Friday, January 29, 2010

Reiki at Baltimore Shock Trauma Center

The chief of anesthesiology explains the institution's scientific standard: “From what they tell us, we think they get better quicker.”

AHA policy statement on regional systems of care for out of hospital cardiac arrest

Stroke, trauma and STEMI all have their regional centers of care. Now that we have a post resuscitation bundle, why not for out of hospital cardiac arrest? It’s time.

Antimalarial use in SLE

For years the thinking regarding SLE was that one treats manifestations and complications but that there was no basic treatment for the disease itself. Over time that perception has changed with accumulating evidence that antimalarials might alter the natural history of the disease and maybe even improve survival. A new study posted ahead of print in Arthritis and Rheumatism indicates a protective effect of hydroxychloroquine against thrombovascular events:

Fifty-four cases were identified and matched to 108 controls. Univariate analyses identified age (OR, 95%CI = 1.04, 1.01-1.07) or being older than 50 years old (3.5, 1.4-8.6) and hypertension (2.5, 1.0-5.8) as being associated with an increased risk of TE while use of antimalarials (0.31, 0.13-0.71) was associated with a decreased risk of TE. Separate analyses were done for arterial and venous TE. In multivariate analysis, use of antimalarial drugs (0.32, 0.14-0.74) and age (1.04, 1.01-1.07) were the only two variables that remained significant for all TE.

We demonstrate in this nested case-control study adjusting for disease severity, duration of disease and calendar cohort that antimalarial drugs are thromboprotective with a risk reduction of thrombovascular event of 68% and of at least 26% and as high as 86%.

This Medscape commentary discusses other data on protective effects of hydroxychloroquine and quotes the authors:

"The data presented, taken in conjunction with the data from the published literature, suggest that antimalarials should be used in all lupus patients regardless of their disease manifestation or disease duration," the authors conclude.

Drug induced acute liver injury

An excellent review was recently published in Seminars in Liver Disease. Free full text access is available via Medscape.

Points of interest:

Prognosis is largely determined by the presence or absence of coagulopathy and encephalopathy. Transplant free survival is poor if these are present.

Acetaminophen is the most frequent culprit.

N-acetylcysteine therapy may benefit some patients with non-acetaminophen induced injury.

Thursday, January 28, 2010

Hyperkalemia and the electrocardiogram

Another in the series by James Roberts, M.D., on at-a-glance electrocardiographic patterns that portend disaster.

MIBG imaging and heart failure prognosis

I first mentioned imaging of heart failure patients with metiodobenzylguanidine (AdreView) here. Now JACC has published a review summarizing the state of the art of MIBG imaging:

Cardiac sympathetic imaging with meta-iodobenzylguanidine (mIBG) is a noninvasive tool to risk stratify patients with heart failure (HF). In patients with ischemic and nonischemic cardiomyopathy, cardiac mIBG activity is a very powerful predictor of survival. Cardiac sympathetic imaging can help in understanding how sympathetic overactivity exerts its deleterious actions, which may result in better therapy and outcome for patients with HF.

If rapid response teams improve outcomes it takes time

In this new before and after study it took 4 years to see a reduction in mortality. Although the data were severity adjusted they did not take into account other hospital improvements that may have taken place over time. (It really gets complicated when one considers that other process improvements may have been driven by the rapid response system itself).

Internal Medicine News on You Tube

Internal Medicine News is now posting videos on You Tube which you can view here.

Microscopic colitis

An underappreciated cause of chronic diarrhea in older adults. Review in Age and Ageing.

Wednesday, January 27, 2010

Double standard for DTC advertising

Academic medical centers don’t have to (and seldom do) adhere to the same standards drug companies do. H/T to Erik DeLue.

Marketing campaign “disguised as evidence based medicine” saved lives! Who'da thunk it?

For over a decade the pharmascolds have been preaching that industry marketing is harmful to patients even though there's not a shred of evidence that it's true. Arguably the most maligned of all industry supported promotions is the Surviving Sepsis Campaign, widely criticized as being little more than marketing disguised as evidence based medicine:

Seeing in these bundles a potentially powerful vehicle for promoting their products, pharmaceutical and medical-device companies have begun to invest in influencing the adoption of guidelines that serve their own financial goals. A case in point is the development of guidelines for the treatment of sepsis, which was orchestrated as an extension of a pharmaceutical marketing campaign.1,2 Although its advocates viewed this effort as an important approach to reducing sepsis-related mortality, the campaign appears to have usurped guideline development for commercial purposes, possibly compromising highly regarded, third-party arbiters of medical quality in the process. Such intrusion into an initiative to benefit public health is of particular concern...

