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The Impact of Race on Outcomes Following Emergency Surgery: An American College of Surgeons National Surgical Quality Improvement Assessment
The Journal of Emergency Medicine, Vol. 45, No. 6, pp. 975–980, 2013 Copyright Ó 2013 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter
Abstracts , YIELD OF ROUTINE PROVOCATIVE CARDIAC TESTING AMONG PATIENTS IN AN EMERGENCY DEPARTMENT-BASED CHEST PAIN UNIT. Hermann LK, Newman DH, Pleasant WA, et al. JAMA Intern Med 2013;173:1128–33. The American Heart Association recommends provocative cardiac testing for patients who present to the emergency department (ED) with symptoms representing acute coronary syndrome, for further risk stratification to identify who might benefit from coronary revascularization. This study aimed to assess both the diagnostic and therapeutic yield of routine provocative stress testing in a single ED-based chest pain unit. Prospective data were collected between March 2004 and May 2010. All patients without a known history of coronary artery disease (CAD) who were admitted to the chest pain unit with negative ischemic electrocardiography findings and negative cardiac biomarkers were included in the study. Of 4181 patients included in the study, 3908 (93.5%) initially reported chest pain and 2464 (58.9%) reported shortness of breath. Three thousand sixty-two patients (73.2%) were determined to be at intermediate risk for coronary artery disease. Routine cardiac testing was positive for inducible coronary ischemia in 470 patients (11.2%). Of these 470 patients, 123 underwent subsequent coronary angiography, and 347 patients (74%) were discharged home with a presumptive diagnosis of CAD and a plan for medical management. Of the 123 patients who underwent coronary angiography, 63 patients (51%) had confirmed obstructive disease, and 28 of these had findings consistent with potential benefit from revascularization, < 1% of the total cohort. Sixty patients of 123 (49%) were found to have false-positive obstructive disease (31 patients had normal angiography results and 28 patients had nonobstructive disease). [Jessica Slim, MD Denver Health Medical Center, Denver, CO]
, THE IMPACT OF RACE ON OUTCOMES FOLLOWING EMERGENCY SURGERY: AN AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT ASSESSMENT. Causey MW, McVay D, Hatch Q, et al. Am J Surg 2013;206:172–9. The goal of this American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) study was to determine the association between ethnicity and short-term perioperative outcomes in patients undergoing emergency abdominal surgery, as previous studies have noted relationships between minority patients and inferior health care outcomes. This was a retrospective review of 75,280 patients in the ACS-NSQIP database who underwent abdominal surgery for a bowel obstruction, perforated hollow viscous, colectomy, incarcerated hernia, cholecystectomy, or appendectomy. The authors found that the overall complication and mortality rates were highest in the black population (24.3% and 5.3%, respectively), compared to 18.7% and 4.9%, respectively, in Whites. The Hispanic (11.7%, 1.8%, respectively) and Pacific Islander populations (10.2%, 1.8%, respectively) had the lowest rates of complications and overall mortality. The authors concluded that discrepancies exist in outcomes between different ethnic groups in the acute care surgery setting. [David Otten, MD Denver Health Medical Center, Denver, CO] Comment: Although interesting, the main limitation of this study relates to its design as a retrospective review. There were likely many confounders that the authors were not able to analyze (access to health care, socioeconomic class, etc.) that also make the findings questionable. Still, this article demonstrates once again how racial background may impact on health care outcomes. What should be done about this goes unanswered in this article and remains unclear on the whole.
Comments: If the results are reproducible, this study raises serious questions about the current practice of using chest pain units with broad-based admission criteria, as well as the American Heart Association recommendation for admission for provocative testing of these patients. If the outcome of interest is as defined in this study, then it would seem as though significant improvements in specificity could be achieved without impacting sensitivity. There are, however, several important limitations of the study, not the least of which is the fact that this was performed at one center, so the generalizability of the results is unclear. The other important issue relates to the stress test itself, which is widely recognized as being of limited value in this patient population.
