Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial.

INTRODUCTION: Older patients with fragility fractures are not commonly tested or treated for osteoporosis. Compared to usual care, a previously reported intervention led to 30% absolute increases in osteoporosis treatment within 6 months of wrist fracture. Our objective was to examine longer-term outcomes, reproducibility, and cost-effectiveness of this intervention. METHODS: We conducted an extended analysis of a non-randomized controlled trial with blinded ascertainment of outcomes that compared a multifaceted intervention to usual care controls. Patients >50 years with a wrist fracture treated in two Emergency Departments in the province of Alberta, Canada were included; those already treated for osteoporosis were excluded. Overall, 102 patients participated in this study (55 intervention and 47 controls; median age: 66 years; 78% were women). The interventions consisted of faxed physician reminders that contained osteoporosis treatment guidelines endorsed by opinion leaders and patient counseling. Controls received usual care; at 6-months post-fracture, when the original trial was completed, all controls were crossed-over to intervention. The main outcomes were rates of osteoporosis testing and treatment within 6 months (original study) and 1 year (delayed intervention) of fracture, and 1-year persistence with treatments started. From the perspective of the healthcare payer, the cost-effectiveness (using a Markov decision-analytic model) of the intervention was compared with usual care over a lifetime horizon. RESULTS: Overall, 40% of the intervention patients (vs. 10% of the controls) started treatment within 6 months post-fracture, and 82% (95%CI: 67-96%) had persisted with it at 1-year post-fracture. Delaying the intervention to controls for 6 months still led to equivalent rates of bone mineral density (BMD) testing (64 vs. 60% in the original study; p = 0.72) and osteoporosis treatment (43 vs. 40%; p = 0.77) as previously reported. Compared with usual care, the intervention strategy was dominant - per patient, it led to a $13 Canadian (U.S. $9) cost savings and a gain of 0.012 quality-adjusted life years. Base-case results were most sensitive to assumptions about treatment cost; for example, a 50% increase in the price of osteoporosis medication led to an incremental cost-effectiveness ratio of $24,250 Canadian (U.S. $17,218) per quality-adjusted life year gained. CONCLUSIONS: A pragmatic intervention directed at patients and physicians led to substantial improvements in osteoporosis treatment, even when delivered 6-months post-fracture. From the healthcare payer's perspective, the intervention appears to have led to both cost-savings and gains in life expectancy.

Development of the specialty of emergency medicine in Israel: comparison with the UK and US models.

OBJECTIVES: To describe the development of emergency medicine (EM) in Israel and review the specific problems faced by the discipline and describe the solutions that were found. METHODS: A comprehensive literature search was conducted for data on development of EM in the UK and in North America, and the personal knowledge of two of the authors (PH and YW) was used in preparing the article. RESULTS: There are differences in development of EM between Israel and the UK/US models. In Israel the specialty developed within the context of established high quality clinical practice and consequently it met resistance from the system, which did not wish to invest in what it felt might be marginal improvements in patient care. The economics of Israeli medicine also dictated that EM be made into a super-specialty rather than a primary specialty. Certified specialists from family medicine, paediatrics, internal medicine, general surgery, anaesthesia, and orthopaedic surgery can access training positions in EM. Currently there are seven active EM programmes of 2.5 years duration and 16 residents. The curriculum is flexible and a national certification examination is being developed. CONCLUSIONS: Development of EM can and should take different paths according to the specific local needs and realities. There is no single ideal model suitable for all circumstances. The practice of clinical EM in Israel is comparable with that of any developed country and daily progress is being made in the academic areas of teaching and research. There are worldwide similarities in the process of developing EM as a distinct discipline.

Brain abscess in patients with hereditary hemorrhagic telangiectasia: case report and literature review.

Hereditary hemorrhagic telangiectasia (HHT), or Osler-Weber-Rendu disease, affects multiple organ systems. Brain abscess is a potential complication, and this disease carries a high mortality. In the setting of HHT the abscess most likely results from paradoxical septic emboli or bacterial seeding of an ischemic portion of the brain after paradoxical sterile emboli. Brain abscess is the diagnosis that must be ruled out in patients with HHT presenting with new onset neurologic symptoms. The clinician can be misled by seemingly benign and nonspecific symptoms, signs, and laboratory test results. Appropriate diagnostic imaging with computed tomography or magnetic resonance imaging of the head is mandatory. We present a case of brain abscess in a patient with HHT presenting to the Emergency Department. The review of the literature deals with the pathophysiology and manifestations of HHT with particular focus on the pathologic and clinical features, and management of cerebral abscess in this setting. Differences between patients with brain abscess with or without HHT are highlighted.