And on it goes. And the results of this marketing campaign disguised as EBM? Reduced mortality and better guideline adherence!

About this time last year the results were presented at the SCCM annual meeting (related post here). Now, a year later, we have formal publication of the results in the February issue of Critical Care Medicine:

Measurements and Main Results: Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mortality. Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 yrs (p less than .0001). Compliance with the entire management bundle started at 18.4% in the first quarter and increased to 36.1% by the end of 2 yrs (p = .008). Compliance with all bundle elements increased significantly, except for inspiratory plateau pressure, which was high at baseline. Unadjusted hospital mortality decreased from 37% to 30.8% over 2 yrs (p = .001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, resulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 yrs (95% confidence interval, 2.5–8.4).

The mortality was still dropping at two years indicating even better results had the campaign continued longer. Baseline mortality rates among hospitals that entered the campaign at varying points in time were similar, suggesting that the mortality reduction attributable to the campaign was real, rather than a result of other factors.

So this is one of many studies that tell us guideline adherence matters, but it's more. This is the first study ever to record patient outcomes following the introduction of an industry supported promotion. The outcomes were good. The pharmascolds were wrong.

A hospitalist’s wish list

From Robert Harrington, Jr., MD. Funny. And true.

Updated international consensus recommendations for management of patients with nonvariceal UGI bleeding

Via Annals Intermal Medicine.

Pulmonary involvement in patients with inflammatory bowel disease

Pulmonary complications of several types are emerging as important extra intestinal manifestations of Crohn’s disease and ulcerative colitis. Free full text review here.

Review of corticosteroid induced psychiatric symptoms

This may be more common we think. Via Psychiatry Online.

Tuesday, January 26, 2010

Alpha 1: the forgotten etiology

Here’s another review of alpha 1 antitrypsin deficiency, again making the point that this disorder is widely under diagnosed. Screening is recommended on all individuals with emphysema, unremitting asthma and in certain other circumstances.

The future of quackademic medicine is secure

---if this, the largest survey of its kind, is any indication:

In the largest national survey of its kind, researchers from UCLA and UC San Diego measured medical students' attitudes and beliefs about complementary and alternative medicine (CAM) and found that three-quarters of them felt conventional Western medicine would benefit by integrating more CAM therapies and ideas.

The findings will be published in the online issue of Evidence-based Complementary and Alternative Medicine (eCAM) on January 20, 2010.

"Complementary and alternative medicine is receiving increased attention in light of the global health crisis and the significant role of traditional medicine in meeting public health needs in developing countries," said study author Ryan Abbott, a researcher at the UCLA Center for East-West Medicine. "Integrating CAM into mainstream health care is now a global phenomenon, with policy makers at the highest levels endorsing the importance of a historically marginalized form of health care."

Excited delirium syndrome

Now recognized as a distinct entity. More here.

Quackademic medicine leaders head to India

---to learn more about Ayurveda:

The purpose of the U.S. delegation’s visit is to explore the possibilities of introduction of evidence-based Ayurveda, Yoga, meditation, and oil massage treatment in the United States medical education, research, and patient care areas, and also to study the possibilities of joint Indo-U.S. research under NIH funding.

Estimation of creatinine clearance in morbid obesity

American Journal of Health-System Pharmacy via Medscape.

Monday, January 25, 2010

DIC correlates with lactate levels in sepsis

---at least when the balance is shifted toward microthrombosis:

Our observations show that, in the course of human septic shock, activation of coagulation and, particularly, inhibition of activated fibrinolysis are independently associated with hyperlactatemia. This suggests a contribution of DIC resulting from a coagulation/fibrinolysis imbalance to microvascular obstruction, tissue hypoxygenation and thereby to ultimate demise.

The preoperative medical evaluation: consult, don't insult

Tips form the Perioperative Medicine Summit.

Medical textbooks available on Google Books

You can't access the entire content, but large portions. Via Clinical Cases and Images.

