A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care

In 2010, Dr. Howard Brody wrote:

“the best rebuttal to the antireform argument that all efforts to control medical costs amount to the ‘government getting between you and your doctor’ is to have physicians, not ‘government,’ take the lead in identifying the waste to be eliminated. Mark Twain said, ‘Always do right. This will gratify some people and astonish the rest.’ Today, meaningful health care reform seems to be in danger of taking a back seat to special-interest pleading and partisan squabbling. If physicians seized the moral high ground, we just might astonish enough other people to change the entire reform debate for the better.”

Dr. Brody made an argument for specialty societies to take the lead and develop a list of tests or procedures that are commonly ordered but according to current evidence do not provide meaningful benefit. Many specialty societies joined the Choosing Wisely Campaign and have released their “Top 5” list but ACEP was notably absent from this movement.

We discussed ACEP’s absence from this list at our last advocacy meeting and unanimously agreed that Emergency Medicine should be part of the Choosing Wisely Campaign. Fresh off the heels of this discussion we discovered that ACEP had reversed their decision. They are now a partner in the campaign and plan to reveal their list of “top 5” tests or procedures that should be questioned or discussed and not just routinely ordered.

An article, just released, in the American Journal of Emergency Medicine establishes the case for why it is important for emergency physicians to be stewards of our available resources and to take the lead in establishing what areas of care should be examined for opportunities to reduce costs.

In the article “A ‘Top Five’ list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care,” Drs. Venkatesh and Schuur discuss their recommendations for an approach to developing this top 5 list and the path forward after development of this list.

The authors begin by pointing out that if we as emergency physicians do not take the lead in being stewards of society’s resources and taking responsibility for health care costs, private insurers and government regulators will certainly fill that void and impose policies on the specialty. Furthermore, they argue that we have an ethical obligation to address the cost of care in our departments and that we as emergency medicine experts should define where we can limit testing and in the process demonstrate the value of emergency care.

The first step is to identify overuse. What are the tests, treatments, and disposition decisions that don’t change the care we provide? For example, 37% of all ED patients have a CBC drawn during their ED visit with little evidence that this test affects care. The authors argue that instead of actually doctoring which they say is “emphatic listening, physician examination, and clear communication,” we are too frequently using technology as a crutch. Other areas of overuse that could be targeted were identified. These include CT imaging which has seen a 330% increase in use since 1996 with no increase in diagnostic yield, antibiotics for upper respiratory infections and bronchitis, and IV fluids and medications. A recent study that has been accepted for publication showed that 50% of IVs inserted in an ED were unused.

Another issue the authors took up was the ability of the ED to serve as a definitive site of care. Interestingly, only 6% of patients are discharged without a recommendation for planned follow-up when there is no evidence that the majority of these follow up visits are needed. Most conditions seen in the ED are self-limited and can be treated as such. We as emergency physicians can ease the burden of a significant portion of primary care usage by providing complete diagnosis, treatment and education for conditions that don’t require follow up care.

The authors next addressed barriers to emergency physicians participating in cost reduction. A common cited reason for over-testing is legal concerns, however there is no good evidence that additional testing, or “defensive medicine” provides any medico-legal protections. The authors acknowledge that many hospitals may put pressure on physicians to maintain admissions and a certain level of testing as this is a major contributor to revenue. In the end, emergency physicians should advocate for a patient-centered model of care and a payment system that rewards patient-oriented outcomes and reducing health care spending as opposed to continuing the status quo.

The answers to many of the issues raised may not yet be known and more research needs to be done. However, the creation of a top five list will also help to stimulate research priorities and will likely lead to many more identified opportunities to reduce health care costs while improving emergency care.

It is becoming more clear that if we do not lead the effort to identify areas of overuse within our specialty others will step in and do it for us. It is likely not in our best interest or our patients to have these changes imposed upon us by others whose interests and expertise are different from ours. This article provides a good framework for identifying our “top 5” list and is something we all should read and consider as we try to provide the best care we can for our patients.

For more information, check out the linked papers in the resource section!

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Advocacy Track Workshop: Health Literacy

The IUEM Advocacy Track hosted a workshop entitled “Health Literacy in the Emergency Department: Barriers and Solutions” with the help of our resident expert Jill Sracic and invited guest panelists from the School of Nursing and The Indiana Center for Intercultural Communication. The turnout, passion, and creative conversations about integrating improved patient communication for better health outcomes was inspiring. At one point. Dr. Carol Shieh from the School of Nursing said, “I feel better about my daughter being a second year medical student knowing that there are doctors out there like you.”

According to the 2004 IOM Prescription to End Confusion:

“More than a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic, and conceptual knowledge. Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health. At some point, most individuals will encounter health information they cannot understand. Even well educated people with strong reading and writing skills may have trouble comprehending a medical form or doctor’s instructions regarding a drug or procedure.”

