UMEM Educational Pearls - By Steve Schenkel

In a fascinating perspective piece, Matt Bivens and colleagues explain that the combination of struggle and restraint leads to death not because of hypoxia, but because of acidosis.

The sequence is something like this: exertion or struggle results in an acidotic state -> restraint reduces respiratory ability, especially when held prone or weight is applied to back or chest -> acidosis worsens with the potential for cardiac arrhythmia and arrest.

In this setting, “I can’t breathe” does not mean that there is no air movement over the vocal cords but that respiration is impaired, much as it is in asthma or obstructive lung disease.

Use of sedation in this setting reduces respiration even further, worsening acidosis and risking death. It’s not hypoxia that kills; it’s acidosis.

See the complete perspective here: https://www.nejm.org/doi/full/10.1056/NEJMp2407162.

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Clinical practice in the world of the Electronic Medical Record has made many a clinician question the value of electronic reminders. 

Banners warn of sepsis, the need for repeat evaluation, vital signs outside expected limits,  wait times, and risks for readmission.

Can they instead help ED flow?

Sayan Dutta and colleagues suggest that they can. When clinicians chose to receive notice of a lab or imaging result, push notification reduced time between final result and ED disposition by 18 minutes (95% CI: 15-21 minutes). 

The likely key here? Clinicians actively chose when and about what to be notified.

See: Result Push Notifications Improve Time to Emergency Department Disposition: A Pragmatic Observational Study, Annals of Emergency Medicine, 85(1), 53-62. https://www.annemergmed.com/article/S0196-0644(24)00404-9/abstract.

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Does physician altruism influence quality metrics? This study suggests yes.

45 physicians were defined as “altruistic” based on their willingness to share a $250 cash prize with a stranger in an on-line version of the dictator game, something you might have played in an economics class.

Of 250 physicians drawn from primary care and cardiology, 45 met the definition of altruistic and 205 did not. 

Overall, patients of altruistic physicians:

• Were less likely to experience ambulatory care sensitive admissions (absolute decrease of 1%, relative decrease of 38%, adjusted odds ratio 0.6 (0.38-0.97))
• Were less likely to experience ambulatory care sensitive emergency department visits (absolute decrease of 1.5%, relative decrease of 41%, adjusted odds ratio 0.64 (0.43-0.94)
• Had lower total spending (adjusted decrease of $800, relative change of -9.3% (16.2-2.3). [Note: the unadjusted results run in the other direction.]

The authors suggest that this difference may be on account of altruistic physicians being more willing to consider the appropriateness of tests or treatment or “devote more time and energy to their patients.”

They also note that while most physicians were categorized as not altruistic, at 18% this group of physicians exceeds the 5% of the general US population that would meet this definition. 

Perhaps there is something quantitatively demonstrable to being a “good” doctor.

See https://jamanetwork.com/journals/jama-health-forum/fullarticle/2824419

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Traditional Medicare now covers < 50% of Medicare beneficiaries. It reimburses on a fee-for-service basis. For beneficiaries, it includes deductibles and coinsurance requirements that yield average annual out-of-pocket expenses measured in the thousands of dollars.

Medicare Advantage, the new alternative, has grown quickly. Plans typically promise beneficiaries fewer co-pays and more services. It relies on private insurers (think United, Blue Cross, Kaiser Permanente) to coordinate care and rein in costs. Subsidies to Medicare Advantage have helped spur growth, subsidies that mean costs per beneficiary for Medicare Advantage exceed those for traditional Medicare.

Which means Medicare still needs to figure out how to save money and remain viable while the US population over 65 grows.

When listening to a lecture about Medicare or reading a study that uses Medicare data, take a moment to ask “Which Medicare? Fee-for-service? Or Advantage?”

For a take on the future of Medicare, see McWilliams JM, The Future of Medicare and the Role of Traditional Medicare as Competitor, NEJM, August 22/29, 763-769.

To understand why Medicare Advantage plans are popular, see https://www.kff.org/medicare/issue-brief/10-reasons-why-medicare-advantage-enrollment-is-growing-and-why-it-matters/.

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“Administrative harm” (defined as “the adverse consequences of administrative decisions within health care”) is a relatively new term for challenges that arise in complex health care work environments. 

41 mostly hospitalists participating in interviews and focus groups found that the concept resonated, and that administrative harms could arise at all levels of leadership, negatively impacted both workforce and patients, were challenging to measure, and pointed to a lack of leadership responsibility and accountability. The group also suggested many approaches and solutions for prevention.

The article is here, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2820266. If interested, take a look at the thematic tables 2 and 3.

There is a brief editorial comment here, https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2820275.

Emergency Medicine staffing groups can be organized in any number of ways. Here’s Leon Adelman’s take:

• There are EDs staffed by non-physician-owned corporations. The two largest of these are Teamhealth and the restructured Envision, owned by Blackstone and a consortium of investors, respectively.
• Then there are physician-owned groups. The largest of these is USACS, but these range in size from staffing for a single ED to USACS’ 297 EDs.
• A third of EDs are staffed directly by health systems, think Medstar locally. This is probably also the category Edelman uses for academic centers, though physicians may be employed by a separate faculty practice or by the medical school instead of the hospital.

Read more at https://emworkforce.substack.com/p/state-of-the-us-emergency-medicine-677. Read closely and you’ll find a reference to Maryland.

The relationship between an Emergency Physician and the hiring group (whether large or small) may be one of employer-employee or contactor-independent contractor. There are legal job protections for employees that don’t exist for independent contractors. There are also regulations that define an independent contractor. Enforcement of these regulations varies but may be increasing. This has implications for the Emergency Medicine job market. We have the highest percentage of independent contractors of any medical specialty. 

See more at Leon Adelman’s Emergency Medicine Workforce Newsletter, here https://emworkforce.substack.com/p/thousands-of-employed-emergency-physicians

Approximately half of all Medicare beneficiaries are now enrolled in Medicare Advantage plans. Why does this matter?

• Traditional insurers (for example, United & Blue Cross) run Medicare Advantage (MA) plans. The federal government pays the insurers. This is different from Traditional Medicare which the Federal Government both funds and runs.
• MA plans may include prescription drug, vision, and dental care. They also often include out-of-pocket caps.
• MA plans may limit flexibility in provider choice with in-network and out-of-network provisions.
• So far, MA costs the federal government more than traditional Medicare.

Intrigued? Learn more at https://www.nejm.org/doi/full/10.1056/NEJMhpr2302315 or https://www.kff.org/medicare/issue-brief/medicare-advantage-2024-spotlight-first-look/.