Friday, May 30, 2008
Not as a Stranger
I watched the 1955 film on TCM the other night. For its time it was an incredibly perceptive commentary on the profession of medicine. Catch it on TCM when you can; it’s not available on DVD. Although it’s fallen into obscurity it’s a much better film than the schmaltzy block buster doctor movie Magnificent Obsession which came out the year before.
Do you really want to promote quality and safety at your hospital?
I really enjoy listening to Donald Berwick, the quality and safety maven who heads up the Institute for Healthcare Improvement. I think we have a lot to learn from him. (Careful, though: he can mesmerize you with a few non-evidence based claims and cause you to take the big leap that says quality equals single payer health care, and come out thinking they were all your ideas).
As I listened to his talk on the web archives of SHM 2008 I started feeling expansive about quality and safety. A few thoughts on the subject follow, some straight from Berwick’s talk along with others from my own random musings.
Although concern for patient safety is as old as the profession it began a 180 degree turn on October 4, 1984. On that evening an 18 year old college freshman was admitted to New York Hospital with fever and mental status changes. Cared for by sleep deprived and overworked house staff with no supervision, she died early the next morning. She was Libby Zion, daughter of powerful attorney and journalist Sidney Zion whose outrage set off a legal and media firestorm. Most readers are familiar with the case and know that it brought us the 80 hour work week rule for residents. Beyond that, it began a shift in the focus of patient safety.
The old notion was that a tireless and vigilant super doc hero was responsible for all details of the patient’s care, constantly intercepting dangers that lay at every turn in the treacherous hospital environment. If something went wrong it meant the doctor, ultimately responsible for everything, just had to work harder. I was trained in that culture. We could never do too much for the patient, even if we had to pass our own medications. A mentor who influenced me deeply, proud of the fact that he ran a very punishing residency program, once told us: “Each of you has the capability to be the best doctor in the world. If you’re not the best doctor in the world you need to work harder.”
Berwick was trained in that culture too, and it took him years to realize how wrong the thinking was. You won’t enhance patient safety by beating up on people to work harder. The new thinking? Systems and design. It’s Berwick’s first rule and it means that the safety nets and redundancies to intercept inevitable human error must be part of your system’s design. We’ve heard “systems approach” to patient safety until it sounds trite. But Berwick’s examples and arguments bring the concept to life.
Design is rule number 1. Rule number 2, my own rule, is to be proactive. Don’t wait for Joint Commission and CMS to tell you what to do. A corollary is not to limit yourself to what JC and CMS require you to do. The problem with the so called core measures is that hospitals, in their quest for good report cards, focus on them to the exclusion of quality improvements that matter more. The core measures as currently promulgated have been largely ineffective, not because they’re not evidence based (many are) but because unintended consequences of playing for the report card counterbalance benefits. Opportunities to put more robust measures into practice tend to be slighted. Examples are applied hypothermia after cardiac arrest and early goal directed therapy for sepsis, measures which have fallen short of widespread implementation years after publication of evidence. Getting a commitment from your institutional leaders, who no doubt want to “focus on the core measures”, may be a challenge.
Rule number 3 is not to get unnecessarily bogged down in your hospital’s committees. Your hospitalist group can brainstorm and formulate an initiative faster and more effectively than your hospital’s committee structure. Most proposals have to go through several committees, some of which may only meet once a quarter. If your proposal requires institutional commitment it will ultimately have to go through committees, but have the details and the supporting evidence ready to present first.
As I listened to his talk on the web archives of SHM 2008 I started feeling expansive about quality and safety. A few thoughts on the subject follow, some straight from Berwick’s talk along with others from my own random musings.
Although concern for patient safety is as old as the profession it began a 180 degree turn on October 4, 1984. On that evening an 18 year old college freshman was admitted to New York Hospital with fever and mental status changes. Cared for by sleep deprived and overworked house staff with no supervision, she died early the next morning. She was Libby Zion, daughter of powerful attorney and journalist Sidney Zion whose outrage set off a legal and media firestorm. Most readers are familiar with the case and know that it brought us the 80 hour work week rule for residents. Beyond that, it began a shift in the focus of patient safety.
The old notion was that a tireless and vigilant super doc hero was responsible for all details of the patient’s care, constantly intercepting dangers that lay at every turn in the treacherous hospital environment. If something went wrong it meant the doctor, ultimately responsible for everything, just had to work harder. I was trained in that culture. We could never do too much for the patient, even if we had to pass our own medications. A mentor who influenced me deeply, proud of the fact that he ran a very punishing residency program, once told us: “Each of you has the capability to be the best doctor in the world. If you’re not the best doctor in the world you need to work harder.”
