EM Quick Hits 39 Overdiagnosis, Lytics for Submassive PE, Pericardial Effusion, Hemophilia Treatment

Topics in this EM Quick Hits podcast Justin Morgenstern & Eddy Lang on the problem of overdiagnosis in EM (0:37) Anand Swaminathan on an approach to the indications and dosing of systemic thrombolytics for submassive pulmonary embolism (27:06) Taraha Bhate's QI corner on pericardial effusion (33:20) Brit Long on emergency treatment of the bleeding hemophilia patient ( part 2 of 2 part series) (40:25) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Saly Halawa, Brit Long, edited by Anton Helman Cite this podcast as: Helman, A. Swaminathan, A. Lang, E. Morgenstern J. Bhate, T. Long, B. EM Quick Hits 39 - Overdiagnosis, Lytics for Submassive PE, Pericardial Effusion, Hemophilia Treatment. Emergency Medicine Cases. June, 2022. https://emergencymedicinecases.com/em-quick-hits-june-2022/. Accessed [date]. Overdiagnosis in Emergency Medicine * Definition of overdiagnosis: Labelling a person with a disease or abnormal condition that would not have caused the person harm if left undiscovered. Individuals derive no clinical benefit from overdiagnosis and can experience physical, psychological, and financial harm * 5 main causes of overdiagnosis * Over reliance on medical tests. A societal belief in prevention and early diagnosis, despite the general lack of evidence to support cancer screening to decrease mortality * Increasingly sensitive diagnostic tests, leading to findings of of questionable importance * Risk averse medical culture * Expanding disease definitions and thresholds/over-medicalization of disease * Pervasive financial incentives from industry * Common ED clinical scenarios * Subsegmental PE – with higher resolution CTs pulmonary emboli are more prevalent than ever, yet PE mortality has not changed in decades * CT angiogram for suspected subarachnoid hemorrhage - leads to detection of lesions that may not be causative but may result in follow-up burden without clinical benefit * Exercise stress testing in low-risk chest pain has a high false positive rate with risk of needless downstream invasive testing (see Journal Jam 15 Cardiac Stress Testing for deep dive) * Anaphylaxis – recent increase in the incidence of the diagnosis as many patients do not meet the disease threshold, leading to costly over-prescription of epinephrine auto-injectors. * Solutions to the overdiagnosis problem in EM * A collective understanding that in the pursuit of making a diagnosis in the ED diagnosis we should seek to balance our desire for a near zero miss rate with the downstream deleterious effects of overdiagnosis * Use shared decision making so that patients understand the problems of overdiagnosis * Aim to educate medical students, residents staff docs and each other about the downstream effects of overdiagnosis. The more we are collectively aware of the problems, the more likely we will be to address them. Expand to view reference list * Vigna M, Vigna C, Lang ES. Overdiagnosis in the emergency department: a sharper focus. Intern Emerg Med. 2022 Apr;17(3):629-633. doi: 10.1007/s11739-022-02952-8. Epub 2022 Mar 5. PMID: 35249191.