Save the date!

The 35th Annual Tutorials in the Tetons will be held August 28-31, 2009. Note the change in dates from those I posted last year. Please refer to that post for details and background about the conference. For an idea of course content here’s last year’s brochure. I have attended 26 times. I return home each year feeling expansive and full of ideas to incorporate in my practice.

Content ranges from cutting edge (genetics of cardiovascular disease, advances in revascularization) to practical (hypertension, heart failure, other nuts-and-bolts topics) and includes at least one session devoted to stress and life style as they relate to cardiovascular disease in honor of the meeting’s founder Robert Eliot, M.D.

The 14 hours of CME are spaced to allow plenty of free time. Hike the spectacular trails of Grand Teton National Park. Take the short drive up to Yellowstone. Enjoy fine dining and shopping in nearby Jackson. Heck, you can even blog to a spectacular mountain view in the comfort of the wifi zone of the conference hotel, the Jackson Lake Lodge. (It doesn’t get much better than that!).

I’ll be there barring any unforeseen conflicts. Cyber friends and blogging colleagues please let me know if you plan to attend. I’d love to see you there!

Registration for this year’s conference opens in a couple of weeks. Click here for the preliminary announcement and a link to on line registration. I’ll post updates as they become available.

Typical hospital admission

The other day a buddy of mine told me about his recent admission to a hospital (not mine).

ER wait time---6 hours.

Discharge time---9:30 PM (waiting for a test report).

Who were your doctors? I asked. Didn’t have a clue.

What did they tell you? “Nobody really told me anything.”

All too typical.

The drug development pipeline

---is clogged with “me too” drugs and reformulated “patent extenders” as we experience a dearth of important new medications. Why? Because, according to Alastair J.J. Wood, M.B., Ch.B., speaking at Vanderbilt’s Discovery Lecture:

The current period of patent and other protections barely cover the time it takes to develop and test truly new classes of drugs, Wood explained.

The system encourages the low-risk development of copies of existing drugs, while the development of truly new drugs to treat and prevent diseases like Alzheimer's and osteoarthritis go wanting.

Wood calls for a regulatory revamp to incentivize drug companies to develop truly innovative drugs. Wood’s proposal was detailed in this NEJM piece.

The Doctor’s Channel

I only recently got a chance to explore The Doctor’s Channel although it’s been around for a while. It’s like many medical news aggregators. If a short (1-2 minute) video presentation suits your learning style this may be a resource for you.

The latest meta-analysis on the adult pneumococcal vaccine

There are multiple reasons why performances measures fail. Sometimes the theory is good but the unintended consequences result in harm (four hour antibiotic rule for pneumonia). In other cases the individual recommendations are “evidence based” (performed well in clinical trials) but the shame game of public reporting negates their effectiveness (heart failure core measures, ventilator bundle). Still other measures were never evidence based at all. Such is the case for the adult pneumococcal vaccine. Although it will probably continue as a performance measure the latest meta-analysis serves as another nail in the coffin of evidence. According to the synthesis of high level clinical trials, for recurrent presumptive pneumococcal pneumonia, recurrent all cause pneumonia and death the vaccine doesn’t do squat, even in the high risk patients for whom it is commonly recommended.

Do common sense and belief trump evidence on RRTs?

Erik DeLue, MD, blogging over at Today’s Hospitalist thinks so:

Yes, I am aware that Peter Pronovost, MD—a MacArthur Genius, no less—warned us in the Oct. 2, 2006, JAMA, that we should “Walk, Don’t Run” in embracing RRTs. Yet, the “truthiness” (there’s Mr. Colbert again) of how effective RRTs are has been unmistakable in every community hospital at which I have worked. I have plenty of observational data, albeit far from publishable grade, that demonstrates decreased number of code blues and ICU transfers after a hospital’s RRT team has been put in place. But ultimately, common sense has been the biggest mandate for RRTs in my institutions.

If it’s working at your institution by all means keep it going. But, absent high level evidence, please don’t make it into a performance measure.

Codapedia

This Wiki for medical coding will launch in April.

Kevin MD on comparative effectiveness research

I agree on most issues with my blogging colleague Kevin MD. Today, however, I must take issue with him concerning his recent USA Today op-ed on comparative effectiveness research (CER).

The title of the piece, Unbiased research for doctors is good medicine, implies that government funded CER is somehow inherently and uniquely unbiased. That premise, while it may appeal to popular belief, is false. The boosters of CER have revealed their biases. According to this New York Times article Representative Pete Stark, an enthusiastic supporter of CER and chairman of the Ways and Means Subcommittee on Health, seems to know what the research results will be before the research even starts: it’ll save money. Translate: it will favor cheaper drugs.

If you’ve any doubt about whether this program is biased just read the Congressional Budget Office paper which originally pitched the proposal, prefaced by the not-so-unbiased Peter Orzag, the new White House budget director. From the introduction to the paper (italics mine):

…because federal health insurance programs play such a large role in financing medical care and account for such a large share of the budget, the federal government itself has an interest in generating evaluations of the effectiveness of different approaches to health care.

The government has a financial interest in the outcome of the research. That’s a conflict. It’s a bias.

There’s more:

To affect medical treatment and reduce health care spending in a meaningful way, the results of comparative effectiveness analyses would not only have to be persuasive but also would have to be used in ways that changed the behavior of doctors, other health professionals, and patients.

That's telling. The government is already planning how to use the results. And this:

Generating additional information about comparative effectiveness and making corresponding changes in incentives would seem likely to reduce health care spending over time—potentially to a significant degree.

There’s more, but enough for now. Clearly this is agenda-driven, through and through. It’s politics informing science. It’s supposed to be the other way around! An unbiased, objective approach would seek to find out which treatments are best. The government’s plan is to design research to prove what they already think they know. That’s not objective science. Objective science is neutral and disinterested.