Berwick was trained in that culture too, and it took him years to realize how wrong the thinking was. You won’t enhance patient safety by beating up on people to work harder. The new thinking? Systems and design. It’s Berwick’s first rule and it means that the safety nets and redundancies to intercept inevitable human error must be part of your system’s design. We’ve heard “systems approach” to patient safety until it sounds trite. But Berwick’s examples and arguments bring the concept to life.
Design is rule number 1. Rule number 2, my own rule, is to be proactive. Don’t wait for Joint Commission and CMS to tell you what to do. A corollary is not to limit yourself to what JC and CMS require you to do. The problem with the so called core measures is that hospitals, in their quest for good report cards, focus on them to the exclusion of quality improvements that matter more. The core measures as currently promulgated have been largely ineffective, not because they’re not evidence based (many are) but because unintended consequences of playing for the report card counterbalance benefits. Opportunities to put more robust measures into practice tend to be slighted. Examples are applied hypothermia after cardiac arrest and early goal directed therapy for sepsis, measures which have fallen short of widespread implementation years after publication of evidence. Getting a commitment from your institutional leaders, who no doubt want to “focus on the core measures”, may be a challenge.
Rule number 3 is not to get unnecessarily bogged down in your hospital’s committees. Your hospitalist group can brainstorm and formulate an initiative faster and more effectively than your hospital’s committee structure. Most proposals have to go through several committees, some of which may only meet once a quarter. If your proposal requires institutional commitment it will ultimately have to go through committees, but have the details and the supporting evidence ready to present first.
Thursday, May 29, 2008
Chylomicronemia syndrome
These patients present with extreme hypertriglyceridemia and abdominal pain which may or may not be associated with pancreatitis. Clinical manifestations and treatment are reviewed here. (Via American Journal of Medicine).
Hospitalists’ quest to define their value---are there lessons from emergency medicine?
Through the years I’ve watched emergency medicine mature and grow from humble beginnings into a well established specialty. There are parallels and lessons there for the hospitalist movement. Emergency medicine is a specialty defined by location. Like hospital medicine today, emergency medicine once competed with a “traditional model” of care. Under the traditional model emergency rooms, lacking dedicated physician staffing, were covered by community physicians. When emergentologists entered the scene community physicians viewed it as an intrusion and many chose to continue seeing their own patients in the ER. Patients asked “where’s my doctor?” and often complained to administration. How attitudes have changed!
But there’s one parallel I don’t see. I don’t recall an obsession among emergency medicine doctors with convincing others of their “value”. The value of emergency medicine was self evident. The need was there and emergency medicine responded.
Self promotion is a distraction. Maybe the hospitalist movement should relax. If we concentrate on taking better and better care of hospitalized patients others will see our value.
But there’s one parallel I don’t see. I don’t recall an obsession among emergency medicine doctors with convincing others of their “value”. The value of emergency medicine was self evident. The need was there and emergency medicine responded.
Self promotion is a distraction. Maybe the hospitalist movement should relax. If we concentrate on taking better and better care of hospitalized patients others will see our value.
European docs aren’t adhering to evidence based heart failure strategies
---according to this paper in the European Heart Journal, anyway. Although at the bottom of the paper is says “Conflict of interest: none declared” I suspect the authors represent subspecialists who have an interest in heart failure patients being referred to them and in cardiac imaging being performed.
DB’s Medical Rants offers a useful perspective on the issue. I would only add that the BBC News piece which covered the story got it wrong about echocardiography. A caption reads: “An echocardiogram should be used to confirm heart failure.” Wrong. An echo is indicated to classify heart failure, better understand the patient’s cardiac anatomy and physiology and guide treatment, not to diagnose or confirm. The ACC guidelines say this about diagnosing heart failure:
DB’s Medical Rants offers a useful perspective on the issue. I would only add that the BBC News piece which covered the story got it wrong about echocardiography. A caption reads: “An echocardiogram should be used to confirm heart failure.” Wrong. An echo is indicated to classify heart failure, better understand the patient’s cardiac anatomy and physiology and guide treatment, not to diagnose or confirm. The ACC guidelines say this about diagnosing heart failure:
It should be emphasized that HF is not equivalent to cardiomyopathy or to LV dysfunction; these latter terms describe possible structural or functional reasons for the development of HF. Instead, HF is defined as a clinical syndrome that is characterized by specific symptoms (dyspnea and fatigue) in the medical history and signs (edema, rales) on the physical examination. There is no single diagnostic test for HF because it is largely a clinical diagnosis that is based on a careful history and physical examination.
