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Primary Care Physician Characteristics Associated with Low Value Care Spending.

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Primary Care Physician Characteristics Associated with Low Value Care Spending.

J Am Board Fam Med. 2019 Mar-Apr;32(2):218-225

Authors: Barreto TW, Chung Y, Wingrove P, Young RA, Petterson S, Bazemore A, Liaw W

Abstract
BACKGROUND: Previous work has shown that $210 billion may be spent annually on unnecessary medical services and has identified patient and hospital characteristics associated with low value care (LVC). However, little is known about the association between primary care physician (PCP) characteristics and LVC spending. The objective of this study was to assess this association.
METHODS: We performed a retrospective analysis by using Medicare claims data to identify LVC and American Medical Association Masterfile data for PCP characteristics. We included PCPs of adults aged 65 years and older who were enrolled in Medicare in 2011. We measured Medicare spending per attributed patient on 8 low value services.
RESULTS: Our final sample contained 6,873 PCPs with 1,078,840 attributed patients. Lower per-patient LVC Medicare spending was associated with the following PCP characteristics: allopathic training, smaller Medicare patient panel, practiced family medicine, practiced in the Midwest region, were a recent graduate, or practiced in rural areas. The largest associations were seen in Medicare patient panel size and geographic region. The average per-patient LVC spending was $14.67. LVC spending among PCPs with small patient panels was $3.98 less per patient relative to those with larger panels. PCPs in the Midwest had $2.80 less per patient LVC spending than those in the Northeast.
CONCLUSION: Our analysis suggests that LVC services are associated with specific PCP characteristics. Further research should assess the strength of these associations, and future policy efforts should focus on systemic interventions to reduce LVC spending.

PMID: 30850458 [PubMed - in process]

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

Richard Robinson, MD - Wed, 03/06/2019 - 17:13
Related Articles

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

J Clin Med Res. 2019 Mar;11(3):157-164

Authors: Knowles H, Huggins C, Robinson RD, Mbugua R, Laureano-Phillips J, Trivedi SM, Kirby J, Zenarosa NR, Wang H

Abstract
Background: We aim to externally validate the status of emergency department (ED) appropriate utilization and 72-h ED returns among homeless patients.
Methods: This is a retrospective single-center observational study. Patients were divided into two groups (homeless versus non-homeless). Patients' general characteristics, clinical variables, ED appropriate utilization, and ED return disposition deviations were compared and analyzed separately.
Results: Study enrolled a total of 63,990 ED visits. Homeless patients comprised 9.3% (5,926) of visits. Higher ED 72-h returns occurred among homeless patients in comparison to the non-homeless patients (17% versus 5%, P < 0.001). Rate of significant ED disposition deviations (e.g., admission, triage to operation room, or death) on return visits were lower in homeless patients when compared to non-homeless patient populations (15% versus 23%, P < 0.001).
Conclusions: Though ED return rate was higher among homeless patients, return visit case management seems appropriate, indicating that 72-h ED returns might not be an optimal healthcare quality measurement for homeless patients.

PMID: 30834037 [PubMed]

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

Hao Wang, MD - Wed, 03/06/2019 - 17:13
Related Articles

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

J Clin Med Res. 2019 Mar;11(3):157-164

Authors: Knowles H, Huggins C, Robinson RD, Mbugua R, Laureano-Phillips J, Trivedi SM, Kirby J, Zenarosa NR, Wang H

Abstract
Background: We aim to externally validate the status of emergency department (ED) appropriate utilization and 72-h ED returns among homeless patients.
Methods: This is a retrospective single-center observational study. Patients were divided into two groups (homeless versus non-homeless). Patients' general characteristics, clinical variables, ED appropriate utilization, and ED return disposition deviations were compared and analyzed separately.
Results: Study enrolled a total of 63,990 ED visits. Homeless patients comprised 9.3% (5,926) of visits. Higher ED 72-h returns occurred among homeless patients in comparison to the non-homeless patients (17% versus 5%, P < 0.001). Rate of significant ED disposition deviations (e.g., admission, triage to operation room, or death) on return visits were lower in homeless patients when compared to non-homeless patient populations (15% versus 23%, P < 0.001).
Conclusions: Though ED return rate was higher among homeless patients, return visit case management seems appropriate, indicating that 72-h ED returns might not be an optimal healthcare quality measurement for homeless patients.

