Sherry Boschert

SAN FRANCISCO—Not many patients e-mail their physicians, and of those who do, the majority click “send” less than once a month, an online survey of 1,881 people suggests.

Fewer than 17% of respondents reported recently e-mailing their physicians, Thomas K. Houston, M.D., said at the triennial congress of the International Medical Informatics Association. The survey recruited respondents mainly from the Aetna InteliHealth Web site (www.intelihealth.com

In-depth phone interviews with 56 of the 311 respondents who had e-mailed their physicians revealed that 30 did so less than once a month, 12 e-mailed about once per month, and 14 e-mailed their physicians more frequently, said Dr. Houston of the University of Alabama, Birmingham.

“Certainly, one of the concerns that physicians have had is being overwhelmed by e-mail” if they offer that option to patients, he said. These results suggest that this is not a problem, but that conclusion could change if more patients begin e-mailing, he added.

E-mail messages were mostly requests for prescription renewals or lab results, but some patients tried to use e-mail to communicate urgent problems such as chest pains. “That is a big concern,” and suggests the need for patient education about e-mail use, he said.

Half the e-mail messages went to general internists, about 25% went to subspecialty internists, and the rest went to family physicians, ob.gyns., surgeons, pediatricians, and other specialists.

These “early adopters” of e-mail communication with physicians liked the efficiency of e-mail and the ability to communicate without a face-to-face appointment, Dr. Houston said. Some patients said they felt more comfortable communicating things that they might not have been able to talk about in person.

On the other hand, they sometimes worried that they would not get a reply, and they were concerned about bugging their physicians with too many e-mails. Patients were less concerned about privacy issues, he noted.

Although getting e-mail responses from their physicians made patients feel that physicians cared more about them, they complained of a lack of empathy in each individual e-mail.

Most patients were willing to pay $3 per e-mail response from a physician.

The patients interviewed were mostly white women and tended to be better educated than the general population, Dr. Houston said.

SAN FRANCISCO—Not many patients e-mail their physicians, and of those who do, the majority click “send” less than once a month, an online survey of 1,881 people suggests.

Fewer than 17% of respondents reported recently e-mailing their physicians, Thomas K. Houston, M.D., said at the triennial congress of the International Medical Informatics Association. The survey recruited respondents mainly from the Aetna InteliHealth Web site (www.intelihealth.com

In-depth phone interviews with 56 of the 311 respondents who had e-mailed their physicians revealed that 30 did so less than once a month, 12 e-mailed about once per month, and 14 e-mailed their physicians more frequently, said Dr. Houston of the University of Alabama, Birmingham.

“Certainly, one of the concerns that physicians have had is being overwhelmed by e-mail” if they offer that option to patients, he said. These results suggest that this is not a problem, but that conclusion could change if more patients begin e-mailing, he added.

E-mail messages were mostly requests for prescription renewals or lab results, but some patients tried to use e-mail to communicate urgent problems such as chest pains. “That is a big concern,” and suggests the need for patient education about e-mail use, he said.

Half the e-mail messages went to general internists, about 25% went to subspecialty internists, and the rest went to family physicians, ob.gyns., surgeons, pediatricians, and other specialists.

These “early adopters” of e-mail communication with physicians liked the efficiency of e-mail and the ability to communicate without a face-to-face appointment, Dr. Houston said. Some patients said they felt more comfortable communicating things that they might not have been able to talk about in person.

On the other hand, they sometimes worried that they would not get a reply, and they were concerned about bugging their physicians with too many e-mails. Patients were less concerned about privacy issues, he noted.

Although getting e-mail responses from their physicians made patients feel that physicians cared more about them, they complained of a lack of empathy in each individual e-mail.

Most patients were willing to pay $3 per e-mail response from a physician.

The patients interviewed were mostly white women and tended to be better educated than the general population, Dr. Houston said.

SAN FRANCISCO—Not many patients e-mail their physicians, and of those who do, the majority click “send” less than once a month, an online survey of 1,881 people suggests.

Fewer than 17% of respondents reported recently e-mailing their physicians, Thomas K. Houston, M.D., said at the triennial congress of the International Medical Informatics Association. The survey recruited respondents mainly from the Aetna InteliHealth Web site (www.intelihealth.com

In-depth phone interviews with 56 of the 311 respondents who had e-mailed their physicians revealed that 30 did so less than once a month, 12 e-mailed about once per month, and 14 e-mailed their physicians more frequently, said Dr. Houston of the University of Alabama, Birmingham.

“Certainly, one of the concerns that physicians have had is being overwhelmed by e-mail” if they offer that option to patients, he said. These results suggest that this is not a problem, but that conclusion could change if more patients begin e-mailing, he added.

E-mail messages were mostly requests for prescription renewals or lab results, but some patients tried to use e-mail to communicate urgent problems such as chest pains. “That is a big concern,” and suggests the need for patient education about e-mail use, he said.

Half the e-mail messages went to general internists, about 25% went to subspecialty internists, and the rest went to family physicians, ob.gyns., surgeons, pediatricians, and other specialists.

These “early adopters” of e-mail communication with physicians liked the efficiency of e-mail and the ability to communicate without a face-to-face appointment, Dr. Houston said. Some patients said they felt more comfortable communicating things that they might not have been able to talk about in person.

On the other hand, they sometimes worried that they would not get a reply, and they were concerned about bugging their physicians with too many e-mails. Patients were less concerned about privacy issues, he noted.

Although getting e-mail responses from their physicians made patients feel that physicians cared more about them, they complained of a lack of empathy in each individual e-mail.

Most patients were willing to pay $3 per e-mail response from a physician.

The patients interviewed were mostly white women and tended to be better educated than the general population, Dr. Houston said.

SAN FRANCISCO—Half of 83 prescriptions for analgesics written for 77 children being sent home from the hospital contained one or more errors, including 2 prescriptions with errors that could have significantly harmed the patients, Benjamin H. Lee, M.D., said at the annual meeting of the American Academy of Pediatrics.

Unbeknownst to the primary medical or surgical physicians who wrote the discharge analgesic prescriptions, investigators from the Johns Hopkins Medical Institutions' (Baltimore) pediatric pain service secretly monitored the prescriptions during the study and rewrote any they considered dangerous, so no children were harmed, said Dr. Lee of Johns Hopkins.

“We were surprised at this potential adverse drug event rate of 2.4%. That's not insignificant in this small patient series,” he said, adding, “I don't think this is something that's limited to Johns Hopkins Hospital.”

Discharge time is a vulnerable period for inpatients, who lose the safety net of pharmacists, nurses, and multiple physicians who look at medication orders while the patient is hospitalized, he explained. When the patient is sent home with analgesics, a single physician writes the prescription and the discharge orders, which are reviewed usually by a single nurse, with no pharmacists or other providers involved.

The two dangerous prescriptions in the study were for opioids. One included a 10-fold overdose error. The other included instructions for a long-acting medication that could lead a patient to take multiple doses all at once. All patients got prescriptions for opioids at discharge, and 7% also received NSAIDs.

Most of the prescription errors were not clinically significant; the study used a strict definition of error. The two most common causes of errors, however, illustrate problems that could lead to patient harm: a lack of any identification of weight or weight-based dosing in the prescription, and incomplete information about dispensing of the medication.

For patients weighing less than 40 kg, no weight was recorded on 45% of analgesic prescriptions. They found discrepancies between the written prescriptions and the discharge data form in 10% of cases. Physicians wrote an incorrect name or patient identifier in 4% of analgesia prescriptions.

A separate study is underway to see if using a computerized prescription-writing program that includes weight-based dosing for pediatric patients will reduce errors and improve patient safety, Dr. Lee said.

