Emergency department visits after hours by lung cancer patients in Japan

Purpose

The aims of this study were to clarify frequency with which Japanese lung cancer patients visited an emergency department (ED) after hours and their final outcome.

Methods

This is a retrospective and single institutional study. We reviewed medical records of patients who died of lung cancer from January 2008 to June 2012 at Osaka Police Hospital who had been followed up since diagnosis of lung cancer until death. We compared patients who had visited the ED after hours on weekdays, weekends, or holidays over their lives with cancer (ED visitors) and patients who had never visited the ED (non-ED visitors).

Results

Overall, 245 patients met the inclusion criteria for analysis. There were 149 after hours ED visits by 106 lung cancer patients. Mean number of ED visits was 0.6 for all patients. Median interval from ED visit to death was 49 days. The most common chief compliant for these patients was respiratory problems (37.6 %). Most patients visited the ED during chemotherapy (32.9 %) or for best supportive care (42.3 %). Directly after ED visits, 56.4 % of ED visitors were finally hospitalized. In a multivariate analysis, performance status (PS) (odds ratio [OR]: 11.2, 95 % confidence interval [CI]: 2.1–59.0, p?=?0.004) and cancer stage (OR: 0.003, 95 % CI: 0.0006–0.014, p?<?0.001) at diagnosis were statistically associated with ED visits after hours.

Conclusions

Japanese patients with lung cancer frequently visit ED after hours. An ED visit is itself an indicator of poor prognosis.     

A prospective,open-label,multicenter study of the clinical efficacy of extended-release hydromorphone in treating cancer pain inadequately controlled by other analgesics

Purpose

The objective of this study was to evaluate whether extended-release hydromorphone (osmotic-controlled release oral delivery system [OROS] hydromorphone) treatment provided pain relief in cancer patients whose pain was inadequately controlled by other analgesics.

Methods

In this prospective, open-label, multicenter trial, patients who have sustained cancer pain with other analgesics were enrolled. After the baseline evaluation (visit 1), OROS hydromorphone was administered. Two evaluations (visits 2 and 3) were made: 29?±?7 and 57?±?7 days later, respectively. The primary end point was the pain intensity difference (PID) at visit 3 relative to visit 1 (expressed as percent PID).

Results

In total, 879 patients were screened and 432 completed all three visits. Of the 874 full analysis set patients, 343 (39.2 %) improved by more than 30 % PID. Of the 432 per-protocol patients, 282 (65.3 %) improved by more than 30 % PID. At visits 2 and 3, the degree of sleep disturbance, the number of awakenings, and the degree of sleep satisfaction were significantly better than at visit 1 (all P?<?0.0001 for both visit 1–visit 2 and visit 1–visit 3). However, this pain relief was not associated with improved quality of life (P?=?0.326 and P?=?0.055 for visit 1–visit 2 and visit 1–visit 3, respectively).

Conclusions

This study suggested that active pain management using the strong opioid OROS hydromorphone was beneficial in the management of cancer pain that was not controlled by other analgesics.     

Risk factors for recurrent emergency department visits for hyperglycemia in patients with diabetes mellitus

Background

Patients with poorly controlled diabetes mellitus may present repeatedly to the emergency department (ED) for management and treatment of hyperglycemic episodes, including diabetic ketoacidosis and hyperosmolar hyperglycemic state. The objective of this study was to identify risk factors that predict unplanned recurrent ED visits for hyperglycemia in patients with diabetes within 30 days of initial presentation.

Methods

We conducted a 1-year health records review of patients ≥18 years presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic state. Trained research personnel collected data on patient characteristics and determined if patients had an unplanned recurrent ED visit for hyperglycemia within 30 days of their initial presentation. Multivariate logistic regression models using generalized estimating equations to account for patients with multiple visits determined predictor variables independently associated with recurrent ED visits for hyperglycemia within 30 days.

