Monday, May 31, 2010
As I re-read the New York Times article on hospitalists and surveyed blog reactions something else struck me. For all the uncritical praise of hospitalists for their value as business solutions there was not one word about what I think is really special about hospitalists: superior clinical skills developed on the ascent of the steep learning curve of caring for horribly ill patients day in and day out. Nothing about septic shock, respiratory failure or decompensated heart failure and the nuances of care. The Times even went so far as to characterize the specialty as a “breed of physician-administrator.” That was not a founding principle. If true, the field is devolving.
With the exception of a few negative anecdotes DB's and my reactions were the only critical blog posts I found. Most were mere regurgitations of the Times piece. The few that stood out were credulous in their praise. Bob Wachter thought the article hit the right notes. This post was effusive with unsubstantiated claims about the movement. So, good intentions may ultimately damage the movement, paving the way to misplaced expectations and false attributions.
We found that adenosine, a neuromodulator with anti-nociceptive properties, was released during acupuncture in mice and that its anti-nociceptive actions required adenosine A1 receptor expression. Direct injection of an adenosine A1 receptor agonist replicated the analgesic effect of acupuncture. Inhibition of enzymes involved in adenosine degradation potentiated the acupuncture-elicited increase in adenosine, as well as its anti-nociceptive effect. These observations indicate that adenosine mediates the effects of acupuncture and that interfering with adenosine metabolism may prolong the clinical benefit of acupuncture.
The release of the adenosine was local, right at the site of the acupuncture needle, as were the anti-nociceptive effects. Local tissue damage by the needle releases the adenosine precursor purines into the extracellular fluid. Through a series of dephosphorylations ATP is converted to ADP, then to AMP and finally adenosine. Although AMP piles up, as its dephosphorylation to adenosine is the rate limiting step, the overall effect is short lived, with adenosine levels down to baseline in an hour or so. Adenosine itself dissipates quickly. (As anyone who has ever pushed adenosine to convert AVNRT knows, if you don't push fast enough, in a vein close enough to the heart, it doesn't work. In the circulating blood adenosine is gobbled up by RBCs and endothelial cells with a half life of 9 seconds). In the study, any analgesic effects were gone by a matter of hours.
Because the adenosine effect is local and transient, this study contributes little toward an explanation for the claims of acupuncture, the principal ones of which are chronic pain relief and distant effects such as improvement in hypertension, nausea, headache and the like. It also does nothing to support the claimed mechanisms involving Qi, meridians etc.
Friday, May 28, 2010
Guess what girls -- don't be envious of the most beautiful women in the world.
Look at Elin, look at Sandra Bullock, look at Halle, Britney,JLo, Reese, Julia Roberts, Jessica Simpson -- they've ALL been cheated on!
But what I want to know is, do they cheat more often? I mean, would this song be so funny if it didn't have a ring of truth? Just askin'.
DB linked to the article and noted:
Of course, even the Times cannot write a nuanced article about either primary care or hospital medicine. Since I have spent much time working in both fields, I can see the omissions and flaws in their articles.
If they must simplify this issue, then what happens in their other articles.
I’ve never known the Times to nuance much of anything concerning health care. So let’s go through the article. Concerning hospitalists it says:
Over a decade, this breed of physician-administrator has increasingly taken over the care of the hospitalized patient from overburdened family doctors with less and less time to make hospital rounds — or, as in Mr. Keita’s case, when there is no family doctor at all.
As DB pointed out, the piece fails to distinguish between family practice and internal medicine. The next paragraph reads:
Because hospitalists are on top of everything that happens to a patient — from entry through treatment and discharge — they are largely credited with reducing the length of hospital stays by anywhere from 17 to 30 percent, and reducing costs by 13 to 20 percent, according to studies in The Journal of the American Medical Association.
That paragraph, although literally true, is deceptive. Yes, hospitalists are widely credited with reducing lengths of stay and costs but that claim, as I have pointed out several times before, is not supported by evidence, bolstered by a huge case of publication bias.
In the next paragraph (my italics):
Under the new legislation, hospitals will be penalized for readmissions, medical errors and inefficient operating systems. Avoidable readmissions are the costliest mistakes for the government and the taxpayer, and they now occur for one in five patients, gobbling $17.4 billion of Medicare’s current $102.6 billion budget.
