The answer provided in a recent issue of the Annals of Internal Medicine suggests use of U/S to help determine how long to continue anticoagulation in cases of DVT is a qualified yes. See here for abstract,full article requires subscription.
Why qualified? As is often the case the exclusion criteria for entry into a clinical trial limits the applicability. In this instance, patients were excluded if they have prior DVTs,"continuing risk factors or thrombophilic factors ( except for factor V Leiden)."
Previously I wrote about some evidence that an elevated d-dimer may be worthwhile used as indicator of the need for continuing anticoagulation. There appears to be some plausible pathophysiological rationale for both tests.( I remember when internists like to talk about pathophysiology rather than guidelines,quality indicators and coding techniques.)
Friday, May 29, 2009
Thursday, May 28, 2009
Annals Internal Medicine commentary laments imminent death of internal medicine
Dr. David D. Nerenbert writing in the May 19,2009 issue of the Annals of Internal Medicine offers his analysis of why internal medicine is dying;"the progressive devaluation of individualized clinical judgment". See here for abstract.Subscription is required for full text.
In the past,he continues, "careful thought was thought to be our forte".He correctly observes that a physician cannot do justice to the complex,complicated patients with multiple medical problem in fifteen minutes. There is no time for careful thought and still stay in practice, at least not if you play the Medicare and third party player game. Can you do it all in fifteen minutes?Of course, you can't.Why are we even trying? How did the hour we used to spend for new patients and perhaps 30 minutes for return visits morph into the now prototypical 10 to 15 minute farce?" Because we can't afford to spend the time any more because the per visit charges are too low and we are trying to mitigate the economic loss by increasing volume.
Is it really all about money? Is the root cause simply the imposition of price controls by Medicare and the third party payers generally following suit. The practice pattern of internists in the 70s and early 80s of spending time with patients in the office AND caring for patients in the hospitals was made possible by the income level internists enjoyed in that era. Not only did the practice patterns depend on a reasonable level of income but the practice environment-bereft as it was of mandates and insurance company driven requirements-was one in which there was a strong sense of professional identity and satisfaction and prestige among other physicians,patients and others in the health care endeavor. And then the price controls from Medicare came on the scene around 1991 and gradually everything changed.See here for my earlier attempt at summarizing the events that marked the beginning of the end of the internist as we once knew him.
Is the rise of NPs and PAs and the birth and development of hospitalists based on the same economic causes? The consequences of price controls are well known and include: shortages, poor quality and black markets or rationing by favoritism. We have all of that except black markets (unless retainer practices are ultimately outlawed and then we will see the full spectrum of the effects of wage controls)
A small single digit increase in Medicare payments, federal funds to increase the number of internists trained, or a plan to help with medical student loans will not fix the internist's plight. More residency slots are not the answer when the current slots do not fill now.Those who choice a retainer practice may be able to sidestep the problem on an individual basis.Hospitalists can salvage one aspect of the practice on the internists of the 80's but some worry they can do so only at the pleasure of the hospitals and there is no guarantee of that in the future.
The origin of the internists dilemma is government imposed price controls and tweaking the prices a bit and increasing the role of government in medical care will not fix the systemic problem. Mandating health insurance for everyone will not fix the problem of too few primary care doctors; it will make it worse. Again, I point to Massachusetts as the canary in the mine shaft. See here for recent update in waiting times. Dr.Nerenberts's suggestion of a pilot program with internists being on government salary to take care of Medicare patients is again to purpose a governmental solution to a government caused problem, and I think few internists, as upset as they are with the way things are now,would sign up for a salaried government job.
In the past,he continues, "careful thought was thought to be our forte".He correctly observes that a physician cannot do justice to the complex,complicated patients with multiple medical problem in fifteen minutes. There is no time for careful thought and still stay in practice, at least not if you play the Medicare and third party player game. Can you do it all in fifteen minutes?Of course, you can't.Why are we even trying? How did the hour we used to spend for new patients and perhaps 30 minutes for return visits morph into the now prototypical 10 to 15 minute farce?" Because we can't afford to spend the time any more because the per visit charges are too low and we are trying to mitigate the economic loss by increasing volume.
Is it really all about money? Is the root cause simply the imposition of price controls by Medicare and the third party payers generally following suit. The practice pattern of internists in the 70s and early 80s of spending time with patients in the office AND caring for patients in the hospitals was made possible by the income level internists enjoyed in that era. Not only did the practice patterns depend on a reasonable level of income but the practice environment-bereft as it was of mandates and insurance company driven requirements-was one in which there was a strong sense of professional identity and satisfaction and prestige among other physicians,patients and others in the health care endeavor. And then the price controls from Medicare came on the scene around 1991 and gradually everything changed.See here for my earlier attempt at summarizing the events that marked the beginning of the end of the internist as we once knew him.
