length of stay.

CONCLUSIONS: This study demonstrates substantial differences in resource utilization between ED physicians in similar practice settings. 59 references. Email This email address is being protected from spambots. You need JavaScript enabled to view it. for reprints [subject = The Center for Medical Education Abstract Request”.
Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 9/11 - #22

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Another one of my pet peeves is the drive to make doctors and nurses use computers to generate medical records. It seems like more and more lemmings are going over the cliff of “we must adopt an EMR system.” I fundamentally ask, “Will we be able to seem patients more efficiently using these systems?”  “Will we be able to provide better quality care with these systems?” The assumption seems to be that the answer to one or both of these questions is “Yes.” But where is the data to support these assertions? All I here is that making doctors and nurses be computer data entry personnel in the process of generating their histories, physicals and progress notes is substantially decreasing productivity (seeing less patients per hour) and not demonstrably improving quality. I know most hospital administrators have drunk the Kool-Aide that says we have to emulate the airline industry and the banking industry and all the other businesses that have been revolutionize by computerization, however, the analogy breaks down when it comes to the practice of medicine.

So here are some articles that will make no difference at all -- but are intended to annoy the zealots. They’re the folks who believe that asking front line doctors and nurses to switch from much more user friendly ways of documenting to sitting at a computer terminal is the way to improve the practice of medicine.  The first two article looks at quality improvements (there was none of note) and the third says lets take a rational approach to proving the value of computer-generated records that are produced by doctors and nurses before we screw up the provision of healthcare even further.

ELECTRONIC HEALTH RECORD ADOPTION AND QUALITY IMPROVEMENT IN US HOSPITALS
Jones, S.S., et al, Am J Man Care 16(12):SP64, December 2010

BACKGROUND: The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 offers substantial financial incentives to implement the use of electronic health records (EHRs), based on the unproved assumption that EHR use will lead to improved patient care.

METHODS: The authors, from RAND Corporation and Harvard, examined the association between EHR use in 2003 and 2006 and 17 quality-of-care indicators for acute myocardial infarction (AMI), congestive heart failure (CHF) and pneumonia in 2004 and 2007 in 2,021 US hospitals.

RESULTS: The percentage of participating hospitals with no EHR system decreased from 76% in 2003 to 62% in 2006. The number using a basic EHR system (consisting of a clinical data repository, electronic patient record and clinical decision support) increased from 22% to 26%, and the number using an advanced EHR system (the aforementioned components plus computerized physician order entry) increased from 2% to 12%. From 2004 to 2007, quality scores for all three conditions of interest improved, regardless of EHR use. Compared to hospitals with no EHR, hospitals with basic EHRs had greater improvement in quality measures for heart failure care (by 2.6%) but not for care of AMI or pneumonia, and quality scores in hospitals with advanced EHRs did not improve more or less than scores in hospitals without EHRs. Of note, quality scores for AMI and heart failure in hospitals that newly adopted an advanced EHR improved less than in hospitals that did not adopt EHR, and there was no relationship between adoption or upgrade of an EHR and quality improvement for pneumonia.

CONCLUSIONS: These data fail to show a clear relationship between use of EHRs and improvement in quality measures for inpatient care. 51 references. Email This email address is being protected from spambots. You need JavaScript enabled to view it. [subject = “The Center for Medical Education Abstract Request”]. No reprints.
Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 7/11 - #10

THE CASE FOR RANDOMIZED CONTROLLED TRIALS TO ASSESS THE IMPACT OF CLINICAL INFORMATION SYSTEMS
Liu, J.L.Y., et al, J Am Med Inform Assoc 18(2):173, March 1, 2011

