Friday, August 31, 2007

What will be the consequences, intended and unintended, of the new Medicare coding rules for adverse events in hospitalized patients?

Recently I objected to the new CMS rules on two principles. First, they are unfair because they operate on a presumption of blame for adverse events, many of which are unavoidable. In addition, as a result of the rules, Medicare Part A, which has under-reimbursed hospitals for a quarter century will now reimburse even less when these events occur. Thus the conflicts of interest created by negative cost incentives built in since 1983 will get even worse in 2008.

But these objections are abstract. What will be the real world impact on patient care? Will mistakes decrease as a result of the new policy? It’s not likely, since the most common events addressed by the new rules are not the result of “mistakes”. As David Catron pointed out in a post entitled Medicare’s Latest Assault on Hospitals:

The new rule is very unlikely to reduce hospital errors. It will, however, reduce the number of hospitals. As I have pointed out here, hospitals cannot operate in the red and survive.

Let’s consider some of the adverse events targeted by the new rules. If there’s one area where patients might benefit it’s the prevention of catheter associated urinary tract infections. Hospitals will have an incentive to implement pathways for limiting the insertion of catheters, and for their early removal.

What about decubitus ulcers? There’s no reason to think the new rules will improve outcomes in this area. Hospitals already have strong medico-legal incentives to avoid decubitus ulcers. (Note that three of the top four Google hits for “decubitus ulcers” are resources for attorneys and legal experts). Hospital nursing staffs are already over taxed, so until researchers at the NCCAM figure out a way to levitate patients the only way to improve prevention efforts will be the more widespread use of expensive high tech specialty beds. Medicare’s negative cost incentives will make this prohibitively expensive, and the most likely way around the problem for many hospitals will be earlier discharge of patients with decubitus ulcers to long term acute care (LTAC) hospitals for “wound care”. That may ease the burden for hospitals but will not benefit patients.

What about fall prevention? Restraints are risky and tend to be restricted by Joint Commission and other agencies. Another proposed solution is the widespread use of Vail beds but these devices are expensive and have been associated with major risks. Ideally, all geriatric patients should be attended by an individual sitter day in and day out. Again, Medicare’s financial incentives will discourage hospitals from doing this. Hospitals, already in a no win situation, will suffer more and patients will not be helped. The unintended adverse consequences will outweigh any benefits.

Monday, August 27, 2007

Medicare and mistakes: more fallout

Implicit in the new CMS rules for hospital reimbursement is the idea that every patient fall, every catheter related infection and every decubitus ulcer is the result of a medical error. The idea is ridiculous. No one who understands hospital care believes it, but the media are lapping it up. Another example of this media credulity comes from the Boston Globe (via Medpundit), in which bed sores and patient falls are equated with errors:

Hospitals also need to make public the rate of other medical errors listed by the Medicare regulators, and lay out their strategies to prevent them. These include the number of times patients fall and the number of pressure ulcers, commonly called bedsores, caused by prolonged bed stays.

One of my commenters, a patient activist with her own blog, supports the CMS policy but believes it goes beyond mistakes to criminal neglect:

…but prior to Oct '08, the times those hospitals will have been reimbursed when they should not have been rewarded for errors and neglect, will have already allowed them to get away with these crimes on patients for too many years.

Medical crimes and negligence can be penalized when due process is followed. What’s unfair is the uniform presumption of guilt just because an adverse event occurred. I asked my commenter point blank if she believed in the presumption of guilt and, if not, how crime and neglect in the hospital setting can be fairly adjudicated.

Meanwhile a commenter to a New York Times article on the same subject was quoted by Medpundit:

So, I admit Mrs. Jones, an elderly patient of mine, to the hospital because she has pneumonia. Because of the stress of the infection, she becomes delirious, which puts her at high risk of falling.In the interest of safety, I restrain and sedate her, which necessitates an indwelling urinary catheter.One week later, despite meticulous nursing care, Mrs. Jones develops a urinary tract infection and a minor pressure sore on her back because of her debilitated, immobilized state.My hospital administrator then suggests that I remove the restraints and the catheter and reduce the doses of her sedatives so that the conditions don’t get worse and our hospital doesn’t lose money.Two days later, Mrs. Jones falls out of bed and breaks her hip.How, exactly, has the new Medicare policy improved Mrs. Jones’s safety?

