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pubmed: 0196-0644



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Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma.
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Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma.

Ann Emerg Med. 2017 Aug 18;:

Authors: Wu X, Malhotra A, Geng B, Liu R, Abbed K, Forman HP, Sanelli P

Abstract
STUDY OBJECTIVE: Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population.
METHODS: A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies.
RESULTS: The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed.
CONCLUSION: MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result.

PMID: 28826754 [PubMed - as supplied by publisher]




Posttraumatic Stress Disorder in Emergency Medicine Residents.
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Posttraumatic Stress Disorder in Emergency Medicine Residents.

Ann Emerg Med. 2017 Aug 18;:

Authors: Vanyo L, Sorge R, Chen A, Lakoff D

PMID: 28826753 [PubMed - as supplied by publisher]




Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs.
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Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs.

Ann Emerg Med. 2017 Aug 18;:

Authors: Ross S, Liu EL, Rose C, Chou A, Battaglioli N

PMID: 28826752 [PubMed - as supplied by publisher]




What Antibiotic Regimen Is Most Efficacious in Treating Pelvic Inflammatory Disease?
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What Antibiotic Regimen Is Most Efficacious in Treating Pelvic Inflammatory Disease?

Ann Emerg Med. 2017 Aug 16;:

Authors: Long B, April MD

PMID: 28822590 [PubMed - as supplied by publisher]




Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study.
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Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study.

Ann Emerg Med. 2017 Aug 12;:

Authors: Ali NJ, McWilliams JM, Epstein SK, Smulowitz PB

Abstract
STUDY OBJECTIVE: We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts.
METHODS: An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs-from departmental resources to physician incentives-to help achieve accountable care organization goals of decreasing spending and improving quality.
RESULTS: Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost-reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self-reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%.
CONCLUSION: The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals.

PMID: 28811123 [PubMed - as supplied by publisher]




Acute Kidney Injury After Computed Tomography: A Meta-analysis.
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Acute Kidney Injury After Computed Tomography: A Meta-analysis.

Ann Emerg Med. 2017 Aug 12;:

Authors: Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR

Abstract
STUDY OBJECTIVE: Computed tomography (CT) is an important imaging modality used in the diagnosis of a variety of disorders. Imaging quality may be improved if intravenous contrast is added, but there is a concern for potential renal injury. Our goal is to perform a meta-analysis to compare the risk of acute kidney injury, need for renal replacement, and total mortality after contrast-enhanced CT versus noncontrast CT.
METHODS: We searched MEDLINE (PubMed), the Cochrane Library, CINAHL, Web of Science, ProQuest, and Academic Search Premier for relevant articles. Included articles specifically compared rates of renal insufficiency, need for renal replacement therapy, or mortality in patients who received intravenous contrast versus those who received no contrast.
RESULTS: The database search returned 14,691 articles, inclusive of duplicates. Twenty-six unique articles met our inclusion criteria, with an additional 2 articles found through hand searching. In total, 28 studies involving 107,335 participants were included in the final analysis, all of which were observational. Meta-analysis demonstrated that, compared with noncontrast CT, contrast-enhanced CT was not significantly associated with either acute kidney injury (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.83 to 1.07), need for renal replacement therapy (OR 0.83; 95% CI 0.59 to 1.16), or all-cause mortality (OR 1.0; 95% CI 0.73 to 1.36).
CONCLUSION: We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.

PMID: 28811122 [PubMed - as supplied by publisher]




Emergency Department Use in the Perinatal Period: An Opportunity for Early Intervention.
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Emergency Department Use in the Perinatal Period: An Opportunity for Early Intervention.

Ann Emerg Med. 2017 Aug 12;:

Authors: Malik S, Kothari C, MacCallum C, Liepman M, Tareen S, Rhodes KV

Abstract
STUDY OBJECTIVE: We characterize emergency department (ED) utilization among perinatal women and identify differences in risk factors and outcomes between women who use versus do not use the ED during the perinatal period.
METHODS: This is a retrospective cross-sectional study comparing patients who used the ED versus did not use the ED during the perinatal period. Patient data were collected from medical chart review and postpartum interviews.
RESULTS: Of the 678 participants, 218 (33%) had at least 1 perinatal ED visit. Women who used the ED were more likely than those who did not to be adolescent (relative risk [RR] 2.23; 95% confidence interval [CI] 1.38 to 3.63), of minority race (RR 1.94; 95% CI 1.46 to 2.57), and Medicaid insured (RR 2.14; 95% CI 1.71 to 2.67). They were more likely to smoke prenatally (RR 3.42; 95% CI 2.34 to 4.99), to use recreational drugs prenatally (RR 3.53; 95% CI 1.78 to 7.03), and to have experienced domestic abuse (RR 1.78; 95% CI 1.12 to 2.83). They were more likely to have delayed entry to prenatal care (RR 2.01; 95% CI 1.46 to 2.77) and to experience postpartum depression (RR 2.97; 95% CI 1.90 to 4.64). Their infants were nearly twice as likely to be born prematurely (RR 1.92; 95% CI 1.07 to 3.47).
CONCLUSION: Results highlight that pregnant patients using the ED are a high-risk, vulnerable population. Routine ED screening and linkage of this vulnerable population to early prenatal care and psychosocial interventions should be considered as a public health strategy worth investigating.

PMID: 28811121 [PubMed - as supplied by publisher]




Evaluation and Treatment of Minors.
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Evaluation and Treatment of Minors.

