Friday, February 27, 2009

Comparative effectiveness research---the New York Times doesn’t get it

On the subject of comparative effectiveness research (CER), I’ll mention briefly some choice examples of specious reporting from the New York Times. They have been cited by other bloggers. I have a contrarian view.

Robert Pear’s piece, published February 15, is simplistically titled U.S. to Compare Medical Treatments. As if we’ve never compared treatments before. But this is particularly rich:

“The new research will eventually save money and lives,” said Representative Pete Stark, Democrat of California.

The United States spends more than $2 trillion a year on health care, but “we have little information about which treatments work best for which patients,” said Mr. Stark, who is the chairman of the Ways and Means Subcommittee on Health.

In the absence of information on what works, Mr. Stark said, patients are put at risk, and billions of dollars are spent each year on ineffective or unnecessary treatments.

Wow. Pete Stark says doctors don’t have information on what works. If it were true it might be a convincing argument for spending the $1.1 billion.

Paul Krugman’s NYT blog post from February 10 is titled Ignorance is bliss:

Health care costs are the main reason long-term fiscal projections look so scary — and here we have corporate interest trying to prevent us, not from trying to spend our health dollar more wisely, but from even trying to find out what we get for the health care dollar.

This is truly vile.

I could rant and rave about what’s wrong with popular reporting on medical issues but I wouldn’t do nearly as good a job of making that point as these pieces do all by themselves.

DNA amplification tests for Tb ready for prime time!

Nucleic acid amplification tests for Tb can cut the time for laboratory diagnosis from weeks to days. In its updated guidelines for the use of amplification tests the CDC has issued this strong statement:

NAA testing should be performed on at least one respiratory specimen from each patient with signs and symptoms of pulmonary TB for whom a diagnosis of TB is being considered but has not yet been established, and for whom the test result would alter case management or TB control activities.

The guideline lists some commercially available testing services and provides an algorithm. CME on this topic is available here via Medscape.

Klebsiella pneumoniae Carbapenemases---mediators of emerging gram negative resistance

Klebsiella pneumoniae carbapenemases (KPCs) cause resistance not only in Klebsiella, but also in other gram negatives. The topic is reviewed in a Medscape Infectious Disease Expert Column. Tigecycline may be the best option but experience is limited. Polymixins are agents of last resort. The role, if any, of quinolones and aminoglycosides was not mentioned. I don’t know of anything in the pipeline.

Public Citizen weighs in on industry supported CME

They wrote a letter to the AMA and, predictably, they support a ban:

We strongly support a ban on all commercial support of CME because the consequences of any corrupting influence of commercial support on CME are so significant.

Problem is, there’s no evidence to support that assertion.

Dr. Wes wrote a butt-kicking post addressing several issues including the unintended consequences:

Next year, we'll be holding our national meeting in my garage (it will be down-sized significantly) and fold our advocacy groups (I hear they receive 50% of their entire annual budgets from the sale of the evil pharma and device industry's display space on convention floors - can you believe that???) But who needs advocacy in these times of change for doctors? Certainly not us.

Read the rest.

Thursday, February 26, 2009

Mendelian inheritance explained to school kids

The clip below is from Thread of Life, another of the wonderful Bell Laboratory science films.

Post-cardiac arrest evaluation and care

---is a long neglected topic in terms of formal systematic recommendations. Publication of this ILCOR Consensus Statement is a welcome development. While we might think we know all this stuff there’s tremendous variation in post-arrest care. Moreover, in the past 50 years survival has improved very little in patients who achieve return of spontaneous circulation (ROSC).

Regarding treatment, the Statement says (italics mine):

Given the complex nature of post–cardiac arrest care, it is optimal to have a multidisciplinary team develop and execute a comprehensive clinical pathway tailored to available resources. Treatment plans for post–cardiac arrest care must accommodate a spectrum of patients, ranging from the awake, hemodynamically stable survivor to the unstable comatose patient with persistent precipitating pathology. In all cases, treatment must focus on reversing the pathophysiological manifestations of the post–cardiac arrest syndrome with proper prioritization and timely execution. Such a plan enables physicians, nurses, and other healthcare professionals to optimize post–cardiac arrest care and prevents premature withdrawal of care before long-term prognosis can be established. This approach improved outcomes at individual institutions compared with historical controls.

That sounds like a worthwhile project for any hospitalist program. While the concepts outlined in this report are straightforward there are substantial barriers, mainly administrative and institutional, to their implementation.

How evidence based are the recommendations? Randomized controlled trials support therapeutic hypothermia. A meta-analysis indicates an impressive NNT of 6 for improvement in neurologic outcome. Most of the other recommendations are supported by lower levels of evidence and pathophysiologic rationale. The entire report, however, is consistent with the principles of EBM, which require that the best available evidence be applied to each question, not that every intervention must be supported by RCTs.

Huge ECG teaching file

---found at Medscape’s ECG of the week.

Dexmedetomidine better for ventilator sedation?

In this study dexmedetomidine (Precedex), while comparable to midazolam (Versed) in effectiveness of sedation, was associated with less delirium and shorter time on mechanical ventilation. Here is the Medscape report on the presentation at SCCM 2009 (non-industry supported CME available).

Other popular agents for ventilator sedation, lorazepam and propofol, were not in the comparison groups.

Wednesday, February 25, 2009

Who says we don’t have comparative effectiveness research?

A lot of folks, apparently. I can think of few issues in medicine about which there’s been more public confusion. This is the first opportunity I’ve had to weigh in in any detail, and it may be the first of several posts from here on the topic.

Several of my respected blogging colleagues have already written posts. DB said (my emphasis):

I strongly believe that CER will help physicians practice better, more cost-effective medicine. ….

When I can spend less money for equal benefits, then both the patient and I are happy. CER will provide the data to help us make such decisions.

And, in another post:

We cannot get such data unless we have a centralized process. Industry will never do such studies. No foundations have supported such expensive research.

Kevin M.D. weighed in here, saying we need CER.

Bob Wachter wrote:

Since nothing can happen without the research, the new funding for comparative effectiveness is welcome and helpful.

The faulty premise implied in each of those statements is that we don’t already have CER. Here are a few---just a few, mind you---examples to challenge that premise. This is just a drop in the bucket of CER we already have:

Which pressor is better in septic shock (multiple comparative studies)?

Discharge planning using a multidisciplinary intervention group is better than usual care.

CT is no better than V/Q for diagnosis of PE.

In sepsis, an early quantitative resuscitation strategy is better than a late quantitative resuscitation strategy or a qualitative resuscitation strategy (meta-analysis of multiple comparative studies).

In the early post operative period after cardiac surgery tighter glycemic control is better than less tight glycemic control.

Multiple studies comparing glycemic targets in medical patients with critical illness have failed to establish the best target.

In mechanically ventilated patients, integrating sedation interruption and spontaneous breathing as a single protocol works better than when these protocols are separate.

In patients with type 2 diabetes, intensive glycemic control is no better for macrovascular disease than less aggressive control over 5 years.

Intensive glycemic control is better for macrovascular outcomes when measured at 10 years.

Amiodarone is more effective than sotalol or propafenone for the prevention of recurrences of atrial fibrillation.

Rate control is as good as rhythm control for patients with atrial fibrillation (two comparative studies).

Devices are better than drugs post MI for prevention of sudden cardiac death in patients with reduced ejection fraction (two comparative studies).

Amiodarone is better than lidocaine for shock resistant VF.