USMLE You Tube videos

It never hurts to review the basics even if you're long past USMLE.

Via Clinical Cases and Images.

Friday, January 22, 2010

Radical environmentalism

The new religion?

Instead of religious sins plaguing our conscience, we now have the transgressions of leaving the water running, leaving the lights on, failing to recycle, and using plastic grocery bags instead of paper. In addition, the righteous pleasures of being more orthodox than your neighbor (in this case being more green) can still be had—

Read the rest at Secondhand Smoke.

New study on rapid response teams

A systematic review and meta-analysis was just published in the Archives of Internal Medicine, concluding thusly:

Conclusion Although RRTs have broad appeal, robust evidence to support their effectiveness in reducing hospital mortality is lacking.

One curious finding was that although RRTs didn't impact mortality they reduced the number of arrests outside the ICU, which may merely mean that RRTs get people to the ICU before they code with no resulting impact on mortality.

As I said before, results such as this don't mean RRTs are useless. Your hospital may benefit if you use the process for all it's worth. Results such as this DO mean that RRTs should not be a performance standard, and no one can make the claim that RRTs save lives.

Related editorial.

Variation in interpretation of CT scans to evaluate for PE

From the American Journal of Emergency Medicine:

We found a very good interobserver agreement in MDCT evaluation for the diagnosis of massive PE, whereas we observed a lower concordance in regard to segmentarian and subsegmentarian PE. In the case of negative or nonmassive PE diagnosis, a second evaluation of the CT performed by an expert CT radiologist would probably be effective to decrease the CT evaluation error.

The present degree of confidence in CT angiography over ventilation perfusion lung scanning for the diagnosis of PE is unwarranted.

Thursday, January 21, 2010

Massachusetts election upset a sentinel event for democrats

Maybe they should do a root cause analysis. Two Medscape articles offer a perspective on how this will affect health care reform.

New York Times review of The Checklist Manifesto

From the review:

A hospital, as the saying goes, is no place for sick people. It’s filled with hazards to your health, not least of which are the myriad infections, missed diagnoses, dosage mistakes and other complications that arise from human error. And in a hospital, human error seems all but inevitable. How can any one individual, or even any one team of individuals, keep all the tasks straight and anticipate all eventualities 100 percent of the time?

You can't, but checklists may help, and that's apparently what the book is about. Why not make your own checklist to cover the areas most likely to bite you? Did you address DVT prophylaxis? Did you continue the home meds that need to be given and hold the ones that need to be held? Have you looked at today's labs and ordered tomorrow's? You can use the EMR to incorporate these into your daily rounding note.

This might be a book worth having. Now where did I put that Barnes and Noble gift card?

Via Clinical Cases and Images.

Catheter based and surgical treatments for massive DVT

Medscape has posted some presentations from the 36th Annual VEITH Symposium. This one
makes a strong pitch for catheter based and surgical treatments in patients who have extensive (iliofemoral) DVT. Although the speakers appealed to the ACCP guidelines their statement was somewhat stronger than the guideline recommendation, which suggests that in patients with extensive DVT, an anticipated survival of over a year and low bleeding risk such treatments may be used to reduce acute symptoms and post thrombotic syndrome if appropriate expertise is available.

On a related note, do the guidelines recommend catheter directed or surgical treatments for upper extremity DVT? Not across the board, but if there are severe symptoms of recent onset and low bleeding risk they make similar recommendations to those for lower extremity DVT.

Tuesday, January 19, 2010

Why doesn't the American College of Physicians just merge with AAFP and get it over with?

The American College of Physicians has for some time been complicit with an agenda to eliminate Internal Medicine as a unique specialty. Retired Doc offers the latest absurd example. General Internal Medicine is on the way out. It's about pay in part, but it's mainly about loss of professional identity.

Unintentional acetaminophen overdose

A review in CCJM.

Telomeres and disease

NEJM review.

Therapeutic hypothermia made simple

Scott D. Weingart, MD, RDMS really sums up the nuts and bolts.

Management of acute decompensated heart failure

Open access review.

More acid base resources

This excellent collection from Clinical Cases and Images contains some resources I had not linked to before.

A Tale of Two MRIs

Is this what we have to look forward to under Obamacare?

