Failure of a patient-centered intervention to substantially increase the identification and referral for-treatment of ambulatory emergency department patients with occult psychiatric conditions: a randomized trial [ISRCTN61514736]

BACKGROUND: We previously demonstrated that a computerized psychiatric screening interview (the PRIME-MD) can be used in the Emergency Department (ED) waiting room to identify patients with mental illness. In that trial, however, informing the ED physician of the PRIME-MD results did not increase the frequency of psychiatric diagnosis, consultation or referral. We conducted this study to determine whether telling the patient and physician the PRIME-MD result would result in the majority of PRIME-MD-diagnosed patients being directed toward treatment for their mental illness. METHODS: In this single-site RCT, consenting patients with non-specific somatic chief complaints (e.g., fatigue, back pain, etc.) completed the computerized PRIME-MD in the waiting room and were randomly assigned to one of three groups: patient and physician told PRIME-MD results, patient told PRIME-MD results, and neither told PRIME-MD results. The main outcome measure was the percentage of patients with a PRIME-MD diagnosis who received a psychiatric consultation or referral from the ED. RESULTS: 183 (5% of all ED patients) were approached. 123 eligible patients consented to participate, completed the PRIME-MD and were randomized. 95 patients had outcomes recorded. 51 (54%) had a PRIME-MD diagnosis and 8 (16%) of them were given a psychiatric consultation or referral in the ED. While the frequency of consultation or referral increased as the intervention's intensity increased (tell neither = 11% (1/9), tell patient 15% (3/20), tell patient and physician 18% (4/22)), no group came close to the 50% threshold we sought. For this reason, we stopped the trial after an interim analysis. CONCLUSION: Patients willingly completed the PRIME-MD and 54% had a PRIME-MD diagnosis. Unfortunately, at our institution, informing the patient (and physician) of the PRIME-MD results infrequently led to the patient being directed toward care for their psychiatric condition

Impact of Patient Affect on Physician Estimate of Probability of Serious Illness and Test Ordering

Purpose The authors hypothesize patient facial affect may influence clinician pretest probability (PTP) estimate of cardiopulmonary emergency (CPE) and desire to order a computerized tomographic pulmonary angiogram (CTPA). Method This prospective study was conducted at three Indiana University–affiliated hospitals in two parts: collecting videos of patients undergoing CTPA for suspected acute pulmonary embolism watching a humorous video (August 2014–April 2015) and presenting the medical histories and videos to clinicians to determine the impact of patient facial affect on physicians’ PTP estimate of CPE and desire to order a CTPA (June–November 2015). Patient outcomes were adjudicated as CPE+ or CPE− by three independent reviewers. Physicians completed a standardized test of facial affect recognition, read standardized medical histories, then viewed videos of the patients’ faces. Clinicians marked their PTP estimate of CPE and desire for a CTPA before and after seeing the video on a visual analog scale (VAS). Results Fifty physicians completed all 73 videos. Seeing the patient’s face produced a > 10% absolute change in PTP estimate of CPE in 1,204/3,650 (33%) cases and desire for a CTPA in 1,095/3,650 (30%) cases. The mean area under the receiver operating characteristic curve for CPE estimate was 0.55 ± 0.15, and the change in CPE VAS was negatively correlated with physicians’ standardized test scores (r = −0.23). Conclusions Clinicians may use patients’ faces to make clinically important inferences about presence of serious illness and need for diagnostic testing. However, these inferences may fail to align with actual patient outcomes

Peer Reviewed Evaluation of Registered End-Points of Randomised Trials (the PRE-REPORT study): a stepped wedge, cluster-randomised trial.

OBJECTIVE: To test whether providing relevant clinical trial registry information to peer reviewers evaluating trial manuscripts decreases discrepancies between registered and published trial outcomes. DESIGN: Stepped wedge, cluster-randomised trial, with clusters comprised of eligible manuscripts submitted to each participating journal between 1 November 2018 and 31 October 2019. SETTING: Thirteen medical journals. PARTICIPANTS: Manuscripts were eligible for inclusion if they were submitted to a participating journal during the study period, presented results from the primary analysis of a clinical trial, and were peer reviewed. INTERVENTIONS: During the control phase, there were no changes to pre-existing peer review practices. After journals crossed over into the intervention phase, peer reviewers received a data sheet describing whether trials were registered, the initial registration and enrolment dates, and the registered primary outcome(s) when enrolment began. MAIN OUTCOME MEASURE: The presence of a clearly defined, prospectively registered primary outcome consistent with the primary outcome in the published trial manuscript, as determined by two independent outcome assessors. RESULTS: We included 419 manuscripts (243 control and 176 intervention). Participating journals published 43% of control-phase manuscripts and 39% of intervention-phase manuscripts (model-estimated percentage difference between intervention and control trials = -10%, 95% CI -25% to 4%). Among the 173 accepted trials, published primary outcomes were consistent with clearly defined, prospectively registered primary outcomes in 40 of 105 (38%) control-phase trials and 27 of 68 (40%) intervention-phase trials. A linear mixed model did not show evidence of a statistically significant primary outcome effect from the intervention (estimated difference between intervention and control=-6% (90% CI -27% to 15%); one-sided p value=0.68). CONCLUSIONS: These results do not support use of the tested intervention as implemented here to increase agreement between prospectively registered and published trial outcomes. Other approaches are needed to improve the quality of outcome reporting of clinical trials. TRIAL REGISTRATION NUMBER: ISRCTN41225307

