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Are You Afraid to Be Wrong?

Richard Smith, a former editor of the British Medical Journal, wrote a thoughtful essay offering guidance for new medical students. (Full text here.) Although it was published in 2003, someone just brought it to my attention via Twitter. Dr. Smith lists many pearls of wisdom in a scholarly and lightly humorous way. I disagree with only one of his statements: “Do not be afraid to be wrong.” It is not that this is bad advice. To me, a timid doctor is prone to failure. Sometimes you have to take your best shot based on the information at hand. The problem is that in today’s medical world, we are expected to be perfect. If you make a wrong diagnosis and the patient suffers a poor outcome, you have a good chance of being sued and a better chance of experiencing an inquisition by emissaries from the quality improvement and/or risk management departments, AKA the “thought police.” I once did some expert witness work for a malpractice insurance company. There is rarely a case that does not have many opportunities for second-guessing. When you know the outcome, you can always find something in the medical record that could have been done differently. The current medicolegal and patient safety climate creates a feeling among physicians that any error is going to be extensively scrutinized. This results in a situation analogous to an athlete trying not to lose a game instead of trying to win. For those of you not familiar with sports, that strategy usually fails. Fear of being wrong can lead to excessive testing too. Many say that medicine should have...
HIV: From Prevention to Care and Treatment

HIV: From Prevention to Care and Treatment

The incidence of HIV in the United States has remained stable over the last 15 years, while the number of people living with the disease has increased by about 60%. “As more people are living with HIV, it’s important to analyze and assess our efforts to identify people with the infection and ensure that they remain on treatment,” says Stacy M. Cohen, MPH. “With effective care and treatment, individuals with HIV can live long, healthy lives.” Intriguing New Findings on HIV Diagnoses Cohen and colleagues had a study published in the December 2011 issue of Morbidity and Mortality Weekly Report that highlights the importance of identifying persons with HIV and making sure they remain in medical care and receive treatment. The investigation estimated the overall proportion of persons with HIV in the U.S. who have achieved viral suppression (see also, The Role of Demographics in HIV Clinical Outcomes). To accomplish this, the research team looked at the estimated numbers of American adults living with and diagnosed with HIV, and evaluated the percentages of those diagnosed with the infection who: Are receiving HIV care. Have been prescribed antiretroviral therapy (ART). Achieved viral suppression. Received prevention counseling from healthcare providers. Approximately 77% of people diagnosed with HIV were linked to care within 3 to 4 months of diagnosis, but only 51% were retained in ongoing care. About 89% of adults with HIV who were in care had been prescribed ART. Of these, 77% had a suppressed viral load at their most recent test (Table). Despite effective tools for HIV treatment, only 28% of all HIV-infected people had a suppressed viral load...

Pediatric Fracture-Related Pain: The Crowding Effect

According to published studies, pain is the most common reason for seeking care in the ED, accounting for up to 78% of visits. Underuse of analgesics is common, especially among pediatric patients. There are many reasons that contribute to this problem, but key themes have emerged as culprits, says Marion R. Sills, MD, MPH. “Studies have found that higher crowding levels appear to delay treatment of pain in adult patients who visit the ED, but little research has been conducted in pediatric populations. The effect of ED crowding on children is growing as a research priority.” The Pediatric Population & ED  Crowding For adults, crowding has been associated with decreased quality across all six Institute of Medicine (IOM) quality dimensions: timeliness, effectiveness, equity, patient-centeredness, safety, and efficiency. In an effort to address these dimensions in the context of crowding in ED pediatric patients, Dr. Sills and colleagues conducted a study involving children with acute long-bone fracture-related pain who visited an ED (see also, ED Crowding: The Impact on Child Asthma Care). “Extremity fractures are among the most common reasons children seek ED care, resulting in 850,000 ED visits nationwide each year,” adds Dr. Sills. “These fractures can be especially painful for children.” The study by Dr. Sills and colleagues, which was published in the December 2011 issue of Academic Emergency Medicine, measured the association between ED crowding and the quality of pain management for children with long-bone fractures. The objective was explored in three of the IOM’s six dimensions of quality: effectiveness, timeliness, and equity. The research team measured the dose-response effect of ED crowding on quality by comparing quality...

