Sex bias in cardiovascular testing: the contribution of patient preference.

STUDY OBJECTIVE: Women with potential acute coronary syndromes are less likely to receive cardiac catheterization or revascularization than men. We hypothesize that this may be due to different diagnostic test preferences of female and male patients. METHODS: We conducted a cohort study at 4 emergency departments enrolling patients who presented with symptoms of potential acute coronary syndromes. After hearing the potential benefits and harms of each test, subjects completed a 21-item survey assessing their preference for noninvasive testing versus cardiac catheterization. Based on hypothetical test results, similar questions about medical versus interventional management were asked. Subjects were also queried about likelihood of following physician recommendation for each test or intervention. Actual 30-day testing and interventions were recorded. The main outcome was patient preference about each procedure and the likelihood of patient saying they would accept the physician recommendation. RESULTS: One thousand eighty patients enrolled; 652 (60%) were admitted to the hospital. With regard to diagnostic test preference, both women and men preferred stress test to catheterization (women 58% versus men 52%; difference 6% [95% confidence interval {CI} -0.06% to 12%]), and the proportion of women and men who would accept the physician recommendation for stress tests was similar (85% for both); however, the stated acceptance rate for cardiac catheterization was lower for women (65% versus 75%; difference -10% [95% CI -15% to -4%]). Women were 6% less likely (67% versus 73%; 95% CI for difference 12% to 0.5%) to accept percutaneous coronary intervention over medical therapy and 7% less likely (61% versus 68%; 95% CI for difference -13% to 1%) to desire coronary artery bypass grafting over medical therapy. The survey results are consistent with the patients' clinical course. During the initial hospitalization, women were less likely to receive diagnostic testing of any type (38% versus 45%; difference -7%; 95% CI for the difference -13% to -1.5%) and cardiac catheterization (10% versus 17%; difference -7% [95% CI -11% to -2%]). Revascularization was infrequent in both groups (4% versus 6%; difference -2% [95% CI -5% to 0.6%]). CONCLUSION: Although women and men had similar preferences about cardiac diagnostic tests and treatment options, women were less likely than men to say they would accept the physician recommendation for any intervention. Patient preference may partially explain the disparity in cardiovascular testing between women and men.

A time and imaging cost analysis of low-risk ED observation patients: a conservative 64-section computed tomography coronary angiography "triple rule-out" compared to nuclear stress test strategy.

STUDY OBJECTIVE: The study aimed to examine time and imaging costs of 2 different imaging strategies for low-risk emergency department (ED) observation patients with acute chest pain or symptoms suggestive of acute coronary syndrome. We compared a "triple rule-out" (TRO) 64-section multidetector computed tomography protocol with nuclear stress testing. METHODS: This was a prospective observational cohort study of consecutive ED patients who were enrolled in our chest pain observation protocol during a 16-month period. Our standard observation protocol included a minimum of 2 sets of cardiac enzymes at least 6 hours apart followed by a nuclear stress test. Once a week, observation patients were offered a TRO (to evaluate for coronary artery disease, thoracic dissection, and pulmonary embolus) multidetector computed tomography with the option of further stress testing for those patients found to have evidence of coronary artery disease. RESULTS: We analyzed 832 consecutive observation patients including 214 patients who underwent the TRO protocol. Mean total length of stay was 16.1 hours for TRO patients, 16.3 hours for TRO plus other imaging test, 22.6 hours for nuclear stress testing, 23.3 hours for nuclear stress testing plus other imaging tests, and 23.7 hours for nuclear stress testing plus TRO (P < .0001 for TRO and TRO + other test compared to stress test ± other test). Mean imaging times were 3.6, 4.4, 5.9, 7.5, and 6.6 hours, respectively (P < .05 for TRO and TRO + other test compared to stress test ± other test). Mean imaging costs were $1307 for TRO patients vs $945 for nuclear stress testing. CONCLUSION: Triple rule-out reduced total length of stay and imaging time but incurred higher imaging costs. A per-hospital analysis would be needed to determine if patient time savings justify the higher imaging costs.