I have dealt with sloppy language about “medical errors” at length before and will not belabor it here. The next sentence on avoidable readmissions has no evidence to back it up. 30 and 90 day readmission rates have been cited for some diagnoses but we have no research data on how many of those are avoidable. It goes on:
“Where we were headed was not a mystery to anyone immersed in health care,” said P. J. Brennan, the chief medical officer for the University of Pennsylvania’s hospitals. “We were getting paid to have people in the hospital and the part of that which was waste was under the gun…”
That’s not entirely true. Since 1983 Medicare has not reimbursed hospitals for the care patients received and hospitals lose money on many Medicare admissions. Then a few paragraphs down:
Bad discharges generally result from hurried instructions to patients and families and little thought to where they are headed. One such situation was the centerpiece of a class taught for doctors at Mount Sinai Medical Center in New York. The patient, an elderly woman in the hospital for scoliosis, a spinal condition, was discharged by a hospitalist on a Friday night, with a prescription for a narcotic pain reliever that her pharmacy, as it turned out, did not stock. No one explained how her new medication differed from the old, or gave her a contact number for help. Without medication, by Tuesday, her ankles swollen and her breathing irregular, the woman was back in the hospital.
Since when does withdrawal from narcotics cause ankle swelling and irregular breathing?
PATIENTS AND METHODS We performed a cohort study with historical controls at a 303-bed,freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included.
RESULTS After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008–0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%–40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.
It's not the greatest quality data but I don't know if we can expect much better. Reuters Health interviewed a health IT expert from UA Birmingham about the study:
"There have been a couple of studies previously that have taken a similar approach and have found the opposite result" of the current study, said Nir Menachemi, an expert in health information technology and policy at the University of Alabama at Birmingham. "I was more surprised by those studies."
The debate over whether CPOE is working as intended is hardly over, said Menachemi: "I think it would be foolish to believe that any one study can end the discussion."
Paul Levy at Running a Hospital thinks differently:
Let's go back to the basics. Hand-written drug orders are subject to transcription errors at both ends, the person writing them and the person reading them. Each time you add an intermediary in the drug ordering process, you add an opportunity for error. Also, unless there is real-time and accurate checking for drug-drug interactions, allergies, assessment of doses based on body weight and the like, there will be some percentage of preventable medication errors.
Maybe I live in a rarefied world of early CPOE adopters, but does anyone out there think this is still subject to debate?
Yes, I and a lot of other people do. Levy's problem in understanding this, I suspect, is not that he lives in the world of early adopters, but that he doesn't have experiential knowledge of what entering orders on the wards is really like in both systems, paper and electronic. Those intermediaries he's talking about are personnel who are trained in the secretarial skills of order entry and, by doing safety checks of their own, may actually reduce errors.
It cuts both ways. CPOE has theoretical advantages. There are also unintended consequences. The implementation of CPOE can be a mess. Take a bunch of time pressed doctors and suddenly add secretarial duties to their work flow. Not pretty.
The field of health information technology will mature. Doctors will gradually become more adept at the secretarial skills of order entry. Some day most practicing doctors will have grown up on CPOE, having never known any other system. By then maybe CPOE will have saved lives. I doubt that there will ever be a study to prove it. The debate about the risks and benefits of the electronic medical record is alive and healthy, and should go on.
Related post: We’ve been doing CER for years.
Thursday, May 27, 2010
In summary, RRSs take the skills and expertise of the critical care team beyond the walls of the ICU within minutes to the bedside of deteriorating patients, whose condition may well progress to cardiac or respiratory arrest. RRSs would stabilize patients, prevent development of critical illness or cardiopulmonary arrest and contribute to the optimization of the care of other patients through education of healthcare givers working in the general medical and surgical wards. Their implementation requires significant resources and involves a change in the culture of healthcare provision. Although their merits look obvious and thus their deployment in hospitals seems to be intuitive, the available evidence for their effectiveness in improving the outcomes of such patients is weak and of suboptimal quality. Whether they should become the standard of acute hospital care needs to be answered.
