TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include an Advent-themed exercise program, conservative strategies for neck and back pain, substance use and road user accidents, and misdiagnosis in the emergency department (ED).
Program notes:
0:36 Diagnostic errors in the ED
1:35 About 370,000 per year
2:35 Female and non-white experienced more
3:35 Spine care randomized trial
4:35 How much did it cost the healthcare system?
5:35 Usual care comparison
6:25 Alcohol and drug prevalence in road user accidents
7:25 Active THC at 25%
8:28 National epidemic
8:44 Advent-themed exercise
9:44 “Easy Elf”
10:45 Calendar with dates
12:23 End
Transcript:
Elizabeth: Conservative therapies for acute and subacute back or neck pain.
Rick: Diagnostic errors in the emergency department.
Elizabeth: Can an Advent calendar help you get up and get moving?
Rick: And what’s the prevalence of alcohol and drug use among seriously injured road users?
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, how about if we start with this problem of what’s going on in the emergency department? Lots of diagnostic errors, a federal review from the Agency for Healthcare Research and Quality.
Rick: It’s actually amazing for the number of people we see in the emergency room how few diagnostic errors there are. But because there are such a huge number, it involves large volumes of individuals.
When they look at the overall diagnostic accuracy in the emergency department, they discovered it’s overall high. But some patients still receive an incorrect diagnosis and that percentage is about 5.7% across all of the studies that were looked at. Patients that suffer an adverse event because of the incorrect diagnosis are about 2%. Some of them are very serious and it’s about 0.3%, which means about 1 in every 350 individuals that receive an incorrect diagnosis suffer permanent disability or death.
Because we have over 130 million emergency department visits each year, that amounts to about 370,000 individuals that suffer serious harms from diagnostic errors. When you look at the average emergency department that has about 25,000 visits, you’re talking about 50 deaths per emergency department over the course of the year.
Elizabeth: Did they go further into what these diagnostic errors usually involved?
Rick: Right. First, they looked at the most common diagnoses. The five most common conditions in which there was an error are stroke, heart attack, aortic aneurysm or dissection, spinal cord compression or injury, and venous thromboembolism that account for about 40%. When they expand it to 15 diseases, they encompassed about 70%.
People present with atypical symptoms or they present at an age in which you don’t expect for this condition to happen. For example, a 17-year-old you don’t expect them to have a stroke. An 80- or 90-year-old you don’t expect them to have acute appendicitis, because either the symptoms are atypical or the patient is somewhat atypical. That’s the most common reasons that result in the diagnostic errors.
Elizabeth: I think it’s rather disconcerting that either being female or non-white was associated with an increased incidence in these diagnostic errors.
Rick: Exactly why that is isn’t really known. There was an increased risk in younger patients, by the way. The risk of missing a stroke in a young person was about seven-fold higher.
Elizabeth: It also talks about that these root causes were mostly cognitive errors linked to the process of bedside diagnosis. Since that is evaluated as one of these major factors, I’m wondering what you think might help.
Rick: The recognition that either nonspecific or atypical symptoms could be a manifestation of a particular process. You just have to keep that in the back of your mind.
Elizabeth: I’m wondering if some kind of decision support tool that would implement a lot of these factors might help with this.
Rick: Elizabeth, that’s a great thought. You can imagine one of two scenarios, either where it does help or secondly where you end up chasing rabbits all the time. I do think it’s worthwhile investigating. [Editors’ note: See a critique of the report from MedPage Today editor-in-chief Jeremy Faust, MD.]
Elizabeth: Let’s turn now to JAMA. This is the SPINE CARE randomized clinical trial in which they take a look at biopsychosocial intervention or postural therapy on disability and healthcare spending in patients with acute and subacute spine pain, including, of course, the cervical spine as well as the lumbar spine.
They had an N of 992. They finally ended up stratifying into three different groups — what’s called ICE [identify, coordinate, and enhance], which is an integrative care model using physical therapy, health coach counseling, and consultation from a specialist in pain management, rehabilitation — this postural therapy approach that combines physical therapy with building self-efficacy and self-management, and then usual care.
These were people who had pain in their spine, but not really longstanding pain. They ended up following these folks from baseline to 3-month follow-up and they looked at this disability score. Then they also looked at how much did it cost the healthcare system to take care of these folks.
It turned out that both of the interventions had a modest improvement in patients’ disability score. One of them was significantly more expensive — this individualized strategy for taking care of this pain — than the other two were.
Rick: Unfortunately, spine and back pain ended up being chronic conditions that affect literally millions of individuals across the world and the U.S. In fact, it accounted for more healthcare spending than any other health condition in the U.S. in 2016. What we’ve come to realize is that for most of these conditions, the pain resolves on its own and that doing surgery isn’t any better than using a more conservative therapy.
The question is, what’s the best non-surgical treatment? There are two different treatments offered to these patients. One is they threw the book at them — health coaches and pain management individuals — and the other one was they taught them postural exercises to try to improve and self-manage it on their own. They are both equally effective.
Elizabeth: When you looked at just usual care, also it wasn’t like a giant difference in the total amelioration of their pain.