Monday, January 18, 2010

The Big Five personality test and medical school success

Medical school admission candidates are evaluated for both their cognitive abilities and their personalities. The evaluation of cognitive ability is quantitative (grades, MCATs). Personality evaluation, however, is subjective, based on interviews and letters of recommendation. Is evaluation of the candidate's personality predictive of long term success? Can it be more systematic?

A large group of students in Belgium underwent psychological testing using quantitative methodology at beginning of their medical training and were then followed long term. Results were published here:

In this longitudinal investigation, an entire European country’s 1997 cohort of medical students was studied throughout their medical school career (Year 1, N = 627; Year 7, N = 306). Over time, extraversion, openness, and conscientiousness factor and facet scale scores showed increases in operational validity for predicting grade point averages. Although there may not be any advantages to being open and extraverted for early academic performance, these traits gain importance for later academic performance when applied practice increasingly plays a part in the curriculum. Conscientiousness, perhaps more than any other personality trait, appears to be an increasing asset for medical students: Operational validities of conscientiousness increased from .18 to .45. In assessing the utility of personality measures, relying on early criteria might underestimate the predictive value of personality variables.

Pauline Chen, MD, commented on the study in the New York Times:

The investigators found that the results of the personality test had a striking correlation with the students’ performance. Neuroticism, or an individual’s likelihood of becoming emotionally upset, was a constant predictor of a student’s poor academic performance and even attrition. Being conscientious, on the other hand, was a particularly important predictor of success throughout medical school. And the importance of openness and agreeableness increased over time, though neither did as significantly as extraversion. Extraverts invariably struggled early on but ended up excelling as their training entailed less time in the classroom and more time with patients.

DB's Medical Rants offered commentary here and here.

How would you have measured up? Take the test here! Think back to when you were applying to medical school and answer the questions as you would have answered them then. I took the test twice, entering “then and now” responses. My “then” responses accurately predicted that I would do much better in the basic science years than the clinical years. When I hit the wards third year I was terrified. I just wasn't ready, and didn't handle the disconnect too well. Fortunately, by the time of the last rotation of my senior year, thanks in part to some patient and understanding residents, I was beginning to hit my stride.

The stresses of training and practice, as the test also predicted, were particularly difficult for me. Fortunately I looked on life's difficulties as character building events and sought to turn stress into strength. Professional life, like my test score, is good now.

Bob Wachter resuscitates USCF medical grand rounds

Faced with dwindling attendance and the suggestion that the program be discontinued Bob Wachter decided to save the tradition, noting this:

First, in a world in which we can increasingly segment our information (i.e., watch Glenn Beck or Rachel Maddow), making a habit of attending grand rounds is one of the few ways for physicians to be exposed to information and people outside their professional silos. We are all in danger of accruing new information about only those things we already know and like.

Second, grand rounds can help build, or promote, community. Think about it: increasingly, texting, email, and Facebook mean that we can get through our days without actual human contact. Grand rounds provides a venue for all the members of a social network (in this case, a department of medicine) to schmooze and bond.

Finally, grand rounds are an opportunity for faculty to connect with their peers, letting their colleagues and trainees know what they’re up to. These interactions create the mutual respect that fuels a great department, along with many serendipitous collaborations. But for this mixing to occur, I have to attend my colleague’s lecture, and she mine. Remember Yogi Berra’s famous observation: “If you don't go to somebody's funeral, they won't come to yours.”

But aside from all that, for me and many other physicians lecture based CME is a very effective learning method. And while didactic education is currently under attack by the medical thought police, most departments of medicine have continued the format and many post the lectures on line, which I view regularly and many of which I have linked here and here.

Glorified housestaff?

The recent Today's Hospitalist piece on management of patients with intracranial hemorrhage got a lively response from readers:

The truth is that neurosurgeons are trained to manage these patients, and the bottom line is that no one wants to get out of bed. What you call a “paradigm shift” in your December 2009 cover story, I call “turf.”

I resent this shift, but I think it will be transient. With cost and reimbursement cutbacks, payers are NOT going to continue to pay two doctors when only one is needed. Hospitalists will not be paid to manage hypertension in an ICH patient when the appropriate admitting doctor (the neurosurgeon) has for years been capable of doing so.