‘Nuf said.

Sunday, August 26, 2007

Criticize Sicko, face the Thought Police

A recent tirade in NEJM on the U.S. health care system, ironically published as a Perspective piece, accused a USA Today editorial writer of blustering because she dared to criticize Michael Moore’s Sicko and defend the U.S. health care system. Citing many distortions and inaccuracies in the movie, she wrote:

Michael Moore's movies are provocative, but this one should be seen for what it is and is not. A no-holds-barred assault on our present health care system? Yes. A balanced documentary? No.

Moore wants a government takeover. To make his case, he relies on one-sided anecdotes — some dating back to the 1980s — that grossly distort the role of health insurance plans in providing access to care to more than 200 million people.

Are anecdotes from 10 to 20 years ago relevant to the state of health care today? The NEJM writer, Jacob S. Hacker, Ph.D., opens with a scene from 1993. Managed care, a player in this story, has been somewhat self correcting over the years and was a more formidable beast in 1993. The story is about an 18 month old seen in an emergency room with a “life-threatening bacterial infection” (I’m guessing sepsis or meningitis). The ER doc was appropriately suspicious and wanted to administer antibiotics. But a phone call to a managed care physician reviewer revealed that treatment was not covered and that the patient had to be transferred another hospital, where she died a few hours later after deteriorating and suffering seizures.

Very likely this tragedy was played out in court somewhere and analyzed extensively, but important details are missing from the NEJM article and, I suspect, (I haven’t seen it) the movie. The limited account we are given raises important questions. Did the first hospital really withhold antibiotics as implied by the article? If so, and if the doctor at the first hospital really recognized a life-threatening bacterial infection as the article states, then this patient suffered as a result of an EMTALA violation and not a deficiency in the U.S. health care system. EMTALA was enacted in 1986 specifically to avert this sort of outcome. Those are some pretty big “ifs”, but since we are to accept this anecdote as a reflection on our health system Dr. Hacker owes it to us to address that glaring question.

Dr. Hacker’s only criticism of Sicko, it seems, is that it doesn’t offer the solution he prefers, “Medicare for all”. While praising Medicare Hacker has this to say about private insurance: “Insurers erect obstacles to care, hassle patients and doctors….” It’s safe to say Dr. Hacker doesn’t take care of Medicare patients. If he did he’d be aware of daily Medicare obstacles to patient care and hassles and threats to doctors’ autonomy.

This piece would be more appropriate for USA Today, perhaps as an editorial counterpoint, than for the NEJM. Dr. Hacker seems more interested in propaganda than nuanced discussion. He writes “We could use more populism and less caution in our health care debate” and wants to see more “populist anger”. I hate to see politically motivated material such as this in the scholarly NEJM, and I hope the journal doesn’t devolve into a political rag.

Medicare won’t pay for mistakes?

This has been covered heavily in the blogs recently. I’ve been mulling over whether to weigh in these last few days, and up to now things have been too hectic for me to give this topic sufficient time and depth.

Despite the simplistic media spin this isn’t a simple matter of whether Medicare will “pay for mistakes”. It’s not as if Medicare even pays for the all the appropriate hospital care patients actually get. Medicare hasn’t done that since the advent of DRGs in 1983. That’s not a joke or an abstraction; it’s true in the real world, as evidenced by the fact that hospitals lose money on Medicare inpatients.

For a glimpse of what’s really going on check out the primary sources. Here’s the full text of the regs from the Centers for Medicare and Medicaid Services (CMS). (Warning: large pdf with over 2000 pages containing difficult to decipher alphabet soup and jargon along with innumerable rules inventing an untold number of crimes. Those who want “Medicare for all” take note).

Since Medicare doesn’t even pay for all necessary and appropriate hospital care what is meant by “not paying for mistakes”? As the CMS press release explains, the new rules actually constitute a complete revamp of DRGs including, among many other changes, a list of newly designated hospital complications which can no longer be coded to enhance the DRG payment. Thus hospitals can no longer recoup losses sustained as a result of certain complications which occur during hospitalization.

