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Thursday, December 30, 2010

Richard Holbrooke: a terrible way to die

Veteran U.S. Diplomat Richard Holbrooke died of an aortic dissection. The man considered largely responsible for the Dayton Peace Accords, which ended the war(s) in the former Yugoslavia, had an outsized personality in a world usually replete with protocol and bureaucracy (don't let those wikileaks cables fool you).

One thing Holbrooke seldom gets credit for is the way he negotiated a settlement on the billions in dues owed by the U.S. to the United Nations when he was U.N ambassador during the Clinton Administration. Imagine having to convince 192 or so foreign governments to cut you some slack, one-by-one.

Sadly, his death was unexpected, and will leave incomplete what he probably hoped would be his biggest legacy: some type of lasting peace and stability in Afghanistan and Pakistan.

The news stories report he was meeting with Secretary of State Hillary Clinton when started to feel ill. The next thing we're told is he was rushed to George Washington Hospital (very close to the State Department in Washington) and taken to a 20+ hour operation to repair the tear in his aorta.

Over the weekend we were told he was in "critical" condition, and by Monday his obituaries ran.

Image from Wikimedia CommonsThink of the aorta as a huge muscular pipe that takes blood pumped from your heart and streams it to the rest of your body. That pipe is constructed in layers, the innermost of which is called the intima. For unknown reasons, that inner lining can sometimes tear away from the rest of the pipe, causing the blood to go haywire, clotting in the pipe, and causing there to be a significant diminution of blood going where it's supposed to go. Imagine your legs going numb. Or your arms.

The strange thing is, even though we think of the aorta as a pipe, it's well innervated (connected to our nervous systems). So the tear is exceedingly painful--classically described as chest pain that radiates through to the back.

It's a nightmare to diagnose, and as you can tell by the effort to save Holbrooke, a bloody mess to treat.

To diagnose it you first have to think of it. The test of choice is something called a CT angiogram, a specialized CT scan that looks at the blood vessels in the chest and/or abdomen. (Wait! Didn't I just read something interesting about CT scans recently? Where was it?)

If you actually make the diagnosis of a big tear like Holbrooke had, it's off to surgery. As fast as possible.

Though I wrote that we don't truly understand what causes dissections, we do know some things that increase the risk: High blood pressure. Smoking. For some reason, being male. Atherosclerosis.

John Ritter is said to have died from a dissection. Famously, Dr. Michael DeBakey, the pioneering cardiovascular surgeon, suffered a dissection at age 97. He supposedly knew what was happening to him, and his young second wife, in spite of his protests, called paramedics and got him medical attention. He managed to survive to age 99.

I can imagine the scene in the GW emergency room as Holbrooke "presented." Utter chaos. The news accounts make the hospital look clean and efficient, as though there was no trouble diagnosing this horrible condition and rushing this famous diplomat off to a heroic life-saving operation.

Sadly, neither image jibes with reality.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, 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 that inhabit them.

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Wednesday, December 29, 2010

11 health care predictions for 2011

Here are 11 things that are absolutely going to happen* in 2011 (they're in no particular order….or are they?):
1. There will be no big compromise between President Obama and the Republicans on health care reform. Why? Because the law is such a massive collection of, well, stuff, that it is pretty much impossible to find pieces of it that you could cut a deal on, even if you wanted to. And no, the federal district court decision on the individual mandate doesn't change my mind ... and in fact may breathe new life into other parts of the law). State governments, insurance companies, and private businesses have made all kinds of important and hard to reverse choices based on the law as is. There's not much of an appetite outside of people trying to score political points for making big changes.

2. No major employer will drop their health benefits. No major employer is going to outsource their health care benefits to the government any time soon. Employers, particularly the big self-insured employers that pay for health care costs as a bottom-line expense, see their benefits as an integral part of their business and competitive strategies. As Congress looks at this issue more closely, they will learn this.

3. Time that doctors spend with patients will be less in 2011 than earlier years. It's a long-term trend, and the factors that create this problem aren't getting better. The latest government data show that the average doctor visit features face to face time with the patient of 15 minutes or less. With an aging population, increasing numbers of people getting health insurance, and no influx of new doctors, this problem will keep getting worse.

4. Misdiagnosis will emerge as the hot new topic in health care quality. More and more attention is being paid to the root causes of health care quality failures. People will increasingly look to the groundbreaking work being done by doctors like Patrick Crosskerry and others. Start out with the wrong diagnosis and you're headed down a very perilous path.