Another response:

We are often seen as little more than glorified housestaff as we admit patients more appropriately admitted by a specialist. The only thing we accomplish is to improve specialists’ lifestyle—at the expense of providing appropriate, timely care.

Friday, January 15, 2010

Thursday, January 14, 2010

Do eICUs improve outcomes?

A study from 2004 had found that they improved mortality and resource utilization. This newer study did not. Both were before-and-after intervention studies. Given the setting and the conditions of the newer study I have to wonder what the eICU really added, given that most of the study ICUs were “closed” meaning that many patients were cared for by intensivists in the pre-intervention period. Also, utilization of the eICU by individual physicians was limited.

I suspect eICUs are like rapid response teams in that, while it is difficult to prove benefit in the aggregate, individual hospitals may benefit if they utilize them for all they're worth.

Wednesday, January 13, 2010

When woo invades hospitals

---what will hospitalists do?

Can you imagine doing comanagement with this guy?

Woo, under the guise of integrative medicine, is rapidly invading hospitals, especially academic medical centers. The Society of Hospital Medicine should take a stand against this assault on scientific medicine in hospitals and provide resources and support to help the individual hospitalist respond in an appropriately critical manner.

Unfortunately, if an article in the latest issue of The Hospitalist (an official publication of the Society) is any indication, I'm not optimistic. The article discusses a mixture of a few plausible alternative methods and some of the wooiest woo, towards which it takes a disturbingly uncritical stance.

Primary influenza pneumonia

Reviewed in Critical Care:

Primary influenza pneumonia has a high mortality rate during pandemics, not only in immunocompromised individuals and patients with underlying comorbid conditions, but also in young, healthy adults. Clinicians should maintain a high index of suspicion for this diagnosis in patients presenting with influenza-like symptoms that progress quickly (2-5 days) to respiratory distress and extensive pulmonary involvement.

...Ensuring an appropriate oxygenation and ventilation strategy, as well as prompt initiation of antiviral therapy, is essential in management.

Tuesday, January 12, 2010

Bicarb for prevention of contrast-induced nephropathy

The pendulum is swinging back. According to the latest systematic review:

The effectiveness of sodium bicarbonate treatment to prevent CIN in high-risk patients remains uncertain. Earlier reports probably overestimated the magnitude of any benefit, whereas larger, more recent trials have had neutral results. Large multicenter trials are required to clarify whether sodium bicarbonate has value for prevention of CIN before routine use can be recommended.

Another antiphospholipid syndrome review

This one is similar to the one I cited recently, but focuses more on the under appreciated association of thrombocytopenia and its management.

Monday, January 11, 2010

The role of hospitalists in stroke care

Who admits stokes? That question has been debated for decades. Now that hospital based neurologists are in short supply hospitalists are increasingly being asked to assume care. An excellent discussion and lots of great links can be found here. Something tells me this will be a major area of focus on the hospital medicine board exam.

Does simvastatin cause more myopathy than the other statins?


Recent evidence suggests that the risk of severe muscle toxicity with simvastatin may be higher than that with other statins, particularly when used in combination with cytochrome P450 isoenzyme inhibitors. However, the lack of direct comparative clinical trials assessing the risk of myotoxicity among the statins in equivalent doses precludes definitive conclusions. Data sources examining low-to-moderate doses of simvastatin suggest that myotoxicity with this agent is infrequent, with rates similar to those seen with other statins. Conversely, findings from clinical trials using the maximum daily dose (80 mg) and a clinical trials database of varying doses of simvastatin suggest a possible increase in rates of myotoxicity with the 80-mg dose compared with lower doses and a higher incidence rate when compared with maximum doses of other statins.

Friday, January 08, 2010

Should hospitalists be in charge of patients admitted with intracranial hemorrhage?

It may be a moot point because, like it or not, hospitalists are increasingly being asked to admit and be the attending physician for these patients. According to an article in Today's Hospitalist the number of head bleeds considered “surgical” is shrinking:

"Neurosurgeons are stepping further and further back from this disease because there really is not a role for surgery in ICH," points out Dr. Josephson, director of the neurohospitalist program and assistant professor of neurology at UCSF. The exceptions are cerebellar hemorrhages and those hemorrhages that are close to the surface. "Probably less than between 5% and 10% of ICH patients need surgical intervention," he says.