Improving Cancer Care Decision-Making

When patients are facing a cancer diagnosis, they often need help understanding their treatment options as well as the risks and benefits of each choice. Treatment decisions can become fraught with emotion and cognitive difficulties. In addition, many Americans have low numeracy and health literacy skills. To assist clinicians, here are some strategies that can improve patients’ understanding of the information they’re given: Use plain language. When using written and verbal materials, plain language will be more understandable for patients. Present information in a jargon-free yet respectful way to ensure trust and make messages less ambiguous. Use absolute risks. For example, instead of saying a particular drug will cut their risk in half, say a drug will lower their risk of cancer from 4% to 2%. This information puts the data you’re sharing in better perspective. Inform patients of the exact benefit that may be obtained from using the drug. Use visual aids. Presenting information in pictographs can help people understand the meaning behind the numbers. People learn by different methods. Visualization may make a greater impact than statistics alone. Use frequencies. Presenting risks in frequencies rather than percentages may increase patients’ understanding of their risks. Instead of saying 60% of men who have a certain treatment will have a specific side effect, have them imagine 60 of 100 men in a room having this side effect. Highlight additional risks. Provide patients with additional or incremental risks of treatment from preexisting baseline levels. Ensure that the risk number you’re presenting is the risk due to the treatment and not a risk they would face regardless. Order matters. Preliminary research...

Diabetes Duration Tied to Ischemic Stroke Risk

American research suggests that diabetes dura­tion appears to be independently associated with ischemic stroke after adjusting for risk factors. Among study participants with diabetes, the risk for stroke increased 3% each year and tripled when patients had diabetes for 10 years or longer.  Abstract: Stroke, May...

2012 Heart Disease & Stroke Stats Unveiled

The American Heart Association has released an executive summary on heart disease and stroke statistics for 2012. Available for free at http://circ.ahajournals.org, the update indicates that America’s cardiovascular health is far from ideal. Calorie consumption increased by 22% in women and 10% in men between 1971 and 2004. Abstract: Circulation, January 3,...

Controlling Glucose in Diabetes Patients With AMI

An investigation of patients with diabetes who were hospitalized for acute myocardial infarction (AMI) suggests that few undergo glucose therapy intensification (GTI) at discharge. The research team added that long-term glucose control appears to be poor among patients with diabetes who suffer an AMI. Only about 31% of patients in the study underwent GTI, which occurred most frequently among those in whom clinical A1C was measured. Abstract: Diabetes Care, March 12, 2012...

Trends in Physical Activity Recommendations

According to CDC research conducted between 2000 and 2010, the percentage of adults whose healthcare providers recommended exercise or physical activity increased from 21.0% to 30.3% in men and from 23.9% to 34.1% in women. Among those aged 85 and older, the percentage receiving such advice nearly doubled, increasing from 15.3% in 2000 to 28.9% in 2010. The largest percentage increases during the decade were observed among those who were overweight or obese. Source:...

Admission Site Tied to Mortality in Sepsis

Admission for sepsis through the ED, when compared with direct admission to the hospital, appears to be associated with lower early and overall inpatient mortality. Results from a large national sample of hospitalizations with a principal diagnosis of sepsis showed that overall sepsis inpatient mortality was 17.1% for ED admissions, compared with a 19.7% rate for direct admissions. Patients admitted through the ED: Had a greater proportion of comorbid conditions. Were more likely to have Medicaid or be uninsured. Were more likely to be admitted to urban, large bed-size, or teaching hospitals. Abstract: American Journal of Emergency Medicine, March...

Hyperlactatemia & Ischemic Stroke

In patients with ischemic stroke, initial hyperlactatemia appears to be an independent risk factor for poor outcomes, according to South Korean investigators. In a retrospective analysis involving 292 patients with ischemic stroke, 183 individuals (62.7%) were considered to have poor outcomes and 16 (5.5%) died. Seventy (24.0%) of the study participants had initial hyperlactatemia. In multivariable logistic regression analyses, hyperlactatemia was associated with a 2.15-times greater risk of poor outcome at 3 months and a 4.31-times greater risk of death when compared with those without hyperlactatemia. Abstract: American Journal of Emergency Medicine, March...