Emergency Medicine Physicians Would Prefer Using Cannabis Over Opioids for First-Line Treatment of a Medical Condition if Provided With Medical Evidence: A National Survey.

OBJECTIVE:  To determine emergency medicine (EM) physicians' preferences for using medical cannabis versus opioids if medical cannabis was legalized. METHODS: We surveyed US physicians at the largest national EM conference (American College of Emergency Physicians' Annual Conference) held in San Diego, CA from October 1 to 4, 2018. Of the thousands of conference participants approached, 539 US physicians completed the anonymous written survey, which represented 15.2% of the US physicians attending the conference. RESULTS: The mean age of the participants was 39.6 ± 10.9 years, men composed 57.5% of the participants, and whites made up 72.8% of the respondents. Participants practicing in medically legal (54.8%) and medically plus adult-use legal cannabis states (23.1%) totaled 77.9%. A majority (70.7%) of the participants believed that cannabis has medical value. EM physicians preferred cannabis over opioids as a first-line treatment addressing a medical condition provided that medical studies found that cannabis was equally effective (p < 0.001, X 2 = 36.8 [95% CI 2, 415]), and overwhelmingly preferred cannabis over opioids if it were more effective (p < 0.001, X 2 = 90.8 [95% CI 2, 415]). Physicians appeared to prefer opioids over cannabis if medical studies found that cannabis was less effective though it was not significant (p > 0.05). Subgroup analyses showed that belief in the medical value of cannabis significantly increased the odds ratio of choosing cannabis over opioids if cannabis was equally or more effective than opioids. CONCLUSION: Our study shows that EM physicians believe cannabis has medical value and would prefer using cannabis over opioids if provided with equivalent findings. We believe our findings reflect EM physicians' experience of the opioid epidemic and suggest the need for further study of this potential therapeutic.

The emergency department care of the cannabis and synthetic cannabinoid patient: a narrative review.

BACKGROUND: Cannabis is the most prevalent illegal drug used and the second most common cause of ED drug-related complaints in the USA. Recently, newer more potent strains, concentrated THC products, and consumption methods have become available. OBJECTIVE: Our first objective was to define cannabis use in the USA and provide a summary background on its current preparations, pharmacokinetics, vital sign and physical exam findings, adverse effects, and laboratory testing. Our second objective, using the aforementioned summary as relevant background information, was to present and summarize the care and treatment of the most commonly reported cannabis-related topics relevant to ED physicians. METHODS: We first performed an extensive literature search of peer-reviewed publications using New PubMed and Cochrane Central Register of Controlled Trials to identify the most commonly reported cannabis-related topics in emergency care. Once the six topic areas were identified, we undertook an extensive narrative literature review for each section of this paper using New PubMed and Cochrane Central Register of Controlled Trials from the inception of the databases to September 30, 2020. RESULTS: The six subject areas that were most frequently reported in the medical literature relevant to cannabis-related ED care were acute intoxication/overdose, pediatric exposure, cannabinoid hyperemesis syndrome, cannabis withdrawal, e-cigarette or vaping product use-associated lung injury (EVALI), and synthetic cannabinoids. CONCLUSION: As cannabis becomes more widely available with the adoption of state medical cannabis laws, ED-related cannabis visits will likely rise. While cannabis has historically been considered a relatively safe drug, increased legal and illegal access to newer formulations of higher potency products and consumption methods have altered the management and approach to ED patient care and forced physicians to become more vigilant about recognizing and treating some new cannabis-related life-threatening conditions.

Education, Knowledge, and Practice Characteristics of Cannabis Physicians: A Survey of the Society of Cannabis Clinicians.

