Thursday, December 06, 2007
Risk factors for death in bacteremia
Smoking and obesity lead the list in this study from BMC Infectious Diseases.
Another report on methadone related deaths
This is getting monotonous. Like other reports, this one links the increase in deaths to pain treatment activism of the last several years.
Is the ABIM contributing to the demise of general Internal Medicine?
Dr. Faith Fitzgerald thinks so. Via Internal Medicine News.
Wednesday, December 05, 2007
Perioperative consultation and co-management of surgical patients
This has been trumpeted as an important role for hospitalists. Recent data from UCSF, though, are a bit disappointing. Consultation with generalists (read: hospitalists) in this study had no impact on cost, length of stay or outcome. The rate of VTE prophylaxis was increased (on PO day 1 only) but that was about it.
Essentials of TIA management
A recent topic review in Cleveland Clinic journal of Medicine presents the nuts and bolts of patient evaluation and management including an update on recently promulgated risk score systems.
Tuesday, December 04, 2007
Dennis Quaid sues Baxter Health Care
…over the heparin overdose given to his newborn twins last month. What piece of this am I missing? From Reuters:
It’s great that the Quaids and their lawyer want to champion the cause of patient safety but isn’t there a more constructive way? In order to bring suit don’t there have to be damages?
There’s more:
Whadaya bet?
Their lawyer Susan Loggans said the babies were now back home and "doing fantastic."
"The last thing the Quaids want to do is to file a lawsuit but the objective is to prevent this happening to someone else," Loggans said.
It’s great that the Quaids and their lawyer want to champion the cause of patient safety but isn’t there a more constructive way? In order to bring suit don’t there have to be damages?
There’s more:
Loggans said Quaid had not yet decided whether to sue Cedars-Sinai, one of the leading hospitals in the United States, over the mix-up.
"Cedars-Sinai has already apologized and we are waiting to see what they do to respond," Loggans said.
Whadaya bet?
A new treatment for peripartum cardiomyopathy?
When I posted earlier today about reversible cardiomyopathy I mentioned peripartum cardiomyopathy but overlooked this post by Dr. Wes from yesterday. It seems that a cleaved (16 kDa) form of prolactin is instrumental in the pathogenesis of peripartum cardiomyopathy (there’s pathophysiologic rationale and a mouse model) and a JACC article reports treatment of two patients with bromocriptine. Preliminary but interesting.
The ethical problems of template charting
It’s clear to many of us in clinical practice that the medical record has been hijacked by the coders and bean counters. What’s equally clear, at least to those of us who have been in practice for a long time, is that the coders and bean counters were aided and abetted in this effort by the rising popularity of template based medical records. Templates became popular in the paper era and are rising to a whole new level with electronic medical records.
Potential benefits of templates are more efficient coding and documentation. Paragraphs of clinical information can be generated by a few clicks of the mouse. What’s more, the template prompts the user to document more components of the history and physical exam to enhance coding.
I’ve often wondered whether these templates push the envelope of fraud. Through the years I’ve seen template generated notes with what I thought was gratuitous documentation. (It may not be fraud, but do you really need a 12 system review and a comprehensive physical exam for a single problem encounter?).
I’ve never directly observed or verified a case of template generated fraud. But this blogger has, and it’s rampant in his emergency department:
For years a logical fallacy has been shoved down the throats of doctors, and it goes like this: “if you didn’t document it you didn’t do it.” Is it any surprise, then, that some doctors might embrace the inverse of that statement, the equally false premise that “if you did document it you did do it?" Those electronic templates make it all too tempting and all too easy.
I agree with blogger ER Murse that the electronic template is merely the enabler. Part of the recipe for fraud is a susceptible provider---one who is under financial or administrative pressure to “improve coding and documentation” or, perhaps, one who buys into the logical fallacy cited above.
The ER Murse post has links to some good documentation and compliance resources for EMRs, but for the most part template facilitated fraud has been missing from the discussion of unintended consequences. Maybe it’s an elephant in the room that people would rather not talk about. It needs to be on our radar screen.
