On "unnecessary" ED visits: background reading

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:

1) Great overview of many systemic issues which funnel patients to emergency departments, by Annals of Emergency Medicine Editor in Chief Mike Callaham*:
The Prudent Layperson’s Complicated and Uncertain Road to Urgent Care

2) We can't discern low acuity diagnoses from chief complaints, by Maria Raven, Robert Lowe, Judith Maselli, and Renee Hsia in JAMA:
Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “ Nonemergency” Emergency Department Visits

3) Low acuity ED visits is just not where the money is, by Peter Smulowitz, Leah Honigman and Bruce Landon, in Annals of EM:
A novel approach to identifying targets for cost reduction in the emergency department.

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 Annals by Brent Asplin et al A conceptual model of emergency department crowding, and 2 of my blog posts 4A) here and 4B) here).

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):
RAND HIE

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:
6) Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care by Jesse Pines in Annals
7) Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending by J Scott Ashwood, Martin Gaynor, Claude Setodji, Rachel Reid, Ellerie Weber, and Ateev Mehrotra in Health Affairs. 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.


*COI: I am Social Media Editor for Annals which makes Mike my boss.

It’s the Medicaid Expansion, Stupid

I came across this nice post:

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.
But wait, "childless adults"? That sounds familiar!

"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."

I followed the link and noticed the normal, understated citation at the bottom of the post:
Source: Kaiser Family Foundation: Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?
The title on KFF's page is, not surprisingly:

Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?

This reminds me of the famous desaturation curve which appears in every airway lecture, as mandated by CMS due to Obamacare:

Note the title of the source of this familiar graph: Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine.

(Benumof, Dagg, Benumof. Anesthesiology. 1997 Oct;87(4):979-82.)

How often are these graphs shared without noting their expressed purpose? 

PE in Syncope: An External Validation of the Wells Score

I'm not going to reinvent the wheel -- see some of the fantastic analyses of PESIT (in no particular order) at:

St. Emlyns - Simon Carley
EM Lit of Note - Ryan Radecki
EMNerd at EMCrit - Rory Spiegel

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.

Just look at Table 2, emphasis mine, which looks a lot like their Table 1, which is (gasp!) the Wells Score:


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.

Literally the only non-Wells factors they find are tachypnea and hypotension.

You cannot make this up: