Should you admit that TIA?

Practices vary greatly from one community to another with regional variations in malpractice risk guiding decisions. Evidence based medicine has now come to the rescue. The ABCD-squared stroke risk score can help stratify patients presenting with or soon after TIA into high, intermediate and low risk categories. The score takes into account clinical features, blood pressure, history of diabetes and duration of symptoms. This should help standardize decision making when patients present with TIA. The validation study was published in Lancet and is linked here via Medscape.

Bet you didn’t know

That direct to consumer drug ads are deceptive. Wow. Who'da thunk it.

Unintended consequences of a “quality” measure

The “four hour antibiotic rule” for patients presenting to the hospital with pneumonia has become a mandate from JCAHO and CMS as well as a pay-for-performance initiative. This has caused hospital case managers and administrators to put pressure on ER physicians to jump to a diagnosis of pneumonia. A study presented as a poster abstract (poster 211) at the 2006 IDSA annual meeting demonstrated that the four hour rule is associated with over-diagnosis of pneumonia, evidenced by more diagnoses of pneumonia in patients with negative chest x-rays and a lower percentage of patients initially given antibiotics for pneumonia having the diagnosis confirmed at discharge.

The overuse of antibiotics as a result of the four hour mandate has been demonstrated before as I posted here. The implications concerning breeding antibiotic resistance are obvious.

American medical schools: slouching toward Hogwarts

Harry Potter would thrive in some medical schools today. I’ve been beating the drum about medical education’s egregious uncritical incorporation of non-evidence based woo for some time, starting with this post.

Science blogger Orac weighed in again yesterday with Medical schools going the wrong way in which he mentions a new wrinkle, the incorporation of woo into graduate medical education. Not surprisingly, it’s being promoted by the American Medical Student Association.

Yes, medical schools are going the wrong way. Does anyone in academic medicine care about the integrity of medical education? Who are you, and why aren’t you raising a stink? Medschool woo needs to be exposed. Maybe it’s time somebody wrote a book.

What malpractice crisis?

Public Citizen thinks it’s a hoax. Why then the four-fold variation in malpractice coverage rates between California and states without damage caps?

Via Kevin M.D.

Another risk factor for atrial fibrillation

Corticosteroids, equivalent to 7.5 mg prednisone daily or more, received in the previous month. Via Archives Internal Medicine.

Anaphylaxis

This review of anaphylaxis, though a little dated, is useful enough to be linked here. (Via Seminars in Respiratory and Critical Care Medicine).

Proposals by the American College of Physicians to improve health care quality and reimbursement---is the devil in the details?

Last year the American College of Physicians (ACP) warned of the collapse of primary care. This year they have proposed a series of reforms to help solve the problem, which they say will improve reimbursement and quality.

I have more than a few concerns about the proposals. They’re supposed to shift compensation incentives from procedures to comprehensive care. But haven’t we heard this before? The resource based relative value scale, conceived in the 1980s, was supposed to improve compensation for “cognitive” services. It wasn’t long, though, before physicians realized that RBRVS stood for “real bad reimbursement very soon.”

Worse yet, the proposals are another failure of the ACP to reclaim the identity of internal medicine. In defining the way internists fill the primary care role the proposals make no distinction from family practice. Is it any wonder there is a growing perception that the only way to be an internist is to be a hospitalist? Laurence Wellikson, M.D., CEO of the Society of Hospital Medicine, said it well: “General internal medicine had a chance to define itself as physicians who are master diagnosticians—the only doctors capable of handling the complexities of comorbidties, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with family practitioners and nurse practitioners to be the traffic cop for resource use and burgeoning specialization.” I have expressed this same view, though not as eloquently, here, here and here.

To me the proposals read like a mixture of physician DRGs, capitation, discounted fee for service, gate keeping, P4P and quality gamesmanship. They don’t make general internal medicine look very appealing.

Review of Echinocandins

The echinocandins comprise a new class of antifungal agents which act by inhibiting fungal cell wall synthesis. They tend to be fungicidal against yeasts (although inactive against cryptococci), fungistatic against molds and inactive against dimorphic fungi.

A two part review was recently published in the American Journal of Health-System Pharmacy, available in full text via Medscape. Part 1 addresses chemistry, pharmacokinetics and pharmacodynamics. Part 2 deals with clinical usage and role of echinocandins in the relative to other antifungal agents.

Naturopathic medicine topics at the American Medical Student Association’s Annual National Convention

From the talks listed it looks like they’re taking a promotional rather than a critical approach.

Joint Commission wants to set standards for how hospitals deal with disruptive behavior

I’ve posted about the concept of the “disruptive physician” here, here, here, here and here. Joint Commission’s latest proposal defines the problem this way (italics mine): “Disruptive behavior is conduct displayed by a health care professional that negatively impacts the quality or safety of care or has the potential to do so. Disruptive behavior may also intimidate staff, affect staff morale, and lead to staff turnover. Disruptive behavior may be verbal or non-verbal, and often involves the use of rude language, facial expressions, threatening manners, or even physical abuse.” Well, that’s kind of scary. Any behavior somebody else doesn’t like could be interpreted as disruptive and result in corrective measures (counseling, sensitivity training, psychiatric evaluation or worse) for the “offender.” It could also provide leverage to shove somebody out whose thinking happens to be a bit too original.

There’s one aspect of the proposal that I like. It doesn’t single out physicians. There’s a uniform standard that applies to all---physicians, administrators, nurses, etc.

(Via MSSPNexus blog)

Sniffing out C. diff

Lately I’ve been getting this call from nurses: “Mrs. so-and-so just had a liquid stool that smells like C. diff. Shall I send it down to the lab?” An informal poll revealed that many nurses are convinced they can detect the infection by smell. Is there anything to this?

Apparently, in the micro lab, blood agar colonies of Clostridium difficile have “a barnyard odor that is unmistakable” due to elaboration of P-cresol. But what are the test characteristics of olfaction at the bedside?

Observations of an ER nurse on how conflicts of interest trump evidence based medicine

Mention conflict of interest in medicine and the knee jerk response, nearly always, is to raise the issue of the pharmaceutical companies and their influence on doctors. Other conflicts, seldom appreciated, may play a larger role. ER nurse blogger girlvet mentions some of them in ER medicine is a free for all. The wide variations in practice she sees in her ER are anything but evidence based and, in her view, are driven by liability concerns, payer source and coding (the patient comes in with a tummy ache, but find 5 other diagnoses to document and you can code higher).

She warns doctors who may be reading: “you may not like what’s ahead….” Hey, I thought it was pretty good.

Via Kevin MD.

Medical Economics readers polled about doctor bashing web sites

If trashed on a doctor rating web site what would you do? In early results of a Medical Economics poll 50% of readers would ignore it, 35% would ask to post a rebuttal and 15% would threaten legal action.

Public Citizen: The medical liability crisis is a hoax

They “prove” it here. Point of Law offers this expose of the Public Citizen report. (Via Kevin MD).

Tygecycline for community acquired pneumonia

In a phase 3 double blind multicenter RCT presented as a poster abstract at the IDSA 2006 annual meeting (poster 171) Tygecycline was as safe and effective as Levofloxacin in patients with community acquired pneumonia (CAP).

Tygecycline is off label at present for CAP. I expect this study will be submitted to the FDA to approve the indication.

Propylene glycol toxicity due to high dose lorazepam infusions

Propylene glycol is a diluent for parenteral preparations of lorazepam and other drugs. Toxicity may occur with high or escalating intravenous doses of lorazepam and may be manifested by wide anion gap metabolic acidosis, renal failure and increasing osmolar gap. A brief review in ISMP Medication Safety Alert contains recommendations for minimizing the risk of toxicity, including daily chemistries and calculation of the osmolar gap in patients receiving high doses. An osmolar gap exceeding 20 may herald impending toxicity.

Vasoactive drugs in septic shock

A review was recently published in Seminars in Respiratory and Critical Care Medicine.

Brugada syndrome review

Brugada syndrome has been recognized with increasing frequency and in increasingly diverse populations since it was originally established as a distinct clinical entity in 1992. Recognition of the Brugada electrocardiographic patterns can be lifesaving and is thus an essential skill for emergency physicians, hospitalists and primary care physicians.

Although initial recognition of telltale electrocardiographic signs is straightforward, recent understanding of certain diagnostic nuances has been in a state of flux. In addition, new concepts regarding epidemiology, environmental factors, acquired patterns and mimics have rapidly accumulated. For these reasons a recent review in the journal PACE is timely and merits mention here.

Pertussis---not just for kids

Think of it when that cough won’t go away. (Patient Care).


Audio files of the characteristic cough, with and without the whoop. (Texas Health Department).

Why is EBM controversial?

Four bloggers (myself included) try to parse that question in the latest Medscape Roundtable Discussion. You can access the article here. The Roundtable Discussion archives can be found here.

Web based doctor bashing---Medical Economics weighs in

Rate MDs and several other web sites provide an open access, anonymous free-for-all where patients can rant and vent their frustrations about their doctors. This has been discussed recently by several medical bloggers and now Medical Economics profiles Rate MDs and other similar sites.

Though this sort of trash isn’t deserving of serious attention doctors are upset and wonder what legal recourse can be taken. Site owners are defiant, saying in effect “just try”. An expert quoted by Medical Economics says legal remedies, while difficult and expensive, are available, and several strategies are discussed.

Background:
Doctor rating with an attitude
More on Rate MDs
Rate MDs suggested as a tool for doctor credentialing

The OPTIMIZE-HF database: heart failure core quality measures disappoint

An analysis of clinical outcomes in the OPTIMIZE-HF registry appeared in the January 3 issue of JAMA. An attempt to relate compliance with “core quality” measures for heart failure to clinical outcomes was somewhat disappointing, with most measures showing no effect. Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) were associated with no improvement in mortality through 90 days although a decrease in the composite endpoint of re-hospitalization and mortality did reach statistical significance. The most robust improvement in outcomes was associated with one evidence based treatment which was not one of the core measures: beta blockers.

DB has already ranted on this issue, stating “Perhaps the concept of performance measures has flaws.” (I would strike the word perhaps). He correctly points out “Medical care has greater complexity than simple rules would suggest.”

There are many reasons not to be surprised at these findings. The web based reporting system for the registry depended on chart documentation and was of questionable accuracy regarding eligibility for various interventions. The rush by hospitals to get a good report card may have diverted attention from other life saving therapies such as devices and aldosterone receptor antagonists.

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.

The second measure was documentation of left ventricular systolic function. This is important in the identification of patients who are candidates for certain therapies. I’m reminded of a recent anecdote (unconfirmed but believable) about a nurse-case manager who wouldn’t allow a heart failure patient to be discharged until an echocardiogram was done whether the patient needed one at that time or not.

The third measure was the prescription of an ACEI or ARB for patients with left ventricular systolic dysfunction. These medications have been proven to increase heart failure outcomes. The disappointing results in the OPTIMIZE-HF registry may be due to the short follow up period. The same reason may apply to the negative findings concerning the other two measures, smoking cessation counseling and anticoagulant use for patients with atrial fibrillation.

Can we make sense of the findings? It would be wrong to conclude that the measures are not worthwhile. On the other hand the findings add to growing skepticism of “quality” mandates as they are now implemented.

Nephrogenic systemic fibrosis

This is a newly emerging entity (resource links here) occurring in patients with varying degrees of renal impairment. The more severe the renal disease the greater the risk, irrespective of the type of renal disease. Recently it has been associated with the use of gadolinium based magnetic resonance imaging contrast agents in patients with renal disease as described in this Medscape alert.

New age fluff at Wake Forest University Medical Center

Read about their promotions of Therapeutic Touch here. Here is their Grand Rounds schedule for Holistic and Integrative Medicine. They even have a conceptual model of how all this is supposed to fit together.

Top 10 issues in hospital medicine for 2006---issue 1: enthusiasm versus skepticism in quality and patient safety

With great fanfare, and with the help of the media, the Institute for Healthcare Improvement (IHI) this year announced the “success” of its campaign to save 100,000 lives. But a more sober assessment of the campaign cited methodological flaws and problems with the analysis of “lives saved” with the conclusion that the true impact of the campaign is unknown. This point-counterpoint illustrates the growing tension between the enthusiasts and the skeptics, and at the end of 2006 the skeptics are winning. The debate was nicely framed in a recent JAMA commentary by Robert Wachter, M.D.

Let’s look at some recent evidence.

Measured against Medicare’s performance measures, the difference in mortality between the top and bottom performing hospitals was of statistical, but questionable clinical significance. (JAMA editorial comment here).

Rapid response teams, recommended by the IHI and being considered for a Joint Commission initiative, are not supported by high level evidence. [1] [2]

Computerized Physician Order Entry was associated with an increase in mortality in a pediatric hospital population.

The four hour antibiotic mandate for pneumonia, a widely promulgated quality measure, is associated with unnecessary antibiotic use and has not been proven to improve outcomes.

Pneumococcal vaccination, another core quality and P4P measure, does not prevent pneumonia and is not cost effective with the preparation now licensed for use in adults.

What does it all mean? It means the quality and patient safety movements should move forward but individual measures should withstand scientific scrutiny before they are mandated by federal agencies and advocacy groups.

Top 10 issues in hospital medicine for 2006---issue 2: electronic medical records and computerized physician order entry

I elevated this topic from number 6 last year to number 2 due to increasing controversy and pressure for implementation. I sounded a cautionary note in last year's post, citing difficulties in physician acceptance and the potential for computerized physician order entry (CPOE) to increase certain types of errors.

Much more has been published this year including an insightful Medscape General Medicine Video Editorial by hospitalist thought leader and patient safety advocate Robert Wachter, M.D. Wachter sets out to temper irrational enthusiasm, pointing out that early studies which drove this enthusiasm took place in a select group of top notch institutions and looked only at “process” improvements. Until recently we had no data on patient outcomes. Wachter’s editorial reminds us of more recent papers showing a 3 fold increase in mortality in a pediatric hospital population following the implementation of a commercially available CPOE system and a powerful anecdote about a fatal insulin error related to bar code technology.

Issues regarding implementation are controversial. In another Medscape General Medicine Video Editorial AHRQ director Carolyn Clancy, M.D. thinks we should move full speed ahead and implies we should take advantage of readily available “off the shelf” systems. But Wachter warns that the systems that really seem to work are home grown and developed over years.

With the disasters in implementation and adverse patient consequences we’ve seen it would seem wise to move slowly.