Is the rise of NPs and PAs and the birth and development of hospitalists based on the same economic causes? The consequences of price controls are well known and include: shortages, poor quality and black markets or rationing by favoritism. We have all of that except black markets (unless retainer practices are ultimately outlawed and then we will see the full spectrum of the effects of wage controls)
A small single digit increase in Medicare payments, federal funds to increase the number of internists trained, or a plan to help with medical student loans will not fix the internist's plight. More residency slots are not the answer when the current slots do not fill now.Those who choice a retainer practice may be able to sidestep the problem on an individual basis.Hospitalists can salvage one aspect of the practice on the internists of the 80's but some worry they can do so only at the pleasure of the hospitals and there is no guarantee of that in the future.
The origin of the internists dilemma is government imposed price controls and tweaking the prices a bit and increasing the role of government in medical care will not fix the systemic problem. Mandating health insurance for everyone will not fix the problem of too few primary care doctors; it will make it worse. Again, I point to Massachusetts as the canary in the mine shaft. See here for recent update in waiting times. Dr.Nerenberts's suggestion of a pilot program with internists being on government salary to take care of Medicare patients is again to purpose a governmental solution to a government caused problem, and I think few internists, as upset as they are with the way things are now,would sign up for a salaried government job.
Tuesday, May 26, 2009
Cogent commentary about the Dartmouth Atlas conclusions by a senior medical educator and troublesome observations by Atul Gawande
The Obama administration is promoting the idea that we can finance a wide and expensive variety of government programs-including better quality health care for everyone- by getting the waste out of medical care. The factual (alleged) basis for this claim to some degree comes from a widely quoted ecological study, the Dartmouth Atlas. The publications from this project apparently has had significant influence on policy recommendations.
This study divided the nation into five Medicare quintiles and then compared money spent with several outcomes.When the region's selected outcomes did not improve as expenses increased they concluded that the difference in expenditures was "wasted" money. Other conclusions are possible and from what I read may make more sense although no one speculation based on aggregate data should stand unchallenged. One such conclusion is that differences in poverty level and in total medical expenditure offer a better explanation ( see below) that the notion that for some basically unexplained reason physicians in some regions just are prone to waste money by doing too much in terms of health care services.
I suppose the suggestion is that greedy and/or misinformed physicians tend to congregate in certain parts of the country.There is at least some anecdotal evidence that that certain cities may in fact have significantly higher medical expenditures due to variations in medical practices at least some of which may be profit driven.
A recent article in the New Yorker by the prolific Dr.Atul Gawande seems to argue the case that McAllen Texas is such a city. The article is worth reading and I found it very troublesome as Gawande relates stories (mostly heresay) of physicians requesting kickbacks for hospital admission and thinly disguised kickbacks from nursing homes. How widespread are the practices narrated by Gawande and to what extent overall health care expenditures are impacted are questions that remain unanswered as does the question why would that be regional.
Go here to read analysis from a former medical school dean, and longtime physician,Dr. Richard (Buz) Cooper, who obviously has spent much time and effort in studying this problem. He argues that Medicare spending is not an accurate proxy for total medical care expenditure and that in states with more total medical spending medical care is better, a conclusion 180 degrees from the Dartmouth conjectures.
I continue to be impressed by how often aggregate data can be used to reach conclusions and policy advice that is conjectural and at times agenda driven. The Dartmouth project may be one .Another is the recent NEJM article on hospital readmission rates of Medicare patients, a topic for a future blog.In both instances the numbers are real but the underlying factors are difficult to tease out and may be refractory to statistical techniques designed to eliminate confounding.Data gathering and statistical analysis have become cheap and widely available ,what to do with the data requires reasoning and that is as scarce as ever.
Dr. RW (see here) has recently commented on the illogical and overreaching conclusions of the Dartmouth folks.
The Dartmouth Atlas project is funded by three large insurance companies or their foundations ( Aetna,United Health care and Well Point) with the other two contributors being The Robert Wood Johnson Foundation and The California Health Group Foundation.
To claim that results may be influenced by their source of funding risks accusations of indulging in a version of an ad hominem argument. Still you have to wonder if large insurance companies would continue funding for a long standing project that published results that did not further their business interests or if they would spend much money in supporting research such as that discussed by Dr.Cooper.If you run a medical insurance company you have to like a study that claims to demonstrate widespread wasted medical spending. It is of interest that here waste is defined by a third party observer not by either the providers nor the recipients of the services. Having said that, the results are either valid or not (or we just can't tell) independent of who financed the project.
I remember learning that ecological studies might at best serve as hypothesis generating activities not as generating answers so definite and certain that they could form the basis for sweeping health care changes.
I continue to be very suspicious about conclusions from studies based on aggregate data.Serious and thoughtful and non-biased commentators are able to offer opposite stories to "explain" the data. However, Dr. Gawande's observations about practices and hospitals in several cities with significantly different practice patterns and levels of medical cost (and profits) and perhaps quality of care make me wonder if the Dartmouth conclusions might be not quite as unjustified that I want to believe as that conclusion painfully bumps up against my philosophical priors and epistemological biases. At least I am less inclined to dismiss them out of hand even though there must be more to the story than marked regional variations in greed.
addendum; Minor spelling,grammar and syntax changes were made on 8/28/14.