Device therapy is better than amiodarone for ischemic and non-ischemic dilated cardiomyopathy.

Aspirin plus a PPI was a better strategy for prevention of GI bleeding than substitution of clopidogrel in patients with a history of aspirin induced GI bleeding.

Benazepril–amlodipine is better than benazepril–hydrochlorothiazide in hypertension treatment.

Four antihypertensive agents were compared head to head.

Streptokinase compared head-to-head with aspirin in patients with myocardial infarction.

Three thrombolytic drugs compared head-to-head in patients with MI (ISIS 3).

Two thrombolytic agents compared head-to-head in patients with MI (GISSI 2).

Rifaximin compared with lactulose in hepatic encephalopathy.

Magnesium compared to antiarrhythmic drugs in the acute management of atrial fibrillation.

Multiple studies have compared the hospitalist model of care with the traditional model, with mixed results.

Rivaroxaban compared with enoxaparin for DVT prophylaxis.

Fixed dose unfractionated heparin compared with low molecular weight heparin for VTE.

For ARDS and ALE, at least three studies have compared recruitment PEEP with conventional PEEP.

Crystaloid compared colloid for volume resuscitation.

Unfractionated heparin compared with low molecular weight heparin for VTE prophylaxis (many studies).

Tygecycline compared with levofloxacin for community acquired pneumonia.

PA catheter compared with CVP guided treatment of ALI and ARDS.

Two fluid management strategies compared in ALI and ARDS.

Enoxaparin compared with fondaparinux in patients with NSEMI.

Nesiritide compared with nitroglycerine in acute decompensated heart failure.

Not convinced yet? OK, then check out the Cochrane Collaboration where countless other comparative effectiveness studies are reviewed.

Yes, we have comparative effective research to guide us. Lots of it. The notion that doctors don’t have data with which to compare treatments is just plain wrong. Do we need more? Sure. Is another $1.1 billion or our tax dollars earmarked for CER going to bring uniform adherence to best practice? No, not when we can’t even adhere to the evidence we already have. Will there be unintended consequences? You bet. More soon.

Tuesday, February 24, 2009

Rank and file doctors want industry support for CME to continue

In his latest jab at industry supported CME Dr. Daniel Carlat cites a survey of Mayo Clinic attendees published a couple of years ago in the American Journal of Medicine. He takes, to put it kindly, considerable license in his interpretation of the study.

First a look at the study. Mayo CME planners, who receive lots of feed back from participants, wanted formal data on doctors’ attitudes about industry support. Investigators surveyed attendees from two Mayo industry supported meetings and two of their non-supported meetings. Some of the results:

In response to question 3, “Do you believe CME courses should accept industry support if doing so reduces the overall cost of the course?”, 62.3% of respondents answered “yes”…. Responses to this question also differed significantly by course attended (P less than .001). A majority of industry-supported course attendees (71.5%) answered “yes,” whereas the attendees of the non-industry-supported courses were more evenly divided (48.7% answered “yes,” 33.1% answered “no”).

So how does Dr. Carlat spin the results (my bold)?

The bottom line of this survey is that opinions about commercial support of CME depend entirely upon which physicians you sample. If you choose to sample doctors who are in the midst of a free conference with the nicest meals, the flashiest slides and the biggest names that industry money will buy, they will defend the wisdom of their choice. But if you sample physicians who choose to pay for their own medical education, you will find that doctors overwhelmingly reject industry funding of CME.

Not quite. The majority of physicians in the survey, 62.3%, all of whom paid for their CME, favored industry support. The little detail Dr. Carlat leaves out of his analysis is that all of the survey respondents paid a pretty penny for their CME whether it was industry supported or not. I checked the Mayo CME web site and found information about three of the four courses in question. All three are very expensive. One industry supported offering, the Mayo Internal Medicine Board Review, costs $1050! The other supported offering, Mayo Clinical Reviews, costs $725. One of the non-supported offerings, Mayo Selected Topics in Internal Medicine, costs $839. There’s not much difference in the price per hour of CME among these offerings. I doubt that tuition fees alone would cover the non-industry supported offerings---they’re subsidized from somewhere. (Mayo, singular in its ability to do this is, after all, awash in cash).

Dr. Carlat posted the American journal of Medicine article in order to take issue with another study which found physicians overwhelmingly in favor of industry support. Concerning that study he concludes:

I find it sad, though quite revealing, that the CME industry has found it necessary to latch onto this non-peer reviewed survey in order to further its political aims.

Well, with all due respect, Dr. Catlat, I find it rather amusing that you have to misrepresent the aforementioned peer reviewed study in order to advance your agenda against sponsored CME. By the way, the authors of the Mayo study acknowledge in their discussion that doctors want industry support to continue and believe that current safeguards are adequate. They conclude:

How should concerns about industry support of CME be addressed? First, CME organizers should explicitly acknowledge that the primary function of CME is to improve the welfare of patients by enhancing the knowledge and skills of physicians,6 not to facilitate physician–industry interactions. Several professional organizations, including the American Medical Association,10 the ACCME,13 and the American College of Physicians,9 have made recommendations regarding industry support of CME programs. Taken together, these recommendations can be summarized as follows:

•Industry support must be completely unrestricted;

•All CME faculty conflicts of interest must be declared before the program begins;

•The industry sponsor should have no role in the planning or evaluation of program content;

•The topics should be presented without bias, particularly if the products of the industry sponsor are discussed; and

•Support should not be given to participants but to the program organizers to reduce registration fees.

Adherence to these recommendations should prevent most inappropriate industry influence or bias in CME programs.

The two studies in question are not the only ones showing favorable attitudes towards industry support. Here are two more.

Dr. Carlat, we can’t cherry pick the data. None of the studies are perfect. The Mayo clinic sample you cited is a select group of doctors who are willing to pay relatively large sums of money for their CME (yes, even the ones attending the industry supported courses; they’re just as expensive).

Finally, a digression for a word or two about bias. Dr. Carlat talks a great deal about bias in his anti-industry postings. It’s an important issue but one which has become the subject of considerable obfuscation and selective outrage. It’s also one in which my own position has been mischaracterized. Neither in my recent back-and-forth with Dr. Carlat nor in any other discussions have I ever made the claim that industry supported CME is unbiased. I have challenged detractors to come up with evidence of pervasive and systematic bias (they can’t) but I realize that absence of evidence does not equal evidence of absence.

On the subject of Mayo CME, when I attended their industry supported 2007 hospital medicine course I made some real time blogging observations about bias. There were three presentations I felt were biased. The speakers were promoting treatments they themselves provided for a living. One was acupuncture, one was Yoga and one concerned IVC filters for thromboembolism. None of these biases could be attributed to the pharma companies supporting the meeting.

The point is that bias in medicine is pervasive and not restricted to the influence of the pharmaceutical industry. It would be simplistic and naïve, not to mention non-evidence based, to assume that industry is the only, or even the major, source of bias.

These questions suggest the appropriate burden of proof for this debate:

Is there systematic evidence that the bias in industry supported CME is worse than in non-supported CME?

Is the bias pervasive and systematic in favor of industry products?

New guidelines for aneurysmal subarachnoid hemorrhage published

The free full text is available here.

The nuts and bolts of this large document are distilled in this article from Medscape.

Statins to impact the progressin of calcific aortic stenosis?

The jury is still out. We may have better answers soon. Evidence summary here.

What’s the economic future for hospitalists?

Competing theories are examined in Today’s hospitalist.