PMID: 30834037 [PubMed]

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

Charles Huggins, MD - Wed, 03/06/2019 - 17:13
Related Articles

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

J Clin Med Res. 2019 Mar;11(3):157-164

Authors: Knowles H, Huggins C, Robinson RD, Mbugua R, Laureano-Phillips J, Trivedi SM, Kirby J, Zenarosa NR, Wang H

Abstract
Background: We aim to externally validate the status of emergency department (ED) appropriate utilization and 72-h ED returns among homeless patients.
Methods: This is a retrospective single-center observational study. Patients were divided into two groups (homeless versus non-homeless). Patients' general characteristics, clinical variables, ED appropriate utilization, and ED return disposition deviations were compared and analyzed separately.
Results: Study enrolled a total of 63,990 ED visits. Homeless patients comprised 9.3% (5,926) of visits. Higher ED 72-h returns occurred among homeless patients in comparison to the non-homeless patients (17% versus 5%, P < 0.001). Rate of significant ED disposition deviations (e.g., admission, triage to operation room, or death) on return visits were lower in homeless patients when compared to non-homeless patient populations (15% versus 23%, P < 0.001).
Conclusions: Though ED return rate was higher among homeless patients, return visit case management seems appropriate, indicating that 72-h ED returns might not be an optimal healthcare quality measurement for homeless patients.

PMID: 30834037 [PubMed]

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

Roderick Y. Kim DDS, MD - Wed, 03/06/2019 - 17:13
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Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

J Oral Maxillofac Surg. 2019 Feb 07;:

Authors: Burkes JN, Campos L, Williams FC, Kim RY

Abstract
Spindle cell and pleomorphic lipomas (SC/PLs) are a rare form of lipomatous tumors. They typically occur as a slow-growing localized mass in the subcutaneous fatty tissue of the posterior neck, back, and shoulders. This benign variant represents less than 1.5% of all lipomas and is relatively uncommon in the head and neck area. A manifestation in the larynx is even rarer. Unlike other anatomic locations, laryngeal lipomas can pose life-threatening symptoms secondary to acute obstruction of the upper aerodigestive tract. This report presents a case of a large SC/PL of the larynx associated with hoarseness, dysphagia, globus sensation, and neck fullness. The tumor was successfully removed through an anterior transcervical approach with infrahyoid myotomy. The authors review the literature concerning head and neck adipocytic tumors with spindle cells and discuss the difficulties in distinguishing SC/PLs from liposarcomas. To the best of the authors' knowledge, this is the first case to be reported in the oral and maxillofacial surgery literature.

PMID: 30826392 [PubMed - as supplied by publisher]

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

Related Articles

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

J Clin Med Res. 2019 Mar;11(3):157-164

Authors: Knowles H, Huggins C, Robinson RD, Mbugua R, Laureano-Phillips J, Trivedi SM, Kirby J, Zenarosa NR, Wang H

Abstract
Background: We aim to externally validate the status of emergency department (ED) appropriate utilization and 72-h ED returns among homeless patients.
Methods: This is a retrospective single-center observational study. Patients were divided into two groups (homeless versus non-homeless). Patients' general characteristics, clinical variables, ED appropriate utilization, and ED return disposition deviations were compared and analyzed separately.
Results: Study enrolled a total of 63,990 ED visits. Homeless patients comprised 9.3% (5,926) of visits. Higher ED 72-h returns occurred among homeless patients in comparison to the non-homeless patients (17% versus 5%, P < 0.001). Rate of significant ED disposition deviations (e.g., admission, triage to operation room, or death) on return visits were lower in homeless patients when compared to non-homeless patient populations (15% versus 23%, P < 0.001).
Conclusions: Though ED return rate was higher among homeless patients, return visit case management seems appropriate, indicating that 72-h ED returns might not be an optimal healthcare quality measurement for homeless patients.

