Why the CAP No Longer Supports 'Excited Delirium' as a Cause of Death - January 2024 Advocacy Recap

Alec Bose:

Hello and welcome to the CAP Advocacy Recap. This month, we'll look at a prior authorization rule that could pave the way for legislation to reduce burdens on clinicians, a grant awarded to the CAP to improve healthcare communication action on Medicare cuts, and more.

We begin the recap with a term, "excited delirium." This is a term often used by law enforcement as a reason why some suspects die in police custody. The CAP followed the National Association of Medical Examiners and no longer using this as a cause of death. We sat down with Dr. Anna Tart to understand this position and what it means moving forward. Thank you for joining us, Dr. Tart. We really appreciate you being here with us today.

Dr. Anna Tart:

Yeah, I'm glad to be here.

Alec Bose:

So just to start out, can you define what excited delirium is and what it's used to describe from a pathologist perspective?

Dr. Anna Tart:

Sure. So extended delirium is a term that typically is only used by forensic pathologists, so a special subspecialty within pathology, and it's used to describe a constellation of findings. And typically these findings are based off of scene reports, descriptions from bystanders, witnesses, law enforcement, emergency medical services, and trying to sort of bring everything together to describe a cause of death.

Alec Bose:

Thank you. Why did the College support the position of the National Association of Medical Examiners and no longer use it as an official cause of death?

Dr. Anna Tart:

So like I said, it was like a constellation of symptoms, and the problem with trying to describe a constellation is that we don't get great detail. And so the National Association for Medical Examiners put out a statement saying that this was not a specific cause of death. Instead NAME, the National Association for Medical Examiners, was encouraging forensic pathologists to instead use underlying causes as to why someone may have been in a state of excited delirium to better give a more specific cause of death.

Alec Bose:

Has there been any sort of response from law enforcement at all or any sort of response from them as to this decision?

Dr. Anna Tart:

Yeah, I haven't heard any pushback or support from law enforcement in particular. There was a bill that was introduced and passed by the California legislature stating that it could no longer be used as a cause of death. And, sorry, this might go on a bit of a tangent, but although, yes, National Association for Medical Examiners and the College of American Pathologists agree that this is not a good cause of death, we don't support the legislative action of government on the medical diagnoses and the medical opinions of the pathologists.

Alec Bose:

Absolutely. And how does this specific decision impact forensic pathologists and what can they do to learn more about this?

Dr. Anna Tart:

So what the hope is is that it will, more than anything, educate forensic pathologists to give better descriptions for cause of death. When we write a death certificate, this is used for vital statistics, it's used for epidemiology, it's used for data and for public health purposes. And so when we put a more specific cause of death, we can better identify maybe problems within communities, better alert those community members, service workers in those communities to either be on the lookout for and hopefully ultimately prevent deaths better. We're really trying to be at the forefront of public health in this decision. Part of that also that vital statistics goes along with excited delirium wasn't ever a recognized diagnosis for even people who, physicians who work in emergency departments or anything else. And so we're trying to better match up our diagnoses also to, again, give better continuity and patient care and answers for families to learn more.

They can always, forensic pathologists can always reach out to the CAP and to NAME to get clarification, to get better ideas and maybe how to find better answers when it comes to what questions can we ask, law enforcement, emergency medical services witnesses, how can we have better investigations into root causes? And so reaching out to peers, colleagues in other states, other jurisdictions for these ideas can certainly be helpful. I think one thing to certainly say is we also want to recognize that oftentimes excited delirium is used in law enforcement apprehensions and often comes at the expense of minorities. And so we've been trying to recognize that bias and again, just try and be as specific as we possibly can for families, no matter race, ethnicity, situation, anything like that, but just trying to be as precise as we can to provide better data and better answers to families.

Alec Bose:

Well, I think that's a perfect note to leave it off on. Thank you so much, Dr. Tart, for talking to us. We really appreciate it.

Dr. Anna Tart:

Of course. Thank you for having me.

Alec Bose:

We turn now to updates related to prior authorization. The CMS released the final rule that makes important reforms in prior authorization programs for medical services. The rule comes as the house continues to advance the bipartisan improving seniors timely access to the CARE act, a prior authorization bill to better serve patients and reduce unnecessary administrative burdens. For clinicians, this legislation would specifically establish an electronic prior authorization process that would streamline approvals and denials, create a process for real-time decisions for certain items and services that are routinely approved require beneficiary protections that would ensure the electronic prior authorization serves seniors and implement a number of provisions to benefit Medicare Advantage plans. This rule is a direct result of important advocacy efforts taken by the CAP together with the American Medical Association and other physician organizations to address prior authorization in government regulated health plans. As a result of the recent final rule, legislators now see a path forward to enacting this legislation and making these reforms into law and other positive news.

The CAP and six other specialty societies receive grants of $100,000 each to advance mechanisms for providing feedback about diagnostic decision-making to frontline clinicians on their performance in clinical registries. The grant, which came from the University of California San Francisco in partnership with the Council of Medical Specialty Societies and funded by the Gordon and Betty Moore Foundation, will focus on improving communication of test results by providing feedback on circumstances of diagnostic uncertainty and how it is communicated. The CAP has been awarded these types of grants in the past, one that focused on understanding patients' experiences with their pathology report and another to address the challenge of redesigning a pathology report that effectively communicates pathology test results to patients and all members of the care team. We will continue to update you as the grant is implemented.

And we end the day with the advocacy to stop Medicare cuts. The CAP, AMA, and hundreds of other medical organizations and societies are lobbying Congress to quickly pass legislation to reverse the 3.37% Medicare physician payment cut. In a letter to Congress, the coalition called on lawmakers to eliminate the cuts in full by increasing the Medicare physician fee schedule conversion factor.

Pathologists and their laboratories have endured several challenges in recent years to meet the demands of the US Health System while facing declining reimbursements. "Our commitment to our patients is unwavering," CAP President Dr. Donald Karcher said in a statement. At the same time, physicians cannot continue to do more with fewer resources while coping with workforce shortages and inflationary pressures. We must still invest in new technology and advance laboratory infrastructure to maintain and enhance the quality of patient care. Congress must honor its commitment to seniors and the physicians who care for them by stabilizing Medicare Pay. In the short and long-term, the CAP has urged its members to contact their representatives and advocate for the passing of the Preserving Seniors Access to Physicians Act. A bill that would reverse the 3.37% cut. Be sure to visit our website to find out how you can advocate for payment protection. That's all for this edition of the advocacy recap. Thank you so much for listening. For more information on any stories you hear today, be sure to subscribe to our weekly newsletter and follow us on X at CAPDCadvocacy. Once again for CAP advocacy communications, I'm Alec Bose and we'll see you next month.

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