A conceptual model of emergency physician decision making for head computed tomography in mild head injury

The use of computed tomographic scanning in blunt head trauma has increased dramatically in recent years without an accompanying rise in the prevalence of injury or hospital admission for serious conditions. Because computed tomography is neither harmless nor inexpensive, researchers have attempted to optimize utilization, largely through research that describes which clinical variables predict intracranial injury, and use this information to develop clinical decision instruments. Although such techniques may be useful when the benefits and harms of each strategy (neuroimaging vs observation) are quantifiable and amenable to comparison, the exact magnitude of these benefits and harms remains unknown in this clinical scenario. We believe that most clinical decision instrument development efforts are misguided insofar as they ignore critical, nonclinical factors influencing the decision to image. In this article, we propose a conceptual model to illustrate how clinical and nonclinical factors influence emergency physicians making this decision. We posit that elements unrelated to standard clinical factors, such as personality of the physician, fear of litigation and of missed diagnoses, patient expectations, and compensation method, may have equal or greater impact on actual decision making than traditional clinical factors. We believe that 3 particular factors deserve special consideration for further research: fear of error/malpractice, financial incentives, and patient engagement. Acknowledgement and study of these factors will be essential if we are to understand how emergency physicians truly make these decisions and how test-ordering behavior can be modified

Opioid prescription patterns among patients who doctor shop; Implications for providers.

INTRODUCTION:Patients who doctor shop for opioids are a vulnerable population that present a difficult dilemma for their health care providers regarding best methods of immediate treatment and how to manage their risk of harm from opioids. We aim to describe and compare opioid prescription patterns among high quantity prescription patients who doctor shopped, high quantity prescription patients who did not (doctor shopping eligible patients), and the remaining patients who received opioid prescriptions to guide population health policies for high risk opioid use patients. METHODS:We performed a cross-sectional descriptive analysis of opioid prescriptions during an 8-year period using California's de-identified Controlled Substance Utilization Review and Evaluation System (CURES) database from years 2008-2015. We identified the prevalence of patients who doctor shopped and depicted their opioid prescription patterns including prescriber characteristics, in comparison to the aforementioned groups. Doctor shopping was defined by patients who received greater than 6 or more prescriptions from at least 6 different prescribers within 6 months of time. RESULTS:Among the 3 million individuals who received an opioid prescription during the 8-year period, 1.3% met the doctor shopper definition. These patients received high levels of chronic opioids with 82% and 33% averaging greater than 20 and 100 morphine milligram equivalents (MME) daily, respectively, in comparison to 72% and 18% in the doctor shopping eligible group. Patients who doctor shopped received a significant proportion of their MME from 1 main prescriber (54%) and only received 2-5% of their total MME from episodic care providers, despite 88% receiving a prescription from these providers. CONCLUSIONS:Patients who doctor shop are at high risk of opioid use disorder but represent a small fraction of those with dangerous opioid use. Furthermore, these individuals do not receive substantial opioids from episodic providers, which challenges the utility of prescription reduction programs in curbing use among this population. These results suggest we re-evaluate physician roles in the care of these patients and focus on referral to treatment and harm reduction strategies

Is National Resident Matching Program Rank Predictive of Resident Performance or Post-graduation Achievement? 10 Years at One Emergency Medicine Residency

Introduction: Each year residency programs expend considerable effort ranking applicants for the National Residency Matching Program (NRMP). We explored the relationship between residents’ NRMP rank list position as generated at our institution and their performance in residency and post-graduation to determine whether such efforts are justified.Methods: Faculty who were present for the 10 consecutive study years at an allopathic emergency medicine residency retrospectively evaluated residents on their overall performance, medical knowledge, and interpersonal skills. Residency graduates were surveyed regarding their current position, hours of clinical practice, academic, teaching and leadership roles, and publications. We compared match position to performance using graphical techniques as the primary form of analysis.Results: Ten faculty evaluated the 107 residents who graduated from the program during these 10 years by class year. Eighty-four residents responded to the survey. In general, we found little correlation between NRMP rank and faculty rank of resident performance. There was also little correlation between position in the NRMP rank list and the probability of having an academic career, publishing research, or having a teaching or leadership role.Conclusion: We found that the position on our NRMP rank list was of little value in predicting which residents would do best in residency or take on academic or leadership roles once graduated. Residencies should evaluate the processes they use to generate their rank list to determine whether the ranking process is sufficiently predictive to warrant the effort expended