SAN FRANCISCO—Half of 83 prescriptions for analgesics written for 77 children being sent home from the hospital contained one or more errors, including 2 prescriptions with errors that could have significantly harmed the patients, Benjamin H. Lee, M.D., said at the annual meeting of the American Academy of Pediatrics.

Unbeknownst to the primary medical or surgical physicians who wrote the discharge analgesic prescriptions, investigators from the Johns Hopkins Medical Institutions' (Baltimore) pediatric pain service secretly monitored the prescriptions during the study and rewrote any they considered dangerous, so no children were harmed, said Dr. Lee of Johns Hopkins.

“We were surprised at this potential adverse drug event rate of 2.4%. That's not insignificant in this small patient series,” he said, adding, “I don't think this is something that's limited to Johns Hopkins Hospital.”

Discharge time is a vulnerable period for inpatients, who lose the safety net of pharmacists, nurses, and multiple physicians who look at medication orders while the patient is hospitalized, he explained. When the patient is sent home with analgesics, a single physician writes the prescription and the discharge orders, which are reviewed usually by a single nurse, with no pharmacists or other providers involved.

The two dangerous prescriptions in the study were for opioids. One included a 10-fold overdose error. The other included instructions for a long-acting medication that could lead a patient to take multiple doses all at once. All patients got prescriptions for opioids at discharge, and 7% also received NSAIDs.

Most of the prescription errors were not clinically significant; the study used a strict definition of error. The two most common causes of errors, however, illustrate problems that could lead to patient harm: a lack of any identification of weight or weight-based dosing in the prescription, and incomplete information about dispensing of the medication.

For patients weighing less than 40 kg, no weight was recorded on 45% of analgesic prescriptions. They found discrepancies between the written prescriptions and the discharge data form in 10% of cases. Physicians wrote an incorrect name or patient identifier in 4% of analgesia prescriptions.

A separate study is underway to see if using a computerized prescription-writing program that includes weight-based dosing for pediatric patients will reduce errors and improve patient safety, Dr. Lee said.

SAN FRANCISCO—Half of 83 prescriptions for analgesics written for 77 children being sent home from the hospital contained one or more errors, including 2 prescriptions with errors that could have significantly harmed the patients, Benjamin H. Lee, M.D., said at the annual meeting of the American Academy of Pediatrics.

Unbeknownst to the primary medical or surgical physicians who wrote the discharge analgesic prescriptions, investigators from the Johns Hopkins Medical Institutions' (Baltimore) pediatric pain service secretly monitored the prescriptions during the study and rewrote any they considered dangerous, so no children were harmed, said Dr. Lee of Johns Hopkins.

“We were surprised at this potential adverse drug event rate of 2.4%. That's not insignificant in this small patient series,” he said, adding, “I don't think this is something that's limited to Johns Hopkins Hospital.”

Discharge time is a vulnerable period for inpatients, who lose the safety net of pharmacists, nurses, and multiple physicians who look at medication orders while the patient is hospitalized, he explained. When the patient is sent home with analgesics, a single physician writes the prescription and the discharge orders, which are reviewed usually by a single nurse, with no pharmacists or other providers involved.

The two dangerous prescriptions in the study were for opioids. One included a 10-fold overdose error. The other included instructions for a long-acting medication that could lead a patient to take multiple doses all at once. All patients got prescriptions for opioids at discharge, and 7% also received NSAIDs.

Most of the prescription errors were not clinically significant; the study used a strict definition of error. The two most common causes of errors, however, illustrate problems that could lead to patient harm: a lack of any identification of weight or weight-based dosing in the prescription, and incomplete information about dispensing of the medication.

For patients weighing less than 40 kg, no weight was recorded on 45% of analgesic prescriptions. They found discrepancies between the written prescriptions and the discharge data form in 10% of cases. Physicians wrote an incorrect name or patient identifier in 4% of analgesia prescriptions.

A separate study is underway to see if using a computerized prescription-writing program that includes weight-based dosing for pediatric patients will reduce errors and improve patient safety, Dr. Lee said.

SAN FRANCISCO—The digital divide in your waiting room can be crossed, and technology can compensate for low literacy levels in some patients, said David F. Lobach, M.D.

A randomized, controlled, crossover study of 567 patients found that patients of differing literacy levels and differing levels of computer skills successfully answered a 75-item computerized clinical questionnaire that adapted to their skill levels through a tool named MADELINE (Multimedia Adaptive Data Entry and Learning Interface within a Networked Environment), he said at the triennial congress of the International Medical Informatics Association.

Patients in two clinics (an academic family practice and a health center for indigent patients) were randomized to first complete either a paper version of the questionnaire or the computer version, then the other version, with satisfaction surveys immediately following each version and a separate questionnaire at the end asking them to compare the two modalities. Questions at the beginning of each survey assessed patient literacy and computer skill and ranked them as low or high.

Patients with low-literacy levels were less likely to complete the paper questionnaire, compared with highly literate patients; 80% vs. 90%, respectively, answered all questions. Thanks to MADELINE, completion rates increased significantly in both groups, to 96% and 97%, respectively.

“We lessened the digital divide and brought the low-literacy users up to par with the high-literacy users,” said Dr. Lobach of Duke University Medical Center, Durham, N.C.

He and his associates developed MADELINE over a 3-year period. The U.S. Agency for Healthcare Quality and Research provided most of the funding for the study.

A review of charts on 20% of the patients found comparable accuracy between the paper and computer survey responses. Low-literacy patients required an average of 28 minutes to complete the computer survey, compared with 16 minutes for the paper version. High-literacy patients completed the computer survey in 15 minutes and the paper survey in 11 minutes.

Approximately 50% of patients had high literacy and high computer skills, 25% had low literacy and computer skills, 15% were highly literate but had low computer skills, and 10% had low literacy but high computer skills.

Patients could take the survey in English or Spanish, and MADELINE can be configured to include other languages and questionnaires. It begins by asking about language preference, then introduces the user to the questionnaire via instructional videos and practice questions. The user then logs on using a number assigned to his or her name and record number and answers six questions to assess literacy and computer skill.

At this point MADELINE presents the questionnaire in different ways for patients with low or high skills.

Those with low computer skills, for example, hear an audio component that reads a question on the screen, and they pick an answer by touching the screen. Patients with high computer skills see multiple questions per screen and use a mouse to click on responses.

For low-literacy patients, the program adapts to a fifth-grade reading level and predominantly uses multiple-choice questions. For high-literacy patients, the program adapts to a 10th- to 12th-grade reading level and has more questions requiring text-entry responses instead of a multiple-choice selection.

Below a fifth-grade reading level “we lost the ability to collect any meaningful information” by paper or computer, Dr. Lobach said.

A report on the patient's answers could be read online or could be printed out after completing the questionnaire.

SAN FRANCISCO—The digital divide in your waiting room can be crossed, and technology can compensate for low literacy levels in some patients, said David F. Lobach, M.D.

A randomized, controlled, crossover study of 567 patients found that patients of differing literacy levels and differing levels of computer skills successfully answered a 75-item computerized clinical questionnaire that adapted to their skill levels through a tool named MADELINE (Multimedia Adaptive Data Entry and Learning Interface within a Networked Environment), he said at the triennial congress of the International Medical Informatics Association.

Patients in two clinics (an academic family practice and a health center for indigent patients) were randomized to first complete either a paper version of the questionnaire or the computer version, then the other version, with satisfaction surveys immediately following each version and a separate questionnaire at the end asking them to compare the two modalities. Questions at the beginning of each survey assessed patient literacy and computer skill and ranked them as low or high.

Patients with low-literacy levels were less likely to complete the paper questionnaire, compared with highly literate patients; 80% vs. 90%, respectively, answered all questions. Thanks to MADELINE, completion rates increased significantly in both groups, to 96% and 97%, respectively.