The value team is generally not afraid of a subprime hospitalist salary meltdown. One subset of this group argues, “You can’t run a hospital without nurses, but how much revenue do they raise? Now try to run a hospital without hospitalists!” It’s likely that this can no longer be done, especially for hospitals that have already gone the hospitalist route.

Monday, February 23, 2009

Singulair and neuropsychiatric effects---is there a link?

Post marketing reports via MedWatch suggest a link berween Singulair (montelukast) and possibly the two other approved drugs which act on the leukotriene pathway (Accolate aka zafirlukast and Zyflo aka zileuton). The FDA continues to monitor post marketing reports and is examining clinical trial data.

Via Medscape.

Random thoughts 2/23/09

Sequential compression devices work better when attached to the patient.

I wonder if the incidence of acute renal failure is rising with the non-evidence based replacement of V/Q scanning by CT for the diagnosis of pulmonary embolism. Somebody should do a paper.

Do you ever fantasize about being Dr. House?

Heart failure instructions generated by EMRs save time and improve performance ratings, but are boiler plate in their language and seldom address patient and family concerns. The evidence from which this measure was drawn was based on individualized, detailed verbal counseling with a specialty trained physician extender. No wonder the Optimize data were disappointing.

The New York Times just doesn't get it about comparative effectiveness research. I'll explain later.

Friday, February 20, 2009

Candidemia update

From Future Microbiology. IDSA guidelines are expected out later this year.

Internal Medicine 2009, ACP’s annual meeting

---is coming up in April. Get a load of the industry sponsorship brochure. In addition, based on last year’s meeting, over 30 drug companies and around 40 device companies are expected to lease space in the exhibit hall. If the current purge against industry supported CME wins, what will happen to meetings such as this? Support from the non-profits, recruiting firms and book vendors (if they survive the purge) would be inadequate to sustain a meeting of this scope. If industry support is banned, the ACP would no doubt find a way to continue the meeting with some combination of increased registration fees and a markedly reduced selection of educational content, but it could not survive in its present form. It’s about educational content, not nice things.

Is this what we really want? The Coalition for Healthcare Communication mentions the Medscape Roundtable and provides links for readers to express concerns to the AMA and political representatives.

Thursday, February 19, 2009

Emergency medicine case simulations

EKGs and more.

Electrocardiography beyond the basics

Hein Wellens and Richard Conti discuss some nuances of electrocardiography in this Medscape article. Not beginners’ stuff but practical.

Another study of rapid response teams

RRTs are intuitively appealing but up to now the evidence has pretty consistently failed to show benefits. In this recent study, though, they helped. What’s the state of the evidence today? Mixed.

End of life decisions in the ICU

This topic was recently reviewed in Clinical Pulmonary Medicine. It is one of the better articles I have read on this topic and is worth obtaining in full text.

Wednesday, February 18, 2009

The 7-valent pneumococcal vaccine licensed for kids

---is the bomb. Here’s the latest update from MMWR and here’s an earlier report. After the introduction of the vaccine pneumococcal disease dropped like a rock.

I’m envious. The pediatricians have an effective pneumococcal vaccine, why can’t we? Newer conjugate vaccines with more serotypes are in the pipeline, apparently.

The hospital as a Potemkin village

It’s what happens when Joint Commission arrives.

Via The Ether Way.

Which pressor for septic shock?

What’s the best guiding principle---Levophed, leave ‘em dead or Who’s the dope who started dopamine?

Although recent evidence tended to favor norepinephrine this new study favors dopamine.

I still believe the best perspective, offered in this Chest review, is to individualize therapy based on hemodynamic goals.

Is it ever lupus?

SLE is under diagnosed and over diagnosed. Many patients are mislabeled. This CCJM review has several pearls.

Treatment is not for lupus per se. Treatment is for manifestations. However, prevention of cardiovascular disease and osteoporosis, for which patients are at increased risk, is assuming increasing importance.

Tuesday, February 17, 2009

Docs ignoring safety guidelines for second generation antipsychotics

We’re getting better and better at searching and appraising evidence. In contrast we’ve made little or no progress in that final and most important step of EBM: putting the evidence into practice. We know the rate of uptake is poor. Figures of 30%-50% are often tossed around. But for guideline recommended metabolic monitoring of patients given second generation antipsychotics it’s almost zilch:

A total of 5,787 preguideline patients and 17,832 postguideline patients were identified. Baseline lipid testing rates were 8.4% for the preguideline cohort and 10.5% for the postguideline cohort, and the 12-week testing rates were 6.8% and 9.0%, respectively. Baseline glucose testing rates were 17.3% for the preguideline cohort and 21.8% for the postguideline cohort, and the 12-week testing rates were 14.1 and 17.9%, respectively.

Metabolic complications of these drugs occur gradually and are heralded by weight gain and laboratory changes. Adherence to the monitoring guidelines would make them much safer drugs.

As I’ve said many times drug safety is more about how doctors use drugs than it is about drugs’ inherent properties.

Via Heartwire.

Lessons in single payer health care

---from Canada.

Shona Holmes, another Ontario court challenger, endured a similarly harrowing struggle. In March of 2005, Ms. Holmes began losing her vision and experienced headaches, anxiety attacks, extreme fatigue and weight gain. Despite an MRI scan showing a brain tumor, Ms. Holmes was told she would have to wait months to see a specialist. In June, her vision deteriorating rapidly, Ms. Holmes went to the Mayo Clinic in Arizona, where she found that immediate surgery was required to prevent permanent vision loss and potentially death. Again, the government system in Ontario required more appointments and more tests along with more wait times. Ms. Holmes returned to the Mayo Clinic and paid for her surgery.

Almost 2 years ago a biased and politically motivated “systematic review” concluded:

…although Canadian outcomes were more often superior to US outcomes than the reverse, neither the United States nor Canada can claim hegemony in terms of quality of medical care and the resultant patient-important outcomes.

No matter what you think about population health outcomes in the U.S. and Canada, stories like the one cited above from the Wall Street Journal remind us that health care in Canada is not patient centered. If you advocate for single payer care in the U.S. don’t talk out of the other side of your mouth about timely patient centered care.

Via Secondhand Smoke.

Point-counterpoint on conflicts of interest

Has the hunt for conflict of interest gone too far? In an issue of BMJ last March Kirby Lee, assistant professor of clinical pharmacology at UCSF, argues no. Thomas P. Stossel, professor of medicine at Harvard Medical School, argues yes.

Lee begins correctly noting abuses in the pharmaceutical industry and runs down some of the well known examples of unethical and even criminal corporate behavior. Predictably he trots out Vioxx, citing questionable promotions and implying illegal activity. Granted, drug companies could stand to clean up their marketing act. That would earn them more credibility with doctors. When they go outside legal boundaries of promotion they should be prosecuted. But Dr. Lee is wrong in his interpretation of the Vioxx example:

The most notable case illustrating how direct marketing to doctors can lead to serious harm was the rofecoxib scandal.

In the VIGOR trial Vioxx was compared with naproxen, a non steroidal anti-inflammatory drug singular in its cardiovascular safety. In that trial it was associated with an increased risk of myocardial infarction. But in the real world of promotion Vioxx was competing with a variety of older generation NSAIDs most of which have been found to carry similar or even greater cardiovascular risk! [1] [2] [3] [4] Moreover, in its promotion as a pain medication Vioxx may have been competing with narcotic analgesics, a class of drugs associated with a rising body count over the past decade. My point is that neither the VIGOR trial nor any corporate improprieties surrounding it constitute evidence that pharmaceutical industry marketing has had a net harmful effect on patient outcomes. In fact, as I argued in a recent Medscape Roundtable piece, there’s not a shred of evidence that this is true of promotions in general.