A Promising Community-Based Program for Diabetes

A study from the CDC suggests that a nation­wide community-based lifestyle intervention program for preventing type 2 diabetes would appear to be an efficient use of healthcare resources. How­ever, such a program may require participation of all health insurers in order to share prevention costs. Researchers found that after 25 years, the program would prevent or delay about 885,000 cases of type 2 diabetes and yield savings of $5.7 billion. Abstract: Health Affairs, January...
2012 Guidelines for Diabetic Foot Infection

2012 Guidelines for Diabetic Foot Infection

New guidelines released by the Infectious Diseases Society of America (IDSA) and publishing in the June issue of Clinical Infectious Diseases emphasize that proper treatment of diabetic foot infections not only saves limbs – but can save lives. Diabetic foot infections are becoming more common, and about 50% of patients who have a foot amputation die within 5 years. According to the new IDSA guidelines, about half of lower extremity amputations that aren’t caused by trauma can be prevented through proper care of foot infections. The new guidelines include 10 common questions with extensive, evidence-based answers, which the panel that wrote the guidelines determined were most likely to help a healthcare provider treating a patient with diabetes who has a foot wound. Key points from the guidelines include: Evidence of infection generally includes at least two of the following signs: redness, warmth, tenderness, pain, or swelling.  The guidelines note that half of ulcers are not infected and don’t require antibiotics. Rapid and appropriate therapy for treating infected wounds on the feet, typically including debridement, antibiotic therapy, and/or removing pressure on the wound and improving blood flow to the area. When a foot sore infection is detected, imaging the foot is usually necessary to determine if the bone is infected. A culture of infected wounds should be performed to determine the bacteria causing the infection and to help guide antibiotic treatment. Antibiotic therapy is often insufficient in the absence of proper wound care and surgical interventions. Use of a multidisciplinary team to assess and address various aspects of the problem is recommended. Over-prescribing and inappropriate prescribing of antibiotics is common...

Wide Disparity in Hospital Charges for Appendicitis. Why?

If you wonder why hospitals are under fire for outrageous and often baffling accounting practices, look no further than a brief paper published last month in Archives of Internal Medicine. Hospital charges for straightforward appendectomies done for acute appendicitis in California in 2009 were examined with the following inclusion criteria: Patients between the ages of 18 and 59 Hospital stays fewer than 4 days Discharged home For the more than 19,000 records reviewed, the median hospital charge was $33,611 with a low of $1,529 and a high of $182,955. Not included in the article but mentioned in news stories about the paper were more details about the care of the two patients at the extremes of charges. From the Huffington Post: “The costliest bill, totaling $182,955, involved a woman who also had cancer. She was treated at a hospital in California’s Silicon Valley. Her bill didn’t show any cancer-related treatment. The smallest bill, $1,529, involved a patient who had her appendix removed in rural Northern California. Otherwise, the cases were similar: Both patients were hospitalized for one day, had minimally invasive surgery, and had similar numbers of procedures and tests on their bills.” A California Healthline story about this clarifies the issue. It said: “Dave Glyer, CFO for Community Memorial Health System, said that the study ‘assumed that hospital charges matter when they don’t,’ making it ‘completely off base.’ He said that insured patients pay rates negotiated by health insurers and that certain uninsured patients are aided by assistance programs.” It’s all clear to me now. Hospital charges don’t matter. What if you have no insurance and are not...

Biomarkers of Stroke in Postmenopausal Women

Among postmenopausal women, baseline triglycerides, very low-density lipoprotein size, and intermediate-density lipoprotein particle number appear to be significantly associated with incident ischemic stroke, according to findings from a prospective study. The authors noted, however, that no significant baseline differences were observed for total cholesterol, LDL cholesterol, and lipoprotein(a). Abstract: Stroke, February 2, 2012...
Diabetes-Related LEAs: The Impact of Location

Diabetes-Related LEAs: The Impact of Location

About 80,000 lower-extremity amputations (LEAs) are performed each year on patients with diabetes in the United States. Statistical analyses have shown that the annual incidence of LEA in older patients with diabetes was 5.0 per 1,000 in 2006-2007, but decreased to 4.0 per 1,000 in 2008. “While the downward trend is encouraging, it’s important to also analyze variations in the rates of LEAs throughout the country,” says David J. Margolis, MD, PhD. Previous studies have shown that there appears to be geographic variation in the incidence of LEAs among Medicare beneficiaries with diabetes. Furthermore, about $52,000 is reimbursed annually for a Medicare beneficiary with diabetes and an LEA. “By learning more about geographic variation in LEA, we can then identify causes and develop targeted interventions for prevention,” Dr. Margolis says. Assessing Geographic Variation of LEAs In the November 2011 issue of Diabetes Care, Dr. Margolis and colleagues conducted a study to explore graphic variation of incident LEAs among Medicare beneficiaries with diabetes. The investigators performed a study of the full population of Medicare beneficiaries because it is, in essence, the largest healthcare insurance provider in the U.S. and the largest government-funded medical entitlement program. The geographic unit of analysis was hospital referral regions (HRRs). The study then evaluated the incidence of LEA by HRRs as a function of geographic location throughout the country. Other items analyzed in the study included sociodemographic factors, risk factors for LEA, diabetes severity, provider access, and cost of care. “Our findings showed that rates of amputation varied greatly according to where patients lived, but questions remain as to why this occurs,” says Dr. Margolis....

