ER-hospitalist tensions

Having trouble getting along with your ER colleagues? Talk to each other! That and other tips from Today’s Hospitalist.

Tricks of the trade in the management of C diff

Two recent articles form The Hospitalist offer some tips.

Fournier’s gangrene

Review in Hospital Physician.

Experts can be good for patients

---and now that’s evidence based. From JAMA:

Conclusions In this registry, nonelectrophysiologists implanted 29% of ICDs. Overall, implantations by a nonelectrophysiologist were associated with a higher risk of procedural complications and lower likelihood of receiving a CRT-D device when indicated compared with patients whose ICD was implanted by an electrophysiologist.

Via Dr. Wes.

Urine sediment exam in acute renal failure

I love it when low technology offers powerful diagnostic tools. Thomas E. Brittingham, M.D., one of Vanderbilt’s great teachers, would tell third year medical students:

Examination of the peripheral blood film and of the urinary sediment are powerful diagnostic tools, much as is physical examination of the heart. The power of these tests is unappreciated by many physicians….

Recently the performance of urine microscopy in the diagnosis of ATN was systematically evaluated:

Results: The urinary sediment scoring system was highly predictive of the final diagnosis of ATN. In patients with a high pretest probability of ATN (initial diagnosis of ATN), any casts or RTEC (score 2) resulted in very high positive predictive value and low negative predictive value for a final diagnosis of ATN. In patients with a low pretest probability of ATN (initial diagnosis of prerenal AKI), lack of casts or RTEC on urinary
sediment examination had a sensitivity of 0.73 and specificity of 0.75 for a final diagnosis of prerenal AKI. The negative predictive value of lack of casts or RTEC in patients with low pretest probability of disease was 91%.

Conclusions: Urine sediment examination is a valuable diagnostic tool for confirming the diagnosis of ATN. A score of 2 on an ATN urinary sediment scoring system is an extremely strong predictor of ATN.

Pneumococcal vaccines

Read this. Then imagine how your world as a hospitalist would change if we had an adult pneumococcal vaccine that actually worked.

A double evidentiary standard

If it’s a drug or a surgical procedure insist on a randomized clinical trial. If it’s a system of care (e.g. rapid response teams) go with your passions and instincts, says Donald Berwick in this keynote address from somewhere.




I respectfully disagree.

DB on comparative effectiveness research

DB was recently blogging from the ACP national meeting. His post on the keynote, about comparative effectiveness research (CER), opens with:

Many med bloggers do not appear to support CER. Many "conservatives" appear to oppose CER. I truly believe that opposition is not based on an understanding of CER’s importance.

I am one of the med bloggers who has been less than enthusiastic about the new CER agenda and I am a political conservative. While I don’t know if I am one of the bloggers referenced by DB as being opposed to CER I think this would be a good time for me to clarify my views and pose some questions.

First, I don’t know of any med bloggers or politicians who are truly opposed to CER. If they were they would have raised objections to the CER that has been going on for decades long before it became a political agenda.

In over 30 years of clinical practice I have taken advantage of a great deal of CER to help me make decisions. Ever aware that science is a work in progress and that we will always need more and more research at many levels it never occurred to me that we needed a special agenda. I have never been opposed to CER, but I am suddenly very skeptical now that it has become politicized.

So, I don’t think this discussion is mainly about CER. I think it’s about an agenda for more government largesse based in part on distrust of the pharmaceutical industry. I had to laugh when I read this paragraph from Harold Sox’s keynote at the ACP meeting (italics mine):

In summary, the public isn’t getting its money’s worth from our system of industry sponsored clinical research. The public pays the costs of drug trials through higher drug prices drugs but gets research with tells us everything we need to know to make good decisions. We get more for our money with the NIH-sponsored trials that we support with our taxes.

Again I'll remind readers that we've already spent about a billion on research sponsored by a subsidiary of the NIH which by any reasonable account has been a tremendous waste.

DB concludes with:

CER will provide more unbiased data - I do not understand how that could be bad.

No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.

What’s going on with swine flu?

Over the last couple of days I’ve been trying to cut through the hype about swine flu. It’s been difficult because media reports are coming at a dizzying pace. Here follows the result of my attempt in Q&A format:

Is this the same swine flu that caused the 1976 scare? Although both are of the H1N1 subtype, apparently this one is different. Officials have indicated that this is a strain never before isolated. Recall that fears that the 1976 Fort Dix swine flu outbreak would morph into a pandemic were unfounded.

This virus is of the H1N1 subtype. So was the virus that caused the 1918 pandemic. Are they the same virus? No. Again, officials say this virus has never been seen before, and it has elements of three animal strains and one human strain. The 1918 pandemic virus resulted from a direct mutation of a pure avian strain.

