Letters
to primary care physicians without other changes is sufficient to increase the quality of primary care or to reduce the utilization of acute care. Meredith B. Rosenthal, PhD Mark W. Friedberg, MD, MPP Eric C. Schneider, MD, MSc Author Affiliations: Harvard School of Public Health, Harvard University, Boston, Massachusetts (Rosenthal); RAND Corporation, Boston, Massachusetts (Friedberg, Schneider); Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (Friedberg, Schneider). Corresponding Author: Meredith B. Rosenthal, PhD, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 ([email protected]). Conflict of Interest Disclosures: None reported.
Comments Regarding “My Thyroid Story” To the Editor “My Thyroid Story”1 raised the important question of what should be done in the case of a young person with a very low-grade malignant neoplasm. To forgo surgery or ablative radiation therapy, it would be necessary to be able to distinguish cancers that have the potential to cause mortality or morbidity over 50 years (or more) from those that do not. If we lack that ability, what choice is there but to proceed with definitive treatment? For an otherwise healthy 30-year-old patient with a “generally benign” type of cancer, is watchful waiting ever really an alternative? The author also mentioned being required to eat a “zerosalt diet” prior to her postthyroidectomy follow-up scan, which she found unpleasant. Radioactive iodine scans are best performed after a period of reduced iodine ingestion, which promotes the uptake of the tracer (usually iodine 123) by functioning thyroid cells (malignant or benign).2 Patients are advised to avoid iodized salt; however, noniodized salt is commercially available3 and can be substituted to comply with iodine restriction while maintaining a palatable diet. David L. Keller, MD Corresponding Author: David L. Keller, MD, PO Box 14295, Torrance, CA 90503 ([email protected]).
their accelerated diagnostic protocol. Such an interpretation of this study would be misleading. The safety of the protocol relies on combining the accelerated diagnostic protocol with expedited outpatient cardiac testing. All the low-risk patients in the experimental arm discharged from the ED underwent a functional cardiac study within 72 hours (most within 24 hours). The importance of such testing is highlighted by the single missed MACE in the experimental group, a patient discharged from the ED whose acute myocardial infarction followed an unrecognized abnormal outpatient stress test result. This MACE rate could be presented as 2.2%, well above the accepted miss rate,4 given that only 46 low-risk patients in the experimental arm were ultimately discharged directly from the ED. The authors unfortunately did not report how many outpatient stress test findings lead to subsequent cardiovascular interventions. In their earlier observational study, 18.3% of the low-risk population had therapeutic interventions and 2.0% went on to have revascularization procedures.2 It is difficult to argue that these therapies did not mitigate the number of 30-day MACE in both studies. We also wonder if the difference in rates of rapid ED discharge was driven less by the accelerated diagnostic protocol and more by the ability to reliably secure expedited outpatient stress testing, an option which was apparently not available to clinicians in the control arm. This is strongly suggested by the fact that the gaps in length of stay between the 2 groups persist consistently out to 16 hours, well beyond any efficiency gained in ruling out acute myocardial infarction with a 2-hour approach. These nuances should encourage clinicians and administrators to mobilize resources toward improving emergency physician access to outpatient stress testing appointments instead of focusing on marginally accelerated troponin testing. Though the Invited Commentary by Rahko5 asserts that most medical centers have the capacity for immediate stress testing or coronary computed tomography, it is our opinion that this is almost exclusively an office-hours phenomenon and accordingly contributes little to reducing hospital admissions or alleviating ED overcrowding during “off” (and often peak-volume) hours.
Conflict of Interest Disclosures: None reported. 1. Redberg RF. My thyroid story. JAMA Intern Med. 2013;173(19):1769. 2. ThyCa: Thyroid Cancer Survivors' Association Inc website. http://www.thyca .org/pap-fol/lowiodinediet/. Accessed October 28, 2014. 3. Amazon.com website. Sodium Chloride, Salt USP, 1 Cup, $10.39. http://www .amazon.com/Sodium-Chloride-Salt-USP-Cup/dp/B004SOZI2O/ref=sr_1_3?s=hpc& ie=UTF8&qid=1382980457&sr=1-3&keywords=non-iodized+salt. Accessed October 28, 2013.
Low-Risk Chest Pain in the Emergency Department: Should We Be Focusing on Better Follow-up Instead of Accelerated Testing? To the Editor We would like to thank Than and colleagues1-3 for their efforts to safely streamline the emergency department (ED) evaluation of low-risk patients with chest pain. We are concerned, however, that their data could be read to suggest that 30-day major adverse cardiac events (MACEs) can be safely excluded in emergency department (ED) patients with possible acute coronary syndrome based purely on low-risk results using jamainternalmedicine.com
Dustin G. Mark, MD David R. Vinson, MD Author Affiliations: Department of Emergency Medicine, Kaiser Permanente, East Bay, Oakland, California (Mark); Department of Emergency Medicine, Kaiser Permanente, Roseville, Roseville, California (Vinson). Corresponding Author: Dustin G. Mark, MD, Department of Emergency Medicine, Kaiser Permanente, East Bay, 280 W Macarthur Blvd, Oakland, CA 94611 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58. 2. Than M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol. 2012;59(23):2091-2098. 3. Cullen L, Mueller C, Parsonage WA, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol. 2013;62(14):1242-1249.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/25/2015
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to primary care physicians without other changes is sufficient to increase the quality of primary care or to reduce the utilization of acute care. Meredith B. Rosenthal, PhD Mark W. Friedberg, MD, MPP Eric C. Schneider, MD, MSc Author Affiliations: Harvard School of Public Health, Harvard University, Boston, Massachusetts (Rosenthal); RAND Corporation, Boston, Massachusetts (Friedberg, Schneider); Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (Friedberg, Schneider). Corresponding Author: Meredith B. Rosenthal, PhD, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 ([email protected]). Conflict of Interest Disclosures: None reported.
