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Thursday, September 18, 2014

Emergency room doctors can safely use bedside ultrasound to diagnose kidney stones, saving billions of dollars and preventing some radiation induced cancers

I have been following the progress of bedside ultrasound (using ultrasound as a diagnostic tool during physical exam of patients) as it gets a foothold in standard medical practice. It has been part of my practice for almost 3 years now, during which time I have been repeatedly amazed by how helpful it is for guiding my clinical decisions. There is good research showing how useful it is for all sorts of applications, from heart problems to intestinal obstruction, but it is still slow to catch on.

An article came out just recently in the New England Journal of Medicine, which has a large circulation and should make a bit of a splash. This multi-center study looked at the option of having patients (excluding the very obese, pregnant and critically ill) with abdominal and flank pain suspected of having kidney stones evaluated first by emergency physicians with ultrasound of the kidneys and bladder before considering getting a CT scan. Normally a patient with suspected kidney stones (crampy pain in the back or abdomen, blood in the urine, suggestive history) will be referred for an abdominal and pelvic CT scan, which costs over $3000 and carries a significant amount of radiation exposure. In perfect circumstances performing the test and getting the results takes an hour, but it can end up taking several hours due to the usual delays. Sometimes patients with kidney stone type symptoms are referred by the emergency physician for an ultrasound by the radiology department, which takes about the same amount of time as the CT which takes the same amount of time, but costs a bit less and delivers no ionizing radiation. CT scans have beautiful pictures and can often find the kidney stone, if it's in there, and not finding the stone is strongly suggestive that the diagnosis of what is causing the pain must be sought elsewhere. Ultrasound can show if the kidney is blocked by showing lack of flow into the bladder or buildup of fluid in the kidney (hydronephrosis) but rarely actually visualizes the stone. This information, however, is adequate to make the diagnosis in most cases, when combined with a good clinical history, physical exam and lab tests.

It turns out that the bedside ultrasound exam done by emergency room docs (in this study they were from multiple medical centers including University of California at San Francisco, Cook County and Rush Medical Centers in Chicago, Group Health in Seattle and many more high quality locations) is adequate in cases of abdominal or flank pain as a first evaluation to rule in or out kidney stones. It is much more focused than an ultrasound performed by the radiology department and it only takes about 5 minutes or less to perform. Since it is done by the physician examining the patient it is also a time to take more history and do more general observation, which is always a good thing. About 40% of the patients initially evaluated this way got an official radiology ultrasound or CT scan which were felt to be necessary by the ER physician to clarify what was going on. About a million patients with kidney stones visit emergency rooms each year in the US and more than 10 times that many visit ER's with symptoms that sound a bit like kidney stones and have to be evaluated for them. If all of them got bedside ultrasound as the initial evaluation of their kidneys, my back-of-the-envelope calculations suggest that multiple billions of dollars could be saved on imaging costs and lives could potentially be saved due to reduced radiation exposure. The study showed no significant increase in complications in the patients first receiving bedside ultrasound. Actual cost savings were calculated, but not reported in the study (why?)

We can't just start doing this because not all ER doctors are yet comfortable performing and interpreting bedside ultrasound of the kidneys and bladder. But they could be. It is not hard. Pretty much anybody could learn to do this in maybe an hour and could certainly be competent after doing 50 exams. The implications of this are bigger than the article points out. When ER physicians start doing regular bedside (or "point of care" as it's sometimes termed) ultrasound they are going to get better at it. They will start to use ultrasound more and develop some pattern recognition skills that can't be predicted which will likely lead to more accurate diagnoses of other diseases, and possibly less dependence on ionizing and expensive radiation in the form of CT scans.

Unfortunately CT scans for abdominal pain in the emergency room  are an important source of revenue for both radiologists and hospitals which puts a little kink in the clear path toward adopting bedside ultrasound as a diagnostic procedure of choice. It's not clear what to do with this, because we could surely use the expertise of radiologists and radiology technicians in training physicians to be good bedside ultrasonographers and presently that would be a pretty big conflict of interest for them. Still, there is so much good stuff going on in the field of high tech ultrasound that is not in the scope of bedside ultrasound that radiologists and technicians could be kept gainfully occupied by doing things that other physicians can't and shouldn't do. In the journal of the American Institute of Ultrasound in Medicine there were several articles about amazing and technically challenging imaging applications that non-radiologists might be wise not to try. There were articles about ultrasound of the midbrain to evaluate Parkinson's Disease, ultrasound of the liver to look at severity of cirrhosis, ultrasound of children with intestinal intussusception (telescoping of the bowel) to follow the success of noninvasive treatments and detailed prenatal evaluations for conditions I didn't even know existed. Ultrasound to diagnose appendicitis has become nearly standard now, but is really hard to learn and ultrasonographers and radiologists do it well (some ER physicians do it well too, but it's far from an entry level skill.) Looking at the kidneys in 5 minutes in the ER is clearly fine for evaluating possible kidney stones. An abdominal ultrasound in the radiology department with their big powerful machine with the gorgeous images combined with the stunning command of anatomy of radiology professionals is a different and differently beneficial thing. This recent article may help move us as hospitalists, ER physicians and primary care providers toward doing more bedside ultrasound, which could be a very good thing. Perhaps more radiologists will find peace with that and can bring themselves to help teach other medical staff who need to learn how to do it.