Rick: You’re right. They were statistically better and clinically a little better, but it didn’t completely do away with the pain. I do think we have come a long way, though, in realizing that surgical management in this subacute pain isn’t very helpful. I do understand your point is that we’d like for conservative therapy and the best we have, to be dramatically better than usual care.
But what we do have is we do have some ideas of what the cost is. In the ICE, it was $1,450. In the IPT [individualized postural therapy], it was $2,500, and the usual care about $1,600. We can apply conservative, non-surgical management and do it at a somewhat cheaper rate than the usual care with some modest benefit.
Elizabeth: Let’s go on then to this analysis from the National Highway Traffic Safety Administration looking at alcohol and drug prevalence among seriously or fatally injured road users.
Rick: We’ve reported before on accidents and how drugs and alcohol can contribute to those. This study is different. It looks not only at drivers, but it looks at pedestrian and bicycle riders as well. It updates what we have known. Oftentimes we’ve focused on alcohol and its relatedness to some of the serious outcomes and fatal outcomes in road users.
But the drug use has changed. Cannabis is now legalized in many states. We have a lot more opioid use and a lot more prescription drug use. It’s only been recently, really over the last 10 years, where they have looked not only at alcohol but a panoply of drugs.
This national study showed that overall about 56% of the injured or killed roadway users tested positive for one or more drugs. That’s 6 in 10, Elizabeth. The most prevalent drug category among all road users was active THC or cannabinoids, with about 25% tested positive there, followed by alcohol at 23%, stimulants at 11%, and opioids at 9%. About 1 in 5 tested positive for two or more categories of drugs as well.
Elizabeth: It’s hard to know exactly what to say about this outside of, gosh, using something that is altering your consciousness and getting behind the wheel of a vehicle, or going into an environment where there are a lot of vehicles around that go really fast and have the potential to really hurt you, is probably not the best idea.
Rick: I think many users of either alcohol or THC, or opioids, or prescription drugs, don’t understand that or don’t realize that their ability to interact on a roadway in complex situations, their reaction time, and their judgment is all impaired by these, even though we don’t realize it at the time. It directs us towards national guidelines and national communication to try to decrease this threat to all of us. What we certainly need to do is something that changes this, I’m going to call, a national epidemic.
Elizabeth: Particularly in view of the fact that road fatalities are rather daunting and increasing, as we have reported before.
Rick: One of the things that this mentions is that as a result of COVID, we changed our driving behaviors because there were fewer people on the road, but they were engaging in riskier behaviors as well.
Elizabeth: Finally, let’s turn to something lighter. The BMJ, of course, does its annual Christmas issue. This time we have selected one study that’s in this. This is a Christmas-themed physical activity intervention to increase participation in physical activity during Advent.
What they did was create Christmas-themed physical activities that were, I would say, titularly related to Advent and basically consisted of a daily email during this time period that asked people to engage in one of three physical activity ideas: “Easy Elf,” which was light intensity; “Moderate Mrs Claus,” which is moderate intensity; or “Strenuous Santa,” vigorous intensity physical activity. I would definitely refer listeners to this study because the pamphlet is printed in its entirety and it’s actually really very charming.
As far as Easy Elves are concerned, they recommend for your daily activity things like 25 walking lunges or a 30-minute stroll around. If you wanted to do your Moderate Mrs Claus, you could do 50 squats or 10×10 second sprint intervals. If you really wanted to be strenuous and jump into competition with Santa, you could do a 30-minute run or 100 squats, or 25 strenuous burpees.
They recruited people to be a part of this study and their N at the end of it was 107 inactive adults. They note that, of course, during the holiday season people tend to be less active and they tend to eat and drink a whole lot more.
They ended up with 71 in their intervention group and 36 in their comparator group. Overall, 70% of 60 participants in the intervention group reported they liked this intervention and just about 70% reported they completed the active Advent intervention ideas each day.
Rick: This is really cute because it’s got a calendar with days 1 through 24. You didn’t mention it. For example, for the Easy Elf, one of the things you do is one Christmas song dance. Or if you’re a Moderate Mrs Claus, you do three of those. Or if you’re Strenuous Santa, you could do five Christmas song dances.
For most of us during the holiday, our usual activity is pushing ourselves away from the table. This really does encourage us, even before the New Year comes and we make our New Year’s resolutions, to say let’s start this early. And a lot of fun. As the study shows, if you make it fun, it can actually be effective.
Elizabeth: Right, and maybe it would be something that persists. They do note that they validated this with accelerometry and they also noted that one thing that was missing were muscle-strengthening exercises. As we’ve reported, guys, those have a big bang for your buck when it comes to mortality.
Rick: Any activity, especially over the holidays, can be helpful. There are a couple of these that are going to be harder for some than others. For example, they have ice skating. It’s going to be a little bit harder in Texas to do that. But, obviously, in El Paso we have a mountain in the middle of the city, and they talk about walking for mountain climbers and we can do that. The ice skating is out. Mountain climbing is good. Christmas song dances can be done anywhere, inside or outside. It’s going to be a lot of fun.
Elizabeth: On that note then, we wish everyone safe and joyous holidays. That’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy holiday choices.
Source: MedicalNewsToday.com