Results

There were 833 ED visits for hyperglycemia in the 1-year period. 54.6% were male and mean (SD) age was 48.8 (19.5). Of all visitors, 156 (18.7%) had a recurrent ED visit for hyperglycemia within 30 days. Factors independently associated with recurrent hyperglycemia visits included a previous hyperglycemia visit in the past month (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.1–5.8), age <25 years (OR 2.6, 95% CI 1.5–4.7), glucose >20 mmol/L (OR 2.2, 95% CI 1.3–3.7), having a family physician (OR 2.2, 95% CI 1.0–4.6), and being on insulin (OR 1.9, 95% CI 1.1–3.1). Having a systolic blood pressure between 90–150 mmHg (OR 0.53, 95% CI 0.30–0.93) and heart rate >110 bpm (OR 0.41, 95% CI 0.23–0.72) were protective factors independently associated with not having a recurrent hyperglycemia visit.

Conclusions

This unique ED-based study reports five risk factors and two protective factors associated with recurrent ED visits for hyperglycemia within 30 days in patients with diabetes. These risk factors should be considered by clinicians when making management, prognostic, and disposition decisions for diabetic patients who present with hyperglycemia.

     

Seizure visits in US emergency departments: epidemiology and potential disparities in care

Introduction

While epilepsy is a well-characterized disease, the majority of emergency department (ED) visits for “seizure” involve patients without known epilepsy. The epidemiology of seizure presentations and national patterns of management are unclear. The aim of this investigation was to characterize ED visits for seizure in a large representative US sample and investigate any potential impact of race or ethnicity on management.

Methods

Seizure visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2003 were analysed. Demographic factors associated with presentation, neuroimaging and hospital admission in the USA were analysed using controlled multivariate logistic regression.

Results

Seizure accounts for 1 million ED visits annually [95% confidence interval (CI): 926,000–1,040,000], or 1% of all ED visits in the USA. Visits were most common among infants, at 8.0 per 1,000 population (95% CI: 6.0–10.0), and children aged 1–5 years (7.4; 95% CI: 6.4–8.4). Seizure was more likely among those with alcohol-related visits [odds ratio (OR): 3.2; 95% CI: 2.7–3.9], males (OR: 1.4; 95% CI: 1.3–1.5) and Blacks (OR: 1.4; 95% CI: 1.3–1.6). Neuroimaging was used less in Blacks than Whites (OR: 0.6; 95% CI: 0.4–0.8) and less in Hispanics than non-Hispanics (OR: 0.6; 95% CI: 0.4–0.9). Neuroimaging was used less among patients with Medicare (OR: 0.4; 95% CI: 0.2–0.6) or Medicaid (OR: 0.5; 95% CI: 0.4–0.7) vs private insurance and less in proprietary hospitals. Hospital admission was less likely for Blacks vs Whites (OR: 0.6; 95% CI: 0.4–0.8).

Conclusion

Seizures account for 1% of ED visits (1 million annually). Seizure accounts for higher proportions of ED visits among infants and toddlers, males and Blacks. Racial/ethnic disparities in neuroimaging and hospital admission merit further investigation.     

Comparing Statewide and Single‐center Data to Predict High‐frequency Emergency Department Utilization Among Patients With Asthma Exacerbation

Background

Previous studies examining high‐frequency emergency department (ED) utilization have primarily used single‐center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were 1) to create a predictive model to prospectively identify patients at risk of high‐frequency ED utilization for asthma and 2) to examine how that model differed using statewide versus single‐center data.

Methods

To track ED visits within a state, we analyzed 2011 to 2013 data from the New York State Healthcare Cost and Utilization Project State Emergency Department Databases. The first year of data (2011) was used to determine prior utilization, 2012 was used to identify index ED visits for asthma and for demographics, and 2013 was used for outcome ascertainment. High‐frequency utilization was defined as 4+ ED visits for asthma within 1 year after the index visit. We performed analyses separately for children (age < 21 years) and adults and constructed two models: one included all statewide (multicenter) visits and the other was restricted to index hospital (single‐center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using Akaike's Information Criterion scores, 10‐fold cross‐validation, and receiver operating characteristic curves.