5. More employers will start charging employees surcharges for being overweight, smoking, or otherwise not taking care of themselves. Among self-insured employers, who pay for a huge proportion of American health care costs, this is becoming increasingly mainstream. These employers are saying to their employees: "It's your business if you don't take good care of yourself, but it's mine to pay for the consequences of it." So employees are being told they need to pay extra for their health coverage, unless they participate in programs the employer makes available to help them quit smoking, lose weight, and manage their chronic illnesses.

6. The health insurance system will start to take on more and more of the bad aspects of the workers compensation system. If you get hurt at work, you end up in an often strange parallel health care system, where lawyers and rules and regulations may seem as important to your care as medicine. Some say that aspects of health care reform will bring that same dynamic to regular health care, and I think they have a point. If health care policymakers were more aware of how our workers compensation system works, they'd implement more of it. Look for that to start to happen.

7. A doctor will get sued by offering medical advice to a patient online. It's America, so it's bound to happen. When it does, it will make for a great media story.

8. Google or Microsoft will emerge as the leading standard for electronic medical records. One of the biggest problems with getting electronic medical records (EMRs) implemented is that there isn't any agreed-upon standard. Who has a better chance of creating an industry standard? A clever health care IT company, or a massive company in the business of creating industry standards for IT? I'm betting on the big boys.

9. State governments will start major redesigns of their health care benefits programs. States are spending enormous amounts of money on benefits packages that are far richer than anything in the private sector. There's a tremendous amount of money to be saved for state governments by modernizing their benefits programs. Look for this to start to happen in 2011.

10. "ACO" will be the hot buzzword in health care. If you don't know what an ACO is, you will. Parts of the reform law encourage providers to set up these entities, which are something like HMOs, version 2.0. Creating an ACO requires a lot of changes to the way providers operate. We'll see if they end up being successful, but they will be a hot topic.

11. Health care reform will become more popular in the polls. It can only go up.

We'll check back at the end of 2011 to see how I did.

*By "absolutely going to happen," I mean "unless I'm wrong."

This post by Evan Falchuk, JD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Is it bad patient behavior or poor doctor-patient communication?

It seem like everyone these days is focused on changing some aspect of patient health behavior. You know, getting patients to get a mammogram or PSA test, exercise more, take medications as prescribed, or simply becoming more engaged in their healthcare. If only we could change unhealthy patient health behaviors, the world would be a better place.

I agree with the sentiment, but I think that patients and their health behavior often get a "bad rap" from health care professionals. I would even go so far as to say that much (not all) of what we attribute to poor patient behavior is more correctly attributable to ineffective doctor communications with patients.

In my last post I talked about the link between strong physician advocacy, e.g., I recommend, and desirable health outcomes, i.e., patients getting more preventive screening.

Here's what I mean. Mammography studies have consistently shown that screening mammograms rates would be much high if more physicians "strongly recommended" that women get screened, e.g., "I recommend" you get a mammogram. In studies where physicians advocated for screening, mammography screening rates were always higher compared to physicians that did not advocate for them. The same phenomenon can be found in studies dealing with exercise, weight loss, colorectal cancer screening, HVP immunization, and patient participation in clinical trials.

In cases where physicians unequivocally recommended to patients that they do XYZ, patients were much more likely to do it--or at least they were much more likely to try. I am not naive enough to believe that an unequivocal recommendation from a physician is a "cure all" for the most recalcitrant patients. Factors such as level of patient trust in the physician and patient's agreement with the physician's diagnosis are mediating factors. Depression and fatigue from dealing with chronic conditions also play a role. But the evidence clearly suggests that a good many patients probably would respond positively to a strong recommendation from their physician.

Here's an anecdotal experience describe by a physician comment on my last blog post: "I agree that doctor-patient communication is critically important. My 50 year-old best friend shuns doctors, but told me he is getting a colonoscopy because his doctor strongly recommended it."

Here's the basis for my thinking. Many patients operate on the principle that if my doctor thinks something is important they will tell me. On this point patients can be quite literal. I have seen studies in which obese patients do not see themselves as "obese." Their self-perception is validated every time their doctor fails to tell the patient that they have a serious weight problem and that they need to lose 20 pounds in no uncertain terms. If I have such a big weight problems, why hasn't my doctor said anything?

Think back to your recent trips to the doctor. If you are like me, you may be hard pressed to think of a single instance in which your physicians ever said the words "I recommend" to you.

The only such instance I can recall was when my wife's oncologist (stage 4 lung cancer) said: "I recommend that you start the chemo treatment immediately--tomorrow wouldn't be too soon." My wife did what her doctor recommended and she is alive today some six years later.

REFERENCES:
Carroll, J., et al. "Clinician-Patient Communication about Physical Activity in an Underserved Population." Journal of the American Board of Family Medicine. 2008;21:118–127.

Taylor, V., et al. "Colorectal Cancer Screening Among African Americans: The Importance of Physician Recommendation." Journal National Medical Association. 2003;95:806-812.