Apparently, all kinds of terrible things happen to you as you age while male, according to the book. Hair grows out of your ears, you can't hear well and your balance begins to suck. Women, even those who are not so young, walk by as if you are not there. And everyone in the office sees you as retirement material. In addition, you get hit with something called "the Ugly Stick" where you wake up one day and find out that you've turned into a real dog...
Exercise, not surprisingly, is stressed.
Wednesday, May 26, 2010
Tuesday, May 25, 2010
Not only evidence based medicine but science based medicine may take a back seat in Donald Berwick's vision for patient centered care
At last year's IOM Summit on Integrative Medicine, as I mentioned before, Berwick's speech was very friendly towards non-evidence based and implausible alternative medicine:
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!
The British NHS, which Berwick loves, funds homeopathy.
Stramonium and related anticholinergic alkaloids were early asthma remedies which were ground up into a powder and smoked. Their anticholinergic properties included bronchodilation, the basis for modern day development of the atropine derivatives Atrovent and Spiriva.
Here is a review of the history of smoked remedies for asthma.
In North Carolina, John McCain voters (losers) had increases in post-outcome cortisol levels, whereas Barack Obama voters (winners) had stable post-outcome cortisol levels. The present research provides novel evidence that societal shifts in political dominance can impact biological stress responses in voters whose political party becomes socio-politically subordinate.
Paul Levy, the blogging CEO of Boston’s Beth Israel Deaconess Medical Center, found himself in hot water last month over an inappropriate relationship with a female subordinate. While some of the details of the transgression remain sketchy, I think I now know enough to opine on it. To my mind, Paul has been an extraordinary healthcare leader, and – while the episode represents a lapse in judgment that deserves censure – he should not lose his job.
Pretty much the same sentiments I expressed here. Great things happened at BIDMC under Levy's leadership, but has he lost his moral authority? From a Boston Globe piece yesterday:
Levy’s signature moment, until recently, had been persuading his employees to take pay cuts last year that saved low-income workers from being laid off. He said he was able to win that concession because of his personal credibility, authority that has now taken a serious hit.
“I could go in front of them and say ‘I want to do what I can for the low-income workers but that means everyone will have to take a bigger sacrifice.’ I was able to do that because I had the moral authority to say those things,’’ he said. “If it were today, would I have the same amount of moral authority?’’
Well, that might depend on how much of a pay cut Levy himself took. In the interest of transparency it would be nice to know. But for the most part the legacy doesn't have to be about Levy or his moral authority. As I pointed out long before Levy's personal difficulties became public, on their own merits his claims regarding never events are implausible and his transparency selective.
Monday, May 24, 2010
Sunday, May 23, 2010
According to Abraham Verghese's lecture to the American Clinical and Climatological association the AMA combined this slogan with Sir Luke Fildes' famous painting,The Doctor, to help defeat Harry Truman's proposal for nationalized health care in 1949. What other words might we substitute for politics?
Friday, May 21, 2010
Data Synthesis: Compared with standard therapy, continuous positive airway pressure reduced mortality (relative risk [RR], 0.64 [95% CI, 0.44 to 0.92]) and need for intubation (RR, 0.44 [CI, 0.32 to 0.60]) but not incidence of new MI (RR, 1.07 [CI, 0.84 to 1.37]). The effect was more prominent in trials in which myocardial ischemia or infarction caused ACPE in higher proportions of patients (RR, 0.92 [CI, 0.76 to 1.10] when 10% of patients had ischemia or MI vs. 0.43 [CI, 0.17 to 1.07] when 50% had ischemia or MI). Bilevel ventilation reduced the need for intubation (RR, 0.54 [CI, 0.33 to 0.86]) but did not reduce mortality or new MI. No differences were detected between continuous positive airway pressure and bilevel ventilation on any clinical outcomes for which they were directly compared.
Limitations: The quality of the evidence base was limited. Definitions, cause, and severity of ACPE differed among the trials, as did patient characteristics and clinical settings.
Conclusion: Although a recent large trial contradicts results from previous studies, the evidence in aggregate still supports the use of NIV for patients with ACPE. Continuous positive airway pressure reduces mortality more in patients with ACPE secondary to acute myocardial ischemia or infarction.
Thursday, May 20, 2010
View part 1 here.
