CT Scans to Determine Heart Disease in the Emergency Room

Courtesy of Physorg.com, Nov 27, 2007. Source: University of Pennsylvania.

In the future, patients who arrive at a hospital Emergency Department complaining of chest pain may be diagnosed with a sophisticated CT scan. If the diagnosis is negative, the patient can go home—and the total time at the hospital will be much shorter than it is today.

That is the theory behind a study being presented at the RSNA (Abstract ID: 5009389) by Rajan Agarwal, M.D., a resident in Radiology at the University of Pennsylvania School of Medicine.

“The cost of chest pain triage (where patients in the Emergency Department are prioritized based on their symptoms) and management has been estimated to be as high as $8 billion annually, with most patients ultimately not having to remain in the hospital. Therefore,” Dr. Agarwal states, “there is a tremendous opportunity to reduce health care costs if we can demonstrate the cost-effectiveness of this procedure with low-risk patients who go to the Emergency Department.”

Further, this reduced length of stay improves resource utilization by decreasing costs, improving inpatient bed shortages and reducing crowding in the Emergency Department.

In the study, a total of 202 patients, older than age 30, who came to the Emergency Department at the Hospital of the University of Pennsylvania between October 2005 and February 2007, and whose primary complaint was chest pain, were given an electrocardiogram and a specialized CT scan.

Patients were excluded from the study who were allergic to an iodine contrast, had an abnormal heart rate or could not take beta blockers. Patients who were admitted to the hospital were also excluded.

“We looked to determine the length of stay and times between critical points in the treatment of low-risk patients,” Dr. Agarwal explained.

“Patients were divided into three areas: all patients who received CT scans; patients who received the scans during 7 a.m. to 6 p.m. (ON hours) when the scans were available and 6 p.m. to 6 a.m. (OFF hours) when the scans were not available.

Results showed that patients who came into the Emergency Department during ON hours spent a total of 9 hours and 39 minutes in the department before being discharged; patients who came to the Emergency Department during OFF hours spent a total of 12 hours and 15 minutes in the unit. Patients who were referred to the CDU (Clinical Decision Unit, which provided the CT scan, as well as additional evaluation and observation) spent 21 hours and 50 minutes in the hospital if they came during ON hours and 18 hours and 38 minutes if they came during OFF hours.

Future studies, Dr. Agarwal suggests, will look at all the costs, including lab tests and diagnostic tests, associated with a low-risk patient’s visit to the Emergency Department.

Google Uses Searches to Track Flu’s Spread

New York Times - Technology

By MIGUEL HELFT

Published: November 11, 2008

SAN FRANCISCO — There is a new common symptom of the flu, in addition to the usual aches, coughs, fevers and sore throats. Turns out a lot of ailing Americans enter phrases like “flu symptoms” into Google and other search engines before they call.

That simple act, multiplied across millions of keyboards in homes around the country, has given rise to a new early warning system for fast-spreading flu outbreaks, called Google Flu Trends.

Tests of the new Web tool from Google.org, the company’s philanthropic unit, suggest that it may be able to detect regional outbreaks of the flu a week to 10 days before they are reported by the Centers for Disease Control and Prevention.

In early February, for example, the C.D.C. reported that the flu cases had recently spiked in the mid-Atlantic states. But Google says its search data show a spike in queries about flu symptoms two weeks before that report was released. Its new service at google.org/flutrends analyzes those searches as they come in, creating graphs and maps of the country that, ideally, will show where the flu is spreading.

The C.D.C. reports are slower because they rely on data collected and compiled from thousands of health care providers, labs and other sources. Some public health experts say the Google data could help accelerate the response of doctors, hospitals and public health officials to a nasty flu season, reducing the spread of the disease and, potentially, saving lives.

“The earlier the warning, the earlier prevention and control measures can be put in place, and this could prevent cases of influenza,” said Dr. Lyn Finelli, lead for surveillance at the influenza division of the C.D.C. From 5 to 20 percent of the nation’s population contracts the flu each year, she said, leading to roughly 36,000 deaths on average.