Brown, T., et al. "Predictors of Cardiac Rehabilitation Referral in Coronary Artery Disease Patients." Journal of the American College of Cardiology. Vo. 54, 2009.

Albrecht, T., et al. "Influence of Clinical Communication on Patients' Decision." Clinical Oncology. 26:2666-2673. 2008.

This post by Steven Wilkins, MPH, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Tuesday, December 28, 2010

Going against medicine: courageous or foolish?

Every once I awhile a story catches my eye as I scan the news websites. There was one this morning on CNN with this catchy title: "Mom Defies Doctor, Has Baby Her Way." The article describes a story where a mother was going to have her fourth baby. Her previous three were born via C-section. Mom did not want another C-section done, and "defied" her doctor's order for the procedure. "You're being irresponsible," the patient was told.

The middle of the article talks about the current thinking and statement of the American College of Obstetrics and Gynecology saying that "it's reasonable to consider allowing women who've had two C-sections to try to have a vaginal delivery." Of course, there's risks with proceeding with a vaginal delivery and risks of another C-section.

What's always interesting to me are the comments following the article. I applaud the physicians who are fighting back the anti-physician sentiment and those who are pushing (no pun intended) the only home birth agenda.

In the article, this person is being held up as a hero--as someone who defied the paternalistic medical establishment and did it her way. Good for her--or is it? What if that 0.4-0.9 percent possibility of severe complication occurred and there was a problem with mom and/or the baby? What would happen then?

According to the court of public opinion, there would be always someone to blame for the bad outcome, and I'm not thinking that people would be pointing fingers at mom. They would of course, people would be blaming the doctor and the entire medical establishment for not fully explaining the risks of a choice like this. And, of course, there would be the usual lawsuits when a bad outcome happens.

My point is this: I'm all for patient empowerment, and I have written about the rise of the e-patient (empowered patient), in the past. But, in the U.S. healthcare system, there is still not enough patient responsibility that has occurred among all patients. Good outcomes are usually attributed to patient's taking initiative and bad outcomes are usually attributed to bad doctors. This frustrates me. Isn't there somewhere in the middle that both those perceptions can meet?

This post by Michael Sevilla, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Remembering Gene

Gene Goldwasser died last week. He was 88, and he was my friend.

I wrote previously about a series of conversations I conducted with Gene and Rabbi A.J. Wolf a few years ago. I met Gene one spring day after calling to invite him to sit in on a class I was teaching to a small group of medical students about social issues in health care.

I'd read about him in a book called "The $800 Million Pill," by Merrill Goozner. In the book, Goozner writes the story of Gene's two decade hunt to isolate the hormone erythropoietin (EPO).

Part of the story relates how Gene tried to interest traditional big pharma companies in his discovery, only to be brushed aside. Instead, Gene wound up sharing his discovery with what became Amgen. The company went on to make a windfall from recombinant production of the hormone and licensing it as a drug for patients with anemia and kidney failure.

A molecular model of EPO. (photo from Wikipedia)Gene never profited from his discovery, the way that scientists and inventors now clamor to patent everything in sight. He believed that his discovery should be shared with the public; after all, the government had funded his research career. He figured the taxpayers ought to get the benefit of his discovery.

Gene was old fashioned that way. He was also old fashioned in the way his interests outside of work were so protean. He was a fiend for culture, attending concerts and plays on an almost nightly basis until his health no longer permitted him to.

He told me of his great love for sailing, for travel, for reading. He even was a biographer, penning the story of his great mentor at the University of Chicago, Leon O. "Jake" Jacobson, M.D.

Gene fought prostate cancer for more than 20 years. He vastly outlived his life expectancy given the stage of the disease, and when it recurred this past summer he was grateful for the second life he'd been given.

The cancer eventually caused his kidneys to fail, and rather than decide to start undergoing dialysis treatments, Gene and his wife Deone elected hospice and comfort care to cure. He spent his final days in their beautiful apartment, literally entertaining family and friends and saying his goodbyes.

After 10 days at home, Gene drifted into a gentle coma, and died within two days, surrounded by his family.

He chose a good death.

Shortly before he died, Gene completed work on his own memoir. I can't wait to read it.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, 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 that inhabit them.

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Thursday, December 23, 2010

QD: News Every Day--About that placebo effect. . .

Placebos helped ease symptoms of irritable bowel syndrome even when patients knew that was what they were taking, a new study reports.

Researchers randomly assigned 80 patients with IBS to receive placebo pills (openly labeled as such) or no treatment over a three-week period. Patients taking placebos had significantly higher mean scores on the IBS Global Improvement Scale at 11 and 21 days, and also reported significant improvements in symptom severity and relief. The results of the study, which was funded by the National Center for Complementary and Alternative Medicine, were published online Dec. 22 by PLoS ONE.