Comments Regarding “My Thyroid Story” To the Editor “My Thyroid Story”1 raised the important question of what should be done in the case of a young person with a very low-grade malignant neoplasm. To forgo surgery or ablative radiation therapy, it would be necessary to be able to distinguish cancers that have the potential to cause mortality or morbidity over 50 years (or more) from those that do not. If we lack that ability, what choice is there but to proceed with definitive treatment? For an otherwise healthy 30-year-old patient with a “generally benign” type of cancer, is watchful waiting ever really an alternative? The author also mentioned being required to eat a “zerosalt diet” prior to her postthyroidectomy follow-up scan, which she found unpleasant. Radioactive iodine scans are best performed after a period of reduced iodine ingestion, which promotes the uptake of the tracer (usually iodine 123) by functioning thyroid cells (malignant or benign).2 Patients are advised to avoid iodized salt; however, noniodized salt is commercially available3 and can be substituted to comply with iodine restriction while maintaining a palatable diet. David L. Keller, MD Corresponding Author: David L. Keller, MD, PO Box 14295, Torrance, CA 90503 ([email protected]).
their accelerated diagnostic protocol. Such an interpretation of this study would be misleading. The safety of the protocol relies on combining the accelerated diagnostic protocol with expedited outpatient cardiac testing. All the low-risk patients in the experimental arm discharged from the ED underwent a functional cardiac study within 72 hours (most within 24 hours). The importance of such testing is highlighted by the single missed MACE in the experimental group, a patient discharged from the ED whose acute myocardial infarction followed an unrecognized abnormal outpatient stress test result. This MACE rate could be presented as 2.2%, well above the accepted miss rate,4 given that only 46 low-risk patients in the experimental arm were ultimately discharged directly from the ED. The authors unfortunately did not report how many outpatient stress test findings lead to subsequent cardiovascular interventions. In their earlier observational study, 18.3% of the low-risk population had therapeutic interventions and 2.0% went on to have revascularization procedures.2 It is difficult to argue that these therapies did not mitigate the number of 30-day MACE in both studies. We also wonder if the difference in rates of rapid ED discharge was driven less by the accelerated diagnostic protocol and more by the ability to reliably secure expedited outpatient stress testing, an option which was apparently not available to clinicians in the control arm. This is strongly suggested by the fact that the gaps in length of stay between the 2 groups persist consistently out to 16 hours, well beyond any efficiency gained in ruling out acute myocardial infarction with a 2-hour approach. These nuances should encourage clinicians and administrators to mobilize resources toward improving emergency physician access to outpatient stress testing appointments instead of focusing on marginally accelerated troponin testing. Though the Invited Commentary by Rahko5 asserts that most medical centers have the capacity for immediate stress testing or coronary computed tomography, it is our opinion that this is almost exclusively an office-hours phenomenon and accordingly contributes little to reducing hospital admissions or alleviating ED overcrowding during “off” (and often peak-volume) hours.
Conflict of Interest Disclosures: None reported. 1. Redberg RF. My thyroid story. JAMA Intern Med. 2013;173(19):1769. 2. ThyCa: Thyroid Cancer Survivors' Association Inc website. http://www.thyca .org/pap-fol/lowiodinediet/. Accessed October 28, 2014. 3. Amazon.com website. Sodium Chloride, Salt USP, 1 Cup, $10.39. http://www .amazon.com/Sodium-Chloride-Salt-USP-Cup/dp/B004SOZI2O/ref=sr_1_3?s=hpc& ie=UTF8&qid=1382980457&sr=1-3&keywords=non-iodized+salt. Accessed October 28, 2013.
Low-Risk Chest Pain in the Emergency Department: Should We Be Focusing on Better Follow-up Instead of Accelerated Testing? To the Editor We would like to thank Than and colleagues1-3 for their efforts to safely streamline the emergency department (ED) evaluation of low-risk patients with chest pain. We are concerned, however, that their data could be read to suggest that 30-day major adverse cardiac events (MACEs) can be safely excluded in emergency department (ED) patients with possible acute coronary syndrome based purely on low-risk results using jamainternalmedicine.com
Dustin G. Mark, MD David R. Vinson, MD Author Affiliations: Department of Emergency Medicine, Kaiser Permanente, East Bay, Oakland, California (Mark); Department of Emergency Medicine, Kaiser Permanente, Roseville, Roseville, California (Vinson). Corresponding Author: Dustin G. Mark, MD, Department of Emergency Medicine, Kaiser Permanente, East Bay, 280 W Macarthur Blvd, Oakland, CA 94611 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58. 2. Than M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol. 2012;59(23):2091-2098. 3. Cullen L, Mueller C, Parsonage WA, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol. 2013;62(14):1242-1249.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/25/2015
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