tag:blogger.com,1999:blog-33399159113560782322024-03-13T14:00:06.173-04:00MDaware.orgDon't just do something – stand there.mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.comBlogger164125tag:blogger.com,1999:blog-3339915911356078232.post-336570493676997082023-11-01T11:04:00.005-04:002023-11-01T11:04:53.304-04:00USPSTF CalculatorUSPSTF Calculator
<br />
from the <a href="https://www.uspreventiveservicestaskforce.org/apps/widget.jsp" target="_blank">UPSTF</a><br /><br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://uspreventiveservicestaskforce.org/apps/widget/USPSTFwidget.jsp" style="border: 0; height: 250px; overflow: hidden; width: 178px;" title="Prevention TaskForce Widget"></iframe>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-72669678368251791462023-09-29T15:07:00.001-04:002023-09-29T15:07:21.429-04:00JAMA Network RCT VAs in JAMA<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgTubMMREWcYh8xo2WUVDqDZ9UkmKY9QPi98EUNnpzFb2wm8fJULvklrOyzugeq1dyLYA5rN5tcQP7bRPv2JpTA6qS-aG-w_cLOBtn9IGt3QYuQl2ObLdsCXepGkaHNZ0X4iZpaUwvXle5Mse2AUQ62QBcUubyi0N3pK7CAcxgcM4dSoF_uX0Z-lbBSF2pV" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="538" data-original-width="1636" height="211" src="https://blogger.googleusercontent.com/img/a/AVvXsEgTubMMREWcYh8xo2WUVDqDZ9UkmKY9QPi98EUNnpzFb2wm8fJULvklrOyzugeq1dyLYA5rN5tcQP7bRPv2JpTA6qS-aG-w_cLOBtn9IGt3QYuQl2ObLdsCXepGkaHNZ0X4iZpaUwvXle5Mse2AUQ62QBcUubyi0N3pK7CAcxgcM4dSoF_uX0Z-lbBSF2pV=w640-h211" width="640" /></a></div><br />We published a research letter on our study of visual abstracts of JAMA Network RCT Visual abstracts:<div><br /></div><div><a href="https://jamanetwork.com/journals/jama/fullarticle/2810361" target="_blank">Randomized Clinical Trial Visual Abstract Display and Social Media–Driven Website Traffic</a><br /></div><div><br /></div><div>This was previously "registered" here (<a href="https://mdaware.blogspot.com/2022/03/registry.html" target="_blank">here</a>).</div><div><br /></div><div>See my summary thread:</div><div><br /></div><div><blockquote class="twitter-tweet"><p dir="ltr" lang="en">check out our new study on <a href="https://twitter.com/hashtag/VisualAbstracts?src=hash&ref_src=twsrc%5Etfw">#VisualAbstracts</a> out today in <a href="https://twitter.com/JAMA_current?ref_src=twsrc%5Etfw">@JAMA_current</a> !<br /><br />journals (authors) have been using VAs, including all RCTs in all of the <a href="https://twitter.com/JAMANetwork?ref_src=twsrc%5Etfw">@JAMANetwork</a> journals<br /><br />we used all (205) JN RCTS with VAs from 9/21-5/22 to see how they did 🧵<br /><br />(no paywall)<a href="https://t.co/829EcVpC33">https://t.co/829EcVpC33</a></p>— Seth Trueger (@MDaware) <a href="https://twitter.com/MDaware/status/1707789081092960475?ref_src=twsrc%5Etfw">September 29, 2023</a></blockquote> <script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script></div><div><br /></div><div><br /></div>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-67605016132171731882022-03-08T18:27:00.003-05:002023-09-29T15:11:06.044-04:00Registry<p><i>UPDATE 9/29/2023:</i></p><p><i>Now published in <a href="https://jamanetwork.com/journals/jama/fullarticle/2810361" target="_blank">JAMA</a></i></p><p><i>See also <a href="https://mdaware.blogspot.com/2023/09/jama-network-rct-vas-in-jama.html" target="_blank">this blog</a></i></p><p><i>and <a href="https://twitter.com/MDaware/status/1707789081092960475" target="_blank">summary thread</a></i></p><p><i><br /></i></p><p>Here’s a protocol for a study of visual abstracts. I submitted to clinicaltrials.gov, who (correctly) declined to post it as it doesn’t meet their definition of human participant research. The study is already under way; overall getting it registered hasn’t been a top priority as this is a relatively small study on how VAs may affect journal site traffic and social media metrics. The main goal in posting this here is to show we have not cherry-picked outcomes or done statistical data torture after collecting our results.</p><p><br /></p>
<br />
<iframe allow="autoplay" height="480" src="https://drive.google.com/file/d/1uxCs9LYk4YKOqEgWiKqft96vT98LkPg1/preview" width="640"></iframe>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-265950361975888162021-12-30T17:50:00.006-05:002021-12-30T18:39:05.445-05:00UHC is Still At It Trying to Deny Low Acuity ER Visits<div><i> See <a href="http://mdaware.blogspot.com/2018/01/the-prudent-layperson-standard-or-how-i.html">The Prudent Layperson Standard OR How I Learned to Keep Worrying About Anthem Breaking the Law</a> and <a href="http://epmonthly.com/article/prudent-layperson-meet-imprudent-payer/" target="_blank">Prudent Layperson, Meet Imprudent Payer</a> and of course <a href="http://mdaware.blogspot.com/2017/11/unnecessary-ed-visits-background-reading.html" target="_blank">On "unnecessary" ED visits: background reading</a>.</i></div><div><br /></div><div>In August, UHC announced they were going down the "<a href="https://twitter.com/MDaware/status/1400478036441587718" target="_blank">insurers are probably breaking the law trying to dissuade people from going to the ER</a>" path.</div><div><br /></div><div>Here is their <a href="https://www.uhcprovider.com/content/dam/provider/docs/public/policies/index/commercial/emergency-health-services-urgent-care-center-services-01012022.pdf" target="_blank">recently announced Coverage Determination Guideline</a>.</div><div><br /></div><div>And here is the <a href="https://www.aha.org/lettercomment/2021-12-29-letter-unitedhealthcare-new-coverage-criteria-emergency-level-care" target="_blank">AHA's response</a> (the hospital group, not the cardiologists).</div><div><br /></div>First, the wording is very careful & deliberate, and seems like they
are gearing up to put more pressure here and get away within arguably
the letter but not spirit of the law. If you're a West Wing or Oliver
Platt fan, it reminds me of Babish saying "He did everything
right. He did everything you do if your intent is to perpetrate a
fraud."<div><br /></div><div>They do appropriately define an emergency (or at least close enough to not set off alarm bells when I read this without checking the laws):</div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://lh3.googleusercontent.com/-aBJDXzfoqU0/Yc42cXOyimI/AAAAAAAAKbY/aK_ucUQ0GJIv-PORnDAFNzcKd2i4QkdSwCNcBGAsYHQ/image.png" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="246" data-original-width="1442" height="110" src="https://lh3.googleusercontent.com/-aBJDXzfoqU0/Yc42cXOyimI/AAAAAAAAKbY/aK_ucUQ0GJIv-PORnDAFNzcKd2i4QkdSwCNcBGAsYHQ/w640-h110/image.png" width="640" /></a></div><div><br /></div><div>This is probably the most troubling bit:</div><div><br /></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://lh3.googleusercontent.com/-AISmrWkQodU/Yc42OgbICQI/AAAAAAAAKbU/ZArxTib8kN4U9YaFjIpEyR5pbbN0dKNbACNcBGAsYHQ/image.png" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="386" data-original-width="1474" height="168" src="https://lh3.googleusercontent.com/-AISmrWkQodU/Yc42OgbICQI/AAAAAAAAKbU/ZArxTib8kN4U9YaFjIpEyR5pbbN0dKNbACNcBGAsYHQ/w640-h168/image.png" width="640" /></a></div></div><div><br /></div><div>As the AHA notes, the section on considering other factors -- tests,
treatments disposition -- is concerning. It could all be fine if they're only using it
positively (eg. if you're admitted, you're approved, no need to look further) but the lack of
those things happening doesn't mean there wasn't a prudent layperson
standard emergency so that's the rub. I would suspect they
are going to use this kind of administrative data to identify visits
to scrutinize or just deny off the bat, making ERs & hospitals have to
appeal & justify. If nothing else, another layer of administrative
burden to dissuade providers chasing appropriate reimbursement, and as
someone put it well previously, essentially make providers do unpaid
claims work so they don't have to. </div><div><br /></div><div>The attention to observation is also concerning. Apologies if you're
familiar, will try to keep this short -- a lot of hospitalizations are
clinically indistinguishable from inpatient admissions except are 1-2
days so get billed as obs rather than a full admission, so adding
scrutiny to those is very concerning. (Most of the attention has been
on only paying obs instead of for full admissions, but now it looks
like they're going to put the screws to the lower acuity obs too).</div><div><br /></div><div>Even if this is all above board, there is also the inevitable chilling
effect: policies like this will make people with symptoms think more
about the chance they'll not be covered and will move the needle even
further toward dissuading appropriate care. </div><div><br /></div><div>Along those lines, people don't *want* to come to the ER. They come to
us because they a) need to and b) don't have other options. If
insurers did more to widen their network of providers, paid more for
acute unscheduled care & primary/outpatient care in general, there
would be more options for lower acuity patients to seek acute
unscheduled care.</div><div><br /></div><div>As usual, for further context/reading, I've been compiling <a href="http://mdaware.blogspot.com/2017/11/unnecessary-ed-visits-background-reading.html" target="_blank">a bunch of resources on low acuity ED visits on this blog post</a>. #23 there is a paper I worked on using the similar "what happened to
patients in the ER" to estimate <a href="https://journals.lww.com/lww-medicalcare/Abstract/2017/07000/Incorporating_Alternative_Care_Site.8.aspx" target="_blank">how many could potentially have gone to other sites just based on that administrative data</a>, here's my
blurb: </div><div><br /></div><div><i>We looked at what happened to patients in EDs (eg labs, imaging,
medications, procedures, dispo) and when (evenings, nights, weekends)
and compared what visits theoretically could have been substituted at
primary care offices, retail clinics, and urgent care centers based on
strict vs very generous estimates of alternative sites' capabilities &
hours. Note we did not look at insurance, liability or clinical
comfort, or actual ability to schedule an appointment so these are
pretty generous estimates (on the other hand some things like some
labs or x-rays may have happened more generously at EDs that alternate
sites would be fine not doing; but I doubt this would change our
results much tbh).