Anthony Lembo, MD, a study coauthor, said in a press release that he didn't expect the placebo to work. "I felt awkward asking patients to literally take a placebo. But to my surprise, it seemed to work for many of them," he said.

Ted Kaptchuk, OMD, the study's lead author, told the LA Times that a larger study needs to be done to confirm the findings, and said that he didn't believe such effects would be possible "without a positive doctor-patient relationship."

ACP Internist looked at placebos' place in clinical practice in a 2009 article. (PLoS ONE, Public Library of Science, LA Times, ACP Internist)

[Editor's Note: QD--News Every Day will resume publishing on Jan. 3, 2011]

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Why morning exercise is best

It's the time of the year when dietary temptations lurk around every corner of the hospital. And since completely abstaining is not always possible, the best antidote for this holiday deluge of inflammation is obvious: Exercise.

No doubt, within the boundaries of common sense, all exercise is good. But is there a best time of day to exercise?

Tara Parker-Pope's New York Times piece suggests that the most "productive" time of day to exercise is before breakfast. In concisely reviewing a Belgian exercise physiology study, Ms. Parker-Pope points out that, in blunting the undesirable effects of a high fat and sugar diet, pre-breakast (fasting) exercise was metabolically more efficient than was exercise later in the day. That's really good news for the overweight middle-agers who consistently say: "I really don't eat very much. I must have a slow metabolism."

Scientific studies are one thing, but are they validated in the court of real life?

In the case of the superiority of morning exercise, I believe that the Belgian physiologists are spot on. Here are five supporting observations (no doubt there are more):
1. When I have achieved my best fitness--which is no longer a mystery in the era of power meters-it has always been followed by a period of consistent morning workouts.
2. Most of the strongest cyclists I know have a regular regimen of morning exercise. (At least those non-trust fund types with regular jobs.)
3. To regularly exercise in the early morning hours has its prerequisites. Primarily, that one goes to sleep at an early hour. Sleep=health!
4. Pre-breakfast exercisers are less likely to miss a workout because of life's speed bumps. Things like the three late-afternoon consults, a child's basketball game, or a forgotten early-evening dentist appointment.
5. And then there are those amazingly youthful-appearing elderly patients who, more often than not, are earlier morning exercisers and good sleepers.

It's both true and obvious that not all of life can (or should) be regimented. We're not robots, we're people. But for those who want the most metabolic bang from their exercise, both science and common sense suggest that morning exercise is best. And it feels so good, too.

Simple solutions lie right before our patients' eyes. Can we help them see it?

This post by John Mandrola, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, December 22, 2010

QD: News Every Day--Medicaid continues to stress state budgets

Governors and state budget officials are ending the year on a gloomy note, predicting that a downturn in state revenues will continue to cut Medicaid programs until overarching health care reform changes take effect in 2014.

The Fiscal Survey of States, by the National Association of State Budget Officers and the National Governors Association, outlines how the recession continues to cause declines in revenues and increased demands for services such as Medicaid and the Children's Health Insurance Program (CHIP).

In a rather staid manner for an alarming report, it begins, "After two of the most challenging years for state budgets, fiscal 2011 will present a slight improvement over fiscal 2010. However, even an improvement over one of the worst time periods in state fiscal conditions since the Great Depression states still forecast considerable fiscal stress."

Medicaid spending for fiscal 2010 is estimated at $353.8 billion, an increase of 8.2% percent over fiscal 2009, according to a previous report by the state budget officers. In fiscal 2010, Medicaid is estimated to account for 21.8% of total spending.

The recession drove Medicaid enrollment by an average of 8.5% in fiscal 2010, with states projecting Medicaid enrollment to grow by 6.1% in fiscal 2011, according to a Kaiser Commission report.

Meanwhile, states' revenues continue to lag behind the nation's economic recovery, "which itself has been slow to develop," according to the report. State revenues are forecast to remain well below their pre-recession 2008 levels, and in fiscal year, 2012 a significant amount of state funding made available by the federal economic stimulus package of 2009--$151 billion in flexible emergency funding--will no longer be available.

Medicaid spending, similar to the health care spending, is projected to increase faster than the economy as a whole. Projections over the rest of the decade are projected to rise at an average annual rate of almost 8% due to a growing aging population as well as changes made in the recent health care legislation.

To control the gap between revenue and spending, nearly every state implemented at least one new Medicaid policy to control spending in fiscal 2010 and fiscal 2011, most likely provider cuts, according to the Kaiser Commission on Medicaid and the Uninsured’s 2010 annual survey.