The service covers only the United States, but Google is hoping to eventually use the same technique to help track influenza and other diseases worldwide.

“From a technological perspective, it is the beginning,” said Eric E. Schmidt, Google’s chief executive.

The premise behind Google Flu Trends — what appears to be a fruitful marriage of mob behavior and medicine — has been validated by an unrelated study indicating that the data collected by Yahoo, Google’s main rival in Internet search, can also help with early detection of the flu.

“In theory, we could use this stream of information to learn about other disease trends as well,” said Dr. Philip M. Polgreen, assistant professor of medicine and epidemiology at the University of Iowa and an author of the study based on Yahoo’s data.

Still, some public health officials note that many health departments already use other approaches, like gathering data from visits to emergency rooms, to keeping daily tabs on disease trends in their communities.

“We don’t have any evidence that this is more timely than our emergency room data,” said Dr. Farzad Mostashari, assistant commissioner of the Department of Health and Mental Hygiene in New York City.

If Google provided health officials with details of the system’s workings so that it could be validated scientifically, the data could serve as an additional, free way to detect influenza, said Dr. Mostashari, who is also chairman of the International Society for Disease Surveillance.

A paper on the methodology of Google Flu Trends is expected to be published in the journal Nature.

Researchers have long said that the material published on the Web amounts to a form of “collective intelligence” that can be used to spot trends and make predictions.

But the data collected by search engines is particularly powerful, because the keywords and phrases that people type into them represent their most immediate intentions. People may search for “Kauai hotel” when they are planning a vacation and for “foreclosure” when they have trouble with their mortgage. Those queries express the world’s collective desires and needs, its wants and likes.

Internal research at Yahoo suggests that increases in searches for certain terms can help forecast what technology products will be hits, for instance. Yahoo has begun using search traffic to help it decide what material to feature on its site.

Two years ago, Google began opening its search data trove through Google Trends, a tool that allows anyone to track the relative popularity of search terms. Google also offers more sophisticated search traffic tools that marketers can use to fine-tune ad campaigns. And internally, the company has tested the use of search data to reach conclusions about economic, marketing and entertainment trends.

“Most forecasting is basically trend extrapolation,” said Hal Varian, Google’s chief economist. “This works remarkably well, but tends to miss turning points, times when the data changes direction. Our hope is that Google data might help with this problem.”

Prabhakar Raghavan, who is in charge of Yahoo Labs and the company’s search strategy, also said search data could be valuable for forecasters and scientists, but privacy concerns had generally stopped it from sharing it with outside academics.

Google Flu Trends avoids privacy pitfalls by relying only on aggregated data that cannot be traced to individual searchers. To develop the service, Google’s engineers devised a basket of keywords and phrases related to the flu, including thermometer, flu symptoms, muscle aches, chest congestion and many others.

Google then dug into its database, extracted five years of data on those queries and mapped it onto the C.D.C.’s reports of influenzalike illness. Google found a strong correlation between its data and the reports from the agency, which advised it on the development of the new service.

“We know it matches very, very well in the way flu developed in the last year,” said Dr. Larry Brilliant, executive director of Google.org. Dr. Finelli of the C.D.C. and Dr. Brilliant both cautioned that the data needed to be monitored to ensure that the correlation with flu activity remained valid.

Google also says it believes the tool may help people take precautions if a disease is in their area.

Others have tried to use information collected from Internet users for public health purposes. A Web site called whoissick.org, for instance, invites people to report what ails them and superimposes the results on a map. But the site has received relatively little traffic.

HealthMap, a project affiliated with the Children’s Hospital Boston, scours the Web for articles, blog posts and newsletters to create a map that tracks emerging infectious diseases around the world. It is backed by Google.org, which counts the detection and prevention of diseases as one of its main philanthropic objectives.

But Google Flu Trends appears to be the first public project that uses the powerful database of a search engine to track a disease.

