Date: January 6th, 2015

Guest Skeptics: Dr. Chris Carpenter. Chris is an Associate Professor, Emergency Medicine. Director, Evidence Based Medicine, Washington University. Chris also wrote the book on EMB Co-Author of Evidence Based Emergency Care- Diagnostic, Testing and Clinical Decision Rules.

This is the third episode of the Skeptics’ Guide to Emergency Medicine Hot Off the Press (SGEM-HOP). The SGEM has entered into an arrangement with Society of Academic Emergency Medicine (SAEM) and the Canadian Association of Emergency Physicians (CAEP) to achieve that goal. SAEM publishes the Academic Emergency Medicine (AEM) Journal and CAEP publishes the Canadian Journal of Emergency Medicine (CJEM).

SGEM Hot Off the Press (HOP) Process:

  1. Hot off the PressWe pick a manuscript in conjunction with the Editorial Boards of each journal that has been submitted, peer-reviewd, and ultimately accepted for AEM/CJEM put not published yet.
  2. The SGEM then put a skeptical eye upon the manuscript using the BEEM critical appraisal tool.
  3. One of the authors of the paper will be invited to discuss the strengths/weakness/limitations/clinical application their paper.
  4. A special SGEM Hot Off the Press podcast that will be posted the week the journal gets published.
  5. The SGEM audience will get a chance to respond via the blog, twitter or on Facebook.
  6. A summary of the SGEM critical appraisal will be published in a subsequent issue of each journal including the top social media feedback.

The 1st SGEM-HOP looking at predict falls in the elderly was a huge success (SGEM#89). There were thousands of interactions on Facebook, the SGEM blog and twitter. The bottom line was “These people fall, get injured and even die. We do not have good ED evidence to help us predict accurately or reliably who is at risk of falling. High quality research is need for healthcare providers, funders, and guideline developers to use in deriving screening protocols.”

The summary of SGEM#89 has just been published in Academic Emergency Medicine Journal. The top tweet was from Dr. Jeremy Faust the co-creator of FOAM Cast with Dr. Lauren Westfer. He tweeted about the inability to cut one’s own toenails had the best negative likelihood ratio for 6-month fall risk. If you want to get published in the next future edition than tweet your comments about this episode using the hashtag #SGEMHOP.

Form_Fit_Thumb_SpicaCase: 37 year old right-handed attorney presents with right wrist pain after diving for a racquetball during a competitive game with one of his senior partners. Pain is localized diffusely over the posterior wrist, including concerning pain with thumb longitudinal compression test and resisted supination. No other injuries are identified and x-rays of the wrist reveal no scaphoid fracture or other injury. Your concern is an occult scaphoid fracture, which occurs in about 25% of ED wrist pain patients with suspected scaphoid injury & unremarkable x-rays. In addition to pain control, your management options include:

  1. No thumb spica splint & follow-up with primary care physician (PCP) or Orthopaedic Hand Clinic within 2-weeks for further imaging/management
  2. Thumb spica splint & follow-up with PCP or Orthopaedic Hand Clinic within 2-weeks for further imaging/management
  3. MRI in ED with splinting dependent upon MRI findings

You wish to include the patient in Shared Decision Making about the best management option from his perspective so you provide these options. He uses his right hand daily for work and anticipates significant lost revenue with 2-weeks in a splint, but he nonetheless decides that a splint and follow-up with Orthopaedic Hand Clinic follow-up is the best option for him. You call Orthopaedic Hand Clinic and schedule an appointment 11-days from today. Given his busy schedule, you offer an ED-based reminder that he will receive via his cell phone and he inquires about the need for such a reminder.

Background: Follow-up appointments in the ED, primary care or specialty clinics are often required after emergency department visits. However, patients often do not show up for these appointments.

The reasons for missing appointments are complex but the most common reason provided is that they just forgot. It is known that these follow-ups can prevent bounce-backs to the ED, improve patient outcomes and reduce malpractice risk. People have tried using case management, sending something in the mail or phone calls. These methods are labor intensive and costly.