The naysayers appeal to another body of evidence, and the argument goes like this: Promotions are associated with increased use of the sponsor’s product. Doctors believe they are immune form influence while multiple surveys show they are not. Indeed there is a large body of such evidence but it’s all soft science. None of that research comes close to addressing patient outcomes. Although there is evidence that promotions sometimes lead doctors away from evidence based practice such reports are biased and unbalanced, as I pointed out in that same Roundtable:

Drug detailing sways doctors away from evidence-based practice. Studies in support of this argument do not give a balanced view. Surveys of the effects of drug detailing on doctors' prescribing have focused selectively on areas of overuse, such as antibiotics in the ambulatory setting and new expensive drugs compared with equally effective generics. Although some promotions undermine evidence-based practice, others may enhance it. Because promotional literature is a mix of good and bad information, the net effect on patient care is not known. Many heavily promoted treatments are evidence-based and known to be underutilized by doctors. A good example is the inadequate use of low-molecular-weight heparin for thromboembolism prophylaxis. The promotion of statin drugs and angiotensin-converting enzyme inhibitors for appropriate patients is another example. Such a promotion toward best practice has been ignored in published studies. Research in a broader range of clinical situations is needed before conclusions can be made about the overall effect on evidence-based practice.

The soft evidence, recited faithfully by Dr. Lee, is insufficient to justify the unintended consequences of harsh policy measures such as bans on industry supported CME or putting the government in charge of all clinical research.

Finally, I find Dr. Lee’s concern about conflict of interest to be curiously and inappropriately selective. If we are to address conflict of interest in a realistic and credible manner we must not overlook the pervasive conflicts and abuse that occur outside the arena of industry ties. That’s one of the points Dr. Stossel makes in his counterpoint. In the opening paragraph he notes (my bold):

Their sermons, echoed by medical journals and the news media, warn that medical practitioners, educators, or researchers accepting gifts from or payments for services to companies producing medical products compromise their scientific objectivity and professionalism. Strangely, financial transactions between patients, insurance companies, hospitals, and doctors, encompassing 85% of the medical marketplace, do not count as conflicts of interest.

Stossel goes on to note the lack of evidence of harm attributable to drug industry ties (again, my bold):

Conflict of interest ideology purports to promote scientific rigour yet is far from rigorous itself. Adverse outcomes objectively ascribable to financial conflicts of interest are almost non-existent, especially in the context of overwhelmingly positive commercially driven medical advances. Conversely, purely academic research and education are hardly more reliable than their corporate or corporate sponsored counterparts--arguably less so, because they are not, for example, subject to stringent Federal Drug Administration reporting requirements. Misconduct fells a single academic miscreant but can bring down an entire company.

Stossel may seem like a lone dissenting voice among the academics in this debate. However, surveys and polls indicate that only a very small minority of doctors favor the ongoing purge against physician-industry relations.

Note: Since publication of Stossel’s commentary and our Medscape piece there has been evidence reported---the first ever---documenting the effect of an industry promotion on patient outcomes, and the evidence was positive. You can read about it here.

VTE and cancer

To what extent should patients with “idiopathic” VTE be screened?

What is the role of LMWH (as opposed to standard warfarin treatment) for long term management?

These questions and more are addressed in this free full text review.

The post-resuscitation care bundle

---centers around applied hypothermia, aggressive diagnostic evaluation and secondary prevention. Only true centers of excellence are doing this now. I suspect your average hospital is too distracted by publicly reported measures to really get excited about this. It’s a major institutional commitment. I plan some additional posts on this subject soon.


Posts on applied hypothermia.

Resources from Take Heart America.

Vanderbilt’s protocol.

Monday, February 16, 2009

The asthma capital of the U.S.

---is St. Louis MO, according to the Asthma and Allergy Foundation of America. You can view the rankings here and a more detailed analysis here.

What will the stimulus bill mean to health care?

Dr. Anonymous has a great post on the stimulus package. He wrote:

The other article which has good information on this is from the Wall Street Journal. The writer is Alicia Mundy and the article is entitied, "Drug Makers Fight Stimulus Provision." According to the article, "$1.1 Billion in research funding would be doled out to the National Institutes of Health and other government bodies." Did you read that closely? It said government entities.

This is in reference to comparative effectiveness research (CER). We need more CER. (For a favorable look at CER by DB read here and here). Perhaps the more relevant question is whether such clinical research is best done by the government. The most notable example of government sponsored CER is ALLHAT. ALLHAT is also a notable example of agenda driven research, faulty design and inappropriate spin, every bit as much as you’ll find in pharma sponsored research.

Dr. Anonymous goes on:

The grassroots opposition to this is a coalition called the "Partnership to Improve Patient Care" which includes "lobbying arms of drug, device, and biotechnology industries as well as patient-advocacy groups and medical-professional societies." (I can just imagine the press saying things like patients and docs have gotten in bed with big pharma - yeesh).

A more egregious example of corruption in government sponsored research, while not comparative effectiveness research, is the Trial to Assess Chelation Therapy. Which reminds me. I bet the NCCAM is one of those “other government bodies” in line for a piece of that stimulus pie!

Can anyone make an evidence based case that we should trust big guvment over big pharma?

Lymphangioleiomyomatosis review

Via Clinical Pulmonary Medicine.

The condition may be sporadic or associated with the tuberous sclerosis complex.

When to think of it: woman of child bearing age with emphysema, pneumothorax, chylothorax or progressive dyspnea.

How to diagnose it: You can start with HRCT but by the time you’re in that deep you’ll want to get some help from a pulmonologist.

I’ve previously linked to another review here.

Discharge planning done the right way

Here’s more evidence that it saves resources in the long run.

What makes it work?

Intervention: Arrange the patient’s follow up appointments. Call 2 and 4 days later to make sure the plan is being carried out.

Usual care: Instruct the patients on their follow up needs, leave it to them to make the arrangements, and turn ‘em loose.

Usual care is the CYA approach which may satisfy institutional risk management needs but it’s ineffective, as studies like this prove.

Sunday, February 15, 2009

Dr. Anonymous and Rush Limbaugh

---speak with clarity on You Tube on the health provisions of the stimulus bill. (Rush is linked on Dr. A’s You Tube page).

Dr. A here.

Rush here and here.

Truth be told very few have read the bill. For those who do it will still be impossible to fully anticipate the negative consequences (intended and unintended).

For those interested in primary sources there are some links here.

More on the post by Dr. Anonymous tomorrow.

Friday, February 13, 2009

More evidence favoring point of care lactate measurement

The latest study is from Critical Care. I recently blogged on the topic here.

Contraindicated prescribing of QT prolonging drugs is common

From an AHA presentation:

Nearly 40% of a large series of patients with a known preexisting long QT interval received an order for a QT-prolonging medication while hospitalized, thereby increasing their risk for sudden cardiac death.

Further, at-risk patients rarely underwent monitoring for further widening of the QT interval. Indeed, 8% had an ECG within 48 hours after starting the new QT-prolonging medication, Dr. Ravi K. Mareedu reported ...

Antiarrhythmic agents accounted for more than half of all prescriptions for QT prolonging medications, with amiodarone leading the way. Another 30% were for haloperidol. There were 115 orders for erythromycin and other QT-prolonging antimicrobials, 82 for methadone, and 97 orders for chlorpromazine and other antinausea drugs.