“We lessened the digital divide and brought the low-literacy users up to par with the high-literacy users,” said Dr. Lobach of Duke University Medical Center, Durham, N.C.

He and his associates developed MADELINE over a 3-year period. The U.S. Agency for Healthcare Quality and Research provided most of the funding for the study.

A review of charts on 20% of the patients found comparable accuracy between the paper and computer survey responses. Low-literacy patients required an average of 28 minutes to complete the computer survey, compared with 16 minutes for the paper version. High-literacy patients completed the computer survey in 15 minutes and the paper survey in 11 minutes.

Approximately 50% of patients had high literacy and high computer skills, 25% had low literacy and computer skills, 15% were highly literate but had low computer skills, and 10% had low literacy but high computer skills.

Patients could take the survey in English or Spanish, and MADELINE can be configured to include other languages and questionnaires. It begins by asking about language preference, then introduces the user to the questionnaire via instructional videos and practice questions. The user then logs on using a number assigned to his or her name and record number and answers six questions to assess literacy and computer skill.

At this point MADELINE presents the questionnaire in different ways for patients with low or high skills.

Those with low computer skills, for example, hear an audio component that reads a question on the screen, and they pick an answer by touching the screen. Patients with high computer skills see multiple questions per screen and use a mouse to click on responses.

For low-literacy patients, the program adapts to a fifth-grade reading level and predominantly uses multiple-choice questions. For high-literacy patients, the program adapts to a 10th- to 12th-grade reading level and has more questions requiring text-entry responses instead of a multiple-choice selection.

Below a fifth-grade reading level “we lost the ability to collect any meaningful information” by paper or computer, Dr. Lobach said.

A report on the patient's answers could be read online or could be printed out after completing the questionnaire.

SAN FRANCISCO—The digital divide in your waiting room can be crossed, and technology can compensate for low literacy levels in some patients, said David F. Lobach, M.D.

A randomized, controlled, crossover study of 567 patients found that patients of differing literacy levels and differing levels of computer skills successfully answered a 75-item computerized clinical questionnaire that adapted to their skill levels through a tool named MADELINE (Multimedia Adaptive Data Entry and Learning Interface within a Networked Environment), he said at the triennial congress of the International Medical Informatics Association.

Patients in two clinics (an academic family practice and a health center for indigent patients) were randomized to first complete either a paper version of the questionnaire or the computer version, then the other version, with satisfaction surveys immediately following each version and a separate questionnaire at the end asking them to compare the two modalities. Questions at the beginning of each survey assessed patient literacy and computer skill and ranked them as low or high.

Patients with low-literacy levels were less likely to complete the paper questionnaire, compared with highly literate patients; 80% vs. 90%, respectively, answered all questions. Thanks to MADELINE, completion rates increased significantly in both groups, to 96% and 97%, respectively.

“We lessened the digital divide and brought the low-literacy users up to par with the high-literacy users,” said Dr. Lobach of Duke University Medical Center, Durham, N.C.

He and his associates developed MADELINE over a 3-year period. The U.S. Agency for Healthcare Quality and Research provided most of the funding for the study.

A review of charts on 20% of the patients found comparable accuracy between the paper and computer survey responses. Low-literacy patients required an average of 28 minutes to complete the computer survey, compared with 16 minutes for the paper version. High-literacy patients completed the computer survey in 15 minutes and the paper survey in 11 minutes.

Approximately 50% of patients had high literacy and high computer skills, 25% had low literacy and computer skills, 15% were highly literate but had low computer skills, and 10% had low literacy but high computer skills.

Patients could take the survey in English or Spanish, and MADELINE can be configured to include other languages and questionnaires. It begins by asking about language preference, then introduces the user to the questionnaire via instructional videos and practice questions. The user then logs on using a number assigned to his or her name and record number and answers six questions to assess literacy and computer skill.

At this point MADELINE presents the questionnaire in different ways for patients with low or high skills.

Those with low computer skills, for example, hear an audio component that reads a question on the screen, and they pick an answer by touching the screen. Patients with high computer skills see multiple questions per screen and use a mouse to click on responses.

For low-literacy patients, the program adapts to a fifth-grade reading level and predominantly uses multiple-choice questions. For high-literacy patients, the program adapts to a 10th- to 12th-grade reading level and has more questions requiring text-entry responses instead of a multiple-choice selection.

Below a fifth-grade reading level “we lost the ability to collect any meaningful information” by paper or computer, Dr. Lobach said.

A report on the patient's answers could be read online or could be printed out after completing the questionnaire.

SAN FRANCISCO — The timing of chest compressions in CPR can mean life or death to some patients in cardiac arrest, Lance B. Becker, M.D., said at the annual meeting of the American College of Emergency Physicians.

An observational study of approximately 100 patients being resuscitated in a hospital counted the number and measured the rate of chest compressions through a personal digital assistant operated by a nurse at the rescue scene.

Even in this small group of patients, those who received the 80–100 chest compressions per minute during CPR recommended by the American Heart Association were significantly more likely to survive, compared with those who received lower compression rates, said Dr. Becker, director of the emergency resuscitation center and professor of emergency medicine at the University of Chicago.

The study will be published in the Feb. 1, 2005, issue of the journal Circulation, he said.

The results especially are cause for concern when combined with new concepts about three phases of cardiac resuscitation, Dr. Becker added. He and others have proposed that the first, “electrical” phase of ventricular fibrillation is well treated by defibrillation, but patients in a second, “circulatory” phase may be better treated by first receiving compression, then defibrillation. In a third, “metabolic” phase, newer therapies are needed in addition to compression and defibrillation to save more lives, he said. At present, all patients in ventricular fibrillation undergo defibrillation.

“In that second phase, compression is important, but it has to be good compression,” Dr. Becker explained. “I–m worried about this. I think there are really good data that [show] we're not doing a great job on cardiac compression.”

A randomized, controlled trial in 2003 compared standard defibrillation with CPR first, then defibrillation in approximately 200 patients being resuscitated after cardiac arrest outside of hospitals. In a subgroup of patients reached by rescuers more than 5 minutes after cardiac arrest (who could be considered to be in that second phase of ventricular fibrillation), 20% who underwent compression plus defibrillation remained alive 1 year later, compared with 4% in the defibrillation-only group (JAMA 2003:289;1389–95).

Animal studies back this concept, Dr. Becker said.

Physicians can begin today to save more lives by insisting that CPR be done appropriately, he suggested.

Dr. Becker and his associates are studying a new device to give resuscitators instant feedback on how well they're doing CPR. An accelerometer and a pressure gauge embedded into a sternal pad placed on the patient's chest are wired to a defibrillator and attached to a minicomputer.

The device accurately measures the timing of compressions down to the millisecond and gives a good measurement of the depth of each compression, among other data.

In some patients, the readings show faster ventilation than compression. Hyperventilation in someone who has almost no cardiac output can increase venous return and cause what others have termed “death by ventilation,” Dr. Becker noted.

The investigational device can talk to rescuers with messages such as, “Slow down your ventilation,” or “Speed up your compression.”

It is being studied in U.S. hospitals and on patients arresting outside of hospitals in Europe to see if it improves CPR and, thus, survival.

Early results seem “very promising,” Dr. Becker said.

He has financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.

SAN FRANCISCO — The timing of chest compressions in CPR can mean life or death to some patients in cardiac arrest, Lance B. Becker, M.D., said at the annual meeting of the American College of Emergency Physicians.

An observational study of approximately 100 patients being resuscitated in a hospital counted the number and measured the rate of chest compressions through a personal digital assistant operated by a nurse at the rescue scene.

Even in this small group of patients, those who received the 80–100 chest compressions per minute during CPR recommended by the American Heart Association were significantly more likely to survive, compared with those who received lower compression rates, said Dr. Becker, director of the emergency resuscitation center and professor of emergency medicine at the University of Chicago.

The study will be published in the Feb. 1, 2005, issue of the journal Circulation, he said.

The results especially are cause for concern when combined with new concepts about three phases of cardiac resuscitation, Dr. Becker added. He and others have proposed that the first, “electrical” phase of ventricular fibrillation is well treated by defibrillation, but patients in a second, “circulatory” phase may be better treated by first receiving compression, then defibrillation. In a third, “metabolic” phase, newer therapies are needed in addition to compression and defibrillation to save more lives, he said. At present, all patients in ventricular fibrillation undergo defibrillation.

“In that second phase, compression is important, but it has to be good compression,” Dr. Becker explained. “I–m worried about this. I think there are really good data that [show] we're not doing a great job on cardiac compression.”

A randomized, controlled trial in 2003 compared standard defibrillation with CPR first, then defibrillation in approximately 200 patients being resuscitated after cardiac arrest outside of hospitals. In a subgroup of patients reached by rescuers more than 5 minutes after cardiac arrest (who could be considered to be in that second phase of ventricular fibrillation), 20% who underwent compression plus defibrillation remained alive 1 year later, compared with 4% in the defibrillation-only group (JAMA 2003:289;1389–95).

Animal studies back this concept, Dr. Becker said.

Physicians can begin today to save more lives by insisting that CPR be done appropriately, he suggested.

Dr. Becker and his associates are studying a new device to give resuscitators instant feedback on how well they're doing CPR. An accelerometer and a pressure gauge embedded into a sternal pad placed on the patient's chest are wired to a defibrillator and attached to a minicomputer.

The device accurately measures the timing of compressions down to the millisecond and gives a good measurement of the depth of each compression, among other data.

In some patients, the readings show faster ventilation than compression. Hyperventilation in someone who has almost no cardiac output can increase venous return and cause what others have termed “death by ventilation,” Dr. Becker noted.

The investigational device can talk to rescuers with messages such as, “Slow down your ventilation,” or “Speed up your compression.”

It is being studied in U.S. hospitals and on patients arresting outside of hospitals in Europe to see if it improves CPR and, thus, survival.

Early results seem “very promising,” Dr. Becker said.

He has financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.

SAN FRANCISCO — The timing of chest compressions in CPR can mean life or death to some patients in cardiac arrest, Lance B. Becker, M.D., said at the annual meeting of the American College of Emergency Physicians.

An observational study of approximately 100 patients being resuscitated in a hospital counted the number and measured the rate of chest compressions through a personal digital assistant operated by a nurse at the rescue scene.

Even in this small group of patients, those who received the 80–100 chest compressions per minute during CPR recommended by the American Heart Association were significantly more likely to survive, compared with those who received lower compression rates, said Dr. Becker, director of the emergency resuscitation center and professor of emergency medicine at the University of Chicago.

The study will be published in the Feb. 1, 2005, issue of the journal Circulation, he said.

The results especially are cause for concern when combined with new concepts about three phases of cardiac resuscitation, Dr. Becker added. He and others have proposed that the first, “electrical” phase of ventricular fibrillation is well treated by defibrillation, but patients in a second, “circulatory” phase may be better treated by first receiving compression, then defibrillation. In a third, “metabolic” phase, newer therapies are needed in addition to compression and defibrillation to save more lives, he said. At present, all patients in ventricular fibrillation undergo defibrillation.

“In that second phase, compression is important, but it has to be good compression,” Dr. Becker explained. “I–m worried about this. I think there are really good data that [show] we're not doing a great job on cardiac compression.”

A randomized, controlled trial in 2003 compared standard defibrillation with CPR first, then defibrillation in approximately 200 patients being resuscitated after cardiac arrest outside of hospitals. In a subgroup of patients reached by rescuers more than 5 minutes after cardiac arrest (who could be considered to be in that second phase of ventricular fibrillation), 20% who underwent compression plus defibrillation remained alive 1 year later, compared with 4% in the defibrillation-only group (JAMA 2003:289;1389–95).

Animal studies back this concept, Dr. Becker said.

Physicians can begin today to save more lives by insisting that CPR be done appropriately, he suggested.

Dr. Becker and his associates are studying a new device to give resuscitators instant feedback on how well they're doing CPR. An accelerometer and a pressure gauge embedded into a sternal pad placed on the patient's chest are wired to a defibrillator and attached to a minicomputer.

The device accurately measures the timing of compressions down to the millisecond and gives a good measurement of the depth of each compression, among other data.

In some patients, the readings show faster ventilation than compression. Hyperventilation in someone who has almost no cardiac output can increase venous return and cause what others have termed “death by ventilation,” Dr. Becker noted.

The investigational device can talk to rescuers with messages such as, “Slow down your ventilation,” or “Speed up your compression.”

It is being studied in U.S. hospitals and on patients arresting outside of hospitals in Europe to see if it improves CPR and, thus, survival.

Early results seem “very promising,” Dr. Becker said.

He has financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.

SAN FRANCISCO–Emergency physicians seldom see eye to eye with patients who seek help for chronic pain, according to preliminary results from a small, ongoing study.

The emergency physicians end up frustrated, and the patients seldom get the help they need, Scott M. Fishman, M.D., said at the annual meeting of the American College of Emergency Physicians.

The study recruits patients seen in the ED with a history of pain lasting 6 months or longer who already have been prescribed schedule II medications and who present with a vague complaint of pain in a body part or the whole body. They answer up to 13 questionnaires (as many as possible) and are asked to return within 2 weeks to complete the Structured Clinical Interview for DSM-IV (SCID) with a psychologist. The study also surveys the ED physicians and nurses treating the patients.

A comparison of answers from 39 patients who have completed the study at the halfway point of its 2-year schedule (out of 77 recruited so far) and answers from 54 providers showed significant disagreements on most topics, said Dr. Fishman, professor of anesthesiology at the University of California, Davis, and chief of pain medicine at the university's medical center.

Patients were more likely than providers to believe that chronic pain has little chance of improving, and to think that providers don't believe pain complaints if they lack physical or objective findings. Patients strongly disagreed that they were addicted to their pain medications, and providers were more ambivalent about patients' potential addictions. Patients feared the risk of dependence on opioids more so than did the providers.

All of these differences were significant between patients and providers as a whole, and between patients and either physicians or nurses.

On the Screener and Opioid Assessment for Patients in Pain (SOAPP) survey, nearly every patient scored positive for addiction, “staggering but early data” that raise the question of whether the SOAPP is valid in the ED, Dr. Fishman said.

Nine physicians so far interviewed at length described an emotional toll from caring for these patients.

“The words they used most commonly were frustrated, stressed, overwhelmed, nervous, and angry,” he said.

The physicians felt that chronic pain care is not appropriate for the ED. They were very concerned with differentiating “legitimate” pain from other complaints. Regardless, “almost everybody got a handful of Vicodin [hydrocodone] on the way out,” Dr. Fishman said.

“Is this treating the patient, or treating the physician?”

SAN FRANCISCO–Emergency physicians seldom see eye to eye with patients who seek help for chronic pain, according to preliminary results from a small, ongoing study.

The emergency physicians end up frustrated, and the patients seldom get the help they need, Scott M. Fishman, M.D., said at the annual meeting of the American College of Emergency Physicians.

The study recruits patients seen in the ED with a history of pain lasting 6 months or longer who already have been prescribed schedule II medications and who present with a vague complaint of pain in a body part or the whole body. They answer up to 13 questionnaires (as many as possible) and are asked to return within 2 weeks to complete the Structured Clinical Interview for DSM-IV (SCID) with a psychologist. The study also surveys the ED physicians and nurses treating the patients.

