American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, July 3, 2015

C. difficile and hospital process measures

One of the more difficult things to cover is a study that you've already written about in an accompanying editorial. It's quite hard to come up with anything “new” to write that you haven't already written. Such is the case with a very nice study examining hospital process measures and Clostridium. difficile infections (CDI) just published in BMJ Quality and Safety by Nick Daneman and colleagues from Sunnybrook Health Sciences Centre in Toronto.

Using results of a mandatory CDI prevention practices survey they compared facility-level processes measures and patient level (via ICD-10 codes) CDI rates in 159 Ontario hospitals. Specifically, they looked at implementation of 6 hospital-level measures: (1) isolation at diarrhea onset, (2) audit of antibiotic use, (3) audit of environmental cleaning, (4) vancomycin as first line therapy and (5) on-site diagnostic testing and (6) reporting of rates to senior leadership. Somewhat surprisingly, none of the process measures were associated with lower risk of CDI.

In the editorial, Nasia Safdar and I wrote:

“First, the authors identified low self-reported implementation of most CDI prevention practices, with only 27% of facilities reporting isolation of all patients at onset of diarrhoea, and 16% reporting auditing of antibiotic stewardship practices. Low adherence rates for these two practices in particular are concerning because prompt institution of contact precautions is necessary to reduce nosocomial transmission of C. difficile. And antimicrobial stewardship is at least as important as infection prevention practices, if not more so, for reducing CDI.”

“This study also highlights the importance of implementation science research to tackle the vexing yet pervasive problem of low and variable adherence to evidence-based interventions for reducing HAI, including CDI. The scope of this study did not extend to exploring barriers to implementation or an in-depth assessment of the self-reported practices that may help inform implementation strategies to increase uptake of proven practices.”

and of course my favorite part:

“Last, increasing the evidence base for preventing CDI by undertaking pragmatic randomised controlled trials of novel interventions incorporating efficacy and effectiveness is essential to successfully bridge the quality chasm that currently exists in CDI prevention.”

Reference: Daneman N. et al. BMJ Qual Saf. 2015 Apr 24 (open access)

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Thursday, July 2, 2015

The affect heuristic and conflicts of interest

Understanding the affect heuristic leads one to expand their understanding of the term “conflict of interest”. My simple explanation of the affect heuristic follows:

If you like something, you overestimate the benefits and underestimate the risk. The contrary holds also. If you dislike something, you underestimate the benefits and overestimate the risks.

This concept helps us understand that we should consider multiple conflicts of interest. Clearly the pharmaceutical and device industries have taken advantage of this concept. They hire very likable representatives. These representatives treat physicians very well. Physicians, nurses and office staff like the representatives. Thus, the companies are well considered. When considering a drug that they are selling or a device that they make, the recipients of the kindness attribute benefits and minimize risks for the drug or the device.

The same phenomenon occurs when the business funds research. The recipients of the research funds will have their values changed.

These values change subconsciously. We need not say that the conflict is explicit.

But there are other major conflicts. Our expertise is a conflict. For example, my thoughts about pharyngitis induce the affect heuristic. Being a diabetologist induces the heuristic. Diabetologists overestimate the value of tight control, and suppress the estimates of risks. Interventional cardiologists overestimate the benefits of stenting and underestimate the relative benefits of coronary arty bypass grafting.

Insurance company executives underestimate the benefits of expensive treatments.

The only logical way of avoiding conflicts of interest is to balance our committees and thereby balance the conflicts.

Most guideline writers and performance measurement developers would deny that they have a conflict. But we all have some conflict. We should acknowledge our conflicts and make them explicit.

We cannot avoid conflicts, thus we should consider the competing conflicts.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Yelp!

I have written previously about some “aha moments“ that I have had as a clinician, when something that I knew was coming seemed to arrive with a thud in my own practice. I had another one of those moments a couple of weeks ago.

