Scott G. Weiner

Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain

BACKGROUND It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes. METHODS In this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes. RESULTS The rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group (

Emergency department utilization after the implementation of Massachusetts health reform

4,289 and

Mandatory use of prescription drug monitoring programs.

4,060, respectively; P=0.65). CONCLUSIONS In patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.).

Clinician Impression Versus Prescription Drug Monitoring Program Criteria in the Assessment of Drug-Seeking Behavior in the Emergency Department

STUDY OBJECTIVE Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions. METHODS We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation. RESULTS Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%). CONCLUSION Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.

Multicenter study of limited health literacy in emergency department patients.

The United States is in the midst of a prescription opioid overdose and abuse epidemic. The rate of fatal prescription drug overdoses involving opioids almost quadrupled from 1.4 deaths/100 000 people in 1999 to 5.4 deaths/100 000 people in 2011.1 The rate of emergency department visits involving prescription drug misuse–primarily of opioid, anti-anxiety, and insomnia medications–more than doubled from 214 visits/100 000 people in 2004 to 458 visits/100 000 people in 2011.2 Forty-nine states have responded by developing prescription drug monitoring programs (PDMPs), which digitally store controlled substance dispensing information and make those data accessible to prescribers, pharmacies, and law enforcement officials. Although PDMPs are designed to curb opioid overprescribing, prescriber utilization is low. The median PDMP registration rate among licensed prescribers who issue at least 1 controlled substance prescription is 35%.3 Furthermore, not all enrolled prescribers regularly use PDMPs. Consequently, 22 of the 49 states with PDMPs now legally mandate prescribers to query the system before writing for controlled substances with recognized potential for abuse or dependence.4 These requirements face pushback from prescribers, many of whom consider them to be burdensome incursions into clinical practice.5 For example, physician and dentist group challenges to the breadth of circumstances proposed for PDMP checks have contributed to a 2-year delay in the final implementation of a legally required mandate in Massachusetts.6 On the other hand, proponents argue that required PDMP consultation is necessary to change prescribing behavior, citing early evidence from states that have deployed mandates to demonstrate their potential to reduce opioid abuse.5 Some studies associate state PDMPs with lower rates of prescription drug abuse and altered prescribing practices, although evidence is mixed and inconclusive.7 Small (if any) demonstrated effect sizes, a dearth of detailed prescribing data prior to PDMP implementation, and a lack of precision in characterizing interventions in existing studies make attributing significant changes in total opioid prescribing or health outcomes to PDMPs a challenge.7 Another reason for inconsistent findings may be low and variable prescriber utilization of PDMPs. Prescribers must actually access PDMP data for the systems to have an appreciable effect. In addition, voluntary approaches have self-selection bias: already conscientious opioid prescribers are those likely to use PDMPs. Clear benefits can derive from increased prescriber participation in PDMPs. When prescribers query the database for a patient’s prescription history, they have access to information about the dose, supply, and prescriber of scheduled drugs the patient has filled. With knowledge of this information, practitioners can communicate with patients about their histories, avoid polypharmacy, and refrain from supplying opioids to those who “doctor shop” while comfortably prescribing to those who do not. When a critical mass of prescribers use PDMP information, the collective care each patient receives across providers theoretically can be improved and efficiencies are less likely to be compromised by any one uninformed practitioner. Moreover, prescribers may become accustomed to new practice norms, in which improved information and patient outcomes outweigh perceived