“This seems like a really clever way of using data that is created unintentionally by the users of Google to see patterns in the world that would otherwise be invisible,” said Thomas W. Malone, a professor at the Sloan School of Management at M.I.T. “I think we are just scratching the surface of what’s possible with collective intelligence.

Conventional Wisdom on Uninsured Use of the ED Is Only Half True

By Emily P Walker, Washington Correspondant, MedPage Today

Published Oct 21, 2008

ANN ARBOR, Mich. Oct. 21 -- Three of the six most common assumptions about emergency department use by uninsured patients are false, and three are supported by fact but are true for all ED users, insured and uninsured, according to researchers here.

The single most common assumption -- that uninsured patients present to the ED for non-urgent, inappropriate care -- is one of the three not clearly supported by current data, Manya F. Newton, M.P.H., M.S., of the University of Michigan, and colleagues reported in the October 22/29 issue of the Journal of the American Medical Association.

From 1997 through 2005, non-urgent ED visits by uninsured patients increased from 11% to 16.7%, but that was just slightly greater than the four-percentage-point jump in overall visits, according to the National Hospital Ambulatory Medical Care Survey cited by the study authors.

Policy decisions are often borne from supposed "conventional wisdom" regarding the emergency department use by the uninsured expressed in medical literature, by policy makers, and in the media, the researchers said, but many of those claims have yet to be vetted.

So, to see if facts support oft-repeated statements, they examined 127 peer-reviewed studies or editorials published from 1950 through September 2008 that dealt with ED use by uninsured adults ages 18 to 65, excluding visits for psychiatric or dental care.

The researchers pinpointed the six most frequent assumptions from the literature and culled current peer reviewed studies and national data to back them up -- or refute them.

The other five most common assumptions about uninsured patients, in order, were that they:

lack access to primary care

were using ED facilities more frequently

cause overcrowding

present more often than insured patients

were more expensive to treat in the ED than elsewhere

Adding perspective to the issue that the uninsured present with non-urgent problems, the researchers noted that the uninsured are less likely to be admitted than their insured counterparts. But the truth may be that physicians have a higher threshold to admit uninsured patients than they do for insured patients, the researchers said.

As for the assumption that uninsured patients seek out primary care in the ED because they have nowhere else to go: It is true, the researchers said.

"The problems leading to this national decrease in access to primary care are complex, but substantial evidence exists that uninsured patients' access to sources of care other than the ED has decreased and that ED visits for conditions that could have been prevented with adequate primary care have increased," the researchers wrote.

The percentage of uninsured patients who are evaluated in physicians' offices decreased by 37% between 1996 and 2001, researchers said.

They found that the assumption that the number of uninsured patients presenting to the ED is on the rise is partially supported by current data. But more patients -- both insured and uninsured -- are coming to EDs, so the increase is across the board rather than localized to just uninsured patients.

However, the assumption that uninsured patients are to blame for ED overcrowding is not clearly supported by data.

Of the approximately 115 million annual ED visits, just 17% are made by uninsured patients, which is similar to the proportion of insured and uninsured patients, which suggests that "neither group uses the ED disproportionately," the researchers said.

And ED overcrowding is still an issue in countries with universal insurance, such as Canada and Australia, indicating that the tie between the uninsured and clogged emergency departments isn't necessarily as strong as current rhetoric would indicate.

"The etiology of crowded EDs is multifactorial and includes a lack of staffed inpatient beds, hospital and ED closings, increased ED use by all patients, and an aging population with increasing prevalence of chronic illnesses," the authors wrote.

Although nationally, the uninsured don't account for a large portion of the patients seen at an ED, the researchers noted that in underserved areas, the problem may be more acute.

Another assumption that is true: It is much more expensive to treat uninsured patients in the ED than in other settings such as a physician's office or an urgent care center.

The authors cited a 2005 RAND study that determined that the average cost of treating a patient in the emergency department is between $300 and $400, supporting the "common perception that the ED is an expensive and inefficient place to receive most non-urgent care."