Unstable Angina and NSTEMI guidelines made simple
The 2007 updated ACC guidelines for unstable angina and NSTEMI are complex. At the UCSF hospital medicine conference last October Dr. Edward McNulty helped attendees make sense of it all, and the key points of his lecture are reviewed here in Today’s Hospitalist.
Wednesday, May 28, 2008
Orac debunks Stanford’s therapeutic touch “trial”
It looks more like promotion to me. Post-scientific medicine is on the march. Read here.
What’s hospital medicine’s raison d’etre?
One of Kevin’s commenters, writing in response to my post from yesterday, said:
So we need a reason for our existence---a raison d’etre as Donald Berwick put it in his address at SHM 2008. It was the topic of mental masturbation in San Diego last April and centered around the concept of value. As I posted yesterday, the opening panel talked around what seemed an elusive definition. A disturbing consensus emerged that hospitalists may have to reinvent themselves to take over the inpatient environment and function as “house doctors”, going beyond their comfort zone and training, admitting all patients, doing virtually everything. I noted serious professional satisfaction and burn out issues for hospitalists if that scenario plays out. I’m not the only one concerned. Today another one of Kevin’s commenters said this:
That should sound a note of caution regarding what we ask and expect hospitalists to do.
IHI CEO Donald Berwick, in the talk that followed, presented an even more grandiose vision that takes hospitalists outside the walls of the facility to become “integrators” in the grand scheme of public health and advocates for a universal system. But then we wouldn’t be hospitalists any more, would we? How many of us entered the field to be public health experts and policy wonks? Not many, I’d say.
Judging from today’s blog reactions I think I may have been misunderstood to say the movement is in jeopardy. I don’t believe that at all. Retired Doc said this:
As a hospitalist I can take the same view. If I succeed in stabilizing a few patients and making my hospital a better place I’ve had a good day.
I’ve been an observer and a participant in the movement since the early years. For me the reason to be a hospitalist has always been simple. There’s a niche to fill. That niche was created by professional and economic factors in our health care system. And it’s not going away.
I have long been a sole dissenting voice in the hospitalist debate; I do not think the model will last. Most hospitalist programs are subsidized under the argument that they save money. However, this has not been proven in a significant way. Eventually, they will have outlasted their usefulness and be replaced either by cheaper hospitalist midlevel providers or by the primary care doctors returning to hospital care (not subsidized).
So we need a reason for our existence---a raison d’etre as Donald Berwick put it in his address at SHM 2008. It was the topic of mental masturbation in San Diego last April and centered around the concept of value. As I posted yesterday, the opening panel talked around what seemed an elusive definition. A disturbing consensus emerged that hospitalists may have to reinvent themselves to take over the inpatient environment and function as “house doctors”, going beyond their comfort zone and training, admitting all patients, doing virtually everything. I noted serious professional satisfaction and burn out issues for hospitalists if that scenario plays out. I’m not the only one concerned. Today another one of Kevin’s commenters said this:
I was a hospitalist for 5 years at a major New York hospital. Their solution for getting the most for their money was by having us do a lot of non-hopsitalist work.. i.e. teach physical diagnosis to med students, farm us out to a nursing home, cover a dedicated service for a certain insurance company. It sucked, which is why I left. They say the average life span of a hospitalist is 5 years. There's a reason.
That should sound a note of caution regarding what we ask and expect hospitalists to do.
IHI CEO Donald Berwick, in the talk that followed, presented an even more grandiose vision that takes hospitalists outside the walls of the facility to become “integrators” in the grand scheme of public health and advocates for a universal system. But then we wouldn’t be hospitalists any more, would we? How many of us entered the field to be public health experts and policy wonks? Not many, I’d say.
Judging from today’s blog reactions I think I may have been misunderstood to say the movement is in jeopardy. I don’t believe that at all. Retired Doc said this:
Even as the future for hospitalist might appear less rosy, we should not forget that the safety and quality movement leader guru, Dr. Donald Berwick still has much for them to do as they become the change agents and integrators of a new medical system that will provide quality care, reduce costs and improve public health. I guess it is better that I did not become a hospitalist as all I could do on a good day was to take as good of care of my patients as I could leaving the problems of maximizing public health and obtaining universal medical coverage to someone else.
