October 26, 2012

tweet-in-brief + QOTD: “Special”ties

October 25, 2012

Medicare at 67?

One of the ideas thrown around to save Medicare costs is to increase the age of eligibility from 65 to 67 (Social Security is undergoing a slow transition from 65 to 67, initiated by Congress in 1983). It seems to make sense: people live & work longer, so let's adapt and save some money.

But it looks like it wouldn't help very much.

These numbers below are from a 2011 analysis by the Kaiser Family Foundation I recently reviewed for journal club. For more (but not too much) detail, there's a great Executive Summary on page 5.

If the age change suddenly went into effect in 2014, this is what would happen in the first year:
  • Federal savings: 
    • $5.7 billion (1% of total Medicare costs)
  • Increased costs:
    • 65-66 year olds: $3.7 billion
    • Employers: $4.5 billion
    • States: $0.7 billion (via Medicaid)
    • Premiums: 3% increase for both Medicare recipients and those insured through the Health Insurance Exchanges
A word on their methodology: they make 2 useful assumptions. First, that the ACA stays in force as currently enacted, and implemented as expected (for simplicity, they assume every state expands Medicaid as directed by the ACA). Second, they assume an abrupt increase in the age of Medicare eligibility to 67 (if it were enacted, it would most likely be phased in gradually over at least a few years).

A bit more detail:
  • 5 million enrollees would be affected (there are roughly 50 million now, 42 million >65 years old and 8 million <65 but disabled)
  • Medicare would decrease spending by $31 billion but the total federal savings would only be $5.7 (about 1% of Medicare spending) billion due to increased costs in Medicaid, subsidies through the exchanges, and decreased revenue from Medicare premiums
  • Out-of-pocket costs for 65-66 year olds would rise $3.7 billion
  • Employers would spend an extra $4.5 billion
  • Premiums would increase for 2/3 of 65-66 year olds (about $2200/year each)
  • Premiums would decrease for 1/3 of them, largely through subsidies through the exchanges
  • 42% of 65-66 year olds would receive insurance through employers
    • half would still be working
    • half through a spouse or through a retiree plan
  • 38% would get insurance through the exchanges
  • 20% would get insurance through Medicaid
  • Premiums in Medicare and the exchanges would both increase about 3%
    • Will Rogers phenomenon: the healthiest seniors would leave Medicare, making both the Medicare pool and the non-Medicare pool sicker on average
It's worth noting that over time, the federal share of those covered under the Medicaid expansion slowly drops from 100% to 90% in federal funding, so over time, the federal share will drop a small amount but state costs will increase a bit.

One other point I will add here is that while life expectancy has certainly gone up since Medicare's inception, a lot of that increase is because fewer people die as infants and children. It's not like everyone used to die at age 65 and now they everyone dies at age 78 -- many/most of those who made it out of early childhood a century ago lived into their 70s, and many of the big improvements in population health has been in stopping those early childhood deaths (bringing up the overall average).

What if the ACA is repealed? The fed will save a bunch more money -- very roughly, I would estimate $20 billion based on these numbers.** So let's call that 4% of total Medicaid costs saved. But in the absence of the ACA, the 65-66 year olds would only have 3 options for insurance:
  • Medicaid (if they're poor enough)
  • Employer-sponsored (if they're either working or eligible as a retiree or through a spouse)
  • Private individual market
And a lot of them wouldn't be able to get affordable insurance on the individual market -- without the ACA guaranteed issue regardless of preexisting conditions, and the other premium control mechanisms and subsidies, many 65-66 year olds find it basically impossible to get coverage.

So yes, Medicare is costs a lot. And we need to reign in costs. But increasing the age of eligibility 2 years looks like it will only shave 1% off of Medicare costs, while shifting a huge burden onto individuals, employers, and states. 

NB This post refers to the US Medicare program -- government health insurance for the elderly & disabled.

*nothing below this point is from the KFF paper

**$31b minus $7b in premiums and roughly half of the increased Medicaid costs ($8.9b, so another $4b)

October 15, 2012

Is Roc vs Sux Moot?

I'm a big fan of rocuronium for RSI. The argument is succinctly -- and arguably definitively -- made by Reuben Strayer in 8 minutes.

One of the cornerstones of the argument is the landmark paper by the Benumof Brothers*: patients will invariably desaturate before the sux wears off.

The ubiquitous "time to hemoglobin desaturation curve" that is shown in every airway talk, chapter, paper, etc:
Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology. 1997 Oct;87(4):979-82. 
...not only comes from this paper, but was specifically made to demonstrate that the patient will desaturate before the sux wears off.

