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Department of Emergency Medicine

Department of Emergency Medicine

2011 - August R3 Journal Review

 Baumann BM, Chen EH, Mills AM, Glaspey L, Thompson NM, Jones MK, Farner MC. Patient perceptions of computed tomographic imaging and their understanding of radiation risk and exposure. Ann Emerg Med. 2011 Jul;58(1):1-7.e2. 
The number of CT scans obtained annually has increased from approximately 2 million in 1980 to 72 million in 2007.  Moreover, CT is estimated to cause 1.5-2% of all cancers in the US. This cross sectional study conducted in an inner-city ED from March 2008 to May 2009 (20 hours daily, 7 days a week) had 3 goals: (1) to assess patients’ confidence levels with medical evaluations (MD H&P only; H&P+labs; H&P+labs+US; H&P+labs+CTAP); (2) to assess patients’ understanding of relative radiation exposure by comparing the amount of radiation from one CTAP against increasing numbers of 2-view CXRs; and (3) to measure patients’ understanding of cancer risk from CT exposure by using level of agreement with 2 factual statements: “About 2 to 3 abdominal CTs give the same radiation exposure that survivors of the Hiroshima nuclear bombing received” and “Receiving 2 to 3 abdominal CTs over a person’s lifetime can increase the chance of cancer”. A 100mm Visual Analog Scale (VAS) was utilized for goals 1 and 3 (0=no confidence, no agreement and 100= complete confidence, complete agreement). 1168 patients ≥18yo presenting with nontraumatic abdominal pain lasting ≤72hrs were administered a questionnaire immediately after the initial MD encounter. The study excluded pregnant women, patients who sustained abdominal trauma or had abdominal surgery in last 7 days, or were unable to complete the questionnaire including Spanish-speaking-only patients. A pilot questionnaire was developed and improved upon for this study. 67% of participants were women, 57% White, 26% with household income <$20K. Goal 1: Level of confidence in H&P only was VAS 20 compared to increased confidence to VAS 84 with H&P+labs. This increased to VAS 90 for H&P+labs+CTAP. Goal 2: 77% of respondents underestimated the relative amount of radiation from a CTAP to CXR (1 CTAP <100 CXRs) vs 19% who estimated correctly (1 CTAP=100-250 CXR). 50 participants expressed confusion with this question because they though CT delivered less radiation than a 2 view CXR.  Goal 3: low level of agreement with “CT radiation is same as Hiroshima” shown by median VAS 13 with only 5% agreeing VAS ≥90 (10% VAS ≥70). Higher overall level of agreement with “CTs increase cancer risk” with median VAS 45 and 13% VAS ≥90 (23% VAS ≥70). Of interest, 795 patients stated they had ever received a previous CT scan (confirmed in 581 (68%) patients who had 1+ in the last 5 years by EMR, mean 5.4 scans). Of 365 patients who reported no previous CT, 142 (39%) had 1+ in the last 5 years (mean 2.4 scans). Limitations included lower generalizability (inner city ED, convenience sample, one site), as well as incomplete surveys (respondents did not complete all portions due to confusion on questions), inability to control if patient was told by MD that they would undergo imaging (may sway responses), and lastly underestimation of previous CTs that may have been obtained at other hospitals or clinics. In conclusion, patients have higher level of confidence with evaluations that include labs and imaging. Patients also underestimate the amount of radiation exposure of a CTAP. Continued efforts to curtail unnecessary imaging and educate patients about radiation risk and cancer are needed.

- Vivienne Ng

Jones AE, Troyer JL, Kline JA. Cost-effectiveness of an emergency department-based early sepsis resuscitation protocol. Critical Care Med 20011 June; 39(6) 1306-12.
This was a prospective before and after, single-center study conducted at Carolinas Medical Center, a large urban emergency department with >110,000 visits per year. The purpose of this study was to assess the cost-effectiveness of implementing early goal-directed therapy as a routine protocol within the ED. Data was prospectively collected on a total of 287 patients, 79 patients during the before phase between August, 2005 to September, 2005 and 206 patients in the after phase between November, 2005 to October, 2007. Inclusion criteria for both phases included (1) Age over 17, (2) suspected or confirmed infection, (3) two or more SIRS criteria, (4) SBP < 90 or MAP < 65 after a 20mL/kg isotonic fluid bolus or anticipated need for ICU care and a serum lactate > 4. Exclusion criteria were the need for immediate surgery or a contraindication to chest central venous catheterization. Implementation of EGDT was associated with a decrease in in-hospital mortality from 27% to 18%, a decrease in 1-year mortality from 49% to 37%, an increase in total in-hospital costs (adjusted to 2006 US dollars by GDP Implicit Deflator) from $13,261 to $20,289, an increase in ICU length of stay from 2.0 to 4.1 days, an increase in hospital length of stay from 8.0 to 10.0 days, an increase in discounted (by 3%) sepsis-adjusted (life expectancy multiplied by 0.51) life expectancy from 5.7 to 7.2 days, and an increase in discounted (3%) quality-adjusted (multiplied by 0.69) life years from 5.1 to 6.4. This results in a cost of $4,667 per life-year gained and a cost of $5,397 per quality-adjusted life-years gained. Using a willingness to pay 50,000 per quality-adjusted life-year (QALY), a net monetary benefit analysis indicates a 98% probability (p=0.038) that EGDT is cost-effective. This study concluded that implementation of EGDT is cost-effective. Statistically significant differences between the two groups were more dialysis patients in the before group (32% vs 14%) and some indicators for increased severity of illness in the after group [lower initial SBP (72 vs 85), higher initial respiratory rate (30 vs 26), and higher initial sequential organ failure assessment score (7 vs 5)]. Limitations included that this is a single-center study and that it is a before and after study, so any other changes besides EGDT between the before and after phases may confound the results.

- Jacob Gessin