Ann Emerg Med. 2017 Aug 05;:

Authors: Benjamin L, Ishimine P, Joseph M, Mehta S

Abstract
Many patients under the age of majority present to emergency departments (EDs) without parents or guardians. This may create concern in regard to evaluation of these patients without formal consent to treat. The Emergency Medical Treatment and Labor Act mandates that all patients presenting to EDs receive a medical screening examination and does not exclude these minors. Standards for who can provide consent for a patient vary from state to state and address important issues such as consent by parent surrogates, as well as adolescent emancipation, reproductive health, mental health, and substance use. This document addresses current federal and state legal implications of providing emergency care to minors, as well as guidance in obtaining consent, maintaining confidentiality, and addressing refusal of care.

PMID: 28807682 [PubMed - as supplied by publisher]




An Emergency Medicine-Primary Care Partnership to Improve Rural Population Health: Expanding the Role of Emergency Medicine.
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An Emergency Medicine-Primary Care Partnership to Improve Rural Population Health: Expanding the Role of Emergency Medicine.

Ann Emerg Med. 2017 Aug 05;:

Authors: Greenwood-Ericksen MB, Tipirneni R, Abir M

Abstract
The health of rural America is failing and our traditional approaches have proved ineffective at improving health in rural communities. Rural populations are now a health disparity population, facing higher mortality rates for the 5 leading causes of death compared with their urban counterparts. We must generate novel, rural-specific approaches to solve this challenge-and there is a clear role for the field of emergency medicine. Building on emergency departments' (EDs') expanding role in health care delivery and emergency medicine's increasing involvement in population health, we propose a new health care delivery model for rural population health based on partnership between emergency medicine and primary care that embraces the important role that EDs play in rural areas.

PMID: 28802783 [PubMed - as supplied by publisher]




All-Cause Hospital Admissions Among Older Adults After a Natural Disaster.
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All-Cause Hospital Admissions Among Older Adults After a Natural Disaster.

Ann Emerg Med. 2017 Aug 05;:

Authors: Bell SA, Abir M, Choi H, Cooke C, Iwashyna T

Abstract
STUDY OBJECTIVE: We characterize hospital admissions among older adults for any cause in the 30 days after a significant natural disaster in the United States. The main outcome was all-cause hospital admissions in the 30 days after natural disaster. Separate analyses were conducted to examine all-cause hospital admissions excluding the 72 hours after the disaster, ICU admissions, all-cause inhospital mortality, and admissions by state.
METHODS: A self-controlled case series analysis using the 2011 Medicare Provider and Analysis Review was conducted to examine exposure to natural disaster by elderly adults located in zip codes affected by tornadoes during the 2011 southeastern superstorm. Spatial data of tornado events were obtained from the National Oceanic and Atmospheric Administration's Severe Report database, and zip code data were obtained from the US Census Bureau.
RESULTS: All-cause hospital admissions increased by 4% for older adults in the 30 days after the April 27, 2011, tornadoes (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). When the first 3 days after the disaster that may have been attributed to immediate injuries were excluded, hospitalizations for any cause also remained higher than when compared with the other 11 months of the year (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). There was no increase in ICU admissions or inhospital mortality associated with the natural disaster. When data were examined by individual states, Alabama, which had the highest number of persons affected, had a 9% increase in both hospitalizations and ICU admissions.
CONCLUSION: When all time-invariant characteristics were controlled for, this natural disaster was associated with a significant increase in all-cause hospitalizations. This analysis quantifies acute care use after disasters through examining all-cause hospitalizations and represents an important contribution to building models of resilience-the ability to recover from a disaster-and hospital surge capacity.

PMID: 28789804 [PubMed - as supplied by publisher]




Preliminary Performance on the New CMS Sepsis-1 National Quality Measure: Early Insights From the Emergency Quality Network (E-QUAL).
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Preliminary Performance on the New CMS Sepsis-1 National Quality Measure: Early Insights From the Emergency Quality Network (E-QUAL).

Ann Emerg Med. 2017 Aug 05;:

Authors: Venkatesh AK, Slesinger T, Whittle J, Osborn T, Aaronson E, Rothenberg C, Tarrant N, Goyal P, Yealy DM, Schuur JD

Abstract
STUDY OBJECTIVE: We describe current hospital-level performance for the Centers for Medicare & Medicaid Services' Severe Sepsis/Septic Shock Early Management Bundle (SEP-1) quality measure and qualitatively assess emergency department (ED) sepsis quality improvement best practice implementation.
METHODS: Using a standardized Web-based submission portal, we surveyed quality improvement data from volunteer hospital-based EDs participating in the Emergency Quality Network Sepsis Initiative. Each hospital submitted preliminary SEP-1 local chart review data, using existing Centers for Medicare & Medicaid Services definitions. We report descriptive statistics of SEP-1 data availability and performance. The primary outcome for this study was SEP-1 bundle compliance, defined as the proportion of all severe sepsis and septic shock cases receiving all required bundle elements, and secondary outcomes included conditional compliance on reported SEP-1 numerator components and ED implementation of sepsis quality improvement best practices.
RESULTS: A total of 50 EDs participated in the survey; 74% were nonteaching sites and 26% were affiliated with academic centers. Of all participating EDs, 80% were in regions with relatively high population density. The mean hospital SEP-1 bundle compliance was 54% (interquartile range 30% to 75%). Bundle compliance improved during fiscal year 2016 from 39% to 57%. Broad variation existed for each bundle component, with intravenous fluid resuscitation and repeated lactate bundle elements having the widest variation and largest gaps in quality. At least one consensus sepsis quality improvement best practice implementation occurred in 92% of participating sites.
CONCLUSION: Preliminary data on SEP-1 performance suggest wide hospital-level variation in performance, with modest improvement during the first year of data collection.

PMID: 28789803 [PubMed - as supplied by publisher]