ABSTRACT
OBJECTIVE: The purpose of this article is to explore concerns regarding sections of the federal workers' compensation law that apply to the treatment and management of work-related injuries of federal employees by chiropractors, and to offer a call to action for change. DISCUSSION: A 1974 amendment to the Federal Employees' Compensation Act (FECA) stipulates that chiropractic services rendered to injured federal workers are reimbursable. However, the only reimbursable chiropractic treatment is "manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist." This means the chiropractor must take radiographs in order to be reimbursed. As with other health care professions, chiropractors are expected to practice according to best practices guided by studies in the scientific literature. Yet in the federal workers' compensation arena, this law requires chiropractors to practice in a manner that is fiscally wasteful, contradicts current radiology standards, and may expose patients to unnecessary X-ray radiation. Presently, there is discord between what the law mandates, chiropractic training and scope, and what professional guidelines recommend. In this article we discuss how FECA creates problems in the following 7 categories: direct harm, indirect harm, contradiction of best practices, ethical dilemma, barriers to conservative treatment, fiscal waste, and discrimination. CONCLUSION: The 1974 FECA provision requiring chiropractors to take radiographs regardless of presenting medical necessity should be updated to reflect current chiropractic education, training, and best practice. To resolve this discrepancy, we suggest that the radiographic requirement and the limitations placed on chiropractic physicians should be removed.
ABSTRACT
BACKGROUND: Since previous studies suggest the emergency department (ED) misdiagnosis rate of heart failure is 10-20% we sought to describe the characteristics of ED patients misdiagnosed as non-decompensated heart failure in the ED. METHODS: We analyzed a prospective convenience sample of 439 patients at 4 emergency departments who presented with signs or symptoms of decompensated heart failure. Patients with a cardiology criterion standard diagnosis of decompensated heart failure and an ED diagnosis of decompensated heart failure were compared to patients with a criterion standard of decompensated heart failure but no ED diagnosis of decompensated heart failure. Two senior cardiology fellows retrospectively determined the patient's heart failure status during their acute ED presentation. The Mann-Whitney u-test for two groups, the Kruskall-Wallis test for multiple groups, or Chi-square tests, were used as appropriate. RESULTS: There were 173 (39.4%) patients with a criterion standard diagnosis of decompensated heart failure. Among those with this criterion standard diagnosis of decompensated heart failure, discordant patients without an ED diagnosis of decompensated heart failure (n = 58) were more likely to have a history of COPD (p = 0.017), less likely to have a previous history of heart failure (p = 0.014), and less likely to have an elevated b-type natriuretic peptide (BNP) level (median 518 vs 764 pg/ml; p = 0.038) than those who were given a concordant ED diagnosis of decompensated heart failure. BNP levels were higher in those with a criterion standard diagnosis of decompensated heart failure than in those without a criterion standard diagnosis (median 657 vs 62.7 pg/ml). However, 34.6% of patients with decompensated heart failure had BNP levels in the normal (<100 pg/ml; 6.1%) or indeterminate range (100-500 pg/ml; 28.5%). CONCLUSION: We found the ED diagnoses of decompensated heart failure to be discordant with the criterion standard in 14.3% of patients, the vast majority of which were due to a failure to diagnose heart failure when it was present. Patients with a previous history of COPD, without a previous history of heart failure and with lower BNP levels were more likely to have an ED misdiagnosis of non-decompensated heart failure. Readily available, accurate, objective ED tests are needed to improve the early diagnosis of decompensated heart failure in ED patients.
ABSTRACT
BACKGROUND: Emergency department (ED) patients with undifferentiated dyspnea are a diagnostic dilemma. We hypothesized that electronic detection of an S3 would be more accurate in determining decompensated heart failure than physician auscultation, and that combining electronic heart sounds with B-type natriuretic peptide (BNP) would provide additional decision making information to the emergency physician, especially in the BNP indeterminate range (100-500 pg/mL). METHODS AND RESULTS: We collected demographic, clinical, and laboratory data in a convenience sample of ED patients presenting with signs or symptoms of acute decompensated heart failure between September 2003 and June 2004. The electronic presence of an S3 or S4 was determined using the Audicor system, a validated device that algorithmically detects S3 and S4 heart sounds. Two independent reviewers determined the presence or absence of acute decompensated heart failure (primary HF) based on chart review, while blinded to BNP and Audicor results. Test characteristics were determined with 95% confidence intervals. Of 422 enrolled patients, 343 had complete data and were included in the final analysis. Median age was 61 years, 54% were female, and 48% were white. The sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of an electronic S3 for primary HF were 34% (26% to 43%), 93% (89% to 96%), 66% (57% to 74%), 7% (4% to 11%), and 70% (65% to 75%) and for physician auscultation were 16% (11% to 24%), 97% (93% to 99%), 84% (76% to 89%), 3% (2% to 7%), and 66% (61% to 71%). The addition of an Audicor S3 to intermediate BNP levels improved the positive LR from 1.3 to 2.9; the positive predictive value from 53% to 80%. CONCLUSION: An S3 is highly specific for primary HF and it is ideally suited for use in combination with BNP to improve diagnostic accuracy in ED patients with dyspnea of unclear etiology.