Via Hospitalist News.

Management of acute hyperkalemia

This review in Critical Care Medicine incorporates recent advances in our understanding of the pathophysiology.

Pain management dogma

I stumbled on this while researching for another post:

Opiates are dangerous to abuse, and those who care to can easily measure the body count associated with the new era of pain control (4). Once again, it’s not small…. and it’s far more the direct product of these campaigns than their architects are willing to admit *. To be fair, it is certain that human nature, human biology, and human avarice are the most important drivers of this problem; these initiatives simply made it worse. Dare I say that while no one ever died of pain, lots of people have died (in the past few years) from its treatment? Or at least in part as a consequence of these initiatives?


Meteora: The Unchained Goddess (1958)

In the 1950s and 60s Bell Laboratories sponsored a series of science education films for school kids. These films were originally made for TV specials, then distributed to schools. They were often shown in science classes and special assemblies. The most popular was probably Hemo the Magnificent, which was about the circulatory system. Since I first blogged about Hemo over 2 years ago a few You Tube videos with clips from the Bell series have surfaced.

Below is an excerpt from Meteora: The Unchained Goddess about weather. The graphics and animation were wonderful for their time. Note that the opening sequence of this 1958 film warns about man made global warming!

Thursday, February 12, 2009

My conversation with Dr. Billy Rubin on industry supported CME

---is in the comment thread of this post. I’m trying to find consistency in his arguments. He either misunderstands or deliberately misrepresents mine. I hope we can hammer this out in a cordial manner until we define the areas of irreducible disagreement. Head on over for a look, then comment here or there.

Update on Acinetobacter baumannii infections

If you don’t have access to the full text of this review in Lancet Infectious Diseases Medscape has a nice summary with CME credit (non-industry supported).

For multi-drug resistant infections tygecycline and the polymyxins show the most promise. Carbapenems are effective in most infections but rising resistance is a concern. Data from clinical trials are scant.

Acinetobacter baumannii EM
Image source: Wikipedia

Poor Medscape just can’t win

Medscape, often accused of being corrupted by Evil Pharma, now seems to be afflicted by CAMphobia:

CAM is not ducks in row waiting to be shot down. In fact, many have proven to be effective and been integrated into main stream medicine. Read this blog to relieve ourself of this bias.

We should expect more from Medscape. But maybe that’s asking too much.

Treatment prospects for non-alcoholic fatty liver disease (NAFLD)

A review published in seminars in liver disease examines life style modifications (arguably the most rational intervention), metformin, TZDs, statins and more novel treatment options.

Yellow nail syndrome

From a case series in Chest:

Yellow nail syndrome (YNS) is a rare disorder first described in 1964 by Samman and White, consisting of yellow nails with lymphedema and/or chronic respiratory manifestations. The respiratory manifestations are diverse and include pleural effusion, bronchiectasis, rhinosinusitis, chronic cough, or recurrent lung infections. The pathophysiology of the syndrome remains unclear, but various anatomic or functional lymphatic drainage abnormalities have been proposed as the underlying cause.

Wednesday, February 11, 2009

Occult cancer in patients with VTE

Interesting findings from this systematic review included:

The prevalence of occult cancer at 12 months was 10%. Only two thirds of cancers were diagnosed at baseline as compared to 12 months. Abdominal and pelvic CT diagnosed significantly more cancers than traditionally recommended clinical assessment.

New safety concerns about fondaparinux

Although we knew it was too good to be true Arixtra once seemed like the perfect drug. Here were the advantages:

It was not known to cause HIT (the molecule was too small for the known mechanism).

Dose labeling for morbidly obese patients was simple and straight forward compared to the low molecular weight heparins.

In contrast to unfractionated and low molecular weight heparins, its “full therapeutic dose” for acute coronary syndrome is low, equal to its DVT prophylactic dose, theoretically leading to lower bleeding risk in the treatment of ACS.

Well, as with all new drugs safety concerns have begun to emerge over time. Some new FDA warnings are reported here via Medscape:

…the potential for elevated activated partial thromboplastin time (aPTT) temporally associated with bleeding events. These events have been reported after administration of fondaparinux sodium injection, with or without concomitant administration of other anticoagulants.

Interesting. It’s a no brainer that anticoagulants will be associated with bleeding events, but fondaparinux isn’t supposed to alter the aPTT. (If it did in any predictable manner that would be an easy means of laboratory monitoring). I don’t know if it would help, but if an elevated aPTT is a harbinger of bleeding in patients on fondaparinux perhaps it should be monitored occasionally.

From the very first, of course, we knew about two unique features contributing to potential bleeding risk: the long half life, particularly in renal failure (absolute contraindication rather than adjustment recommendation for patients with creatinine clearance under 30) and the fact that there is no reliable reversal agent. I wonder how many of these bleeding events were associated with contraindicated use in patients with renal impairment. We’ll never know from these post-marketing reports.

The report also mentions increasing reports of a syndrome resembling HIT. This, as I noted above, is hard to understand mechanistically. When I linked to the first case report of this problem over a year ago I drew skeptical commentary. Now, though, the problem’s really on the radar screen.

The recommendations for dealing with this problem differ from the current algorithm for dealing with suspected HIT. Again from the Medscape report:

Any degree of thrombocytopenia should be monitored closely, and fondaparinux should be discontinued if platelet count decreases to less than 100,000/mm3.

Finally, there’s this little pearl:

Latex-sensitive individuals may have allergic reactions to the dry natural latex rubber in the needle guard of the prefilled syringe of fondaparinux sodium.

My summation? Arixtra isn’t the be-all and end-all. It is an interesting drug with some important niches.

Is transparency always the best policy?

From Medical Economics:

Physicians who admit errors may face the opprobrium of their peers, the anger and disappointment of their patients (and their patients' families), legal entanglement, and economic loss. Unlike in church, confession doesn't necessarily lead to absolution in the world of medicine.

While saying I'm sorry may well be morally correct and soothing to the psyche, our society, unfortunately, provides little reward for contrition. Indeed, the high road often comes with many sharp turns and few guardrails.

Evidence based management of ventilator sedation to improve neurocognitive outcomes

It is well known that survivors of mechanical ventilation experience long term cognitive sequelae. Now there’s evidence, presented at the Society of Critical Care Medicine 38th Critical Care Congress, that protocol driven limitation of ventilator sedation can minimize this complication.

It isn’t entirely clear from the Medscape news piece, but this must be a follow up analysis of the wake-up-and-breathe study which I linked here.

According to one of the investigators:

"The culture of the ICU should change," Dr. Jackson added. "The concept of keeping the patient down should be considered an antiquated concept."

Discharge planning works

---if done the right way, as a multidisciplinary effort, and with sufficient effort to manage the transition from hospital to clinic. The Re-Engineered Discharge (RED project) saved approximately $400 in outcome costs per patient, as described in Hospitalist News.

This sort of thing has been described before, and is similar to the transitions team approach described by Bob Wachter here.

Tuesday, February 10, 2009

What’s in that stimulus bill?

From Bloomberg.

Troubling health provisions have been sneaked into the bill:

One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. The goal is to reduce costs and “guide” your doctor’s decisions (442, 446). These provisions in the stimulus bill are virtually identical to what Daschle prescribed in his 2008 book, “Critical: What We Can Do About the Health-Care Crisis.” According to Daschle, doctors have to give up autonomy and “learn to operate less like solo practitioners.”

And how many new crimes are invented by the hidden health care provisions?

