JournalFeed Weekly Wrap-Up
- Sep 15th, 2018
- Clay Smith
We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter.
Originally published at JournalFeed, a site that provides daily or weekly literature updates.
Incidence of intracerebral hemorrhage (ICH) on CT following minor head trauma in anticoagulated patients was 9%, which means we have to CT all these people.
Scan ’em all
They started with over 10,000 studies and whittled it down to just 5 that met criteria. Almost all had low risk of bias. In this meta-analysis of these 5 prospective studies with 4080 anticoagulated patients with head injury and GCS 15, the incidence of initial or delayed ICH on CT was 9%. When the study with greater risk of bias was removed from the analysis, incidence of ICH was 11%. Of these, 98% were taking warfarin. The newer direct oral anticoagulants and LMWH were not well represented. The implication of this is that patients who are anticoagulated need a head CT even if they look well and have normal GCS. Incidence of intracranial findings is too high to safely avoid it.
Incidence of intracranial bleeding in anticoagulated patients with minor head injury: a systematic review and meta-analysis of prospective studies. Br J Haematol. 2018 Jul 20. doi: 10.1111/bjh.15509. [Epub ahead of print]
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ALiEM posted a review of the literature a couple years back.
The higher cost, lower yield tests to consider avoiding for patients ≥60 with syncope were: EEG, head CT, MRA, cardiac stress test, and EP study.
Why does this matter?
Syncope is a target diagnosis for Medicare to retrospectively audit and decide an admission was “unnecessary.” Given that in this cohort alone the serious 30-day adverse event rate was 25.1%, including such things as MI, stroke, major hemorrhage, SAH, etc, it seems a bit “armchair quarterback-ish” for Medicare to do this. Regardless, there are some low-yield diagnostic tests that may be targets for cost reduction.
DFO (done fell out) workup
This was a prospective multicenter study of 3686 patients ≥60 with syncope or presyncope. The goal was to observe the variability, frequency, yield, and cost of the workup. All patients had a standardized H&P + ECG. Ironically, the second lowest yield test was ECG, with only 1.9% of tests abnormal, just behind troponin at 1.3%. Coronary angiography was infrequently done but had the highest overall proportion of abnormal results at 42%. The most commonly ordered test was troponin in 88%. The most widely variable from hospital to hospital was carotid ultrasound. The most expensive when considering cost per abnormal test was electrophysiology (EP) study at $39,703 per abnormal test. The highest total expense was echocardiogram at $672,648. Of the top 5 tests ordered, echo had the highest proportion of abnormal results at 22%. The biggest outliers in cost per abnormal result were cardiac stress tests, coronary angiogram, EEG, MRA, and EP study. The higher cost, lower yield tests to consider avoiding without a compelling indication were: EEG, head CT, MRA, cardiac stress test, and EP study. Here is a table sorted by percent with an abnormal finding from lowest to highest.
Download the latest JournalFeed Infographic: PE Workup in 5 Steps
This figure is a composite of the great ideas of others, with some adaptation on my part. The following is a list of the resources that went into making this figure. I’m standing on their shoulders.
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