PMID: 30834037 [PubMed]

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

Fayette C. Williams, DDS, MD, FACS - Mon, 03/04/2019 - 05:45

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

J Oral Maxillofac Surg. 2019 Feb 07;:

Authors: Burkes JN, Campos L, Williams FC, Kim RY

Abstract
Spindle cell and pleomorphic lipomas (SC/PLs) are a rare form of lipomatous tumors. They typically occur as a slow-growing localized mass in the subcutaneous fatty tissue of the posterior neck, back, and shoulders. This benign variant represents less than 1.5% of all lipomas and is relatively uncommon in the head and neck area. A manifestation in the larynx is even rarer. Unlike other anatomic locations, laryngeal lipomas can pose life-threatening symptoms secondary to acute obstruction of the upper aerodigestive tract. This report presents a case of a large SC/PL of the larynx associated with hoarseness, dysphagia, globus sensation, and neck fullness. The tumor was successfully removed through an anterior transcervical approach with infrahyoid myotomy. The authors review the literature concerning head and neck adipocytic tumors with spindle cells and discuss the difficulties in distinguishing SC/PLs from liposarcomas. To the best of the authors' knowledge, this is the first case to be reported in the oral and maxillofacial surgery literature.

PMID: 30826392 [PubMed - as supplied by publisher]

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

J Oral Maxillofac Surg. 2019 Feb 07;:

Authors: Burkes JN, Campos L, Williams FC, Kim RY

Abstract
Spindle cell and pleomorphic lipomas (SC/PLs) are a rare form of lipomatous tumors. They typically occur as a slow-growing localized mass in the subcutaneous fatty tissue of the posterior neck, back, and shoulders. This benign variant represents less than 1.5% of all lipomas and is relatively uncommon in the head and neck area. A manifestation in the larynx is even rarer. Unlike other anatomic locations, laryngeal lipomas can pose life-threatening symptoms secondary to acute obstruction of the upper aerodigestive tract. This report presents a case of a large SC/PL of the larynx associated with hoarseness, dysphagia, globus sensation, and neck fullness. The tumor was successfully removed through an anterior transcervical approach with infrahyoid myotomy. The authors review the literature concerning head and neck adipocytic tumors with spindle cells and discuss the difficulties in distinguishing SC/PLs from liposarcomas. To the best of the authors' knowledge, this is the first case to be reported in the oral and maxillofacial surgery literature.

PMID: 30826392 [PubMed - as supplied by publisher]

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

Related Articles

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

J Trauma Acute Care Surg. 2018 02;84(2):372-378

Authors: Hernandez MC, Haddad NN, Cullinane DC, Yeh DD, Wydo S, Inaba K, Duane TM, Pakula A, Skinner R, Rodriguez CJ, Dunn J, Sams VG, Zielinski MD, Choudhry A, Turay D, Yune JM, Watras J, Widom KA, Cull J, Toschlog EA, Graybill JC, EAST SBO Workgroup

Abstract
BACKGROUND: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study.
METHODS: Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed.
RESULTS: There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade.
CONCLUSION: The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms.
LEVEL OF EVIDENCE: Prognostic, level III.

PMID: 29117026 [PubMed - indexed for MEDLINE]

Association between emergency physician self-reported empathy and patient satisfaction.

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Association between emergency physician self-reported empathy and patient satisfaction.

PLoS One. 2018;13(9):e0204113

Authors: Wang H, Kline JA, Jackson BE, Laureano-Phillips J, Robinson RD, Cowden CD, d'Etienne JP, Arze SE, Zenarosa NR

Abstract
BACKGROUND: Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting.
OBJECTIVE: To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience.
RESEARCH DESIGN: A prospective observational study conducted in a tertiary care hospital ED.
METHODS: Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models.
RESULTS: Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107-122) and senior physicians had the highest scores (median 119.5; IQR: 111-129). Similarly, EM residents had the lowest percentage of "very satisfied" responses (65%) and senior physicians had the highest reported percentage of "very satisfied" responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07).
CONCLUSION: This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.