Lastly, the assumption that uninsured patients present more often to the ED than insured patients is not supported, the researchers said.

Half of the studies reviewed found that to be true, but half found no difference in usage patterns between insured and uninsured patients.

Publicly-insured patients, however, do present to the ED much more often than uninsured patients, the researchers said.

Three less common assumptions -- that the uninsured delay seeking care, that they are sicker when they do, and that the uninsured receive less care are "well supported by current data," the researchers said.

They noted that a fourth less common assumption, that uninsured patients go to the ED because it's more convenient to do so, is difficult to prove or disprove because there is no consistent definition of convenience.

The authors noted several limitations to the study, including the fact that it relied entirely on assumptions about ED use that were expressed in the medical literature. A more complete study would include statements by media, policy makers, and private citizens that are expressed as conventional wisdom.

What do you think of this article? Do you believe the research is correct? Submit opinions here on this blog, by clicking the link below.

Health Care Industry Not Immune to Recession

From the St. Louis Today Website (www.stltoday.com)

When people make sacrifices in a tough economy, they usually don't start with their health.

That's one reason the health care industry, if not exactly recession-proof, seems one of the best able to endure the economic downturn.

St. Louis' growing medical sector includes the area's largest employer, BJC HealthCare, with 23,500 workers. Not only are local hospitals not experiencing layoffs, many will continue to hire skilled workers, said Dave Dillon, spokesman for the Missouri Hospital Association.

"There's always going to be a demand for health care," Dillon said .

During economic downturns, sales of prescription drugs and medical devices tend to hold up better than nonessential goods, noted David Wyss, chief economist of Standard and Poor's.

"Generally, you're looking for things that are necessities, not luxuries," Wyss said. "People get sick and need medical care regardless of the state of the economy."

But recent earnings show that drug makers aren't immune from slumping sales that have plagued their peers in the retail and auto industries. Pfizer, which employs 1,200 people in its labs in the St. Louis area, said last month that U.S. sales of its best-selling product, the cholesterol drug Lipitor, fell 13 percent in the last quarter as some financially struggling patients stopped filling their prescriptions.

"The typical safe harbors (for investors) have been pharmaceuticals," said analyst Steve Brozak of WBB Securities. "They're no longer safe; they're now the least bad choice."

Pfizer and Schering-Plough Corp. were able to offset weak revenue in the U.S. with higher sales abroad. But other companies, such as Merck & Co. Inc., have been less successful. Merck said recently it will cut 7,200 jobs after reporting sales declines.

Experts say pharmaceuticals are more vulnerable to economic cycles because employers have shifted more of the financial burden for care to patients, with higher copays and deductibles.

"With consumers having more cost-sharing in their benefits, you're going to see a greater effect on their health care spending right away," said Paul Ginsburg, President of the nonprofit Center for Studying Health System Change.

That means more uninsured or under-insured patients seeking care through hospital emergency rooms and other safety-net providers. Between 2000 and 2005, 125,000 people in Missouri went off employment-based health insurance, said James Kimmey, president and CEO of the Missouri Foundation for Health.

"If the recession leads even more employers to back down a bit from their current coverage levels, it could increase the uninsured pretty fast," Kimmey said.

The lagging economy and rising unemployment have made it harder for health insurers such as UnitedHealth Group Inc. and Humana Inc. to raise prices to offset higher costs and investment losses.

Health care companies least affected are those that sell inexpensive medical products directly to hospitals, bypassing cash-strapped consumers.

Becton, Dickinson & Co. and Baxter International Inc., for example, reported sharp profit gains for the most-recent quarter and boosted their full-year earnings estimates. Becton Dickinson specializes in syringes and surgical tools; Baxter sells drugs to treat blood and immune disorders.

"The products they offer aren't high-tech things," said Aaron Vaughn, an analyst with Edward Jones. "They are health care staples that people need."

A focus on lifesaving medicine also is expected to reward makers of high-priced biotech drugs.

