Citations

Background. We test the hypotheses that use of the Chest Pain Choice (CPC) decision aid (DA) would be similarly effective in potentially vulnerable subgroups but increase knowledge more in patients with higher education and trust in physicians more in patients from racial minority groups. Methods. This was a secondary analysis of a multicenter randomized trial in adults with chest pain potentially due to acute coronary syndrome. The trial compared an intervention group engaged in shared decision making (SDM) using CPC to a control group receiving usual care (UC). We assessed for subgroup effects based on age, sex, race, income, insurance, education, literacy, and numeracy. We dichotomized each characteristic and tested for interactions using regression models with indicators for arm assignment and study site. Results. Of 898 patients (451 DA, 447 UC), over 50% were female, over one-third were black, nearly one-third had a high school education or less, and over 60% had “low” health literacy. The DA did not increase knowledge more in patients with higher education ( P for interaction = 0.06) but did increase knowledge more in the “typical” than in the “low” numeracy subgroup (10.6% v. 4.7%, absolute difference [AD] = 5.9%, P for interaction = 0.025). The DA did not significantly increase patient trust in physicians in racial minorities ( P for interaction = 0.06) but did increase trust more in patients with “low” literacy compared with those with “typical” literacy (3.7% v. –1.4%, AD = 5.1, P for interaction = 0.011). Conclusions. CPC benefited all sociodemographic groups to a similar extent, with greater knowledge transfer in patients with higher numeracy and greater physician trust in patients with “low” health literacy. Tailoring SDM interventions to patient characteristics may be necessary for optimal effectiveness.

AbstractThe idea of shared decision making (SDM) is gaining traction within emergency medicine, although concerns about potential legal consequences of its use may be slowing its adoption. We describe the similarities and differences between informed consent (IC) requirements and SDM, highlighting their different purposes, scope, and implementation. We also illustrate several areas in which SDM may affect clinicians’ liability risks and suggest that while SDM is likely to reduce net liability risks, it may increase providers’ liability risks in certain situations or with select patients. Overall, engaging in SDM should be understood as clearly distinct from the process of obtaining IC and could reduce clinicians’ risk of liability when applied carefully and thoughtfully.

AbstractShared decision making (SDM) is essential to advancing patient‐centered care in emergency medicine. Despite many documented benefits of SDM, prior research has demonstrated persistently low levels of patient engagement by clinicians across many disciplines, including emergency medicine. An effective dissemination and implementation (D&I) framework could be used to alter the process of delivering care and to facilitate SDM in routine clinical emergency medicine practice. Here we outline a research and policy agenda to support the D&I strategy needed to integrate SDM into emergency care.

Purpose of review Biphasic anaphylaxis is a well documented complication of anaphylaxis, but it has been inconsistently defined in the literature. Analysis of contemporary studies of biphasic anaphylaxis based on modern definitions is needed. Recent findings The rate of biphasic reactions in contemporary literature ranges from 0.4 to 14.7% depending on the study population. Observational studies have reported risk factors associated with the development of biphasic reactions; however, findings have been inconsistent and of questionable generalizability. Although life-threatening biphasic reactions are rare, up to 50% of biphasic reactions will require treatment with epinephrine. Early epinephrine administration may have a role in prevention of biphasic reactions, but the role of steroids needs further investigation. The optimal duration of observation is yet to be determined. Summary Given the relative rarity of life-threatening biphasic anaphylaxis and the new context of the NIAID/FAAN standardized definition, further research regarding biphasic anaphylaxis is needed to better elucidate the care model for anaphylaxis patients with a focus on: prevention of biphasic reactions; identification of patients at increased risk of a biphasic reaction; determination of appropriate observation strategies for anaphylaxis patients; and patient education and preparation for management of potential biphasic reactions.

AbstractObjectivesThe objectives were to describe lawsuits against providers for failing to order head computed tomography (CT) in cases of head trauma and to determine the potential effects of available clinical decision rules (CDRs) on each lawsuit.MethodsThe authors collected jury verdicts, settlements, and court opinions regarding alleged malpractice for failure to order head CT in the setting of head trauma from 1972 through February 2014 from an online legal research tool (WestlawNext). Data were abstracted onto a standardized data form. The performance of five CDRs was evaluated.ResultsSixty relevant cases were identified (52 adult, eight children). Of 48 cases with known outcomes, providers were found negligent in 10 cases (six adult, four pediatric), settled in 11 cases (nine adult, two pediatric), and were found not liable in 27 cases. In all 10 cases in which providers were found negligent, every applicable CDR studied would have indicated the need for head CT. In all eight cases involving children, the applicable CDR would have suggested the need for head CT or observation.ConclusionsA review of legal cases reported in a major online legal research system revealed 60 lawsuits in which providers were sued for failing to order head CTs in cases of head trauma. In all cases in which providers were found negligent, CT imaging or observation would have been indicated by every applicable CDR.

AbstractDiagnostic imaging is integral to the evaluation of many emergency department (ED) patients. However, relatively little effort has been devoted to patient‐centered outcomes research (PCOR) in emergency diagnostic imaging. This article provides background on this topic and the conclusions of the 2015 Academic Emergency Medicine consensus conference PCOR work group regarding “Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization.” The goal was to determine a prioritized research agenda to establish which outcomes related to emergency diagnostic imaging are most important to patients, caregivers, and other key stakeholders and which methods will most optimally engage patients in the decision to undergo imaging. Case vignettes are used to emphasize these concepts as they relate to a patient's decision to seek care at an ED and the care received there. The authors discuss applicable research methods and approaches such as shared decision‐making that could facilitate better integration of patient‐centered outcomes and patient‐reported outcomes into decisions regarding emergency diagnostic imaging. Finally, based on a modified Delphi process involving members of the PCOR work group, prioritized research questions are proposed to advance the science of patient‐centered outcomes in ED diagnostic imaging.