What is the pandemic risk? The World Health Organization believes the threat of a pandemic exists. The finding of elements of three animal strains and one human strain suggests that it developed by genetic reassortment rather than a direct mutation. In the past, strains created by genetic reassortment have resulted in milder pandemics (1957, 1968) than that created by direct mutation (1918). The 1957 and 1968 strains, however, were the result of reassortment between one human and one animal strain. The new swine flu strain contains elements from three animal strains and could conceivably be more virulent than the 1957 and 1968 strains. For background information on genetic reassortment as opposed to direct mutation causing pandemic flu consult this reference.

What is the relationship between the U.S. and the Mexico cases? Of the much larger number of cases of severe influenza like illness in Mexico only a small minority are thus far confirmed as swine flu. From the WHO report:

24 April 2009 -- The United States Government has reported seven confirmed human cases of Swine Influenza A/H1N1 in the USA (five in California and two in Texas) and nine suspect cases. All seven confirmed cases had mild Influenza-Like Illness (ILI), with only one requiring brief hospitalization. No deaths have been reported.

The Government of Mexico has reported three separate events. In the Federal District of Mexico, surveillance began picking up cases of ILI starting 18 March. The number of cases has risen steadily through April and as of 23 April there are now more than 854 cases of pneumonia from the capital. Of those, 59 have died. In San Luis Potosi, in central Mexico, 24 cases of ILI, with three deaths, have been reported. And from Mexicali, near the border with the United States, four cases of ILI, with no deaths, have been reported.

Of the Mexican cases, 18 have been laboratory confirmed in Canada as Swine Influenza A/H1N1, while 12 of those are genetically identical to the Swine Influenza A/H1N1 viruses from California.

I don’t usually appeal to the popular media for perspectives in health issues but this piece by Dr. Marc Siegel seemed helpful.

Here’s more from Kevin MD.

Follow CDC Twitter updates here.

Here is CDC’s main swine flu page with additional links.

WHO information here.

Disclaimer: This post is the result of the efforts of a non-expert to make some sense of the media hype by going to primary sources. Don’t accept what I say uncritically. Check the links above. This story is changing rapidly and much of what is stated here may be wrong in a few days.

PE is common in patients hospitalized with COPD exacerbation

---as noted in this recent paper. Another study a couple of years ago found the same thing, and I cited it here.

Authors of the recent paper conclude:

A diagnosis of PE should be considered in patients with exacerbation severe enough to warrant hospitalization, especially in those with an intermediate-to-high pretest probability of PE.

Testing in these patients needs to be individualized and based on careful clinical assessment. Inappropriate knee-jerk CT scanning may result in a spike in renal failure.

Why use CT contrast in the evaluation for appendicitis?

Accumulating evidence suggests it’s not necessary. Emergency Medicine professor Richard Bukata went on a rant about it in a recent issue of Emergency Medicine News. Concerning oral contrast he said:

Many radiologists insist on it even when emergency physicians don't want it, it adds hours to the patient evaluation, and it dumps a large oral fluid load on a patient who may be having surgery, increasing the risk of aspiration, at least theoretically. All sorts of literature on this topic indicate that oral contrast adds little if anything to the evaluation when compared with noncontrast CTs, but this topic seems to be highly resistant to the evidence.

Concerning IV contrast:

IV contrast?! What possible reason could there be for using IV contrast in the patient with suspected appendicitis? I thought IV contrast was about the evaluation of solid organs such as liver, spleen, and kidneys. …. Using oral contrast is bad enough, but IV contrast is not without risks, particularly if there are issues regarding renal compromise.

He cited a couple of papers favoring non-contrast, the older of which I noted here.

Pitfalls in EMR documentation

Recently I’ve posted a couple of anecdotal reports of documentation and coding fraud driven by electronic medical record documentation tools. I could just see the Medicare auditors licking their chops when I read those reports. Now those fears are confirmed. A recent Medical Economics article reports:

Recent audits by federal agencies confirm the warnings about E/M compliance dangers accompanying documentation shortcuts introduced by many current EHR software designs. These audits are a clarion call for stakeholders to eliminate the problems they have created, however unintended.

So how does an auditor know whether or not you actually did a twelve system review? From my read here are some ways EMRs get docs in trouble:

1) The EMR tools drive (sometimes almost force) documentation that is excessive for the severity of the presenting problem. The patient who comes in for a sprained ankle gets a twelve system review and family history because the EMR automatically imports such text, then the folks in your coding department bill accordingly. Medicare looks to see whether the severity of the patient’s problem matches the documentation, and if it doesn’t it’s a red flag.