A comparison of answers from 39 patients who have completed the study at the halfway point of its 2-year schedule (out of 77 recruited so far) and answers from 54 providers showed significant disagreements on most topics, said Dr. Fishman, professor of anesthesiology at the University of California, Davis, and chief of pain medicine at the university's medical center.

Patients were more likely than providers to believe that chronic pain has little chance of improving, and to think that providers don't believe pain complaints if they lack physical or objective findings. Patients strongly disagreed that they were addicted to their pain medications, and providers were more ambivalent about patients' potential addictions. Patients feared the risk of dependence on opioids more so than did the providers.

All of these differences were significant between patients and providers as a whole, and between patients and either physicians or nurses.

On the Screener and Opioid Assessment for Patients in Pain (SOAPP) survey, nearly every patient scored positive for addiction, “staggering but early data” that raise the question of whether the SOAPP is valid in the ED, Dr. Fishman said.

Nine physicians so far interviewed at length described an emotional toll from caring for these patients.

“The words they used most commonly were frustrated, stressed, overwhelmed, nervous, and angry,” he said.

The physicians felt that chronic pain care is not appropriate for the ED. They were very concerned with differentiating “legitimate” pain from other complaints. Regardless, “almost everybody got a handful of Vicodin [hydrocodone] on the way out,” Dr. Fishman said.

“Is this treating the patient, or treating the physician?”

SAN FRANCISCO–Emergency physicians seldom see eye to eye with patients who seek help for chronic pain, according to preliminary results from a small, ongoing study.

The emergency physicians end up frustrated, and the patients seldom get the help they need, Scott M. Fishman, M.D., said at the annual meeting of the American College of Emergency Physicians.

The study recruits patients seen in the ED with a history of pain lasting 6 months or longer who already have been prescribed schedule II medications and who present with a vague complaint of pain in a body part or the whole body. They answer up to 13 questionnaires (as many as possible) and are asked to return within 2 weeks to complete the Structured Clinical Interview for DSM-IV (SCID) with a psychologist. The study also surveys the ED physicians and nurses treating the patients.

A comparison of answers from 39 patients who have completed the study at the halfway point of its 2-year schedule (out of 77 recruited so far) and answers from 54 providers showed significant disagreements on most topics, said Dr. Fishman, professor of anesthesiology at the University of California, Davis, and chief of pain medicine at the university's medical center.

Patients were more likely than providers to believe that chronic pain has little chance of improving, and to think that providers don't believe pain complaints if they lack physical or objective findings. Patients strongly disagreed that they were addicted to their pain medications, and providers were more ambivalent about patients' potential addictions. Patients feared the risk of dependence on opioids more so than did the providers.

All of these differences were significant between patients and providers as a whole, and between patients and either physicians or nurses.

On the Screener and Opioid Assessment for Patients in Pain (SOAPP) survey, nearly every patient scored positive for addiction, “staggering but early data” that raise the question of whether the SOAPP is valid in the ED, Dr. Fishman said.

Nine physicians so far interviewed at length described an emotional toll from caring for these patients.

“The words they used most commonly were frustrated, stressed, overwhelmed, nervous, and angry,” he said.

The physicians felt that chronic pain care is not appropriate for the ED. They were very concerned with differentiating “legitimate” pain from other complaints. Regardless, “almost everybody got a handful of Vicodin [hydrocodone] on the way out,” Dr. Fishman said.

“Is this treating the patient, or treating the physician?”

SAN FRANCISCO — Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer the option of electronic communications to their patients if the e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association.

The study findings suggest that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys were completed by 76 staff members before adoption of Patient Gateway, a secure Web portal for electronic communication with patients. Before the new system, 44 respondents said they feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload. They found the system particularly helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

SAN FRANCISCO — Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer the option of electronic communications to their patients if the e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association.

The study findings suggest that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys were completed by 76 staff members before adoption of Patient Gateway, a secure Web portal for electronic communication with patients. Before the new system, 44 respondents said they feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload. They found the system particularly helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

SAN FRANCISCO — Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer the option of electronic communications to their patients if the e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association.

The study findings suggest that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys were completed by 76 staff members before adoption of Patient Gateway, a secure Web portal for electronic communication with patients. Before the new system, 44 respondents said they feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload. They found the system particularly helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

SAN FRANCISCO — Adding telemedicine to home health care halved the proportion of rural elderly patients who had to move from their homes to hospitals or nursing homes over a period of 2 1/2 years, in a randomized study of 53 patients.

Patients receiving skilled nursing care at home for heart failure, chronic obstructive pulmonary disease, or chronic wound care were randomized to one of three treatment groups. The researchers added simple videoconferencing equipment and Internet access to the homes of 14 patients in a video arm and 20 patients in a monitoring arm, who also received physiologic monitoring equipment—pulse oximeters, electronic spirometers, and/or blood pressure cuffs, depending on their medical problem. The two-way videoconferencing allowed virtual visits by the home health care nurse with the patient at home. In a control group, 19 patients did not get telemedicine equipment. All groups continued with actual home visits by the nurses.

During the study, six patients (18%) in the telemedicine groups (two in the video group and four in the monitoring group) transferred from their homes to a higher level of care. Eight patients (42%) in the control group did so, said Stuart M. Speedie, Ph.D., in a poster presentation at the triennial congress of the International Medical Informatics Association.

Death rates did not differ significantly between groups: Five control patients and seven patients in the two telemedicine groups died. Surveys showed that patients in the monitoring group were significantly more satisfied with their care, compared with control patients, because they believed they had greater choices about their care, felt safer, and reported greater flexibility in scheduling, said Dr. Speedie of the University of Minnesota, Minneapolis.

The mean number of nurse visits did not differ between groups—22 per patient in the control group and 19 per patient in the telemedicine groups. The telemedicine patients averaged 17 virtual visits each. Average patient age was 72 years in the control group and 76 years in the telemedicine groups.

Actual visits cost an average of $44.71, while video-only virtual visits cost $22.96 and video visits for physiologic monitoring cost $29.66. Nursing time during actual visits accounted for the higher average cost. In addition, the telemedicine equipment cost about $1,500 per patient, said Dr. Speedie, who conducted the study with lead investigator Stanley M. Finkelstein, Ph.D., and Sandra Potthoff, Ph.D., both of the university.

Home health nurses rated the technical quality of virtual visits as acceptable in 94% of visits and said that 92% of virtual visits would not have been better if done in person. The nurses said that questions were not asked in 5% of virtual visits that might have been asked in actual visits.

In a separate pilot study presented at the meeting, informal videoconferencing consultations offered once a week to residents of an assisted living facility led to formal clinic appointments for 6 of 31 patients (19%) over a 5-month period, Lawrence Afrin M.D., and his associates at the Medical University of South Carolina, Charleston, reported in a poster.

They provided the telemedicine service for free as a goodwill gesture. Third-party payers seldom pay for telemedicine services, but the results suggest that the service may be economically viable if it leads to normal clinic services that are billable, Dr. Afrin said. Assisted living facilities might be willing to pay a small fee for the service to gain a competitive advantage.

Five university physicians rotated duty on the sessions, discussing problems such as cardiovascular issues, allergies, pain, cancer, anemia, thalassemia, sleep disorders, and neurological disorders.

A man checks his wife's blood pressure during a videoconference with a nurse. Tri County Hospital

SAN FRANCISCO — Adding telemedicine to home health care halved the proportion of rural elderly patients who had to move from their homes to hospitals or nursing homes over a period of 2 1/2 years, in a randomized study of 53 patients.