Context: Medical cannabis use has increased in recent years despite being a federally illegal drug in the United States. States with medical cannabis use laws require patients to be certified by physicians. However, little is known about the education, knowledge, and practice characteristics of physicians who recommend and supervise patients' use of medical cannabis. Objective: This study assessed how U.S. physicians who practice cannabis medicine are educated, self-assess their knowledge, and describe their practice. Methods: In fall 2017, a 57-item, electronic survey was sent to all members of the Society of Cannabis Clinicians. Because California has had legalized medical cannabis for longer than any other state, we analyzed responses for 14 items between California and non-California physicians. Results: Of 282 surveyed, 133 were eligible and 45 completed the survey. Of those, multiple medical specialties were represented. Only one physician received education during medical school about cannabis medicine, but physicians gained knowledge through conferences (71%, 32/45), the medical literature (64%, 29/45), and websites (62%, 28/45). Just over half (56%, 20/45) felt that there was sufficient information available to practice cannabis medicine. Of the 37 who answered the knowledge question, most felt knowledgable about cannabinoids (78%, 29/37) and the endocannabinoid system (76%, 28/37). There was a wide variation in the number of cannabis recommendations provided by physicians over the course of their practice career (median 1200; interquartile range, 100-5000), and most provided condition-specific treatment (69%, 31/45) and dosing recommendations (62%, 28/45). The majority (81%, 30/37) of physicians received referrals from mainstream medical providers. No differences were found between California and non-California physicians, except more women were from California (p=0.02). Conclusions: The use of medical cannabis continues to increase in the United States and globally. All states that allow medical cannabis require a physician's recommendation, yet few states require specific clinical training. Findings of this study suggest the need for more formal education and training of physicians in medical school and residency, more opportunities for cannabis-related continuing medical education for practicing physicians, and clinical and basic science research that will inform best practices in cannabis medicine.

Knowledge and attitudes of emergency department patients regarding radiation risk of CT: Effects of age, sex, race, education, insurance, body mass index, pain, and seriousness of illness.

OBJECTIVE: The purpose of this study was to assess knowledge and attitudes about radiation from CT among emergency department patients with symptoms prompting CT who were stratified on the basis of demographic variables, pain, and perceived illness. SUBJECTS AND METHODS: This survey study was based on three knowledge and three attitude questions asked of patients who underwent any CT examination from June 23 through July 31, 2008. Data were analyzed with chi-square for categoric data and the Student's t test or analysis of variance for continuous data. RESULTS: The survey was completed by 383 patients (mean age, 48 ± 18 years; 60% women; 40% black; 52% white; 8% other race). In answering the three knowledge-based questions, 79% and 83% of patients correctly estimated their risk of cancer from chest radiography and CT, respectively, as none, small, or very small. Patients who were white, more educated, and had lower pain scores were more likely to be correct. Only 34% of all patients correctly thought that CT gave more radiation than chest radiography; the more educated patients were more likely to be correct. In answering the three attitude questions, 74% of patients believed having their condition diagnosed with CT was more important than worrying about radiation. Patients preferred a better test with more radiation, although 68% wanted their physician to take the time to discuss the risk and benefits rather than using their judgment to order the best test. Privately insured patients preferred to have their condition diagnosed with CT rather than worry about radiation. Blacks and patients with less pain wanted the risks and benefits explained at the expense of time. Whites preferred a more definitive test at the expense of more radiation. CONCLUSION: Patients did not estimate the risk of development of cancer from their imaging examinations as high and were more concerned about having their condition diagnosed with CT than about the risk of future cancer. Knowledge and attitudes differed by age, race, education, insurance status, and pain level but not by sex, body mass index, or perceived seriousness of condition.

Aspirin administration in ED patients who presented with undifferentiated chest pain: age, race, and sex effects.