Finally, while the major expansions to cover the uninsured will not be taking place until Jan. 1, 2014, other changes under national health care reform are affecting health care in states more immediately, including:
--the maintenance of effort provisions for Medicaid and CHIP,
--a new option to cover childless adults in Medicaid using the regular Medicaid match,
--changes to drug rebates under the Medicaid program,
--new long-term care options for community based care, and
--the establishment of temporary high risk pools in each state until the exchanges are operational, and changes in the insurance markets in every state.

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Tuesday, December 21, 2010

QD: News Every Day--Echinacea won't cure the common cold

Annals of Internal Medicine reports today that the popular supplement Echinacea doesn't have a substantial effect on the length or severity of the common cold. Researchers in Wisconsin assigned 719 people who had early cold symptoms to receive no study drug, a pill that they knew contained Echinacea, or a pill that could be Echinacea or a placebo. Patients were asked to keep a record of their cold symptoms twice a day for about a week. Although cold duration was approximately 7 to 10 hours shorter in people who took Echinacea, the difference wasn't statistically significant, and no significant difference in severity was noted, either.

The study's lead author, Bruce Barrett, MD, PhD, told USA Today that echinacea's supporters would probably consider the findings positive but that those who oppose it for the common cold would consider the study "the nail in the coffin." The director of the study's primary funding source, the National Center for Complementary and Alternative Medicine, told USA Today that the center doesn't plan to support future similar research, since existing data make clear that Echinacea's benefit for the common cold, if any, is "very modest."

For more on herbal supplements in internal medicine practice, see this ACP Internist article from October 2009.

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Changing the business of anticoagulation

The emergence of a new generation of anticoagulants, including the direct thrombin inhibitor, dabigatran and the factor Xa inhibitor, rivaroxaban, has the potential to significantly change the business of thinning blood in the United States. For years warfarin has been the main therapeutic option for patients with health conditions such as atrial fibrillation, venous thrombosis, artificial heart valves and pulmonary embolus, which are associated with excess clotting risk that may cause adverse outcomes, including stroke and death. However, warfarin therapy is fraught with risk and liability. The drug interacts with food and many drugs and requires careful monitoring of the prothrombin time (PT) and international normalized ratio (INR).

Recently, when I applied for credentialing as solo practioner, I was asked by my medical malpractice insurer to detail my protocol for monitoring patients on anticoagulation therapy with warfarin. When I worked in group practice at the Emory Clinic in Atlanta I referred my patients to Emory's Anticoagulation Management Service (AMS), which I found to be a wonderful resource. In fact, "disease management" clinics for anticoagulation are common amongst group practices because of the significant liability issues. Protocol based therapy and dedicated management teams improve outcomes for patients on anticoagulation with warfarin.

I spoke with Dr. Donald Davis, Medical Director of the Emory Anticoagulation Management Service, who noted that the AMS was originally established as a service to promote patient safety. However, it has also proved to be lucrative for Emory Healthcare. Currently Emory's AMS has expanded to seven locations in metro Atlanta and cares for 3,400 patients. Piedmont Hospital, the Atlanta VA Medical Center and Kaiser have similar programs. Patients on blood thinners come in as often as two to three times monthly for a nurse visit and monitoring of their PT and INR. A patient of mine on chronic warfarin therapy recently shared his medical bills with me, questioning the high fees he was charged for each of his anticoagulation clinic visits. Fortunately for him, his health insurance will foot those bills.

The advantage of the newer drugs, dabigatran and rivaroxaban, is that they do not require laboratory monitoring and do not appear to interact with other drugs and foods. Dabigatran was recently approved by the FDA based on results of RE-LY, which compared it to warfarin in patients with atrial fibrillation for prevention of stroke. At a dose of 110 mg twice daily, dabigatran had similar efficacy and lower bleeding risk than warfarin. At a higher dose (150 mg twice daily) it had superior efficacy and equivalent risk of hemorrhage. For now, dabigatran's approval is limited to the prevention of stroke in patients with non-valvular atrial fibrillation. However, the RE-COVER trial compared dabigatran to warfarin in patients with venous thromboembolism. In this trial the drugs were found to have equivalent efficacy, though dabigatran was found to have a lesser risk of major bleeding. Dabigatran is currently approved for use in Europe for the prevention of venous thromboembolism in patients undergoing orthopedic surgery. It has not yet been approved for this indication in the United States.