Conclusions: The implementation of the Surviving Sepsis Campaign guidelines was associated with a significant decrease in mortality. The benefits depend on the number of interventions accomplished within the time limits. The 6-hr resuscitation bundle showed greater compliance and effectiveness than the 24-hr management bundle. (Crit Care Med 2010; 38:1036–1043).
For example, “leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat,” Berwick says. “One e-mail correspondent asked me, ‘Should patient “wants” override professional judgment about whether an MRI is needed?’ My answer is, basically, ‘Yes.’ On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.”
The Republicans, who worry that Berwick would ration and restrict care, don't understand what he's really about. There's plenty to worry about, but not for the reasons they think. Related posts here and here.
Wednesday, May 19, 2010
Prednisolone (at 40 mg) once daily for a week does not improve outcome in hospitalized patients with CAP. A benefit in more severely ill patients cannot be excluded.. Because of its association with increased late failure and lack of efficacy prednisolone should not be recommended as routine adjunctive treatment in CAP.
Related Medscape CME activity (where some important limitations of the study, such as how COPD patients fit into the mix, are discussed) here.
Recent studies suggest that increased rates of nephrotoxicity are associated with aggressive vancomycin dosing. These increased rates are confounded by concomitant nephrotoxins, renal insufficiency, or changing hemodynamics. These studies also have demonstrated that vancomycin's nephrotoxicity risk is minimal in patients without risk factors for nephrotoxicity. Clinicians unwilling to dose vancomycin in accordance with clinical practice guidelines should use an alternative agent because inadequate dosing increases the likelihood of selecting heteroresistant methicillin-resistant S. aureus isolates.
Republicans have opened an assault on the nomination of Harvard professor Donald Berwick to lead the huge agency that runs Medicare and Medicaid, calling Berwick an advocate for “rationing’’ health care…
But GOP lawmakers are becoming increasingly vocal in their attacks on Berwick, citing his support of controlling costs and his statements praising aspects of the United Kingdom’s national health system. They contend his positions show that he would seek to transform US health care into a tightly controlled system, reducing patient choices and delaying treatments.
That may be true but on other occasions Berwick has taken to opposite position of advocating for radical consumerism, suggesting that patients should be the decision makers in their own care and receive whatever care they want, whenever they want it.
It appears that Berwick has been talking out of both sides of his mouth on this issue, and that’s what should be worrying both Republicans and Democrats. Maybe as people try and pin him down during the confirmation process we’ll find out where he stands. It should be fun to watch.
Tuesday, May 18, 2010
Conclusions: An elevated INR in the setting of CLD does not appear to protect against the development of hospital-acquired VTE. The notion that “auto-anticoagulation” protects against VTE is unfounded. Use of DVT prophylaxis was extremely low in this population.
Monday, May 17, 2010
You've seen it over and over again. EMS personnel respond to the call. The victim has been “down” for an undetermined period of time. ACLS measures are in progress upon arrival. There has been no response but you continue resuscitation a while longer. After half an hour or so things look futile, then boom! The epi has kicked in and the patient has a bounding pulse. The patient is admitted to the ICU but never recovers brain function. Do we have resuscitation drugs to thank for these outcomes? Maybe in some cases according to this study:
Design, Setting, and Patients Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008.
Interventions Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration...
Results Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P=.61), 32% vs 21%, respectively, (P less than .001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P=.45) for survival with favorable neurological outcome, and 10% vs 8% (P=.53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, 0.69-1.91).
Conclusion Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival.
So resuscitation drugs increase survival to hospital admission but not discharge. It's tempting to think that arrival to the ICU with return of spontaneous circulation might give future patients a chance to benefit from some of the newer advances in post resuscitation science. However, it appears the patients in this study got state of the art post resuscitation care, with over 70% receiving therapeutic hypothermia.
It's not time to abandon resuscitation drugs just yet. We already knew this regarding amiodarone. Drug effects may be more meaningful for in hospital cardiac arrest and in the context of the new cardiocerebral resuscitation which will be more widely adopted in the near future.