I was finishing up with a new patient, and had explained to him and his wife my assessment and recommendations, and had answered a bunch of questions they had. I was frankly feeling pretty good about how the encounter had gone and as he was walking out of the exam room he said (more or less): “Thanks doc; I'm glad I came to see you, and I am going to give you a really nice review on Yelp.” He was not kidding.

I didn't know quite what to say immediately, but I ended up thanking him (somewhat awkwardly, I suspect) and then recovered enough to tell him that while I would of course appreciate a nice review on Yelp, I wanted him to know that he might be getting a patient satisfaction survey in the mail, and I would really appreciate it if he filled it out and sent it back in. Encounter over. New world order in place.

As someone who has written a lot about measuring the patient experience it came as no surprise that there were plenty of opportunities out there for patients to rate my performance. Indeed, the presence of all of these “rating sites” is one of the reasons why I support the public reporting of validated survey data from real patients. It is a way for us to displace “bad” data (like a review that could have been entered by someone who didn't even see me—gee, thanks Mom!) with “good” data, and by so doing, reinforce the trust our patients place in us.

Look, I don't love the idea that every patient encounter can lead to an internet review, but that is the world in which we live, and I think it is way better to embrace it than pretend it will go away.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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Wednesday, July 1, 2015

Paying smokers to quit

Smoking is a major cause of heart attacks, strokes, emphysema, and lung cancer. Smoking rates have steadily declined in the U.S. in the last 50 years, but about a fifth of U.S. adults still smoke. Helping them quit would make a major contribution to their health.

A study in the current issue of the New England Journal of Medicine (NEJM) studied the effectiveness of different incentive programs on smoking cessation. Over 2,500 smokers were randomized into 3 groups. One group received “usual care”, meaning encouragement to quit smoking and information about quitting programs and nicotine replacement products. Another group was invited to join a “reward program” in which each subject who successfully quit smoking for 6 months received an $800 reward. The third group was invited to join a “deposit program” in which each subject had to pay $150 which would be forfeited if the subject kept smoking. If the subject quit smoking for 6 months, however, she would receive her deposit back and an additional $650.

Six percent of the usual care group had successfully quit smoking for 6 months. Ninety percent of those invited to join the reward program enrolled, and 16% of them successfully quit smoking for 6 months, much more than the usual care group. Of the subjects invited to join the deposit program only 14% accepted. But of those who accepted, over half successfully quit smoking for 6 months (or 7.6% of those invited).

So overall, the deposit group did worse than the reward group, because so few people accepted enrollment into the deposit group. Of those who enrolled in both groups, the deposit group did much better. The findings of the study are well summarized in this short video.

This study sits at an intersection between health research and a relatively new field called behavioral economics. Behavioral economics studies the consistent ways that people make irrational decisions. One finding that has been substantiated by many studies in behavioral economics is the phenomenon of loss aversion—people avoid losses more then they seek gains. For example, most of us will work harder or sacrifice more to avoid a $50 loss than to make $50.

A related NEJM editorial makes the point that this study demonstrated loss aversion in 2 ways. One was that the subjects who agreed to the deposit program were much more likely to quit smoking than those who agreed to the reward program. That means that people were more willing to quit smoking to recoup their own money than to make additional money. The second demonstration of loss aversion is that so few people agreed to enroll in the deposit program.

I'm sure there are practical lessons here both for policy makers and for friends and colleagues of smokers. If I had a close friend who smoked I would suggest that he write a check to a cause or a candidate or a group that he absolutely loathes. He hands the check to me. I promise that if he quits smoking and doesn't restart in a year I tear up the check, but if he doesn't then I mail the check. I suspect if the check amount was painful enough, the success rate would be very high.

Learn more:
Healthy, Wealthy (NEJM Quick Take video)
Nudging Smokers (NEJM editorial)
Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation (NEJM article)
Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965–2011 (CDC)
Quitters, Inc. (A short story by Stephen King about a very effective program to quit smoking)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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