Results

Among children, high‐frequency ED utilization for asthma was observed in 2,417 of 94,258 (2.56%) using all statewide visits, compared to 1,853 of 94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779 of 159,874 (4.87%) and 5,053 of 159,874 (3.16%), respectively. In the multicenter visit model, the area under the curve (AUC) from 10‐fold cross‐validation for children was 0.70 (95% confidence interval [CI] = 0.69–0.72), compared to 0.71 (95% CI = 0.69–0.72) in the single‐center visit model. The corresponding AUC results for adults were 0.76 (95% CI = 0.76–0.77) and 0.76 (95% CI = 0.75–0.77), respectively.

Conclusion

Data available at the index ED visit can predict subsequent high‐frequency utilization for asthma with AUC ranging from 0.70 to 0.76. Model accuracy was similar regardless of whether outcome ascertainment included all statewide visits (multicenter) or was limited to the index hospital (single‐center).

     

Pediatric Emergency Department Utilization and Reliance by Insurance Coverage in the United States

Objectives

For many children, the emergency department (ED) serves as the main destination for health care, whether it be for emergent or nonurgent reasons. Through examination of repeat utilization and ED reliance (EDR), in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care.

Methods

Nationally representative data from the 2010 to 2014 Medical Expenditure Panel Survey were used to examine the annual ED utilization of children age 0 to 17 years by insurance coverage. Overall utilization, repeat utilization (two or more ED visits), and EDR (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High EDR was defined as having > 33% of outpatient visits in a year being ED visits.

Results

A total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a 1‐year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.40–1.73) than children with private insurance, whereas uninsured children were less likely (aOR = 0.64, 95% CI = 0.51–0.81). Children age 3 and under were significantly more likely to visit the ED than children age 15 to 17, whereas female children and Hispanic and non‐Hispanic other race children were significantly less likely to visit the ED than male children and non‐Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a 1‐year period. Children with public insurance were more likely to have two or more visits to the ED (aOR = 1.53, 95% CI = 1.19–1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR = 1.70, 95% CI = 1.47–1.97) and uninsured children (aOR = 1.90, 95% CI = 1.49–2.42) were more likely to be reliant on the ED than children with private insurance.

Conclusions

Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and EDR. Demographic characteristics, including sex, age, income, and race/ethnicity were important predictors of ED utilization and reliance.

     

Impact of a Shared Decision Making Intervention on Health Care Utilization: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial

Background

Patients at low risk for acute coronary syndrome are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the health care system.

Objectives

The purpose of this investigation was to measure the effect of the Chest Pain Choice (CPC) decision aid on overall health care utilization as well as utilization of specific services both during the index emergency department (ED) visit and in the subsequent 45 days.

Methods

This was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the ED with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by the CPC decision aid to a control group receiving usual care. Hospital‐level billing data were used to measure utilization for the index ED visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording health care utilization over the same 45‐day period. Outcomes assessed included length of time in the ED and observation, ED visits, office visits, hospitalizations, testing, imaging, and procedures.

Results

Of the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45‐day health care diary review. There was no difference in patient‐reported health care utilization between the study arms. Hospital‐level billing data were obtained for all 898 (100%) patients. During the initial ED visit the length of stay (LOS) was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit LOS was 95 minutes (95% confidence interval [CI] = 40.8–149.8) shorter in the CPC arm and the mean number of tests was lower in the CPC arm (decrease in 19.4 imaging studies per 100 patients, 95% CI = 15.5–23.3). When evaluating the entire encounter and follow‐up period, the intervention arm underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI = 29.3–221.6). More specifically, there were fewer advanced cardiac imaging tests completed (25.8 fewer per 100 patients, 95% CI = 3.74–47.9) in the intervention arm.

Conclusions

Shared decision making in low‐risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.

     

The Impact of a Pediatric Emergency Department Facility Verification System on Pediatric Mortality Rates in Arizona

Background

The Emergency Medical Services for Children State Partnership Program, as well as the Institute of Medicine report on pediatric emergency care, encourages recognition of emergency departments (EDs) through categorization and verification systems. Although pediatric verification programs are associated with greater pediatric readiness, clinical outcome data have been lacking to track the effects and patient-centered outcomes by implementing such programs.

Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children

Objective

The objective was to test the hypothesis that in‐hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit.

Methods

This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as “ED return admissions” (discharged at ED index visit and admitted at return visit) or “readmissions” (admission at both ED index and return visits). In‐hospital outcomes for ED return admissions and readmissions were compared to “index admissions without return admission” (admitted at ED index visit without 7‐day return visit admission).

Results

Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = –$193; 95% CI = –$479 to $93) compared to index admissions without return admission.

Conclusions

Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.

     

Errors in fracture diagnoses in the emergency department – characteristics of patients and diurnal variation

Background

Evaluation of the circumstances related to errors in diagnosis of fractures at an Emergency Department may suggest ways to reduce the incidence of such errors.

Methods

Retrospective analysis of all cases during a two year period (2002–2004) where a fracture had been overlooked or an injury had been erroneously diagnosed as a fracture (n = 61). 100 random selected patients with correctly diagnosed fractures served as control group.

Results

In the two year period 5879 patients visited the ED with injuries. 1% of all visits to the ED resulted in an error in fracture diagnosis and 3.1% of all fractures were not diagnosed at the initial visit to the ED. 86% of such errors had consequences for treatment. No patient characteristics could be identified as risk factors for a misdiagnosis of a fracture. There was a peak in errors in fracture diagnoses between 8 pm and 2 am (47% against 20% in controls, p < 0.005).

Conclusion

A considerable number of fractures were not correctly diagnosed at the initial ED visit. There was a diurnal variation in the rate of misdiagnosis of fractures with a significant peak from 8 pm to 2 am. Where there was an error in fracture diagnosis, the patients did not appear to have a characteristic profile as regarding e.g. age, sex or capability to communicate with the ED staff. Increased consultancy service in radiology may reduce the frequency of errors in diagnosis, particularly in the evenings between 8 pm and 2 am.     

ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis

Introduction

Routine medical clearance testing of emergency department (ED) patients with acute psychiatric illnesses in the absence of a medical indication has minimal proven utility. Little is known about the variations in clinical practice of ordering medical clearance tests.

Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France

Background

For several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED.

Methods

We conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit.

Results

Of 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%).

Conclusions

The lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.     

Risk of unplanned visits for colorectal cancer outpatients receiving chemotherapy: a case-crossover study

Aim

This study was conducted to evaluate the impact of chemotherapy on the risk of unplanned visit in a cohort of colorectal cancer outpatients. Chief complaints for unplanned visits and risk factors for hospital admission were also analyzed.

Patients and methods

Clinical data of 229 consecutive colorectal cancer patients who were unexpectedly presented to our acute oncology clinic between 2006 and 2009 were reviewed. A case-crossover statistical analysis was applied to study the association between exposure to chemotherapy (trigger event) and the occurrence of unplanned visit (acute outcome) in three time windows (7, 15, and 21 days from the closest previous chemotherapy treatment). Cox model was used to assess the risk factors for hospitalization.

Results

There were 469 unplanned visits registered. Most of the patients had Eastern Cooperative Oncology Group performance status (ECOG PS) 0–1 (80 %) and advanced cancer stage (78 %). The majority of unplanned visits (72 %) occurred within 30 days since last chemotherapy. The most frequent presenting complaints were pain, fatigue, and anorexia. The two time windows associated with higher risk of visit were 15 and 21 days from last treatment, both for early (odds ratio [OR] 3.8, CI 1.4–10.2 and OR 3.8, CI 1.4–10.2) and advanced disease stage (OR 1.71, CI 1–2.9 and OR 3, CI 1.5–5.9). Of the unplanned visits, 10 % resulted in hospital admission. Presenting with multiple symptoms and with deteriorated PS were both predictors for hospitalization.

Conclusion

Chemotherapy exposition triggers the need for unplanned visits over the second and third week after treatment. The prompt and effective management of unexpected events may be cost- and time-saving and reduce pressure on oncology services.     