As a hospitalist I can take the same view. If I succeed in stabilizing a few patients and making my hospital a better place I’ve had a good day.
I’ve been an observer and a participant in the movement since the early years. For me the reason to be a hospitalist has always been simple. There’s a niche to fill. That niche was created by professional and economic factors in our health care system. And it’s not going away.
Tuesday, May 27, 2008
A bumpy ride ahead for the hospitalist movement?
As a member of the Society of Hospital Medicine I have the opportunity to view archived presentations of SHM 2008. Last night I watched the lecture by Institute for Healthcare Improvement CEO Donald M. Berwick, MD and the panel discussion immediately preceding. It was both fascinating and disturbing.
A recurring theme was that health care providers with competing agendas are seeking bigger and bigger pieces of a shrinking financial pie. How will hospitalists fare in the competition, particularly with Medicare’s impending move toward bundling of payments and even a proposal for combining payment to the hospital and the physicians for episodes of care? The panel, coming just short of considering it a fait accompli, would do well to remember a little history. Just such a proposal was floated in 1984: the Kennedy-Gephardt bill. Among other provisions it sought to:
Thank goodness it died. But if after 24 years it’s resurrected hospitalists will finally be employees in every sense of the word. Tension between white coats and suits will mount. Does it mean the bubble of increasing hospitalist salaries will burst?
Two answers emerged from the panel. The first was nebulous: hospitalists must demonstrate “value”. What does that mean, exactly? As hospitalists we think our model has value, but how is it measured? Not only is it vague, but, as the panel pointed out, it’s a shifting target. Early in the movement we thought we could demonstrate value in terms of reduced costs and better outcomes. But research on those metrics during the ensuing years was disappointing. Moreover, according to an abstract presentation at the meeting, the move toward hospitalist shift work and the resulting fragmentation of care during hospitalization may be eroding any slim advantage the model had in cost savings. So what’s left that we can demonstrate as value? Patient satisfaction in an age of consumer driven and “patient centered” care? Research suggests we’re value neutral in that area. So the latest buzz seems to be that hospitalists will take advantage of the fact that other doctors are fleeing the building faster than you can say “code brown”. That means admitting all comers, doing “everything” and functioning outside our training and comfort zones, essentially becoming “house doctors”. It's sure to create job satisfaction and burnout issues, already a problem for the movement.
The other answer was more down to earth: the bubble will burst the morning CEOs wake up and realize that there is no longer a shortage of hospitalists. Don’t expect that to happen for decade or so according to the panel. One thing we can all agree on---it’ll be a bumpy ride.
A recurring theme was that health care providers with competing agendas are seeking bigger and bigger pieces of a shrinking financial pie. How will hospitalists fare in the competition, particularly with Medicare’s impending move toward bundling of payments and even a proposal for combining payment to the hospital and the physicians for episodes of care? The panel, coming just short of considering it a fait accompli, would do well to remember a little history. Just such a proposal was floated in 1984: the Kennedy-Gephardt bill. Among other provisions it sought to:
Attempt to "improve' PPS further by including inpatient physician services within DRG payments to hospitals. "It will be the responsibility of the hospitals and the physicians providing the care to allocate the payment.'
Thank goodness it died. But if after 24 years it’s resurrected hospitalists will finally be employees in every sense of the word. Tension between white coats and suits will mount. Does it mean the bubble of increasing hospitalist salaries will burst?
Two answers emerged from the panel. The first was nebulous: hospitalists must demonstrate “value”. What does that mean, exactly? As hospitalists we think our model has value, but how is it measured? Not only is it vague, but, as the panel pointed out, it’s a shifting target. Early in the movement we thought we could demonstrate value in terms of reduced costs and better outcomes. But research on those metrics during the ensuing years was disappointing. Moreover, according to an abstract presentation at the meeting, the move toward hospitalist shift work and the resulting fragmentation of care during hospitalization may be eroding any slim advantage the model had in cost savings. So what’s left that we can demonstrate as value? Patient satisfaction in an age of consumer driven and “patient centered” care? Research suggests we’re value neutral in that area. So the latest buzz seems to be that hospitalists will take advantage of the fact that other doctors are fleeing the building faster than you can say “code brown”. That means admitting all comers, doing “everything” and functioning outside our training and comfort zones, essentially becoming “house doctors”. It's sure to create job satisfaction and burnout issues, already a problem for the movement.
