Date: January 27th, 2020

Guest Skeptics: Dr. Richelle Cooper is a Professor of Emergency Medicine at the UCLA Department of Emergency Medicine. Dr. Maia Dorsett is an Emergency and EMS Physician at the University of Rochester Medical Center.

Reference: Dorsett et al. Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J 2019

This is an SGEM Xtra based on a recent publication by Dr. Dorsett and her team. It is an article of ten recommendations on how we might provide a more balanced approach to healthcare tailored to the needs of the patients we see in the emergency department. One of the authors of the article was the Legend of Emergency Medicine, Dr. J. Hoffman.

SGEMers have heard about over-testing, over-diagnosing and over-treating. These authors have some concerns about what they call the unmentioned “elephant in the room“.

“While specialty societies do undertake advocacy work to address the health needs of the public, they also have a fundamental duty to advocate for and protect the interests of their specialty. Furthermore, healthcare dollars that are ‘wasted’ are of course not actually thrown away but rather end up in someone’s pocket; thus, there is clearly a conflict of interest when specialty societies address the overuse of extremely lucrative medical procedures that provide substantial income to their members.”

Choosing Wisely is an initiative trying to address the issue of over-testing, over-diagnosing and over-treating. To be clear, these authors are not against Choosing Wisely.

“Important to note that we are not against choosing wisely, however the issue is larger and more nuanced. It is not just about “low value” care and costs but about harms, harms from overuse of diagnostic tests and treatment and also from underuse in other cases. The right care alliance is concerned about the right care for the right patients at the right time, thus not just overused tests.”

The organization this group of authors are associated with is called the Right Care Alliance (RCA). How is it different from the Choosing Wisely Campaign?

“The Right Care Alliance was formed in 2015 by the Lown Institute, a healthcare think tank. Many of us, such as myself, became involved with the work of the Lown because of our interest in reducing the harms of overtesting and overdiagnosis. But we quickly realized that talking about Right Care was actually a conversation about the Right amount of care and that this was more than just about too much care, it was also about underuse, health care access and a focus on treating the whole patient. It was this realization – that we cannot address overuse without talking about underuse – that lead to the formation of the RCA. The powerful part of the RCA is that it is a grassroots coalition of not just healthcare practitioners, but also patients and community members.”

Where does emergency medicine fit into the RCA initiative?

“Nowhere in healthcare is the unfortunate dichotomy between overuse and underuse as apparent as in our emergency departments, which function simultaneously as centers of high acuity healthcare and healthcare safety nets. Organizationally, the RCA has a number of subcommittees or “councils”. The Emergency Medicine (EM) Council is one of these subgroups and is composed primarily of emergency physicians and nurses.”

“In May 2016, the RCA asked its specialty councils to create their own ‘top 10’ lists, The goal was to identify not merely interventions that are overused but also others that need to be used more widely, if we are to achieve both better and more equitable health outcomes and financial savings.”

What were the guiding principles put forward by the RCA to generate the top 10 list?

Guiding Principles for Top 10 List:

  1. Patient-centred
  2. Holistic in approach
  3. Understandable to both healthcare professionals and non-health care professionals
  4. Meaningful to everyone who participates in the healthcare system

Criteria Used to Select the Top 10 Items:

  1. Matter to patients
  2. Have high potential to harm or to benefit
  3. Be common (overuse) or rare (underuse) enough that avoiding or doing the item routinely would move the needle towards the right care
  4. Examine or illustrate how it ties to system failures.

The committee was predominantly made up of emergency physicians, including residents, faculty and community physicians, and emergency medicine nurses.

Patients were invited to participate on all the committees, and it was required that members of the Patient council review and provide input to all lists.

The Emergency Medicine (EM) members of the RCA were all invited to participate, ultimately 125 gave input on potential items. They participated in each part of the scoring and ranking and in a smaller group for the discussion of the items. Similarly, Maia presented and received input from patients/patient advocates at a Lown conference.

Two Overriding Principles of the EM Right Care Top 10 List:

  1. “The quixotic search for certainty’ describes the all too common attempt by clinicians to find the last few patients who may be in danger even though an evaluation has shown that risk is minimal. Along with this fear of missing even a single patient with a serious problem, most clinicians have been taught to believe (incorrectly) that ‘tests’ are more ‘objective’ than clinical judgement and, thus, that doing more is ‘safer’ and more ‘evidence based”.
  2. “Medical care is not the sole, or even the most important, determinant of health outcomes. Social determinants—including, but not limited to, food insecurity, homelessness and addiction—are profoundly important to the health of a great many patients. These issues must be addressed as part of the larger healthcare system, but it is also critical that ED clinicians pay attention to and address social factors in their patients, individual by individual”.

EM Right Care Top 10 List:

Listen to the SGEM podcast to hear Dr. Dorsett and Cooper expand on each of these items.

  1. Avoid further testing beyond history, physical exam, clinical gestalt and ECG in patients who are at minimal risk of an acute coronary syndrome (ACS).
  2. Avoid further testing beyond history, physical exam and clinical gestalt in patients who are at minimal risk of pulmonary embolus (PE).
  3. Be judicious with the use of imaging, especially advanced imaging, in trauma patients.
  4. Avoid routine laboratory testing.
  5. Consider non-medical reasons for a patient’s presentation to the ED.
  6. Tailor the intensity of care to the goals of the patient.
  7. Employ shared decision-making (SDM) where appropriate.
  8. When prescribing an intervention, make an effort to ensure that the patient is capable of accomplishing what is recommended.
  9. Tailor discharge instructions and follow-up recommendations to the individual patient.
  10. Be an advocate.

Dr. Cooper

Conclusion: “The RCA is working to change the conversation about American healthcare, advocating for access for all individuals to high-quality care without financial hardship, eliminating overuse and underuse, and championing the partnership between the patient and clinician. The EM Council’s top 10 list seeks to serve as a starting point to focus ED clinicians in achieving the goals of the RCA. While other lists exist, and we agree with many Choosing Wisely areas of focus, we seek to move the needle even further. In what is ultimately an impossible attempt never to miss a single case with a life-threatening diagnosis, we paradoxically cause a great deal of harm to the overall population through over-testing and contribute to the untenable rising cost of healthcare.”

Dr. Dorsett

“When we fail to spend the time needed to understand the context of our patients’ lives outside of the ED, we miss the opportunity to improve the patient’s health. While some problems are big and may take decades to fix, micro-changes in our daily practice— listening more, ordering more thoughtfully—are possible today. One patient at a time, one shift at a time, one ED, one hospital and one community at a time, we as clinicians need to help drive the change. We do not need more research to show unnecessary testing is occurring; we need effective means to implement change and support clinicians in putting the best interests of their patients first.”

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over 10 years to less than 1 year using the power of social media. So, patients get the best care, based on the best evidence.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.