CMS promotes the new measure as a quality incentive and a means to more “accurate” reimbursement. It’s been widely applauded in the popular media. It is simplistically argued that Medicare should stop rewarding hospitals for preventable complications. That argument doesn’t stand up to close examination. The new policy is unfair on more than one level. First of all, DRG payments under Medicare’s Inpatient Prospective Payment System (IPPS) have never rewarded hospitals for appropriate or even perfect care, let alone for mistakes. The IPPS is an under funded mandate for hospital care of the sickest and most complex patients. Like a hidden provider tax it has penalized rather than rewarded hospitals for years. With its new policy CMS is merely stiffening the penalty.

Implicit in the policy of penalizing hospitals for adverse events is the idea of blame. CMS attempts to justify its position by citing prevention guidelines for each of the conditions listed. The newspaper spin is that potentially preventable adverse events such as falls and decubitus ulcers are medical mistakes which hospitals have been “blasé” about preventing. To anyone with experience in the care of hospitalized patients that’s patently absurd. Orac did a masterful job of exposing the absurdity in a recent post:

I know what some of you are thinking, particularly those less inclined to like doctors. You're probably thinking: Greedy doctors! No wonder they oppose something like this. There's just one problem. Most of the items on the list, although potentially preventable, are not 100% preventable even under ideal conditions. Take pressure ulcers (bedsores), for example. There are certainly nursing care interventions that can greatly decrease the risk of pressure ulcers, but no intervention will reduce that risk to zero. I've seen patients where everything was done right, the patients were turned frequently and placed on the latest beds designed to minimize pressure, who still got ulcers. Remember, Christopher Reeve, who presumably got the best skin care available after he became quadriplegic, died from sepsis due to an infected pressure ulcer.

By CMS and popular media standards, apparently, Reeve’s death was the result of a medical mistake. Pressure ulcers will never be eliminated until someone figures out a way to levitate patients. That would be the ultimate in woo. It’s beyond the pale even for the alties. (Well, most of them, anyway).

The reality is that Medicare’s IPPS forces hospitals to play a game in order to survive. It’s a game with many dimensions in the areas of coding, documentation, case management and cross subsidization. Hospitals that can’t play the game close. When other hospitals get good at the game over time Medicare changes the rules. From where I sit the impending rule change is just the latest of many vagaries of the Medicare game over the years.

Saturday, August 25, 2007

Hormone therapy and the risk of thromboembolic disease

A review in Current Opinion in Hematology summarizes the evidence on this topic. Interactions between hormonal therapies and intrinsic risk factors such as hereditary thrombophilias are discussed.

Chest X ray interpretation

Just the basics. Via Continuing Education in Anaesthesia, Critical Care & Pain.

Thursday, August 23, 2007

Vitamin D update

The science behind the latest buzz on vitamin D is summarized in this review from Current Opinion in Rheumatology. The vitamin D receptor is a transcription factor with varying actions at widespread tissue sites, involving more than calcium and bone metabolism. Implications regarding cancer, diabetes and immunity are discussed.

Wednesday, August 22, 2007

Atypical antipsychotics

This review in Cleveland Clinic Journal of Medicine compares the atypicals with older antipsychotics and reviews safety concerns. Recommendations for the monitoring and treatment of adverse metabolic effects (diabetes, weight gain, dyslipidemia) are presented.

Tuesday, August 21, 2007

Woo attitudes and use at University of California, Irvine

This paper from a few months ago in BMC Medical Education looked at attitudes toward and use of complementary and alternative medicine (CAM) at UCI. Students, faculty and house staff were surveyed. The survey is difficult to interpret because the faculty members selected for survey were only those who taught or were planning to teach CAM. There were some interesting tidbits, nevertheless.

Figure 2 summarizes the results and indicates significant rates of use of homeopathy, therapeutic touch and Curanderismo (folk healing) by faculty.

Perhaps more interesting than the paper itself is this survey (also from UCI) which it cited, showing that medical student use of CAM modalities exceeded rates of CAM use in the general population! Students’ use of CAM didn’t decrease over time. The list of modalities used included vitamins, meditation, massage, herbals, chiropractic, traditional Oriental, T'ai Chi, homeopathy, Ayurveda, therapeutic touch and Curanderismo.

Influenza, COPD and statin use

Statin use is associated with reduced mortality in these conditions according to a study published in Chest.