Potential benefits of templates are more efficient coding and documentation. Paragraphs of clinical information can be generated by a few clicks of the mouse. What’s more, the template prompts the user to document more components of the history and physical exam to enhance coding.
I’ve often wondered whether these templates push the envelope of fraud. Through the years I’ve seen template generated notes with what I thought was gratuitous documentation. (It may not be fraud, but do you really need a 12 system review and a comprehensive physical exam for a single problem encounter?).
I’ve never directly observed or verified a case of template generated fraud. But this blogger has, and it’s rampant in his emergency department:
Our ED Physician came in and did his exam from the door way holding his Tablet PC marking off items into the Electronic T-sheet while he asked a few basic questions. He was in and out in less than a minute. Out of curiosity, I reviewed his documentation and not surprisingly there was a comprehensive assessment documented. Abdominal findings, lungs sounds, heart sounds, pupils and ocular movements, neuro exam, all beautifully documented in a long paragraph and all normal. Not bad for an exam conducted from the doorway. I watched without comment throughout the day and noticed the same general exam pattern on most of his patients and the same comprehensive documentation of his exams. About one half of the Docs in this ED practice operate in a similar way…
For years a logical fallacy has been shoved down the throats of doctors, and it goes like this: “if you didn’t document it you didn’t do it.” Is it any surprise, then, that some doctors might embrace the inverse of that statement, the equally false premise that “if you did document it you did do it?" Those electronic templates make it all too tempting and all too easy.
I agree with blogger ER Murse that the electronic template is merely the enabler. Part of the recipe for fraud is a susceptible provider---one who is under financial or administrative pressure to “improve coding and documentation” or, perhaps, one who buys into the logical fallacy cited above.
The ER Murse post has links to some good documentation and compliance resources for EMRs, but for the most part template facilitated fraud has been missing from the discussion of unintended consequences. Maybe it’s an elephant in the room that people would rather not talk about. It needs to be on our radar screen.
Reversible cardiomyopathy
When patients present with non ischemic dilated cardiomyopathy (DCM) they are often labeled as idiopathic. In some cases “viral myocarditis”, all too often a waste basket, becomes the default diagnosis. Underappreciated causes of cardiomyopathy was the subject of a recent article in Cardiology in Review.
When confronted with a patient with “idiopathic” DCM how often do you consider the following diagnoses?
Iron overload cardiomyopathy. This can present as either a restrictive or a dilated cardiomyopathy, and may result from hereditary hemochromatosis or various secondary iron overload syndromes
Acromegalic cardiomyopathy presents with left ventricular hypertrophy and/or systolic dysfunction and responds to octreotide.
Thyrotoxic cardiomyopathy may be mediated by a combination of chronic tachycardia, autoimmune damage and the direct effects of thyroid hormone excess.
Chronic tachycardia induced cardiomyopathy may be the most reversible of those listed and has been discussed previously here.
Amyloid cardiomyopathy carries a poor prognosis, but survival is improved with treatment of the underlying serum protein disorder.
The cardiomyopathy of Fabry’s disease may respond to enzyme replacement.
Peripartum cardiomyopathy and takotsubo cardiomyopathy were also mentioned. These are underappreciated disorders although clinical circumstances usually suggest their presence.
When confronted with a patient with “idiopathic” DCM how often do you consider the following diagnoses?
Iron overload cardiomyopathy. This can present as either a restrictive or a dilated cardiomyopathy, and may result from hereditary hemochromatosis or various secondary iron overload syndromes
Acromegalic cardiomyopathy presents with left ventricular hypertrophy and/or systolic dysfunction and responds to octreotide.
Thyrotoxic cardiomyopathy may be mediated by a combination of chronic tachycardia, autoimmune damage and the direct effects of thyroid hormone excess.
Chronic tachycardia induced cardiomyopathy may be the most reversible of those listed and has been discussed previously here.
