sociology

[5] Elkayam U, Akhter W, Singh H, Khan S, Bitar F, Hameed A, et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation 2005;111:2050–5.

[6] Amos AM, Jaber WA, Russell SD. Improved outcomes in peripartum cardiomyopathy with contemporary. Am Heart J 2006;152:509–13.

Waxman et al in NEJM does not disprove defensive practices in the ED

In October 2014, Waxman et al [1] published an article in The New England Journal of Medicine that attempted to measure how new legal protections in South Carolina, Texas, and Georgia affected resource use and defensive practices in the emergency department (ED). Lawmakers in these jurisdictions had changed the standard of negligence in the ED from simple negligence to gross negligence. The new standard essen- tially requires that providers be consciously indifferent to be negligent of malpractice and is considered near immunity from suit. Waxman et al sought to determine whether the new protections decreased defensive practices measured by the number of admissions, per case expenditures, and computed tomography (CT)/magnetic resonance imaging (MRI) ordered in the ED.

The results of the Waxman study showed that there was no change in ordering of CT/MRIs or admissions after the new legal protections were instituted. With respect to expenditures, there was a small decrease in expenditures in Georgia [1]. Given these results, the authors questioned whether providers in the ED really order advanced imaging for defensive medicine purposes. The authors concluded that “[i]n the context of the existing literature, our findings suggest that physicians are less motivat- ed by legal risk than they believe themselves to be.”

Did this article show that physicians are less motivated by legal risk than previously believed? To answer this question, it is important to read the article by Waxman et al critically [1]. This article simply showed that changing the legal standard to gross negligence in South Carolina, Texas, and Georgia failed to change expenditures (with the exception of Georgia), diagnostic testing, and admissions in the ED. It did not address the issue of fear of malpractice nor did it mea- sure it. In addition, the article did not determine whether the providers in these jurisdictions understood the new legal protections nor did it discern whether they felt less fearful or protected after the legislation was enacted.

Prior survey data show that emergency medicine (EM) physicians admit to frequently engaging in defensive medicine practices [1-3]. In particular, EM physicians have previously reported engaging in unnecessary imaging because of legal concerns [1-3]. In one survey, 70% of EM physicians stated they “often” order tests not diagnostically indi- cated because of legal concerns [2]. In another survey of Massachusetts providers, 30% of CTs and 19% of MRIs ordered by EM physicians were reportedly ordered solely for defensive purposes [3]. Prior studies have also shown that EM physicians with increased fear of malpractice are more likely to order unnecessary tests and admit patients [4,5]. Katz et al [4] measured the fear of malpractice among EM physicians using a validated survey instrument. They then followed up providers to determine how they evaluated patients with potential acute coronary syndrome. Providers with high malpractice fear scores were significantly more likely to admit low-risk patients and order chest x-rays and cardiac enzymes compared with peers with low malpractice fear [4]. Katz et al also showed that the fear of malpractice was specific and did not correlate to independent survey assessment of risk-taking behavior [4].

The article by Waxman et al did not measure any data regarding perceptions or motivations of doctors in these jurisdictions nor how such perceptions were affected by the legislative protections. If fear of malpractice is a driver of defensive practices, then such fear should be assessed. Prior studies have shown that tort reform fails to decrease

fear of malpractice among providers [6]. In addition, providers in South Carolina, Texas, and Georgia may not have felt that they were protected by the new law. In their discussion, Waxman et al consider that the data may be confounded by the fact that providers in the reform jurisdictions may not believe that they are fully protected by the new laws. However, the authors did not go on to address this issue [1]. All that can be concluded from the study is that the malpractice reforms failed to decrease testing, admissions, and costs in Georgia, South Carolina, and Texas. It does not prove anything about the motivation of the providers or defensive practices.

If fear causes defensive practice, such fear may likely be unjustified given the real liability exposure in the ED. Notably, among 25 specialties previously surveyed, EM rated about average with respect to the specialty’s yearly risk of lawsuit [7]. In addition, a prior review of ED malpractice claims showed that only 19% of these cases named the EM physician as the primary defendant [8]. In addition, of the 11,529 claims reviewed in this study, 64% were dropped or dismissed, 29% settled, and only 1% resulted in a verdict for the plaintiff at trial. Through education of true litigation risk, perhaps we could mitigate malpractice fear and, thus, defensive practices.

Finally, if the first step to solving any problem is recognition, the article by Waxman et al may represent a step backward in addressing the issue of defensive medicine. It has potentially created a false impres- sion in the field that defensive practices do not really exist.

