Cancer diagnosis and outcomes in Michigan EDs vs other settings.

OBJECTIVE: This study determined the proportion of incident colorectal and lung cancers with a diagnosis associated with an emergency department (ED) visit. The characteristics of these patients and the correlation between diagnosis near an ED visit and stage at diagnosis were also examined. METHODS: A population-based sample of all Michigan cancer cases diagnosed in all EDs and other health care settings was used to extract a sample of patients >65 years old, diagnosed with colorectal and lung cancers between January 1, 1996, and June 30, 2000 (n = 20 311). Logistic regressions were used for the statistical analysis. RESULTS: Patients with a colorectal cancer diagnosis associated with an ED visit were more likely insured by Medicaid before diagnosis (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.17-1.60), had an inpatient admission before diagnosis (OR, 1.29; 95% CI, 1.06-1.56), had 3 or more comorbidities (OR, 4.11; 95% CI, 3.53-4.79), were more likely to be female (OR, 1.18; 95% CI, 1.07-1.31), and were more likely to be aged 85 years and older (OR, 1.89; 95% CI, 1.57-2.27). Patients who had at least one primary care physician (PCP) visit before diagnosis were less likely to have a diagnosis associated with an ED visit (OR, 0.68; 95% CI, 0.61-0.76). Patients diagnosed with lung cancer in association with an ED visit were also more likely to have an inpatient admission before diagnosis (OR, 1.21; 95% CI, 1.02-1.43), a higher comorbidity burden (OR, 12.44; 95% CI, 10.18-15.20), be female (OR, 1.13; 95% CI, 1.02-1.25), African-American (OR, 1.42; 95% CI, 1.21-1.66), and older (80 years and older) (ages 80-84 years: OR, 1.33; 95% CI, 1.13-1.57; age 85 years and older: OR, 1.52; 95% CI, 1.25-1.85). Patients with an ED visit near a colorectal cancer (OR, 1.28; 95% CI, 1.15-1.42) or lung cancer diagnosis (OR, 1.65; 95% CI, 1.44-1.88) were more likely to be diagnosed at a later stage compared with patients diagnosed in other settings. CONCLUSIONS: An examination of patients' patterns of care leading to a cancer diagnosis in association with an ED visit lends insight to conditions precipitating a more immediate diagnosis and their associated outcomes.

Structure and function of emergency care research networks: strengths, weaknesses, and challenges.

The ability of emergency care research (ECR) to produce meaningful improvements in the outcomes of acutely ill or injured patients depends on the optimal configuration, infrastructure, organization, and support of emergency care research networks (ECRNs). Through the experiences of existing ECRNs, we can learn how to best accomplish this. A meeting was organized in Washington, DC, on May 28, 2008, to discuss the present state and future directions of clinical research networks as they relate to emergency care. Prior to the conference, at the time of online registration, participants responded to a series of preconference questions addressing the relevant issues that would form the basis of the breakout session discussions. During the conference, representatives from a number of existing ECRNs participated in discussions with the attendees and provided a description of their respective networks, infrastructure, and challenges. Breakout sessions provided the opportunity to further discuss the strengths and weaknesses of these networks and patterns of success with respect to their formation, management, funding, best practices, and pitfalls. Discussions centered on identifying characteristics that promote or inhibit successful networks and their interactivity, productivity, and expansion. Here the authors describe the current state of ECRNs and identify the strengths, weaknesses, and potential pitfalls of research networks. The most commonly cited strengths of population- or disease-based research networks identified in the preconference survey were access to larger numbers of patients; involvement of physician experts in the field, contributing to high-level study content; and the collaboration among investigators. The most commonly cited weaknesses were studies with too narrow a focus and restrictive inclusion criteria, a vast organizational structure with a risk of either too much or too little central organization or control, and heterogeneity of institutional policies and procedures among sites. Through the survey and structured discussion process involving multiple stakeholders, the authors have identified strengths and weaknesses that are consistent across a number of existing ECRNs. By leveraging the strengths and addressing the weaknesses, strategies can be adopted to enhance the scientific value and productivity of these networks and give direction to future ECRNs.

Value of simultaneous functional assessment in association with acute rest perfusion imaging for predicting short- and long-term outcomes in emergency department patients with chest pain.

BACKGROUND: Rest tomographic myocardial perfusion imaging (MPI) has significant utility for clinical decision making in emergency department chest pain patients. The role of functional data, commonly acquired with perfusion, has not been systematically evaluated. METHODS AND RESULTS: Low- to moderate-risk patients undergoing rest MPI for risk stratification were included. The patients' MPI findings were classified as normal (normal perfusion or function), abnormal (perfusion defect with abnormal regional function), or discordant (perfusion defect with normal regional function). Ejection fraction was determined from the gated MPI studies. Events based on perfusion classifications and ejection fraction were evaluated. A total of 2,826 consecutive patients (abnormal MPI results in 40%, normal in 32%, and discordant in 27%) were studied. Outcomes were similar for those with normal MPI results versus those with discordant MPI results (myocardial infarction [MI] based on troponin I [TnI], 3.5% vs 4.0%; MI based on creatine kinase-MB, 1.5% vs 1.7%; revascularization, 5.2% vs 5.5%; and MI/revascularization based on TnI, 7.9% vs 8.1%) (P = not significant for all). Both groups had significantly fewer events (P < .001 for all) when compared with patients with abnormal MPI studies (MI based on TnI, 15%; MI based on creatine kinase-MB, 10%; revascularization, 17%; MI based on TnI or revascularization, 24%). The mortality rate was not different among the 3 groups. Multivariate analysis showed that mild/moderate and severe systolic dysfunction were independent predictors of 30-day and 1-year mortality rates (P = .001). CONCLUSIONS: The concurrent evaluation of perfusion and function (regional and global) with MPI provides significant risk/outcome predictive power.

ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction?

Despite substantial progress in the diagnosis and treatment of acute ST-segment elevation myocardial infarction (STEMI), implementation of this knowledge into routine clinical practice has been variable. It has become increasing clear that primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion if it can be performed in a timely manner. Recent European data suggest that transfer for direct PCI may also be preferable to fibrinolytic therapy. We believe it is time to establish a national policy for treatment of patients with STEMI to develop a coordinated system of care similar to that of the level 1 trauma system.

Accelerating time to reperfusion in acute myocardial infarction: prehospital and emergency department strategies, systems of care, and pharmacologic interventions.

Although primary percutaneous coronary intervention has emerged as the preferred reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), it is available only in a minority of US hospitals. The fundamental problem is that there is presently no organized, uniform, national STEMI triage and treatment system that is comparable to the well-developed, highly successful system in the United States that directs major trauma victims to verified trauma centers. This article reviews prehospital and emergency department triage strategies, systems, and pharmacologic interventions for patients with STEMI that can help shorten the time to reperfusion in these patients.

Should the Emergency Department be society's health safety net?

In the US health care system, a core safety net provider has two defining characteristics: (1) either by legal mandate or explicitly adopted mission, they maintain an "open door," offering patients services regardless of their ability to pay; and (2) a substantial portion of their patients are uninsured, on Medicaid, and/or otherwise vulnerable. The hospital Emergency Department (ED), by all accounts, falls within the definition of a core safety net provider. Yet many would argue that this is a primary health care role for which the ED was not originally intended or equipped. Should the ED be society's health-care safety net? Should it be the main provider of care for the indigent? Is this placing an unbearable strain on the ED? Should it be providing primary health-care? If not, what are the alternatives?

A comprehensive strategy for the evaluation and triage of the chest pain patient: a cost comparison study.

BACKGROUND: Our objective was to determine the cost-effectiveness of a comprehensive, risk-based triage system, composed of multiple critical pathways, with the use of early myocardial perfusion imaging (MPI) in low-risk patients. We found previously that a chest pain evaluation system that uses MPI in low-risk patients was safe and effective, but the cost-effectiveness of this approach was not studied. METHODS AND RESULTS: We compared two groups. The Acute Cardiac Team (ACT) group (n = 874) was assigned prospectively to 1 of 4 risk levels by emergency department (ED) physicians. Level 1, 2, and 3 patients were admitted; level 4 patients were evaluated in the ED. Level 3 and 4 patients underwent ED MPI. The control group (n = 713) represented consecutive patients evaluated in the prior year according to standard care and assigned retrospectively to an ACT level based on the presenting electrocardiographic and clinical data. Record and hospital administrative data were assessed for clinical variables, outcomes, lengths of stay, and all expenses incurred within 30 days of the index visit. The baseline characteristics of the two groups were similar, including age, sex, myocardial infarction prevalence, and 30-day revascularization rates within each level or between the two groups. Mean costs per encounter were reduced for the ACT patients for each level, which was significant when all patients were compared ($5,030 +/- $7,081 vs $6,044 +/- $10,432, P =.02). Use of MPI in the low-risk patients was associated with reduced costs (level 3, $4,958 +/- $4,948 vs $5,051 +/- $7,036; level 4, $1,529 +/- $2,664 vs $1,794 +/- $6,854) and was associated with a significantly lower angiography rate and shorter length of stay. CONCLUSIONS: Implementation of a comprehensive strategy for chest pain evaluation and triage reduced overall costs for patients with chest pain on presentation. Acute MPI in the ED setting did not increase net cost.

Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program.

BACKGROUND: The use of critical pathways for a variety of clinical conditions has grown rapidly in recent years, particularly pathways for patients with acute coronary syndromes (ACS). However, no systematic review exists regarding the value of critical pathways in this setting. METHODS: The National Heart Attack Alert Program established a Working Group to review the utility of critical pathways on quality of care and outcomes for patients with ACS. A literature search of MEDLINE, cardiology textbooks, and cited references in any article identified was conducted regarding the use of critical pathways for patients with ACS. RESULTS: Several areas for improving the care of patients with ACS through the application of critical pathways were identified: increasing the use of guideline-recommended medications, targeting use of cardiac procedures and other cardiac testing, and reducing the length of stay in hospitals and intensive care units. Initial studies have shown promising results in improving quality of care and reducing costs. No large studies designed to demonstrate an improvement in mortality or morbidity were identified in this literature review. CONCLUSIONS: Critical pathways offer the potential to improve the care of patients with ACS while reducing the cost of care. Their use should improve the process and cost-effectiveness of care, but further research in this field is needed to determine whether these changes in the process of care will translate into improved clinical outcomes.