Hyponatremia and the brain

CCJM review.

Hereditary thrombophilia review

Via Thrombosis Journal.

Thursday, August 16, 2007

Hepatocellular cancer

This topic was recently reviewed in the American Journal of Medicine. Cirrhosis of any cause is the principal risk factor, particularly related to hepatitis B and C infections, chronic alcohol abuse and non-alcoholic steatohepatitis in the settings of obesity and type 2 diabetes.

Associated paraneoplastic syndromes may occur due to the elaboration of erythropoietin, insulin-like growth factor and parathyroid related protein.

Screening for HCC is controversial although some organizations recommend ultrasound every 6 months in high risk patients.

Diagnostic and treatment strategies are presented.

COPD update

An update, summarizing key papers for 2006, was published in the American Journal of Respiratory and Critical Care Medicine. The article is open access full text.

Cardiovascular update ‘07

Highlights of a recent Cleveland Clinic Grand Rounds covering perioperative cardiovascular medicine, drug eluting stents, statins and cerebrovascular disease. (Via CCJM).

Tuesday, August 14, 2007

No woo is beyond the pale

---for the National Center for the Promotion of Pseudoscience (NCPP) or, if you prefer, the National Center for Complementary and Alternative Medicine (NCCAM). It’s been a while, at least a few weeks, since I’ve picked on the NCPP. Maybe I had grown weary and needed to give it a rest. But today Orac stoked the flames with this exposé in the wake of their 2008 budget announcement.

He makes this point that I’ve hammered on many times before:

Indeed, there appears to be no woo so implausible, so without basis in science, that NCCAM won't take it seriously. Homeopathy? Check. Qi gong? Check. Craniosacral manipulations? Check. In children, yet! Shamanic healing? Check! Distant healing? Check!

And this:

Here's the problem. Negative studies don't matter. If a study shows that a particular CAM "remedy" does no better than placebo, CAM practitioners don't believe it. Can anyone point me in the direction of a single "alternative" remedy that, after multiple negative studies, has been abandoned?

The Orac challenge! But worse yet not only do the practicing woomeisters not abandon debunked woo, neither does the NCCAM! Take chelation. (Please!). In spite of high level evidence against the use of chelation in the treatment of cardiovascular disease the NCCAM is funding a large multi-center trial (one which, as I demonstrated before, is riddled with conflicts of interest and methodological flaws). And, of course, there’s echinacea.

The NCCAM just won’t give up on anything. In this editorial they, in effect, rationalize away all their negative studies and explain why they have to do them all over again. They even propose to fund omics analysis on previous negative studies of CAM modalities.

And on and on it goes.

Monday, August 13, 2007

HIT antibody positivity as a vascular risk factor

The presence of HIT antibodies (antibodies to heparin-platelet factor four complex) has been found in multiple studies to confer risk of arterial and venous thrombosis even in the absence of overt thrombocytopenia. Results of these studies along with pathophysiologic mechanisms are discussed in this review in American Heart Journal.

I previously cited a study showing a relationship between antibody positivity and a variety of adverse outcomes in patients undergoing cardiac surgery. Data such as these beg the question of whether patients (those with previous heparin exposure) should be screened for antibodies on a wide scale. The review authors suggest patient selection for antibody testing, but do not believe widespread testing is cost effective.

Yes, there is free lunch at Mayo Clinic Medicine Grand Rounds

And it improved attendance by 38.4% in a recent study published in BMC Medical Education. Pharmaceutical industry support was used to help defray the costs. The authors felt they addressed any ethical concerns about industry support:

Industry support of MGR raises the ethical concern of industry influence over MGR organizers, content, speakers, and attendees (1-3,17,18). This concern can be addressed by using the following guidelines: 1) industry support should be unrestricted; 2) MGR speakers should disclose to attendees any conflicts of interest; 3) industry representatives should not determine MGR content; and 4) presentations at MGR should be unbiased, especially when the industry sponsor’s products are discussed (3,19,20). These guidelines are rigorously followed at our institution.

They concluded:

Providing free food may be an effective strategy for increasing attendance at medical grand rounds.

Thought Police update

You should not say the U.S. has the best health care. You should not even think the U.S. has the best health care. So says Dr. Christopher Murray, head of the Institute for Health Metrics and Evaluation at the University of Washington:

“The starting point is the recognition that the U.S. does not have the best health care system. There are still an awful lot of people who think it does.”

