This week's Healthcare Triage news is likely to upset some docs. Get your popcorn ready.

(Healthcare Triage intro)

I'm sure our first story ticked off a lot of people over the holiday. It was published in JAMA Internal Medicine, and here's the gist: there are two big cardiology meetings every year, and when they occur, lots of cardiologists go to them. Few of them are left behind to take care of patients at home. So researches looked at how patients admitted to the hospital fared during those meeting dates compared to the three weeks before and after the conferences. Specifically, the looked at 30-day mortality for patients admitted with acute MIs, heart failure, or cardiac arrest.

When I first looked at the study, I assumed they were concerned that patients would fare worse during the meetings. I thought they were worried that with all the cardiologists at the meetings, patients might have worse outcomes. But the opposite happened. High risk patients admitted with heart failure during meetings had a 30-day mortality rate of 17.5%, compared to 24.8% when more cardiologists were there. Cardiac arrest 30-day mortality was 59% during meetings and 69% at other times. Not surprisingly, the rates of percutaneous coronary intervention were lower during meetings, too at 21% versus about 28%.

So since you've watched all of our videos on research methods, you recognize that there are some concerns here. And the researchers addressed a number of them. Maybe any meeting affects patient care. But they found that cardiac mortality wasn't effected by oncology, gastroenterology, or orthopedic meetings.
They also found that mortality from GI or orthopedic issues wasn't effected by hospitalization during the cardiology meetings. This was strictly a cardiology meeting associated with cardiologic outcomes.

The researches had no measurement of staffing during those meetings, so we can't really know what was the cause of the finding. Were fewer cardiologists really available? We don't know. 

There are a number of ways to interpret this study. Maybe the best cardiologists were the ones who stayed home. Maybe with fewer cardiologists available, fewer invasive procedures got done, and that leads to better outcomes. Maybe they tell more low-risk patients to wait when fewer cardiologists are available, which gets the high-risk patients more attention and better outcomes. Maybe it's something else.

But here's the thing: whatever's different during the meetings, it's associated with lower intensity care and better outcomes. That's probably worth looking into.

(2:13)
Our second story is based on a paper published just this week. It's about concussions in kids and how we should care for them. If I had a cohort study of kids with concussions, and I showed you that kids who were told to rest for 1-2 days had fewer symptoms than kids who were told to rest for 5 days, it'd be a mistake to immediately assume that 1-2 days is better. After all, it's just an association, and causation is not the same as association.

Maybe the kids who were injured less severely were assigned 1-2 days of rest, and those who were injured more severely were assigned 5 days of rest. In that case, it's the injury -- and outcomes -- driving the recommendation, as opposed to the recommendation driving the symptoms.

In order to establish causality, you need a randomized control trial! To the research!

Researches enrolled kids 11-22 years old who came to a pediatric emergency department within 24 hours of a concussion. They were all evaluation, and then randomly assigned to either 5 days of rest or 1-2 days of rest, followed by a return to normal activity.
Patients recorded lots of stuff and symptoms in diaries in the post-evaluation period. They were also all examined three and ten days after the injury.

Not surprisingly, both groups had a decrease in energy exertion and physical activity after being seated in the emergency department. Also not surprisingly, kids assigned 1-2 days of rest reported about twice as much school and after-school attendance in the following days than the kids in the five days of rest group. But, wait for it, there were no clinically significant differences in outcomes between the two groups. Except for this: kids in the 5 days of rest group reported more daily post-concussive symptoms than kids in the 1-2 days of rest group. They also reported that their symptoms took longer to go away. In the beginning, they were more nauseous and had more headaches. Later, they had more irritability and sadness.

The CDC recommends, and International Consensus Guidelines concur, that 1-2 days of rest followed by a stepwise return to activity is appropriate. Many physicians, and some other groups, have been prescribing and calling for longer periods of rest and for more restrictions on activity. Some are even advocating "cocoon therapy," where patients are put into dark rooms for multiple days.

(4:16)
I agree that concussions are significant, and that we should be concerned about them, but we should do more only when doing more makes a difference. In this randomized control trial, doing more did not improve outcomes. It did, however, cause a slower resolution of symptoms and made the kids feel worse. So why are some people doing that?