Based on 2011 NHAMCS we found these strict–generous estimates of how
many ED patients had services that theoretically could have been done
at alternative sites: "Our criteria classified 5.5%–27.1%, 7.6%–20.4%,
and 10.6%–46.0% of visits as substitutable in primary care offices,
retail clinics, and urgent care centers, respectively." </i></div><div><i><br /></i></div><div><i>Just because something could be seen at a (cheaper) site doesn't mean
it's not a PLS emergency, eg ankle sprain at 6pm. Could an urgent care
have taken care of it? Of course. But if none are open, and it might
be broken, etc… </i><p><i> </i></p></div></div>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com1tag:blogger.com,1999:blog-3339915911356078232.post-85965616734608179042020-05-06T17:32:00.000-04:002020-05-06T17:32:53.303-04:00On CNN re: COVID19<iframe allow="autoplay; fullscreen" allowfullscreen="" frameborder="0" height="480" src="https://player.vimeo.com/video/415681400" width="640"></iframe>
I had the opportunity to talk to John King on CNN about COVID-19 in the ER (May 6, 2020) in my first national news appearance.mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-15536194139535412132020-05-04T20:59:00.000-04:002020-05-06T17:32:44.484-04:00Push Dose Pressors feat. Jon Cole & Ryan Marino<iframe src="https://player.vimeo.com/video/414965803" width="640" height="480" frameborder="0" allow="autoplay; fullscreen" allowfullscreen></iframe>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-2533322334299769832019-07-10T15:58:00.000-04:002019-07-10T16:23:39.942-04:00Pre-Reflections on Re-Reading the House of God<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://1.bp.blogspot.com/-70DrVu9e0qg/XSZCcS8imhI/AAAAAAAAJhg/xHOngG2qmgMy8yvv8P-Z5G4VTInBwMcNACLcBGAs/s1600/hog.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="768" data-original-width="1024" height="240" src="https://1.bp.blogspot.com/-70DrVu9e0qg/XSZCcS8imhI/AAAAAAAAJhg/xHOngG2qmgMy8yvv8P-Z5G4VTInBwMcNACLcBGAs/s320/hog.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The most apt Google Image result labeled for reuse</td></tr>
</tbody></table>
<i>Some log-rolling: check out the fantastic video* </i>JAMA <i>made: <a href="http://ja.ma/HouseofGod">ja.ma/HouseofGod</a>.</i><br />
<i><br /></i>
I've read the <i>House of God</i> twice: First, as a senior in college, having done some shadowing and research work in EDs (and already accepted in med school) and again after my medicine sub-internship (on the advice of my brother-in-law/EM doc/premed mentor).<br />
<br />
My first reaction on my first pre-med school read: <i>OH WOW this is all so bizarre and dehumanizing what did I get myself into?!</i><br />
<i><br /></i>
My reaction after my med sub-I: <i>yeah that's about right</i>.<br />
<br />
I haven't re-read it since then, and am currently planning to (on the library waitlist) so of course all of the grains of salt.<br />
<br />
First, to some of the good points: the reasons it initially and still resonates speaks to it's "truth telling." Medicine is a fairly unique field for a number of reasons, including the dehumanizing nature of (particularly) hospital-based medical training, as well as the re-humanizing nature of the privilege I have in putting on pajamas and helping people who are usually some combination of sick and scared; I am rather well-paid to be let into their lives.<br />
<br />
To some of the... less good points: there are a lot of sexist and probably racist aspects of/in the book; I haven't read the book in 12 years, and I am a pretty privileged cis-het white male, and I still remember a bit of that. The easy excuse is "well of course a book written 4 decades ago--known for its truth telling--is not very PC!" but perhaps, if nothing else, it reflects the sexism and racism that permeated medicine then and still do now. I'm not letting the book off the hook but I guess at the bare minimum that is where we were and where we are.**<br />
<br />
I was speaking with some coworkers about it and one of them described The Fat Man in a way which I think applies well to the book as a whole: it is easy to see him only through his shallow cynicism, but it doesn't take much to see that he is trying to reach a deeper humanity in a very cynical world.<br />
<br />
My favorite of the laws--Law #4--is similarly a microcosm of this. "The patient is the one with the disease" can mean a lot of things. It is a good reminder both for professional wellness--no matter how bad my shift, I was paid to be here, and I get to go home at the end. And, it's a nice reminder that we're here *for* the patients, to help them, as they are the one with the disease. (I wrote about some of this previously <a href="https://epmonthly.com/article/who-is-the-poor-historian/">Who is the Poor Historian? in EP Monthly</a>).<br />
<br />
I'm looking forward to rereading largely because I'm curious how much my memory holds up and how much my perspective has changed.<br />
<br />
Lastly, I will repeat my oft-repeated opinion that the hands-down most accurate portrayal of what it's like to work in a hospital is <i>Scrubs</i>.<br />
<br />
<br />
<br />
<br />
*and outstanding hyperlink. For the record I did not work on this at all, but I do get to work with the amazing people who made this video on <i><a href="https://twitter.com/JAMANetworkOpen/status/1148668545162571778" target="_blank">JNO Live</a>.</i><br />
<br />
**I don't mean to be too cynical but I would not be surprised if I need to edit and update this paragraph after people much smarter and better able to speak to these issues give me much needed feedback.<br />
<br />
<br />mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-63540810877595052802018-04-05T11:27:00.001-04:002018-04-05T11:30:02.061-04:00Pick a Scalpel, Any Scalpel<div class="separator" style="clear: both; text-align: left;">
I've always found the scalpel numbering system unintuitive. Here's how I remember which is which:</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-RF_qyZfEkyM/WsY__Gi9wWI/AAAAAAAAJUg/ZA6RLuQm5lku2hxty2G0RLRqh5nvgy7hACLcBGAs/s1600/scalpels2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="428" data-original-width="1600" height="106" src="https://4.bp.blogspot.com/-RF_qyZfEkyM/WsY__Gi9wWI/AAAAAAAAJUg/ZA6RLuQm5lku2hxty2G0RLRqh5nvgy7hACLcBGAs/s400/scalpels2.JPG" width="400" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
#10 has a big curve, like a 0.<br />
#11 is pointy, like the fallen 11.<br />
#15 has a small curve, as only part of a 5 is curved.mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-41493831503643537802018-01-29T15:51:00.001-05:002018-03-01T15:12:47.200-05:00The Prudent Layperson Standard OR How I Learned to Keep Worrying About Anthem Breaking the Law<b><i>UPDATE 3/1/18: this post is now expanded into an article at EPMonthly: <a href="http://epmonthly.com/article/prudent-layperson-meet-imprudent-payer/" target="_blank"> Prudent Layperson, Meet Imprudent Payer</a></i></b><br />
<b><i><br /></i></b>
<b><i>This is taken from my <a href="https://twitter.com/MDaware/status/958038772272246785" target="_blank">twitter thread on the prudent layperson standard</a> which was in response to <a href="https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate" target="_blank">this article by Sarah Kliff in Vox</a> on Anthem denying claims for ER visits based on final diagnoses.</i></b>
<br />
<br />
The ACA made the prudent layperson standard federal law (<a href="https://www.acep.org/Clinical---Practice-Management/ACEP-Initiative-Supporting--Prudent-Layperson--Standard-Becomes-Law-in-Health-Care-Reform-Act/#sm.00000dkj9tbqbrdpdqyhublmubvzy" target="_blank">ACEP piece</a>). 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.<br />
<br />
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. <br />
<br />
Notably: *severe pain alone* is by law a medical emergency.<br />
[That's the case in the <a href="https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate" target="_blank">Vox article</a>]. Here’s the <a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2719A" target="_blank">rule if you’re interested</a>:<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-CNjd-dUAc_8/Wm-HRQP_OKI/AAAAAAAAJRc/OTLJc1Uh3vIFIxEcXDoKIhZ2_FotfIiMwCPcBGAYYCw/s1600/rule.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="247" data-original-width="727" height="108" src="https://4.bp.blogspot.com/-CNjd-dUAc_8/Wm-HRQP_OKI/AAAAAAAAJRc/OTLJc1Uh3vIFIxEcXDoKIhZ2_FotfIiMwCPcBGAYYCw/s320/rule.png" width="320" /></a></div>
Oh and <a href="https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf" target="_blank">it’s written into the legislation</a>, too:<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-iZhoz0MGOTQ/Wm-HpGcpNLI/AAAAAAAAJRk/P_1LcjSzgQ8rw8uKKK7ddQPnVA9fB-FMQCPcBGAYYCw/s1600/leg.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="142" data-original-width="384" height="118" src="https://2.bp.blogspot.com/-iZhoz0MGOTQ/Wm-HpGcpNLI/AAAAAAAAJRk/P_1LcjSzgQ8rw8uKKK7ddQPnVA9fB-FMQCPcBGAYYCw/s320/leg.png" width="320" /></a></div>
In fact,<a href="https://www.acep.org/Content.aspx?id=32140#sm.00000dkj9tbqbrdpdqyhublmubvzy" target="_blank"> most states (32+DC) had state prudent layperson standards</a> well before the ACA made it federal, including Indiana [where the case in the Vox article took place] [<i style="font-weight: bold;">UPDATE 2/13/18: according to <a href="http://www.seacoastonline.com/news/20171112/emergency-action-needed-to-protect-er-patients" target="_blank">this article</a>, 47 states + DC currently have prudent layperson laws.</i>]<br />
<br />
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.<br />
<br />
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.<br />
<br />
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 <a href="https://jamanetwork.com/journals/jama/fullarticle/1669818" target="_blank">this fantastic paper by Maria Raven et al</a>.<br />
<br />
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.<br />
<br />
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.<br />
<b><i><br /></i></b>
<b><i>See my <a href="http://mdaware.blogspot.com/2017/11/unnecessary-ed-visits-background-reading.html" target="_blank">previous post with a bunch more resources</a> on how worthless and dangerous it is to try to decrease “unnecessary” ER visits.</i></b><br />
<b><i><br /></i></b>
<b><i>UPDATE 2/17/18: <a href="https://www.consumerreports.org/healthcare-costs/patients-getting-stuck-with-big-bills-after-er-visits/" target="_blank">Consumer Reports just published a piece</a> on a patient getting denied ED coverage for severe headache that turned out to be "just" mastoiditis. </i></b>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-50354956478335974512017-11-14T16:45:00.011-05:002024-01-26T12:30:31.481-05:00On "unnecessary" ED visits: background reading<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-6_Zd5xqABKk/WgtjwIndWlI/AAAAAAAAJMk/cCJEpPEsBIwhVoVvsuwh1eeWfmeby4ZwQCLcBGAs/s1600/sardines.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="420" data-original-width="625" height="214" src="https://3.bp.blogspot.com/-6_Zd5xqABKk/WgtjwIndWlI/AAAAAAAAJMk/cCJEpPEsBIwhVoVvsuwh1eeWfmeby4ZwQCLcBGAs/s320/sardines.png" width="320" /></a></div>
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:<br />
<br />
1) Great overview of many systemic issues which funnel patients to emergency departments, by <i>Annals of Emergency Medicine</i> Editor in Chief Mike Callaham*:<br />
<a href="http://www.annemergmed.com/article/S0196-0644(17)31538-X/fulltext" target="_blank">The Prudent Layperson’s Complicated and Uncertain Road to Urgent Care</a><br />
<br />
2) We can't discern low acuity diagnoses from chief complaints, by <a href="https://twitter.com/mravenEM" target="_blank">Maria Raven</a>, Robert Lowe, Judith Maselli, and <a href="https://twitter.com/ReneeYHsia" target="_blank">Renee Hsia</a> in <i>JAMA:</i><br />