2) The EMR tools generate implausible documentation, e.g. the one year old who is oriented times three, or whose pupils react to accommodation.

3) The templates generate multiple records with nearly identical text. This is a red flag which may cause the Medicare recovery auditor to cast a deeper and wider net.

4) The templates default to multisystem reviews and exams whether you do them or not, and it takes time and trouble to edit them out. If too many of your notes are so rich in documentation the auditor will look askance.

Not long ago a physician pitching a certain EMR product showed how to generate a complete H&P with a few mouse clicks. Very little editing was necessary, he told us, because almost all patients who presented with that particular problem had similar findings.

Unfortunately doctors are being held to a double standard regarding the old maxim: if you didn’t document it you didn’t do it. So don’t expect the Medicare auditor to believe that just because you did document it you did do it.

Although the article focused on coding and documentation, other downsides of the EMR were mentioned:

Physicians have long been counseled that a well-documented medical record provides the best defense in the event of a claim of medical liability. The June 2008 issue of the Journal of AHIMA quoted EHR legal expert Patricia Trites on the potential danger of electronic systems that permit copying of near-identical documentation into large numbers of patient records: "From a medical-legal standpoint, what would [lawyers] do when they [see] this chart?" she asks. "They are going to rip it apart."

One of the commenters noted:

I have personally been an expert witness in 5 malpractice case in two years caused directly by EHR's. The Veterans Agency EHR, touted by many as one of the top systems was involved in 2 of them. I counted 1012 pages of template heavy notes in one simple 8 month long chart and 157 times that this patient was supposedly screened for PTSD. Who are they kidding?

I frequently review records faxed from outside hospitals on patients admitted to my service. The ones which are electronically generated, including those from the VA, are generally so full of electronic clutter that I have a difficult time deciphering what really happened to the patient let alone what the docs were thinking. It’s electronic illegibility, often much worse than doctors’ handwriting.

H/T to Kevin MD.

The changing face of infective endocarditis

It’s more often an acute disease, and more often due to S. aureus.

Via Archives of Internal Medicine.

Which patients with fever need anti-staphylococcal coverage?

This study adds to our understanding:

Of 1015 patients enrolled, 181 patients (17.8%) had clinically significant bacteremia, including 77 patients (7.6%) with S. aureus bacteremia. Clinical characteristics associated with S. aureus bacteremia were the presence of a hemodialysis graft or shunt (odds ratio [OR] 3.22; 95% confidence interval [CI], 1.85-5.61), chills (OR 2.38; 95% CI, 1.43-3.98), and a history of S. aureus infection (OR 2.68; 95% CI, 1.38-5.20). Peripheral vascular catheters were inversely associated with S. aureus bacteremia (OR 0.42; 95% CI, 0.26-0.69). Clinical characteristics associated with any bloodstream infection were central venous access, chills, history of S. aureus infection, and hemodialysis access.

(BTW: you can translate S. aureus as MRSA).

A world without industry support

ACP Advocate Blog author Bob Doherty is reporting from ACP convention headquarters in Philadelphia. He’s pumped up about the annual meeting, Internal Medicine 2009. He writes:

Today and for the rest of the week, I will be blogging from the Philadelphia Convention Center, where ACP will be holding its annual scientific meeting. Convention center workers are now doing all of the prep work for a successful medical convention, including setting up the exhibit hall.

But this year the looming ban on industry support for CME brings new concerns. He goes on:

A premier scientific meeting like ACP's clearly services a public good (helping doctors keep up-to-date in their clinical knowledge and skills), and drug industry support, within strict guidelines, helps keep the meeting affordable. If industry support for CME was to be prohibited, I wonder where the money would come from to allow internists to continue to have access to CME at a price they can afford.

He’s probably wondering if this year’s premier internal medicine conference will be the last.

The moderate players in this debate would be content to bolster the existing safeguards and firewalls for industry supported CME and find a way to provide more resources of the ACCME so they can do a better job of evaluating content. The more likely scenario, unfortunately, is that the agitators will continue to demagogue this issue in the popular media until there’s nothing left of industry support.

H/T to DB’s Medical Rants.

Allergic bronchopulmonary aspergillosis

---is underappreciated in asthma patients. Review here. From the abstract:

Because many patients with ABPA may be minimally symptomatic or asymptomatic, a high index of suspicion for ABPA should be maintained while managing any patient with bronchial asthma whatever the severity or the level of control. This underscores the need for routine screening of all patients with asthma with an Aspergillus skin test.