JoAnn E. Manson, MD, DrPH, made a little appreciated point (about 7:30 in): research, even research that compares treatments, doesn't address real world situations very well. It's all about the distinction between effectiveness (how a treatment performs in the real world) and efficacy (how a treatment performs in the hands of clinical investigators in controlled conditions). What's popularly known as comparative effectiveness research, then, is really comparative efficacy research. Translating that into comparative effectiveness remains a challenge. True comparative effectiveness research is, almost of necessity, “lower level” on the EBM hierarchy, e.g. observational studies, before-and-after studies and the like.
Dr. Manson made another distinction (8:25): of equal importance to comparing treatments is comparing ways of doing and organizing health care. For example, are performance measures and bundles effective?
Finally, all the comparative effectiveness research and comparative efficacy research in the world (and we already have a great deal of both) won't address the fundamental problem: doctors do a poor job of using the research information they already have. But they need tools, not coercion (see below) to help them do better.
So, well and good, you might say. Comparative effectiveness is great. Sure it is in its pure notion. But listen carefully at 9:28, where Dr. Manson reveals the true agenda of comparative effectiveness as a government sponsored movement: to leverage more involvement by policy makers and payers in clinical decisions. In other words take EBM away from the doctors. Can that work in the U.S.? Look at the history of managed care or Medicare.
There's more. While I don't agree with everything the panelists said, this video adds needed clarity to the often confusing discussion on CER.
Friday, May 14, 2010
The principles of bedside right heart catheterization were sound, but I contend that relatively few physicians and critical care nurses recorded data correctly, whch is why research studies were negative and we finally pulled the catheter.
Thursday, May 13, 2010
Although the platelet count, prothrombin time (PT), and partial thromboplastin time were different (P less than .05) between the 2 patient groups, after regression analysis, only PT and profound thrombocytopenia remained associated with TTP-HUS (P= .001 and P= .003, respectively). A platelet count of less than 20 × 103/μL (20 × 109/L) and a PT within 5 seconds of the upper limit of the reference interval had a specificity of 92% for TTP-HUS. Our data confirm that readily available laboratory assays in the proper clinical scenario can increase the likelihood of TTP-HUS over DIC.
From there she goes on to address what skills (and consequently what training needs) are important for the individual doc, and that's where it gets muddy. She writes:
Physicians need new knowledge and skills – including the ability to manage teams, information, resources and population-level data.
It's not clear where she's going here, because none of these areas are new. The management of teams, which is multidisciplinary care under the physician's direction, has been a cornerstone of the quality and safety movement for at least a decade. The management of resources became critical, and a major focus of practice in 1985 with the advent of DRGs and later in the mid 90s with managed care. And what is the management of population-level data? It sounds like EBM, which started as a “movement” in 1992.
She goes on (my italics)---
More specifically, doctors need special expertise in longitudinal care for a population of patients – built by a trusting, personal relationship that is not limited to site of care, organ system or disease type.
Sounds like a move away from the hospitalist model back to traditional practice. Interesting.
Wednesday, May 12, 2010
Lisa Sanders writes seriously about real cases. But as technical advisor to the show, her suggestions are not always followed:
The lead character, Gregory House, MD, verbally abuses patients, goes overboard ordering tests and above all, he’s “a jerk,” Dr. Sanders said. But after all, it’s television, and the former CBS news producer turned med student turned Yale professor understands the difference between reality and good drama. Besides, as one of the show’s writers said after listening to Dr. Sanders’ lengthy lecture on proper medical procedures, “You’re right. But my way is funnier.”
Read the rest here.
Tuesday, May 11, 2010
The electrocardiograms of these patients will demonstrate “non-specific T wave abnormality.” Non-specific but not insignificant.
Monday, May 10, 2010
The UC Television description reads:
Nearly half the US populations turns to complementary, alternative and integrative practices to maintain or improve their health. Beverly Burns of UCSF's Osher Center for Integrative Medicine explores traditional Chinese medicine including acupuncture, meridians and chi. Series: "UCSF Mini Medical School for the Public" [12/2007] [Health and Medicine] [Show ID: 13073]
ARBs are misclassified as ACE inhibitors.
Moricizine is rated as the number one antiarrhythmic, superior to beta blockers and amiodarone.
Metformin, arguably the best overall agent for type two diabetes, was rated 9th, below several sulfonylureas.
Binding resins are rated above statins for lipid lowering.
I could go on. Suffice it to say I'm not impressed.
H/T to Clinical Cases and Images.