<a href="https://jamanetwork.com/journals/jama/fullarticle/1669818" target="_blank">Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department Visits</a> and <a href="https://jamanetwork.com/journals/jama/fullarticle/1669802" target="_blank">accompanying editorial</a> by my (now) chair:<br />
<blockquote class="tr_bq">
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.</blockquote>
and from his <a href="https://jamanetwork.com/journals/jama/fullarticle/1700488" target="_blank">response </a>to a Letter:<br />
<blockquote class="tr_bq">
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.</blockquote>
3) Low acuity ED visits is just not where the money is, by <a href="https://twitter.com/petersmulowitz" target="_blank">Peter Smulowitz</a>, <a href="https://twitter.com/LeahHonig" target="_blank">Leah Honigman</a> and Bruce Landon, in <i>Annals of EM</i>:<br />
<a href="https://www.ncbi.nlm.nih.gov/pubmed/22795188" target="_blank">A novel approach to identifying targets for cost reduction in the emergency department.</a><br />
<br />
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 <i>Annals </i>by Brent Asplin et al <a href="https://www.ncbi.nlm.nih.gov/pubmed/12883504" target="_blank">A conceptual model of emergency department crowding</a>, and 2 of my blog posts 4A) <a href="http://mdaware.blogspot.com/2012/10/a-spoon-in-bucket.html" target="_blank">here </a>and 4B) <a href="http://mdaware.blogspot.com/2013/01/empty-dishwasher.html" target="_blank">here</a> and 14 below)<br />
<br />
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):<br />
<a href="https://en.wikipedia.org/wiki/RAND_Health_Insurance_Experiment" target="_blank">RAND HIE</a><br />
<br />
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:<br />
6) <a href="http://www.annemergmed.com/article/S0196-0644(16)31206-9/fulltext" target="_blank">Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care</a> by <a href="https://twitter.com/DrJessePines" target="_blank">Jesse Pines</a> in <i>Annals</i><br />
7) <a href="https://www.ncbi.nlm.nih.gov/pubmed/26953299" target="_blank">Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending</a> by J Scott Ashwood, <a href="https://twitter.com/MartinSGaynor" target="_blank">Martin Gaynor</a>, Claude Setodji, Rachel Reid, Ellerie Weber, and <a href="https://twitter.com/Ateevm" target="_blank">Ateev Mehrotra</a> in <i>Health Affairs. </i>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.<br />
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<b><i>UPDATE 12/5/2017</i></b><br />
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 <i>Health Affairs:</i><br />
<a href="https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0218" target="_blank">The Uninsured Do Not Use The Emergency Department More—They Use Other Care Less</a><br />
<br />
<b><i>UPDATE 12/18/2017 & 12/25/2017</i></b><br />
9) Another great new paper from <a href="https://twitter.com/mravenEM" target="_blank">Maria Raven</a> 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):<br />
<a href="http://www.annemergmed.com/article/S0196-0644(17)31796-1/fulltext" target="_blank">A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization</a><br />
<br />
10) and while finding (9) I found this great review by <a href="https://twitter.com/mravenEM" target="_blank">Maria Raven</a> et al in <i>Annals</i> showing ED visit reduction programs generally don't work:<br />
<a href="http://www.annemergmed.com/article/S0196-0644(16)30083-X/abstract" target="_blank">The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review</a><br />
<br />
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 <i>EMJ</i><br />
<a href="http://emj.bmj.com/content/33/7/495" target="_blank">Primary care services located with EDs: a review of effectiveness</a><br />
<br />
12) This great episode of EM Over Easy on <a href="https://emovereasy.com/2017/12/04/episode-47-fundamentalattributionerror/" target="_blank">fundamental attribution error</a><br />
and<br />
13) David Foster Wallace's <a href="https://www.youtube.com/watch?v=8CrOL-ydFMI" target="_blank">This Is Water</a>.<br />
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.<br />
<br />
14) And here are my 2 blog posts on crowding:<br />
<a href="http://mdaware.blogspot.com/2012/10/a-spoon-in-bucket.html" target="_blank">A Spoon in the Bucket?</a><br />
<a href="http://mdaware.blogspot.com/2013/01/empty-dishwasher.html" target="_blank">Empty the Dishwasher</a><br />
<br />
<br />
<b><i>UPDATE 1/29/2018</i></b><br />
<b><i>See my <a href="https://twitter.com/MDaware/status/958038772272246785" target="_blank">twitter thread on the prudent layperson standard</a> [now <a href="http://mdaware.blogspot.com/2018/01/the-prudent-layperson-standard-or-how-i.html" target="_blank">here in blog form</a> and here in <a href="http://epmonthly.com/article/prudent-layperson-meet-imprudent-payer/" target="_blank">EP Monthly</a>] which was in response to <a href="https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate" target="_blank">this article by Sarah Kliff in Vox</a></i></b><br />
<br />
15) friendly reminder that the legal definition of a medical emergency is<br />
"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.)"<br />
<br />
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.<br />
<br />
16) it's legislated federal law in the ACA (<a href="https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf" target="_blank">text</a>)<br />
<br />
17) and here is the regulatory version (<a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2719A" target="_blank">text</a>)<br />
<br />
(for both of these, ctrl+F prudent layperson) to find it<br />
<br />
summarized by me here in <b><i><a href="http://epmonthly.com/article/prudent-layperson-meet-imprudent-payer/" target="_blank">EP Monthly</a></i></b><br />
<br />
18) and before it was federal law for private insurers, it was state law in 32 states + DC (<a href="https://t.co/Fm2qC5EJT5" target="_blank">pdf from ACEP</a>)<br />
<br />
<br />
<b><i>UPDATE 9/4/2018</i></b><br />
19) <a href="https://t.co/svcU1vYHJ3" target="_blank">interesting paper</a> from <a href="https://twitter.com/sjpoon" target="_blank">Sabrina Poon</a>, <a href="https://twitter.com/JSchuurMD" target="_blank">Jeremiah Schuur</a>, and <a href="https://twitter.com/Ateevm" target="_blank">Ateev Mehrotra</a> analyzing Aetna data:<br />
changes in "low acuity visit" from 2008-2015:<br />
-overall increased by 31% (from 143 to 188 visits per 1,000 members)<br />
-non-ED increased by 140% (from 54 to 131 visits per 1,000 members)<br />
-urgent care increased by 119% (from 47 to 103 visits per 1,000 members)<br />
-retail clinic increased by 214% (from 7 to 22 visits per 1,000 members)<br />
-low acuity ED visits <b>decreased </b>by 36% (from 89 to 57 visits per 1,000 members)<br />
-average overall spending per member increased by 14% (from $70 to $80 per member per year)<br />
<br />
[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, <a href="https://jamanetwork.com/journals/jama/fullarticle/1669818" target="_blank">hindsight bias</a>; and, doesn't look at office-based care; acute unscheduled office care is hard to analyze, etc.]<br />
<br />
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.<br />
<br />
<b><i>UPDATE 11/26/2018</i></b><br />
20) <a href="https://twitter.com/achou01" target="_blank">Andy Chou</a>, <a href="https://twitter.com/suhas_gondi" target="_blank">Suhas Gondi</a>, Olesya Baker, <a href="https://twitter.com/arjunvenkatesh" target="_blank">Arjun Venkatesh</a>, and <a href="https://twitter.com/JSchuurMD" target="_blank">Jeremiah Schuur</a> published a paper in <i><a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707430" target="_blank">JAMA Network Open**</a> </i>looking at what fraction of patients who could potentially get denied by Anthem's low-acuity ED visit denial policy (<a href="http://epmonthly.com/article/prudent-layperson-meet-imprudent-payer/" target="_blank">see my summary</a>) 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.<br />
<br />
And a <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707422" target="_blank">nice accompanying editorial</a> by <a href="https://twitter.com/mravenEM" target="_blank">Maria Raven</a>.<br />
<br /><b><i>UPDATE 9/23/2020</i></b><br />21) More from <a href="https://twitter.com/achou01" target="_blank">Andy Chou</a>, <a href="https://twitter.com/suhas_gondi" target="_blank">Suhas Gondi</a>, <a href="https://twitter.com/scottweinermd" target="_blank">Scott Weiner</a>, <a href="https://twitter.com/JSchuurMD" target="_blank">Jeremiah Schuur</a>, <a href="https://www.hsph.harvard.edu/benjamin-sommers/" target="_blank">Benjamin Sommers</a>:<div>Medicaid expansion associated with only small decreases in ED use among low-income adults--those who reported barriers to care. This is not surprising, as the majority (74%) of low-income adults reported using the ED due to perceived severity of illness. Only 12% came to the ED because clinics were closed, and only 9.5% due to barriers to care. This reinforces that people use the ED because they think they are having an emergency (which is the appropriate and legal definition of an emergency):</div><div><br /></div><div>(Thank you to <a href="https://twitter.com/KellyMDoran/status/1308776251348393985" target="_blank">Kelly Doran for this great summary thread</a>.)</div><div><br /><a href="https://journals.lww.com/lww-medicalcare/Fulltext/2020/06000/Medicaid_Expansion_Reduced_Emergency_Department.3.aspx" target="_blank">Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care</a><div><br /></div><div><b><i>UPDATE 12/1/2020</i></b></div><div>22) Very nice but obviously frustrating thread by <a href="https://twitter.com/michaelannica/" target="_blank">Michael Anne Kyle</a>, a health policy PhD student at Harvard who details her experience trying to get her minor foot injury worked up without, but ultimately only being able to go to the ED:</div><div><a href="https://twitter.com/michaelannica/status/1333484466879205378" target="_blank">Michael Anne Kyle's Twitter Thread</a> </div><div><br /></div><div><b><i>UPDATE 12/4/2020</i></b></div><div>23) Didn't realize I never added the paper <a href="https://twitter.com/mdaware" target="_blank">I</a> wrote with <a href="twitter.com/kaopingchua" target="_blank">Kao-Ping Chua</a>, Aamir Hussein, <a href="twitter.com/AishaTerryMD" target="_blank">Aisha (Liferidge) Terry</a>, <a href="twitter.com/chowkydar" target="_blank">Steve Pitts</a>, and <a href="twitter.com/DrJessePines" target="_blank">Jesse Pines</a>: <br />We looked at what happened to patients in EDs (eg labs, imaging, medications, procedures, dispo) and when (evenings, nights, weekends) and compared what visits theoretically could have been substituted at primary care offices, retail clinics, and urgent care centers based on strict vs very generous estimates of alternative sites' capabilities & hours. Note we did not look at insurance, liability or clinical comfort, or actual ability to schedule an appointment so these are pretty generous estimates (on the other hand some things like some labs or x-rays may have happened more generously at EDs that alternate sites would be fine not doing; but I doubt this would change our results much tbh). </div><div>Based on 2011 NHAMCS we found these strict–generous estimates of how many ED patients had services that theoretically could have been done at alternative sites: "Our criteria classified 5.5%–27.1%, 7.6%–20.4%, and 10.6%–46.0% of visits as substitutable in primary care offices, retail clinics, and urgent care centers, respectively."