Another blood thinner, the factor Xa inhibitor, rivaroxaban's efficacy has been demonstrated in the recently published results of the Acute DVT and Continued Treatment Study of the EINSTEIN program. In these trials, rivaroxaban therapy was compared with standard therapy for acute DVT with enoxaparin followed by a vitamin K agonist (i.e. warfarin). Rivaroxaban at an initial dose of 15 mg twice daily and then 20 mg once daily was found to have similar efficacy and risk. In the Continued Treatment Study rivaroxaban was compared with placebo and found to reduce the incidence of recurrent thrombotic events and to have an acceptable risk of bleeding. FDA approval of rivaroxaban is still pending.

There has been significant discussion about the cost of these newly developed drugs. At Publix pharmacy in Atlanta dabigatran runs $271.95 for 60 150-mg tablets. A recent study published in the Annals of Internal Medicine found the drugs are likely to be cost-effective. After reviewing my patient's bills from anticoagulation clinic I can attest to the likelihood that the drugs will be cost-effective when taking into account the lab and office visit fees required for monitoring. However their use will create a shifting of reimbursement away from medical centers (anticoagulation clinics) to the pharmaceutical industry. If insurers don't cover the full cost of these drugs consumers could bear more costs.

Health systems, such as the Veterans Administration or Emory Healthcare, that have established anticoagulation programs, may have to reorganize as the need for intense monitoring becomes obsolete. Will the need for reorganization slow the adoption of new anticoagulants onto hospital formularies? As with any new drug, the long term safety of dabigatran and rivaroxaban has not been proven. In 2006 a direct thrombin inhibitor, ximelagatran, was pulled from the market because it was found to cause liver toxicity. What occurs with anticoagulation adoption and use within the United States could prove to be an interesting example of how economic conflicts of interest drive medical decision-making.

Time will tell how the new anticoagulants compare with warfarin in terms of safety and efficacy. However, it seems likely that economics will be a factor in the way in which these drugs are adopted and used in medical practice. But, let's hope that the primary factor will be the health and quality of life of our patients.

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.

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iPhone diagnosis of Raynaud's disease

Thanks to modern technology (an iPhone) a picture is worth a thousand words in diagnosing a condition. This young woman had been exercising outside by the Golden Gate Bridge in San Francisco (the temperature was a chilly 49 degrees F) and when she finished her hand looked like this:



It felt numb and began stinging when she ran hot water on it. I was not available in the office to see her so I asked her to send me a photo from her iPhone and this is what I saw.

What is seen is classic Raynaud's disease. It is a condition that causes some areas of the body like the fingers, toes, tips of nose and ears to have limited blood circulation in response to cold temperatures. It affects women more than men and the skin can turn blue or white or purple in blotchy areas. It is common to feel swelling and stinging as the circulation improves (such as immersing in hot water). An attack can last several minutes to hours.

With Raynaud's, there is a vasospasm of the small blood vessels that go to the digits. This limits blood supply which causes the skin to turn pale. Cold temperatures are most likely to trigger an attack but emotional stress can also cause it. We think it is an inherited disorder.

Most of the time, Raynaud's does not require treatment. Patients learn to avoid sudden cold (like refrigerators) and to wear gloves when it is cold outside. If the attacks are frequent or severe, medications that dilate the blood vessels can be prescribed. These are medications like nifedipine, amlodipine and felodipine.

The iPhone photo saved her from a visit to the emergency department (by when it is likely the vasoconstriction would have already resolved).

This is a form of "telemedicine."

This post originally appeared at Everything Health. Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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Monday, December 20, 2010

QD: News Every Day--Speaking fee bans are being bypassed

It takes a long time to change the culture of medicine, and that applies not only to novel treatment paradigms, but also to prohibitions on speaking fees. Although many institutions have adopted stringent restrictions on their academic physicians accepting pharmaceutical speaking fees, many continue to do so, according to the investigative reporters at ProPublica.

ProPublica, a non-profit organization dedicated entirely to investigative journalism, compared faculty members at a dozen medical schools and teaching hospitals to its database of seven drug companies that publicly report speaking fees. While academic medical centers prohibit their physicians from taking pharma dollars for speaking fees, "permissive interpretations" of the policies and relying on self-reports of speaking engagements mean that doctors still take the money, sometimes hundreds of thousands of dollars.

"Because the majority of the more than 70 drug companies in the United States don’t report such payments, the review provides only a glimpse of possible lapses at schools," the reporters wrote.