The other answer was more down to earth: the bubble will burst the morning CEOs wake up and realize that there is no longer a shortage of hospitalists. Don’t expect that to happen for decade or so according to the panel. One thing we can all agree on---it’ll be a bumpy ride.
Friday, May 23, 2008
Guidelines for the evaluation of fever in the ICU
This guideline, jointly prepared by the Infectious Disease Society of America and the Society of Critical Care Medicine, is available as free full text at the IDSA web site and represents the first revision in 10 years. Points of interest follow:
A new fever should trigger a clinical assessment rather than automatic orders for laboratory and radiographic testing.
Blood cultures, however, are indicated in all patients except those in whom the clinical assessment strongly indicates a non-infectious source of fever. Paired cultures rather than single cultures are recommended.
A clear approach to fever in patients with central venous lines is outlined.
Consider chest CT scanning in patients with negative plain chest x rays who are suspected of having pulmonary infections, particularly if immunocompromised.
Don’t forget nosocomial sinusitis.
“Catheter-associated bacteriuria or candiduria usually represents colonization,
is rarely symptomatic…” (Clinical documentation specialists, take note!).
Information on post operative fever and empiric antibiotic therapy is presented.
A new fever should trigger a clinical assessment rather than automatic orders for laboratory and radiographic testing.
Blood cultures, however, are indicated in all patients except those in whom the clinical assessment strongly indicates a non-infectious source of fever. Paired cultures rather than single cultures are recommended.
A clear approach to fever in patients with central venous lines is outlined.
Consider chest CT scanning in patients with negative plain chest x rays who are suspected of having pulmonary infections, particularly if immunocompromised.
Don’t forget nosocomial sinusitis.
“Catheter-associated bacteriuria or candiduria usually represents colonization,
is rarely symptomatic…” (Clinical documentation specialists, take note!).
Information on post operative fever and empiric antibiotic therapy is presented.
Improve hospital efficiency by defining the goals of hospitalization
Do this at the outset. Otherwise patients and families may expect you to “fix everything” that’s wrong with the patient. From Hospitalist News:
…ensure patient and family “buy-in” to the hospitalization goal. As our hospital patients continue to get sicker, I have found that patients and their families see the hospital as a place to solve all of their medical problems. There has to be a limit on tangential evaluations that lead to testing that is unrelated to why the patient is in the hospital.
Thursday, May 22, 2008
Can the electrocardiogram help diagnose MI in patients with LBBB or ventricular pacing?
We were once taught that the presence of LBBB or ventricular pacing precludes electrocardiographic diagnosis of MI or ischemia. It ain’t necessarily so.
If ST changes of acute STEMI occur in the same direction as secondary ST changes of LBBB, exaggerated ST displacement may be noted. If they occur in the opposite direction highly specific concordant ST changes may be seen, reflecting a “tug o’ war on the stylus.”
For clues to old infarction look for Cabrara’s sign along with qS or Qs complexes.
Pseudoinfarcton patterns can be seen with cardiac memory, fusion and bi-ventricular pacing.
The electrocardiographic clues for infarction in patients with RV pacing differ slightly from those in patients with LBBB.
All the nuances were discussed, and fascinating tracings provided, in two reviews from Cardiology Clinics.
If ST changes of acute STEMI occur in the same direction as secondary ST changes of LBBB, exaggerated ST displacement may be noted. If they occur in the opposite direction highly specific concordant ST changes may be seen, reflecting a “tug o’ war on the stylus.”
For clues to old infarction look for Cabrara’s sign along with qS or Qs complexes.
Pseudoinfarcton patterns can be seen with cardiac memory, fusion and bi-ventricular pacing.
The electrocardiographic clues for infarction in patients with RV pacing differ slightly from those in patients with LBBB.
All the nuances were discussed, and fascinating tracings provided, in two reviews from Cardiology Clinics.
Allopurinol hypersensitivity syndrome
---is characterized by severe dermatologic manifestations and sometimes multiorgan failure. It is believed to be due to accumulation of a metabolite and may be dose related. Risk can be decreased by following labeling recommendations for dose adjustment in renal failure, but such recommendations are often ignored. A case summary and brief review are presented in the American Journal of Medicine.