</div><div><br /></div><div>Just because something could be seen at a (cheaper) site doesn't mean it's not a PLS emergency, eg ankle sprain at 6pm. Could an urgent care have taken care of it? Of course. But if none are open, and it might be broken, etc…</div><div><br /></div><div><a href="https://journals.lww.com/lww-medicalcare/Abstract/2017/07000/Incorporating_Alternative_Care_Site.8.aspx" target="_blank">Incorporating Alternative Care Site Characteristics Into Estimates of Substitutable ED Visits</a></div><div><br /></div><div><b><i>UPDATE 4/13/2021</i></b></div><div>24) Are urgent care visits near an ED associated with lower ED visits? Is adding an urgent care near an ED associated with lower ED visits? <a href="https://twitter.com/bill_w_wang" target="_blank">Bill Wang</a>, <a href="https://twitter.com/Ateevm" target="_blank">Ateev Mehrotra</a>, and <a href="https://twitter.com/AriBFriedman" target="_blank">Ari Friedman</a> look at some lower acuity diagnoses visits at EDs & UCCs by ZIP code; they also looked at when a ZIP crossed from <90th percentile in UCC visits to >90th percentile, suggesting a high-volume UCC was opened in a ZIP.</div><div><br /></div><div>No surprises:</div><div>-an increase of 37 lower-acuity urgent care center visits per enrollee was associated with a decrease of a single lower-acuity ED visit per enrollee (54 when excluding the 3 states with the most FSEDs)</div><div>-each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs</div><div><br /></div><div>Obviously not each of these 37 visits would have otherwise been an ED visit; some would have been primary care; many more would not have happened at all (pent-up demand vs supply-induced demand). Regardless, access to UCCs is not magically "fixing" low-acuity ED visits.</div><div><br /></div><div><a href="https://twitter.com/bill_w_wang/status/1379175193004933126" target="_blank">Thread by author Bill Wang</a></div><div><br /></div><div><a href="https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.01869?journalCode=hlthaff" target="_blank">Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending</a></div><div><br /></div><div><br /></div><div><b><i>UPDATE 12/30/2021</i></b></div><div>25) Fantastic overview & update of crowding by a number of academic emergency medicine chairs in NEJM catalyst, just absolutely fantastic:</div><div><br /></div><div>Gabor D. Kelen, Johns Hopkins University</div><div><a href="https://twitter.com/richwlf" target="_blank">Richard Wolfe</a>, Beth Israel Deaconess</div><div><a href="https://twitter.com/DonofrioGail" target="_blank">Gail D’Onofrio,</a> Yale</div><div><a href="https://twitter.com/AngelaMMills" target="_blank">Angela M. Mills</a>, Columbia</div><div>Deborah Diercks, UTSW</div><div><a href="https://twitter.com/SusanSternmd" target="_blank">Susan A. Stern</a>, University of Washington</div><div><a href="MCWadman" target="_blank">Michael C. Wadman</a>, UNMC</div><div>Peter E. Sokolove, UCSF</div><div><br /></div><div><a href="https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217" target="_blank">Emergency Department Crowding: The Canary in the Health Care System</a></div><div><br /></div><div><b><i>UPDATE 1/30/2023</i></b></div><div><div>26) Pall Care doc <a href="https://twitter.com/ErekMajka" target="_blank">Erek Majka</a> and I discuss, well, all of this in the context of patients with cancer in JNO:</div><div><br /></div><div><a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800619" target="_blank">Emergency Department Visits Among Patients With Cancer in the US</a></div><div><br /></div><div><div><b><i><br /></i></b></div><div><b><i>UPDATE 1/26/2024</i></b></div><div>27) Theodoros Giannouchos, Benjamin Ukert and <a href="https://bsky.app/profile/bradwrightphd.bsky.social" target="_blank">Brad Wright</a> did essentially a Raven 2.0 (2 above) again demonstrating very little association between reasons for visit and diagnosis in JAMA Network Open**.</div></div><div><br /></div><div><a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813806">Concordance in Medical Urgency Classification of Discharge Diagnoses and Reasons for Visit</a></div><div><br /></div></div><div>and an accompanying commentary from <a href="https://bsky.app/profile/jschuurmd.bsky.social" target="_blank">Jay Schuur</a>:</div><div><br /></div><div><a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813809">https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813809</a></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div><br /></div><div>*COI: I <strike>am</strike> was Social Media Editor for <i>Annals</i> which <strike>makes</strike> made Mike my boss.<br />
**COI: I am Digital Media Editor for <i>JAMA Network Open</i></div><div><i><br /></i>
<br /></div></div>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-24162585621417987102016-11-28T13:20:00.002-05:002016-11-28T19:00:11.697-05:00It's the Medicaid Expansion, StupidI came across this <a href="http://www.nejm.org/health-policy-data-watch" target="_blank">nice post</a>:<br />
<blockquote class="twitter-tweet" data-lang="en">
<div dir="ltr" lang="en">
Health Policy Data Watch: Breakdown of the Uninsured Population <a href="https://t.co/iEodXLMWVJ">https://t.co/iEodXLMWVJ</a> <a href="https://t.co/NlfuBS4QyU">pic.twitter.com/NlfuBS4QyU</a></div>
— NEJM (@NEJM) <a href="https://twitter.com/NEJM/status/803297886150815744">November 28, 2016</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script><br />
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.<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-fR3H-SL5qbU/WDyMp-FJrkI/AAAAAAAAI58/ksB-RD_erq4pq06j7yKOWvpmj0AeUZ8SQCLcB/s1600/kff.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="160" src="https://2.bp.blogspot.com/-fR3H-SL5qbU/WDyMp-FJrkI/AAAAAAAAI58/ksB-RD_erq4pq06j7yKOWvpmj0AeUZ8SQCLcB/s320/kff.png" width="320" /></a></div>
But wait, "childless adults"? That sounds familiar!<br />
<br />
"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."<br />
<br />
I followed the link and noticed the normal, understated citation at the bottom of the post:<br />
<blockquote class="tr_bq">
<span style="background-color: white; color: #333333; font-family: "arial" , "helvetica" , sans-serif; font-size: 13px;">Source: Kaiser Family Foundation: </span><em style="background-color: white; border: 0px; color: #333333; font-family: Arial, Helvetica, sans-serif; font-size: 13px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><a href="http://kff.org/slideshow/who-is-impacted-by-the-coverage-gap-in-states-that-have-not-adopted-the-medicaid-expansion/" style="border: 0px; color: #006892; font-style: inherit; font-weight: inherit; margin: 0px; outline: 0px; padding: 0px; text-decoration: none; vertical-align: baseline;" target="_blank">Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?</a></em></blockquote>
The title on KFF's page is, not surprisingly:<br />
<br />
<h2 class="blue-serif bare-title" style="border: 0px; color: #153569; font-family: "Droid Serif", Georgia, serif; font-size: 35px; font-stretch: inherit; font-variant-numeric: inherit; font-weight: inherit; line-height: 42px; margin: 0px 0px 10px; padding: 0px; vertical-align: baseline;">
Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?</h2>
<div>
This reminds me of the famous <a href="http://mdaware.blogspot.com/2015/11/roc-vs-sux-revisited-cochrane-update.html" target="_blank">desaturation curve</a> which appears in every airway lecture, as mandated by CMS due to Obamacare:</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div style="margin-left: 1em; margin-right: 1em;">
<img src="https://4.bp.blogspot.com/-XpEuA22o17s/VkZ-pHqcJII/AAAAAAAAInY/UQswt_wFCyg/s320/benumof%2Bdiagram.jpeg" /></div>
<br />
<div>
</div>
<div>
<span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 17.6px;">Note the title of the </span><a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948683" style="background-color: white; color: #3034b0; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 17.6px; text-decoration: none;" target="_blank">source</a><span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 17.6px;"> of this familiar graph: </span><i style="background-color: white; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 17.6px;"><b>Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine.</b></i><br />
<span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 17.6px;"><br /></span>
<span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 17.6px;">(Benumof, Dagg, Benumof. </span><i style="background-color: white; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 17.6px;">Anesthesiology. </i><span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 17.6px;">1997 Oct;87(4):979-82</span><i style="background-color: white; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 17.6px;">.</i><span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 17.6px;">)</span></div>
<div>
<span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 17.6px;"><br /></span></div>
<div>
<span style="background-color: white; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 17.6px;">How often are these graphs shared without noting their expressed purpose? </span></div>
mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com2tag:blogger.com,1999:blog-3339915911356078232.post-32677220383354002512016-10-21T14:27:00.002-04:002018-10-24T19:17:11.000-04:00PE in Syncope: An External Validation of the Wells ScoreI'm not going to reinvent the wheel -- see some of the fantastic analyses of <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1602172" target="_blank">PESIT</a> (in no particular order) at:<br />
<br />
<a href="http://stemlynsblog.org/prevalence-of-pe-in-patients-with-syncope-st-emlyns/" target="_blank">St. Emlyns</a> - <a href="http://twitter.com/emmanchester" target="_blank">Simon Carley</a><br />
<a href="http://www.emlitofnote.com/?p=3640" target="_blank">EM Lit of Note</a> - <a href="http://twitter.com/emlitofnote" target="_blank">Ryan Radecki</a><br />
<a href="http://emcrit.org/emnerd/the-case-of-the-incidental-bystander/" target="_blank">EMNerd at EMCrit</a> - <a href="http://twitter.com/emnerd_" target="_blank">Rory Spiegel</a><br />
<br />
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.<br />
<br />
Just look at Table 2, emphasis mine, which looks a lot like their Table 1, which is (gasp!) the Wells Score:<br />
<a href="http://4.bp.blogspot.com/-4rN82v3sUxw/WApdCmQNx9I/AAAAAAAAI3k/N7vLJrHZicomH9DAekBGNK-aPtPdUykSwCK4B/s1600/seth%2Btable%2Bpesit.png" imageanchor="1"><img border="0" src="https://4.bp.blogspot.com/-4rN82v3sUxw/WApdCmQNx9I/AAAAAAAAI3k/N7vLJrHZicomH9DAekBGNK-aPtPdUykSwCK4B/s1600/seth%2Btable%2Bpesit.png" /></a><br />
<br />
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.<br />
<br />
Literally the only non-Wells factors they find are tachypnea and hypotension.<br />
<br />
You cannot make this up:<br />
<a href="http://3.bp.blogspot.com/-kcsd-PipRMg/WApdxC8Os4I/AAAAAAAAI3s/VpT_wY_99wsSLMfwgoM54K5ZYOu3N0i_gCK4B/s1600/table%2B1%2Bwells.png" imageanchor="1"><img border="0" height="221" src="https://3.bp.blogspot.com/-kcsd-PipRMg/WApdxC8Os4I/AAAAAAAAI3s/VpT_wY_99wsSLMfwgoM54K5ZYOu3N0i_gCK4B/s320/table%2B1%2Bwells.png" width="320" /></a><br />
<br />
UPDATE:<br />
no surprise: rate of PE in US syncope patients <1% in <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2670036" target="_blank">JAMA IM</a>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-65002783654466170012016-08-24T10:00:00.000-04:002016-08-24T10:00:01.667-04:00Grand Rounds 2.0: Acute care & healthcare delivery system reform by Brendan Carr<b><i>See also <a href="http://mdaware.blogspot.com/2015/06/grand-rounds-acute-care-healthcare.html" target="_blank">Dr. Carr's grand rounds</a> from University of Chicago June 2, 2015
</i></b><br />
<br />
<div class="storify">
