Graham-Cassidy Bill Doesn’t Add Up

The latest Republican health care bill meant to replace the Affordable Care act comes from Senators Bill Cassidy (LA) and Lindsey Graham (SC). This one presents a more substantial change to the way things are run. Most of this comes from an article in the 9/23/2017 issue of the Economist.

  • The Federal government would play a much smaller role, giving money to the states proportional to the number of inhabitants between 50% and 138% of the Federal Poverty Level.
  • The decisions on how to structure care is passed down to the states. They can petition Health and Human Services to drop ObamaCare provisions such as the Essential Health Benefits that were meant to provide a basal level of care in each plan.

The thought is that this may encourage experimentation in each of the states, however three problems exist.

  1. States are now responsible for structuring care. There is no guarantee they can do a better job. States are also required to have a balanced budget, so the Medicare money may go instead to paying other debts.
  2. There is no increase in money if conditions change. If a state is hit with a disaster, say an opiate epidemic, and requires more money to address this… there is no more money.
  3. Doesn’t fix existing problems with the health insurance marketplace. Premiums have already risen under the ACA and insurers are leaving markets. This new plan has the potential of further raising premium prices (with healthy people leaving the market without the pressure of a mandate) and discouraging insurers from participating (with less healthy people, they are taking more risk).
Graham-Cassidy Bill Doesn’t Add Up

Discharge Instructions

The October edition of EM-RAP had a great section on how to write good discharge instructions. This is not the pre-printed stuff that comes with the EMR but instructions written specifically for each patient. I modified my DCI (discharge instruction macro) to make those points more obvious.

 
You have been diagnosed with ***, this is ***. Your evaluation in the emergency deparmtent was significant for ***.

1. FOLLOW-UP: Please see your primary doctor within a week. If you do not have a primary doctor, call the number above to arrange to establish a relationship with a doctor. Your condition may change and so it is important to have your condition re-assessed. 
2. RETURN IF: Please return immediately if you get worse, if you don't get better, if your symptoms change, if you have any new or concerning symptoms. If your symptoms change, then we need to reassess potential causes. 
3. MEDICATIONS: You have been prescribed ***. Take the medicines as described in the instructions provided by teh pharmacy. In taking this medicine, you should note ***.

It is also useful to build some specific macros for things that come up often (e.g., more than once). For example, for Levaquin.

the antibiotic LEVAQUIN is associated with tendon rupture in some patients. Please rest from strenous activity while on this medication. If you have questions, ask your doctor or pharmacist.

Or for narcotic medications.

the pain killer NORCO has an opioid mixed with Tylenol. The opioid can make you drowsy, even to the point of stopping breathing. Do not opeate heavy machinery, drive or perform any potentially dangerous tasks while on this medicine. Also do not take it with other sedating substances like alcohol or even Benadryl. The medicine also contains Tylenol, so do not take any othe Tylenol containing products while on this medication. You can run the risk of severe liver damage. If you have questions, ask your doctor or pharmacist.

I also make a practice of talking to every patient before they leave to explain the instructions. I dont typically document that conversation, but it is a good habit. Include the following in the ED COURSE SUMMARY macro.

Additional discharge verbal instructions were given and discussed with the patient. Patient had the opportunity to ask questions and these were answered.
Discharge Instructions

HEART Score

Used to risk stratify patients for further cardiac workup in the ER according to risk of major adverse cardiac events (MACE).

History	
2: highly suspicious
1: moderately suspicious
0: slightly or non-suspicious

ECG	
2: significant ST-depression
1: non-specific repolarization
0: normal

Age	
2: > 65 years old
1: 45-65 years old
0: < 45 years old

Risk Factors (DM, recent smoker <1m, HTN, HLP, fam Hx, obesity)	
2: 3+ risk factors (or prior CAD)
1: 1-2 risk factors
0: none

Troponin	
2: 3x normal limit
1: 1-3x normal limit
0: < normal limit 

LOW: 0-3 → 1.7% to 2.5% MACE over next 6 weeks (discharge home) 
MED: 4-6 → 16.6% to 20.3% MACE over next 6 weeks (observation) 
HIGH: 7-10 → 50.1% to 72.7% MACE over next 6 weeks (early invasive strategies)

According to University of Maryland Shared Decision Making program for low risk chest pain, additional ECG and troponin testing can decrease low risk group to approximately 1.7% MACE. Stress testing brings it down to 1%.
  1. Backus BE, Six AJ, Kelder JH. Risk scores for patients with chest pain: evaluation in the emergency department. Current cardiology …. 2011.
  2. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-2158. doi:10.1016/j.ijcard.2013.01.255.
  3. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-196.
HEART Score