Before Barrack Obama's next televised speech, prepare your "Obama Bullshit Bingo" card by drawing a square. I find that 5" x 5" is a good size -- and dividing it into columns –five across and five down. That will give you 25 1-inch blocks.
Write one of the following words/phrases in each block:
Included are restored our reputation, strategic fit, leverage (as a verb), win-win, affordable health care, greed on Wall Street, empower...
Check off the corresponding block when you hear one of the words or phrases. See how long it takes you to get 5 across, down or diagonally.
Sunday, May 09, 2010
Let's kick it off with a lecture about the CAM perspective on pandemic flu from the Oregon Health and Science University's CAM Grand Rounds series. You can access it here. It's pure woo and, it seems to me, a little anti-vax in its slant.
Friday, May 07, 2010
To be very clear, no evidence has surfaced that Levy, financially speaking, did anything untoward. These are questions, not accusations. But when the CEO of a major Boston hospital has a relationship with a direct subordinate, who is transferred to a job with a better title before she departs with a severance package, it raises not just logical, but critical, questions. Left unanswered in a public setting, they are a cancer on the hospital’s leadership — and its reputation.
This, not Levy's personal life, is the issue. The extent it may have affected hospital operations and finances is as important for the public to know as is the hospital’s central line infection rate. BIDMC is fast distinguishing itself as a leader in selective transparency.
Results: Seventy percent of patients were started on AST on admission. Of these, 73% were unnecessary. Stress ulcers prophylaxis in low risk patients or the concomitant use of ulcerogenic drugs motivated initiation of therapy most frequently. Sixty nine percent of patients started on inappropriate AST were discharged on the same regimen. Admitting diagnosis, age of patient, length of stay, or concomitant use of ulcerogenic drugs did not predict continuation of unnecessary AST at discharge.
The inappropriate use is an unintended consequence of performance measures, bundles and clinical pathways. Inappropriate continuation after discharge is a consequence of medication reconciliation.
Thursday, May 06, 2010
He goes on to give a few examples. About 3 minutes in he talks about how the coders want us to make the completely meaningless distinction between “simple pneumonia” and “aspiration pneumonia.” I guess they haven't heard that the pathogenesis of all bacterial pneumonia, including ordinary pneumococcal pneumonia, is colonization followed by aspiration.
The results are presented here along with some thoughtful and creative ideas from a few programs around the country to help improve retention. I observed nothing at HM 2010 to allay my long held concern that SHM is not doing enough to address this problem.
Some of the popular hang outs and watering holes downtown were damaged, not to mention the entire Opry complex. The Gaylord was evacuated and the Opry was forced to relocate to two of its former homes, the Ryman auditorium and the War Memorial Auditorium. Missing a show was not an option. The Saturday night show, the Opry's official version, has had over 4000 consecutive performances in the nearly 85 years of the Opry's history.
Here are a few local blogs:
Musings about Music City has posts here and here.
Posts at Fayfare's Opry Blog provide details about the far reaching effects of the shutdown of the entire Opry complex.
Local blogger and author Stephen Mansfield said it best:
Nashville is sophistication in denim. It is where the South meets Yankee culture with a smile and without letting go of too much. It is where the self-important never last but the art never ends. Nashville is my home. I love the accents, the heritage and the way the past calls gently through monuments and architecture to an all too unaware present. I’ve gotten use to how a road can change names three times before you get where you’re going and how the restaurant you loved last week is gone this week and how tourists think nothing of asking you if you’re somebody famous. I love Nashville.
Over this past weekend, my city drank in nearly 14 inches of rain. For perspective, the most rain she had endured at one time in all her history was just under 7. Now, much of my city is under water. There is fear and anguish, heartache and the disorientation that comes from the feeling that life is spinning out of control.
My city is going to rise.
Wednesday, May 05, 2010
The Board of Directors of Beth Israel Deaconess Medical Center, with the assistance of outside counsel, has completed its review of allegations made involving President and CEO Paul Levy. The review focused on a personal relationship with a former employee of the Medical Center. The Board found that over time the situation created an improper appearance and became a distraction within the hospital.
The Board believes that Mr. Levy should have recognized this situation in a more timely fashion and should have conducted himself in keeping with business protocol appropriate for the office of the CEO.