Patients receiving skilled nursing care at home for heart failure, chronic obstructive pulmonary disease, or chronic wound care were randomized to one of three treatment groups. The researchers added simple videoconferencing equipment and Internet access to the homes of 14 patients in a video arm and 20 patients in a monitoring arm, who also received physiologic monitoring equipment—pulse oximeters, electronic spirometers, and/or blood pressure cuffs, depending on their medical problem. The two-way videoconferencing allowed virtual visits by the home health care nurse with the patient at home. In a control group, 19 patients did not get telemedicine equipment. All groups continued with actual home visits by the nurses.

During the study, six patients (18%) in the telemedicine groups (two in the video group and four in the monitoring group) transferred from their homes to a higher level of care. Eight patients (42%) in the control group did so, said Stuart M. Speedie, Ph.D., in a poster presentation at the triennial congress of the International Medical Informatics Association.

Death rates did not differ significantly between groups: Five control patients and seven patients in the two telemedicine groups died. Surveys showed that patients in the monitoring group were significantly more satisfied with their care, compared with control patients, because they believed they had greater choices about their care, felt safer, and reported greater flexibility in scheduling, said Dr. Speedie of the University of Minnesota, Minneapolis.

The mean number of nurse visits did not differ between groups—22 per patient in the control group and 19 per patient in the telemedicine groups. The telemedicine patients averaged 17 virtual visits each. Average patient age was 72 years in the control group and 76 years in the telemedicine groups.

Actual visits cost an average of $44.71, while video-only virtual visits cost $22.96 and video visits for physiologic monitoring cost $29.66. Nursing time during actual visits accounted for the higher average cost. In addition, the telemedicine equipment cost about $1,500 per patient, said Dr. Speedie, who conducted the study with lead investigator Stanley M. Finkelstein, Ph.D., and Sandra Potthoff, Ph.D., both of the university.

Home health nurses rated the technical quality of virtual visits as acceptable in 94% of visits and said that 92% of virtual visits would not have been better if done in person. The nurses said that questions were not asked in 5% of virtual visits that might have been asked in actual visits.

In a separate pilot study presented at the meeting, informal videoconferencing consultations offered once a week to residents of an assisted living facility led to formal clinic appointments for 6 of 31 patients (19%) over a 5-month period, Lawrence Afrin M.D., and his associates at the Medical University of South Carolina, Charleston, reported in a poster.

They provided the telemedicine service for free as a goodwill gesture. Third-party payers seldom pay for telemedicine services, but the results suggest that the service may be economically viable if it leads to normal clinic services that are billable, Dr. Afrin said. Assisted living facilities might be willing to pay a small fee for the service to gain a competitive advantage.

Five university physicians rotated duty on the sessions, discussing problems such as cardiovascular issues, allergies, pain, cancer, anemia, thalassemia, sleep disorders, and neurological disorders.

A man checks his wife's blood pressure during a videoconference with a nurse. Tri County Hospital

SAN FRANCISCO — Adding telemedicine to home health care halved the proportion of rural elderly patients who had to move from their homes to hospitals or nursing homes over a period of 2 1/2 years, in a randomized study of 53 patients.

Patients receiving skilled nursing care at home for heart failure, chronic obstructive pulmonary disease, or chronic wound care were randomized to one of three treatment groups. The researchers added simple videoconferencing equipment and Internet access to the homes of 14 patients in a video arm and 20 patients in a monitoring arm, who also received physiologic monitoring equipment—pulse oximeters, electronic spirometers, and/or blood pressure cuffs, depending on their medical problem. The two-way videoconferencing allowed virtual visits by the home health care nurse with the patient at home. In a control group, 19 patients did not get telemedicine equipment. All groups continued with actual home visits by the nurses.

During the study, six patients (18%) in the telemedicine groups (two in the video group and four in the monitoring group) transferred from their homes to a higher level of care. Eight patients (42%) in the control group did so, said Stuart M. Speedie, Ph.D., in a poster presentation at the triennial congress of the International Medical Informatics Association.

Death rates did not differ significantly between groups: Five control patients and seven patients in the two telemedicine groups died. Surveys showed that patients in the monitoring group were significantly more satisfied with their care, compared with control patients, because they believed they had greater choices about their care, felt safer, and reported greater flexibility in scheduling, said Dr. Speedie of the University of Minnesota, Minneapolis.

The mean number of nurse visits did not differ between groups—22 per patient in the control group and 19 per patient in the telemedicine groups. The telemedicine patients averaged 17 virtual visits each. Average patient age was 72 years in the control group and 76 years in the telemedicine groups.

Actual visits cost an average of $44.71, while video-only virtual visits cost $22.96 and video visits for physiologic monitoring cost $29.66. Nursing time during actual visits accounted for the higher average cost. In addition, the telemedicine equipment cost about $1,500 per patient, said Dr. Speedie, who conducted the study with lead investigator Stanley M. Finkelstein, Ph.D., and Sandra Potthoff, Ph.D., both of the university.

Home health nurses rated the technical quality of virtual visits as acceptable in 94% of visits and said that 92% of virtual visits would not have been better if done in person. The nurses said that questions were not asked in 5% of virtual visits that might have been asked in actual visits.

In a separate pilot study presented at the meeting, informal videoconferencing consultations offered once a week to residents of an assisted living facility led to formal clinic appointments for 6 of 31 patients (19%) over a 5-month period, Lawrence Afrin M.D., and his associates at the Medical University of South Carolina, Charleston, reported in a poster.

They provided the telemedicine service for free as a goodwill gesture. Third-party payers seldom pay for telemedicine services, but the results suggest that the service may be economically viable if it leads to normal clinic services that are billable, Dr. Afrin said. Assisted living facilities might be willing to pay a small fee for the service to gain a competitive advantage.

Five university physicians rotated duty on the sessions, discussing problems such as cardiovascular issues, allergies, pain, cancer, anemia, thalassemia, sleep disorders, and neurological disorders.

A man checks his wife's blood pressure during a videoconference with a nurse. Tri County Hospital

SAN FRANCISCO — Patients admitted to the hospital through the emergency department generated significant profit and produced double the relative profitability of patients admitted directly to the hospital, Brian J. Browne, M.D., reported at the annual meeting of the American College of Emergency Physicians.

The results of his retrospective analysis debunk the image of the emergency department (ED) as a “cost center” or “loss leader”—in other words, a necessary expense supported by the rest of the hospital's clinical services, said Dr. Browne, chief of emergency medicine at the University of Maryland, Baltimore, and director of emergency medical services at the University of Maryland Medical Center.

The findings should be useful to ED administrators when they need to lobby for institutional support, he said.

The investigators defined the direct margin as the amount by which net revenue exceeded the sum of direct fixed and variable components. Out of the margin, the hospital pays overhead expenses, and what remains is profit. Net profit was the amount by which net revenue exceeded the sum of all costs, both direct and indirect.

In the study of 89,757 discharges during July 2000-June 2003, patients admitted to the ED generated 19% of the hospital revenue, 20% of the direct margin, and 33% of profits from all hospital admissions, said Dr. Browne and coinvestigator, Dick Kuo, M.D., also of the medical center.

Patients who were admitted directly to the hospital produced higher totals for net revenue, costs, direct margin, and profit because more patients entered the hospital directly rather than through the ED—73% vs. 27%, respectively. However, it's notable that patients admitted through the ED generated profit—totaling a third of all profits—despite inclusion of ED costs, Dr. Browne said.

Patients admitted directly to the hospital generated about 81% of revenues, 80% of the direct margin, and 67% of total profits. (Percentages may not add up because of rounding.)

The ED patient group, however, had a higher direct margin (expressed as a percentage of net revenue), compared with the direct-admission group—40% vs. 37%. And ED admissions were twice as efficient when comparing profit as a percent of the revenue—10% vs. 5% in the direct-admission group, Dr. Browne said.