<iframe allowtransparency="true" frameborder="no" height="750" src="//storify.com/MDaware/grand-rounds-2-0-acute-care-healthcare-delivery-sy/embed?header=false&border=false&template=slideshow" width="100%"></iframe><script src="//storify.com/MDaware/grand-rounds-2-0-acute-care-healthcare-delivery-sy.js?header=false&border=false&template=slideshow"></script><noscript>[<a href="//storify.com/MDaware/grand-rounds-2-0-acute-care-healthcare-delivery-sy" target="_blank">View the story "Grand Rounds 2.0: Acute care & healthcare delivery system reform by Brendan Carr" on Storify</a>]</noscript></div>
mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-2102496468131244622016-08-18T10:30:00.000-04:002016-08-18T10:30:25.520-04:00Using New Technologies to Create Interactive Learning Environments by David Salzman, MD, MEd<div class="storify"><iframe src="//storify.com/MDaware/david-salzman/embed?header=false&border=false&template=slideshow" width="100%" height="750" frameborder="no" allowtransparency="true"></iframe><script src="//storify.com/MDaware/david-salzman.js?header=false&border=false&template=slideshow"></script><noscript>[<a href="//storify.com/MDaware/david-salzman" target="_blank">View the story "Lecture: Using New Technologies to Create Interactive Learning Environments by David Salzman, MD, MEd" on Storify</a>]</noscript></div>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-90669334023720937822016-07-25T16:12:00.001-04:002021-05-04T16:54:39.234-04:00So You've Decided to Tweet<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-wvPAcCG1wi4/V5Zv9GmSo6I/AAAAAAAAIyw/v25UCISdcyw3sVZn3hTcea85WKBY6AiYQCLcB/s1600/revenge.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="236" src="https://3.bp.blogspot.com/-wvPAcCG1wi4/V5Zv9GmSo6I/AAAAAAAAIyw/v25UCISdcyw3sVZn3hTcea85WKBY6AiYQCLcB/s320/revenge.jpg" width="320" /></a></div>
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 <a href="http://www.ncbi.nlm.nih.gov/pubmed/25523012" target="_blank">benefit to using social media as a medical professional</a>, and here are some of the ways I "maintain professionalism" (read: keep myself out of trouble).<br />
<br />
One of my big keys is to not try to "not violate HIPAA" – that's easy and too low of a bar.<br />
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).<br />
<br />
<b>Twitter is a Giant Elevator</b><br />
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.<br />
<br />
<b>Patient Privacy</b><br />
Easy version: never talk about real patients.<br />
<br />
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.<br />
<br />
Two mistakes people make: date of service and age over 90 are HIPAA-protected PHI. The number one thing I do <b>if I am referencing something that happened to a real patient is that I don't do it the same day</b> (or even the same week).<br />
<br />
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).<div><br /></div><div>UPDATE 5/4/21:</div><div>Great thread on respecting patiet privacy on Twitter from<a href="https://twitter.com/aoglasser/status/1236053604080873473" target="_blank"> Dr. Avital O'Glasser -- "Post the Pearl, Not the Patient"</a><br />
<br />
<b>On Anonymity</b><br />
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.<br />
<br />
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.<br />
<br />
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.</div>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-24903178724385311932016-04-25T10:30:00.000-04:002016-04-27T14:12:14.018-04:00Grand Rounds: Medical Reversal by Dr. Adam Cifu<div class="storify">
<iframe allowtransparency="true" frameborder="no" height="750" src="//storify.com/MDaware/medical-reversal/embed?header=false&border=false" width="100%"></iframe><script src="//storify.com/MDaware/medical-reversal.js?header=false&border=false"></script><noscript>[<a href="//storify.com/MDaware/medical-reversal" target="_blank">View the story "Medical Reversal" on Storify</a>]</noscript></div>
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-dSm39X6uabw/VyEA8vFeTLI/AAAAAAAAIu0/Op17ig3aNqsw2xumTGXJvMUErQbRH25MgCLcB/s1600/54561.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="150" src="https://4.bp.blogspot.com/-dSm39X6uabw/VyEA8vFeTLI/AAAAAAAAIu0/Op17ig3aNqsw2xumTGXJvMUErQbRH25MgCLcB/s200/54561.jpg" width="200" /></a></div>
<br />mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-30904765355841582762016-04-08T12:31:00.000-04:002019-01-08T14:42:04.079-05:00Urine Drug Screen False Positives<i>Update: a version of this is now in <a href="https://www.ncbi.nlm.nih.gov/books/NBK499901/" target="_blank">PubMed Central</a> -- thanks <a href="https://twitter.com/ercowboy" target="_blank">Pik Mukherji!</a></i><br /><span style="background-color: white; color: #222222; font-family: monospace; font-size: 13px;">Mukherji P, Sharma S. Toxicology Screening. [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.</span><span class="bk_cite_avail" style="background-color: white; color: #222222; font-family: monospace; font-size: 13px;">Available from: https://www.ncbi.nlm.nih.gov/books/NBK499901/</span><br />
<span style="color: #222222; font-family: monospace;"><span style="font-size: 13px;"><br /></span></span>Urine drug screens aren't completely useless, but they have a <a href="http://mdaware.blogspot.com/2011/05/unnecessary-testing.html" target="_blank">number of limitations</a>. Here is a table where I have compiled all of the false positive causing drugs I could find (<a href="https://www.dropbox.com/s/39omrw34nn505vt/False%20Positive%20PDF%20UDS.pdf?raw=1" target="_blank">pdf</a>):<br />
<br />
<iframe height="800" src="https://docs.google.com/spreadsheets/d/1PXKyMPbynDkkXSGGeuxM7GTEGAU-vWT8ghIL8Q3fQoA/pubhtml?widget=true&headers=false" width="500"></iframe>
<br />
<br />
<i><u>Update 4/22/2016:</u></i><br />
Here are my sources:<br />
<br />
I <a href="http://mdaware.blogspot.com/2011/05/unnecessary-testing.html" target="_blank">started</a> with this paper which was I originally heard on <a href="http://ccme.org/EMA/" target="_blank">EM Abstracts</a> (Jan 2011):<br />
<br />
Brahm NC, Yeager LL, Fox MD, Farmer KC, Palmer TA.<br />
Commonly prescribed medications and potential false-positive urine drug screens.<br />
<i>Am J Health Syst Pharm</i>. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20689123" target="_blank">2010 Aug 15;67(16):1344-50.</a><br />
<br />
Special thanks to Jon Cole from Hennepin who made this <a href="http://hqmeded.com/pitfalls-of-the-urine-drug-screen-2/" target="_blank">fantastic video</a>.<br />
<br />
Other sources include:<br />
<a href="http://www.med.umich.edu/1info/FHP/practiceguides/pain/drugtesting.pdf" target="_blank">UMHS Guidelines for Clinical Care May 2009</a><br />
<br />
Standridge JB, Adams SM, Zotos AP.<br />
Urine drug screening: a valuable office procedure.<br />
<i>Am Fam Physician</i>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/20187600" target="_blank">2010 Mar 1;81(5):635-40.</a><br />
<br />
<br />
Reisfield GM, Haddad J, Wilson GR, Johannsen LM, Voorhees KL, Chronister CW, Goldberger BA, Peele JD, Bertholf RL.<br />
Failure of amoxicillin to produce false-positive urine screens for cocaine metabolite.<br />
<a href="https://www.ncbi.nlm.nih.gov/pubmed/18430300" target="_blank">J Anal Toxicol. 2008 May;32(4):315-8.</a><br />
<br />
Ly BT, Thornton SL, Buono C, Stone JA, Wu AH.<br />
False-positive urine phencyclidine immunoassay screen result caused by interference by tramadol and its metabolites.<br />
<i>Ann Emerg Med</i>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/21924518" target="_blank">2012 Jun;59(6):545-7.</a><br />
doi: 10.1016/j.annemergmed.2011.08.013<br />
<br />
Swift RM, Griffiths W, Cammera P.<br />
False positive urine drug screens from quinine in tonic water.<br />
<i>Addict Behav</i>. <a href="http://www.ncbi.nlm.nih.gov/pubmed/2728958" target="_blank">1989;14(2):213-5</a>.<br />
<br />
<i>Updates 5/1/2016</i><br />
Reordered alphabetically<br />
Added lamotragine -> PCP<br />
Geraci MJ, Peele J, McCoy SL, Elias B. Phencyclidine false positive induced by lamotrigine (Lamictal®) on a rapid urine toxicology screen. Int J Emerg Med. <a href="https://www.ncbi.nlm.nih.gov/pubmed/21373301" target="_blank">2010 Dec; 3(4): 327–331.</a> <br />
<br />
Added a few more -> PCP<br />
Phencyclidine (PCP) Test Systems Executive Summary. Chemistry and Toxicology Devices. FDA<br />
2013 Apr 25, <a href="http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ClinicalChemistryandClinicalToxicologyDevicesPanel/UCM348937.pdf" target="_blank">Link</a>.mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com2tag:blogger.com,1999:blog-3339915911356078232.post-36232738428593769232015-12-30T12:05:00.001-05:002015-12-30T12:07:13.999-05:00And I Didn't Know ItInspired by Saurabh Jha:
<br />
<blockquote class="twitter-tweet" data-conversation="none" lang="en">
<div dir="ltr" lang="en">
<a href="https://twitter.com/MDaware">@MDaware</a> <a href="https://twitter.com/TirathPatelMD">@TirathPatelMD</a> <a href="https://twitter.com/Skepticscalpel">@Skepticscalpel</a> <a href="https://twitter.com/krchhabra">@krchhabra</a> In my previous life I was an "op note writer." I tried to write limericks</div>
— Saurabh Jha (@RogueRad) <a href="https://twitter.com/RogueRad/status/682031717817954304">December 30, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script>
Not exactly op notes, but some ED limericks I wrote:
<br />
<br />
Mr. Jones ate some bad guacamole <br />
press on his belly, he shouts "holy moley!"<br />
we did a CT<br />
and what could it be?<br />
then he went for a lap'r'scopic chole<br />
<br />
<br />
Mrs. Smith was awoke from her nappy<br />
her belly was feeling quite snappy<br />
white count? twasn't high<br />
a fever? tad shy… <br />
but the CT, of course, showed an appy<br />
<br />
<br />
there once was a man from Bologna<br />
thought he had caught a touch of pneumonia<br />
he seemed like whiner<br />
and he got a d dimer<br />
no PE; just some bad allodynia<br>
<br>
Of course the cake goes to:
<blockquote class="twitter-tweet" data-conversation="none" lang="en"><p lang="en" dir="ltr"><a href="https://twitter.com/MDaware">@MDaware</a> <a href="https://twitter.com/RogueRad">@RogueRad</a> <a href="https://twitter.com/TirathPatelMD">@TirathPatelMD</a> <a href="https://twitter.com/Skepticscalpel">@Skepticscalpel</a> <a href="https://twitter.com/krchhabra">@krchhabra</a> I did triage notes in Haiku one night. Only one doc noticed</p>— Craig RN, CEN, CCRN (@CraigCCRNCEN) <a href="https://twitter.com/CraigCCRNCEN/status/682059187237613568">December 30, 2015</a></blockquote>
<script async src="//platform.twitter.com/widgets.js" charset="utf-8"></script>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-3994793505225663262015-11-16T10:45:00.000-05:002015-11-16T10:45:00.614-05:00Roc vs Sux Revisited: Cochrane Update<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-D7aIz1bWZB8/VkaD34tMTSI/AAAAAAAAIoo/W4rdXbzODTU/s1600/One-balanced-rock.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="http://1.bp.blogspot.com/-D7aIz1bWZB8/VkaD34tMTSI/AAAAAAAAIoo/W4rdXbzODTU/s320/One-balanced-rock.jpg" width="320" /></a></div>
<div class="MsoNormal">
I’m not going to <a href="http://lifeinthefastlane.com/ruling-the-resus-room-004/" target="_blank">reinvent the wheel</a>,
so a sweeping summary:</div>
<div class="MsoNormal">
Traditionally, succinylcholine has been the paralytic of
choice for RSI. However, succinylcholine can (rarely) lead to hyperkalemia,
particularly in patients with chronic neurological problems.* Proponents of
rocuronium for RSI suggest avoiding potentially fatal hyperkalemia by routinely
using roc, summarized superbly by <a href="http://emupdates.com/2010/01/14/rocuronium-vs-succinylcholine/" target="_blank">Reuben Strayer here</a>.