Much of the government’s enthusiasm is driven by interest in the Dartmouth Atlas Project. What’s the Dartmouth Atlas Project? It’s a large repository of data on health care expenditures and outcomes. In a collection of maps it demonstrates that there’s great variability in care by region and no correlation between expenditures and quality. That is, regions that spend more don’t necessarily get better care. The reasons for this are multiple and complex, often cultural and may involve systems of care as much as drugs and devices. It is a stretch to divine from such data that cheaper treatments are generally better. Yet, that’s the stretch the government sponsors seem to be making, and they are setting out to prove it with their CER agenda.

If all that’s not enough to convince you that government sponsored research can be very biased just look the track record of another $1 billion (and counting) government project, the National Center for Complementary and Alternative Medicine, a subsidiary of the NIH. Wasteful, conflicted and biased, and the sponsor of arguably one of the most disgraceful research boondoggles in all of medicine.

After pointing out the obvious, that doctors need research to help them make clinical decisions, Kevin goes on to say Currently, comparison research is largely conceptual… I disagree. As I pointed out in a recent post, comparative effectiveness research is a reality and has been with us for years.

Do we need more research? Sure. Always have, always will. Science is a work in progress. Is a politically driven agenda the best way to go about it? No.

On a final note, what about the wasteful variation in health care so vividly demonstrated by the Dartmouth Atlas Project? What’s the etiology of the problem? Is it a lack of research? No. It’s the abysmal penetration of evidence we already have into clinical practice. It’s less than 50%. It’s as low as 10% in some surveys. 10% uptake of $1.1 billion worth of research won’t fix the problem.

Should internal medicine and family practice be merged?

That’s the topic of our latest Medscape Roundtable Discussion, which opens with a video blog by Robert W. Morrow, MD.

I expressed the view I’ve offered before here---that general internal medicine is fading fast, and that the merger proposal represents the final finishing blow unless the American College of Physicians and the Society of General Internal Medicine do a better job of advocating for internal medicine as a unique specialty.

A Medscape poll is linked on the video blog page where readers can vote on the issue.

NSAIDs and cardiovascular risk

There has been mounting evidence that the older non-selective COX inhibiting NSAIDs are just as risky to cardiovascular health as are the COX -2 inhibitors. I have linked to a number of earlier studies that bear this out. [1] [2] [3] Now there’s even more evidence of harm associated with old and new NSAIDs, published in a recent issue of the Archives of internal Medicine. In this analysis of several large registries diclofenac had the highest hazard ratio for death and MI.

More from Heartwire.

Diclofenac

More on the clopidogrel-statin interaction

The pendulum seems to be swinging back and forth on this question. The latest study, from the journal Pharmacotherapy, suggests that in the case of atorvastatin the interaction is not significant even at the 80mg dose.


I still don’t think we have a final answer.

Does chronic Lyme disease exist?

This controversy continues to heat up. The “mainstream” view, as promulgated in the 2006 IDSA guidelines, is that it is essentially nonexistent. The “alternative view”, supported by the ILADS, advocates for recognition of chronic Lyme disease and supports long term antibiotic treatment.

The ILADS position is problematic because it allows for antimicrobial treatment absent laboratory confirmation and based on vague symptoms. On the other hand the IDSA was investigated by the Connecticut Attorney General's Office which found conflicts of interest and other problems in the IDSA guideline development process. At the recommendation of the Attorney General the IDSA has agreed to a review of the 2006 guidelines by a disinterested panel, with the potential for revision or replacement of the guidelines. That review is a work in progress, with recent updates here and here.

Recent journal articles representing the competing views can be found here and here.

EMRs in U.S. hospitals

The rate of adoption is low. Very, very low according to survey data published in the NEJM. The paper is available as free full text here.

An accompanying editorial, also freely available in full text, is an important and educational read for those unfamiliar with the health care provisions of American Recovery and Reinvestment Act of 2009 (ARRA), the recently passed stimulus bill. The editorial focuses on the information technology piece of the bill, known as the Health Information Technology for Economic and Clinical Health (HITECH) act. It provides strong financial incentives to doctors and hospitals in the form of subsidies for timely adopters and penalties for non-adopters. One of the more concerning provisions is that providers must have “certified” EMRs and that the use of said systems must be “meaningful.” While these terms await better definition most would agree that one requirement will be interoperability by which EMRs of different facilities are somehow connected. How is that supposed to work? In my locale I can think of six large facilities with EMRs, all from different vendors, none of which talk to one another. What type of infrastructure will need to be put in place to accommodate interconnectivity of these systems? What types of upgrades will be needed? Will some systems have to be dismantled and replaced with “certifiable” systems? The editorial addresses this issue:

Second, much will depend on the federal government's skill in defining two critical terms: "certified EHR" and "meaningful use." ONCHIT currently contracts with a private organization, the Certification Commission for Health Information Technology, to certify EHRs as having the basic capabilities the federal government believes they need. But many certified EHRs are neither user-friendly nor designed to meet HITECH's ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT. Similarly, if EHRs are to catalyze quality improvement and cost control, physicians and hospitals will have to use them effectively. That means taking advantage of embedded clinical decision supports that help physicians take better care of their patients. By tying Medicare and
Medicaid financial incentives to "meaningful use," Congress has given the administration an important tool for motivating providers to take full advantage of EHRs, but if the requirements are set too high, many physicians and hospitals may rebel — petitioning Congress to change the law or just resigning themselves to forgoing incentives and accepting penalties.

I suspect these concerns will delay adoption of EMRs by some health systems, pending clarification of system requirements for certification.

The editorial ends with:

The nation's economic woes have given birth to an unprecedented federal effort to modernize the information systems of a troubled health care system. It is now up to the government and the nation's health care professionals and facilities to turn this opportunity into real improvements in the health and health care of Americans.

That’s optimistic. It may be decades before the EMR improves our nation’s health. It’ll be one thing to develop a really good system nation wide. An even greater challenge will averting and fixing the adverse consequences of the new culture that will surround adoption of electronic health records.

Can patients with critical aortic stenosis undergo noncardiac surgery?