But the information he’s basing that statement on, statistics indicating that the U.S. longevity ranking has slipped to 42nd in recent years, offers no proof of that assertion. It comes from this piece of spin at MSNBC which, in typical sloppy popular media style, didn’t bother to cite the primary source. (I did some poking around, and I think it’s here).

Via Dr. Helen.

Clinical Cases and Images weighs in here.

Saturday, August 11, 2007

Are you guilty of medical thought crime?

You may be if you hold to certain political views. I’m not talking about extreme positions and ideas that most decent human beings, regardless of political affiliation, know are morally outrageous. But our professional culture is becoming increasingly Orwellian as an ideologically correct medical thought police, expressing itself through journals, the web and other media, increasingly defines what is acceptable in the realm of speech and ideas.

Though I’ve observed the trend for a long time several recent examples have emboldened me to challenge the prevailing orthodoxy. Recently I linked to this Kevin post about the Lucidicus Project and suggested that medical students check it out as an alternative to the popular dogma concerning single payer health care. This was met with indignant and morally superior comments from two anonymous readers. One, apparently in academic medicine, implied that conservative thinking equals greed:

This philosophy starts at the top with our president who feels tax cuts for his friends the uber rich are clearly more important than health care for children.The best definition I've heard for compassionate conservatism is I feel your pain,I just don't plan to to a damn thing about it. So be greedy, and selfish, but don't complain when some calls you that.

The other commenter was outraged at the mere suggestion that medical students read material supporting capitalism:

So RW the champion of critical thought & skepticism is championing a site that suggests medical students need to read ayn rand and propaganda material about how capitalism is good for medicine? Give me a break.

Of course I wasn’t championing anything. The commenter was clearly rankled. Does he/she believe that medical students should be banned from reading politically conservative literature?

More examples:

Not long ago we were told that if we didn’t feel guilt and shame about global warming we need psychiatric help to increase our anxiety.

And there’s this JAMA commentary that tells us what we may and may not say about health care in the U.S.

More recently Retired Doc dropped a bomb with this post about a JAMA piece which appears to redefine medical ethics in terms of a sociopolitical agenda which favors increased government intrusion into our profession and implies that failure to support such an agenda is a betrayal of ethical principles to which physicians are honor bound.

If you want to promote your political agenda I’m willing to be convinced with evidence or logic. Engage me in a collegial discussion, but don’t try to shame me or impugn my character if I happen to disagree.

Background reading: PC, M.D.: How Political Correctness Is Corrupting Medicine. (Hurry, before it’s banned).

Thursday, August 09, 2007

Web 2.0 review

It’s the best explanation of Web 2.0 I’ve seen yet, complete with a historical time line, glossary and examples (including, of course, the Clinical Cases and Images blog).

Via eMJA.

Tuesday, August 07, 2007

How should scientific findings be presented to the public?

The Scientist has an article (h/t to Medpundit) examining this controversial issue. If the raw facts are too complex or boring for the general public how should scientists present information in a way that informs? One commenter, Greg Van Citters, comes close:

We need to approach communication for the masses at an entry level that assumes perhaps exposure to one high school course in biology. This in no way implies we should "spin" the facts or omit anything important. To the contrary, we need to provide the basic story anyone can understand, and also provide resources for more in-depth investigation. This tiered approach to communication allows the outsider to understand the basics and the more experienced to go beyond, all the way to the original research articles if they so desire.

The best scientists can do is to present the facts in plain language and direct the audience to primary sources. But Professor Matthew Nisbet and author Chris Mooney, writing in Science and the Washington Post apparently don’t think presenting the facts is enough. Their Washington Post piece is titled “Thanks for the Facts. Now Sell Them”. They write:

We're not saying that scientists and their allies should "spin" information; doing that would only harm their credibility. But discussing issues in new ways and with new messengers can be accomplished without distorting the underlying science. Good communication is by its very nature informative rather than misleading. Making complicated issues personally meaningful will activate public support much more effectively than blinding people with science.

Well, it sounds like spin to me. How, for example, can an issue of science be made “personally meaningful”? What can that possibly mean, other than the presentation of an issue in such a way as to play on public fear or special interest? And what does it mean to “activate public support” if not to advance an agenda?