The analysis looked at direct and indirect costs. Data for the ED patient group included all costs generated both in the ED and in the hospital for patients admitted through the ED. The analysis included only revenues actually collected, not charges that were never collected. “Many previous papers looked at charges, which is not real,” Dr. Browne said.

The direct-admission group included both elective admissions and transfers into the hospital that did not go through the ED, including 21,223 admissions to the trauma center.

The Case Mix Index and average length of stay were comparable between groups. The Case Mix Index is a measure of case severity (complexity and acuity), so the ED patients were slightly less severe cases than direct-admit patients. The Case Mix Index was 1.10 in the ED group and 1.28 in the direct-admit group. The length of stay after admission (not including time in the ED) averaged 5.8 days in the ED group and 6 days in the direct-admit group.

Under traditional cost accounting practices, the ED is seen only as a source of admissions, with associated costs. “That model is unfair, and doesn't recognize the full impact of the ED and those patients for the finances of the hospital accurately,” Dr. Browne said.

Hopefully, the data will help change the traditional view of the ED, Dr. Browne said, so that “when I ask for something for the common good of the ED—like an information system update, or ultrasound equipment, or a lab—the administration should recognize that the ED is a major player in profitability.”

SAN FRANCISCO — Patients admitted to the hospital through the emergency department generated significant profit and produced double the relative profitability of patients admitted directly to the hospital, Brian J. Browne, M.D., reported at the annual meeting of the American College of Emergency Physicians.

The results of his retrospective analysis debunk the image of the emergency department (ED) as a “cost center” or “loss leader”—in other words, a necessary expense supported by the rest of the hospital's clinical services, said Dr. Browne, chief of emergency medicine at the University of Maryland, Baltimore, and director of emergency medical services at the University of Maryland Medical Center.

The findings should be useful to ED administrators when they need to lobby for institutional support, he said.

The investigators defined the direct margin as the amount by which net revenue exceeded the sum of direct fixed and variable components. Out of the margin, the hospital pays overhead expenses, and what remains is profit. Net profit was the amount by which net revenue exceeded the sum of all costs, both direct and indirect.

In the study of 89,757 discharges during July 2000-June 2003, patients admitted to the ED generated 19% of the hospital revenue, 20% of the direct margin, and 33% of profits from all hospital admissions, said Dr. Browne and coinvestigator, Dick Kuo, M.D., also of the medical center.

Patients who were admitted directly to the hospital produced higher totals for net revenue, costs, direct margin, and profit because more patients entered the hospital directly rather than through the ED—73% vs. 27%, respectively. However, it's notable that patients admitted through the ED generated profit—totaling a third of all profits—despite inclusion of ED costs, Dr. Browne said.

Patients admitted directly to the hospital generated about 81% of revenues, 80% of the direct margin, and 67% of total profits. (Percentages may not add up because of rounding.)

The ED patient group, however, had a higher direct margin (expressed as a percentage of net revenue), compared with the direct-admission group—40% vs. 37%. And ED admissions were twice as efficient when comparing profit as a percent of the revenue—10% vs. 5% in the direct-admission group, Dr. Browne said.

The analysis looked at direct and indirect costs. Data for the ED patient group included all costs generated both in the ED and in the hospital for patients admitted through the ED. The analysis included only revenues actually collected, not charges that were never collected. “Many previous papers looked at charges, which is not real,” Dr. Browne said.

The direct-admission group included both elective admissions and transfers into the hospital that did not go through the ED, including 21,223 admissions to the trauma center.

The Case Mix Index and average length of stay were comparable between groups. The Case Mix Index is a measure of case severity (complexity and acuity), so the ED patients were slightly less severe cases than direct-admit patients. The Case Mix Index was 1.10 in the ED group and 1.28 in the direct-admit group. The length of stay after admission (not including time in the ED) averaged 5.8 days in the ED group and 6 days in the direct-admit group.

Under traditional cost accounting practices, the ED is seen only as a source of admissions, with associated costs. “That model is unfair, and doesn't recognize the full impact of the ED and those patients for the finances of the hospital accurately,” Dr. Browne said.

Hopefully, the data will help change the traditional view of the ED, Dr. Browne said, so that “when I ask for something for the common good of the ED—like an information system update, or ultrasound equipment, or a lab—the administration should recognize that the ED is a major player in profitability.”

SAN FRANCISCO — Patients admitted to the hospital through the emergency department generated significant profit and produced double the relative profitability of patients admitted directly to the hospital, Brian J. Browne, M.D., reported at the annual meeting of the American College of Emergency Physicians.

The results of his retrospective analysis debunk the image of the emergency department (ED) as a “cost center” or “loss leader”—in other words, a necessary expense supported by the rest of the hospital's clinical services, said Dr. Browne, chief of emergency medicine at the University of Maryland, Baltimore, and director of emergency medical services at the University of Maryland Medical Center.

The findings should be useful to ED administrators when they need to lobby for institutional support, he said.

The investigators defined the direct margin as the amount by which net revenue exceeded the sum of direct fixed and variable components. Out of the margin, the hospital pays overhead expenses, and what remains is profit. Net profit was the amount by which net revenue exceeded the sum of all costs, both direct and indirect.

In the study of 89,757 discharges during July 2000-June 2003, patients admitted to the ED generated 19% of the hospital revenue, 20% of the direct margin, and 33% of profits from all hospital admissions, said Dr. Browne and coinvestigator, Dick Kuo, M.D., also of the medical center.

Patients who were admitted directly to the hospital produced higher totals for net revenue, costs, direct margin, and profit because more patients entered the hospital directly rather than through the ED—73% vs. 27%, respectively. However, it's notable that patients admitted through the ED generated profit—totaling a third of all profits—despite inclusion of ED costs, Dr. Browne said.

Patients admitted directly to the hospital generated about 81% of revenues, 80% of the direct margin, and 67% of total profits. (Percentages may not add up because of rounding.)

The ED patient group, however, had a higher direct margin (expressed as a percentage of net revenue), compared with the direct-admission group—40% vs. 37%. And ED admissions were twice as efficient when comparing profit as a percent of the revenue—10% vs. 5% in the direct-admission group, Dr. Browne said.

The analysis looked at direct and indirect costs. Data for the ED patient group included all costs generated both in the ED and in the hospital for patients admitted through the ED. The analysis included only revenues actually collected, not charges that were never collected. “Many previous papers looked at charges, which is not real,” Dr. Browne said.

The direct-admission group included both elective admissions and transfers into the hospital that did not go through the ED, including 21,223 admissions to the trauma center.

The Case Mix Index and average length of stay were comparable between groups. The Case Mix Index is a measure of case severity (complexity and acuity), so the ED patients were slightly less severe cases than direct-admit patients. The Case Mix Index was 1.10 in the ED group and 1.28 in the direct-admit group. The length of stay after admission (not including time in the ED) averaged 5.8 days in the ED group and 6 days in the direct-admit group.

Under traditional cost accounting practices, the ED is seen only as a source of admissions, with associated costs. “That model is unfair, and doesn't recognize the full impact of the ED and those patients for the finances of the hospital accurately,” Dr. Browne said.

Hopefully, the data will help change the traditional view of the ED, Dr. Browne said, so that “when I ask for something for the common good of the ED—like an information system update, or ultrasound equipment, or a lab—the administration should recognize that the ED is a major player in profitability.”

SAN FRANCISCO — Managing patients who present to the emergency department with a transient ischemic attack in an ED observation unit rather than admitting them to the hospital reduced costs and lengths of stay for the initial visit, preliminary results of a prospective, randomized study showed.

Investigators randomized 46 patients with a transient ischemic attack (TIA) to be admitted to a hospital bed under the care of their primary physicians. Fifty-three patients were randomized to management by an emergency department physician in the ED observation unit, which was considered an accelerated diagnostic protocol.