Genzyme Corp. and Celgene Corp., for example, have built businesses around niche drugs for life-threatening diseases. Health care investment firm Leerink Swann gives both companies an "outperform" rating, along with peers Amgen Inc., Biogen Idec Inc. and Gilead Sciences Inc.

Texas Medical Board Issues Record Number of Physician Licenses

From the Texas Medical Board Fall 2008 Newsletter, found at www.tmb.state.tx.us

With the help of additional resources appropriated by the Texas Legislature, along with some streamlining of its processes, the Texas Medical Board set a record in Fiscal Year 2008 by licensing more than 3,600 doctors. This surpassed the previous record, set in FY 2007, by almost 300 licenses. TMB also eliminated an application backlog that had grown to more than 500 applications by February. The Board also took steps to improve efficiency in the application processing system by conducting a statewide series of licensing seminars to provide training for credentialing, recruiting and other health care entity staff responsible for assisting physicians with their licensure applications. Fewer mistakes on completed applications will usually result in faster processing time.

 “Texas is a popular place to practice medicine, as evidenced by the dramatic increase over the past few years in the number of doctors who apply to be licensed here,” said Dr. Roberta Kalafut, TMB’s board president. “We have applicants coming to Texas from all over the country and all over the world.

 “Our staff has responded to this greatly increased and varied demand,” Dr. Kalafut said. “We are issuing more licenses than ever, more quickly than ever, and we have eliminated the backlog of applications awaiting processing, all without compromising the quality of physicians licensed in Texas.”

 TMB licensed 3,621 doctors in FY 2008, an increase of almost nine percent over the former record of 3,324 licenses that were issued in FY 2007. The 2007 record eclipsed by almost 500 licenses the previous record, 2,828 licenses, which were issued in FY 2002.

 Processing times for licenses also have been greatly reduced, and exceed legislative requirements. The Board licensed 1,549 doctors in the fourth quarter of 2008 in an average of 42 days. The Texas Legislature in 2007 appropriated six additional employees for the licensing division, while mandating that licenses be issued in an average of 51 days or less.

 To build on this success, during the spring and summer of 2008 TMB conducted 13 licensing seminars in all regions of the state. About 200 individuals attended the three-hour seminars, which offered in-depth instruction on proper preparation of a physician licensure application, with an emphasis on the most common mistakes found on applications. If applications are complete and correct when TMB receives them, processing can be completed much more quickly.

 The training is helpful because of the complexity of license applications. Before TMB can license a physician, it first must determine that the physician’s education and training are substantially equivalent to the medical education and training provided in Texas. This can prove challenging, as TMB last year licensed physicians who were trained in 45 states and 83 other countries.

 Almost 30 percent of the physicians licensed in Texas last year, 1,032, received their medical educations at international schools.

Positive Motion: Helping 3rd World Countries Provide Emergency Medical Care

PositiveMotion is a company dedicated to providing medical equipment to third world countries around the globe. A team of 20 students, medical providers, and their families from Arizona and Texas attended an annual mission trip to New Hope Primary School and Orphanage in Kampala, Uganda. New Hope was started over 8 years ago when preacher Chris Lubega began finding abandoned children on his door step, from tragedies such as AIDS and wars along Uganda's borders. New Hope is now home to more than 800 orphans, 30 teachers and staff. The school provides an education and opportunity for a better future for the children of Uganda. Heading up the Texas team was Dr Eric Wilke, CMO and Medical Director for Affilion. The following is an excerpt from the PositiveMotion website and blog. 

"The idea for PositiveMotion began during a mission trip to Uganda in March of 2008. Noticing the lack available transportation for people who are sick or injured, I began sketching out a motorcycle pulling a modified stretcher. My thought was to create a "motorcycle ambulance" for the third world. I also asked the physicians at Mengo Hospital what the acute equipment needs were. Some of the top items included an ECG machine and IV infusion pumps.