But wait a minute. This is from 1997. This was before NODESAT -- the use of nasal cannula during laryngoscopy to maintain oxygen saturation.

Does nasal oxygenation during laryngoscopy bring succinylcholine's shorter duration of action back into the question?

My thoughts are below this other mandatory airway management picture:

My answer is no: roc still beats sux.

  • Sux risks hyperkalemia, i.e. succinylkalemia
  • When the sux wears off, the patient won't be breathing calmly & cleanly. They will be fighting like heck because people are stabbing them in the back of the throat
  • The patient who can't get intubated in 8 minutes still needs to be intubated (there is no "cancel case" in the ED) -- and more paralyis is helpful for bagging, placing an LMA, cric, etc
  • Intubating conditions are as rapid and as good with roc
  • Sux may lead to faster desaturation, because even with NODESAT...
  • NODESAT is amazing but not 100% perfect:
This is just an anecdote** of course, but I had a patient who was preoxygenated perfectly with 100% oxygen via NIV with PEEP using DSI, and even with the nasal cannula at 15 L/min during laryngoscopy, desaturated within 15 seconds.

So I still think roc wins. But of course, I was trained by big fans of roc.

*There are 2 Benumof authors on the paper -- Jonathan and Reuben. I don't know for certain but I like to think they are brothers, and I think they should play the Brugada Brothers in a game of basketball.

**Level of Evidence: A for Anecdote

October 14, 2012

Guest Glossary Term: Little Bitty PE

Don't forget to check out the other glossary entries!

from Casey Parker (@broomedocs):

lung lint - noun

The small, subsegmental PE you wish you had not diagnosed as it almost certainly clinically irrelevant.

"Who ordered the d-dimer?!"

October 13, 2012

Another Glossary Entry: Make 'em Glow

hypoCTemia - noun

The state or condition of urgently needing a CT scan, possibly due to low levels of endogenous CT.

Don't forget to check out the other glossary entries!

October 1, 2012

A Spoon in the Bucket?

I got in a recent twitter discussion with a number of people -- mostly @movinmeat -- on the impact of low acuity patients in the ED. He responded with an excellent, well-reasoned, but probably incorrect blog post (update: recently reposted at KevinMD). This is largely a response to both that conversation (edited Storify version here) and his excellent post. He asks: are low acuity patients congesting the ED? And his answer is yes. But I disagree. And it's fun to argue with people who you generally agree with.

Nobody likes the low acuity patients who come to the ED. Few of us went into EM to take care of not-so-sick patients, there's a lot of charting, and there are just so many of them, which is why for years everyone thought that they were cause of crowding in the ED. But they're not. It's been studied very well, and the overwhelming cause of ED crowding is the boarding of admitted inpatients. ACEP has a report about it. There's even a big IOM report about it. Low acuity patients are frustrating, but not the problem.

When it comes to crowding, are low acuity patients just a drop in the bucket?*

The basic model is input/throughput/output. There are so many patients who come to the ED (input), they take so much time in the ED getting histories, IVs, xrays, etc (throughput) and then they eventually leave (output). The patient with the cold takes, say, an hour. The patient getting serial troponins for chest pain takes 6 hours. The patient admitted for an appy takes 4 hours... PLUS whatever time he sits around waiting for a bed upstairs (boarding). It's easy to see why 1 admitted patient waiting around for an upstairs bed takes up a much bigger piece of the pie than the silly URIs.

(One bit of background: there's some decent work that shows that time in the ED is a great estimate for overall resource use in the ED -- patients who are there longer take up nursing time, ask the doctors questions, use more tests, take up a spot, etc.)

Next, consider what clogging the system really means.

We are quick to think about low-acuity ED visits as "unnecessary visits" -- like the healthy patient with a cold. Isn't the admitted patient boarding in the ED in the ED unnecessarily?

Here's a simple example: a patient comes in with a twisted ankle. We do 2 main things: make sure this was a mechanical fall (history) and apply the Ottawa rules (physical), which is negative (assessment) and we tell the patient that they don't need an xray (plan). Rx 800mg ibuprofen, send home with return instructions. Explain again that they don't need an xray. Realistically, this takes an hour from door to door (although it probably shouldn't).

Now a 50 year old with diabetes and CAD comes in with chest pain, with some concerning T-wave changes. Took his aspirin just before he got here. Is otherwise rock-stable. Slam dunk admission. Write some notes & orders, talk to the hospitalist. Done in 10 minutes. Now they just need to go to that inpatient bed. What happens if they board for an hour? or 4? or 12 hours?

When I was in residency we would routinely board 30 patients at least 6 hours each every weekday. That's 180 patient-hours. As MM notes, the total facility time is a great estimate for resource load.