A literature review was presented at the Perioperative Medicine Summit:

Conclusion: Critical AS needs to be detected preoperatively, given its prognostic importance. When detected, surgery may still be considered even if AVR is not feasible, and requires a comprehensive co-management team involving anesthesia, cardiology, surgery, and internal medicine.

A recent article on Alpha1-Antitrypsin deficiency (AATD)

---in the Archives of Internal Medicine is something of a rant which makes some of the same points about AATD I’ve made in the past about disease associations, under diagnosis and the need for screening of all patients with COPD and unremitting asthma.

The long awaited NICE-SUGAR results

---won’t seem very nice if you’re an advocate for tight glucose control in critically ill patients:

Conclusions In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter.

The Surviving Sepsis Guideline authors, aware of the lack of evidence for a specific glycemic target, made a reasonable guess at a recommendation of 150mg/dl. I think they made a pretty good guess.

(Retired Doc beat me to it with this insightful post).

The Quality Improvement Hospitalist

This blog appears to focus mainly on publicly reported measures. Although I have expressed before why I think performance is the wrong way to go in the pursuit of real quality, performance measures are with us and we must deal with them. This site may be a useful resource to keep up with developments in the field.

Blood glucose levels and mortality in patients with myocardial infarction

An observational study just out in the Archives of Internal Medicine found that among hyperglycemic patients admitted with MI (some known diabetics and some not) reductions in blood sugar level over the course of their hospitalization were associated with improved survival, whether associated with insulin treatment or spontaneous. We can conclude nothing about treatment of hyperglycemia based on this study. The lower mortality associated with decreasing blood sugar levels over the course of hospitalization could just as easily reflect declining insulin counter-regulatory stress hormones indicative of milder infarction as it could the effects of treatment. The authors, in the paper’s conclusion and a Medscape/Heartwire interview, were circumspect.

For patients with ACS and hyperglycemia, somewhere out there there’s an optimal glycemic target for insulin treatment. But as of early 2009 we still don’t know what it is. The AHA scientific statement is still the best document we have to guide us.

Contextual errors in medicine

---are examined in this article from The Hospitalist. The quick-and-dirty on this is take a social history. I mean take the time to get a real social history. It just may contain the critical data to unlock the secret of the patient’s problem. It’s exactly what my blogging colleagues and I were talking about in a Medscape Roundtable from last spring.

Discontinuity of care at hospital discharge---can the discharge summary close the gap?

Communication between hospitalists and primary physicians at discharge is notoriously poor. Discharge summaries, which are supposed to address this problem, tend to be lacking in useful information and timeliness.

So what’s the most effective discharge summary? Discussants in a recent article in ACP Hospitalist seemed to agree that a uniform template is best, containing these key elements:

Problem that led to hospitalization
Key findings and test results
Final diagnoses (primary and secondary)
Brief hospital course
Condition at discharge
Discharge destination
Medications at discharge
Follow-up appointments and proposed management plan
Anticipated problems and suggested interventions
Pending laboratory work and tests
Recommendations of subspecialty consultants
Documentation of patient education
Name and 24-hour phone number for hospital physician records.

One advantage of the electronic medical record, which generates this type of summary, is speed. You can create the summary on the spot with a few clicks, and if the PCP is not in your network you can give the patient a printed copy to take to the follow up appointment.

A part of me longs for the days of the old fashioned narrative summary. It told the patient’s story as well as what the doctors were actually thinking (or whether they were thinking at all).

Steroids for severe CAP?

According to the noise I’ve been hearing it shows promise but needs more study. According to this new systematic review it is favored by low to moderate quality evidence only, with somewhat mixed results. I think it may show up in the next guidelines as a weak recommendation.

The osmolar gap in toxic alcohol poisoning

A paper in BMC Emergency Medicine reported a systematic evaluation of test characteristics of the osmolar gap to identify patients with levels of methanol and ethylene glycol considered toxic:

Conclusion: In this sample, an osmole gap threshold of 10 has a sensitivity and negative predictive value of 1 for identifying patients for whom hemodialysis is recommended, independent of the ethanol coefficient applied. In patients potentially requiring antidotal therapy, applying an ethanol coefficient of 1.25 resulted in a higher specificity and positive predictive value without compromising the sensitivity.

Caution: Although the test characteristics were good this study only looked at the ability of the osmolar gap to predict direct measurements of toxic alcohol levels, not clinical outcomes. Late in the course of toxic alcohol ingestion the parent alcohol becomes extensively metabolized to toxic acids which dissociate in the blood. After buffering of hydrogen ion the anionic species must be associated with sodium ion which enters into the osmolarity calculation. These acids, then, contribute to the anion gap but not the osmolar gap. The osmolar gap, which reflects the concentration of the parent compound, may be deceptively low late in the course of ingestion.

The best discussion of toxic alcohol ingestion I’ve seen is the section in UpToDate, which makes the above points and emphasizes that there’s no absolute cut off in the osmolar gap for treatment decisions.

In the body of the BMC paper there are some useful clinical points as well as equations for calculation the osmolar gap in patients with elevated ethanol levels, with and without a correction factor.

Taming the monster of hospitalist comanagement

When you give something a catchy name, like hospitalist, it takes on a life of its own. Sometimes you end up creating a monster as it morphs into all sorts of things you didn’t intend. That seems to be what’s happening with the idea of hospitalist comanagement.

What are some of the negative consequences? Here are a few.

Specialists become disengaged from all the non-procedural aspects of their area of expertise. Procedure done, then it’s adios! It not only leaves the hospitalist holding the bag with issues h/she is not qualified to address, but it also relegates the specialist to the status of technician.

It can quickly turn your hospitalist program into an H&P and discharge service, majoring in what I call “clerical scut.” It’s a sure recipe for burnout and increased turnover in your program.

As a corollary, it diverts time and focus from what hospitalists do best---caring for the really, really sick patients.

It blurs the demarcations of responsibility. Who’s responsible for the pain management? Wound problems? Who decides when the post laparotomy patient can have his/her NG tube removed? Who should be called by the nurses for what issues?