STUDY OBJECTIVES: The study aimed to determine whether aspirin therapy was differentially administered according to race, sex, or age in patients with undifferentiated chest pain who presented to an urban academic emergency department. METHODS: This was a prospective observational cohort study of patients older than 24 years who presented with chest pain between July 1999 and March 2002. Patients were grouped according to 30-day final diagnosis: acute myocardial infarction AMI, unstable angina USA, and non-acute coronary syndrome (ACS) chest pain. Data were analyzed using Fisher exact test and relative risk regression using the Gaussian estimating equation. RESULTS: There were 4478 patient visits, of which 4470 (99.8%) had complete information. Mean age was 52.2 +/- 15.8 years. Blacks were 70.1% (n = 3135), whites 26.3% (n = 1175), and other 3.6% (n = 159). Women comprised 59.0% (n = 2639) of the patients. Aspirin therapy differed by race, sex, age, and final diagnosis. Patients who received aspirin were more likely to be white (60% vs 54%, P = .0009) or have an ACS diagnosis (82% vs 50%, P < .0001). By final diagnosis, there were no race, sex, or age differences for AMI or USA (P > .05). There were significant sex and age differences for non-ACS chest pain patients: men (53% vs 48% women, P = .0009) and older patients (>55 years, 60% vs 44% younger, P < .0001) had higher aspirin therapy due to administration to the patients with non-ACS chest pain. CONCLUSION: For patients with undifferentiated chest pain, overall race, sex, and age differences were explained by higher rates of aspirin administered to older men with non-ACS chest pain.

A history of the Society of Cannabis Clinicians and its contributions and impact on the US medical cannabis movement.

The US medical marijuana movement has come about in a relatively short period of time. Despite millennia in which cannabis was used medically, it was taxed and then banned in the US during the 20th century. It would take a number of factors working concurrently-increasing social use, scientific developments, the AIDS epidemic, and political activism-before its use became accepted again. Some of the groundwork for the medical marijuana movement to take hold was laid out by cannabis clinicians, practitioners who recognized the medical potential of the plant and its constituent compounds, kept abreast of the relevant scientific discoveries, and risked their medical licenses, professional reputations and even arrest to approve and guide medical use to their patients as it became legal in their states. Once the tide started moving, it did so relatively quickly. In this article, a history detailing the first and oldest U.S. medical organization promoting the use of medical cannabis and its founder is reviewed, shedding light on an aspect of history within the medical cannabis movement that is largely unrecognized.

A Survey on the Effect That Medical Cannabis Has on Prescription Opioid Medication Usage for the Treatment of Chronic Pain at Three Medical Cannabis Practice Sites.

OBJECTIVE: The opioid epidemic continues to claim thousands of lives every year without an effective strategy useful in mitigating mortality. The use of medical cannabis has been proposed as a potential strategy to decrease opioid usage. The objective of this study was to determine how the use of medical cannabis affects prescribed opioid usage in chronic pain patients. METHODS: We conducted an online convenience sample survey of patients from three medical cannabis practice sites who had reported using opioids. A total of 1181 patients responded, 656 were excluded for not using medical cannabis in combination with opioid use or not meeting the definition of chronic pain, leaving 525 patients who had used prescription opioid medications continuously for at least three months to treat chronic pain and were using medical cannabis in combination with their prescribed opioid use. RESULTS: Overall, 40.4% (n=204) reported that they stopped all opioids, 45.2% (n=228) reported some decrease in their opioid usage, 13.3% (n=67) reported no change in opioid usage, and 1.1% (n=6) reported an increase in opioid usage. The majority (65.3%, n=299) reported that they sustained the opioid change for over a year. Almost half (48.2%, n=241) reported a 40-100% decrease in pain while 8.6% (n=43) had no change in pain and 2.6% (n=13) had worsening pain. The majority reported improved ability to function (80.0%, n=420) and improved quality of life (87.0%, n=457) with medical cannabis. The majority (62.8%, n=323) did not want to take opioids in the future. While the change in pain level was not affected by age and gender, the younger age group had improved ability to function compared with the middle and older age groups. CONCLUSIONS: Patients in this study reported that cannabis was a useful adjunct and substitute for prescription opioids in treating their chronic pain and had the added benefit of improving the ability to function and quality of life.

The Impact of Medical Cannabis on Intermittent and Chronic Opioid Users with Back Pain: How Cannabis Diminished Prescription Opioid Usage.

Objective: To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users. Design: Retrospective cohort study. Setting: A single-center cannabis medical practice site in California. Patients: A total of 180 patients who had a chief complaint of low back pain were identified (International Classification of Diseases, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed. Interventions: Cannabis recommendations were provided to patients as a way to mitigate their low back pain. Outcome Measures: Number of patients who stopped opioids and change in morphine equivalents. Results: There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR=1.75-11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels. Conclusions: In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.