This study divided the nation into five Medicare quintiles and then compared money spent with several outcomes.When the region's selected outcomes did not improve as expenses increased they concluded that the difference in expenditures was "wasted" money. Other conclusions are possible and from what I read may make more sense although no one speculation based on aggregate data should stand unchallenged. One such conclusion is that differences in poverty level and in total medical expenditure offer a better explanation ( see below) that the notion that for some basically unexplained reason physicians in some regions just are prone to waste money by doing too much in terms of health care services.
I suppose the suggestion is that greedy and/or misinformed physicians tend to congregate in certain parts of the country.There is at least some anecdotal evidence that that certain cities may in fact have significantly higher medical expenditures due to variations in medical practices at least some of which may be profit driven.
A recent article in the New Yorker by the prolific Dr.Atul Gawande seems to argue the case that McAllen Texas is such a city. The article is worth reading and I found it very troublesome as Gawande relates stories (mostly heresay) of physicians requesting kickbacks for hospital admission and thinly disguised kickbacks from nursing homes. How widespread are the practices narrated by Gawande and to what extent overall health care expenditures are impacted are questions that remain unanswered as does the question why would that be regional.
Go here to read analysis from a former medical school dean, and longtime physician,Dr. Richard (Buz) Cooper, who obviously has spent much time and effort in studying this problem. He argues that Medicare spending is not an accurate proxy for total medical care expenditure and that in states with more total medical spending medical care is better, a conclusion 180 degrees from the Dartmouth conjectures.
I continue to be impressed by how often aggregate data can be used to reach conclusions and policy advice that is conjectural and at times agenda driven. The Dartmouth project may be one .Another is the recent NEJM article on hospital readmission rates of Medicare patients, a topic for a future blog.In both instances the numbers are real but the underlying factors are difficult to tease out and may be refractory to statistical techniques designed to eliminate confounding.Data gathering and statistical analysis have become cheap and widely available ,what to do with the data requires reasoning and that is as scarce as ever.
Dr. RW (see here) has recently commented on the illogical and overreaching conclusions of the Dartmouth folks.
The Dartmouth Atlas project is funded by three large insurance companies or their foundations ( Aetna,United Health care and Well Point) with the other two contributors being The Robert Wood Johnson Foundation and The California Health Group Foundation.
To claim that results may be influenced by their source of funding risks accusations of indulging in a version of an ad hominem argument. Still you have to wonder if large insurance companies would continue funding for a long standing project that published results that did not further their business interests or if they would spend much money in supporting research such as that discussed by Dr.Cooper.If you run a medical insurance company you have to like a study that claims to demonstrate widespread wasted medical spending. It is of interest that here waste is defined by a third party observer not by either the providers nor the recipients of the services. Having said that, the results are either valid or not (or we just can't tell) independent of who financed the project.
I remember learning that ecological studies might at best serve as hypothesis generating activities not as generating answers so definite and certain that they could form the basis for sweeping health care changes.
I continue to be very suspicious about conclusions from studies based on aggregate data.Serious and thoughtful and non-biased commentators are able to offer opposite stories to "explain" the data. However, Dr. Gawande's observations about practices and hospitals in several cities with significantly different practice patterns and levels of medical cost (and profits) and perhaps quality of care make me wonder if the Dartmouth conclusions might be not quite as unjustified that I want to believe as that conclusion painfully bumps up against my philosophical priors and epistemological biases. At least I am less inclined to dismiss them out of hand even though there must be more to the story than marked regional variations in greed.
addendum; Minor spelling,grammar and syntax changes were made on 8/28/14.
Thursday, May 21, 2009
The IOM speaks: mandatory nap time for house staff
The very name Institute of Medicine for reasons that have eluded me seems to mean to many a venerable assortment of very wise people who unlike the rest of the human race are able to act without personal bias or agenda and do what it right or as the myth goes act in the public interest. Their latest unfunded quasi-mandate is to mandate nap time for residents and for the ACGME to monitor the program,which I guess means make sure everyone gets their naps.
Thanks goodness, for a change, some one has the gumption, to at least, question the consequences of this IOM's pronouncement. This article in the NEJM dared to ask the questions:what would the cost be and what is the evidence that the suggestions would achieve their stated goals. The answers: It would cost a lot and the evidence of beneficial outcome is lacking.
The IOM which has been around since 1970 is a non-governmental organization that was chartered as part of the US National Academies of Science.
Thanks goodness, for a change, some one has the gumption, to at least, question the consequences of this IOM's pronouncement. This article in the NEJM dared to ask the questions:what would the cost be and what is the evidence that the suggestions would achieve their stated goals. The answers: It would cost a lot and the evidence of beneficial outcome is lacking.
The IOM which has been around since 1970 is a non-governmental organization that was chartered as part of the US National Academies of Science.
More and More data is ganging up on Proton pump inhibitors
The story of PPIs apparently interfering with the beneficial effect of Plavix is widely distributed and read. Now we see data (see here for abstract) that links spontaneous bacterial peritonitis (SBP) in advanced cirrhosis with PPI use. This was a case control study with an OR of 4.3,so I cannot make my typical whinny remark about the appropriate level of concern with relative risks of less than 2.