Mr. Levy agrees that it was a serious lapse in judgment and agrees with the Board’s conclusions. He has apologized to us and to the entire staff of the hospital.
Although our outside counsel found that Mr. Levy did not violate hospital policy, the board determined that he showed poor judgment and the board expressed its disappointment. Accordingly, the board has voted to take appropriate actions by:
1. imposing a financial penalty of $50,000 to be paid to the hospital in the current fiscal year.
2. instructing that this matter be considered in determining the CEO's compensation for the next fiscal year.
Although in this instance, Mr. Levy has not lived up to the standards we set for our CEO, the Board also considered his exemplary record over the course of his tenure at BIDMC...
What more do we know? The employee in question was a woman who worked in several positions in the organization, including as Levy's special assistant. The relationship was brought to the board's attention by an anonymous whistle blower. As reported here, (see video) the situation with the female employee created a distraction (can you say disruptive?) for the hospital.
Although a Boston Herald reporter was hounding Levy about the incident on the way to Columbus Ohio where he spoke to a group of physicians, at the meeting he deflected concerns about the media presence thusly:
The morning after a Herald reporter specifically quizzed him about the relationship as he headed to a keynote speech on hospital transparency, Levy insisted he did not know why the reporter was seeking his comment.
“Our hospital is subject to what they call a corporate campaign by Service Employees International Union,” an apologetic Levy told the crowd at the Columbus, Ohio, conference as he began his speech, “Why Transparency is Important to Patient Safety.”
“And one of the things they like to do is show up at events where I am and try to disrupt those events with irrelevant questions or demonstrations and the like,”...
Now I'm not sure about the $50K. Can a hospital fine its CEO? I'm guessing it was reimbursement for a severance package they paid the employee in question, but it's not clear.
A commentary from WBUR in Boston said this:
But for an administrator who has been such an aggressive advocate of transparency in medicine, Levy’s apology today is anything but. Now that he’s said sorry, and the matter appears to be resolved, will we soon read a post about what, actually, happened? I suspect Mr. Levy’s loyal readers would like to know.
So how much do we really need to know? A reporter from the Boston Herald has a blog devoted to the subject, and seems determined to uncover all the salacious details. Jaz-Michael King, blogging over at A Scanner Brightly, sees it differently:
It is my opinion, and my opinion only, that a figure with as much publicity as Mr Levy should not avoid the fact entirely on his many outlets, especially given his use of his blog as a glimpse in to his personal as well as his professional life. The modern world and its modern communications channels necessitate that we bloggers and tweeters and users of the Web cannot but give up much of our privacy, and separating personal from professional has never been harder now that we are all profiled and LinkedIn'ed...
But this pious outpouring that he should be fully documenting his tribulation for all of us to benefit from his transparency is nothing but sanctimonious codswallop.
Now a few observations of my own. If the reports are true Levy's behavior was disruptive. It was a distraction and, judging from comments from defenders and detractors, divisive. It may have resulted in the loss of an employee. BIDMC is to be applauded for recognizing that zero tolerance for disruptive behavior applies all across the organization, to administrators as well as physicians.
Levy's lapse was not only in judgment but also in transparency (about which he has been beating the drum for some time), as he apparently chose not to deal with this openly until someone blew the whistle. Do the principles of transparency apply to his personal life? Yes, to the key people at BIDMC who have responsibility to find out why this was allowed to happen and take preventive measures (a root cause analysis, if you will). But the public doesn't need to know more. There's Levy's family to consider.
I have no idea how institutional politics play out at BIDMC, but I hope the board dealt with the situation in a fair and even handed way. I also hope Levy stays on. I am glad that the board chose to honor him for his past accomplishments. Despite my previous skepticism about his statements on transparency and zero error rates, I believe the institution has prospered under his leadership. Finally, I hope the lessons here are not lost. Administrators, nurses and doctors should be held to an even standard regarding disruptive behavior. Transparency and disclosure are nuanced issues. They are difficult, and they have consequences.
Tuesday, May 04, 2010
Monday, May 03, 2010
Sunday, May 02, 2010
Weren't police officers trained in CPR in the 1980s? Grady didn't seem to know what to do after the pulse check at 6:26.