Radiation dose in a "triple rule-out" coronary CT angiography protocol of emergency department patients using 64-MDCT: the impact of ECG-based tube current modulation on age, sex, and body mass index.

OBJECTIVE: "Triple rule-out" coronary CT angiography (CTA) using 64-MDCT technology is a new approach for evaluating emergency department patients presenting with symptoms suggestive of acute coronary syndrome (ACS). Our objective was to evaluate the reduction in effective radiation dose through the use of tube current modulation in patients who underwent a triple rule-out coronary CTA evaluation and to document how effective radiation dose was impacted by patient age, sex, and body mass index (BMI). MATERIALS AND METHODS: A retrospective analysis of triple rule-out coronary CTA examinations performed on a 64-MDCT scanner was ordered on a prospective cohort of 267 consecutive low- to moderate-risk emergency department patients with suspected ACS from a single university hospital between October 2006 and March 2008. Tube current modulation was generally used in patients with heart rates below 65 beats per minute during the second half of the study period as a way to reduce radiation exposure. We calculated effective radiation exposure using actual patient coronary CTA scanning parameters by age, sex, and BMI. RESULTS: Among the 172 patients evaluated without tube current modulation, effective dose averaged (+/- SD) 18.0 +/- 5.6 mSv (range, 9.9-31.3 mSv). Of the 95 patients who underwent CTA examination with tube current modulation, effective dose was significantly lower at 8.75 +/- 2.64 mSv (range, 5.4-16.6 mSv; p < 0.0001) and image quality was better (p < 0.0001) as compared with examinations without tube current modulation. There were no significant radiation differences by patient age, but tube current modulation decreased radiation exposure by at least half. Among the studies in which tube current modulation was not used, women received less radiation than men (17.0 vs 19.5 mSv, respectively; p < 0.001). For the studies with tube current modulation, there were no radiation differences by sex. Obese patients received significantly more radiation than overweight and normal-weight patients in the non-tube current modulation groups (20.9 mSv vs 15.0 and 14.9 mSv, respectively; p < 0.0001) and in the tube current modulation groups (10.3 mSv vs 7.6 and 7.1 mSv, p < 0.0001). CONCLUSION: The overall effective radiation dose for triple rule-out coronary CTA was reduced by more than 50% with ECG-based tube current modulation without loss of image quality. Tube current modulation should be used for triple rule-out coronary CTA examinations whenever possible.

Evaluation of a "triple rule-out" coronary CT angiography protocol: use of 64-Section CT in low-to-moderate risk emergency department patients suspected of having acute coronary syndrome.

PURPOSE: To determine whether coronary computed tomographic (CT) angiography "triple rule-out" evaluation of emergency department (ED) patients presenting with symptoms suggestive of acute coronary syndrome (ACS) can help identify a subset of patients who can be discharged without adverse clinical outcomes within 30 days. MATERIALS AND METHODS: This protocol was approved by the university institutional review board. Each patient provided written informed consent prior to inclusion. Coronary CT angiography was performed in 201 consecutive low-to-moderate risk ACS patients. A triple rule-out protocol was used to evaluate for coronary disease, pulmonary embolism, aortic dissection, and other thoracic disease. Four patients were excluded because of technical problems. The remaining subjects underwent a 30-day follow-up. RESULTS: A disease process other than coronary atherosclerosis that explained the presenting symptoms was diagnosed in 22 (11%) of 197 patients. Clinically important noncoronary diagnoses that did not explain patient symptoms were identified in 27 (14%) of 197 additional patients. With respect to coronary artery disease, 10 patients had severe disease (>70% stenosis), 12 had moderate disease (50%-70% stenosis), 46 had mild disease (up to 50% stenosis), and 129 had no disease. No further diagnostic testing was performed in 133 (76%) of 175 of patients with no to mild coronary disease. At 30-day follow-up, the negative predictive value of coronary CT angiography with no more than mild disease was 99.4%. There were no adverse outcomes at 30 days. CONCLUSION: Triple rule-out coronary CT angiography evaluation of low-to-moderate risk ACS patients presenting to the ED provided a noncoronary diagnosis that explained the presenting complaint in 11% of patients, suggested the presence of significant moderate-to-severe coronary disease in 11% (22 of 197) of patients, and precluded additional diagnostic cardiac testing in the majority of patients with no adverse outcomes at 30-day follow-up.