PPIs seem to be the mirror image of statins which have an increasing number of studies indicating a new benefit.With regard to PPIs, we may have to worry more and more about bad effects including: pneumonia ( see here for a rather unconvincing study), fractures ( see here), heart attacks ( see here for a good review of the Plavix-PPIs issue by Dr. Richard Fogoros) and now SBP. I would not be surprised if H2 blocker sales may have an uptick.
PPIs seem to be the mirror image of statins which have an increasing number of studies indicating a new benefit.With regard to PPIs, we may have to worry more and more about bad effects including: pneumonia ( see here for a rather unconvincing study), fractures ( see here), heart attacks ( see here for a good review of the Plavix-PPIs issue by Dr. Richard Fogoros) and now SBP. I would not be surprised if H2 blocker sales may have an uptick.
Monday, May 18, 2009
Electronic Medical Records, tool to save health care costs or windfall for the tool makers
One of the package of health care "reforms" that will increase quality, provide care for all and save money is the widespread implementation of electronic medical records (EMR). The other major elements are comparative effectiveness research and preventive medicine.
Here is one economist's take on one aspect of the EMR issue.As much as
"change" was heralded as a major characteristic of the new administration it appears that some things change very little.Lobbyists still stalk the halls of government and sometimes score big.
Whether the massive savings alleged by the proponents of the health care reform will accrue from EMRs or not will have to be seen in time. We do not have to wait to see how certain purveyors of these systems will make out. See here for a Washington Post article on the efforts,some of which have been years in the making, to cash in on the federal outlay of
See a detailed discussion of this special interest issue as well as concerns about the safety of this rush to implementation of EMR by one expert on this subject at Health Care Renewal.
Here is one economist's take on one aspect of the EMR issue.As much as
"change" was heralded as a major characteristic of the new administration it appears that some things change very little.Lobbyists still stalk the halls of government and sometimes score big.
Whether the massive savings alleged by the proponents of the health care reform will accrue from EMRs or not will have to be seen in time. We do not have to wait to see how certain purveyors of these systems will make out. See here for a Washington Post article on the efforts,some of which have been years in the making, to cash in on the federal outlay of
See a detailed discussion of this special interest issue as well as concerns about the safety of this rush to implementation of EMR by one expert on this subject at Health Care Renewal.
Friday, May 15, 2009
Is the latest medical world cahoots insurance companies and academia
The Last Psychiatrist (TLP). suggests that an unholy alliance between medical insurance companies and medical academia is well underway.See here.
He discusses an article from medical academia that apparently concludes that the much hated by physicians "prior authorization" for medication is really a good thing. Good for whom? TLP suggests that the drug promoted is as likely as not neither the cheapest nor the best but rather the one for which a deal has been struck between the drug manufacturer and the insurers and or the medication management company. They don't need any stinking comparative effectiveness research.
The poster child for the new insurance company-medical academia alliance is found at Harvard where is found the "only medical school department cosponsored by a health plan". The plan is the Harvard Pilgrim Health Care and the department's name is The department of Ambulatory and Preventive Care.
Here is one paragraph from TLP:
"If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca. The next unholy alliance is between academic medicine and insurers/providers. The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare."
Next we will have to not allow medical students to have pens and mugs with insurance company logos.
He discusses an article from medical academia that apparently concludes that the much hated by physicians "prior authorization" for medication is really a good thing. Good for whom? TLP suggests that the drug promoted is as likely as not neither the cheapest nor the best but rather the one for which a deal has been struck between the drug manufacturer and the insurers and or the medication management company. They don't need any stinking comparative effectiveness research.
The poster child for the new insurance company-medical academia alliance is found at Harvard where is found the "only medical school department cosponsored by a health plan". The plan is the Harvard Pilgrim Health Care and the department's name is The department of Ambulatory and Preventive Care.
Here is one paragraph from TLP:
"If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca. The next unholy alliance is between academic medicine and insurers/providers. The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare."
Next we will have to not allow medical students to have pens and mugs with insurance company logos.
Tuesday, May 12, 2009
More on the three magic elements of reforming health care.
To reform" health care" (and to fix the nation's economy) we are told we must have electronic medical records, government funded and managed comparative effectiveness research and more prevention.
In regard to the first I strongly recommend that you go here and read about just how much trouble there has been so far with the security of computerized medical information and why does anyone really believe that problem will just go away. Go here to see a good summary of other non-security related serious issues with the EMR proposed panacea.
In regard to the second I strongly recommend that you go here to learn the real reason that Dr.Rich favors government funded and managed comparative effectiveness research which he designates as "CER" as opposed to the generic term of cer. Dr Fogoros makes the argument that all cer may be biased so it is not the case that he favors CER because it will be not biased.Read his entry to see where his argument goes. I suspect more that a few advocates of CER will not be pleased.
