What If I Do Not Match? Scrambling for a Spot and Going Outside the Match.

Matching into emergency medicine (EM) is getting progressively more competitive. Applicants must therefore prepare for the possibility of not matching and, accordingly, be ready to participate in the Supplemental Offer and Acceptance Program (SOAP). In this article, we elaborate on the SOAP and the options for applicants who fail to match during Match Week. Alternative courses of action include applying for a preliminary year, matching into a categorical residency program, or aiming to secure EM spots outside the Match through the Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine, and American Association of Medical Colleges

Identifying and characterizing COPD patients in US managed care. A retrospective, cross-sectional analysis of administrative claims data

<p>Abstract</p> <p>Background</p> <p>Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death among US adults and is projected to be the third by 2020. In anticipation of the increasing burden imposed on healthcare systems and payers by patients with COPD, a means of identifying COPD patients who incur higher healthcare utilization and costs is needed.</p> <p>Methods</p> <p>This retrospective, cross-sectional analysis of US managed care administrative claims data describes a practical way to identify COPD patients. We analyze 7.79 million members for potential inclusion in the COPD cohort, who were continuously eligible during a 1-year study period. A younger commercial population (7.7 million) is compared with an older Medicare population (0.115 million). We outline a novel approach to stratifying COPD patients using "complexity" of illness, based on occurrence of claims for given comorbid conditions. Additionally, a unique algorithm was developed to identify and stratify COPD exacerbations using claims data.</p> <p>Results</p> <p>A total of 42,565 commercial (median age 56 years; 51.4% female) and 8507 Medicare patients (median 75 years; 53.1% female) were identified as having COPD. Important differences were observed in comorbidities between the younger commercial versus the older Medicare population. Stratifying by complexity, 45.0%, 33.6%, and 21.4% of commercial patients and 36.6%, 35.8%, and 27.6% of older patients were low, moderate, and high, respectively. A higher proportion of patients with high complexity disease experienced multiple (≥2) exacerbations (61.7% commercial; 49.0% Medicare) than patients with moderate- (56.9%; 41.6%), or low-complexity disease (33.4%; 20.5%). Utilization of healthcare services also increased with an increase in complexity.</p> <p>Conclusion</p> <p>In patients with COPD identified from Medicare or commercial claims data, there is a relationship between complexity as determined by pulmonary and non-pulmonary comorbid conditions and the prevalence of exacerbations and utilization of healthcare services. Identification of COPD patients at highest risk of exacerbations using complexity stratification may facilitate improved disease management by targeting those most in need of treatment.</p

Racial and Ethnic Disparities in Emergency Department Analgesic Prescription

Objectives. We examined racial and ethnic disparities in analgesic prescription among a national sample of emergency department patients. Methods. We analyzed Black, Latino, and White patients in the 1997–1999 National Hospital Ambulatory Medical Care Surveys to compare prescription of any analgesics and opioid analgesics by race/ethnicity. Results. For any analgesic, no association was found between race and prescription; opioids, however, were less likely to be prescribed to Blacks than to Whites with migraines and back pain, though race was not significant for patients with long bone fracture. Differences in opioid use between Latinos and Whites with the same conditions were less and nonsignificant. Conclusions. Physicians were less likely to prescribe opioids to Blacks; this disparity appears greatest for conditions with fewer objective findings (e.g., migraine)

Comparison of Canadian versus United States emergency department visits for chronic obstructive pulmonary disease exacerbation

