Hemal K. Kanzaria

Nutritional Status and Serum Cytokine Profiles in Children, Adolescents, and Young Adults with Schistosoma japonicum–Associated Hepatic Fibrosis, in Leyte, Philippines

In a cross-sectional study of 641 Schistosoma japonicum-infected individuals in Leyte, Philippines, who were 7-30 years old, we determined the grade of hepatic fibrosis (HF) by ultrasound and used anthropometric measurements and hemoglobin levels to assess nutritional status. Serum levels of interleukin (IL)-1, IL-6, and IL-10; tumor-necrosis factor (TNF)-alpha; soluble TNF- alpha receptor I; and C-reactive protein (CRP) were measured to examine the association between these markers of inflammation and HF grade. HF was present in 8.9% of the cohort; the majority of cases were mild (grade I), and severe (grade II or grade III) cases occurred only in male individuals. Compared with individuals without HF, those with severe HF--and, to a lesser degree, those with mild HF--had a significantly lower body-mass index (BMI) and BMI z-score, a higher prevalence of anemia, and a higher level of CRP and were more likely to produce IL-6; furthermore, those with severe HF had a significantly higher level of IL-1, compared with those either without HF or with mild HF. These findings suggest that even mild HF is associated with nutritional morbidity and underscore the importance of early recognition and treatment. In addition, our data are consistent with the hypothesis that, by systemically increasing the levels of the proinflammatory cytokines IL-1 and IL-6, HF causes undernutrition and anemia.

Intolerance of error and culture of blame drive medical excess

Jerome R Hoffman and Hemal K Kanzaria argue that efforts to reduce overdiagnosis and overtreatment should focus on changing professional and public attitudes towards medical error and uncertainty

Malaria treatment-seeking behaviour and recovery from malaria in a highland area of Kenya

BackgroundMalaria epidemics in highland areas of Kenya cause significant morbidity and mortality.MethodsTo assess treatment-seeking behaviour for malaria in these areas, a questionnaire was administered to 117 randomly selected households in the highland area of Kipsamoite, Kenya. Self-reported episodes of malaria occurred in 100 adults and 66 children.ResultsThe most frequent initial sources of treatment for malaria in adults and children were medical facilities (66.0% and 66.7%) and local shops (19.0% and 30.3%). Adults and children who initially visited a medical facility for treatment were significantly more likely to recover and require no further treatment than those who initially went to a local shop (adults, 84.9% v. 36.8%, P < 0.0001, and children, 79.6% v. 40.0%, P = 0.002, respectively). Individuals who attended medical facilities recalled receiving anti-malarial medication significantly more frequently than those who visited shops (adults, 100% vs. 29.4%, and children, 100% v. 5.0%, respectively, both P < 0.0001).ConclusionA significant proportion of this highland population chooses local shops for initial malaria treatment and receives inappropriate medication at these localshops, reslting in delay of effective treatment. Shopkeeper education has the potential to be a component of prevention or containment strategies for malaria epidemics in highland areas.

A conceptual model of emergency physician decision making for head computed tomography in mild head injury.

The use of computed tomographic scanning in blunt head trauma has increased dramatically in recent years without an accompanying rise in the prevalence of injury or hospital admission for serious conditions. Because computed tomography is neither harmless nor inexpensive, researchers have attempted to optimize utilization, largely through research that describes which clinical variables predict intracranial injury, and use this information to develop clinical decision instruments. Although such techniques may be useful when the benefits and harms of each strategy (neuroimaging vs observation) are quantifiable and amenable to comparison, the exact magnitude of these benefits and harms remains unknown in this clinical scenario. We believe that most clinical decision instrument development efforts are misguided insofar as they ignore critical, nonclinical factors influencing the decision to image. In this article, we propose a conceptual model to illustrate how clinical and nonclinical factors influence emergency physicians making this decision. We posit that elements unrelated to standard clinical factors, such as personality of the physician, fear of litigation and of missed diagnoses, patient expectations, and compensation method, may have equal or greater impact on actual decision making than traditional clinical factors. We believe that 3 particular factors deserve special consideration for further research: fear of error/malpractice, financial incentives, and patient engagement. Acknowledgement and study of these factors will be essential if we are to understand how emergency physicians truly make these decisions and how test-ordering behavior can be modified.

Perceived Appropriateness of Shared Decision-making in the Emergency Department: A Survey Study

OBJECTIVES The objective was to describe perceptions of practicing emergency physicians (EPs) regarding the appropriateness and medicolegal implications of using shared decision-making (SDM) in the emergency department (ED). METHODS We conducted a cross-sectional survey of EPs at a large, national professional meeting to assess perceived appropriateness of SDM for different categories of ED management (e.g., diagnostic testing, treatment, disposition) and in common clinical scenarios (e.g., low-risk chest pain, syncope, minor head injury). A 21-item survey instrument was iteratively developed through review by content experts, cognitive testing, and pilot testing. Descriptive and multivariate analyses were conducted. RESULTS We approached 737 EPs; 709 (96%) completed the survey. Two-thirds (67.8%) of respondents were male; 51% practiced in an academic setting and 44% in the community. Of the seven management decision categories presented, SDM was reported to be most frequently appropriate for deciding on invasive procedures (71.5%), computed tomography (CT) scanning (56.7%), and post-ED disposition (56.3%). Among the specific clinical scenarios, use of thrombolytics for acute ischemic stroke was felt to be most frequently appropriate for SDM (83.4%), followed by lumbar puncture to rule out subarachnoid hemorrhage (73.8%) and CT head for pediatric minor head injury (69.9%). Most EPs (66.8%) felt that using and documenting SDM would decrease their medicolegal risk while a minority (14.2%) felt that it would increase their risk. CONCLUSIONS Acceptance of SDM among EPs appears to be strong across management categories (diagnostic testing, treatment, and disposition) and in a variety of clinical scenarios. SDM is perceived by most EPs to be medicolegally protective.

Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians

&NA; Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient’s capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician‐directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high‐quality, patient‐centered emergency care.

The association between advanced diagnostic imaging and ED length of stay.

OBJECTIVE There has been a rise in advanced diagnostic imaging (ADI) use in the emergency department (ED). Increased utilization may contribute to longer length of stay (LOS), but prior reports have not considered improved methods for modeling skewed LOS data. METHODS The 2010 National Hospital Ambulatory Medical Care Survey data were analyzed by 5 common ED chief complaints. Generalized linear model (GLM) was compared to quantile and ordinary least squares (OLS) regression to evaluate the association between ADI and ED LOS. Receipt of computed tomography or magnetic resonance imaging was the primary exposure. Emergency department LOS was the primary outcome. RESULTS Of the 33,685 ED visits analyzed, 17% involved ADI. The median LOS for patients without ADI was 138 minutes compared to 252 minutes for those who received ADI. Overall, GLM offered the most unbiased estimates, although it provided similar adjusted point estimates to OLS for the marginal change in LOS associated with ADI. The effect of imaging differed by LOS quantile, especially for patients with abdominal pain, fever, and back symptoms. CONCLUSIONS Generalized linear model offered an improved modeling approach compared to OLS and quantile regression. Consideration of such techniques may facilitate a more complete view of the effect of ADI on ED LOS.

Is emergency department closure resulting in increased distance to the nearest emergency department associated with increased inpatient mortality

STUDY OBJECTIVE We seek to determine whether patients living in areas affected by emergency department (ED) closure, with subsequent increased distance to the nearest ED, have a higher risk of inpatient death from time-sensitive conditions. METHODS Using the California Office of Statewide Health and Planning Development database, we performed a nonconcurrent cohort study of hospital admissions in California between 1999 and 2009 for patients admitted for acute myocardial infarction, stroke, sepsis and asthma or chronic obstructive pulmonary disease. We used generalized linear mixed-effects models comparing adjusted inpatient mortality for patients experiencing increased distance to the nearest ED versus no change in distance. RESULTS Of 785,385 patient admissions, 67,577 (8.6%) experienced an increase in distance to ED care because of an ED closure. The median change for patients experiencing an increase in distance to the nearest ED was only 0.8 miles, with a range of 0.1 to 33.4 miles. Patients with an increase did not have a significantly higher mortality (adjusted odds ratio 1.04; 95% confidence interval 0.99 to 1.09). In subgroups, we also observed no statistically significant differences in adjusted mortality among patients with acute myocardial infarction, stroke, asthma or chronic obstructive pulmonary disease, and sepsis. We did not observe any significant variations in mortality for time-sensitive conditions in sensitivity analyses that incorporated a lag effect of time after change in distance, allowance for a larger affected population, or removal of ST-segment elevation myocardial infarction from the acute myocardial infarction subgroup. CONCLUSION In this large population-based sample, less than 10% of the patients experienced an increase in distance to the nearest ED, and of that group, the majority had less than a 1-mile increase. These small increased distances to the nearest ED were not associated with higher inpatient mortality among time-sensitive conditions.

Health Systems Science

Medical school graduates are required to master basic science and clinical skills in order to deliver compassionate, high-quality, patient-centered care. Increasingly, however, physicians are expected to go beyond caring for an individual patient, and improve the health of communities and populations in a manner that is equitable, efficient, and cost-effective. Unfortunately, the current United States (US) health system is fragmented, complex, and unsustainably costly. This article is protected by copyright. All rights reserved.

Quality measures based on presenting signs and symptoms of patients.

Quality Measures Based on Presenting Signs and Symptoms of Patients Health care reform efforts, such as accountable care organizations, focus on improving value partly through controlling use of services, including diagnostic tests. Some have expressed concern that these efforts may result in delayed diagnosis and subsequent patient harm.1 Publicly reported quality measures that evaluate care provided prior to arriving at a diagnosis could prevent financial incentives from producing harm. The Institute of Medicine (IOM) previously developed a conceptual framework for categorizing process quality measures.2 The IOM framework includes criteria related to prevention, screening, evaluation/diagnosis, management, and follow-up.2 The National Quality Forum (NQF) currently serves as the consensus-based quality-measure–endorsement entity called for in the Affordable Care Act. Measures are submitted to the NQF by professional societies, government agencies, health systems, nonprofit organizations, and industry. Multistakeholder expert committees assess proposed measures using specific evaluation criteria. Endorsed measures are often adopted by the Centers for Medicare & Medicaid Services in payment and public reporting programs.3 We determined how NQF-endorsed process measures match the entire IOM framework and concentrated on quality measures that evaluate the prediagnostic care of patients presenting with signs or symptoms. We then compared these sign/symptom-based quality measures with the most common reasons people seek care.