Emergency physician Breena Taira, MD, MPH, sees a certain kind of patient fairly frequently at Olive View-UCLA Medical Center in Sylmar, CA. “A young male, maybe 18 or 19, presents with chest pain,” she said. “We order an EKG, and maybe an x-ray and blood work, his heart and lungs look fine, and we discharge him home. But then he shows up again a day or two later with the same complaint, and we repeat the whole thing.”
Finally, after his third or fourth visit to the county-funded hospital, someone will think to ask the young man what else is going on in his life, and if everything is OK at home. “And then we find out that he's been a victim of gang violence in El Salvador, his whole family is still there and receiving daily threats. He just arrived in the United States and is undocumented and living on the streets with no money,” said Dr. Taira, a health sciences clinical assistant professor at David Geffen UCLA School of Medicine and Olive View's research director for emergency medicine. “This isn't uncommon. A patient like this doesn't need a fourth evaluation of his heart and lungs—he needs legal help, protection from the gangs, and a place to stay.”
Overdiagnosis and overtreatment has been called an epidemic in American medicine, and emergency medicine is far from immune to this problem. CT and magnetic resonance imaging (MRI) studies ordered in the ED have increased three- and ninefold, respectively, between 2001 and 2010, with little evidence to suggest that this has led to improved care, as a 2015 article noted. (Acad Emerg Med 2015;22:1484.) “For example, despite the increased use of CT to diagnose pulmonary embolism (PE) and the greater number of PEs diagnosed, mortality from PE remains unchanged,” noted lead author Christopher R. Carpenter, MD, an associate professor of emergency medicine and the director of evidence-based medicine for emergency medicine at Washington University in St. Louis.
And it's not just imaging: other frequently-deployed tests, such as cardiac stress testing for patients at low risk of acute coronary syndrome or coronary artery disease, also have a small therapeutic benefit that experts say does not outweigh the burden of false-positive results that lead to costly, invasive further testing.
“In emergency medicine, we are constantly under pressure to see more patients in less time, and make no mistakes,” Dr. Carpenter said. “No one rewards you at any stage of your career for ordering fewer tests. Consultants will pat you on the back, and we perceive less malpractice risk by ordering tests, regardless of what the tests show.”
Still Not Choosing Wisely
The national Choosing Wisely campaign aims to end such practices, promoting conversations about appropriate care between patients and physicians and avoiding care when its harm may outweigh benefits. The American College of Emergency Physicians announced its list of five “Choosing Wisely” recommendations, leading with “avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules” in October 2013.
But a study released in 2015, focused on seven tests and treatments deemed by Choosing Wisely stakeholders to have limited clinical value, found little change in any of them. Imaging tests for uncomplicated headache and cardiac imaging without a history of cardiac conditions did show small declines, but three of the services remained essentially the same, and two—HPV testing in women under 30 and prescription NSAIDs among patients with select chronic conditions (including hypertension and heart failure)—actually went up. (JAMA Intern Med. 2015;175:1913.)
Whether Choosing Wisely will have a similarly minimal impact on emergency medicine remains to be seen because its recommendations are newer, but early signs are not encouraging. A survey of emergency department chairs and division chiefs published in 2015 found that 84 percent had heard of the Choosing Wisely campaign, but only about half could recall any of the ACEP recommendations, and only 45 percent had discussed this issue with patients. (Acad Emerg Med 2015;22:1506.)
“We need a genuine paradigm shift in medicine,” Dr. Carpenter said. “We have to stop thinking that more is better, whether it's scans, tests, or treatments. We have to make sure that every test and treatment we order is value-added and aligned with the patient's priorities.”
That's one of the goals of the Right Care Alliance, a project created by the Lown Institute, a think tank founded by Nobel Prize-winning cardiologist Bernard Lown, MD. The alliance focuses on overtreatment but also undertreatment and mistreatment. “Our vision is of a transformed system in which the pursuit of health is a right and healthcare is based on healing relationships, is close to home, affordable, effective, and just. We all deserve a system in which health professionals and patients alike experience the care they give and receive as necessary and meaningful,” according to the organization's website. (http://rightcarealliance.org/our-vision.)
Harms the System
The alliance consists of about a dozen specialty- and profession-focused councils, including one in emergency medicine, which states on its web page that “the ED decision to hospitalize a patient, and especially to initiate ICU care, is enormously expensive; when done in patients where this is not needed, it harms the overall system in economic terms and in lost opportunity cost. Furthermore, unnecessary high-intensity emergency department care is a leading cause of emergency department overcrowding, a crisis throughout the [United States], which in turn results in increased medical errors, worse outcomes, and further overcrowding.”(http://bit.ly/2sU3hEQ.)
Dr. Taira, who serves on the alliance's organizing committee for the Emergency Medicine Council, said the group is now drafting a list of emergency medicine-focused right care priorities that should be released by the end of the summer.