Resource contribution by Canadian faculties of medicine to the discipline of emergency medicine.

OBJECTIVE: Undergraduate and postgraduate emergency medicine (EM) education has developed rapidly over the last 20 years. Our objective was to establish a national educational inventory, cataloguing the human and financial resources provided to EM programs by Canadian faculties of medicine. METHODS: A 17-question survey was distributed to all 27 Canadian EM program directors, representing 11 Royal College of Physicians and Surgeons of Canada (RCPSC) programs and 16 College of Family Physicians of Canada (CFPC-EM) programs. The questionnaire addressed teaching responsibilities, teaching support and academic support in each program. RESULTS: All 27 program directors returned valid questionnaires. Annually, an estimated 3,049 students and residents participate in EM learning. This includes 1,369 undergraduates (45%), 1,621 postgraduates (53%) and 59 others (2%). Of the postgraduates, 173 are EM residents -- 92 (53%) in RCPSC programs and 81 (47%) in CFPC-EM programs. Overall, 587 EM faculty teach residents and students, but only 36 (6%) of these hold academic geographical full time positions. At the university level, all 16 CFPC-EM programs are administered by departments of family medicine. Of 11 RCPSC programs, 1 has full departmental status, 2 are free-standing divisions, 3 are administered through family medicine, 3 through medicine, 1 through surgery and 1 by other arrangements. Currently 8 programs (30%) have associate faculty, 14 (52%) have designated research directors and 10 (37%) describe other human resources. Sixteen (59%) programs receive direct financial and administrative support and 17 (63%) receive financial support for resident initiatives. Only 8 program directors (30%) perceive that they are receiving adequate support. CONCLUSIONS: Despite major teaching and clinical responsibilities within the faculties of medicine, Canadian EM programs are poorly supported. Further investment of human and financial and human resources is required.

Faculty evaluation by residents in an emergency medicine program: a new evaluation instrument.

OBJECTIVE: Evaluation of preceptors in training programs is essential; however, little research has been performed in the setting of the emergency department (ED). The goal of this pilot study was to determine the validity and reliability of a faculty evaluation instrument-the Emergency Rotation (ER) scale-developed specifically for use in emergency medicine (EM). METHODS: A prospective study comparing the ER scale with two alternative faculty evaluation instruments was completed in three of the five EDs affiliated with an EM teaching program, where emergency physicians are members of the clinical teaching faculty. The participants were 18 residents (postgraduate years 1, 2, and 3) who were completing four-week clinical rotations in EM. Residents at the end of the rotation recorded their evaluations of each emergency physician with whom they had clinical encounters on the following evaluation tools: the ER scale, a longer validated scale (Irby), and a global assessment scale (GAS). Domain scores were correlated with the previously validated scale and the GAS to determine validity using a multitrait-multimethod matrix. The reliability of the ER scale was measured using a Chronbach's alpha coefficient. RESULTS: Forty-eight preceptor evaluations were completed on 29 individual preceptors. The rating of preceptors was high using the ER scale (median: 16 of 20; IQR: 13, 18), Irby (median: 300 of 378; IQR: 267, 321), or GAS (mean: 7.8 of 10; SD: 1.3). Domain scores for each tool were used in the multitrait-multimethod matrix and the correlations between a previously validated tool and the ER scale were found to be high (>0.70) in the various domains. The internal consistency of the ER scale was also high (r = 0.85). CONCLUSIONS: The ER scale appears to be valid and reliable. It performs well when compared with previously psychometrically tested tools. It is a sensible, well-adapted tool for the teaching environment offered by EM.

Acute gastric volvulus: case report and review of the literature.

Gastric volvulus is a rare but potentially life-threatening cause of upper gastrointestinal obstruction. Emergency physicians must maintain a high index of suspicion in patients who present with signs and symptoms suggesting foregut occlusion. We report an illustrative case and review the pathogenesis, classification, diagnosis and treatment of this rare entity.