Of course, even if we have much more cer with the addition of the CER to the data base, it will be all for nothing unless the medical profession gets on board and acts according to the published comparative effectiveness research. The grand guru daddy of the hospitalists. Dr. Bob Wachter suggests for those who won't go along they should be". dragged" along. Wonder who will be doing the dragging. In the new world of CER,will there be the draggers and the dragees? You betcha.Dr. Wachter in his dragging proposal is less concerned than is the new AMA president regarding the risk of malpractice suits if adherence to the CER directed guidance leads to the withholding of certain procedures that arguably lead to bad patient outcomes.
All in all it may be a good time to be a retired doc but as for being a patient, not so much.
In regard to the first I strongly recommend that you go here and read about just how much trouble there has been so far with the security of computerized medical information and why does anyone really believe that problem will just go away. Go here to see a good summary of other non-security related serious issues with the EMR proposed panacea.
In regard to the second I strongly recommend that you go here to learn the real reason that Dr.Rich favors government funded and managed comparative effectiveness research which he designates as "CER" as opposed to the generic term of cer. Dr Fogoros makes the argument that all cer may be biased so it is not the case that he favors CER because it will be not biased.Read his entry to see where his argument goes. I suspect more that a few advocates of CER will not be pleased.
Of course, even if we have much more cer with the addition of the CER to the data base, it will be all for nothing unless the medical profession gets on board and acts according to the published comparative effectiveness research. The grand guru daddy of the hospitalists. Dr. Bob Wachter suggests for those who won't go along they should be". dragged" along. Wonder who will be doing the dragging. In the new world of CER,will there be the draggers and the dragees? You betcha.Dr. Wachter in his dragging proposal is less concerned than is the new AMA president regarding the risk of malpractice suits if adherence to the CER directed guidance leads to the withholding of certain procedures that arguably lead to bad patient outcomes.
All in all it may be a good time to be a retired doc but as for being a patient, not so much.
Monday, May 11, 2009
Will Protecting people from second hand smoke decrease heart attacks?
Well, the early relatively small studies gave the public health rule makers some empirical justification for claiming success, further study suggest the opposite.Here is a blog posting suggesting a couple of reasons why that could be.The blog's author is Milton Friedman's son David who was trained as a physicist but writes about economics and has gained some fame for Friedman 's Law.
I'll bet we will soon be seeing papers that conclude that the attack rate of heart attacks is significantly down since the implementation of various local laws outlawing trans fat.
I'll bet we will soon be seeing papers that conclude that the attack rate of heart attacks is significantly down since the implementation of various local laws outlawing trans fat.
Thursday, April 30, 2009
Whistle blowing is always risky,In Great Britain's NHS even worse,nurse looses a lot
Monday, April 27, 2009
Two of my favorite medical bloggers seem to disagree regarding CER
When I read a recent blog posting by DB,who postings inspired me to start to blog and with whom I rarely disagree, I was sharpening up my blogging tools to respectfully offer a view counter to his, but as is often the case DrRW beat me to the draw (See here).
Those who oppose or at least have serious doubts about government- run CER are likely not against comparing the effectiveness of various medical treatments ( i.e.. not against CER) but are very skeptical of the ability of a government agency to regularly turn out results that will be free of bias and may also reject the thesis that all drug company sponsored research is biased.
Research can be spun one way or the other-there are so many ways to stack the deck and cook the books that lurk beneath behind the pages of a research project.To believe that a government agency is a) without an agenda and b) incapable of making such an agenda-generated bias operational requires much more faith in the integrity of the government that I summon and seems to ignore what we have learned about how governmental entity really operate versus the high school civics views that describes things in terms of purported aims rather than in real results. A leisurely half hour or so with a discussion of Public Choice theory might disabuse many of the vision of government as a hybrid between Santa Claus and superman.
Dr. RW's final paragraph deserves much consideration:
No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.
Those who oppose or at least have serious doubts about government- run CER are likely not against comparing the effectiveness of various medical treatments ( i.e.. not against CER) but are very skeptical of the ability of a government agency to regularly turn out results that will be free of bias and may also reject the thesis that all drug company sponsored research is biased.
Research can be spun one way or the other-there are so many ways to stack the deck and cook the books that lurk beneath behind the pages of a research project.To believe that a government agency is a) without an agenda and b) incapable of making such an agenda-generated bias operational requires much more faith in the integrity of the government that I summon and seems to ignore what we have learned about how governmental entity really operate versus the high school civics views that describes things in terms of purported aims rather than in real results. A leisurely half hour or so with a discussion of Public Choice theory might disabuse many of the vision of government as a hybrid between Santa Claus and superman.
Dr. RW's final paragraph deserves much consideration:
No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.
Thursday, April 23, 2009
Still more thoughts on problems with EMRs and who or what is responsible for the patient
Here is a link to a discussion of more problems with electronic medical records (EMRs) that ties in with the issue of individual versus group responsibility.
The particular case involved a patient at an academic medical center in which
It took three days for the patient's care team to realize that the results entered into his EMR were for a biopsy they did not order of a lesion he did not have. Before the error was recognized, it had caused the patient "tremendous pain and mental anguish."
The author, John Goodman, continues with a theme I have ranted about before, (see here) the increasing lack of individual responsibility for patient care and the replacement with "team care" and computers systems are, of course,increasingly part of the team.