The need to admit these patients to inpatient wards has been controversial, with some physicians suggesting that management in an ED observation unit might be more cost effective.

All patients underwent four diagnostic tests: carotid imaging, cardiac ultrasound, cardiac monitoring, and serial clinical evaluations. If all tests were negative, patients were discharged home on appropriate medications. Patients in the observation unit with positive diagnostic test results were considered for admission to a traditional hospital bed.

The ED observation unit group averaged 41 hours from arrival in the ED to discharge, a length of stay 23 hours shorter than the average 64 hours seen in the control group, Michael A. Ross, M.D., said in a poster presentation at the annual meeting of the American College of Emergency Physicians.

Seven patients managed initially in the ED observation unit were admitted to the hospital. Even though the length of stay for these patients averaged 167 hours, dramatically shorter stays (23 hours, on average) by the 46 patients who were discharged directly home from the observation unit lowered the overall mean length of stay in that group.

Mean total direct hospital costs (not including professional costs) were lower in the ED observation unit group ($1,392 per patient), compared with the inpatient group ($1,871 per patient), said Dr. Ross of William Beaumont Hospital, Royal Oak, Mich. Again, it was the dramatically lower costs for patients discharged from the ED observation unit ($767 per patient, vs. $5,038 per patient admitted to the hospital from the ED observation unit) that lowered overall costs in that group.

Four patients who were discharged home from the observation unit returned to the hospital within 30 days, compared with no return visits by patients admitted to the hospital either directly or from the observation unit. Costs of return visits were not included in the study.

The incidence of stroke within 90 days of the initial visit was similar between groups, however, with three strokes in the control group and four in the observation-unit group (two each among patients discharged or admitted).

The current study included patients with an emergency physician-confirmed TIA with a resolved deficit, not a crescendo TIA.

Head computerized tomography showed no acute infarct, bleed, or other acute pathology. These or a number of other conditions excluded patients from the study, including a possible embolic source, known carotid stenosis, nonfocal symptoms, severe headache or evidence of cranial arteritis, fever, previous stroke, severe dementia, history of intravenous drug use, residence in a nursing home, or other factors.

The investigators borrowed the accelerated diagnostic protocol concept for TIA from studies of similar ED protocols used to rapidly assess patients with chest pain who are at low to intermediate risk of acute cardiac ischemia.

SAN FRANCISCO — Managing patients who present to the emergency department with a transient ischemic attack in an ED observation unit rather than admitting them to the hospital reduced costs and lengths of stay for the initial visit, preliminary results of a prospective, randomized study showed.

Investigators randomized 46 patients with a transient ischemic attack (TIA) to be admitted to a hospital bed under the care of their primary physicians. Fifty-three patients were randomized to management by an emergency department physician in the ED observation unit, which was considered an accelerated diagnostic protocol.

The need to admit these patients to inpatient wards has been controversial, with some physicians suggesting that management in an ED observation unit might be more cost effective.

All patients underwent four diagnostic tests: carotid imaging, cardiac ultrasound, cardiac monitoring, and serial clinical evaluations. If all tests were negative, patients were discharged home on appropriate medications. Patients in the observation unit with positive diagnostic test results were considered for admission to a traditional hospital bed.

The ED observation unit group averaged 41 hours from arrival in the ED to discharge, a length of stay 23 hours shorter than the average 64 hours seen in the control group, Michael A. Ross, M.D., said in a poster presentation at the annual meeting of the American College of Emergency Physicians.

Seven patients managed initially in the ED observation unit were admitted to the hospital. Even though the length of stay for these patients averaged 167 hours, dramatically shorter stays (23 hours, on average) by the 46 patients who were discharged directly home from the observation unit lowered the overall mean length of stay in that group.

Mean total direct hospital costs (not including professional costs) were lower in the ED observation unit group ($1,392 per patient), compared with the inpatient group ($1,871 per patient), said Dr. Ross of William Beaumont Hospital, Royal Oak, Mich. Again, it was the dramatically lower costs for patients discharged from the ED observation unit ($767 per patient, vs. $5,038 per patient admitted to the hospital from the ED observation unit) that lowered overall costs in that group.

Four patients who were discharged home from the observation unit returned to the hospital within 30 days, compared with no return visits by patients admitted to the hospital either directly or from the observation unit. Costs of return visits were not included in the study.

The incidence of stroke within 90 days of the initial visit was similar between groups, however, with three strokes in the control group and four in the observation-unit group (two each among patients discharged or admitted).

The current study included patients with an emergency physician-confirmed TIA with a resolved deficit, not a crescendo TIA.

Head computerized tomography showed no acute infarct, bleed, or other acute pathology. These or a number of other conditions excluded patients from the study, including a possible embolic source, known carotid stenosis, nonfocal symptoms, severe headache or evidence of cranial arteritis, fever, previous stroke, severe dementia, history of intravenous drug use, residence in a nursing home, or other factors.

The investigators borrowed the accelerated diagnostic protocol concept for TIA from studies of similar ED protocols used to rapidly assess patients with chest pain who are at low to intermediate risk of acute cardiac ischemia.

SAN FRANCISCO — Managing patients who present to the emergency department with a transient ischemic attack in an ED observation unit rather than admitting them to the hospital reduced costs and lengths of stay for the initial visit, preliminary results of a prospective, randomized study showed.

Investigators randomized 46 patients with a transient ischemic attack (TIA) to be admitted to a hospital bed under the care of their primary physicians. Fifty-three patients were randomized to management by an emergency department physician in the ED observation unit, which was considered an accelerated diagnostic protocol.

The need to admit these patients to inpatient wards has been controversial, with some physicians suggesting that management in an ED observation unit might be more cost effective.

All patients underwent four diagnostic tests: carotid imaging, cardiac ultrasound, cardiac monitoring, and serial clinical evaluations. If all tests were negative, patients were discharged home on appropriate medications. Patients in the observation unit with positive diagnostic test results were considered for admission to a traditional hospital bed.

The ED observation unit group averaged 41 hours from arrival in the ED to discharge, a length of stay 23 hours shorter than the average 64 hours seen in the control group, Michael A. Ross, M.D., said in a poster presentation at the annual meeting of the American College of Emergency Physicians.

Seven patients managed initially in the ED observation unit were admitted to the hospital. Even though the length of stay for these patients averaged 167 hours, dramatically shorter stays (23 hours, on average) by the 46 patients who were discharged directly home from the observation unit lowered the overall mean length of stay in that group.

Mean total direct hospital costs (not including professional costs) were lower in the ED observation unit group ($1,392 per patient), compared with the inpatient group ($1,871 per patient), said Dr. Ross of William Beaumont Hospital, Royal Oak, Mich. Again, it was the dramatically lower costs for patients discharged from the ED observation unit ($767 per patient, vs. $5,038 per patient admitted to the hospital from the ED observation unit) that lowered overall costs in that group.

Four patients who were discharged home from the observation unit returned to the hospital within 30 days, compared with no return visits by patients admitted to the hospital either directly or from the observation unit. Costs of return visits were not included in the study.

The incidence of stroke within 90 days of the initial visit was similar between groups, however, with three strokes in the control group and four in the observation-unit group (two each among patients discharged or admitted).

The current study included patients with an emergency physician-confirmed TIA with a resolved deficit, not a crescendo TIA.

Head computerized tomography showed no acute infarct, bleed, or other acute pathology. These or a number of other conditions excluded patients from the study, including a possible embolic source, known carotid stenosis, nonfocal symptoms, severe headache or evidence of cranial arteritis, fever, previous stroke, severe dementia, history of intravenous drug use, residence in a nursing home, or other factors.

The investigators borrowed the accelerated diagnostic protocol concept for TIA from studies of similar ED protocols used to rapidly assess patients with chest pain who are at low to intermediate risk of acute cardiac ischemia.