Hospitals and doctors that are not “meaningful users” of the new system will face penalties. “Meaningful user” isn’t defined in the bill. That will be left to the HHS secretary, who will be empowered to impose “more stringent measures of meaningful use over time” (511, 518, 540-541)

What penalties will deter your doctor from going beyond the electronically delivered protocols when your condition is atypical or you need an experimental treatment? The vagueness is intentional.

A little further down in the article (my bold):

Hiding health legislation in a stimulus bill is intentional. Daschle supported the Clinton administration’s health-care overhaul in 1994, and attributed its failure to debate and delay. A year ago, Daschle wrote that the next president should act quickly before critics mount an opposition. “If that means attaching a health-care plan to the federal budget, so be it,” he said. “The issue is too important to be stalled by Senate protocol.”

Those are the concerns of Betsy McCaughey, former lieutenant governor of New York and adjunct senior fellow at the Hudson Institute. The health provisions, it would appear, were buried in this huge omnibus bill by design, to avert debate.

Here’s more commentary from Secondhand Smoke:

This is why people are so jaded and cynical about their own government. The economic stimulus bill that we are told is too important to really debate and must be passed NOW! NOW! NOW! contains sneak provisions opening the door to national health care.


The fact that our betters in government want to sneak matters of this import into law without a debate tells us all we need to know about how the people would react to these provisions. And their attempt to use the economic crisis as cover, tells us all we need to know about their integrity and respect for the democratic process. This isn't an issue about whether these government controls should be passed or defeated. For now, the issue is that they should be debated. Otherwise, we are losing the right to call ourselves free.

What is the effect of pharmaceutical industry promotion?

Early in my blogging days I reviewed the literature on this topic, concluding that the evidence was soft. That situation had not changed, even as recently as the evidence reviews I presented in our two most recent Medscape Roundtables on physician-industry relations. However, a new development this month warrants a brief revisit.

First a little background. The extensive literature on this subject has been spun by the No Free Lunchers and others as proving that industry promotion is harmful to patients. That conclusion goes far beyond what the evidence warrants. The main points of said evidence are as follows:

Promotions are biased.
Promotions influence attitudes.
Promotions influence prescribing behavior.
Individual doctors, in surveys, believe their colleagues are influenced but tend to underestimate their own susceptibility.

That’s about as far as it goes. Not what you’d call hard clinical endpoints, eh?

Now I don’t consider myself an expert but I’ve followed this literature closely for 10 years. As a participant on the No Free Lunch listserv for several years I heard and examined every argument---over and over again---against industry promotion.

But, hey, don’t take my word for it. It’s easy to check the primary sources. Virtually everything that’s been written on the subject is compiled and nicely organized in a huge repository, the Drug Promotion Database. And, although the web site appears to have an anti-industry bent the conclusion based on its literature review is circumspect. You can read the summary pages here and here and note the conspicuous absence of any evidence about promotional effects on patient outcomes. That’s because there wasn’t any.

Until now.

Yes, there’s finally evidence of the effect of an industry promotion on patient outcomes. And what’s really interesting is it’s one of the most maligned and heavily criticized industry promotions in all of medicine. It’s the Surviving Sepsis Campaign, which has been under extremely heavy fire for its ties with Eli Lilly and Edwards Lifesciences.

This NEJM perspective piece accused the campaign of being a marketing strategy disguised as evidence based medicine. Health Care Renewal (read here and here) and other bloggers heaped on more criticism and, predictably, the popular media jumped into the fray.

So what’s the new evidence?

Recently at the Society of Critical Care Medicine 38th Critical Care Congress the results of a 2 year multicenter study of the effects of the campaign were presented:

"Resuscitation compliance increased from 10.9% at baseline to 30.1% after 2 years," Dr. Levy said. "There was an almost linear increase [in compliance]. It was statistically significant with every quarter."

"Mortality dropped from 37% at baseline to 30% after 2 years," Dr. Levy reported. Although absolute risk reduction was 7%, relative risk reduction was 19% (P less than .01), he added.

To analyze the significance of the drop in mortality, the investigators assessed the baseline mortality on hospital admission.

"Baseline mortality did not change, which suggests a true drop in mortality," Dr. Levy said. "The findings showed us 2 things. One, that we were able to change clinical practice and that we were able to facilitate a knowledge transfer; and 2, that there was a real change in mortality."

Sure enough, industry promotion does influence doctors, and this influence was for the good. It saved lives. What’s interesting is that although guideline adherence almost tripled as a result of the campaign it was still only 30% at study end. It was encouraging that the trend was one of increasing influence over time, suggesting further improvement, and a more robust decline in mortality, had the campaign continued.

Despite these results many critics of physician-industry relations will continue their appeal to ridicule. It’s time to shift to an appeal to evidence.

Monday, February 09, 2009

Carcinoid tumors

Free full text review in CCJM.


Topic update in Chest.

Non-cystic fibrosis bronchiectasis is the focus of the review. Etiologies of non-CF bronchiectasis can be divided into post infectious causes, underlying systemic diseases and idiopathic.

The Straw Man of physician entitlement

Here’s a description of the Straw Man fallacy:

The Straw Man fallacy is committed when a person simply ignores a person's actual position and substitutes a distorted, exaggerated or misrepresented version of that position. This sort of "reasoning" has the following pattern:

Person A has position X.
Person B presents position Y (which is a distorted version of X).
Person B attacks position Y.
Therefore X is false/incorrect/flawed.

This sort of "reasoning" is fallacious because attacking a distorted version of a position simply does not constitute an attack on the position itself.

The Straw Man, a distorted and much weaker argument than the one actually put forth, is a convenient way to ridicule an opponent but fallacious none the less.

A common Straw Man in the debate about physician-industry relations is one erected by Dr. Billy Rubin and Dr. Daniel Carlat in their response to our recent Medscape Roundtable discussion on industry supported CME: “I’m a physician and that entitles me to nice things.” As Dr. Rubin put it:

I am a physician and that entitles me to nice things. Trinkets, such as free hors d'oeuvres at the cocktail hour following the day's professional meetings, fancy dinners on the tab of the local drug rep, tax-deductible trips to "educational conferences" in the Bahamas--all this is part of the trappings of the lifestyle of a doc. Such is the mentality that resists seeing the obvious conflict-of-interest in industry sponsorship of CME; the defense of the indefensible rests on an emotional response, not a rational one.

This is not new. It is a tired canard. Although this sense of “entitlement to nice things” is supposed to be widespread in our profession I have yet to see evidence that it exists to a significant degree, or that it is “the mentality that resists seeing the obvious conflict-of-interest in industry sponsorship of CME;”. Among the many counter arguments against the proposed ban on industry support I have yet to see the “entitlement” position advanced.

Of course, there is agreement on both sides of the debate on one entitlement, but it has nothing to do with nice things: physicians deserve high quality CME. Beyond that, where is the argument? Digression for personal disclosure: I am appreciative or CME meetings held at nice places but do not feel entitled to them. I will be disappointed if they disappear but I am quite grateful and content that I have received more than a square deal in my professional life. Really. Pharma’s support of such meetings helps reduce registration fees, but it provides no funding towards lodging, meals or any other “nice things.” My registration at meetings such as this is paid by my medical group, as are those lodging and transportation costs directly attributable to the educational program, and will be paid regardless of whether the activity remains accredited so long as I attest to the educational value.