I believe that it is not coincidental that the same ACGME in their 2003 general core competencies statement mentions "systems" or "system" seven times but saw no reason to include the statement quoted above. The authors of the competencies are more concerned with team play, group dynamics,system this and system that, and conserving society's resources and fostering social justice than in inculcating in medical trainees a sense of individual responsibility for their individual patients, which is what I thought it was all about.
The particular case involved a patient at an academic medical center in which
It took three days for the patient's care team to realize that the results entered into his EMR were for a biopsy they did not order of a lesion he did not have. Before the error was recognized, it had caused the patient "tremendous pain and mental anguish."
The author, John Goodman, continues with a theme I have ranted about before, (see here) the increasing lack of individual responsibility for patient care and the replacement with "team care" and computers systems are, of course,increasingly part of the team.
At bottom, the error got as far as it did because of the "medical team" approach - no single person was responsible for this patient's care. Each person relied on the (erroneous) electronic medical record for his view of the whole.
We seem to be replacing personal physician responsibility with "systems".
With so much rhetoric these days about instilling professionalism in medical students and house officers how can individual responsibility be given such short shrift? In 2003 the ACGME eliminated the following statement from their pronouncements:
Physicians must recognize their obligation is not discharged at any given time or any given day.
No, that is not a typo -they eliminated what used to be considered a fundamental principle of the doctor-patient relationship,that the physician is responsible for his patient
I believe that it is not coincidental that the same ACGME in their 2003 general core competencies statement mentions "systems" or "system" seven times but saw no reason to include the statement quoted above. The authors of the competencies are more concerned with team play, group dynamics,system this and system that, and conserving society's resources and fostering social justice than in inculcating in medical trainees a sense of individual responsibility for their individual patients, which is what I thought it was all about.
Earth Day -some cogent counterpoints to the standard green koolaid
The first thing I remember about Earth day were reports of some cases of histoplasmosis in a group of well meaning well-meaners who breathed in a bunch of fungal spores when they set out to clean up their little portions of the earth.
Dr. Don Boudreaux,chairman of the economics department at George Mason University, submits this essay on what he is grateful for on earth day. He sums up his thoughts in this closing paragraph:
I am, in short, thankful for private-property markets that are the main driving force behind these (and many other) anti-pollutants -- a force so powerful that we today enjoy the incredible luxury of being able to worry, should we so choose, about very distant and very speculative forms of environmental problems such as species loss and global warming.
Dr. Mark Perry,economics professor at University of Michigan,wrote this editorial explaining what has driven the cleaning and greening of things since the 1970s birth of Earth Day. (hint it was not Al Gore). He ends his essay with this answer to what has made the earth greener.
Dr. Don Boudreaux,chairman of the economics department at George Mason University, submits this essay on what he is grateful for on earth day. He sums up his thoughts in this closing paragraph:
I am, in short, thankful for private-property markets that are the main driving force behind these (and many other) anti-pollutants -- a force so powerful that we today enjoy the incredible luxury of being able to worry, should we so choose, about very distant and very speculative forms of environmental problems such as species loss and global warming.
Dr. Mark Perry,economics professor at University of Michigan,wrote this editorial explaining what has driven the cleaning and greening of things since the 1970s birth of Earth Day. (hint it was not Al Gore). He ends his essay with this answer to what has made the earth greener.
.. capitalism has. Through wealth generated by the free market, we have enough resources to move beyond the subsistence economies that damage the environment, enough disposable income to fund clean-up programs, enough wealth to scrub and polish industry.
Only in advanced economies can the technology needed to recycle hazardous waste or to replace dirty coal-fired power plants with cleaner gas or nuclear plants be developed. That technology cannot be produced in centrally planned economies where the profit motive is squelched and lives are marshalled by the state.
There's nothing wrong with setting aside a day to honor the Earth. In fairness, though, it should be complemented by Capitalism Day. It's important that the world be reminded of what has driven the environmental improvements since Earth Day began in 1970.
Wednesday, April 22, 2009
Health Insurance does not equal health care
Worth reading is this commentary by internist Dr. Marc Siegel who cautions that "health insurance does not equal health care".Neither is the promise of a government of universal coverage equal to the actual delivery or ready availability of health care.
Medicare (which some may remember as the government program that promised not to interfere with the physician-patient relationship) has so limited the payment to physicians (particularly primary care physicians) that the promise for medical care for the elderly increasingly is becoming unfulfilled as more and more primary care docs opt out or at least refuse to see new medicare payments. This is government care for just one segment of the population.In Canada the unfulfilled promises can affect everyone or at least those who cannot go south and pay for their care.
A recent Texas Medicare Association survey indicated that only 38% of primary care doctors are accepting new Medicare patients and the situation is worse with Medicaid patients.
Problems finding a physician in Massachusetts affects everyone since they instituted the brilliant plan of getting medical insurance for all by simply passing a law that mandated it.This is the same plan that is now asking for a federal bailout.See here for how that is working out.