Those are some of the things Bob Wachter, Eric Segal, I and others grappled with in an article in the latest issue of ACP Hospitalist. A tip of the RW hat goes to Stacey Butterfield for taking a diverse, all-over-the-map collection of ideas from the group and putting together something coherent.

There were a few things (I think) we agree on about comanagement:

From the get go be clear on what “comanagement” (a term which is lacking in definition and means many different things to different people) means for your group and your hospital.

Define the boundaries of responsibility in areas such as mentioned above and make sure the nurses have it down pat.

Before making a commitment to expand services make sure you are adequately staffed and set appropriate limits.

Find out what your group members feel about what’s being proposed and protect them from getting bogged down in clerical scut.

Drug induced movement disorders

A review and CME presentation from Medscape. Non-industry supported.

Can watching House and Gray’s Anatomy make you a better doctor?

Researchers at the University of British Columbia incorporated the TV shows into their IM residency curriculum and seem to think it helped residents learn communication skills. To me all the paper really showed was that the residents liked it.

Therapeutic hypothermia after cardiac arrest

---not only saved lives and brains but also ICU days in this study.

The use of vitamin K in non-bleeding patients with excessive INRs

---was no better than placebo in this study. Patients in both groups had warfarin held.

The strategy suggested by these results, that one need only skip a dose or two of warfarin, is consistent with the Chest guidelines. These results cannot be extrapolated to the care of bleeding patients with excessive anticoagulation.

Medscape CME here.

The latest on EMRs and outcomes

A survey of Texas hospitals reported in the Archives of Internal Medicine concluded:

Hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs.

There’s no proof of cause and effect here although the results were adjusted for other variables. The raw data are not nearly as optimistic as the conclusion suggests. Clinical outcomes were mixed although there did seem to be fairly consistent cost saving.

The accompanying editorial was circumspect and made the point that since there will never be prospective randomized trials (too cumbersome and costly, and by the time they could be organized, given the current push for EMR adoption there would not be adequate comparison groups) we have to make the best of available lower level evidence. That evidence will need to be better than what’s offered here. Before and after implementation studies may be the most telling.

Surgery on cocaine positive patients?

When should you cancel? Here’s a discussion from the 2009 Perioperative Medicine Summit.

Ad hominem arguments debase only their purveyors

It seems, according to the WSJ Health Blog, that the editor of JAMA launched a personal attack against Jonathan Leo, professor of anatomy at Lincoln Memorial University concerning his criticism of this JAMA paper. Wow.

Via Kevin MD.

Exercise and mortality

More good news.

Increased physical activity in middle age is eventually associated with reduced mortality risk to the same level as that in men with constantly high physical activity, according to the results of a population-based cohort study reported in the March 6 Online First issue of the BMJ.

Via Med Rants

Don’t Twitter while on jury duty

This happened in my neck of the woods.

When I agree with Daniel Carlat

---it’s noteworthy. He recently wrote:

Industry funding of accredited CME is on its way into the dustbin of medical history…

Indeed it is at the rate things are going now. The vast majority of practicing docs want support to continue but don’t have the organization or the passion to raise their collective voice.

Later in the same post, citing a non accredited promotional activity, he noted:

Is this the kind of promotional education that will replace industry sponsored CME? Probably.

Right again. If support is banned you can strike the word “probably.” It’s exactly what I said in our recent Medscape Roundtable on this subject:

If pharmaceutical companies were banned from spending money on accredited CME, those funds would, in all likelihood, be spent on marketing. Physicians would be bombarded by even more information from industry, but in the absence of the safeguards and quality standards of accredited CME.

This would mean a loss of many high quality accredited programs and a big spike in purely promotional activities. Not a good thing.

The Institute of Medicine’s Summit on Integrative Medicine

---was recently held in Washington, D.C. I couldn’t be there (not that I wanted to) so I did the next best thing by viewing all the available Power Point slides and watching about half the speaker videos. A few observations follow.

Overview: Although the conference promoted woo, the IOM promotes woo and the whole thing was supported by the woo promoting Bravewell Collaborative, many of the talks were not blatantly, directly about woo. That’s good, you say? Not really. The generous portion of non-woo merely gave the real woo behind the effort a greater air of legitimacy. Worse, it helped conference organizers obfuscate the meaning of integrative medicine by confusing the integration of pseudoscience into mainstream medicine with integration as a model of health care delivery systems, the latter being the topic of many of the speakers. No distinction in meaning was attempted and the confusion permeated the conference. Given the massive publicity and influence of the IOM, this confusion is sure to spill over into public discussions and increase the effectiveness of “integrative medicine” as (to borrow a term from Orac) a Trojan Horse by which real woo can sneak into education and public policy. A lot of Kool-Aid was served at this meeting, in woo and other flavors, of which I strongly suspect, given the influence of the IOM, the public and the Obama administration will imbibe deeply. Don’t expect the NCCAM to be defunded anytime soon. A few good points were mixed in with the load of BS, which I’ll try and cite as I go along.

The whole person, hygiene, preventive medicine, genomics, and the interaction of genes and environment--- all concepts which conventional medicine embraces. Yet, explicitly or implicitly (using terms like reductionism and allopathic) the speakers hijacked these ideas for their own promotional use by accusing the mainstream of ignoring them.

A more fluid concept of evidence: David L. Katz, MD, a professor at Yale, thinks the evidentiary standards by which mainstream medicine evaluates treatments are too rigid. He advocated for a “more fluid concept of evidence” (background here). He illustrated this fluid concept with a testimonial about treatment of abdominal adhesions with acupuncture and homeopathy.

Don Berwick speaks: Even without regard to what he had to say it’s significant enough that Donald Berwick, M.D., CEO of the prestigious and (up to now!) very mainstream Institute for Healthcare Improvement, lent his good name to this woo fest. But what he had to say was rich. After introductory remarks about how happy and honored he was to be there he mentioned homeopathy and acupuncture, not to criticize them as health claims, but only to warn that they shouldn’t compete with each other, or with other modalities, for limited health care resources. In other words, let’s stop fighting and work together. (Groan). He praised the IOM for its contributions to the design of health care, starting (now get this) with “traditional, allopathic and curative care and now migrating into this distinguished and important new arena.”