Wednesday, May 21, 2008
Multisystem effects of spontaneous bacterial peritonitis
Dated but interesting, from Hepatology.
In conclusion, patients with SBP frequently develop a rapidly progressive impairment in systemic hemodynamics, leading to severe renal and hepatic failure, aggravation of portal hypertension, encephalopathy, and death. This occurs despite rapid resolution of infection and is associated with an extremely poor prognosis.
Watch those bounce-backs
We all know about the bounce-back---the patient who is readmitted a short time following hospital discharge, often with the same problem. The growing primary care shortage along with economic incentives for hospitals to discharge patients ASAP often leads to fragmented (or nonexistent) post hospital care, thus aggravating the problem of early readmissions.
Bob Wachter, writing about this on his blog late last year, noted that on the hospital side we’re not doing a very good job with transitions:
Right now hospitals have no incentives to prevent bounce-backs. Keeping patients an extra day or two and making detailed arrangements for post hospital care costs money. So what if the patient bounces back in a week or two---the hospital gets a whole new DRG payment.
Wachter indicated in his post that that may be about to change:
Now there are rumblings, via Hospitalist News, that Medicare is considering bundling payments for episodes of hospital care, which it defines as including the 30 days post hospital discharge:
Gainsharing? It sounds more like loss sharing to me. I don’t know what all the verbiage means, but it could mean a “no pay” policy for readmissions within 30 days.
If this causes hospitals to devote more resources to transitions (read Wachter’s suggestions about the Transitions Officer) it’s a good thing, right? It depends on the inevitable unintended consequences. Financially struggling hospitals may be forced to close. Others will continue to play the perpetual and ever changing game: Medicare sets rules---hospitals adapt---Medicare changes rules---hospitals adapt again---Medicare changes rules again.
Bob Wachter, writing about this on his blog late last year, noted that on the hospital side we’re not doing a very good job with transitions:
Although we’re not very good at washing our hands, we are terrific at washing our hands of patients who leave our medical radar screens.
Right now hospitals have no incentives to prevent bounce-backs. Keeping patients an extra day or two and making detailed arrangements for post hospital care costs money. So what if the patient bounces back in a week or two---the hospital gets a whole new DRG payment.
Wachter indicated in his post that that may be about to change:
All of this is about to change. Look for oodles of publicly-reported measures of case-mix-adjusted readmission rates coming online in the next few years, which will force us finally to focus on filling the post-discharge black hole. And that won’t be all. How about a measure of the percent of hospital discharge summaries that made it to the primary physician within 72 hours? The Joint Commission is considering it. Or try this one: a consultant doesn’t get paid until there is documentation that his or her consult report made it back to the requesting doc. Impossible? It’s being batted around in policy circles.
Now there are rumblings, via Hospitalist News, that Medicare is considering bundling payments for episodes of hospital care, which it defines as including the 30 days post hospital discharge:
At its April meeting, the commission (MedPAC) unanimously voted to include a bundling recommendation in its June report to Congress. As a first step, physicians and hospitals should be required to report to the Centers for Medicare and Medicaid Services (CMS) on resource use and readmissions during an “episode of care,” which is proposed to include the first 30 days post hospitalization. The data would be confidential initially, but should be made public by the third year, MedPAC commissioners recommended.
Once the resource and readmission data are in hand, CMS should start adjusting payment to hospitals, according to the recommendation. There would be the possibility for gainsharing among hospitals and physicians. The commissioners also voted to
direct CMS to study the feasibility of “virtual” bundling. With virtual bundling, the payment would be adjusted based on aggregate use of services over an entire episode of care.
Gainsharing? It sounds more like loss sharing to me. I don’t know what all the verbiage means, but it could mean a “no pay” policy for readmissions within 30 days.
If this causes hospitals to devote more resources to transitions (read Wachter’s suggestions about the Transitions Officer) it’s a good thing, right? It depends on the inevitable unintended consequences. Financially struggling hospitals may be forced to close. Others will continue to play the perpetual and ever changing game: Medicare sets rules---hospitals adapt---Medicare changes rules---hospitals adapt again---Medicare changes rules again.
Tuesday, May 20, 2008
Extraintestinal manifestations of Crohn’s disease
A case report of uveitis as the as the presenting manifestation is presented, along with a review of extraintestinal manifestations if IBD and differential diagnostic considerations.
Via Nature Clinical Practice Gastroenterology and Hepatology.