There are many interpretations for the cryptic lyrics of the song "Hotel California" which says in part
"...relax, said the night man, We are programmed to receive. You can checkout any time you like, But you can never leave! "
My interpretation is that the hotel provides the trappings or appearance of a service but not the real service. What does your national health service card mean if you have to wait so long for the care that it might not matter or if the shortage of docs gets to the point where little care is available.
Medicare (which some may remember as the government program that promised not to interfere with the physician-patient relationship) has so limited the payment to physicians (particularly primary care physicians) that the promise for medical care for the elderly increasingly is becoming unfulfilled as more and more primary care docs opt out or at least refuse to see new medicare payments. This is government care for just one segment of the population.In Canada the unfulfilled promises can affect everyone or at least those who cannot go south and pay for their care.
A recent Texas Medicare Association survey indicated that only 38% of primary care doctors are accepting new Medicare patients and the situation is worse with Medicaid patients.
Problems finding a physician in Massachusetts affects everyone since they instituted the brilliant plan of getting medical insurance for all by simply passing a law that mandated it.This is the same plan that is now asking for a federal bailout.See here for how that is working out.
There are many interpretations for the cryptic lyrics of the song "Hotel California" which says in part
"...relax, said the night man, We are programmed to receive. You can checkout any time you like, But you can never leave! "
My interpretation is that the hotel provides the trappings or appearance of a service but not the real service. What does your national health service card mean if you have to wait so long for the care that it might not matter or if the shortage of docs gets to the point where little care is available.
Tuesday, April 21, 2009
In Canada health care is a right,wait ,no it isn't?
In Canada, there is universal health care with a single payer and for the most part no opting of the system.Their supreme court ruled that patient rights were been violated because their access to health care was in some instances so delayed that it was no care at all.
Now consider the case of an orthopedic surgeon, Dr. Brian Day who is involved in legal proceedings with the provincial health care entity in British Columbia for accepting payment from a private citizen for medical care. See here for some details and here for details of Dr. Day's lawsuit which seeks to overturn the law in BC that bans private medical care. In this matter the government is arguing that the supreme court ruling does not apply because health care is not a right after all.
Wait,I thought the government of Canada provided medical care for all because of the belief that medical care was a right but now it isn't.
Now consider the case of an orthopedic surgeon, Dr. Brian Day who is involved in legal proceedings with the provincial health care entity in British Columbia for accepting payment from a private citizen for medical care. See here for some details and here for details of Dr. Day's lawsuit which seeks to overturn the law in BC that bans private medical care. In this matter the government is arguing that the supreme court ruling does not apply because health care is not a right after all.
Wait,I thought the government of Canada provided medical care for all because of the belief that medical care was a right but now it isn't.
Sunday, April 19, 2009
More concerns about Government mandated and financed electronic medical records
To reform medical care we are told that we need three things; 1)electronic medical records (EMR), 2)comparative effectiveness research (done by the federal government)(CER) and 3)more efforts at prevention . From these elements we can derive care for all,better quality care and great cost savings.(Why does this remind me of "cheap,fast and good-pick any two"?)
Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.
While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.
Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.
Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.
Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.
Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.
Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.
I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.
We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.
Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.
While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.
Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.
Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.
Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.
Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.
Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.
I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.
We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.
Tuesday, April 14, 2009
Comparative effectiveness research-more warnings
Those, including several medical bloggers, who seem to have placed more than a little faith in the notion of a government funded and run comparative effectiveness research program (CER) should read the following sobering posting from Health Care Renewal.
The commentary in part expresses concerns about the following recent comments from Governor Sebelius from her congressional hearing for head of HHS.
The author of the Health Care renewal entry is properly alarmed that use of the often garbage type data from EMR have a high likelihood of generating detailed printouts of elaborately presented ( replete with very low p values) results that could be misleading at best and more likely harmful. To expect such " highly uncontrolled" data bases to meaningfully determine if treatment X is better than treatment Y raises unrealistic expectations to a new level.
It seems to me that some pro government CER advocates make two mistakes in their advocacy of the government funded CER.
First, they maintain that we have no or at best very little comparative effectiveness data at all now so the government must provide it. Dr RW in this posting proves that is not the case. A recent example of non-government funded CER is the SYNTAX trial.
Secondly, they conflate the desire to have really good data on what works with the assumption that such will be the product from a government funded CER. Yes,it would be very nice if there were someway to have realms of great CER without bias and without spin but should we really trust a government agency who would somehow be populated by selfless, brilliant, dedicated public servants who would bring no biases to the table and who somehow will be immune to the outside influences that seemed to have plagued every governmental agency ever created and that the output from analysis would not be put to the purpose of limiting government payment for such treatment that they found inferior.
Limiting payment for medical services deemed inferior by data dredging exercises is not what we need to improve medical quality but may well be what government sponsored CER will bring.
The commentary in part expresses concerns about the following recent comments from Governor Sebelius from her congressional hearing for head of HHS.
“The goal,” Sebelius said, “is to provide every American with a safe, secure electronic health record by 2014." The nominee also endorsed efforts to use data gleaned from electronic medical records to conduct “comparative effectiveness research" (the authors bolding)(CER) to provide information on the relative strengths and weaknesses of alternative medical interventions to health providers and consumers.”