“It really is appropriate to talk about right care rather than overdiagnosis,” Dr. Taira stressed. “Because I work in a public hospital in LA, my day-to-day interaction is largely with patients who can't get care, but the national trends are more in overtreatment and overdiagnosis. These things go hand in hand. Overdiagnosis and overtreatment and the systemic factors—such as supply-driven care—that spur these things on, also create more limited access to care in marginalized populations. To my mind, it's a question of an equitable distribution of care.”
Jerome Hoffman, MD, a professor of emergency medicine at UCLA's David Geffen School of Medicine, serves on the alliance's Science and Evidence Council. He agreed with Dr. Taira that a profit-driven health care system has created over- and undertreatment.
“The many Americans who are un- or underinsured are routinely harmed by limited access to care, even when it's truly necessary because spending money on them eats into profits. But for a great many others, who can pay and who may feel immunized against the outrageous prices by the intermediary of insurance, overdoing is what maximizes profits ... so that's what our system incentivizes us to do.”
If the very system upon which health care is built is what's driving over- and undertreatment, what can individual emergency physicians, or even emergency medicine as a whole, possibly do to change things?
Plugging the Dike
“I don't think it's hopeless,” Dr. Hoffman said. “In the big picture, we need a radically different health care system. So, yes, we cannot try to avoid the hard work of creating a national movement, involving not just medical professionals but also a public that is already furious about the cost of care in the U.S. But we also can and must take incremental steps along the way. Educating the public and ourselves about the many myths that are used to fool us—that more is always better, for example, or that higher profits drive innovation, or that technology will solve our problems—is an essential step in driving long-term change. But when such education is done in the context of addressing overtesting and overtreatment, it can also help put a finger in the proverbial dike so we don't all drown while waiting for the larger changes to occur.”
How does that happen? Dr. Carpenter advised emergency physicians to start small, choosing one issue at their institution to focus on, ideally an area that has the potential for some focused testing on patients most likely to benefit and in which emergency medicine can form some alliances with other areas, such as radiology or laboratory medicine.
“At our institution, for example, we've focused on unnecessary CTs for pulmonary embolisms,” he said. “We felt that we were doing too many. So we put together a series of journal clubs involving radiology, a PE specialist, and community hospital colleagues from emergency medicine. Together, we created an algorithm that pops up every time we go to order a CT for a suspected PE, and I think it's been very good at getting people to stratify these patients appropriately.”
The data have not yet been published, but Dr. Carpenter said it showed a 15 percent decrease in CT scans in this population.
Decision support algorithms can be important tools in reducing unnecessary use of tests and treatments, Dr. Hoffman agreed, citing referrals to observation units as an example. “Literature shows that when we admit people to the obs unit, less than one percent prove to have anything requiring intervention. Now, you can't do much better than less than one percent in picking out low-risk patients. So maybe we should have a decision tool saying that every patient you're going to admit to observation you should send home instead, and if you want to violate that, you have to take this extra step.”
Dr. Taira said stressing shared decision-making can improve over- and underdiagnosis and treatment. “We need to sit down and talk with our patients more about our clinical decisions. If you're debating whether or not to use an expensive test, break down that decision-making, clearly outline the risks and benefits, and involve the patient in your decision,” she said. “Practitioners often assume patients want more and more tests and treatments, but when risks and benefits are described, they often choose less than what the practitioner might expect. That's something we can start to do right away in our day-to-day practices.” (Dr. Carpenter also co-authored an article on making this work in the fast-paced, high-pressure setting of the ED, which appeared in Academic Emergency Medicine [2015;22(7):856].)
Many of these steps could be effective at addressing overtreatment, but what options do emergency physicians have to deal with undertreatment on a day-to-day basis, given the lack of universal health coverage? That issue, Dr. Taira said, requires incorporating principles of social emergency medicine into practice. “We have to recognize that ED visits are not just spawned by biomedical problems. People have social emergencies: lack of food, lack of housing, and so on, that either contribute to their medical problems or are the root cause of their presentations to ED in and of themselves.
“We're trained in emergency medicine to ask if there is a life-threatening emergency—yes or no? But in a biopsychosocial model of health, the root cause of ED visits and the perception of an emergency may stem from psychiatric or social causes. Recognizing that those are also causes of ED visits and trying to link patients with appropriate care is really important,” she said.
Drs. Carpenter, Taira, and Hoffman all encouraged emergency physicians to get involved with the Right Care Alliance's Emergency Medicine Council, which is open to all practitioners in emergency medicine. More information is available online at http://bit.ly/2sU3hEQ.
“None of us likes to do things we feel are inappropriate or wrong,” Dr. Hoffman said. “But the pressures are real and powerful. We would love to have a solution that would allow us to do what we know is right. Doctors are ready to change if we're given the opportunity to do that.”
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