Implementation of clinical information systems in the healthcare setting is being encouraged on multiple levels, but they are costly and some studies have suggested that their effects on patient outcomes are not consistently beneficial. The randomized controlled trial (RCT) is considered the standard for the evaluation of drug therapy, but some developers of clinical information systems do not feel that RCTs are an appropriate method of evaluating these systems. These Scottish authors comment on the feasibility and advisability of performance of RCTs to evaluate clinical information systems and promote their evidence-based use. RCTs are clearly indicated in the absence of incontrovertible evidence that the benefits of these systems vastly outweigh their harms and costs. While some argue that these systems are too complex to be subjected to RCTs, these authors note the use of RCTs in the setting of other highly complex interventions and believe that a multiarm approach would facilitate the determination of the relative impact of each component of the systems on patient outcomes. They further suggest that the RCT is the best method of obtaining unbiased estimates of the effects of clinical information systems, and that the information provided by RCTs can be supplemented by studies using other designs. To those who feel that the rapidly expanding technology involved in clinical information systems is not amenable to performance of a RCT, the authors note that other study types involving other rapidly evolving medical interventions also require prolonged follow-up to definitively establish safety and efficacy. The authors challenge the belief that clinical information systems “do no harm,” and suggest that performance of RCTs should be an integral part of their widespread implementation. 115 references (email This email address is being protected from spambots. You need JavaScript enabled to view it. [subject = “The Center for Medical Education Abstract Request”] no reprints).
Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 8/11 - #14


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The next cluster of papers relates to clinical practice. Specifically, they make the compelling case that we should absolute stop the knee-jerk practice of ordering CTs in kids (and adults) with suspected appendicitis… and that other countries are way ahead of us in this regard – way ahead. What should be done instead? – an ultrasound. If the ultrasound is equivocal, then go ahead and order your CT. The absolutely best paper on this topic is below. It shows that 6 ultrasounds were performed for every one CT in adults and 24 (yes, 24) ultrasounds for every one CT in kids.

ROUTINE ULTRASOUND AND LIMITED COMPUTED TOMOGRAPHY FOR THE DIAGNOSIS OF ACUTE APPENDICITIS
Toorenvliet, B.R., et al, World J Surg 34(10):2278, October 2010

METHODS: This prospective Dutch study examined an approach to the diagnosis of acute appendicitis that included clinical evaluation by surgical residents and/or attending surgeons, followed if imaging was believed to be necessary by performance of ultrasonography by a radiologist, and CT scanning if the ultrasound was equivocal. Patients who were not immediately admitted were reevaluated after 24 hours.

RESULTS: Appendicitis was suspected based on the clinical evaluation in 164 of 802 patients with acute abdominal pain. The final diagnosis was appendicitis in 119 of the 802 patients (14.8%, including 104 patients in whom it was clinically suspected and 15 in whom it was not initially suspected). The sensitivity and specificity of the clinical evaluation were 87% and 91%, respectively (positive and negative predictive values 63% and 98%). Among the patients with suspected appendicitis, imaging was performed in 116 (97.5%), including 118 ultrasound studies and 19 CT studies (ratio of ultrasound to CT, about 6:1 overall and 24:1 in children). Sensitivity and specificity were 91% and 98% for ultrasonography and 100% each for CT scanning. Overall, imaging provided an accurate diagnosis in 98% of the patients in whom it was performed, and resulted in a change in management for 20 patients. The negative appendectomy rate was 3.3%. The overall perforation rate was 23.5%, but the rate of missed perforated appendicitis was 3.4%.

CONCLUSIONS: Clinical examination does not appear to be sufficiently reliable to identify or exclude acute appendicitis. The authors feel that their findings support routine imaging when appendicitis is suspected, with ultrasonography as the initial modality followed if equivocal by CT scanning. 43 references (email This email address is being protected from spambots. You need JavaScript enabled to view it. [subject = “The Center for Medical Education Abstract Request”]. No reprints)
Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 2/11 - #14


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Here’s a recent Stanford paper that clearly proves just how far behind we are. It indicates that an “ultrasound first” protocol was used only about half the time and that when it was used it decreased CTs by half. Why was it not used more often? An interview with one of the authors (it’s on the October, 2011, of EMA) noted that EPs were often the culprits given that the protocol was largely initiated by the radiology department.

So here is a big university hospital that deals only with children and is clearly aware of all the issues regarding the potential consequences of CT radiation and even they can’t get their act together – so what can we expect of community hospitals? Emergency physicians should absolutely stop ordering CTs in kids and order ultrasound studies instead. It doesn’t matter what time of day it is, it doesn’t matter if the ultrasound tech needs to be called in from home and it doesn’t matter what the radiologists say about their ability to read ultrasound studies in this setting. They just need to learn and get with it.