So, is this attitude of entitlement pervasive among my colleagues? Where is the whining? If it really exists to the degree that Dr. Rubin and Dr. Carlat and others claim, it is, to say the least, a very troubling statement about our ethics. I decided to take a closer look at the responses to our Roundtable. They were overwhelmingly in favor of industry support. Some respondents bemoaned the high cost of non-supported CME. (High tuition fees are a significant expense to low salaried primary care docs, many of whom are on a tight budget struggling with practice overhead and educational debt. Some fairly inexpensive offerings do exist but the selection is limited. There are a few non-supported free offerings but they are limited in scope and some are of dubious origin). But among all the responses there was not one mention of nice perks or entitlement.

If Dr. Carlat, Dr. Rubin or other readers are aware of any published defense of Pharma supported CME that’s based on the premise of entitlement to nice things I hope they will cite it in the comments below.

Friday, February 06, 2009

Methadone cardiac screening guidelines

The American College of Physicians has re-posted its guidelines on this topic and now it’s available as free access full text. As Medscape explains, the re-posting has revised disclosure and source information but no content changes. Although I linked to it the first time around it’s worth mentioning again.

I guess now for folks taking methadone all the narcotic contracts will need to be altered to include informed consent regarding the arrhythmia risks and an agreement that the patient will comply with the recommended ECG monitoring.

Errors in diagnosis and management of epilepsy

Reviewed in Seminars in Neurology.

EMR template-facilitated fraud

It looks like the Dinosaur has been observing first hand something I blogged about a while back. He writes:

The proliferation of electronic medical records (EMRs) has generated a situation that really roasts my beef, and I am seeing it with increasing frequency. It's the flip side of the lawyers' old canard,

If it isn't documented, it didn't happen.

It seems that more and more doctors are taking that to mean that if something IS documented, then whether or not it actually happened is moot, at least as far as payment is concerned.There are at least two specialist offices who regularly send me letters documenting examinations that I know for a fact did not occur. In one case, the proof is that they document procedures requiring a level of patient cooperation and vocalization incompatible with the patient's age. (ie, How do you get a two-year-old to tell you in which ear the tuning fork sounds louder?) In another, a full body exam is documented at each visit when only the affected limb was examined. Those are the only two where my level of certainty is 100%. There are many others that are highly questionable, but harder to prove because of patient unfamiliarity with examination procedures.

In the paper days there were innocent examples like PERLA (now when was the last time you really checked the patient for accommodation?) as well as some more creative forms of writing. Paper based templates pushed the envelope of fraud, but the EMR became the great enabler.

Examples like those cited above may range from carelessness (to take advantage of the speed of the template generated note you neglect to go back and edit stuff out) to deliberate, thoughtful abuse. In either case you can bet your coding department will bill for what’s in your note!

AMSA takes PharmFree to a new level

They’ve devoted a new web site to it. What does it mean to be PharmFree? According to the web site (my italics):

AMSA promotes the conscientious, explicit and judicious use of the current best evidence in clinical care.

It’s straight out of David Sacket’s definition of evidence based medicine. It’s a joke, though, because the medicine AMSA actually promotes is some of the most extreme and non-evidence based woo of any mainstream medical organization I know of.

Thursday, February 05, 2009

Telavancin likely to be approved soon

As reported in Hospitalist News, this will be another option for MRSA. Like many new antibiotics today the approval will probably be restricted to complicated skin and skin-structure infections, and it’ll be up to the rest of us to figure out its other applications. I know little about it but it sounds like vancomycin “on steroids”:

“I voted 'yes,' because I think vancomycin is a dying drug, and I see vancomycin resistance all the time,” said panelist Dr. W. Kemper Alston, who is at the University of Vermont, Burlington. Those voting “no” on the safety and efficacy question cited concerns about the association of the drug with more than one toxicity.

I blogged about vanco as a dying drug here.

ICU utilization in patients with terminal lung cancer: the effects of discontinuity of care

The hospitalist model of care is one of discontinuity by design. Much attention has been focused on the patient safety hazards associated with this discontinuity. Researchers reporting recently in the Archives of internal Medicine uncovered another downside. Care by a hospitalist was associated with 57% increased odds of terminal patients spending their final admission in the ICU!

D dimer to predict recurrence of VTE after stopping anticoagulants

Decision making regarding the duration of oral anticoagulation following an episode of VTE can be difficult. In this study a positive D dimer after cessation of treatment was associated with over double the risk of recurrence.

Another important clopidogrel interaction

CMAJ reports that proton pump inhibitors (PPIs), which inhibit the cytochrome P450 2C19 enzyme responsible for biotransformation of clopidogrel (Plavix) from prodrug to active drug, cause a clinically significant interaction leading to reduced effectiveness of clopidogrel. The exception among the PPIs appears to be pantoprazole (Protonix). From the article:

Among 13 636 patients prescribed clopidogrel following acute myocardial infarction, we identified 734 cases readmitted with myocardial infarction and 2057 controls. After extensive multivariable adjustment, current use of proton pump inhibitors was associated with an increased risk of reinfarction (adjusted odds ratio [OR] 1.27, 95% confidence interval [CI] 1.03–1.57). We found no association with more distant exposure to proton pump inhibitors or in multiple sensitivity analyses. In a stratified analysis, pantoprazole, which does not inhibit cytochrome P450 2C19, had no association with readmission for myocardial infarction (adjusted OR 1.02, 95% CI 0.70–1.47).

Via Heartwire.

A similar interaction occurs between clopidogrel and some statins which I have previously mentioned here and here. The significance of that interaction has recently been questioned.

Wednesday, February 04, 2009

Insight about performance measures

---from Dilbert.

H/T to The Ether Way.

Loyola University just held their big woo fest

You can read the news release here and the official web page here.

Judging from this news report it must have been an interesting time:

The mood was eerie: relaxed, calm, yet animated. Around 25 participants chatted, bobbing their heads along with their body language, discussing various published studies on acupuncture.It may not have seemed like anything out of the ordinary. Except they all had needles sticking out of the center of their heads.

They call it experiential learning.

The premise seems to be that no matter how implausible the woo if patients want it and believe in it, give it to ‘em with your good name and the credentials of your institution behind it. As one of the speakers explained:

Michelfelder asked the audience to keep an open mind during their day of discovery of different types of integrative medicine. Just because it is not well understood, physicians should not discount it, he said.“You may say to yourself, ‘It makes no sense to me, I’m not even going to recommend it to my patients because I don’t understand it,’” Michelfelder said. But as long as the patient believes it will work and the treatment is inexpensive, he said it’s worth a try.

This little exercise in Quackademic medicine was organized and driven by medical students and, sure enough, the AMSA was in on it.

Boston loses CME convention business as the law of unintended consequences plays out

From the Boston Herald:

A major medical group has canceled a multimillion-dollar convention in Boston, citing the state’s new law cracking down on free gifts, meals and other goodies handed out to doctors by the pharmaceutical industry.

Other life-sciences groups, meanwhile, are sending strong signals that they also won’t
hold conventions in Boston as long as the state’s new law remains unclear and out of sync with industry gift-giving standards.

In a letter to the Massachusetts Convention Center Authority, the executive director of the American Academy of Allergy, Asthma & Immunology said it was pulling out of its 2015 convention contract in Boston because it’s “very difficult” to find sponsorships and to provide education courses under current legal conditions.

The prohibition of gift giving is a moot point in view of Pharma’s voluntary decision to stop the freebies. Massachusetts is not exactly industry-friendly these days and the broader concern is what additional legislation may be in the pipeline, prompting professional societies to play it safe and take their convention business elsewhere.