The article offers opinions and links to primary sources on the medical management of such patients, particularly hypertension management. Included is a section on blood pressure management in ischemic stroke in which the guideline recommended cut off of 220/120 is advocated.

Concerning ICH the larger question is whether hospitalists should be managing them in the first place, either as attending physicians or under some vaguely defined comanagement arrangement. Hospitalists are increasingly being maneuvered into managing patients outside the scope of their training and experience. This may emerge as a liability issue for the field.

Thursday, January 07, 2010

Drug induced torsades: a forme furste of LQTS

A new study published in Circulation: Arrhythmia and Electrophysiology found LQTS mutations as frequently in drug induced cases as in congenital cases:

Conclusions— dLQTS had a similar positive mutation rate compared with cLQTS, whereas the functional changes of these mutations identified in dLQTS were mild. When IKr-blocking agents produce excessive QT prolongation (dLQTS), the underlying genetic background of the dLQTS subject should also be taken into consideration, as would be the case with cLQTS; dLQTS can be regarded as a latent form of long-QT syndrome.

We've suspected this for a long time to explain the fact that drug induced TDP appears to be idiosyncratic.

Which home medications should be continued perioperatively?

Here's a very helpful article from The Hospitalist.

Risk stratification in pulmonary embolism: lessons from the EMPEROR registry

A great deal has recently been written about the use of biomarkers and echocardiography for risk stratification of patients presenting with pulmonary embolism (PE). Data from the EMPEROR study, presented recently at the annual meeting of the Society for Academic Emergency Medicine, compared biomarkers and clinical scores. The presentation was reported in Hospitalist News:

None of the predictors displayed good sensitivity for predicting adverse events. However, a PESI greater than 100 had outstanding specificity and conferred an 8.7-fold increased likelihood of adverse outcome. The shock index performed second best. The two vital signs proved to be slightly better predictors than the two biomarkers.

PESI is the pulmonary embolism severity index and is explained here. The shock index is the ratio of heart rate to systolic blood pressure. A value of over 1 was an adverse sign in EMPEROR.

In patients with pulmonary embolism, routinely calculate the pulmonary embolism severity index (PESI) and shock index, and strongly consider admission to an ICU for patients with elevated values, Dr. Jeffrey A. Kline advised at the annual meeting of the Society for Academic Emergency Medicine.

Although there has been considerable interest in use of biomarkers, echocardiography and clinical assessment to predict good outcomes and select patients for early discharge that was not evaluated in EMPEROR. However, PESI and the Geneva score were evaluated in a 2007 study published in Chest with this conclusion:

The PESI quantified the prognosis of patients with PE better than the Geneva score. This study demonstrated that PESI can select patients with very low adverse event rates during the initial days of acute PE therapy and assist in selecting patients for treatment in the outpatient setting.

Now that prasugrel is approved which thienopyridine should we use? Is new better?

According to this CCJM review greater efficacy must be balanced against increased bleeding risk, and the decision depends on individual patient characteristics:

Compared with clopidogrel, prasugrel is more potent, faster in onset, and more consistent in inhibiting platelets.

Prasugrel should be avoided in patients at higher risk of bleeding, including those with a history of stroke or transient ischemic attack, those age 75 or older, or those who weigh less than 60 kg.

Wednesday, January 06, 2010

Effectiveness of vaccination against pandemic 2009 H1N1 influenza

From Annals of Internal Medicine. Yes, Jeanne, the vaccine matters.

NEJM Sounding Board piece on industry supported CME

Like many other articles this one, written by authors from the Office of Inspector General, cites plenty of opinion but offers no evidence to the effect that industry support of CME is harmful.

Activated protein C in sepsis

This NEJM case presentation and review makes the same point I did last year about paying attention to the PROWESS exclusion criteria in selecting patients for treatment, and notes the trial now in progress which restricts enrollment to patients in septic shock.

Tuesday, January 05, 2010

Perioperative management of diabetes

Multiple practical aspects are covered in an article from the Perioperative Medicine Summit.