Science should have nothing to sell. Science must remain objective. Scientific discussions at their best are sterile and boring. When such discussions enter the arena of public debate great caution is needed.

Sunday, August 05, 2007

How PICO proficient are you?

With all the recent discussion of UpToDate and how it compares with other resources let’s not forget Pub Med. It’s the ultimate site for evidence based medicine. After all, it’s precise and gets you to the primary sources.

A comment to a recent blog post said UpToDate is not as evidence based as Dynamed. It’s even been claimed that only about 10% of UpToDate’s content is evidence based. I don’t know what that means or how it was derived. UpToDate bases some recommendations on expert opinion but when it does, usually because no higher level of evidence exists, it clearly points that out. Other potential downsides are relatively infrequent revisions of content (every 3 months or so) and imprecise searching (partially made up for by ease of navigation and extensive linking).

Other popular EBM “filtered” resources such as Bandolier, Dare and Trip are useful but suffer from limited depth of content and imprecise searching. That brings me back to Pub Med. But Pub Med has a major hurdle. It requires skill which comes only with training and practice. That’s where PICO comes in. The first step in using Pub Med for evidence based searching is to formulate a focused clinical question which can be converted into Pub Med search terms. PICO is an acronym that lists the essential components of a focused clinical question: Patient population, Intervention in question, Comparison group or treatment and Outcome of interest. And that’s only the first step.

Medical schools are supposed to be teaching the skills of Pub Med searching, but given the widespread dependence of students and house staff on UpToDate trainees may not be getting the necessary practice. In fact, easy resources such as UpToDate and Google may have produced a dumbing down of formal searching skills, as I said here:

The medical Internet has grown and information retrieval is much better now, but there may be a downside. As is true in clinical practice, the ease and convenience that comes with new technology can lead to a decline in basic skills. Though the formal discipline of Boolean searching is as necessary now as it was 20 years ago for precise and comprehensive searching, today’s new and more user friendly resources don’t require the skill and many don’t even support it.

That brings me to this interesting study involving medical house staff at Duke, (via BMC Medical Informatics and Decision Making) which looked at residents’ Pub Med skills and the effectiveness of a software tool to enhance searching. The tool was a user friendly PICO template which served as a Pub Med interface installed on a hand held device. The findings, though inconclusive, (it was a pilot study with small numbers) suggested that residents’ skills were lacking, as evidenced by the number of ineffective searches, and improvement with the use of the template. The article is worth the read as much for its excellent general discussion of Pub Med searching as it is for the study results.

Friday, August 03, 2007

Thursday, August 02, 2007

Obesity disease mongering?

Obesity concerns may be just another example of medicalization according to Dr Hamish Meldrum, head of the British Medical Association. According to This is London:

Obese people are often simply greedy and should not always be treated with pills, the head of the British Medical Association has said. Dr Hamish Meldrum believes an obsession with medical labels may be stopping overweight people addressing their own problems. He said the obesity epidemic is being mistakenly targeted with medical treatments and doctors' appointments.

Drug induced QT interval prolongation

This topic was reviewed in a recent issue of American Heart Journal. QT prolongation and associated torsade de pointes (TdP) are the most common reasons for drug restriction in the U.S. market. Although the advent of preclinical molecular testing during drug development lessens the likelihood of new arrhythmogenic drugs unexpectedly entering the U.S. market the list of drugs causing QT prolongation and TdP continues to grow, with the most notable recent addition being an old medication, long believed to be safe, which is methadone.

The review discusses electrophysiologic mechanisms, guidelines for QT interval measurement and QTc determination and points the reader to web resources on drugs which prolong the QT interval, all of which I have previously provided here.

Most patients who develop drug induced TdP have at least one additional risk factor, including female sex, interacting drugs, electrolyte disturbances and genetic polymorphisms. This latter risk factor raises the issue of interaction between genetic susceptibility and drug effects with some patients having a forme fruste of congenital LQTS.

Another tigecycline review

I have linked to several tigecycline reviews in recent months. This one from the Annals of Pharmacotherapy (via Medscape) is more comprehensive than most and warrants inclusion here.