Via Policy and Medicine.

The Medscape Journal of Medicine is ceasing publication

Read about it here. I’m not sure why they are doing this, given the apparent success of the Journal, or what it means for the overall future of Medscape. The editors indicate that the other resources of Medscape will continue.

Tuesday, February 03, 2009

An unsung hero in the patient safety movement

---is Vanderbilt’s Gerald Hickson, honored recently by the Doctors Company Foundation. To me his most fascinating work (I highly recommend a PubMed search by author) is in loss prevention, particularly how perception trumps reality in driving malpractice suits and how good communication can help.

Proportion of ER admissions increasing

More work for hospitalists. Graphic here.

Doctors overwhelmingly oppose a ban on industry supported CME

I’ve cited several lines of evidence in this direction before. Here’s the latest:

A study by healthcare market research firm Manhattan Research found that only 9% of U.S. physicians oppose commercial support for continuing medical education (CME) funding. The results of this study are relevant to the ongoing discussion in the medical community about the role of commercial funding of CME.

The proponents of the ban are a tiny minority. Unfortunately they’re the most vocal. Unless rank-and-file doctors speak up they will face restricted choices of educational content.

Monday, February 02, 2009

Billy Rubin’s unmitigated gall

One of the blog reactions to our recent Medscape Roundtable on pharmaceutical industry support for CME came from the new pseudonymous blogger, researcher, ID doc and part time hospitalist Billy Rubin. (Not to be confused, mind you, with this Billy Rubin). An ad hominem attack and the straw man played tag-team against me to produce some entertaining reading but, unfortunately, a misrepresentation of my section of the Roundtable.

Before I get to the ad hominem I should note that perhaps I started out on the wrong foot with Dr. Rubin in my choice of words. It was my characterization of the relentless hunt for corporate evil in every nook and cranny of medical education and the associated non-evidence based fear mongering as a McCarthyesque purge. OK, it was a little strong. It was intended to grab the attention of folks on both sides of the debate. I smiled when I wrote it. But it must have pushed Dr. Rubin’s choleric button and released some bad humors. It sent him off him on a rant and apparently so rattled him that, suddenly, all self reference shifted to the third person:

Then comes the whammy: The opportunities for continued learning are now better than ever due to the development of the Internet. Unfortunately, there is a movement afoot to limit those options. A growing McCarthyesque purge seeks to restrict our educational choices by banning industry support of continuing medical education (CME).

"McCarthyesque purge"?! Under the category-heading for inappropriate allusions, Doctor Rubin thinks that this statement may likely not be supplanted from its perch for the remainder of 2009. He would point out in detail the foolishness of the historical comparison, but prefers to think it speaks for itself and he has other fish to fry forthwith.

One more thing before I get to the ad hominem. In his opening section Billy asks this very important question:

So who would you want in charge of ensuring this education?

My personal answer to that question, as should be the answer of all practicing doctors, is I want to be in charge of my own education. With the help of self assessment tools such as MKSAP and Harrisons board review I am in a better position than some outsider from the medical thought police to make the best educational choices. Surveys find that the vast majority of doctors also feel that way.

He goes on:

You would think that professional societies, without any affiliations to for-profit companies, would arrange and direct the overwhelming majority of CME activities, but it just ain't so. As of 2001, drug companies paid over sixty percent of the costs of CME, and it does not appear the number is dramatically declining.

The implied premise is that because drug companies help pay for CME they control content. That premise is simplistic. It was partially true 20 years ago, but is much less so today. Gone, for example, are the one company, one drug topic, one speaker restaurant events (they still take place, but they’re no longer accredited). Given that drug company support does influence content to a limited degree even in today’s tightly regulated environment the person in charge is still you, the user. You make the choice. If you want to base that choice on the litmus test of whether the activity in question has industry funding that’s fine. Better that than outsiders making the decision for you. Be assured, though, that if the purge wins you will not be in charge of your CME.

Now on to the ad hominem attack, which was aimed at all four authors. Dr. Rubin wrote (my bold):

None of the four appear to have any expertise in the matter, at least by what Medscape reported about them. Dr. Rubin has no particular problem with non-expert physicians airing their thoughts on medical matters--he is one such non-expert doing so right now--but he does have a problem when the authors are leading a roundtable discussion on a website read by thousands of physicians around the country. Can I huff and puff in my blog? Sure. But I might not be the best person to speak with authority in a more formal setting, unless I had done a good deal of homework beforehand. And it's quite clear from reading the posts that nobody had done a great deal of homework, pro or con.
Authority? Had Dr. Rubin taken a moment to check the background of the Roundtable and find out what it is and purports to be it would have been clear that the series is little more than a soap box (and a very informal one at that) where doctors, medical students, residents and nurses can air out opposing views. No authority or status is implied. If Dr. Rubin wants to make an issue over whether a bunch of bloggers should huff and puff in front of Medscape’s larger audience, I suppose we can debate that some day.

Having thus (what do these non-expert bloggers know anyway) framed the discussion Dr. Rubin goes on to the straw man. Here are some of the positions I did not take, which Dr. Rubin nevertheless attributes to me, then holds up for ridicule:

There's just no evidence that it influences physician behavior in ways beneficial to drug companies! (“It” being commercially supported CME).

To begin with, I made no such statement. Although the proof that CME has any influence on doctors whatsoever is slim let’s hope CME influences doctors just a bit. Otherwise there’d be no point in CME at all. If, of course, I believed CME was pointless I would never have bothered to write the Roundtable piece in question. Taking for granted my position that CME does influence doctors in some way the strong inference is that at least part of the content would be favorable to the use of drugs in some manner.

Physicians just aren't that credulous!

Well, that’s part of what I said. Here’s what I actually said:

Unable to marshal evidence to support their proposal, the proponents of the ban have appealed to a set of beliefs. One such belief is based on the caricature of a credulous physician incapable of critical appraisal of educational content.

A few paragraphs farther down is where Dr. Rubin’s partial representation of this point deteriorates to the level of the straw man:

His last point, one that Doctor Rubin hears time and time again when he chooses to discuss this matter with various colleagues (though truth be told he has learned which colleagues are like-minded on this matter, and tends to avoid the remainder lest he lose his control in public), is perhaps the most precious of all: I'm not biased! Maybe everyone else is, but not...incredibly smart, skeptical me!

Try as I might, reading and re-reading the piece, I just can’t seem to find that particular “last point.”

What gives Dr. Rubin license to make such misattributions? He tells us in his last paragraph (my bold):

Oddly--well, actually, not oddly at all--the real argument running beneath these rationalizations is virtually never spoken of. It's pretty simple, actually, and Doctor Rubin, despite his immense respect and affection for the vast majority of his colleagues, has heard that silent-yet-powerful argument since his early days in med school. The "argument," such as it is, is this: I am a physician and that entitles me to nice things.

Well, I think it is a little odd that Dr. Rubin can hear arguments that aren’t even being expressed. (By the way, although I am biased and at times a little credulous I do confess just a tad of skepticism regarding that particular claim).

But the pièce de résistance comes not from Dr. Rubin but from one his commenters, who wrote:

The Medscape article critiqued here would not have survived editorial review by the Medscape Nursing editors, in my opinion. Physicians, have you written to the editorial director of the Medscape Internal Medicine Web site to request that the article be removed from the site? If not, here is the editor’s contact information…

Wow. When you dislike someone’s opinion piece just petition the editor for a retraction. Wonderful idea.