But here’s the bomb. Berwick, who seems to believe that healthcare should be like any consumer industry, said that quality is defined by patients’ perceptions. This is his idea of patient centered care which he defines as the patient having all the control. The IHI’s metric for quality, he said, is (watch this, now, emphasis mine) “…give me exactly the help I need and want exactly when I need and want it.”

Think about that for a moment. The woosters and quackademicians of the world point to surveys like these which show that patients, in large numbers, really seem to want woo. They support their unscientific promotions by saying that because so many patients seek it out it must be valid. Adherents of science based medicine often point out the silliness of such thinking. Now, though, this argumentum ad populum is given new life and legitimacy because the Institute of Medicine and the Institute for Health Care Improvement endorse it!

As an aside, it’s ironic that Berwick leans toward single payer health care. His radical “I want what I want when I want it” model of patient centeredness could never function in any conceivable form of single payer care in the U.S.

Dean Ornish speaks: Dean Ornish, M.D. is president and founder of the Preventive Medicine Research Institute and Clinical Professor of Medicine at UCSF. His talk had all the trappings of basic science and a deceptive sprinkling of clinical non-woo. Don’t be fooled. Go and read Orac’s analysis. Nuff said.

On a less negative note: There was some appropriate emphasis on the fact that true individualization of care will one day be enabled by genomic medicine. The tools of genomic medicine will be available for prime time in a decade or so, making much of the one size fits all comparative effectiveness research obsolete just as the government’s $1.1 billion is finally spent.

Conclusion: Pseudoscience has been invading mainstream medicine in the areas of education, research, public policy and clinical practice for the past 20 years. The Summit on Integrative Medicine which has just taken place is a watershed event because it legitimizes this invasion like never before. Pseudoscience is winning. Two of the most influential think tanks in all of medicine now publicly support it. Leaders in science based medicine need to unite and smack it down. Hard. And soon.

Need an electronic medical record? Head over to Sam’s Club.

Get this---

Wal-Mart ….said on Wednesday its Sam's Club unit would sell a package including software and Dell computers directly to doctors for electronic medical records.

"We are trying to help the small practice doctor have access to medical records and practice management software as well as the hardware at an affordable cost," Sam's Club spokeswoman Susan Koehler said in a telephone interview.

They plan to provide installation, tech support and all the rest. Talk about off-the-shelf.

Via Reuters and Medscape.

A Sam's Club in suburban St. Louis

Sam's Club's new corporate headquarters, Bentonville, AR

It’s official: the hospitalist movement has taken over

For good or ill, with all its benefits and unintended consequences, it’s now official: Bob Wachter, who gave the original movement life by coining the term, has spoken:

…hospitalists have not only taken over for PCPs in overseeing and coordinating hospital care, they have taken over for specialists and subspecialists.

And

The bottom line is that the rotating PCP model might work here and there, and it is probably better than the traditional model of every PCP coming in every day at daybreak to see 1-2 very sick patients. That said, I believe that calls for its revival represent wistful longings for a system that has clearly lost in the marketplace of ideas and data that determines the organization of hospital care.

Ah, the beloved hospitalist model. Never has been “evidence based”, never will be, here to stay, it is what it is.

I’ve been saying for a long time that the endless and tiresome discussions about the hospitalist model’s value were irrelevant and that it was all about the niche. That position now seems to be “official.”

The NEJM paper Bob cites as possibly the final finishing blow to the old model is interesting and I may have more to say about it later.

St. Louis City Hospital, decaying, c. 1995, years after doctors left the building

The ventilator bundle---going beyond performance to real quality

The effectiveness of the ventilator bundle in preventing ventilator associated pneumonia (VAP) is not known. According to a systematic review just published in Critical Care Medicine (emphasis mine):

Conclusion: Lack of methodologic rigor of the reported studies precludes any conclusive statements about the bundle's effectiveness or cost-effectiveness. To assure efficient allocation of the limited healthcare resources, rigorous evaluation of optimal strategies for VAP prevention is needed to 1) establish best practices and 2) create a benchmark against which new technologies' value can be assessed. The vent bundle is not a viable quality measure in the intensive care unit at this time.

The publicly reported components of the ventilator bundle are these:

Elevation of the head of the bed
Daily "sedation vacations" and assessment of readiness to extubate
Peptic ulcer disease prophylaxis
Deep venous thrombosis prophylaxis

Although commonly referred to as the “VAP bundle” only two of these four measures directly target pneumonia.

A recent quality improvement effort at Vanderbilt to reduce VAP is another example of what I have previously described as going beyond performance to real quality. Here are their measures, most of which are off the public radar screen:

head of the bed elevated at least 30 degrees;
every two hours, mouth swabbed with mouthwash;
every four hours, suctioning to clear the throat;
every 12 hours, teeth brushed;
every 12 hours, physician orders a target sedation level;
every four hours, nursing assesses patient's sedation level;
every 24 hours, respiratory therapy assesses patient readiness for a spontaneous breathing trial; and preventive measures for deep vein thrombosis and gastric ulcers.

Vanderbilt’s IT system tracked adherence in real time, which went from 20% to 90%.

They saw a 41% decrease in VAP rates (note it wasn’t 100%) at an estimated cost saving in the millions and an estimated 13 lives saved over 10 months!

That, my friends, is the difference between performance and quality.

More on hyponatremic encephalopathy

In a recent post on this topic I mentioned differing expert opinions on the aggressiveness of treatment of hyopnatremic encephalopathy. Traditional teaching suggests the use of an infusion of 3% saline with treatment selection based at least in part on the absolute value of the serum sodium concentration. In recent years a more aggressive approach (which I originally cited here) has been suggested by Dr. Juan Carlos Ayus and others. That approach, along with some other aspects of hyponatremia in hospitalized patients, was recently discussed in a nice review in ACP Hospitalist. Key points, along with a few observations of my own:

Menstruant women are at greatest risk, followed by postmenopausal women, followed by men. Estrogen impairs brain adaptation to hyponatremia.