When dosed properly (1.2 mg/kg or higher), time of onset and intubating
conditions are equivalent to between rocuronium and succinylcholine.</div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Defenders suggest that succinylcholine's shorter duration of paralysis
is an advantage: if you can’t get the tube, the patient starts breathing. <a href="https://www.blogger.com/null" style="mso-comment-date: 20151109T1030; mso-comment-reference: NT_3;">Unless the
patient critically desaturates before return to an unparalyzed state</a>:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://4.bp.blogspot.com/-XpEuA22o17s/VkZ-pHqcJII/AAAAAAAAInY/UQswt_wFCyg/s1600/benumof%2Bdiagram.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="244" src="http://4.bp.blogspot.com/-XpEuA22o17s/VkZ-pHqcJII/AAAAAAAAInY/UQswt_wFCyg/s320/benumof%2Bdiagram.jpeg" width="320" /></a></div>
<div>
<br /></div>
<div class="MsoNormal">
Note the title of the <a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948683" target="_blank">source</a> of this familiar graph: <i>Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine </i>(Benumof, Dagg, Benumof. <i>Anesthesiology. </i>1997 Oct;87(4):979-82<i>.</i>)</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In the original <a href="http://www.ncbi.nlm.nih.gov/pubmed/18425883" target="_blank">2008<span style="font-size: 12px;"> </span>Cochrane review</a>, the authors (including Perry & Wells) find that time of onset and intubating conditions are inferior to succinylcholine…
when dosed inadequately. <a href="http://www.cochrane.org/CD002788/ANAESTH_comparison-two-muscle-relaxants-rocuronium-and-succinylcholine-facilitate-rapid-sequence-induction" target="_blank">Cochrane just released another update</a><a href="https://www.blogger.com/null"><span style="font-size: 12px;"> </span></a>and reached the same conclusion with mostly same data, but again, note that
when dosed appropriately, rocuronium is just as good as succinylcholine, with a
<i style="mso-bidi-font-style: normal;">p-value of 1.00</i>.</div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://4.bp.blogspot.com/-du4qqE8dYag/VkaAQfmNxYI/AAAAAAAAIno/FhxEDhC4tg4/s1600/Screen%2BShot%2B2015-11-04%2Bat%2B1.57.05%2BAM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="73" src="http://4.bp.blogspot.com/-du4qqE8dYag/VkaAQfmNxYI/AAAAAAAAIno/FhxEDhC4tg4/s320/Screen%2BShot%2B2015-11-04%2Bat%2B1.57.05%2BAM.png" width="320" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="MsoNormal">
Of course that’s only 86 patients dosed at 1.2 mg/kg, but
the results were <b>identical</b>. The Cochrane authors further find that even some lower
doses of rocuronium (down to 0.9 mg/kg) are just as good:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://2.bp.blogspot.com/-hioP5kK4rSU/VkaAc_U94XI/AAAAAAAAIog/w4xX06wNabk/s1600/Screen%2BShot%2B2015-11-04%2Bat%2B1.58.52%2BAM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="65" src="http://2.bp.blogspot.com/-hioP5kK4rSU/VkaAc_U94XI/AAAAAAAAIog/w4xX06wNabk/s320/Screen%2BShot%2B2015-11-04%2Bat%2B1.58.52%2BAM.png" width="320" /></a></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
but then come to the same conclusion:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://1.bp.blogspot.com/-k8aozByxezI/VkaAclyBC-I/AAAAAAAAIoY/gIexThYyxcw/s1600/Screen%2BShot%2B2015-11-04%2Bat%2B1.58.17%2BAM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="31" src="http://1.bp.blogspot.com/-k8aozByxezI/VkaAclyBC-I/AAAAAAAAIoY/gIexThYyxcw/s640/Screen%2BShot%2B2015-11-04%2Bat%2B1.58.17%2BAM.png" width="640" /></a></div>
<div class="MsoNormal">
This is a bit odd. When I can’t intubate or ventilate a
patient, they don’t nicely wake up in 9 minutes. In fact, more paralysis may
even be preferred, particularly to optimize further attempts at mask ventilation, including EGD placement.
And more importantly, to stop a panicking, suffocating patient from stopping me
from stabbing them in the neck. But the bottom line is that if the succinylcholine
has worn off, then they’ve probably <a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948683" target="_blank">already critically desaturated</a>.<o:p></o:p><br />
<br />
A number of Very Smart People (including <a href="https://twitter.com/doctoRoblivious" target="_blank">Rob Huang</a>, <a href="http://prehospitalmed.com/" target="_blank">Minh Le Cong</a>, <a href="http://twitter.com/precordialthump" target="_blank">Chris Nickson</a>, and <a href="http://twitter.com/emupdates" target="_blank">Reuben Strayer)</a> have all pointed out that Cochrane is supposed to summarize the data, not editorialize:<br />
<blockquote class="twitter-tweet" data-conversation="none" lang="en">
<div dir="ltr" lang="en">
<a href="https://twitter.com/DocBrent">@DocBrent</a> <a href="https://twitter.com/HumanFact0rz">@HumanFact0rz</a> <a href="https://twitter.com/CochraneAnaesth">@CochraneAnaesth</a> cochrane shud stay away from clinical interpretation - just crunch the data, let clinicians decide</div>
— Chris Nickson (@precordialthump) <a href="https://twitter.com/precordialthump/status/661773344425938944">November 4, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script></div>
<div class="MsoNormal">
There are some situations where I still reach for
succinylcholine, primarly when I don’t want to lose my neuro exam for an extra
half hour, mostly severe head trauma and status epilepticus. Also, if I can’t
get a line or an IO and need to use <a href="http://www.annemergmed.com/article/S0196-0644(15)00307-8/fulltext" target="_blank">IM drugs for RSI</a>, rocuronium is probably <a href="http://www.annemergmed.com/article/S0196-0644(15)00307-8/fulltext" target="_blank">too dilute</a>.**<o:p></o:p><br />
<br />
Ultimately, this isn't that big deal. Hyperkalemia is bad, but rare. But if we can avoid it without worsening time to onset or intubating conditions, why not?</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My biggest problem with rocuronium? It comes in 50 mg vials.
One*** great tip I learned from <a href="http://emupdates.com/" target="_blank">Reuben Strayer</a><span class="MsoCommentReference"><span style="font-size: 9.0pt;"><span style="mso-special-character: comment;"> </span></span></span>:
when I ask a nurse for rocuronium, I always clearly specify that I need 2 (or
3) vials.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i>*Most of which are fairly rare and I (fortunately) don’t
need to intubate very frequently. But when that relative zebra is really sick,
I have enough on my mind and I don’t want to have to think to hard about which
drugs may be dangerous. Note that in MG, you can use succinylcholine but have
to use more; you can use a lower dose of rocuronium but a normal dose will just
paralyze them longer, which is much safer than me having to remember this whole
paragraph and do math when the <a href="http://dougfunniesjournal.tumblr.com/post/350267023/episode-6-part-1-doug-mayor-for-a-day" style="mso-comment-date: 20151109T1048; mso-comment-reference: NT_10;">chips are about to hit the fan</a>.<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>**Bad day for everyone. Not ideal but I prefer to have my
quiver more full than my diaper.<o:p></o:p></i></div>
<div class="MsoNormal">
<i><br /></i></div>
<div class="MsoNormal">
<i>***One of too numerous to count. Read and watch everything
at <a href="http://emupdates.com/" target="_blank">emupdates.com</a></i><br />
<i><br /></i>
<i>Special thanks to Minh Le Cong & Reuben Strayer for their prepublication peer review.</i></div>
<br />
Also from Twitter::
<br />
<blockquote class="twitter-tweet" lang="en">
<div dir="ltr" lang="en">
Discussion of data is always welcomed - especially if there's moderate or low quality of evidence!👍😀 <a href="https://twitter.com/hashtag/FOAMed?src=hash">#FOAMed</a> <a href="https://twitter.com/hashtag/FOAMcc?src=hash">#FOAMcc</a> <a href="https://t.co/me4EwmvYmM">https://t.co/me4EwmvYmM</a></div>
— Cochrane Anaesthesia (@CochraneAnaesth) <a href="https://twitter.com/CochraneAnaesth/status/661812000285138944">November 4, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script>
<br />mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-25673401546990458152015-10-25T11:09:00.001-04:002015-10-25T11:09:22.154-04:00Tweet-in-Brief: Do the Right Thing<blockquote class="twitter-tweet" lang="en"><p lang="en" dir="ltr">RT yelled at me for touching vent once, I 1 apologized 2 was really nice 3 gave my card 4 never heard about it again <a href="https://t.co/zcV9z74jzz">https://t.co/zcV9z74jzz</a></p>— Seth Trueger (@MDaware) <a href="https://twitter.com/MDaware/status/658295254509076480">October 25, 2015</a></blockquote>
<script async src="//platform.twitter.com/widgets.js" charset="utf-8"></script>
<blockquote class="twitter-tweet" lang="en"><p lang="en" dir="ltr">1 do what's right for the patient 2 be nice to everyone 3 deal with the consequences, which ideally 4 there won't be <a href="https://t.co/52UCa6iKC1">https://t.co/52UCa6iKC1</a></p>— Seth Trueger (@MDaware) <a href="https://twitter.com/MDaware/status/658295928525344769">October 25, 2015</a></blockquote>
<script async src="//platform.twitter.com/widgets.js" charset="utf-8"></script>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-88052481358552600522015-10-21T14:19:00.000-04:002015-10-21T14:19:55.426-04:00Get What You Pay For & Pay for What You Get<i>This post is co-authored by Seth Trueger & <a href="https://twitter.com/PolicyRx" target="_blank">Cedric Dark</a> and also appears on <a href="http://policyprescriptions.org/get-what-you-pay-for-pay-for-what-you-get" target="_blank">Policy Prescriptions</a>. </i><i>See also the related post on <a href="http://mdaware.blogspot.com/2015/10/narrow-networks-result-of-competition.html" target="_blank">Narrow Networks</a> (<a href="http://www.policyprescriptions.org/narrow-networks-the-result-of-competition-not-the-barrier/" target="_blank">PolicyRx</a>).</i><br />
<br />
<a href="https://twitter.com/xpostfactoid1" target="_blank">Andrew Sprung</a> and I had a great conversation about Republican presidential candidate Donald Trump's claim that premiums are rising (see the <em><a href="https://storify.com/MDaware/aca-premiums-trumps-diamonds" target="_blank">Storify</a></em> below). Our view: premiums are generally flat. There is a lot of variation around this, mostly geographic, and also largely based on whose premiums you're talking about. Comparing premiums from before Obamacare to today’s is like comparing 1995 and 2015 cell phone plans.