CAD & Prostate Cancer Risk

Coronary artery disease (CAD) appears to be significantly associated with a 35% increased risk for a prostate cancer diagnosis, according to findings from an American study. CAD was also associated with higher risks for low- and high-grade prostate cancer. Source: Cancer Epidemiology, Biomarkers & Prevention, February 7, 2012...

Trends in Physical Activity Recommendations

According to CDC research conducted between 2000 and 2010, the percentage of adults whose healthcare providers recommended exercise or physical activity increased from 21.0% to 30.3% in men and from 23.9% to 34.1% in women. Among those aged 85 and older, the percentage receiving such advice nearly doubled, increasing from 15.3% in 2000 to 28.9% in 2010. The largest percentage increases during the decade were observed among those who were overweight or obese. Source:...

Controlling Glucose: Mobile Apps to the Rescue

In the United States, diabetes affects 25.8 million people, for whom the costs of care exceed $100 billion annually. Clinical trials suggest that improved self-care and lifestyle changes can lead to better diabetes-related outcomes. Unfor­tunately, other studies indicate that just 55% of patients with type 2 diabetes receive diabetes education, and only 16% report adhering to recommended self-care practices. Part of the problem behind the poor dissemination of and adherence to behavioral interventions is that patients with diabetes are generally limited to 15-minute office visits with their primary care providers. In that short period, it’s often challenging for physicians and healthcare providers to thoroughly educate patients on their disease. Further complicating the issue is that many patients do not have access to one-on-one or group interventions that can enhance adherence to important self-care practices. Testing a Mobile Apps on Glucose Control In a study published in the September 2011 issue of Diabetes Care, my colleagues and I tested a diabetes coaching system for patients with type 2 diabetes. The system uses mobile phone applications and patient/provider portals to provide feedback on self-management and blood glucose results. It also collects data on lifestyle behaviors and clinical manage­ment. The hope was that this program could reduce A1C levels over 1 year. In our analysis, three intervention groups consisting of patients and physicians received different amounts of infor­mation. Maximal treatment consisted of automated, real-time education and behavioral messaging in response to individu­ally analyzed blood glucose values, diabetes medications, and lifestyle behaviors communicated by cell phone. Quarterly reports were given to providers that summarized patients’ gly­cemic control, medication management, lifestyle behaviors, and evidence-based...

Discharging Patients After Elective PCI

Among Medicare recipients, PCI is one of the most commonly performed cardiac procedures in the United States, with more than 1 million procedures being performed each year. Research has shown that the risks associated with PCI are highest within the first 24 to 48 hours after the procedure. Fortunately, both short- and long-term outcomes after PCI have improved substantially over the years because of the evolution of devices, technology, and pharmacotherapy. Despite recent advances, patients are usually observed overnight in the hospital after elective PCI to monitor for complications, sometimes in short-stay units and other times on traditional nursing floors as inpatients. This practice occurs even though some studies suggest that these patients can be discharged home safely on the same day of PCI without the need for overnight observation. The potential benefits of same-day discharge of patients include the elimination of an overnight hospital stay for patients, increased bed availability for the hospital, and cost savings. New Data on Discharge of PCI Patients Little is known about how often patients are discharged home the same day as their PCI. To shed light on the matter, my colleagues and I conducted a study using data from more than 107,000 patients aged 65 and older from the National Cardiovascular Data Registry CathPCI Registry and linked it with CMS claims data. Patients were either discharged the same day as their procedure or 24 or more hours after it. The investigation, published in the October 5, 2011 JAMA, examined trends in death or rehospitalization occurring within 2 days and by 30 days after PCI. “Same-day discharge was rarely implemented in low-risk Medicare...
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