PMID: 30212564 [PubMed - indexed for MEDLINE]

Actinomyces turicensis Necrotizing Soft-Tissue Infection of the Thigh in a Diabetic Male.

Jeffrey Tessier, MD - Wed, 02/27/2019 - 15:16
Related Articles

Actinomyces turicensis Necrotizing Soft-Tissue Infection of the Thigh in a Diabetic Male.

Surg Infect (Larchmt). 2019 Feb 21;:

Authors: Panwar K, Duane TM, Tessier JM, Patel K, Sanders JM

Abstract
BACKGROUND: Necrotizing soft-tissue infections are a devastating infection that is rarely caused by Actinomyces spp.
CASE REPORT: A 45-year-old obese previously healthy male presented to the emergency department with diabetic ketoacidosis. The patient developed systemic signs of infections and right medial thigh pain subsequently diagnosed as a necrotizing soft-tissue infection. Successful treatment included prompt surgical intervention and initiation of broad-spectrum antimicrobial drugs.
CONCLUSION: Actinomyces turicensis may be the pathogen causing certain necrotizing soft-tissue infections. Clinicians should consider the possibility that this organism represents a true pathogen and not colonization/contamination.

PMID: 30789313 [PubMed - as supplied by publisher]

Actinomyces turicensis Necrotizing Soft-Tissue Infection of the Thigh in a Diabetic Male.

Related Articles

Actinomyces turicensis Necrotizing Soft-Tissue Infection of the Thigh in a Diabetic Male.

Surg Infect (Larchmt). 2019 Feb 21;:

Authors: Panwar K, Duane TM, Tessier JM, Patel K, Sanders JM

Abstract
BACKGROUND: Necrotizing soft-tissue infections are a devastating infection that is rarely caused by Actinomyces spp.
CASE REPORT: A 45-year-old obese previously healthy male presented to the emergency department with diabetic ketoacidosis. The patient developed systemic signs of infections and right medial thigh pain subsequently diagnosed as a necrotizing soft-tissue infection. Successful treatment included prompt surgical intervention and initiation of broad-spectrum antimicrobial drugs.
CONCLUSION: Actinomyces turicensis may be the pathogen causing certain necrotizing soft-tissue infections. Clinicians should consider the possibility that this organism represents a true pathogen and not colonization/contamination.

PMID: 30789313 [PubMed - as supplied by publisher]

The Radiographic Prepatellar Fat Thickness Ratio Correlates With Infection Risk After Total Knee Arthroplasty.

Hugo Sanchez, MD - Wed, 02/20/2019 - 13:28
Related Articles

The Radiographic Prepatellar Fat Thickness Ratio Correlates With Infection Risk After Total Knee Arthroplasty.

J Arthroplasty. 2018 07;33(7):2251-2255

Authors: Wagner RA, Hogan SP, Burge JR, Bates CM, Sanchez HB

Abstract
BACKGROUND: Obesity has been associated with complications after a total knee arthroplasty (TKA). Surgical site infection (SSI) after TKA is one of the feared complications as it increases revision rates, costs, and stress to the patient. There is conflicting evidence in the literature regarding body mass index (BMI) and risk of infection after TKA, and some studies have suggested that site-specific fat distribution may be a better metric for determining risk of postoperative infections. Here, we investigate the correlation of soft tissue distribution about the knee to SSI after TKA.
METHODS: We retrospectively review 572 patients who underwent primary TKA at a single institution from 2006 to 2010. We introduce the prepatellar fat thickness ratio (PFTR) as a radiographic means to quantitatively assess fat distribution about the knee and evaluate this measurement's ability to assess the risk of developing an SSI after TKA.
RESULTS: The PFTR was shown to be a better predictor of SSI than BMI in both the univariate (P = .05) and multivariate (P = .01) analyses.
CONCLUSION: Although BMI cannot fully account for variations in adipose distribution, the PFTR may account for this variability and may be a helpful tool for assessing a patient's preoperative risk of SSI after TKA.