[caption id="attachment_5826" align="alignleft" width="300"]<a href="https://creativecommons.org/licenses/by/2.0/"><img alt="Source: Lauren (Flickr/CC)" class="size-medium wp-image-5826" src="http://www.policyprescriptions.org/wp-content/uploads/2015/10/8199477993_bc0031d85b_z-300x300.jpg" height="300" width="300" /></a> Source: Lauren (Flickr/CC)[/caption]
Yes, some people who were insured on the non-group market prior to the ACA saw their premiums go up significantly. But this is a meaningless critique. First, the fraction of people who had non-group plans prior to the ACA is (and still is) pretty small - about 5% in 2011 [source: <a href="http://kff.org/health-costs/slide/health-care-coverage-and-personal-health-care-expenditures-in-the-u-s-2011/" target="_blank">KFF</a>].
Second, remember that most people who have individual plans only have them for a fairly short period of time; most only enroll in a plan for 6-18 months, such as for a few months while searching for a job and until their next employer-sponsored plan kicks in (see this post <a href="http://www.policyprescriptions.org/the-dynamics-of-health-insurance-post-aca/">for example</a>).
And while some were happy with their coverage, remember the two most important caveats to pre-ACA nongroup premiums:
<br />
<ol>
<li>What did these plans cover?</li>
<li>Who didn't these plans cover?</li>
</ol>
The first of these big problems: people who ostensibly had insurance would find that it didn't help them when they needed it, because they hit annual or lifetime benefits limits; certain medical problems or services weren't covered; or, the insurer cancelled their plan when they made a claim. Even in the best-case situation, remember how frustrating it is to deal with actually getting an insurance claim paid.
<br />
<blockquote>
"If you think government healthcare is bad, wait until Comcast runs it." - Seth</blockquote>
Personal example #1: I (Seth) had cheap private insurance for a few years in med school after getting kicked off my parents plan well before age 26 (Thanks, Obama) and I paid $60+ a month for essentially useless coverage that didn't really cover anything. Fortunately, I never got sick and I only really needed my insurance to satisfy my school’s requirement (and, maybe, piece of mind. But not really).
While we don't know how many people were "happy" with their pre-ACA plan, we can estimate. Per Andrew Sprung, about half of the 16% of people in the non-group market now have grandfathered plans... which is roughly 1/2 of 1/6 of 1/20 of the insurance market, so 1 in 240 insurance plans.
The second of these major issues that arises when comparing premiums before and after the ACA: preexisting conditions. How many people were completely blocked from getting insurance because of a preexisting medical problem? And relatedly, how many people were either charged higher premiums because of a preexisting condition? Or, were only given a plan that didn’t cover anything remotely related to their preexisting condition? ("You can buy insurance from us but we won't cover surveillance or treatment for a relapse of your Hodgkin's Lymphoma.")
Personal example #2: My (Seth’s) wife was previously charged more (plus had to do a ton of frustrating paperwork) for the preexisting condition of "having a pre-cancerous benign mole removed." Remember: private insurance companies aren’t incentivized to keep us healthy; they are incentivized to keep us healthy until we turn 65.
While a small fraction of individuals now pay a little more for their premiums, their insurance actually now has to cover stuff; and, they aren't getting a discount by excluding all the people who have serious health problems (or benign moles). Given all these caveats, it's really remarkable that premiums are pretty much flat at all.
Let’s consider one last thing.
“Premium price" can mean a lot of things. Is it subsidized or unsubsidized? Subsidized premiums are most likely pretty flat, and are what individuals actually pay. Unsubsidized premiums have gone up, but not by as much as people like Trump claim. I'm the first to admit that probably the biggest question the ACA poses is: will premium subsidies simply cost too much? And so far, it doesn't seem like it.
<br />
<blockquote>
We have a great review forthcoming from Laura Medford-Davis on this issue. Stay tuned! - Cedric</blockquote>
Premium subsidies are simply the price we pay for insuring millions and millions of Americans in a functioning market for non-group insurance.
And let’s not forget the quasi-secret but much, much, larger subsidies we already provide to people insured through their employers. We shouldn’t decry subsidies for insurance bought on the market while spending <a href="http://www.policyprescriptions.org/subsidies-for-health-care/">hundreds of billions of dollars</a> subsidizing employer-sponsored insurance.
<br />
<div class="storify">
<iframe frameborder="no" height="750" src="//storify.com/MDaware/aca-premiums-trumps-diamonds/embed?header=false&border=false&template=slideshow" width="100%"></iframe><script src="//storify.com/MDaware/aca-premiums-trumps-diamonds.js?header=false&border=false&template=slideshow"></script><noscript>[<a href="//storify.com/MDaware/aca-premiums-trumps-diamonds" target="_blank">View the story "ACA Premiums, Trumps & Diamonds" on Storify</a>]</noscript></div>
mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-43877271937593393292015-10-13T19:00:00.000-04:002015-10-21T14:21:05.306-04:00Narrow Networks: The Result of Competition, not the Barrier<div style="text-align: left;">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="http://www.policyprescriptions.org/wp-content/uploads/2015/10/office-195960_640-300x300.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img alt="Source: geralt (Pixabay/Public Domain)" border="0" class="size-medium wp-image-5803" src="http://www.policyprescriptions.org/wp-content/uploads/2015/10/office-195960_640-300x300.jpg" height="200" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Source: geralt (Pixabay/Public Domain)</td></tr>
</tbody></table>
<div class="entry clearfix">
<i>This post is co-authored by Seth Trueger & <a href="https://twitter.com/PolicyRx" target="_blank">Cedric Dark</a> and also appears on <a href="http://www.policyprescriptions.org/narrow-networks-the-result-of-competition-not-the-barrier/" target="_blank">Policy Prescriptions</a>. See also the related post on <a href="http://mdaware.blogspot.com/2015/10/get-what-you-pay-for-pay-for-what-you.html" target="_blank">premiums before & after ACA</a> (<a href="http://policyprescriptions.org/get-what-you-pay-for-pay-for-what-you-get" target="_blank">PolicyRx</a>).</i><br />
<br />
This <a href="http://www.forbes.com/sites/dandiamond/2015/09/27/trump-tells-60-minutes-that-obamacare-is-a-disaster-heres-what-he-didnt-say/" target="_blank">fantastic article</a> by <a href="http://twitter.com/ddiamond" target="_blank">Dan Diamond</a> in Forbes on Republican presidential candidate Donald Trump’s gibberish on health care during his <em>60 Minutes</em> interview sparked some great discussion on Twitter – see the <a href="https://storify.com/MDaware/aca-premiums-trumps-diamonds" target="_blank"><em>Storify</em></a> below. Dan makes an amazing analogy: <br />
<blockquote class="tr_bq">
Blaming Obamacare for insurance companies’ behavior is like saying Trump’s responsible for how America nominates its presidents.</blockquote>
Dan’s piece did, however, clumsily brush over one important issue, saying:<br />
<blockquote>
Trump has returned time and again to the idea that
there’s not enough competition in the health insurance market. And you
know what? He’s probably right. More than 40% of the doctor networks
available through Obamacare exchanges are narrow network plans. Around
half of all hospital networks on ACA plans are narrow networks, too.</blockquote>
<div class="wp-caption alignleft" id="attachment_5803" style="width: 310px;">
<div class="wp-caption-text">
</div>
</div>
This isn’t so much wrong as it is <em>non sequitur</em>. Narrow network plans aren’t evidence of insufficient competition in the health insurance market; narrow network plans are <em>the result of competition and negotiation in the health insurance market.</em><br />
<br />
Insurers try to find the best provider network (providers include
both hospitals and doctors, which are negotiated separately) for their
plan at the lowest cost, mostly using their enrollees as leverage.