The disconnect between performance and quality

Two years ago, when I reported about the lack of effectiveness of heart failure performance measures in the OPTIMIZE study, I noted this concerning heart failure instructions as a performance measure:

The first quality measure was the provision of discharge instructions on medications, diet and other aspects of heart failure care. In one study on which this recommendation was based the instructions included a full hour of one-on-one verbal counseling. The intervention was associated with improved outcomes. The “core quality” measure, in contrast, required only that written instructions be given to the patient. It’s one thing to hand patients a ream of paper as they are rushed out the door and quite another to provide detailed counseling. Nominal compliance may earn the hospital a perfect report card while doing little of substance to help patients.

In my recent top 10 post on quality I examined individual performance measures and again noted, concerning heart failure instructions:

Discharge instructions: Same as for smoking cessation above. In the studies which showed discharge instructions to improve outcomes a specialty nurse sat down and spent an hour or two with the patient and family. Hospitals, concerned about bed control and early discharge, don't feel they have time to do this and don't have to to play for the report card.

Now the NEJM reports a disconnect between quality and performance in heart failure instructions:

Methods We examined hospital performance on the basis of two measures of discharge planning: the adequacy of documentation in the chart that discharge instructions were provided to patients with congestive heart failure, and patient-reported experiences with discharge planning. We examined the association between performance on these measures and rates of readmission for congestive heart failure and pneumonia.

Results We found a weak correlation in performance between the two discharge measures (r=0.05, P less than 0.001). Although larger hospitals performed better on the chart-based measure, smaller hospitals and those with higher nurse-staffing levels performed better on the patient-reported measure. We found no association between performance on the chart-based measure and readmission rates among patients with congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile, 23.7% vs. 23.5%; P=0.54) and only a very modest association between performance on the patient-reported measure and readmission rates for congestive heart failure (readmission rates among hospitals performing in the highest quartile vs. the lowest quartile, 22.4% vs. 24.7%; P less than 0.001) and pneumonia (17.5% vs. 19.5%, P less than 0.001).

Although the authors considered both measures as performance measures, the real performance measure was the chart based measure (what the hospitals said they did) whereas the patient's reported experiences were closer to real quality. The correlation between what the institution said it did and what the patient reported was very weak, at r=0.05. Although the patient reported measure was associated with a highly statistically significant reduction in readmission rate the magnitude of the reduction was modest. This may be because the patient questionnaire itself was weak, making it easy to pass the measure (see appendix to the article).

More expensive care sometimes really is better

At least in this study, greater resource expenditure was associated with better outcomes in heart failure.

H/T to Retired Doc. More counterpoints to the Dartmouth Atlas data.

Monday, January 04, 2010

Performance measurement has doctors adrift on Lake Wobegon

In the last JAMA issue of 2009 Donald Berwick mused about quality performance measurement. Doctors' skills vary. Measurement uncovers variation. Variation is considered the enemy of quality. Quality Performance “improvement” initiatives seek to eliminate variation. All doctors would become average. That would never do for most doctors, who need to be above average. What are they to do? Game the system, criticize the methods and indulge in self deception. And so, we remain adrift.

How will Medicare's elimination of consult codes affect hospitalists?

In two ways, most likely. First, it will decrease your own RVUs since much of what you did under the various and ubiquitous comanagement scenarios was, in the past, eligible for consult coding. Now you'll have to use the ordinary admission H&P codes which pay less. Secondly, if you've been having trouble getting subspecialists to do anything other than procedures that will probably get worse, as these physicians will get even less for their cognitive services.

Info from Medscape here and here.

Medullary sponge kidney

Brief discussion in CCJM. A key point is that ultrasound and CT may miss it. You need an IVP. Think if it in a patient with recurrent attacks of pyelonephritis.

Antibiotics for all patients with necrotizing pancreatitis?

This systematic review suggests it may not be warranted:

Based on all available data, antibiotic prophylaxis should not be used in patients with necrotizing pancreatitis. Instead, a more measured, on-demand use of antibiotics is preferred. Antibiotics should be added if signs and symptoms of infection are present (eg, fever, leukocytosis, positive results of cultures). Given improvements in intensive care and nutritional support, recent trials have found a lower incidence of infected necrotizing pancreatitis than before. Therefore, future trials are likely to need higher numbers of patients.