Metastatic epidural spinal cord compression among elderly patients with advanced prostate cancer

Background

A recent randomized trial demonstrated that for metastatic epidural spinal cord compression (MESCC), a complication of advanced prostate cancer, surgical decompression may be more effective than external beam radiation therapy (RT). We investigated predictors of MESCC, its treatment, and its impact on hospital length of stay for patients with advanced prostate cancer.

Methods

We used the SEER-Medicare database to identify patients >65 years with stage IV (n?=?14,800) prostate cancer. We used polytomous logistic regression to compare those with and without MESCC and those hospitalized for treatment with surgical decompression and/or RT.

Results

MESCC developed in 711 (5 %) of patients, among whom 359 (50 %) received RT and 107 (15 %) underwent surgery?±?RT. Median survival was 10 months. MESCC was more likely among patients who were black (OR 1.75, 95 %CI 1.39–2.19 vs. white) and had high-grade tumors (OR 3.01, 95 %CI 1.14–7.94), and less likely in those younger; with prior hormonal therapy (OR 0.73, 95 %CI 0.62–0.86); or with osteoporosis (OR 0.63, 95 %CI 0.47–0.83). Older patients were less likely to undergo either RT or surgery, as were those with ≥1 comorbidity. Patients with high-grade tumors were more likely to undergo RT (OR 1.92, 95 %CI 1.25–2.96). Those who underwent RT or surgery spent an additional 11 and 29 days, respectively, hospitalized.

Conclusions

We found that black men with metastatic prostate cancer are more likely to develop MESCC than whites. RT was more commonly utilized for treatment than surgery, but the elderly and those with comorbidities were unlikely to receive either treatment.     

National characteristics of Emergency Department visits by patients with cancer in the United States

Purpose

The Emergency Department (ED) is an important venue for the care of patients with cancer. We sought to describe the national characteristics of ED visits by patients with cancer in the United States.

Improved care of acute exacerbation of chronic obstructive pulmonary disease in two academic emergency departments

Background

Although several chronic obstructive pulmonary disease (COPD) practice guidelines have been published, there is sparse data on the actual emergency department (ED) management of acute exacerbation of COPD (AECOPD).

Aims

Our objectives were to examine concordance of ED care of AECOPD in older patients with guideline recommendations and to evaluate whether concordance has improved over time in two academic EDs.

Methods

Data were obtained from two cohort studies on AECOPD performed in two academic EDs during two different time periods, 2000 and 2005–2006. Both studies included ED patients, aged 55 and older, who presented with AECOPD, and cases were confirmed by emergency physicians. Data on ED management and disposition were obtained from chart review for both cohorts.

Results

The analysis included 272 patients: 72 in the 2000 database and 200 in the 2005–2006 database. The mean age of the patients was 72 years; 50% were women and 80% white. In 2005–2006, overall concordance with guideline recommendations was high (for chest radiography, pulse oximetry, bronchodilators, all ≥?90%), except for arterial blood gas testing (7% among the admitted) and discharge medication with systemic corticosteroids (42%). Compared to the 2000 data, the use of systemic corticosteroids in the ED improved from 53 to 77% [absolute improvement: 24%, 95% confidence interval (CI): 11–37%], and the use of antibiotics among the patients with respiratory infection symptoms improved from 56 to 78% (absolute improvement: 22%, 95% CI: 6–38%).

Conclusions

Overall concordance with guideline-recommended care for AECOPD was high in two academic EDs, and some emergency treatments have improved over time.     

The YEARS algorithm for suspected pulmonary embolism: shorter visit time and reduced costs at the emergency department

Essentials

• The YEARS algorithm was designed to simplify the diagnostic workup of suspected pulmonary embolism.
• We compared emergency ward turnaround time of YEARS and the conventional algorithm.
• YEARS was associated with a significantly shorter emergency department visit time of ?60 minutes.
• Treatment of pulmonary embolism was initiated 53 minutes earlier with the YEARS algorithm

Summary

Background

Recently, the safety of the YEARS algorithm, designed to simplify the diagnostic work‐up of pulmonary embolism (PE), was demonstrated. We hypothesize that by design, YEARS would be associated with a shorter diagnostic emergency department (ED) visit time due to simultaneous assessment of pre‐test probability and D‐dimer level and reduction in number of CT scans.

