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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 be...

April 5, 2018

Pick a Scalpel, Any Scalpel

I've always found the scalpel numbering system unintuitive. Here's how I remember which is which:
#10 has a big curve, like a 0.
#11 is pointy, like the fallen 11.
#15 has a small curve, as only part of a 5 is curved.

January 29, 2018

The Prudent Layperson Standard OR How I Learned to Keep Worrying About Anthem Breaking the Law

UPDATE 3/1/18: this post is now expanded into an article at EPMonthly:  Prudent Layperson, Meet Imprudent Payer

This is taken from my twitter thread on the prudent layperson standard which was in response to this article by Sarah Kliff in Vox on Anthem denying claims for ER visits based on final diagnoses.

The ACA made the prudent layperson standard federal law (ACEP piece). The prudent layperson standard is exactly what it sounds like: the definition of a medical emergency is that a normal person with an average knowledge of medicine thinks is an emergency -– the patient’s symptoms make it an emergency, not the final diagnosis. So severe abdominal pain that turns out to be “just” an ovarian cyst is, by definition, an emergency.

This is both obvious and good: the patient can’t tell if their severe abdominal pain is something terrible and dangerous like appendicitis or something that’s painful but not dangerous.

Notably: *severe pain alone* is by law a medical emergency.
[That's the case in the Vox article]. Here’s the rule if you’re interested:
Oh and it’s written into the legislation, too:
In fact, most states (32+DC) had state prudent layperson standards well before the ACA made it federal, including Indiana [where the case in the Vox article took place] [UPDATE 2/13/18: according to this article, 47 states + DC currently have prudent layperson laws.]

And once again, this is very important because we shouldn’t expect people to sit at home and worry about whether their severe pain is “just a cyst” or a ruptured appendix or an ovarian cyst causing an ovarian torsion or massive internal bleeding.

If the patient is acting like a “prudent layperson” and thinks they are having an emergency, then it is an emergency and the insurer has to cover the ER visit. Full stop.

This is really important because there is a huge overlap in symptoms between simple benign problems (ovarian cyst) and serious life threatening problems (appendicitis) -- see this fantastic paper by Maria Raven et al.

Anthem is breaking the law by denying claims based on final diagnoses in cases like this and it is terrible and people will get seriously hurt.

Tons of patients end up with final diagnoses like “acute viral bronchitis” which sound simple. Except when the patient is 80 and has CHF and COPD and it could easily be flu or pneumonia or a serious COPD or CHF exacerbation any or all of which could kill them.

See my previous post with a bunch more resources on how worthless and dangerous it is to try to decrease “unnecessary” ER visits.

UPDATE 2/17/18: Consumer Reports just published a piece on a patient getting denied ED coverage for severe headache that turned out to be "just" mastoiditis. 

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 and accompanying editorial by my (now) chair:
some intuitive, oversimplified, yet enduring beliefs about nonurgent patients in the ED should be abandoned. Trying to discern low-acuity conditions and putting up barriers to receiving care or denying payment after receiving care will work no better in future generations than in the past. Attention should be redirected away from penalizing patients, physicians, or hospitals when a condition turns out to be minor. Instead, the emphasis should be on integration across sites of care, especially for the most complex and most expensive patients.
and from his response to a Letter:
The reasons people visit the ED for care are often rational and understandable, driven by a perceived need for immediacy of treatment and lack of an accessible alternative. Many conditions treatable in primary care that are cared for inside EDs in the United States may reflect problems with alternative access to rather than inappropriate actions by the patient.
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 and 14 below)

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):
RAND HIE

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 & 12/25/2017
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 Maria 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) another British review showing putting "unscheduled care centres (UCC)" in the ED doesn't solve much, by Shammi Ramlakhan, Suzanne Mason, Colin O'Keeffe, Alicia Ramtahal, Suzanne Ablard in EMJ
Primary care services located with EDs: a review of effectiveness

12) This great episode of EM Over Easy on fundamental attribution error
and
13) 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.

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


UPDATE 1/29/2018
See my twitter thread on the prudent layperson standard [now here in blog form and here in EP Monthly] which was in response to this article by Sarah Kliff in Vox

15) friendly reminder that the legal definition of a medical emergency is
"a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in... placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; ...serious impairment to bodily functions; ...[or] serious dysfunction of any bodily organ or part.)"

If a regular person with no medical training thinks their symptoms are an emergency, it's an emergency and the insurer has to cover it.

16) it's legislated federal law in the ACA (text)

17) and here is the regulatory version (text)

(for both of these, ctrl+F prudent layperson) to find it

summarized by me here in EP Monthly

18) and before it was federal law for private insurers, it was state law in 32 states + DC (pdf from ACEP)


UPDATE 9/4/2018
19) interesting paper from Sabrina Poon, Jeremiah Schuur, and Ateev Mehrotra analyzing Aetna data:
changes in "low acuity visit" from 2008-2015:
-overall increased by 31% (from 143 to 188 visits per 1,000 members)
-non-ED increased by 140% (from 54 to 131 visits per 1,000 members)
-urgent care increased by 119% (from 47 to 103 visits per 1,000 members)
-retail clinic increased by 214% (from 7 to 22 visits per 1,000 members)
-low acuity ED visits decreased by 36% (from 89 to 57 visits per 1,000 members)
-average overall spending per member increased by 14% (from $70 to $80 per member per year)

[important limitations: single, commercial plan; tough to define what a low acuity visit is (seems to me like their definition gives a useful operational sample, but doesn't define the whole universe of low acuity visits?; and, hindsight bias; and, doesn't look at office-based care; acute unscheduled office care is hard to analyze, etc.]

I have lots of initial thoughts here; mainly, this looks like it didn't save money, we don't know about outcomes, and I think overall this is more about supply-induced demand [funny how non-ED low acuity patients had higher incomes] than meeting unmet demand. But, I also know my priors.

UPDATE 11/26/2018
20) Andy Chou, Suhas Gondi, Olesya Baker, Arjun Venkatesh, and Jeremiah Schuur published a paper in JAMA Network Open** looking at what fraction of patients who could potentially get denied by Anthem's low-acuity ED visit denial policy (see my summary) share symptoms with all ED visitors. No surprises: 15% of patients have diagnoses that might be denied by Anthem; they share symptoms with 87.9% of ED patients.

And a nice accompanying editorial by Maria Raven.


*COI: I am was Social Media Editor for Annals which makes made Mike my boss.
**COI: I am Digital Media Editor for JAMA Network Open

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:


UPDATE:
no surprise: rate of PE in US syncope patients <1% in JAMA IM