burdens associated with checking PDMPs. But are mandates an effective way to increase PDMP use and improve prescribing outcomes? Twenty states require licensed prescribers to register with the state PDMP.8 Use mandates go a step further and dictate the circumstances for PDMP queries. Some states require prescribers to access a patient’s prescription history in the database if they suspect drug abuse; others rely on objective criteria (eTable in the Supplement). In Kentucky, Tennessee, New York, and Ohio—early adopters of comprehensive use mandates—there were substantial increases in queries and reductions in opioid prescribing following implementation. In New York, Tennessee, and Ohio, there were declines in doctor shopping.3,5 Although these results must be rigorously validated, for example, by comparing them to outcomes in states without mandates and controlling for co-interventions, they suggest the potential influence of mandates to reduce unsafe opioid prescribing. Mandates face significant prescriber opposition across the country.5,6 Some objections relate to generic problems with PDMPs that would be exacerbated under a mandate. Prescribers have difficulty obtaining logins, systems can be “down,” information is not integrated into clinical workflow, and data are often incomplete.9 Moreover, minimal guidance exists to assist users in interpreting query results. These drawbacks burden and create ambiguity for physicians and other prescribers. Other objections are specific to mandating PDMP use. Robust evidence is lacking about how to best target mandates to prescriber types and contexts, which makes defining exemptions a policy challenge. Bluntly framed mandates could require physicians and other prescribers to search PDMPs when not clinically indicated or waste time that could be spent otherwise treating patients. Although mandates are not meant to deter opioid prescribing per se, resistant clinicians may simply decline to prescribe opioids, raise prescribing thresholds, refer patients elsewhere, or substitute to nonmonitored drugs–all of which could compromise appropriate symptom management. Mandates also can entail substantial punitive consequences for prescribers. Penalties for failure to appropriately use PDMPs range from increased liability risk to loss of licensure or imprisonment–an extraordinary punishment for failing to access a website that may contain information of uncertain value (eTable in the Supplement). Mandates may influence courts to hold physicians negligent–for example, when a patient overdoses and harms herself or a third party–if PDMP data could have raised concerns about abuse and modified prescribing. To allay penalty concerns, about half of states explicitly provide that prescribers are immune from liability for checking or failing to check the PDMP. Whether these immunity grants provide meaningful protection remains to be seen. Calls for more judicious opioid-prescribing practices and discretionary PDMP use have thus far failed to significantly curtail opioid abuse.10 Although increasing PDMP use seems crucial, mandates may be only one of several paths forward. Policymakers should seriously explore and evaluate more positive approaches, including pay-for-performance, malpractice discounts, or immunity from liability for prescribers who diligently use the systems. Prescription drug monitoring program mandates are a proliferating policy tool. It will be critical to strike a balance between addressing legitimate practitioner concerns and retaining features fundamental to mandate efficacy. System imperfections, such as the lack of real-time, interstate data and lack of full integration into clinical workflow, are important drawbacks that should be addressed. However, these limitations do not render PDMPs useless, nor should they block mandates altogether. But PDMPs should enroll prescribers automatically and without difficulty. Furthermore, mandates should be implemented only when they cover clinically appropriate circumstances and include exceptions similar to those adopted in New York (eTable in the Supplement). Requirements must be evaluated regularly and rigorously. Developing guidance based on available evidence and expert consensus about how to use PDMP data to improve the quality of pain prescribing must also be prioritized. Mandates have potential, but their viability and success will depend on how carefully they are crafted, reviewed, and refined going forward.