Text messaging has surpassed the number of phone calls made on mobile devices. That is why we thought this might be a effective, low cost and acceptable way of addressing the problem of missed follow-up appointments.

Clinical Question: Can an automated text message to remind ED patients of follow-up appointments improve adherence to follow-up?

Dr. Sanjay Arora

Dr. Sanjay Arora

Reference: Arora S, Burner E, Terp S, et al. Improved Attendance at Post-Emergency Department Follow-up Via Automated Text Message Appointment Reminders: A Randomized Controlled Trial, Acad Emerg Med 2015

Sanjay is an Associate Professor of Emergency Medicine at the University of Southern California. He is the Co-Research Director in Emergency Medicine. In addition to conducting research, Sanjay is a prominent educator in his field and received the speaker of the year award at American College of Emergency Physicians and the Essentials of Emergency Medicine in 2011.

  • Population: Urban ED patients over age 18 years who own a text message capable mobile phone, are capable of reading text messages, and have a follow-up appointment scheduled within the Los Angeles county health care system between 3 and 30 days following an episode of ED care.
  • Intervention: English or Spanish personalized mobile phone text message appointment reminders at 7, 3, and 1 day before their first scheduled follow-up appointment.
  • Comparison: Usual care with written follow-up instructions
  • Outcome: Proportion of subjects who attended their first (closest to discharge date) scheduled follow-up appointment.

Authors Conclusions: Automated text message appointment reminders resulted in improvement in attendance at scheduled post-ED discharge outpatient follow-up visits, and represent a low-cost and highly scalable solution to increase attendance at post-ED follow-up appointments, which should be further explored in larger sample sizes and diverse patient populations.

Quality Checklist for Randomized Clinical Trials:checklist-cartoon

  1.  The study population included or focused on those in the ED. YES
    • The study was conducted in the ED at Los Angeles County University of Southern California (USC) Medical Center, which serves 170,000 largely low-income and uninsured patients annually and is the largest ED in the western United States.
  2. The patients were adequately randomized. YES
  3. The randomization process was concealed. YES
  4. The patients were analyzed in the groups to which they were randomized. YES
  5. The study patients were recruited consecutively (i.e. no selection bias). YES
  6. The patients in both groups were similar with respect to prognostic factors. YES
  7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. NO
  8. All groups were treated equally except for the intervention. YES
  9. Follow-up was complete (i.e. at least 80% for both groups). NO
  10. All patient-important outcomes were considered. YES
  11. The treatment effect was large enough and precise enough to be clinically significant. YES

What were the Key Results: Amongst 374/2365 who met eligibility criteria, 70.4% were Hispanic with a median time to ED follow-up appointment of one week.

In the Intention to Treat analysis, appointment attendance was 70.2% in the intervention group vs. 62.1% in the control group, a 8.1% absolute risk reduction (95% CI -1.6% to 17.7%, p = 0.100).

In the per-protocol analysis 46 patients from the intervention arm were excluded because they did not receive the text messages and the appointment attendance rate was 72.6% in the intervention group vs. 62.1% in the control group (ARR = 10.5%, 95% CI 0.3% to 20.8%, p = 0.045)

That give you a NNT: Number Needed to Treat (or number needed to text) of 10 (95% CI 5 to infinity).

In multivariate logistic regression, text message reminders significantly increased appointment adherence in English language for both primary care and specialty care appointment types, but had no significant effect on Spanish speakers regardless of appointment type.

Dr. Chris Carpenter

Dr. Chris Carpenter

SGEM Commentary: Fascinating trial using readily available technology to remove one common barrier to post-ED follow-up: forgetfulness.

The randomization process was not concealed from patients who knew whether they were receiving text message reminders or not, but future trials could remove this methodological criticism by using sham texts in the control group.

In addition, future investigators could evaluate unintended consequences of this intervention. Although patients without text plans would be charged a maximum of $0.80 for the four text messages sent using this study protocol, other text messaging plans may result in larger costs incurred by patients who cannot afford the expense.