Aim

To investigate whether implementation of the YEARS diagnostic algorithm is associated with a shorter ED visit time compared with the conventional algorithm and to evaluate the associated cost savings.

Methods

We selected consecutive outpatients with suspected PE from our hospital included in the YEARS study and ADJUST‐PE study. Different time‐points of the diagnostic process were extracted from the to‐the‐minute accurate electronic patients’ chart system of the ED. Further, the costs of the ED visits were estimated for both algorithms.

Results

All predefined diagnostic turnaround times were significantly shorter after implementation of YEARS: patients were discharged earlier from the ED; 54 min (95% CI, 37–70) for patients managed without computed tomography pulmonary angiography (CTPA) and 60 min (95% CI, 44–76) for the complete study population. Importantly, patients diagnosed with PE by CTPA received the first dose of anticoagulants 53 min (95% CI, 22–82) faster than those managed according to the conventional algorithm. Total costs were reduced by on average €123 per visit.

Conclusion

YEARS was shown to be associated with a shorter ED visit time compared with the conventional diagnostic algorithm, leading to faster start of treatment in the case of confirmed PE and savings on ED resources.

     

Detection of lung cancer relapse using self-reported symptoms transmitted via an Internet Web-application: pilot study of the sentinel follow-up

Purpose

We aimed to investigate whether patient self-evaluated symptoms transmitted via Internet can be used between planned visits to provide an early indication of disease relapse in lung cancer.

Methods

Between 2/2013 and 8/2013, 42 patients with lung cancer having access to Internet were prospectively recruited to weekly fill a form of 11 self-assessed symptoms called “sentinel follow-up”. Data were sent to the oncologist in real-time between planned visits. An alert email was sent to oncologist when self-scored symptoms matched some predefined criteria. Follow-up visit and imaging were then organized after a phone call for confirming suspect symptoms. Weekly and monthly compliances, easiness with which patients used the web-application and the accuracy of the sentinel follow-up for relapse detection were assessed and compared to a routine visit and imaging follow-up.

Results

Median follow-up duration was 18 weeks (8–32). Weekly and monthly average compliances were 79 and 94 %, respectively. Sixty percents of patients declared to be less anxious during the few days before planned visit and imaging with the sentinel follow-up than without. Sensitivity, specificity, positive, and negative predictive values provided by the sentinel (planned imaging) follow-up were 100 %(84 %), 89 %(96 %), 81 %(91 %), and 100 %(93 %), respectively and well correlated with relapse (pχ ²?<?0.001). On average, relapses were detectable 5 weeks earlier with sentinel than planned visit.

Conclusion

An individualized cancer follow-up that schedule visit and imaging according to the patient status based on weekly self-reported symptoms transmitted via Internet is feasible with high compliance. It may even provide earlier detection of lung cancer relapse and care.     

Public opinion of a stroke clinical trial using exception from informed consent

Background

Acute stroke is a leading cause of morbidity and mortality. Clinical trials in stroke are challenging because victims often do not have the capacity to provide informed consent, excluding those patients most likely to benefit from the research.

Aim

We evaluated patient willingness to participate in a hypothetical acute stroke trial using an exception from informed consent.

Methods

Consecutive patients presenting to four emergency departments (EDs) underwent structured interviews regarding a hypothetical stroke trial using an exception from informed consent.

Results

Of 461 (72% of eligible) participants, 55% (95% CI, 50%–59%) were willing to be enrolled in the hypothetical study without giving informed consent. After multivariable analysis, independent predictors of willingness to enroll included Catholic religion (OR 1.57, 95% CI 1.17–2.10) and belief that current therapy offers a >50% chance of full recovery (OR 1.29, 95% CI 1.05–1.57). There was no difference between the proportion willing to enroll in a cardiac arrest study vs. a stroke study (55% vs. 55%, p?=?0.83)

Conclusions

Fifty-five percent of ED patients would be willing to be enrolled in a stroke trial using exception from informed consent.