Sunday, January 03, 2010

A spike in narcotic deaths in Canada after shift in prescribing from short to long acting opioids

CMAJ reports:

From January 1991 to May 2007, the prescribing of opioid analgesics in Ontario increased by 29%, from 458 to 591 prescriptions per 1000 individuals annually (Figure 1). Codeine was the most frequently prescribed agent, although the number of prescriptions for the drug declined gradually during the study period. In contrast, the number of oxycodone prescriptions rose more than 850% during the same period, from 23 per 1000 individuals in 1991 to 197 per 1000 in 2007. The prescribing of hydromorphone, fentanyl and morphine also increased considerably over the same period,....

The prescribing change actually took place after 2000 when long acting oxycodone was introduced to the formulary.

We observed a substantial increase in overall opioid-related mortality following the addition of long-acting oxycodone tothe provincial drug formulary in January 2000. Between 1999 and 2004, the annual number of opioid-related deaths increased by 41% (p = 0.02), from 19.4 to 27.2 per million annually (Figure 2, top panel). The number of oxycodone-related deaths increased by 416% (p less than 0.01) during the same period, from 1.39 per million to 7.17 per million annually (Figure 2, bottom panel). The rise in opioid-related deaths was due in large part to inadvertent toxicity; there was no significant increase in the number of deaths from suicide involving opioids over the study period (Figure 3).

A little background. The beginning of this past decade marked a groundswell of activism for more aggressive pain management. It spread to the regulatory agencies (remember Joint Commission's roll out of pain management standards?), the courts, medical journals and even our CME courses. It was based almost entirely on opinion and dogma with very little science. Typical of the preaching of the day was this WJM editorial from 2001:

...there is a standard of care for pain management, a significant departure from which constitutes not merely malpractice but gross negligence. Even if professional boards might not hold their licensees to that standard, juries will. With the implementation of the new pain standards by the Joint Commission for the Accreditation of Healthcare Organizations, which recognize the right of patients to the appropriate assessment and management of their pain, public expectations will likely increase exponentially.

Public expectations did increase. So did the deaths, according to reports from all over, even in hospitalized patients:

The current emphasis on pain assessment as the fifth vital sign and the use of unscientific pain scales is causing serious injury and death from overmedication...

Overmedication with sedatives/narcotics, during the two periods, clearly contributed to deaths in 13 and 32 patients and probably contributed to deaths in 5 and 14 patients, respectively. This occurred in 17 and 43 patients, respectively, after blunt injury and in 1 and 3 patients, respectively, after penetrating injury. Two clinical scenarios predominated, ie, overmedication in preparation for an imaging study and overmedication after discharge from ICU to the floor. The sequel of hypotension and compromised airway requiring intubation initiated a cascade of negative events that led to death.

Purdue Pharma's illegal and non-evidence based promotion of Oxycontin, described in this NYT article from 2007, has some interesting parallels with what doctors were taught in CME courses and by Joint Commission leaders:

Federal officials said that internal Purdue Pharma documents showed that company officers recognized that, even before the drug was marketed, they would face stiff resistance from doctors concerned about the potential of a narcotic like OxyContin to be abused by patients.

As a result, prosecutors charged, the company effectively started a fraudulent and deceptive marketing campaign aimed at convincing doctors that OxyContin, because of its time-release formula, was less prone to abuse, and that it was less likely to cause addiction or to produce other narcotic side effects than competing drugs. In its plea agreement, the company acknowledged doing so.

It reminds me of some of the dogma they were shoving down doctors' throats at the time, including pain management talks at a couple of hospital medicine courses I attended. Our thought leaders told us that because short acting pain medications tended to be used “prn”, thus encouraging patients to repeatedly ask for more doses as analgesic effects wore off, they encouraged a form of “pseudoaddiction” which was really a symptom of inadequate pain control. Although this concern, as well as the concern about patients getting too much tylenol, had some merit, we were also told that addiction and abuse were rare when patients' pain control was adequate.

Industry promotion may have had a role but didn't explain most of the trend. In the U.S., alongside the spike in Oxycontin use was a spike in its generic, non-promoted but equally dangerous competitor methadone which, among narcotics, has been reported to be associated with the greatest number of deaths.

Friday, January 01, 2010

Will hospital medicine “arrive” in 2010?

Well, it is gradually gaining status as a specialty. We have our own professional organization, an official journal, our own textbooks and now even board certification. So how will we really know hospital medicine has arrived? When our word processors finally recognize the word hospitalist!