Tuesday, September 16, 2014

American College of Physicians blows this one: Pri-med "free" education on safe opiate prescribing, REMS and drug companies

I am mostly a pretty big fan of the American College of Physicians (ACP), the society that (usually) represents me as an internal medicine physician. They present meetings and conferences to spread new and relevant information and they promote gifted and hard working physicians and medical teachers. They are a force for organization in our profession which often fails to pull together and sometimes resembles a group of agitated hedgehogs. Some of the educational offerings that they produce are ground breaking, encouraging us to practice medicine that is more effective and patient centered. I do pay $525 yearly to maintain my membership, but that doesn't seem unfair.

So that is why I opened the slick tri-fold large format postcard that I got in the mail today rather than recycling it immediately. It said, "Practice safe opioid prescribing with ACP's resources." Over-prescribing opiate painkillers such as morphine, oxycodone and hydrocodone is a huge problem in the US. In 2010 60% of the nearly 40,000 opiate overdose deaths were due to prescription medications, and that number is continuing, I believe, to rise every year. In addition to relieving pain, medications of this class can make people stop breathing, fall asleep at inopportune times, make poor decisions, be unable to have bowel movements and other life ending scenarios. The US uses 80% of the prescription opiates produced in the world. Many of the opiates we as physicians prescribe end up being misused or abused or sold illegally. In the 1990s there was a huge increase in understanding that pain needed treatment and in the 10 years between 1997 and 2007 prescriptions for pain medication increased 600%. I see patients frequently in the hospital whose illnesses become life threatening because they use prescription opiate pain medications. There are nearly a half a million emergency room visits each year related to prescription opiate abuse and the cost in healthcare dollars of this problem is many billions of dollars. There is a problem with our prescribing habits.

The tri-fold postcard from the ACP offered a 6 hour continuing medical education credit online course on appropriate prescribing of opiate pain medications, with a focus on avoiding overdose and addiction. The course was free to me. When I went to the ACP site I was re-directed to Pri-Med's site where the audio and slide program was available. Pri-Med is a medical education company which makes low cost (to us) online programs on all sorts of subjects. The programs are so low in cost that they can't possibly actually cover the expense of creating the content. Hmmm. Vewwy Intewwesting.

I went ahead and took the 6 modules which covered appropriate use of long acting opiate pain medications to treat chronic pain. I learned some interesting things about risk factors for prescription pain medication abuse, some obvious (active ongoing drug abuse) and some less so (age 18-45 with family history of drug abuse). I learned about different opiates' side effects and interactions with other drugs based on the cytochrome P450 system. I also heard stuff I already knew, such as the fact that long acting opiates are not supposed to be taken "as needed" but should be scheduled and that most of them must be left intact, not chewed or crushed, in order to remain long acting. Most of all I was exposed to a bunch of brand name opiates and exactly how they worked and what doses were standard and how they compared to each other. What I didn't learn was how much each of these drugs cost and how those costs and potential advantages compared to generic long acting opiates. There was nothing useful about how to help pain patients get off of opiates or alternatives to starting them in the first place.

After a rather long program I felt as if I had been cornered by a drug rep (representative from a pharmaceutical company). I am not pleased. I have been effectively inoculated with wonder drug propaganda. In return I will have a certificate that says I have been educated in safe opiate prescribing, which many state medical boards now require for licensure.

Why did this happen? Here's the story. The FDA now requires that companies that produce long acting opiates do something to make less people die of their drugs. The Food and Drug Administration Amendments Act of 2007 gave FDA the authority to require a Risk Evaluation and Mitigation Strategy (REMS) from manufacturers to ensure that the benefits of a drug or biological product outweigh its risks. For long acting opiates this consists of providing free education to prescribers and proving that at least 60% of them partake of these educational programs. Pri-Med makes its money from the healthcare industry, I'm guessing primarily from drug companies. This particular program skillfully combines risk mitigation with drug detailing. Clever pharma. 

I'm disappointed in the ACP, though. On their website they did mention that this educational activity was supported by industry, but it was in very small print. With $525 of dues money times 140,000+ members, along with other sources of income, the ACP does not need drug company support to create educational material. State boards of medicine require education in safe opiate prescribing, but they do not require that it be provided by drug companies. It sounds like drug companies may have to prove that their educational materials are being disseminated, but that is not the business of the ACP and is not my responsibility. And the shiny tri-fold postcard. Who paid for that?