Amyloid cardiomyopathy carries a poor prognosis, but survival is improved with treatment of the underlying serum protein disorder.
The cardiomyopathy of Fabry’s disease may respond to enzyme replacement.
Peripartum cardiomyopathy and takotsubo cardiomyopathy were also mentioned. These are underappreciated disorders although clinical circumstances usually suggest their presence.
ICU protocol bundles and mortality
After four evidence-based protocols were introduced in their ICU (lung protective strategy for acute lung injury, activated protein C for severe sepsis/septic shock, intravenous insulin for hyperglycemia control and a protocol for sedation/analgesia) Mayo Clinic investigators reported a reduction in mortality. “Using the pre-protocol period as a reference, the severity-adjusted risk (95% confidence interval) of dying was 0.777 (0.655 – 0.922) during the protocol period (P = 0.0038).”
The impact of introducing multiple protocols in critically ill patients had not previously been well studied. Via BMC Emergency Medicine.
The impact of introducing multiple protocols in critically ill patients had not previously been well studied. Via BMC Emergency Medicine.
Monday, December 03, 2007
The trial lawyers are scanning the medical journals
IV colchicine related deaths
Were they med errors, non-evidence based use or woo? Maybe all three. My original post from last May is here. The CDC’s analysis along with case descriptions was just published in JAMA. Patients tended to present with acute illness resembling sepsis which spiraled into refractory multi-organ failure.
Diabulemia
…refers to insulin omission in type 1 diabetes to control weight. Many teens with DM-1 do this at one time or another according to a report from Internal Medicine News.
Topic review of electronic medical records
An article in the Cleveland Clinic Journal of Medicine offers practical tips for implementation and a review of current evidence. And what does the evidence show? Lots of appealing features, “process improvement” tools, a few unintended consequences and no consistent evidence of improvement in “outcomes that matter.” (Try getting a new drug approved with that level of evidence!).
How is the EMR as a communication tool? It depends on the system. The one at Cleveland Clinic works quite well according to the editorial. On the other hand I frequently encounter computer generated notes so cluttered with verbiage to satisfy the coders and core measure police that I can’t tell what’s really going on with the patient, let alone what the doctors are thinking.
How is the EMR as a communication tool? It depends on the system. The one at Cleveland Clinic works quite well according to the editorial. On the other hand I frequently encounter computer generated notes so cluttered with verbiage to satisfy the coders and core measure police that I can’t tell what’s really going on with the patient, let alone what the doctors are thinking.
Sunday, December 02, 2007
Pete has second thoughts about Stark
A post from the Science Business Blog recounts Congressman Fortney “Pete” Stark’s regrets for writing the self-referral laws that bear his name. Kevin M.D. points to the Stark laws as an example of what happens when government officials who know nothing about medicine try to regulate physicians. Physicians eventually learn how to survive while complying with the regulations. Once that happens the regulations change, and on the game goes.
Mainstream promotion of woo is unethical
New York Times Magazine ethicist Randy Cohen gets it right in response to a question from “name withheld”, a St. Louis hospital worker who’s witnessed promotion of therapeutic touch and related energy healing methods:
I would go a step further and say that patients reasonably assume that hospital standards line up with the standards of science. When woo is offered by a hospital, Cohen maintains, it “carries a sense of official approval”. That adds a whole new level of ethical problems over and above the non-mainstream offerings of woo.
H/T to the Health Fraud List.
Something needs to be adjusted here, but it is the nurses’ behavior, not the patients’ energy fields. These nurses, however well intentioned, should not perform unproven therapies — if these are unproven; opinions differ passionately — on unwitting patients. To do so is to tell a kind of lie to patients, who reasonably assume that their care meets hospital standards.
I would go a step further and say that patients reasonably assume that hospital standards line up with the standards of science. When woo is offered by a hospital, Cohen maintains, it “carries a sense of official approval”. That adds a whole new level of ethical problems over and above the non-mainstream offerings of woo.
H/T to the Health Fraud List.
Subscribe to:
Posts (Atom)