Study (2003)

Here's a great study that looked at the use of azithromycin for the treatment of acute bronchitis. It demonstrated what any student of this literature would intuit: no benefit. The reason this study is particularly important is because azithromycin (one of two long-acting macrolides on the market today) would appear to be a particularly good choice for the treatment of bronchitis. The macrolides are known to be generally effective against pneumococci, mycoplasma, chlamydia, and other bacterial organisms associated with routine pulmonary infections. In fact, the American Thoracic Society, in their Pfizer-sponsored guidelines for the outpatient treatment of community-acquired pneumonia, specifically advises the use of a long-acting macrolide as the drug of choice. So, if azithromycin is among the drugs of choice for the outpatient treatment of community-acquired pneumonia, it certainly should be great for a case of bronchitis. Wrong. I urge my colleagues, as the winter approaches, to resist the temptation to call colds bronchitis to justify the unjustified use of antibiotics in these patients. If you routinely give antibiotics for bronchitis, patients will attribute the resolution of their symptoms to the antibiotics and you will be justly punished when they keep returning to you over and over for antibiotics each time they start coughing with a chest cold. Azithromycin for Acute Bronchitis: A Randomised, Double-Blind, Controlled Trial, Evans AT, et al, Lancet 2002;359:1648 BACKGROUND: Most adults with acute bronchitis are treated with antibiotics, despite conflicting evidence regarding the clinical benefits of such treatment and concerns about antibiotic resistance. Azithromycin (Zithromax) is a newer broad-spectrum macrolide that is often prescribed for acute bronchitis. METHODS: In this double-blind, controlled study from Cook County Hospital in Chicago, 220 adults diagnosed with acute bronchitis in the absence of underlying lung disease were randomized to a five-day course of azithromycin or vitamin C (each given as 500 mg initially followed by 250 mg daily). Additional treatment in both groups included dextromethorphan syrup and inhaled albuterol. The patients were interviewed at baseline and after three and seven days using a 22-item acute bronchitis health-related quality of life (QOL) questionnaire. RESULTS: There were no statistical or clinical differences between the treatment groups in mean QOL scores on days three or seven, rates of improvement, return to usual activities, repeat physician visits, or perceived adverse effects of medication. Of multiple outcomes measured, the only possible marginal clinical benefit associated with azithromycin related to daily activities and cough on day three only (with a difference of 0.5 points on a six-point scale), neither of which was apparent by day seven. A return to usual activity by day seven was reported by 89 percent of the patients in both groups. Most patients in both groups (81%) felt that the albuterol inhaler was effective. CONCLUSIONS: In this study, azithromycin was not more effective than low-dose vitamin C in adults with acute bronchitis. EKG Reading Privileges Over the past several years, emergency physicians have been wrestling with charging for interpretation of EKGs and imaging studies vs. letting cardiologists and radiologists do so. Clearly, there would be no issue in this debate if money were not involved. Medicare has indicated that it will pay only one physician for EKG and imaging study interpretations, and given that we EPs are the ones who use our own immediate interpretations in the process of medical decision-making, we are, if anyone, the ones most appropriate to bill for the services. There is substantial potential for disagreement in assigning CPT codes Under the smokescreen of hospital credentialing, some have suggested that emergency physicians need to show specific competence to be able to interpret EKGs. Credentialing was never an issue when emergency physicians were not attempting to bill for these services; everyone knew that reading EKGs was among the core competencies of an emergency physician, particularly those who were board certified, and that getting an overread several days later from the EKG reading panel was almost universally a waste of time and of no consequence to patient care. The following commentary is one of only a few that specifically addresses the issue of emergency physician proficiency at reading EKGs. It suggests that criteria proposed by the American College of Cardiology and the American Heart Association are unduly restrictive (I wonder why) and that if anyone is going to establish such criteria it should be emergency physicians. I personally think that the issue of establishing procedural competence in emergency medicine is a fascinating topic. Do the orthopedists certify our ability to tap a joint? Do the plastic surgeons certify our ability to suture lacerations? Do anesthesiologists certify our ability to intubate patients? The obvious answer to all of these questions and many more like it is “no.” Yet, the anesthesiologists at our hospital, driven by the JCAH, became the designated experts in procedural sedation, and drew up the open-book test that all physicians in the hospital had to take if they wanted to be credentialed to perform this procedure. Clearly, this is not the path we should be going down. We must acknowledge