In case you missed it ...
Low pay, long hours and concerns that government isn't reimbursing services enough is driving doctors to consider new careers, but in this case, it's not the American primary care physician, worried about the doc fix and considering leaving the Medicare system. It's Czech doctors this time around, and they're threatening to emigrate if the government doesn't pay them more. One gastroenterologist with 10 years under his stethoscope works 80-hour weeks and makes only enough rent a modest apartment and buy food. Physicians have taken to protesting by riding around town in a specially marked-up ambulance--its front reads "Pay doctors more than a street sweeper. Keep us here!" and its back reads: "Thank you, we're leaving." (NPR)

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Taking chocolate to heart

It's beginning to look like chocolate, especially dark chocolate, really and truly is a heart healthy snack, though only if it's consumed in small quantities.

organic dark chocolate by Fiona Wilkinson via FlickrA delectable taste of this news came last spring in the form of a study by German scientists which appeared in the European Heart Journal. It was a retrospective study of nearly 20,000 people, and it showed that folks in the highest quartile for chocolate consumption (meaning they consumed 7.5 grams of chocolate per day--the equivalent of 2 to 3 small squares of a Hershey bar), had lower blood pressure, a 27% lower risk of heart attack, and a 48% lower risk of stroke than those in the lowest quartile (about 1.7 grams per day).

Now, a new study in the journal Cardiovascular Pharmacology has lent credence to those findings by suggesting a mechanism through which chocolate reduces blood pressure. In the study, Ingrid Persson and colleagues at Linkoping University showed that dark chocolate inhibits the activity of the angiotensin-converting enzyme (ACE). This enzyme helps regulate fluids and salt metabolism in the body. It is the target of many well-known antihypertensive drugs including captopril, lisinopril and enalopril.

To reach these conclusions, Persson's team somehow managed to recruit 16 volunteers who were between the ages of 20 and 45, and convinced them to eat 75 grams (about 2 1/2 ounces) of dark chocolate which had a cocoa content of 72%. The team measured ACE activity in the subjects' blood before they consumed the treat, and again 30 minutes, one hour, and three hours later.

The scientists found that three hours after the intreprid volunteers consumed the chocolate, ACE activity was 18 percent lower than the baseline established before they had the treat. That's about the same level of ACE inhibition generated by those prescription drugs!

"I was surprised by the great effect," Persson told MyHealthNewsDaily.

One caveat here as we approach the holidays and the overwhelming urge to overeat that they generate in most of us. The benefits of chocolate are achieved after consuming small amounts of chocolate--we're talking about 100 calories worth. No further benefits accrue to those who gobble down more than that, and of course those calories add up quickly. In no way do these studies suggest that consuming large quantities of chocolate is healthy, and certainly chocolate should not be substituted for other healthy foods like fruits, veggies and whole grains. Efforts to maintain a healthy body weight are still of paramount importance. And exercise is, too.

Still, with chocolate, it's looking more and more like a little bit, consumed on a regular basis, can go a long way toward improving heart health. Make mine Lindt!

This post by Glenn Laffel, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Friday, December 17, 2010

Integrative medicine as the butt of a hoax

In 1996, Alan Sokal got a bogus paper published in the journal Social Text. It was a parody full of meaningless statements in the jargon of postmodern philosophy and cultural studies. The editors couldn't tell the difference between Sokal's nonsense and the usual articles they publish.

Now a British professor of medical education, Dr. John McLachlan, has perpetrated a similar hoax on supporters of so-called "integrative" medicine. He reports his prank in an article in the British Medical Journal (BMJ).

After receiving an invitation to submit papers to an International Conference on Integrative Medicine, he invented a ridiculous story about a new form of reflexology and acupuncture with points represented by a homunculus map on the buttocks. He claimed to have done studies showing that:

responses are stronger and of more therapeutic value than those of auricular or conventional reflexology. In some cases, the map can be used for diagnostic purposes.

The organizers asked him to submit an abstract. He did. In the abstract he said he would present only case histories, testimonies, and positive outcomes, since his methods did not lend themselves to randomized controlled trials; and he suggested that his "novel paradigm" might lead to automatic rejection by closed minds.

He received this answer:

We are happy to inform you that the Scientific Committee has reached it's [sic] decision and that your paper has been accepted and you will be able to present your lecture.

He comments that:

this particular hoax parodied the absurdity and credulity of so called integrative medicine. I do not believe that rational medicine could have been fooled with something so intrinsically ridiculous as in this case. Minimum standards of common sense should, I think, have led to a polite but firm rejection--or at least further inquiry. Alternative medicine is not noted for rigorous inquiry, for research designed to prove the null hypothesis, but rather accepts notions on face value.

We have frequently made the same points here on ScienceBasedMedicine.com, but never in such a vivid and amusing fashion. Kudos to Dr. McLachlan! The beginning words of his article say it all, better than I could:

So called integrative medicine should not be used as a way of smuggling alternative practices into rational medicine by way of lowered standards of critical thinking. Failure to detect an obvious hoax is not an encouraging sign.

This post by Harriet Hall, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--When mediating malpractice, include the doctor, study suggests

While mediation to resolve medical malpractice lawsuits offers many benefits, physicians need to be directly included in talks, but never are.