Insurers try to negotiate a discount by bringing volume. Plans basically
say to providers, “Take this price and look how many patients we will
bring you!”<br />
<br />
Hospitals and doctors negotiate for the highest prices and the
largest volume of patients they can get, leveraging their quality and
brand name (i.e. desirability).<br />
<br />
The main “market interaction” in the insurer-provider market is
defining the network for the plan. This is primarily how premiums and
other costs are determined (in addition to deciding which benefits are
covered by the plan).<br />
<br />
<strong>Incidentally, this is pretty much why selling plans across state lines doesn’t magically fix anything. Consider this example.</strong><br />
<br />
An insurer in Illinois still has to negotiate a completely separate
provider network if it were to try to sell a plan in another state like
Indiana or Georgia. That’s where all the work exists. It’s not the
regulatory burden; it’s the provider network negotiation.<br />
<br />
There is, in fact, a lot of competition in health markets, primarily
in the negotiations between insurers and providers. All Obamacare did
was make it so that for insurers to complete against each other they had
to come up with new ways of making profits while keeping premiums and
cost sharing competitive. Instead of the pre-ACA race to see which
insurer could exclude the riskiest people, now insurers fight over
patients by cutting costs while maintaining required coverage — and the
primary way to do that is by narrowing networks and excluding providers
that don’t (as Trump would say) “cut a deal.”</div>
</div>
<br />
<div class="storify">
<iframe allowtransparency="true" frameborder="no" height="750" src="//storify.com/MDaware/aca-premiums-trumps-diamonds/embed?header=false&border=false&template=slideshow" width="100%"></iframe><script src="//storify.com/MDaware/aca-premiums-trumps-diamonds.js?header=false&border=false&template=slideshow"></script><noscript>[<a href="//storify.com/MDaware/aca-premiums-trumps-diamonds" target="_blank">View the story "ACA Premiums, Trumps & Diamonds" on Storify</a>]</noscript></div>
mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-80316320971788099102015-09-21T10:34:00.000-04:002015-09-28T12:55:35.517-04:00Bad Idea Jeans [UPDATED]<b><u><i>UPDATE 9/28/15:</i></u></b><br />
This story <a href="http://well.blogs.nytimes.com/2015/09/14/what-comes-after-the-heimlich-maneuver/?smid=tw-nytimeswell&smtyp=cur&_r=0" target="_blank">NYTimes Well</a> story that instructs laypeople how to perform table-side crics to choking restaurant visitors has, not surprisingly, gotten a bit of play, including a nice <a href="http://www.nytimes.com/2015/09/22/science/letters-to-the-editor.html" target="_blank">Letter to the Editor</a> response from ACEP President Michael Gerardi.<br />
<br />
One point that has been nagging me, however. I'm honestly not that concerned about an untrained layperson slicing the carotid of choking patient who failed Heimlich was going to die anyway in a last-ditch attempt to save them. They were going to die anyway, might help.<br />
<br />
BUT my big concern is <b>who the untrained layperson attempts to cric</b>. I don't want a patient who just needed a good abdominal thump to instead gets a botched cric.<br />
<br />
One of the big cliches in emergency airway teaching is "the most difficult part of performing a emergency cricothyroidotomy is the decision to proceed" -- the <i>Times</i> should not advocate untrained diners make that decision.<br />
<br />
<b><u>ORIGINAL POST:</u></b><br />
<br />
The Heimlich maneuver doesn't always work, maybe it's not such a a good idea for <a href="http://well.blogs.nytimes.com/2015/09/14/what-comes-after-the-heimlich-maneuver/?smid=tw-nytimeswell&smtyp=cur&_r=0" target="_blank">NYTimes Well</a> to recommend this:<br />
<blockquote class="tr_bq">
When all attempts to rescue a choking victim fail and emergency medical help is unavailable, there is a treatment of last resort: a cricothyrotomy, which is easier and quicker to perform than a tracheotomy. With the victim lying flat, tip the head back and locate the bulge of the Adam’s apple. Using a sharp knife, make a half-inch horizontal cut a half-inch deep between the Adam’s apple and the bulge an inch below it, the cricoid cartilage. Insert something like a straw or casing of a ballpoint pen (first remove the ink cartridge) and breathe into it. In case someone’s life depends on your ability to do this, review an illustrated description of the procedure at www.tracheostomy.com/resources/surgery/emergency.htm.</blockquote>
Upside: perhaps I will pay off my student loans selling my new poster to restaurants:<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://4.bp.blogspot.com/-ZymoeNMUZT0/Vf7OBnvDUHI/AAAAAAAAIk0/aV5O61UtTwE/s1600/Slide1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://4.bp.blogspot.com/-ZymoeNMUZT0/Vf7OBnvDUHI/AAAAAAAAIk0/aV5O61UtTwE/s400/Slide1.jpg" width="400" /></a></div>
<br />mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-66843352996949895602015-09-08T10:35:00.000-04:002015-09-08T10:35:00.046-04:00EM Mindset: emDocs<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="http://3.bp.blogspot.com/-QqldnbyJ2v8/Ve33K1j-fjI/AAAAAAAAIj8/Z4RQ8d_xehc/s1600/COU8QUzWwAAYrPe.png" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="160" src="http://3.bp.blogspot.com/-QqldnbyJ2v8/Ve33K1j-fjI/AAAAAAAAIj8/Z4RQ8d_xehc/s320/COU8QUzWwAAYrPe.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">from <a href="https://twitter.com/drrwinters" target="_blank">Rich Winters</a></td></tr>
</tbody></table>
Special thanks to <a href="https://twitter.com/EMHighAK" target="_blank">Alex Koyfman</a> for inviting me to write an EM Mindset essay, Alex and <a href="https://twitter.com/mprizzleer" target="_blank">Manpreet Singh</a> for editing & posting it, and <a href="http://emupdates.com/" target="_blank">Reuben Strayer</a> for the referral.<br />
<div>
<br /></div>
<div>
The post:</div>
<div>
<a href="http://www.emdocs.net/em-mindset-seth-trueger-resuscitation-risk-stratification-care-coordination/" target="_blank">EM MINDSET: SETH TRUEGER – RESUSCITATION, RISK STRATIFICATION, CARE COORDINATION</a></div>
<div>
<br /></div>
<div>
Some early Twitter chatter:</div>
<blockquote class="twitter-tweet" data-conversation="none" lang="en">
<div dir="ltr" lang="en">
<a href="https://twitter.com/EMManchester">@EMManchester</a> <a href="https://twitter.com/emdocsdotnet">@emdocsdotnet</a> I am struggling with <a href="https://twitter.com/MDaware">@MDaware</a> "if you do one test, then you can do 5..." Troubles me as a Ix minimalist ?costs?</div>
— Casey Parker (@broomedocs) <a href="https://twitter.com/broomedocs/status/640978144799911937">September 7, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script>
<blockquote class="twitter-tweet" data-conversation="none" lang="en">
<div dir="ltr" lang="en">
<a href="https://twitter.com/broomedocs">@broomedocs</a> <a href="https://twitter.com/EMManchester">@EMManchester</a> <a href="https://twitter.com/emdocsdotnet">@emdocsdotnet</a> agree unnecessary tests=bad, but marginal cost on sick patients=minimal, your time is more valuable</div>
— Seth Trueger (@MDaware) <a href="https://twitter.com/MDaware/status/640979411605540864">September 7, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script>
<blockquote class="twitter-tweet" lang="en"><p lang="en" dir="ltr">2 min H&P + waiting for routine labs is much worse than 10 min H&P + dispo <a href="https://t.co/xgEKfHTAUs">https://t.co/xgEKfHTAUs</a></p>— Seth Trueger (@MDaware) <a href="https://twitter.com/MDaware/status/640980446449389568">September 7, 2015</a></blockquote>
<script async src="//platform.twitter.com/widgets.js" charset="utf-8"></script>
<br><br>
<blockquote class="twitter-tweet" lang="en">
<div dir="ltr" lang="en">
<a href="https://twitter.com/MDaware">@MDaware</a> I just want to know how I can work in this magical place where hospitalists take pts with labs still pending...</div>
— Jordan Schooler (@JBSchooler) <a href="https://twitter.com/JBSchooler/status/640982640871505920">September 7, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script>mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com0tag:blogger.com,1999:blog-3339915911356078232.post-20650877591334639422015-08-25T10:30:00.000-04:002015-08-25T10:30:01.472-04:00Streetlights & Counting Clicks<div class="separator" style="clear: both; text-align: center;">
<a href="http://3.bp.blogspot.com/-YHRdV5vDDXA/VduZDIxJqCI/AAAAAAAAIjQ/alYtE5CHyxo/s1600/Led_street_light_beam_pattern.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="157" src="http://3.bp.blogspot.com/-YHRdV5vDDXA/VduZDIxJqCI/AAAAAAAAIjQ/alYtE5CHyxo/s200/Led_street_light_beam_pattern.jpg" width="200" /></a></div>
Someone recently sent me this <a href="http://time.com/12933/what-you-think-you-know-about-the-web-is-wrong/" target="_blank">2014 Time Magazine article</a> on metrics for web readership by Tony Haile, the CEO of Chartbeat, which does web metrics.<br />
<br />
My first impression: this article seemed oddly familiar and I realized I read a similar article <a href="http://www.slate.com/articles/technology/technology/2013/06/how_people_read_online_why_you_won_t_finish_this_article.single.html" target="_blank">about Chartbeat by Farzad Manjoo in 2013</a> (with some of the exact same/similar graphs; note that this is not so much of a critique as just amusing to me):<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-4lXy--cv2OQ/VduYABDDl-I/AAAAAAAAIi4/Gm5E97Fzuns/s1600/graph%2B1.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="224" src="http://2.bp.blogspot.com/-4lXy--cv2OQ/VduYABDDl-I/AAAAAAAAIi4/Gm5E97Fzuns/s400/graph%2B1.png" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Different articles, same graph. Bonus: see what's on Seth's bookmark bar</td></tr>
</tbody></table>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://1.bp.blogspot.com/-ncLg4GADYaw/VduYAFDSonI/AAAAAAAAIi8/qOgJjNcloRI/s1600/graph%2B2.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="177" src="http://1.bp.blogspot.com/-ncLg4GADYaw/VduYAFDSonI/AAAAAAAAIi8/qOgJjNcloRI/s320/graph%2B2.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Technically different but essentially the same graphs. </td></tr>
</tbody></table>
<br />
<br />
Go read either or both of these articles and come back here for my thoughts.<br />
<br />
My key impressions:<br />
<br />
-Of course neither clicks nor social media shares are a completely accurate proxy for what we really care about: engaged readers who understand, learn, and remember the content of an article<br />
<br />
-but clicks and social media shares are (most likely) useful proxies.<br />
<br />
Ultimately this is my more optimistic view of the "<a href="https://en.wikipedia.org/wiki/Streetlight_effect" target="_blank">streetlight effect</a>" -- sometimes it makes sense to look for your keys in the the light, where it's easy. See also: fruit, low-hanging.<br />
<br />
Compare:<br />
<br />
Newspaper circulation: of course 1.4 million NY Times readers are not fully apprised of every topic discussed in each daily paper.<br />
<br />
Symplur impressions: #ACEP14 had 33 million impressions; this does not mean that, on average, each emergency physician learned 1,000 things via Twitter during ACEP.<br />
<br />
My take is that in all of these cases, of course there are limitations but these numbers are a "ceiling" -- an upper limit of theoretical impact, and they are still somewhat useful to compare numbers (e.g. one outlet's performance across time, or multiple outlets' performance against each other).<br />
<br />
The rub is how accurate the surrogate marker is as a proxy. Compare impact factor, where it's probably useless to compare a clinical EM journal against an academic mathematics journal, where citations accrue at different rates and may signify more or less (for more on limitations of journal impact factor, see <a href="http://www.annemergmed.com/article/S0196-0644(15)00328-5/fulltext" target="_blank">our piece on Altmetric</a>).<br />
<br />
Complete speculation: I suspect that clicks are a useful measure for <i>Annals of EM</i>, particularly as we have what seem to be fairly high visit durations (nearly 3 minutes) and 2.6 pageviews per visit (if I'm reading the data I have correctly).<br />
<br />
I have not analyzed this formally in any way, but casually following <i>Annals'</i> top Altmetric score articles seems to give a handful of popular topics, in no particular order:<br />
<br />
1) airway (always a popular topic, particularly on social media)<br />
<br />
2) social media (tons of self promotion and mutual congratulations, as well as legitimate interest in social media)<br />
<br />
3) public health (e.g. ACA, injury and violence, even Ebola)<br />
<br />
I suspect the social-media-share-to-actual-reading ratio rises going down this list, particularly as there are a lot of overlapping online communities and general public interest in public health topics.<br />
<br />
One last point about the Time article:<br />
<br />
2/3 of reading is below the fold, which makes sense: the overwhelming majority of clicks result in 15 seconds or less of reading, but the small fraction who read below the fold spend much, much more time, just as half of Medicare spending is on 5% of beneficiaries.mdawarehttp://www.blogger.com/profile/11511273712090189564noreply@blogger.com1