The author of the Health Care renewal entry is properly alarmed that use of the often garbage type data from EMR have a high likelihood of generating detailed printouts of elaborately presented ( replete with very low p values) results that could be misleading at best and more likely harmful. To expect such " highly uncontrolled" data bases to meaningfully determine if treatment X is better than treatment Y raises unrealistic expectations to a new level.
It seems to me that some pro government CER advocates make two mistakes in their advocacy of the government funded CER.
First, they maintain that we have no or at best very little comparative effectiveness data at all now so the government must provide it. Dr RW in this posting proves that is not the case. A recent example of non-government funded CER is the SYNTAX trial.
Secondly, they conflate the desire to have really good data on what works with the assumption that such will be the product from a government funded CER. Yes,it would be very nice if there were someway to have realms of great CER without bias and without spin but should we really trust a government agency who would somehow be populated by selfless, brilliant, dedicated public servants who would bring no biases to the table and who somehow will be immune to the outside influences that seemed to have plagued every governmental agency ever created and that the output from analysis would not be put to the purpose of limiting government payment for such treatment that they found inferior.
Limiting payment for medical services deemed inferior by data dredging exercises is not what we need to improve medical quality but may well be what government sponsored CER will bring.
Monday, April 13, 2009
Medical Home will not be enough, we need the Medical Village
I written before about my skepticism regarding the Medical Home concept.It has been suggested that the home does not go far enough and that a "village "concept should be explored and possibly adopted. Here is one doc's version of how that village concept would be applied to one aspect of medical care. Thanks to Dr. Hal Dall's blog for insightful comments and satire.
Tuesday, April 07, 2009
Statins (or at least one of them) seems to just get better and better
Just as we thought there could not possibly be any more purported benefits of the statin drugs we are treated to still another reason to get on the bandwagon- prevention of venous clots.
At least that is what we are told by more breaking news from the latest paradigm shifting, landmark study, the JUPITER trial. We now learn that in this large , randomized trial of persons whose LDL were less than 130 and their CRP were greater than 2,that there was a 43 % decrease in the incidence of venous thrombotic disease in the rosuvastatin (20 mg) group. See here for the entire article from the NEJM.
Previously I had blogged about the reported benefits of pre-operative statins in terms of fewer deaths,fewer strokes and a lower incidence of atrial fibrillation.
At least that is what we are told by more breaking news from the latest paradigm shifting, landmark study, the JUPITER trial. We now learn that in this large , randomized trial of persons whose LDL were less than 130 and their CRP were greater than 2,that there was a 43 % decrease in the incidence of venous thrombotic disease in the rosuvastatin (20 mg) group. See here for the entire article from the NEJM.
Previously I had blogged about the reported benefits of pre-operative statins in terms of fewer deaths,fewer strokes and a lower incidence of atrial fibrillation.
Monday, April 06, 2009
What the heck could increased variation in red blood cell size have to do with heart disease or mortality?
This article from the Archives of Internal Medicine seems to link a measure of variability in red blood cell (rbc) size with all cause mortality. As the article explains, previously there had several studies that suggested a link between heart disease and RBC size variability as judged by measurement of the RDW by automated blood cell analyzers. (See here for one article linking elevated RDW and adverse clinical outcomes in patients with heart disease). The Archive article examined a large data base for evidence of a similar correlation with all cause mortality and seemed to find one that reached statistical significance.
The RDW is the red cell distribution width which is the standard deviation of red cell width divided by the mean cell width and normally is around 10-15 %. Remember we used to talk about anisocytosis. It may have some limited utility in differentiating iron deficiency anemia from thalassemia with the RDW increased in the former reflecting the fact that in iron deficiency there are two populations of red cells and in thalassemia there is a more homogeneous population of relatively small rbcs. In my experience, it is a by product of automatic blood cell analyzers that most docs ignore, including a couple of hematologist associates I asked about it.
The study authors also wondered how/why RDW seems to correlate with all cause mortality.They investigated the relationship between C reactive protein (CRP) and RDW postulating that somehow inflammation was involved but that did not seem to be the case.
How long will it take for the JUPITER data be dredged to see if statins ( at least rosuvastatin) can lower the RDW?
The RDW is the red cell distribution width which is the standard deviation of red cell width divided by the mean cell width and normally is around 10-15 %. Remember we used to talk about anisocytosis. It may have some limited utility in differentiating iron deficiency anemia from thalassemia with the RDW increased in the former reflecting the fact that in iron deficiency there are two populations of red cells and in thalassemia there is a more homogeneous population of relatively small rbcs. In my experience, it is a by product of automatic blood cell analyzers that most docs ignore, including a couple of hematologist associates I asked about it.
The study authors also wondered how/why RDW seems to correlate with all cause mortality.They investigated the relationship between C reactive protein (CRP) and RDW postulating that somehow inflammation was involved but that did not seem to be the case.
How long will it take for the JUPITER data be dredged to see if statins ( at least rosuvastatin) can lower the RDW?
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