PMID: 29555491 [PubMed - indexed for MEDLINE]

The Radiographic Prepatellar Fat Thickness Ratio Correlates With Infection Risk After Total Knee Arthroplasty.

Related Articles

The Radiographic Prepatellar Fat Thickness Ratio Correlates With Infection Risk After Total Knee Arthroplasty.

J Arthroplasty. 2018 07;33(7):2251-2255

Authors: Wagner RA, Hogan SP, Burge JR, Bates CM, Sanchez HB

Abstract
BACKGROUND: Obesity has been associated with complications after a total knee arthroplasty (TKA). Surgical site infection (SSI) after TKA is one of the feared complications as it increases revision rates, costs, and stress to the patient. There is conflicting evidence in the literature regarding body mass index (BMI) and risk of infection after TKA, and some studies have suggested that site-specific fat distribution may be a better metric for determining risk of postoperative infections. Here, we investigate the correlation of soft tissue distribution about the knee to SSI after TKA.
METHODS: We retrospectively review 572 patients who underwent primary TKA at a single institution from 2006 to 2010. We introduce the prepatellar fat thickness ratio (PFTR) as a radiographic means to quantitatively assess fat distribution about the knee and evaluate this measurement's ability to assess the risk of developing an SSI after TKA.
RESULTS: The PFTR was shown to be a better predictor of SSI than BMI in both the univariate (P = .05) and multivariate (P = .01) analyses.
CONCLUSION: Although BMI cannot fully account for variations in adipose distribution, the PFTR may account for this variability and may be a helpful tool for assessing a patient's preoperative risk of SSI after TKA.

PMID: 29555491 [PubMed - indexed for MEDLINE]

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

Richard Robinson, MD - Wed, 02/06/2019 - 09:11
Related Articles

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

Ann Emerg Med. 2019 Feb 01;:

Authors: Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H

Abstract
STUDY OBJECTIVE: The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post-ED-discharge patient follow-up intervals.
METHODS: We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated.
RESULTS: There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non-low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%).
CONCLUSION: In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.

PMID: 30718010 [PubMed - as supplied by publisher]

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

Hao Wang, MD - Wed, 02/06/2019 - 09:11
Related Articles

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

Ann Emerg Med. 2019 Feb 01;:

Authors: Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H

Abstract
STUDY OBJECTIVE: The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post-ED-discharge patient follow-up intervals.
METHODS: We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated.
RESULTS: There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non-low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%).
CONCLUSION: In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.

PMID: 30718010 [PubMed - as supplied by publisher]

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

Chet Schrader, MD - Wed, 02/06/2019 - 09:11
Related Articles

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

Ann Emerg Med. 2019 Feb 01;:

Authors: Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H

Abstract
STUDY OBJECTIVE: The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post-ED-discharge patient follow-up intervals.
METHODS: We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated.
RESULTS: There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non-low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%).
CONCLUSION: In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.

PMID: 30718010 [PubMed - as supplied by publisher]

Addressing Mental Health Needs among Physicians.

Katherine Buck, PhD - Wed, 02/06/2019 - 09:11

Addressing Mental Health Needs among Physicians.

South Med J. 2019 Feb;112(2):67-69

Authors: Buck K, Grace A, Runyan T, Brown-Berchtold L

PMID: 30708367 [PubMed - in process]

HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

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HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis.

Ann Emerg Med. 2019 Feb 01;:

Authors: Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H

Abstract
STUDY OBJECTIVE: The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post-ED-discharge patient follow-up intervals.
METHODS: We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated.
RESULTS: There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non-low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%).
CONCLUSION: In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.

PMID: 30718010 [PubMed - as supplied by publisher]

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department.

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Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department.

Patient Educ Couns. 2018 04;101(4):717-722

Authors: Lin MP, Probst MA, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Butler K, Runyon MS, Wang H, Courtney DM, Muckley B, Hobgood CD, Hall CL, Kline JA

Abstract
OBJECTIVE: We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging.
METHODS: Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning.
RESULTS: We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%).
CONCLUSION: The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing.
PRACTICE IMPLICATIONS: Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.

PMID: 29173841 [PubMed - indexed for MEDLINE]

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