Darren P. Mareiniss, MD, JD Department of Emergency Medicine

University of Maryland School of Medicine, Baltimore, MD 100 Lancefield Road, Baltimore, Maryland 21209

E-mail addresses: [email protected], [email protected]

http://dx.doi.org/10.1016/j.ajem.2015.04.080

References

[1] Waxman DA, Greenberg MD, Ridgely MS, Kellerman AL, Heaton P. The effect of malpractice reform on emergency department Care. NEJM 2014;371(16): 1518–21.

[2] Studdert DM, Mello MM, Sage WM, DesRochesx WM, Peugh J, Zapert K, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005;293(21):26092617.

[3] Massachusetts Medical Society. Investigation of Defensive Medicine in Massachusetts; 2008 [http://www.massmed.org/defensive-medicine last visited Apil 15, 2015].

[4] Katz DA, Williams GC, Brown RL, Aufderheide TP, Bogner M, Rahko PS, et al. Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med 2005;46(6):525–33.

[5] Wong AC, Kowalenko T, Roahen-Harrison S, Smith B, Maio RF, Stanley RM. A survey of emergency physicians’ fear of malpractice and its association with the decision to order computer tomography scans for children with minor head trauma. Pediatr Emerg Care 2011;27(3):182–5.

[6] Carrier ER, Reshovsky JD, Mello MM, Mayrell RC, Katz D. Physicians’ fears of malpractice law suits are not assuaged by Tort Reforms. Health Aff 2010;29(9):1585–92.

[7] Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med 2011;365:629–36.

[8] Brown TW, McCarthy ML, Kelen GD, Levy F. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers. Acad Emerg Med 2010;17:553–60.

Pain management in type I decompression sickness

To the Editor,

The March issue of The American Journal of Emergency Medicine in- cludes a study by Lee et al [1], which investigated the factors associated with residual symptoms after recompression in type I decompression sickness (DCS). This article is of a good quality, and its results emphasize the importance of early recompression therapy in emergency

1101Correspondence / American Journal of Emergency Medicine 33 (2015) 1093–1107

management of DCS. Despite almost all divers (95%) had musculoskele- tal pain, Lee et al state that the divers were not allowed to have any an- algesics during the study. Pain is the most frequent (sometimes the only) symptom of DCS [2]. Its proper management is important to re- duce patient's suffering. We want to comment on pain management in divers with DCS.

Although recompression therapy is the main treatment of DCS and something that everyone agrees on, there is not a consensus on adjunctive treatment of DCS [2]. There are 2 types of DCS: type I and type II. Type I DCS, which is the subject of the study by Lee et al, includes musculoskeletal pain, cutaneous manifestations, and constitutional symptoms. Type II DCS is more serious than type I and may include a wide range of neurologic symptoms. Most of the patients with type I DCS have musculoskeletal pain as the sole manifestation of the disease [1]. It is generally recommended that a diver with limb pain should not receive analgesics before an eval- uation by a physician experienced in diving diseases because the pain is the only symptom that will aid in the diagnosis of the disease and in the evaluation of the diver's response to recompression ther- apy. If limb pain does not improve within 10 to 20 minutes of recompression therapy, the treatment protocol would be length- ened. The decision of Lee et al [1] not to give analgesics to their pa- tients would seem reasonable in this regard. However, Bennett et al [3] have shown that tenoxicam, a nonsteroidal anti-inflammatory drug, reduces the number of recompression treatments required in DCS without altering the outcome. In their study, patients received tenoxicam after 30 minutes of recompression therapy to allow the physician to evaluate the diver's response to recompression thera- py. They found that the number of divers with pain-only DCS, who required more than 2 recompression treatments, was halved with tenoxicam treatment. Most importantly, they did not observe any adverse effect related to the use of an analgesic in patients with DCS. A recent systematic review identified tenoxicam treatment as the only adjunctive treatment for DCS that has been tested in a ran- domized controlled study [4].

We think that nonspecific nonsteroidal anti-inflammatory drugs can be used for pain management after 30 minutes of recompression thera- py in divers with DCS [3]. Lastly, pain management in DCS is an area re- quiring further research.

