Documentation from trained medical students has a low rate of relative downcoding for emergency medicine encounters.

Background: Since 2018, the Centers for Medicare & Medicaid Services (CMS) guidelines have allowed teaching physicians to bill for evaluation and management services based on medical student documentation. Limited previous data suggest that medical student documentation suffers from a high rate of downcoding relative to faculty documentation. We sought to compare the coding outcomes of documentation performed by medical students, and not edited by faculty, with documentation edited and submitted by faculty. Methods: A total of 104 randomly selected notes from real patient encounters written by senior medical students were compared to the revised notes submitted by faculty. The note pairs were then split and reviewed by blinded professional coders and assigned level of service (LoS) codes 1-5 (corresponding to E&M CPT codes 99281-99285). Results: We found that the LoS agreement between student and faculty note versions was 63%, with 23% of all student notes receiving lower LoS compared to faculty notes (downcoded). This was found to be similar to baseline variability in professional coder LoS designations. Conclusions: Notes from medical students who have completed a focused documentation curriculum have less LoS downcoding than in previous reports.

The HAS-Choice study: Utilizing the HEART score, an ADP, and shared decision-making to decrease admissions in chest pain patients.

OBJECTIVE: The HAS-Choice pathway utilizes the HEART Score, an accelerated diagnostic protocol (ADP), and shared decision-making using a visual aid in the evaluation of chest pain patients. We seek to determine if our intervention can improve resource utilization in a community emergency department (ED) setting while maintaining safe patient care. METHODS: This was a single-center prospective cohort study with historical that included ED patients ≥21years old presenting with a primary complaint of chest pain in two time periods. The primary outcome was patient disposition. Secondary outcomes focused on 30-day ED bounce back and major adverse cardiac events (MACE). We used multivariate logistic regression to estimate the odds ratio (OR) and its 95% confidence interval (CI). RESULTS: In the pre-implementation period, the unadjusted disposition to inpatient, observation and discharge was 6.5%, 49.1% and 44.4%, respectively, whereas in the post period, the disposition was 4.8%, 41.5% and 53.7%, respectively (chi-square p<0.001). The adjusted odds of a patient being discharged was 40% higher (OR=1.40; 95% CI, 1.30, 1.51; p<0.001) in the post-implementation period. The adjusted odds of patient admission was 30% lower (OR=0.70; 95% CI, 0.60, 0.82; p<0.001) in the post-implementation period. The odds of 30-day ED bounce back did not statistically differ between the two periods. MACE rates were <1% in both periods, with a significant decrease in mortality in the post-implementation period. CONCLUSION: Our study suggests that implementation of a shared decision-making tool that integrates an ADP and the HEART score can safely decrease hospital admissions without an increase in MACE.

Reactive oxygen species mediate microRNA-302 regulation of AT-rich interacting domain 4a and C-C motif ligand 5 expression during transitions between quiescence and proliferation.

Normal cell growth consists of two distinct phases, quiescence and proliferation. Quiescence, or G(0), is a reversible growth arrest in which cells retain the ability to reenter the proliferative cycle (G(1), S, G(2), and M). Although not actively dividing, quiescent cells are metabolically active and quiescence is actively maintained. Our results from microRNA PCR arrays and Taqman PCR assays showed a significant decrease (4-fold) in miR-302 levels during quiescence compared to proliferating normal human fibroblasts, suggesting that miR-302 could regulate cellular proliferation. Results from a Q-RT-PCR and dual-luciferase-3'-UTR reporter assays identified ARID4a (AT-rich interacting domain 4a, also known as RBP1) and CCL5 (C-C motif ligand 5) as targets for miR-302. Ionizing radiation decreased miR-302 levels, which was associated with an increase in its target mRNA levels, ARID4a and CCL5. Such an inverse correlation was also observed in cells treated with hydrogen peroxide as well as SOD2-overexpressing cells. Overexpression of miR-302 suppresses ARID4a and CCL5 mRNA levels, and increased the percentage of S-phase cells. These results identified miR-302 as an ROS-sensitive regulator of ARID4a and CCL5 mRNAs as well as demonstrate a regulatory role of miR-302 during quiescence and proliferation.