Wednesday, August 01, 2007

Attention to the fifth vital sign may adversely affect the other four!

The DocSurg is aggravated by the fifth vital sign. So am I. In his July 23 post DocSurg recounts the rise of pain management dogma this decade, focusing on Joint Commission’s mandate and the notion of the fifth vital sign. (By the way, check out his 2005 rant about Joint Commission!). He notes:

And that, my friends, is how we have gotten into the pickle of potentially overmedicating, overnarcotizing, and oversedating patients sometimes to dangerous levels. That doesn't just lead to sleepy can lead to death.

He then goes on to cite this paper from the Journal of the American College of Surgeons. The investigators set out to test the premise that present day use of unscientific pain scales causes injury and death from overmedication by comparing adverse events in time periods before and after the promulgation of pain rating scales and other pain management dogmas (1994-1998 and 2000-2004, respectively). The study showed an increase in the rate of deaths due to overmedication in the 2000-2004 period and concluded:

The current assessment of pain by computer-stored pain scales is in a state of imbalance, with excessive emphasis on undermedication at the same time ignoring overmedication. This imbalance reflects pain-service attempts to comply with external accrediting agencies. This preventable cause of death and disability in trauma patients is also occurring in noninjured patients. Surgeons must correct this problem by insisting on a balanced assessment of overmedication versus undermedication.

These unintended consequences were not unanticipated. But as the pain management initiatives were rolled out 8 years ago practicing doctors’ safety concerns were largely ignored.

The diabetes mafia needs to refine its arguments

We get a lot of preaching these days about glycemic control in hospitalized patients and the evils of the sliding scale. A recent article in the American Journal of Medicine, Sliding Scale Insulin Use: Myth or Insanity?, illustrates what’s wrong with this preaching.

The authors make two important points: 1) hyperglycemia is under treated in hospitalized patients and 2) inpatients with uncontrolled hyperglycemia need basal coverage, usually with long acting insulin. Unfortunately, their arguments suffer from confusion about the term “sliding scale” and from assertions that go beyond what the evidence supports. As is the case with much of the preaching about glycemic control heard today, these defects in their arguments detract from the message.

Although the authors condemn sliding scale insulin, their examples of adverse effects of sliding scale treatment are primarily those in which sliding scale short acting insulin was the sole modality of treatment of hyperglycemia. In the real world, when patients enter the hospital with pre-existing diabetes on pharmacologic treatment, sliding scale insulin is usually given as an adjunct to such treatment.

While experts (including the authors) roundly condemn sliding scale insulin the basal-bolus regimens they recommend are in fact modified sliding scales. This is because the pre-prandial insulin doses, like traditional sliding scales, are subject to modification based on the prevailing capillary blood glucose. Unlike traditional sliding scales a portion of each pre-prandial dose is fixed. Moreover, currently recommended insulin drip protocols for critically ill patients are, conceptually, sliding scales since infusion rates are adjusted up and down based on the capillary blood glucose concentration. In this case the sliding scale, though modified by route of administration (intravenous), blood glucose target (more aggressive) and frequency of checkpoints (hourly) is a sliding scale none the less.

This tends to be confusing to clinicians. When experts categorically denounce sliding scales while recommending modified sliding scales what do they really mean? Physician buy in might improve if experts were more explicit about how current practice should change.

A second weakness of the article is that its recommendations go beyond current evidence. The authors state:

In view of this evidence, a recent position statement by the American Association of Clinical Endocrinologists recommended glycemic targets for hospitalized patients in the intensive care unit between 80 and 110 mg/dL, and in noncritical care settings a preprandial glucose goal less than 110 mg/dL and a random glucose less than 180 mg/dL. The Joint Commission on Accreditation of Healthcare Organization recently proposed tight glucose control for the critically ill as a core quality of care measure for all US hospitals that participate in the Medicare program.

These generalizations are not warranted by current evidence. Preliminary evidence suggests certain aggressive glycemic targets benefit specific subsets of patients, but these data do not warrant broad recommendations. The specific circumstances in which aggressive glycemic control is beneficial, as well as the optimal targets for various subsets of patients are far from settled.

Background: Review from Diabetes Care on inpatient management of hyperglycemia. Although somewhat dated, this review is timely and thorough in its coverage of multiple practical aspects of management.