Preferences for cardiac tests and procedures may partially explain sex but not race disparities.

OBJECTIVE: There are known race and sex differences in emergent cardiac care. Many feel these differences reflect a bias from the physician. We hypothesized these differences may be the result of patient preferences. METHODS: Emergency department (ED) patients 40 years and older with a chief complaint of chest pain were surveyed from July 11 through December 9, 2005, at 2 academic EDs. This prospective survey study included demographics and prior cardiac test experience. Preferences for hypothetical cardiac tests and procedures were compared between race and sex using chi(2) or Fisher exact tests. RESULTS: Two hundred sixteen patients were enrolled. The mean age was 55 +/- 12 years (43% men and 51% black). Blacks compared with whites preferred the electrocardiogram (ECG) to the technetium-99m sestamibi (MIBI) stress test. Blacks also preferred a percutaneous coronary intervention (PCI) compared with whites who were more likely to forego PCI. These racial differences disappeared when a physician recommended a procedure. There were no race preferences between PCI vs coronary artery bypass graft, whether or not a doctor recommended the procedure. For sex, there were no preferences between ECG vs MIBI stress test or cardiac catheterization, whether or not a doctor recommended the test or procedure. With regard to a choice between PCI and coronary artery bypass graft, women were more likely to decline the procedure than men. Even with a physician-recommended procedure, women were more likely to refuse than men, whereas men were more likely to accept it. CONCLUSIONS: Blacks were more likely to prefer the less invasive stress test and wanted PCIs more, but these racial differences disappeared when a physician-recommended test was offered. Women were more likely to refuse the most invasive cardiac procedure compared with men. The sex-related preferences might partially explain why women receive fewer invasive cardiac procedures than men. However, race-related cardiac preferences suggest that other factors beyond patient preference account for fewer PCIs in black patients.

Sixty-four-slice multidetector computed tomography: the future of ED cardiac care.

Multidetector computed tomography (MDCT) imaging, a technological advance over traditional CT, is a promising possible alternative to cardiac catheterization for evaluating patients with chest pain in the emergency department (ED). In comparison with traditional CT, MDCT offers increased spatial and temporal resolution that allows reliable visualization of the coronary arteries. In addition, a "triple scan," which includes evaluation for pulmonary embolism and thoracic aortic dissection, can be incorporated into a single study. This test will enable emergency physicians to rapidly evaluate patients for life-threatening illnesses and may allow safer and earlier discharges of many patients with chest pain in comparison with a traditional rule-out protocol. In this article, we will highlight the technological advances of MDCT imaging, review the literature on coronary angiography via MDCT, and discuss the future of this technology as it relates to the ED.

Strategies for dealing with emergency department overcrowding: a one-year study on how bedside registration affects patient throughput times.

The objective of this study was to determine if the implementation of bedside registration would affect patient throughput times in an urban, academic emergency department. This was a before-and-after interventional study. An 8-month period before initiating bedside registration in November 2001 was compared to three subsequent 4-month intervals. Four times of day and three triage classifications were examined. Data were analyzed using a three-way analysis of covariance. There were 58,225 patient encounters analyzed. There was a significant difference in time from triage to room after bedside registration began (p < 0.0001). When examined by triage class, there were no differences in triage-to-room for emergent patients, a significant decrease for urgent patients initially and a significant decrease for non-urgent patients. Bedside registration by time of day initially reduced all four time-of-day periods but over the year they returned to pre-bedside registration levels, except for the morning period. Bedside registration decreased triage-to-room times for non-urgent patients and urgent patients initially, but this was not sustained at the end of 1 year. It had no effect on emergent patients who are routinely taken into the patient care area immediately. The sustainable effects of bedside registration were during the morning time when emergency department beds were available.