Conceptually it is the rate of fall of the serum sodium (relative to the speed with which the brain can adapt) rather than the absolute concentration of sodium which determines the risk of encephalopathy. This is often not known in practice, so clinical assessment coupled with the serum sodium level must govern treatment.

Hyponatremic encephalopathy is often missed in post operative patients because it resembles ordinary post operative nausea and vomiting.

Hospitalized patients, by virtue of their illnesses and circumstances, have multiple stimuli for vasopressin secretion. It can virtually be taken for granted that a hospitalized patient has elevated vasopressin levels.

In the face of elevated vasopressin levels hypotonic fluid will predictably lower the serum sodium concentration. For this reason the authors advocate that isotonic fluids be used in all hospitalized patients. There may be exceptions to this rule but it is safest in terms of preventing hyponatremic encephalopathy.

For treatment of hyponatremic encephalopathy the authors advocate small (100 ml) boluses of 3% saline rather than continuous infusions.

Concern about osmotic demyelination syndrome due to over correction has been a barrier to effective treatment of hyponatremic encephalopathy. But if the patient really has hyponatremic encephalopathy the risk of under treatment is greater than that of over treatment.

Osmotic demyelination remains a concern. After initial treatment of hyponatremic encephalopathy intervention may be necessary to blunt further rise in serum sodium. The Δ [Na+] at 24-48 hours is a frequently cited risk factor for demyelination.

Neurogenic pulmonary edema and hypercapnic respiratory failure are regular but under appreciated features of hyponatremic encephalopathy. Neurogenic pulmonary edema as a complication of hyponatremic encephalopathy is now known as Ayus-Arieff syndrome, and is treated with hypertonic saline.

What’s really wrong with the cardiology guidelines?

I understand that Dr. Rich has written a couple of great posts on this subject. Before I read and comment on them I want to make a few independent observations on the JAMA article in question and the accompanying editorial, the latter co-authored by our very own DB.

The JAMA authors looked at the strength of evidence multiple ACC/AHA guidelines and found:

Results: Among guidelines with at least 1 revision or update by September 2008, the number of recommendations increased from 1330 to 1973 (+48%) from the first to the current version, with the largest increase observed in use of class II recommendations. Considering the 16 current guidelines reporting levels of evidence, only 314 recommendations of 2711 total are classified as level of evidence A (median, 11%), whereas 1246 (median, 48%) are level of evidence C. Level of evidence significantly varies across categories of guidelines (disease, intervention, or diagnostic) and across individual guidelines. Recommendations with level of evidence A are mostly concentrated in class I, but only 245 of 1305 class I recommendations have level of evidence A (median, 19%).

Conclusions Recommendations issued in current ACC/AHA clinical practice guidelines are largely developed from lower levels of evidence or expert opinion. The proportion of recommendations for which there is no conclusive evidence is also growing. These findings highlight the need to improve the process of writing guidelines and to expand the evidence base from which clinical practice guidelines are derived.

OK, so there’s a problem with the guidelines, but what is it, exactly? Is it that the evidence available to the guideline writers was insufficient or that the writing process itself was faulty? I believe it was the former. The editorial writers seem to think it was both. They cite conflicts of interest and the bias of experts. These are valid concerns but are the problems more in perception than in fact? The guideline writers could do no better than align their recommendations with the best available evidence. In many cases the best available evidence is “low level.” To bolster their case the editorial writers might have given examples in which guidelines were not in accordance with best evidence or associated with negative consequences.

Do cardiology guidelines have negative consequences? Evidence suggests not. In fact, studies show that adherence to cardiology guidelines is associated with better patient outcomes. [1] [2] [3] [4] [5] [6] [7] [8] [9] The editorial writers do mention performance measures. But performance measures fail due to misappropriation of evidence, not true adherence to guidelines.

DRESS syndrome

DRESS syndrome (Drug Rash [or Reaction] with Eosinophilia and Systemic Symptoms) is the term increasingly used to refer to many cases of what has traditionally been called drug hypersensitivity syndrome, including anticonvulsant hypersensitivity syndrome and allopurinol hypersensitivity syndrome.

A case series and literature review was presented in the Archives of Dermatology emphasizing the increasingly recognized role of human herpesvirus 6 reactivation in the pathogenesis.

Elder abuse

---can take many forms. One of the hardest types to spot, and one of the most under reported, is financial abuse. Caregivers who depend on elderly patients’ finances for their livelihood may have a conflict of interest. Here are some of the red flags.

The agenda to dissolve general internal medicine

---is moving forward, and will get a big boost as a result of a recently published paper in Health Affairs which compared resource utilization by FPs and internists. (Conflict of interest alert: According to Bob Doherty’s ACP Advocate Blog the study was conducted by a subsidiary of the American Academy of Family Physicians).

From the abstract:

Use of and spending for subspecialists were similar to those for general internists, and both were significantly higher than those for family physicians.

That horribly confusing sentence structure leaves one guessing at exactly what is meant (where were the proofreaders?) but according to Bob Doherty, who apparently has access to the full text article, they’re saying internists spend more than FPs.

The premise in many discussions about this article will be that spending less is better. But less is better only if achieves comparable clinical outcomes, and outcomes were not addressed in the study.

There’s a more basic and equally faulty premise behind the discussions at Doherty’s blog and DB’s thread on this topic: that internists should be no different from family practitioners. The corollary is that internal medicine training should be more like family practice training, specifically that more training time be devoted to the out patient side. I find a great deal wrong with that thinking. The short version of what’s wrong is that it diminishes general internal medicine as a unique specialty. I wrote a longer version here, where I also linked to two important primary sources in the journal Academic Medicine.

I’m a little disappointed but not surprised that Dr. Doherty didn’t address that point. After all, he is writing for the ACP, which no longer seems interested in promoting internal medicine as a unique specialty.