Adding a drug to improve hypertension control

---worked better than doubling the dose of the initial drug in this meta-analysis:

Blood pressure reduction from combining drugs from these 4 classes can be predicted on the basis of additive effects. The extra blood pressure reduction from combining drugs from 2 different classes is approximately 5 times greater than doubling the dose of 1 drug.

Dissecting quality

In a recent post Bob Wachter discusses the growing backlash against the measurement and public reporting of performance metrics. Research reports over the last few years (some of which I compiled here and elsewhere) have shown that implementation of performance measures is generally ineffective, for a variety or reasons.

According to Bob’s postmortem what we really need is better science and a more circumspect approach, and that those who call for a moratorium on the performance movement have gone too far:

And now we have Groopman and Hartzband arguing that we should take a “time out” on quality measures, leaving it to doctors to make their own choices since only they truly know their patients. Do we really believe that the world will be a better place if we went back to every doctor deciding by him or herself what treatment to offer, when we have irrefutable data demonstrating huge gaps between evidence-based and actual practice? Even when we KNOW the right thing to do (as in handwashing), we fail to do it nearly half the time! Do the authors really believe that the strategy should remain “Doctor Knows Best"; just stay out of our collective hair? Pullease...

Ouch. I kind of liked the Groopman and Hartzband piece. Yes, we need better quality. Yes, there is a huge gap between evidence and practice. The question is what should we do? That’s where Bob and I part company. I don’t believe the performance movement will get us there. I’ll go a step further and question what appears to be a basic premise of his, which is that the measurement and public reporting of performance has anything at all to do with real quality.

So why is the performance movement a failure? Let’s count the ways.

First, what about the science? In his post Bob notes:

Some critics have even suggested that we put a moratorium on new quality measures until the science improves.

But the problem is not the science. The problem is its misappropriation by policy mavens many of whom, I dare say, understand little about real world application of such science.

The science, for example, which informs us that the effectiveness of adult pneumococcal vaccine is somewhere between slim and zilch is just fine, thank you. What about the blood sugar debacle? Here the rush to clamp every hospitalized patient’s glucose between 80 and 110 was based on the misinterpretation of perfectly sound science. But in their enthusiasm for a single study the misguided policy wonks ignored one of the first principles of critical appraisal: ask yourself whether your patient was in that study. Most hospitalists and intensivists working in the real world knew right off the bat that their patients were not represented by that study. In the case of perioperative beta blockers the policy wonks extended the findings of good science far beyond what appropriate critical appraisal warranted.

In some cases science gave us an important, generalizable lesson for real world care but the policy wonks couldn’t see the utter folly of translating the evidence into a “metric.” Such was the case with the four hour antibiotic rule.

Some performance measures were based on science that was strong, generalizable, mature and straightforward to implement, yet they still failed. What could be more evidence based and easy to implement, we thought, than the heart failure measures? So some were more than a little surprised when, in the Optimize-HF database, those measures turned out to be a bust! Why? I dissected the reasons here. The short version of that analysis is that while there’s no doubt the measures are evidence based and underutilized, promulgating them as performance metrics may do all sorts of things that negate their effectiveness.

So what can we do about the horribly low uptake of evidence into practice? Bob cites data suggesting that it’s only around 50%. For many conditions it’s much lower than that. Multiple systemic and cultural barriers exist. Some of the barriers have been created by the performance movement itself! (I explain here, here, and here). The enormous number and complexity of those barriers should make it obvious that no easy fix exists. If any effective fix exists it will be multifaceted and complex. It will involve education and the development of better tools to help doctors put evidence into practice. It won’t come from Washington in the form of more “metrics.”

Bob concludes his post with:

From where I sit, of all our options to meet the mandates to improve quality and safety, tenaciously clinging to a Marcus Welbian (and demonstrably low quality) status quo or creating tests that can be passed by appearing to be working on improvement seem like two of the worst.

I agree. But I wouldn’t stop at two. I’d add performance metrics to that list of failures.

Metformin added to insulin

---improves macrovascular outcomes in DM 2, NNT 16.1 according to this study. Given that so many treatments are macrovascular neutral or even associated with macrovascular harm, this is important information. Since metformin is a generic drug this is a pretty good bang for the buck.

How useful is Wikipedia as a drug information resource?

Not very, according to this study.

Wikipedia has a more narrow scope, is less complete, and has more errors of omission than the comparator database. Wikipedia may be a useful point of engagement for consumers, but is not authoritative and should only be a supplemental source of drug information.

I use it occasionally to check brand names, manufacturer names and as a starting point to find primary sources, but that’s about it.