, IDENTIFICATION OF PATIENTS AT RISK OF ANAPHYLACTOID REACTIONS TO N-ACETYLCYSTEINE IN THE TREATMENT OF PARACETAMOL OVERDOSE. Schmidt LE. Clin Toxicol 2013;51:467–72. Paracetamol (acetaminophen) is a frequent cause of accidental and intentional poisoning worldwide. N-acetylcysteine (NAC) is an effective antidote if administered expeditiously, but can lead to anaphylactoid reactions in some patients. This observational case series looked at a group of patients receiving NAC for acetaminophen overdose and aimed to identify patients
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Abstracts , YIELD OF ROUTINE PROVOCATIVE CARDIAC TESTING AMONG PATIENTS IN AN EMERGENCY DEPARTMENT-BASED CHEST PAIN UNIT. Hermann LK, Newman DH, Pleasant WA, et al. JAMA Intern Med 2013;173:1128–33. The American Heart Association recommends provocative cardiac testing for patients who present to the emergency department (ED) with symptoms representing acute coronary syndrome, for further risk stratification to identify who might benefit from coronary revascularization. This study aimed to assess both the diagnostic and therapeutic yield of routine provocative stress testing in a single ED-based chest pain unit. Prospective data were collected between March 2004 and May 2010. All patients without a known history of coronary artery disease (CAD) who were admitted to the chest pain unit with negative ischemic electrocardiography findings and negative cardiac biomarkers were included in the study. Of 4181 patients included in the study, 3908 (93.5%) initially reported chest pain and 2464 (58.9%) reported shortness of breath. Three thousand sixty-two patients (73.2%) were determined to be at intermediate risk for coronary artery disease. Routine cardiac testing was positive for inducible coronary ischemia in 470 patients (11.2%). Of these 470 patients, 123 underwent subsequent coronary angiography, and 347 patients (74%) were discharged home with a presumptive diagnosis of CAD and a plan for medical management. Of the 123 patients who underwent coronary angiography, 63 patients (51%) had confirmed obstructive disease, and 28 of these had findings consistent with potential benefit from revascularization, < 1% of the total cohort. Sixty patients of 123 (49%) were found to have false-positive obstructive disease (31 patients had normal angiography results and 28 patients had nonobstructive disease). [Jessica Slim, MD Denver Health Medical Center, Denver, CO]
, THE IMPACT OF RACE ON OUTCOMES FOLLOWING EMERGENCY SURGERY: AN AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT ASSESSMENT. Causey MW, McVay D, Hatch Q, et al. Am J Surg 2013;206:172–9. The goal of this American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) study was to determine the association between ethnicity and short-term perioperative outcomes in patients undergoing emergency abdominal surgery, as previous studies have noted relationships between minority patients and inferior health care outcomes. This was a retrospective review of 75,280 patients in the ACS-NSQIP database who underwent abdominal surgery for a bowel obstruction, perforated hollow viscous, colectomy, incarcerated hernia, cholecystectomy, or appendectomy. The authors found that the overall complication and mortality rates were highest in the black population (24.3% and 5.3%, respectively), compared to 18.7% and 4.9%, respectively, in Whites. The Hispanic (11.7%, 1.8%, respectively) and Pacific Islander populations (10.2%, 1.8%, respectively) had the lowest rates of complications and overall mortality. The authors concluded that discrepancies exist in outcomes between different ethnic groups in the acute care surgery setting. [David Otten, MD Denver Health Medical Center, Denver, CO] Comment: Although interesting, the main limitation of this study relates to its design as a retrospective review. There were likely many confounders that the authors were not able to analyze (access to health care, socioeconomic class, etc.) that also make the findings questionable. Still, this article demonstrates once again how racial background may impact on health care outcomes. What should be done about this goes unanswered in this article and remains unclear on the whole.
Comments: If the results are reproducible, this study raises serious questions about the current practice of using chest pain units with broad-based admission criteria, as well as the American Heart Association recommendation for admission for provocative testing of these patients. If the outcome of interest is as defined in this study, then it would seem as though significant improvements in specificity could be achieved without impacting sensitivity. There are, however, several important limitations of the study, not the least of which is the fact that this was performed at one center, so the generalizability of the results is unclear. The other important issue relates to the stress test itself, which is widely recognized as being of limited value in this patient population.
, IDENTIFICATION OF PATIENTS AT RISK OF ANAPHYLACTOID REACTIONS TO N-ACETYLCYSTEINE IN THE TREATMENT OF PARACETAMOL OVERDOSE. Schmidt LE. Clin Toxicol 2013;51:467–72. Paracetamol (acetaminophen) is a frequent cause of accidental and intentional poisoning worldwide. N-acetylcysteine (NAC) is an effective antidote if administered expeditiously, but can lead to anaphylactoid reactions in some patients. This observational case series looked at a group of patients receiving NAC for acetaminophen overdose and aimed to identify patients
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