Propofol infusion syndrome

At CHEST 2008 Mayo Clinic investigators reported 39 patients who developed propofol infusion syndrome while being treated for refractory status epilepticus. Propofol is one of a limited number of options for treatment of SE when third line treatment (for refractory SE) is necessary. The syndrome is highly fatal and the folks at Mayo have abandoned it in favor of midazolam or other alternatives.

Medicare never events policy and the new legal standard

Several months ago, on two occasions, I blogged that Medicare’s never events policy will expand the legal doctrine of res ipsa loquitur to all sorts of unavoidable outcomes in hospitalized patients, and will shift the burden of proof in many cases. Well, it looks as though one of the legal experts writing in the most recent issue of The Hospitalist agrees with me.

More evidence that the Surviving Sepsis guidelines save lives

A single center study is reported here.

Case manager intervention for hip fracture patients

Most patients hospitalized with hip fracture have intervention by a case manager to troubleshoot payment issues, discharge planning, post hospital rehab and the like. Why not take it further? A group of Canadian investigators asked case managers to follow up on hip fracture patients and see that they got proper osteoporosis treatment. In a study from 2007 they showed that the intervention was associated with an increased rate of evidence based osteoporosis treatment post hip fracture. This year they published their outcomes data:

The intervention cost CaD $56 per patient. Compared with usual care, the intervention strategy was dominant: for every 100 patients case managed, 6 fractures (4 hip fractures) were prevented, 4 quality-adjusted life-years were gained, and CaD $260 000 was saved by the health care system.

Dynamite. That this would be a worthwhile quality project is a no-brainer. Don’t expect an easy time convincing your administration, though, because it’s not a publicly reported core measure.

Medscape has been accused of participating in an off label promotion scheme

---through its CME offerings. I want to offer some perspective before the blogosphere blows it out of proportion. First, although documents related to the whistleblower suit have been unsealed the essential facts are not known. Even Merrill Goozner, himself a critic of industry supported CME, after doing some digging, acknowledged that we don’t know what Medscape is supposed to have done wrong:

So what did the complaint accuse Medscape of doing wrong? Nothing -- or nothing that I could read.

Is anything illegal even implied? Off label mention of drugs in CME courses is not illegal, nor is it considered unethical in and of itself (the only requirement being that off label mention of drugs be disclosed). Promotion under cover of CME is biased but not illegal. The whole question of conspiracy may hinge on intent, and only internal documents will reveal whether it occurred. I say let the court decide and if the law was broken those responsible should face the consequences.

This unfortunate episode will bolster faulty arguments for a ban on industry support. Instead of throwing the baby out with the bathwater (by killing off Bob Wachter’s Hospital Medicine Course and downsizing professional society conferences) why not find a way to give ACCME the oversight and resources it needs to do its job?

Via Kevin MD

The mortality of ARDS

---hasn’t budged in over a decade. From the American Journal of Respritory and Critical Care Medicine:

…no temporal associations with mortality were demonstrated in RCTs (any time) or observational studies (after 1994). Pooled mortality from 1994 to 2006 was 44.0 (95% CI, 40.1–47.5) for observational studies, and 36.2% (95% CI, 32.1–40.5) for RCTs. Meta-regression identified study type (observational versus RCT, odds ratio, 1.36; 95% CI, 1.08–1.73) and patient age (odds ratio per additional 10 yr, 1.27; 95% CI, 1.07–1.50) as the only factors associated with mortality.

Why? In a Medscape report the authors speculate:

…that the failure to improve ARDS outcomes reflects the dearth of effective treatments and variable adherence to guidelines that recommend low tidal volume, early aggressive resuscitation, and appropriate antibiotic use and sedation protocols.

Studies included in the systematic review were published in a time period extending through 2006. That may not have been enough time for widespread adoption of low tidal volume ventilation, validated in the ARDSnet trial in 2000.

Hyponatremia

How fast should you raise the serum sodium, and with what, in various clinical circumstances? There have been many reviews on hyponatremia and one could pontificate extensively, but what are the nuts and bolts? Here is one of the nuttiest, bolttiest reviews you’ll find, by one of Vanderbilt’s great teachers, EM professor Corey M. Slovis, MD. He says:

On the basis of the available information, hypertonic saline should be reserved for a previously well individual who is symptomatic with seizures, coma, or new focal neurologic findings and whose serum sodium level is less than 120 mEq/L. (Some experts argue that 110 mEq/L is the limit.)

I recommend that this very select group of patients receive 1.5 mL/kg of 3% hypertonic saline in less than an hour, and have this regimen supplemented with a small dose (20 mg) of intravenous furosemide to facilitate free water diuresis and block ADH secretion from the hypertonic saline infusion. This will raise the serum sodium level by 1-2 mEq/L within 1 hour. A second infusion can be given over another hour if the patient is still symptomatic. Seizures can also be treated aggressively in this routine manner with intravenous benzodiazepines.

This is consistent with what most text books and reviews recommend for the acute situation. One review to which I previously linked suggested a more aggressive approach, in which the hypertonic saline is bolused over 10 minutes, in patients who are actively seizing. (That is more aggressive than other recommendations I’ve seen but, after all, the patient is about to herniate). Those with a single resolved seizure and other milder neurologic symptoms, according to that review, were to be treated with the more traditional hypertonic saline infusion.

Sex ed 1960

This film clip from the Bell Laboratory Science film series is as close as it got in my day.

The American Medical Student Association is promoting naturopathic medicine

---and seems to be taking it to a new level. They’ve devoted a pretty substantial web page to it. And it’s purely promotional:

The Naturopathic Medicine Interest Group was established in 2005 to educate AMSA members about the profession and practice of Naturopathic Medicine through an active listserve, interaction between allopathic and naturopathic medical schools and dynamic programming at the National and Regional conventions. The Group is also dedicated to cultivating a relationship with the members of the Naturopathic Medical Student Association and to helping naturopathic medical students get involved with AMSA.

and---

Naturopathic medicine has as its basis the premise that the body has an innate intelligent force capable of healing itself and our duty as physicians is to support that process by stimulating that force, providing the body with essential nutrients and removing any toxic factors. This is done in the spirit of the therapeutic order, going from the gentlest least harmful modalities and culminating in pharmaceuticals and surgery if necessary.

Naturopathic Physicians (NDs) attend 4 year full-time residential medical schools and are primary care providers trained in conventional medical sciences, diagnosis and treatment, as well as nutrition, botanical medicine, physical medicine, homeopathy, hydrotherapy, counseling and minor surgery. Some NDs choose to receive further training in natural obstetrics and Chinese Medicine.

This is the largest and most influential organization of medical students. Concerning.

Statin use in septic patients

Evidence is trickling in about the benefits of statins in patients hospitalized with a variety of acute illnesses. Most of this evidence is derived by retrospectively comparing outcomes in current users vs non users of statins.

For patients with sepsis, according to a presentation at the Society of Critical Care Medicine 38th Critical Care Congress, current users fared better than remote users or never users and high dose users fared better than low dose users.

Should statins be incorporated into the sepsis bundle? That decision awaits ongoing prospective trials. For now it’s a matter of medication reconciliation according to one of the investigators:

Dr. Hite concluded: "For now, I would not recommend that statins be initiated in a septic patient, but it is reasonable to continue statins in a septic patient previously taking a statin. This is a change that I and many others have made in their practice over the past few years as a result of data similar to the data provided by this study."

The U.S. may be losing its place in the world of biomedical research

---according to this report. Where’s the new hot spot? Biopolis.

What RBC transfusion threshold for hospitalized patients?

A review in The Hospitalist covers the basics.

The American Medical Student Association gets an F in science based medicine

According to the New York Times med students from the AMSA are up in arms over pharma influence in the curriculum at Harvard. It seems a prof in the first year pharmacology course who was a paid consultant to companies which make cholesterol drugs spoke positively about the drugs and minimized their side effects. Well, “cholesterol drugs”, statin drugs anyway, are very beneficial and their adverse effects are minimal. Few would question such a pronouncement from an “unconflicted” and less expert teacher.

In all too typical sloppy reporting the Times didn’t bother to tell us specifically what was objectionable, inaccurate or biased about the lecture content. (It’s hard to see how product bias could creep into first year pharm to any significant degree given that it’s largely about receptors, structure-activity relationships, distribution, elimination and the like).

AMSA rates med schools on their COI policies and recently gave Harvard an F for its industry affiliations. Ironically, they’re not nearly as concerned about the infiltration of non-evidence based woo in medical school curricula. Well, of course they wouldn’t be concerned about that. They promote it.

Via Billy Rubin’s Blog

Biostats primer

From Medpage Today. Just the basic stuff. The minimum you need to know.

Autosomal dominant polycystic kidney disease

Free full text review in CCJM.

Anti-CCP testing for rheumatoid arthritis

According to this review in Archives of Internal Medicine the test, although highly specific for rheumatoid arthritis, has only limited clinical application. Why? Because rheumatoid arthritis is primarily a clinical diagnosis.

Adjusting your computer’s bios settings

I have an ancient spare PC that I’m determined to keep going, just for the sport of it, without spending much money. If it dies it dies and there’s little to lose. That’s why I dare to poke around in the bowels of the machine, in the bios and the registry and other mysterious places---the do it yourself geek thing. Here’s a video I found helpful from the How Stuff Works series.

Be very, very careful when you do this.

A protocol for combined vasopressin and epinephrine and corticosteroids after cardiac arrest

This looks promising. I’m anxious to see more research.

Acute decompensated heart failure

This article in The Hospitalist is a concise evidence based summary of ADHF. Although there’s nothing brand new in terms of evidence presented there the article makes an underemphasized point: Inotropes such as dobutamine and milrinone, once the tools of the intensivist, are assuming an important place in the pharmacopeia of the palliative care specialist due to their principal role of symptom relief and the principle of double effect.

Methadone for chronic pain management

This Medscape CME offering on opiate treatment for chronic pain with a focus on methadone is non-industry supported. It provides a good overview of the pitfalls and precautions of long term opiate prescribing. One glaring omission was the failure to mention the unique cardiac toxicity of methadone and the guidelines for cardiac monitoring.

VTE management pearls

Tracy Minichiello, MD, associate professor of medicine at the University of California, San Francisco, and chief of the San Francisco VA’s Anticoagulation Services is a frequent speaker on venous thromboembolism at Bob Wachter’s conflicted, commercially biased, pharma funded, superb hospital medicine course.

Today’s Hospitalist recently published excerpts from one of her recent talks. Some of the pearls and FAQs she covered:

Risk stratify all patients with a diagnosis of acute PE.

While low molecular weight heparins are generally advantageous consider unfractionated heparin in special circumstances, such as massive or submassive PE and in patients with renal impairment or extremes of weight.

How do you transition from one form of heparin go another?

It’s not uncommon, she pointed out, for hospitalists to receive a patient who was started on unfractionated heparin in the emergency department but will be transitioned to LMWH once admitted. “Our service is often asked how to make this transition,” she said.In an ideal world—one with adequate nursing staff—the best strategy would be to stop heparin one to two hours before starting the LMWH. But Dr. Minichiello said that because she can’t be sure that a nurse will get back to a patient in that short amount of time, she usually starts the LMWH at the same time she orders the unfractionated heparin to be discontinued.And how do you transition a patient from LMWH to unfractionated heparin? Dr. Minichiello said she recommends discontinuing the LMWH and starting a weight-based IV unfractionated heparin drip, without a bolus, one or two hours before the next LMWD dose is due.

Finally, regarding IVC filters:

Given concerns about long-term complications, retrievable filters are now quite commonly used. “But retrievable filters are only temporary if practitioners remember to remove them,” she said.This can be a challenge, particularly for hospitalists who see patients for only a short time and rarely follow patients after discharge. “If you order an IVC filter to be placed,” she said, “you should really own it until it comes out, or make sure you specifically hand off that responsibility, just as you would the follow-up of any other critical test or procedure. Develop a process for follow-up to be sure that removal actually happens. ”