EFFECTIVENESS OF A STAGED US AND CT PROTOCOL FOR THE DIAGNOSIS OF PEDIATRIC APPENDICITIS: REDUCING RADIATION EXPOSURE IN THE AGE OF ALARA
Krishnamoorthi, R., et al, Radiology 259(1):231, April 2011

BACKGROUND: When the clinical presentation is equivocal, imaging typically is used to play a key role in establishing or excluding the diagnosis of appendicitis in children. METHODS: The authors, from Stanford University, performed an implicit chart review regarding their experience with a staged imaging pathway for suspected pediatric appendicitis from January 2003 to December 2008. The pathway called for initial graded compression ultrasonography (interpreted by resident or fellow and attending radiologists) followed by IV contrast-enhanced 64-slice CT scanning only if the initial ultrasound was equivocal. Outcome assessment was based on surgical findings or clinical follow-up.

RESULTS: Of 1,228 children undergoing imaging for suspected appendicitis during the study period, the pathway was followed for 51.3%. Appendicitis was diagnosed in 34.3% of the pathway-compliant group and 38.9% of those imaged outside of the pathway. In the pathway-compliant group, US was positive in 176 and negative in 157, such that CT imaging was required in the 298 patients (47.2% of the overall cohort) in whom ultrasonography was equivocal. The sensitivity and specificity of the imaging pathway for appendicitis were reportedly 98.6% and 90.6%, respectively, for an overall diagnostic accuracy of 93.3%. The pathway protocol results were reportedly false positive in 39 patients (6%) and false negative in three (0.5%), two of whom underwent early surgery based on clinical findings. CONCLUSIONS: This chart review study suggests that a staged imaging protocol in children with possible appendicitis, involving CT scanning only when initial ultrasonography is equivocal, may help avoid CT in about half of such patients, and be associated with reasonable diagnostic accuracy. 24 references (This email address is being protected from spambots. You need JavaScript enabled to view it. - no reprints) (21324843 [PMID])
Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved    10/11 - #

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And speaking about what time of day it is, here’s a paper that says that if you come in with suspected appendicitis at night you are much more likely to get a CT than if you come in during the day (when an ultrasound is easier to obtain). Shame on us. We just need the testosterone to do what is right – and it is not kowtowing to every surgeon who will not see a patient without the CT being done in advance and every radiologist who whines about why they are uncomfortable with reading ultrasounds in the setting of suspected appendicitis.

GLOWING IN THE DARK: TIME OF DAY AS A DETERMINANT OF RADIOGRAPHIC IMAGING IN THE EVALUATION OF ABDOMINAL PAIN IN CHILDREN
Burr, A., et al, J Ped Surg 46(1):188, January 2011

BACKGROUND: “Ultrasound first” with performance of CT scanning only if the ultrasound is equivocal has been suggested as an effective imaging strategy for the evaluation of children with suspected appendicitis to reduce the use of CT scanning. Implementation of this strategy requires the participation of a specialized ultrasound technician, which is often not available at night.

METHODS: The authors, from University of Massachusetts Memorial Medical Center in Worcester, retrospectively compared the imaging performed in 265 children presenting with possible appendicitis in 2004-2009 during daytime hours (when an ultrasound technician was available, 7:30AM to 5:30PM) and 160 comparable children presenting during evening/nighttime hours.

RESULTS: During the daytime hours, most of the children underwent ultrasonography (230/265) and only 35 CT scans were performed. At night, this pattern was reversed, with ultrasonography being performed in 50/160 and CT scanning in 110/160. The average cost of initial imaging was $2,491.06 during the daytime hours but $4,045.00 at night (“cost” is probably a misstatement actually referring to charges). The average radiation dose delivered was 0.52mSv per patient during the daytime hours but 2.75mSv per patient at night.

CONCLUSIONS: Children undergoing imaging for possible appendicitis during off-hours are subjected to CT scanning much more frequently than those presenting during the day. They are exposed to much higher radiation doses, and incur higher imaging costs. The authors cite the importance of expanding the availability of ultrasound imaging. 15 references (email This email address is being protected from spambots. You need JavaScript enabled to view it. [subject = “The Center for Medical Education Abstract Request”] No reprints.
www.ncbi.nlm.nih.gov/pubmed/21238664
Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 7/11 - #16

What is the common thread in this month’s papers? Emergency physicians need to step up to the plate and take on the challenges and opportunities that these papers elucidate. Some are more of a global nature and will be a lot more difficult (like dealing with EMRs) but others are a lot easier and hit home more directly, like measuring and addressing variation in practice in your ED and pushing back on the pressure to do CTs in everybody with suspected appendicitis when there are safer strategies.


 

 

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