Other unintended consequences might include accidents related to distractions of text messages received at inopportune times (while driving or involved in other high-concentration activities).

Although the concurrent reporting of intention-to-treat (ITT) and per-protocol results may be viewed by evidence based medicine advocates as flawed because only the ITT analysis retains the equal distribution of measured and unmeasured prognostic factors between the intervention and control groups, the approach of reporting both provides the best of both worlds: the purist researcher minimally biased ITT result and the real-world pragmatist per-protocol result.

They report forgetting appointments is the most commonly reported barrier to more efficient post-ED follow-up, but all four of their supporting references are from the United Kingdom with universal access to health care. The situation may be more complex in the United States where indigent urban populations are largely uninsured and those that are insured are most often underinsured with limited access to high quality outpatient follow-up.

Other unmeasured barriers to post-ED follow-up include access to transportation, limited health literacy, job status and ability to miss work for appointments, and ability to afford clinic co-pays.

The pre-study sample size calculation (80% power, two-sided alpha 0.05) included a sample size of 626, but they only enrolled 374. This probably explains the wide confidence intervals on the NNT.

Future studies could look at two-way messaging between patient and the follow-up provider, texting the elderly or impaired patients’ caregivers and looking at sub-populations (dialysis patients, chronic pain patients, frequent flyers, frail older adults, and those with high co-morbid disease burdens).

Comment on authors conclusion compared to SGEM Conclusion: Using the Knowledge Translation Pipeline as the schematic model illustrating the leaks that occur between best-evidence awareness and achievable patient-centric outcomes, post-ED discharge adherence with follow-up recommendations is likely one large problem.

Following a brief period of interaction with ED nurses and physicians, patients need to understand the ED diagnosis and expected prognosis, pharmaceutical and non-pharmaceutical therapy rationale, and reason for follow-up appointments.

Current research implies that most patients and families do not understand these elements of ED care.

The current single-center study provides proof-of-concept that text messaging reminders can be initiated from busy urban multilingual ED settings, but additional research is required to understand barriers to efficient follow-up care in North America and the role that text messaging serves to improve this efficiency.

Future studies need to assess unintended adverse consequences and target sub-populations most likely to benefit from text messaging reminders.

SGEM Bottom Line: Under-powered single-center randomized controlled trial with per-protocol analysis suggesting that English- or Spanish language text messaging improves post-ED appointment compliance with NNT 10, although the effect is not apparent in Spanish speaking patients.

Unknown-1Case Resolution:  The 37 year-old lawyer with the wrist injury receives the text reminder on the day before his appointment, remembers to follow-up with Orthopaedic Hand Clinic, and is able to discontinue his thumb-spica splint with a painless wrist without any further imaging.

Clinically Application: None yet, since this is a single-center exploratory trial and the results merit replication before investing in the infrastructure needed for EDs to provide specific post-discharge follow-up appointment dates/times/locations with text messaging to reinforce later patient recall of the appointment. Nonetheless, this approach is cheap, readily available, and appears promising for future widespread use if the results can be reproduced in other settings.

What do I tell my patient? EDs provide acute care and are not designed to serve as a permanent medical home, operating room, or subspecialty clinic for all medical issues. Complete assessment of your medical condition often requires follow-up with another healthcare provider so prior to being discharged from the ED today you have been provided an appointment with another physician. Because you probably do not feel well today and because ED providers gave you a lot of information to think about today, remembering when and where your appointment is can be challenging. Recent research suggests that a text reminder written by you and to you 7-, 3-, and 1-day before your appointment can help you to make it to that office visit with 10 patients like you requiring a text for one to make it to their appointment who otherwise would not.

Keener Kontest: Last weeks winner was Jake Turner from England. He knew the name of the C-131 aircraft used by NASA is called the Vomit Comet.

To play the keener kontest this week listen to the podcast for the question. The first person to email me back with the correct answer to theSGEM@gmail.com with keener/gunner in the subject line will receive a cool skeptical prize. 


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Remember to be skeptical of anything you learn,

even if you heard it on the Skeptics’ Guide to Emergency Medicine.