that there are core competencies that are intrinsic to being board certified in a specialty, and as such, it is not the prerogative of every specialty in the hospital to certify emergency physicians in procedures more or less unique to their specialty. Emergency Physician Interpretation of the Electrocardiogram, Michelson A, et al, Acad Emerg Med 2002;9(4):317 The American College of Cardiology and the American Heart Association (ACC/AHA) recently issued guidelines for establishing physician proficiency in the interpretation of electrocardiograms. Several organizations that participated in drafting these recommendations, including the Society for Academic Emergency Medicine, disagreed with the final report and refused to endorse it. The authors of this commentary on the ACC/AHA position paper agree with its stated position that all physicians who interpret EKGs as part of clinical decision-making must be sufficiently competent to make a correct diagnosis. They point out that emergency physicians are often the first specialists to assess and treat patients with a cardiovascular emergency, and therefore that such competence is essential for EPs. Citing multiple studies which suggest that EPs are by-and-large already competent to read EKGs in this setting, the authors contend that the proposed ACC/AHA criteria to establish EKG interpretation proficiency (listed in the paper) are far too restrictive, and are not based upon scientific evidence. Furthermore, they note that EPs gain experience interpreting EKGs in the real-life environment of providing patient care, frequently under hectic conditions, and that strategies for teaching EKG interpretation in emergency medicine should therefore be unique to this specialty. They conclude by calling upon the emergency medicine community to develop criteria for establishing competency in EKG interpretation in the ED setting. Variability Found in Coding For any emergency physician particularly interested in the financial side of practice, the following study is absolutely essential reading. It clearly demonstrates what all of us know but none of us has rigorously documented — that coding for emergency services is a very subjective affair. The design of the study was very simple: Give coders charts and compare their coding. Agreement between coders concerning the level of care was, at best, fair. In a whopping 29 percent of cases, coding disagreements of at least two levels were noted. How can such a subjective system exist? It clearly results in inconsistent payment for services. How about a totally new system that is not so rigid about charting? (Did you miss one of the official 14 elements in the review of systems?) How about outpatient and inpatient DRGs for physicians? Although clearly they would be problematic as well, they would be less likely to reward the heavy test orderers among us who routinely turn level 4 cases into level 5 projects, and they would align incentives better. Right now hospitals are pushing to decrease their lengths of stay, but physicians are paid by Medicare on a daily visit basis, a total misalignment of incentives. What if both hospitals and physicians were motivated to get patients out of the hospital in the most medically prudent time frame? Clearly, a DRG system for physicians is not without its problems, but it can't be much worse than what we have now. Reliability of Assigning Correct Current Procedural Terminology-4 E/M Codes, Bentley PN, et al, Ann Emerg Med 2002;40(3):269 BACKGROUND: Current Procedural Terminology-4 (CPT-4) codes have been developed by the AMA, and are used by the federal government as a method of assigning proper levels of reimbursement for medical services. A key assumption in this process is the belief that assigning CPT-4 codes is reliable. Coding discrepancies may be a cause of prosecution for fraud. METHODS: This prospective observational study, based on three separate randomized, blinded trials from the William Beaumont Hospital System in Royal Oak, MI, examined two interagency and one intraagency comparisons for consistency in assigning CPT-4 codes for five levels of evaluation and management in the provision of ED care (codes 99281 through 99285). A kappa level of 0.76 to 1.00 was consistent with excellent agreement, and a level of 0.4 to 0.75 was consistent with fair to good agreement. RESULTS: There was poor agreement (kappa=0.28) in a trial in which 194 ED records were coded by two independent external agencies, and in a separate trial in which 195 ED records also were coded by two independent agencies. In the intraagency trial, 100 randomly selected ED records were separately coded by five professional coders within a single system. The level of agreement was fair (kappa=0.44). In the interagency comparisons, the same codes were assigned by all four agencies for only 15 percent of the charts, and in six percent, there was no agreement among the agencies. Code discrepancies exceeded two levels in 29 percent of the records included in the interagency comparisons. Code distributions were significantly different for all three comparisons. CONCLUSIONS: The findings of this study quantify the substantial potential for disagreement in current methods of assigning CPT codes for medical services. ACLS Medications in Cardiac Arrest Among the techniques advocated in cardiac arrest when IV access is impossible is use of endotracheal drugs. I personally don't recall a