INTRODUCTION: Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs

Reasons for Using the Emergency Department: Results of the EMPATH Study

Objectives: Emergency Medicine Patients\u27 Access To Healthcare (EMPATH) was a cross-sectional, observational study conducted to identify the principal reasons why patients seek care in hospital emergency departments (EDs) in the United States. Methods: Twenty-eight U.S. hospitals, stratified by geographic region and hospital characteristics, participated in this study. Demographic, clinical, and insurance data were collected for a 24-hour period at each site, using chart reviews and a structured interview administered to all consenting adult patients seeking treatment during that period. Patients\u27 reasons for presenting to the ED were assessed by their level of agreement (on a three-point Likert scale) with 21 carefully worded statements designed to capture a range of possible reasons for seeking care in the ED. Factor analysis was used to consolidate highly correlated responses and to identify the principal factors explaining patients\u27 reasons for coming to the ED. Results: A total of 1,579 patient interviews and 2,004 chart reviews were obtained from a diverse sample that was 55.4% female, 58.3% white, 28.3% African American, 7.0% Hispanic, and 6.0% other ethnic groups. This exploratory analysis yielded five factors characterizing patients\u27 principal reasons for seeking ED care, with medical necessity the most frequent, followed by ED preference, convenience, affordability, and limitations of insurance. Conclusions: Use of the ED is, for most people, an affirmative choice over other providers rather than a last resort; it is often a choice driven by lack of access to or dissatisfaction with other sources of care

Increased alignment sensitivity improves the usage of genome alignments for comparative gene annotation

Genome alignments provide a powerful basis to transfer gene annotations from a well-annotated reference genome to many other aligned genomes. The completeness of these annotations crucially depends on the sensitivity of the underlying genome alignment. Here, we investigated the impact of the genome alignment parameters and found that parameters with a higher sensitivity allow the detection of thousands of novel alignments between orthologous exons that have been missed before. In particular, comparisons between species separated by an evolutionary distance of >0.75 substitutions per neutral site, like human and other non-placental vertebrates, benefit from increased sensitivity. To systematically test if increased sensitivity improves comparative gene annotations, we built a multiple alignment of 144 vertebrate genomes and used this alignment to map human genes to the other 143 vertebrates with CESAR. We found that higher alignment sensitivity substantially improves the completeness of comparative gene annotations by adding on average 2382 and 7440 novel exons and 117 and 317 novel genes for mammalian and non-mammalian species, respectively. Our results suggest a more sensitive alignment strategy that should generally be used for genome alignments between distantly-related species. Our 144-vertebrate genome alignment and the comparative gene annotations (https://bds.mpi-cbg.de/hillerlab/144VertebrateAlignment_CESAR/) are a valuable resource for comparative genomics

Cognitive and affective predictors of smoking after a sentinel health event

Objective: This study examined how smoking-related causal attributions, perceived illness severity, and event-related emotions relate to both intentions to quit and subsequent smoking behavior after an acute medical problem (sentinel event). Methods: Three hundred and seventy-five patients were enrolled from 10 emergency departments (EDs) across the USA and followed for six months. Two saturated, manifest structural equation models were performed: one predicting quit attempts and the other predicting seven-day point prevalence abstinence at 14 days, three months, and six months after the index ED visit. Stage of change was regressed onto each of the other predictor variables (causal attribution, perceived illness severity, event-related emotions) and covariates, and tobacco cessation outcomes were regressed on all of the predictor variables and covariates. Results: Non-White race, baseline stage of change, and an interaction between causal attribution and event-related fear were the strongest predictors of quit attempt. In contrast, abstinence at six months was most strongly predicted by baseline stage of change and nicotine dependence. Conclusion: Predictors of smoking behavior after an acute medical illness are complex and dynamic. The relations vary depending on the outcome examined (quit attempts vs. abstinence), differ based on the time that has progressed since the event, and include significant interactions

Effect of a Stewardship Intervention on Adherence to Uncomplicated Cystitis and Pyelonephritis Guidelines in an Emergency Department Setting

<div><p>Objective</p><p>To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention.</p><p>Methods</p><p>The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18 – 65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2).</p><p>Results</p><p>Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (<i>P</i>≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (<i>P</i><.001 and <i>P</i> = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (<i>P</i><.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods.</p><p>Conclusions</p><p>A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.</p></div