So even if we are pessimists and assume every ankle and URI takes an hour, that's still 180 URIs we could have seen.

Here's a graph that MM posted showing distribution of ED patients by LOS and disposition:

His conclusion: "The lower-acuity patients are there less time, it is true. About 1-2 hours on average."

Lots of discharged patients are in the ED for a few hours. But I think this graph is misleading with respect to how much time they spent in the ED.

I reran his same numbers (being as true as possible from these graphs). I broke this up into 3 groups: discharged in 2 hours or less, discharged but LOS 2.5 hours or more, and admitted.

One major caveat: with these data, anyone who stayed 6 hours or later is counted only counts for 6 hours. That is, my numbers underestimate the burden of the patients with high LOS (which is 1/3 of the admitted patients)

How many patients were there in each group?

DC 0-2h: 41%
DC 2.5-6h: 39%
Admit: 20%

How was LOS divided among these patients?

DC 0-2h: 20%
DC 2.5-6h: 45%
Admit: 35%

That is, 40% of the patients are discharged in 2h or less, but only take up 20% of the hours. The 20% of patients who got admitted take up 35% of the LOS, and again, that underestimates their share because it treats everyone over 6 hours as taking only 6 hours. And, this is assuming that everyone who is discharged in 2 hours or less is a low-acuity patient.

So maybe not a drop, and maybe more than a spoon. But the quick discharges are taking only a small portion of the total resources. And remember, this is only 1 hospital, and it's a hospital with remarkably little boarding.

But even further: is that even the right group of patients to consider as "low acuity" or "shouldn't be in the ED"?

It's very tough to properly measure the low-acuity patients.

I agree that the 8% figure frequently quoted by ACEP is misleading. Not only is it based merely on triage category, which as @movinmeat notes may be incredibly misleading, but those recommended to-be-seen times are entirely made up. And it's very hard to figure this out based on administrative data.

These are all patients that we frequently see and discharge with neck pain:
  • mild fender bender
  • serious MVC
  • 30th visit for chronic neck pain (gabapentin refill)
  • 80 year old who was worked up (appropriate or not) for a cervical artery dissection

Is discharge from the ED a sign that the visit was unnecessary? Of course not. How many patients get seen for potentially worrisome chief complaints and end up being discharged home? (Hence the prudent layperson standard.)

About 80-85% of all ED visits get discharged. Were these all visits that didn't need to be seen in the ED? What are the alternatives? Primary care offices? Urgent care center? Walgreen's? How easy is it to get into any of those? What are the hours? Most PMD offices are open during business hours, which is when many of us are actually at work. If you twist your ankle and don't know if it's broken, is it inefficient to come to the ED, where the lights are already on, the x-ray machine is running, and the tech is there?

I don't enjoy the low-acuity patients. They're not that interesting, they make the haystack bigger (when a big part of our job is looking for needles), they talk back more, and if I wanted to work in an outpatient clinic I work in an outpatient clinic.

But low acuity patients:

*I had modified that to a spoon in the bucket

UPDATE 11/8/2012
I fiddled around with the graph a bit and made this graph. The light blue and light red are the same as movinmeat's: number of discharged and admitted patients for each LOS. The dark blue and dark red are their "patient-hours." Each dark bar shows the total number of hours in the department for the patients in each group, e.g. the 17.5% of patients who are there for 1 hour get shown as 17.5 patient-hours (17.5x1-17.5) and the 12% of patients there for 2 hours are 24 patient-hours (12x2=24).

This demonstrates 2 things. First, the admits have an outsized influence in patient-hours (which we know): the 7% of admitted patients who were there for 6h get 42 patient-hours of care (!). And further, the group in the middle -- patients who hang around the ED for a while but eventually get discharged -- seem to take up a big chunk of patient-hours. This is in line with a recent study from Steve Pitts, Michael Handrigan, Art Kellermann, and Jesse Pines, where they looked at NHAMCS data** and showed a big influence on  crowding is ED workup: labs, imaging, etc., a lot of which might be resource-saving in the long-run because it avoids admissions. But it does look like "output" is no longer the only culprit in ED crowding: "throughput" may be as big of a factor. But it's still not input (not yet, anyway).

**There was a great recent paper by Steven Green pointing out some weaknesses in NHAMCS -- primarily, up to a quarter of patients who were intubated did not go to either a critical bed or die (although at my residency hospital, a lot of intubated patients went to the floor). I admit that NHAMCS has some limitations (as any giant database will) but it's still probably a useful database and the best we have right now. Although admittedly I'm biased, as I'm currently working on an analysis of NHAMCS data with Steve Pitts and Jesse Pines....