Prescription Drug Monitoring Programs: Examining Limitations and Future Approaches

STUDY OBJECTIVE We compare emergency provider impression of drug-seeking behavior with objective criteria from a state prescription drug monitoring program, assess change in opioid pain reliever prescribing after prescription drug monitoring program review, and examine clinical factors associated with suspected drug-seeking behavior. METHODS This was a prospective observational study of emergency providers assessing a convenience sample of patients aged 18 to 64 years who presented to either of 2 academic medical centers with chief complaint of back pain, dental pain, or headache. Drug-seeking behavior was objectively defined as present when a patient had greater than or equal to 4 opioid prescriptions by greater than or equal to 4 providers in the 12 months before emergency department evaluation. Emergency providers completed data forms recording their impression of the likelihood of drug-seeking behavior, patient characteristics, and plan for prescribing pre- and post-prescription drug monitoring program review. Descriptive statistics were generated. We calculated agreement between emergency provider impression of drug-seeking behavior and prescription drug monitoring program definition, and sensitivity, specificity, and positive predictive value of emergency provider impression, using prescription drug monitoring program criteria as the criterion standard. A multivariate logistic regression analysis was conducted to determine clinical factors associated with drug-seeking behavior. RESULTS Thirty-eight emergency providers with prescription drug monitoring program access participated. There were 544 patient visits entered into the study from June 2011 to January 2013. There was fair agreement between emergency provider impression of drug-seeking behavior and prescription drug monitoring program (κ=0.30). Emergency providers had sensitivity 63.2% (95% confidence interval [CI] 54.8% to 71.7%), specificity 72.7% (95% CI 68.4% to 77.0%), and positive predictive value 41.2% (95% CI 34.4% to 48.2%) for identifying drug-seeking behavior. After exposure to prescription drug monitoring program data, emergency providers changed plans to prescribe opioids at discharge in 9.5% of cases (95% CI 7.3% to 12.2%), with 6.5% of patients (n=35) receiving opioids not previously planned and 3.0% (n=16) no longer receiving opioids. Predictors for drug-seeking behavior by prescription drug monitoring program criteria were patient requests opioid medications by name (odds ratio [OR] 1.91; 95% CI 1.13 to 3.23), multiple visits for same complaint (OR 2.5; 95% CI 1.49 to 4.18), suspicious history (OR 1.88; 95% CI 1.1 to 3.19), symptoms out of proportion to examination (OR 1.83; 95% CI 1.1 to 3.03), and hospital site (OR 3.1; 95% CI 1.76 to 5.44). CONCLUSION Emergency providers had fair agreement with objective criteria from the prescription drug monitoring program in suspecting drug-seeking behavior. Program review changed management plans in a small number of cases. Multiple clinical factors were predictive of drug-seeking behavior.

Tourniquet Use in a Civilian Emergency Medical Services Setting: A Descriptive Analysis of the Boston EMS Experience

OBJECTIVES The objective was to evaluate the prevalence of limited health literacy and its association with sociodemographic variables in emergency department (ED) patients. METHODS This was a cross-sectional survey in three Boston EDs. The authors enrolled consecutive adult patients during two 24-hour periods at each site. They measured health literacy by the short version of the Test of Functional Health Literacy in Adults (S-TOFHLA). Using multivariate logistic regression, the authors evaluated associations between sociodemographic variables and limited health literacy, as classified by S-TOFHLA scores. RESULTS The authors enrolled 300 patients (77% of eligible). Overall, 75 (25%; 95% confidence interval [CI] = 20% to 30%) of participants had limited health literacy. Limited health literacy was independently associated with older age (compared to 18-44 years, odds ratio [OR] 4.3 [95% CI = 2.0 to 9.2] for 45-64 years and OR 3.4 [95% CI = 1.4 to 8.5] for >or=65 years), less education (compared to high school graduates, OR 2.7 [95% CI = 1.1 to 7.3] for some high school or lower and OR 0.43 [95% CI = 0.21 to 0.88] for some college or higher), and lower income (OR 2.8 [95% CI = 1.2 to 6.6] for <or=

Single-operator ultrasound-guided intravenous line placement by emergency nurses reduces the need for physician intervention in patients with difficult-to-establish intravenous access.

40,000 compared to >

Emergency department patient knowledge, opinions, and risk tolerance regarding computed tomography scan radiation.

40,000). Although ethnicity, race, and language were associated with limited health literacy in unadjusted analyses, the associations were not significant on multivariate analysis. CONCLUSIONS In this sample, one-quarter of ED patients would be expected to have difficulty understanding health materials and following prescribed treatment regimens. Advanced age and low socioeconomic status were independently associated with limited health literacy. The ability of a significant subgroup of ED patients to understand health information, especially during illness or injury, requires further study.

Characteristics of state prescription drug monitoring programs: a state-by-state survey.

Prescription drug abuse is a leading cause of accidental death in the United States. Prescription drug monitoring programs (PDMPs) are a popular initiative among policy makers and a key tool to combat the prescription drug epidemic. This editorial discusses the limitations of PDMPs, future approaches needed to improve the effectiveness of PDMPs, and other approaches essential to curbing the rise of drug abuse and overdose.