İbrahim Arziman, MD Department of Emergency Medicine, Gulhane Military Medical Academy

06100, Etlik, Ankara, Turkey

Günalp Uzun, MD Department of Underwater and Hyperbaric Medicine, Gulhane Military

Medical Academy, 06100, Etlik, Ankara, Turkey Corresponding author. Department of Underwater and Hyperbaric

Medicine, Gulhane Military Medical Academy, 06100 Etlik Ankara, Turkey

Tel.: +90 312 304 4799, +90 533 667 7782 (mobile) E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2015.04.076

References

[1] Lee J, Kim K, Park S. Factors associated with residual symptoms after recompression in type I decompression sickness. Am J Emerg Med 2015;33(3):363–6. http://dx.doi.org/ 10.1016/j.ajem.2014.12.011.

[2] Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression illness. Lancet 2011; 377(9760):153–64. http://dx.doi.org/10.1016/S0140-6736(10)61085-9.

[3] Bennett M, Mitchell S, Dominguez A. Adjunctive treatment of decompression illness with a non-steroidal anti-inflammatory drug (tenoxicam) reduces compression re- quirement. Undersea Hyperb Med 2003;30(3):195–205.

[4] Bennett MH, Lehm JP, Mitchell SJ, Wasiak J. Recompression and adjunctive thera- py for decompression illness. Cochrane Database Syst Rev 2012;5:CD005277. http://dx.doi.org/10.1002/14651858.CD005277.pub3.

Why Do Head and Neck Cancer Patients Visit the Emergency Department?☆,☆☆,★

To the Editor,

Head and neck cancer (HNC) is the sixth most common cancer in the world [1], and a trend of rising incidence has been noted worldwide [2]. In 2011, there were 6955 new oral cavity, oropharynx, and hypophar- ynx cancer patients diagnosed in Taiwan, representing approximately 6.93% of all cancer cases [3]. To date, little data have been available on emergency department (ED) use by cancer patients. Bozdemir et al [4] found that 38% of those cancer patients had more than 1 ED visit, 37.3% of patients were admitted to the hospital, and 49.4% of those pa- tients died within 3 months after their ED visit. Barbera et al [5] demon- strated that 83.8% of deceased cancer patients had visited the ED during their last 6 months of life. Mayer et al [6] found that 77.2% of the patients had only 1 ED visit and a total of 63.2% of the visits resulted in hospital admittance. The 3 principal complaints were related to pain, respiratory distress, and gastrointestinal issues. In short, ED visits and unplanned hospital readmissions result from complications of cancer or its treat- ment, other comorbidities, or symptoms near the end of life [7-9]. This was the first study to use a nationwide population-based data set to in- vestigate the reasons why patients with HNC use the ED and to identify which patients are admitted.

We used data sourced from the Longitudinal Health Insurance Data- base 2000, which randomly selected 1000000 beneficiaries from the year 2000 Registry of Beneficiaries (n = 23.72 million) of the National Health Insurance program. The Longitudinal Health Insurance Database 2000 consists of encrypted deidentified secondary data released to the public for research purposes and is therefore exempt from full review following consultation with the Institutional Review Board of Kaohsiung Veterans General Hospital.

Descriptive statistics are presented as the numbers of cases, percentages, and the mean and SD of ED visit and hospital admit- tance frequency. All statistical calculations were performed using the Statistical Analysis Software package (SAS System for Windows, version 9.4).

In 2000 to 2012, there were a total of 279411 HNC-related visits, including inpatient, outpatient, and ED services. The number of visits in- creased steadily from 2833 in 2000 to 41862 in 2012 (Fig. 1). The patient characteristics are detailed in Table 1. Over a period of 12 years, 1660 patients with HNC visited the ED. May, June, and July were the 3 top-ranked months for ED visits (Fig. 2). Of these patients, 1521 (91.63%) were male, and 139 (8.37%) were female. The mean age was 55.28 ± 12.5 years. The majority of the HNC patient ED visits occurred at a medical center (n = 1183, 71.27%). Higher rates of medical center ED visits may be the result of the clinical management protocols of the ED or subspecialty services, particularly with respect to the inclusion of training physician

In Table 2, regarding the proportion of ED visits, 517 patients (31.14%) visited the ED 1 time, and the mean number of ED visits was 4.01 ± 4.69. Although 798 patients (40.87%) did not require admission to the hospital, 489 patients (29.46%) were admitted 1 time; 193 patients (11.63%), 2 times; and 180 patients (10.84%), more than 3 times. The HNC patients in our cohort appeared to have higher rates of ED visits and admissions than patients with other cancer types [4-6,10].

☆ Study funding: None. ☆☆ Conflicts of interest: There is no conflict of interest. ★ Contributorships: None.

1102 Correspondence / American Journal of Emergency Medicine 33 (2015) 1093–1107

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.