At the end of the session, everyone generated a personal learning point that they planned to incorporate into their practice immediately. Here they are:

1) Stop asking people, “Do you understand?” to end the discharge instruction process. They will usually say yes even when they mean no.
2) Anticipate cultural differences instead of waiting for them to be a problem. Educate yourself on cultures commonly seen in your ED.
3) Talk about the discharge plan on the first visit. That way when you come back, they have had time to think about it.
4) Understand “cultural humility” even in truly emergency situations. What we do can have lasting impact even beyond medical management.
5) Explain how to take medicine then ask the patient to explain it back.
6) Be aware of the differences between us and our patients and try to bridge the gap.
7) The more you know, the more humble you become.
8) Edit discharge instructions.
9) Add a question to the end of the discharge instructions about the content to assess understanding.
10) Verify new medications with the patient and one more person.
11) Communication is not one size fits all.
12) We should try to have a better understanding of a patient’s healthcare environment. (Home, primary care, transportation, etc.)
13) Don’t think only about patients with poor health literacy as deficits. Try to see the strengths they have as well.

Resources:

http://www.healthinfotranslations.org

Indiana Center for Intercultural Communication
http://liberalarts.iupui.edu/icic

Check out the IOM document in the Resources section!

“Caring for patients from different cultures” by Geri-Ann Galanti

LaMorris Crawford – Treating the Impoverished

In the world of emergency medicine, we care for many people who live in poverty. There are many reasons but largely this is due to the fact that we turn no one away. We will see and care for anyone who walks into our department, whether or not they can pay. For those who chose a career in emergency medicine, not choosing who we see was an attractive feature of EM. We are the safety net of medicine and we’re proud of it. The reality of this, however, is that we confront the challenges of caring for those in poverty every day and we are not always equipped to provide optimal care.

There are several barriers as we care for those who live in poverty. Some are unavoidable and need system wide changes. Some, however, come from our own lack of understanding. For this reason we held a workshop about poverty. Our goal was to learn more about the people for whom we provide care. Perhaps this would lead to us providing better care. If not, at the very least, perhaps through a greater understanding of poverty we will also have a greater compassion towards those we encounter in the ED.

In order to accomplish our goal we invited LaMorris Crawford. Crawford was born in Altgeld Gardens on the South side of Chicago. He grew up in a high poverty neighborhood where crime and drugs were the norm. Crawford says that he became a product of his environment, active in gang culture and drug trade. After seeing many of his friends and family end up dead or in jail he knew that he had to make a different life for himself. He completed an associate degree at a local Community College and went on to not only get a Bachelor’s degree but also completed his Master’s in Organizational Leadership. LaMorris now speaks regularly to athletes, sports teams and groups like ours.

Feedback was clear that Crawford’s talk was thought-provoking and challenged how we care for those in poverty. First and foremost he encouraged us to get to know our patients. This doesn’t need to take long but asking a simple question to get to know someone beyond their physical need connects us to them as people and we no longer identify them by their chief complaint. Getting to know our patients not only creates more fulfilling interactions for us but also shows that we care. If our patients leave feeling like they were cared for, it leaves a lasting impact no matter what their body feels like.

Crawford also discussed Assets. He explained that the assets, or what is important to us and vital to our existence, can be so vastly different for those in poverty compared to those in the middle class or living in wealth. Having an understanding of this causes us to remove our preconceived notions of how we think our patients should act or what we think should be important to them. Through a greater understanding of what motivates our patients and what is important to them, we can work alongside them to find the best solution to what ails them instead of feeling like they don’t care or don’t want to do what we think is best for them.

Everyone who was at the poverty workshop was enriched in some way. LaMorris did an amazing job at taking a topic that can certainly be complicated and presenting it in a way that helped us have a better understanding and gave us tools to better care for our patients.

We are grateful to LaMorris for sharing his life experiences with us and giving us insight into the lives of so many of the patients that we see every day. Taking a few extra seconds to show that we care for our patients as people and understand that their daily priorities are different from ours will not only lead to a greater job satisfaction but also to better and more fulfilling patient care.

Check out the presentation at:
LaMorris Crawford – Approaching Poverty

Please join us on September 12 at 6pm for our next Advocacy Track Workshop where we will be focusing on Health Literacy!

Testimonies to Senator Miller

Today Dr. Lindsay Harmon, IUEM grad and current faculty, testified in front of Senator Miller and Committee about a new bill addressing opioid abuse in Indiana. Dr. Harmon addressed specifically the chronic pain program at Methodist hospital and how opioid abuse is handled in the emergency department setting. Other testimonies from previous opioid abuse victims, addiction psychiatrists, pediatricians and other task force members provided enlightening views on how this national issue affects other areas of medicine and the community.

Please visit the following link for more information:
http://www.nabp.net/news/indiana-medical-board-to-adopt-emergency-opioid-prescribing-rules-at-request-of-state-legislature