patient ever surviving who was treated by this route, but perhaps it was just my own atypical experience. Not according to Jim Neimann and colleagues at Harbor/UCLA Medical Center. They looked at 101 patients getting endotracheal drugs for prehospital cardiac arrests, and found no survivors to discharge. ET administration of ACLS medications was less successful than IV administration in cardiac arrest This is not to say that this technique should be abandoned (or maybe it should), but at the very least, physicians should have no delusions that it is likely to be helpful. This is just one more aspect of ACLS that is more dogma than science, and it is surprising how few studies have been published on this topic over the past 20 years (and the few that have been performed also have demonstrated miserable results). Endotracheal Drug Administration During Out-of-Hospital Resuscitation: Where are the Survivors?, Niemann JT, et al Resuscitation 2002;53:153 BACKGROUND: Endotracheal (ET) instillation of ACLS drugs has been advocated when IV access is not possible in cardiac arrest patients. Although effective absorption of these drugs has been reported in normal pulmonary blood flow, it also has been observed that blood flow during closed chest cardiac massage is less than 20 percent of normal. It is recommended that the dose of epinephrine or atropine be doubled if the ET route is used. METHODS: The authors from Harbor-UCLA Medical Center in Torrance, CA, reviewed case records in 495 adults with nontraumatic prehospital cardiac arrest who were given ACLS medications via the IV route by paramedics, and 101 patients who received medications by the ET route. RESULTS: When compared with the IV group, the ET group was older (mean, 71 vs. 66 years), more likely to experience the arrest in a nursing home (47% vs. 24%), and to have asystole as the initial arrest rhythm (56% vs. 37%). There were no differences between the groups in the frequency of witnessed arrest, provision of CPR, or paramedic response time. The rate of return of spontaneous circulation was 27 percent in the IV group vs. 15 percent in the ET group. The rate of survival to hospital admission was 20 percent vs. nine percent, respectively, and the corresponding rate of survival to discharge was five percent vs. 0, respectively. CONCLUSIONS: ET administration of ACLS medications at twice the recommended dose was associated with less success than IV administration in patients with prehospital cardiac arrest. The authors acknowledge major baseline differences in the two study groups, however. Throughput Times Here's an amazing study. It points out that being seen in an ED sooner than expected results in high levels of patient satisfaction. This is certainly not any earth-shattering revelation, but when you look at some of the throughput times reported by the Department of Emergency Medicine at Oregon Health Sciences University, you find the real reason people were happy with their service: they had remarkably good throughput times. A median time from arrival to a room of 14 minutes and a median room-to-doctor time of 13 minutes are absolutely laudable, particularly in a university hospital. Congratulations to Jerris Hedges and his colleagues. These are remarkable times. There probably is another way for the rest of us to accomplish the goal of having patients seen sooner than expected: Put up a big sign telling patients to expect a wait of two hours, then when we see them in “only” one hour, they should be happy. Satisfied Patients Exiting the Emergency Department (SPEED) Study, Hedges JR, et al Acad Emerg Med 2002;9(1):15 BACKGROUND: The relative importance of actual and perceived emergency department waiting intervals on patient satisfaction has not been clearly defined. METHODS: This prospective study from the Oregon Health Sciences University in Portland evaluated the relationship between satisfaction with ED care and various measures of waiting times for 126 adult visits. These included the actual measured waits, the amount of time each patient expected to wait, and the amount of time the patient subsequently perceived that he had waited. RESULTS: The median interval from arrival to disposition to a room was 14 minutes (maximum, 83 minutes), and the median wait in a room until being seen by a physician was 13 minutes (maximum, 98 minutes). The median total time spent in the ED was 142 minutes (maximum, 596 minutes). There was no statistical relationship between overall patient satisfaction with the visit and the concurrent ED census, discharge disposition, patient acuity or patient ethnicity. Increasing patient satisfaction is linked to focusing on patient expectations about waiting times Overall, patient satisfaction was much more strongly associated with the perception that the interval was shorter than anticipated than with either the estimated wait interval or the actual measured wait. This was true both with regard to the time delay before placement in a treatment room and the waiting time before the patient was seen by a physician. CONCLUSIONS: Programs to increase patient satisfaction with ED care may increase success if they focus on patient expectations regarding likely waiting times than if they focus only on achieving decreases in actual ED waiting times, especially if the changes achieved are likely to be of a minor degree. EMN on the Web! 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