Via Nature Clinical Practice Gastroenterology and Hepatology.
From meeting presentation to peer reviewed journal---POISE hits the pages of Lancet
The POISE (Perioperative Ischemic Evaluation) beta blocker study was presented at AHA last November. I blogged about it in a year end wrap up of developments in perioperative medicine. Last Tuesday the study was published in Lancet. The spin regarding this study has been largely negative. Missing from the discussion is the fact that the beta blocker use was associated with benefit for the primary endpoint. From the Lancet:
But wait a minute. Secondary endpoints pointed to harm associated with metoprolol:
Clinical trial experts criticize conclusions based on secondary endpoints when such endpoints are positive, as seen in the PROACTIVE controversy.
So, how should we view the POISE results? In the case of POISE the secondary endpoints were those that mattered more. The authors concluded:
Understated, perhaps, but true. The second sentence was interesting in that it acknowledged the role of patient participation in decision making.
DB blogged about the study Friday as an important lesson for the performance and safety movement:
It gets you thinking---who makes up these safety and performance measures anyway? What are their credentials other than being effective cheerleaders (“champions” is the trendy term, I believe)?
DB also linked to Medscape’s Heartwire report about the trial. Dr Philip J Devereaux, who originally presented the POISE data at AHA, said in the report:
Where’s the press coverage of all these deaths? While a few reports such as this one hyped the results by and large the media response was modest. They didn’t have Big Pharma to pick on. What if, instead of an old, cheap off-patent medication the drug in question had been a new expensive block buster which had been heavily promoted by one of the big drug companies? I can only imagine.
The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal cardiac arrest……Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint (244 [5·8%] patients in the metoprolol group vs 290 [6·9%] in the placebo group; hazard ratio 0·84, 95% CI 0·70–0·99; p=0·0399). Fewer patients in the metoprolol group than in the placebo group had a myocardial infarction (176 [4·2%] vs 239 [5·7%] patients; 0·73, 0·60–0·89; p=0·0017).
But wait a minute. Secondary endpoints pointed to harm associated with metoprolol:
However, there were more deaths in the metoprolol group than in the placebo group (129 [3·1%] vs 97 [2·3%] patients; 1·33, 1·03–1·74; p=0·0317). More patients in the metoprolol group than in the placebo group had a stroke (41 [1·0%] vs 19 [0·5%] patients; 2·17, 1·26–3·74; p=0·0053).
Clinical trial experts criticize conclusions based on secondary endpoints when such endpoints are positive, as seen in the PROACTIVE controversy.
So, how should we view the POISE results? In the case of POISE the secondary endpoints were those that mattered more. The authors concluded:
Our results highlight the risk in assuming a perioperative β-blocker regimen has benefit without substantial harm, and the importance and need for large randomised trials in the perioperative setting. Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol.
Understated, perhaps, but true. The second sentence was interesting in that it acknowledged the role of patient participation in decision making.
DB blogged about the study Friday as an important lesson for the performance and safety movement:
Second, the performance indicator and safety movement which has a "ready, fire, aim" philosophy, must reevaluate their strategies. One must wonder if our current push towards performance measurement has caused strokes and death in some patients. Finally, 30 years after finishing my residency, I continue to reshape my medical knowledge. As new knowledge appears we must quickly adjust our practice. I am interested in the ability of the performance movement to adjust. Of course, they will shrug off the unintended consequences that they caused here.
It gets you thinking---who makes up these safety and performance measures anyway? What are their credentials other than being effective cheerleaders (“champions” is the trendy term, I believe)?
DB also linked to Medscape’s Heartwire report about the trial. Dr Philip J Devereaux, who originally presented the POISE data at AHA, said in the report:
"If even only 10% of physicians followed these guidelines—which incidentally in the United States are used in quality assessments, where you have people going around ranking hospitals in terms of whether or not they are giving perioperative beta blockers—and if the POISE data are true, then in the past decade 800,000 people would have died prematurely and 500,000 would have had a major stroke perioperatively because we gave beta blockers….”
Where’s the press coverage of all these deaths? While a few reports such as this one hyped the results by and large the media response was modest. They didn’t have Big Pharma to pick on. What if, instead of an old, cheap off-patent medication the drug in question had been a new expensive block buster which had been heavily promoted by one of the big drug companies? I can only imagine.
Monday, May 19, 2008
Subscribe to:
Posts (Atom)