Tuesday, August 23, 2016

ER care in VA hospitals


I found this interesting report from the American Journal of Emergency Medicine:

Conclusions

Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having university affiliations, traditional academic activities (eg, teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women's health.

Monday, August 22, 2016

Checklists, daily goal assessments, and clinician prompts


Here's another “systems improvement” initiative that didn't work. From a recent paper:

Importance The effectiveness of checklists, daily goal assessments, and clinician prompts as quality improvement interventions in intensive care units (ICUs) is uncertain.

Objective To determine whether a multifaceted quality improvement intervention reduces the mortality of critically ill adults.

Design, Setting, and Participants This study had 2 phases. Phase 1 was an observational study to assess baseline data on work climate, care processes, and clinical outcomes, conducted between August 2013 and March 2014 in 118 Brazilian ICUs. Phase 2 was a cluster randomized trial conducted between April and November 2014 with the same ICUs. The first 60 admissions of longer than 48 hours per ICU were enrolled in each phase.

Interventions Intensive care units were randomized to a quality improvement intervention, including a daily checklist and goal setting during multidisciplinary rounds with follow-up clinician prompting for 11 care processes, or to routine care.

Main Outcomes and Measures In-hospital mortality truncated at 60 days (primary outcome) was analyzed using a random-effects logistic regression model, adjusted for patients’ severity and the ICU’s baseline standardized mortality ratio. Exploratory secondary outcomes included adherence to care processes, safety climate, and clinical events.

Results A total of 6877 patients (mean age, 59.7 years; 3218 [46.8%] women) were enrolled in the baseline (observational) phase and 6761 (mean age, 59.6 years; 3098 [45.8%] women) in the randomized phase, with 3327 patients enrolled in ICUs (n = 59) assigned to the intervention group and 3434 patients in ICUs (n = 59) assigned to routine care. There was no significant difference in in-hospital mortality between the intervention group and the usual care group, with 1096 deaths (32.9%) and 1196 deaths (34.8%), respectively (odds ratio, 1.02; 95% CI, 0.82-1.26; P = .88). Among 20 prespecified secondary outcomes not adjusted for multiple comparisons, 6 were significantly improved in the intervention group (use of low tidal volumes, avoidance of heavy sedation, use of central venous catheters, use of urinary catheters, perception of team work, and perception of patient safety climate), whereas there were no significant differences between the intervention group and the control group for 14 outcomes (ICU mortality, central line–associated bloodstream infection, ventilator-associated pneumonia, urinary tract infection, mean ventilator-free days, mean ICU length of stay, mean hospital length of stay, bed elevation to ≥30°, venous thromboembolism prophylaxis, diet administration, job satisfaction, stress reduction, perception of management, and perception of working conditions).

Conclusions and Relevance Among critically ill patients treated in ICUs in Brazil, implementation of a multifaceted quality improvement intervention with daily checklists, goal setting, and clinician prompting did not reduce in-hospital mortality.




Sunday, August 21, 2016

Hypoxic hepatitis


An article on this topic recently appeared in The American Journal of Emergency Medicine. The paper focused on the post cardiac arrest situation but it is seen in other types of circulatory collapse. This entity has also been called ischemic hepatitis and shock liver. From the introduction of the paper:

Hypoxic hepatitis (HH) is frequently observed in critically ill patients and is associated with poor outcomes [1] . In HH, hypoperfusion with subsequent ischemia and passive congestion of the liver, severe systemic arterial hypoxemia, and/or impaired hepatic oxygen extraction induces centrilobular liver cell necrosis 2 3 4 5 . According to Henrion et al [2 6] , a diagnosis of HH could be clinically assumed if the following 3 conditions are met: (1) an appropriate clinical setting of cardiac, respiratory or circulatory failure; (2) a sharp increase in serum aminotransferase levels that reach at least 20 times the upper limit of normal; (3) the exclusion of other causes of acute liver cell necrosis, particularly viral or drug-induced hepatitis.

The complex relationships between obesity, hypertension and CKD


Review here.

Autoimmune hemolytic anemia


Linked here are two great review articles. This one addresses such questions as “What are the differences between warm and cold antibody hemolytic anemias?” “What is the difference between primary and secondary AIHA and what are some of the secondary causes?” “How can the ratio of conjugated to total bilirubin help differentiate between biliary disease and hemolysis as the cause of hyperbilirubinemia?”

This one discusses the pathophysiology of AIHA, explains the roles of antibody and complement, and explains why spherocytes are present in peripheral blood in AIHA.

Saturday, July 16, 2016

NEJM report on ACOs



Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics...

Results

Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was −$144 per beneficiary in the 2012 ACO cohort as compared with the control group (P=0.02), consistent with a 1.4% savings, but only −$3 per beneficiary in the 2013 ACO cohort as compared with the control group (P=0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P=0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others.

Conclusions

The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in independent primary care groups than in hospital-integrated groups.


So as far as cost savings go these results were modest and somewhat mixed. I have to wonder if the effects of ACOs on costs will mirror what happened in the mid 90s with the wave of managed care, when there was an initial slash in costs but the “success” was short lived, as the reductions were not sustainable. I put very little stock in the statement that there was partial improvement in quality, since quality really means the weak and unproven surrogate of performance.

Wednesday, July 13, 2016

Higher prevalence of pancreatic cancer in patients newly diagnosed with type 2 diabetes


This is an association that has long been suspected. Additional evidence for the association was found in this study.