Upon returning to the US, I contacted the Bioengineering Department at Texas A&M and began work on creating a design. Shortly after, I partnered with Dr. Mark Benden, PhD to help further the design process and expand on my original ideas.

Since then, we have teams working on the motorcycle ambulance, an inexpensive ECG machine that interfaces with a laptop and inkjet printer, and an IV infusion pump.

Now, we are launching PositiveMotion as a company to create, produce, and distribute medical devices and products to the developing world. We will continue to post images, video, and blog entries to chronicle our progress. Also, if you have any ideas or contacts to help us with our goal, please contact us."

PositiveMotion.org

CIN Protection: Post Contrast Nephropathy

Dr. Eric Wilke is back again with another insightful video for ER docs.

Click Here for the Google Document Outline

Email Your Comments to Dr. Wilke

Physician Shortage Fuels Local Recruiting Efforts

We all have heard that the physician shortage is getting worse and worse in the United States. According to an article at www.timesnews.net, we'll be short by about 200,000 physicians within the next decade! The article states a projection of 200 job offers for every physician graduating from residency within the next 10 years. 

The article points out that the U.S. government tried to stop the physician shortage back in the 1990's by "dialing down" funding for sub-specialties and "dialing up" funding for primary care. The thought was that having too many specialists in the system would inflate the cost of health care. That led to many well-trained family physicians, but not enough specialists to fill rising needs from, specifically, the baby-boomer generation.

Many recruiters work with excellent hospital systems in great locations across the country, but they're still finding it a burden to recruit. Why? Because there simply aren't enough medical providers to fill the need.

So what does this all mean for you as a physician? How will it affect hospitals and offices as they search for physicians in high demand across the nation? How do companies differentiate themselves and their offers to stay competitive, without breaking the bank? 

Post your thoughts and ideas on the blog by clicking the "comment" link below.

Read the full article  by clicking here . 

Video Blog: Protocol and Order Set for Induced Hypothermia

Affilion's Chief Medical Officer and Medical Director of the College Station Medical Center Emergency Department, Dr. Eric Wilke, MD, has posted an excellent 12-minute video explaining a full-coverage protocol and order set for induced hypothermia.

click here to watch the video

What do you think of this video? Do you have any additional thoughts or comments? Send me an email and I'll pass all questions and comments to Dr. Wilke so he can respond right here, on this site.

email me

Researchers Evaluate the Effect of the Emergency Department Wait on Patient Satisfaction

In the Wall Street Journal Health Blog (read full article here) (10/30), Jacob Goldstein asked "how long is too long?" when it comes to the willingness of patients to happily ride out the emergency department (ED) wait. Researchers at Michigan's William Beaumont Hospital posed the same question, "and got a pretty clear answer: Three and a half hours." After looking "at more than 2,000 patient-satisfaction surveys from the first part of the 2007, "the investigators discovered that "patients whose stays in the" ED " lasted up to there and a half hours had satisfaction scores in the 83rd percentile as compared with patients at comparable" ED's "around the country." For patients "who spent between three and a half and four hours," however, "satisfaction plunged to the 49th percentile," while spending more than four hours waiting pushed that score into the 24th percentile.

Yet, according to a second Health Blog posted by Goldstein in Wall Street Journal (read full article here)(10/30), the researchers found that telling patients that "the wait is a little longer than it's really likely to be" may ironically cause "patients [to] feel better about their trip through the' trauma ward. The researchers "calculated the mean time it took to get through the" ED "for a given test of procedure -- then added 20 percent when they told patients what to expect." Through "a standard patient satisfaction survey," the team discovered that "all nine variables related to wait times improved after the" ED "adopted this policy," according to data presented during a meeting of "the American College of Emergency Physicians meeting." Asked if the practice was ethical, lead investigator Russell Rae, M.D., said that by "providing people with the exact mean time, half of the time we'd be underestimating how long it's going to take." Now, "there are signs up on the" ED "walls that tell patients how long they can expect to wait for various procedures," some "20 percent above the mean."