Mediation has the potential to reduce the costs of litigation, offer closure to plaintiffs and change procedures in hospitals to prevent further errors. The study, published in the Journal of Health, Politics, Policy and Law, looked at 31 cases from 11 nonprofit hospitals in New York City in 2006 and 2007 that went to mediation. About 70% of the cases settled for amounts from $35,000 to $1.7 million.

Mediation offers several advantages:
--The outcome is under the parties' control;
--Plaintiffs can receive payment sooner;
--Defendants do not have to pay outside lawyers to try the case;
--Members of the medical staff do not have to prepare for discovery and a trial; and
--Unsuccessful mediation may still create enough momentum to lead to a settlement.

But major challenges exist. In none of the cases studied did a doctor take part in the mediation. The study authors wrote, "[I]t is possible that plaintiffs would have been even more satisfied with the process had their physicians demonstrated respect and caring" by attending the mediation.

Defense lawyers often cited the doctors' work schedules to explain their absence. Others did not want to subject the doctors to being verbally attacked by the plaintiff. This "deprives them and their patients of the opportunity for healing, understanding, forgiveness, and repair of broken relationships and failed communication," the study concluded.

The authors cited research that found patients expect an apology after a medical error, and that most doctors want to oblige, but won't for fear of legal liability. However, mediation talks are confidential and inadmissible in court.

"Anecdotes abound of injured patients and their family members who have continued to seek care from--and even recommended to their friends--hospitals that apologize for medical errors and adverse events," according to the study.

The absence of doctors in mediation also limits the ability, the authors write, for doctors and hospitals to learn from the medical errors and improve the quality of care.

"Change will require medical leaders, hospital administrators, and malpractice insurers to temper their suspicion of the tort system sufficiently to approach medical errors and adverse events as learning opportunities, and to retain lawyers who embrace mediation as an opportunity to solve problems, show compassion, and improve care," the authors wrote.

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Thursday, December 16, 2010

QD: News Every Day--Six large systems seek best practices for common conditions

Six of the nation's leading health care systems will collaborate on outcomes, quality, and costs across eight common condition or procedures in an effort to share best practices and reduce costs with the entire health care system.

Cleveland Clinic, Dartmouth-Hitchcock, Denver Health, Geisinger Health System, Intermountain Healthcare and Mayo Clinic will to share data among their 10 million patients with The Dartmouth Institute, which will analyze the data and report back to the collaborative and the rest of the country, according to a press release.

The collaborative will focus on eight conditions and treatments for which costs have been increasing rapidly and for which there are wide variations in quality and outcomes across the country. The first three conditions to be studies are knee replacement, diabetes and heart failure. They will be followed by asthma, weight loss surgery, labor and delivery, spine surgery and depression.

Health care hiring
Health care hiring is seeing an uptick, especially among experienced staff and some novel fields, reports the Los Angeles Times. While it's not gangbusters growth--health care job growth has stayed below 2% through 2009 and 2010--the need for electronic health records is driving hiring for data analysts and performance improvement analysts. Experienced nurses are in demand, but not new graduates, and among operations staff as well.

'Doc fix' enacted
As expected President Obama signed Wednesday night the Medicare and Medicaid Extenders Act of 2010 that extends Medicare payments to physicians, while Congress takes up the idea of a permanent solution to how doctors get paid.

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Wednesday, December 15, 2010

QD: News Every Day--Political challenges to health care reform play out in the courts

The Obama administration will appeal the decision of the one judge who has so far ruled the mandate that individuals buy health insurance is unconstitutional, while the administrations opponents mull their own challenges to court cases they've lost.

With other district court judges having ruled the mandate is constitutional and other cases still being heard, the case is expected to reach the Supreme Court.

The legal challenges are really political ones playing out in the courts, according to pediatrician Dr. Aaron Carroll, who reminds his readers that in the 1990s, Republicans proposed a health care reform package that included an individual mandate. Massachusetts' health reform law, signed by a Republican governor who ran for president, also includes an individual mandate. As recently as a year ago, Republican Sen. Charles Grassley, then the ranking member of the Finance Committee, wrote an editorial that the mandate was possible with bipartisan support before his conservative Iowa constituents told him otherwise. (Wall Street Journal, Business Week, CNN, Politico, TIME)

That's not to imply all physicians share the same views on the matter. One in particular, U.S. Rep. Michael Burgess, a Republican physician from Texas, wants to vote for repeal when his party takes control of the House in January.

In case you missed it ...
Isabel V. Hoverman, MACP, will serve as chair of the Joint Commission's Board of Commissioners. She has served on the Joint Commission's board since 2003, and has served as an ACP regent. She's in private practice in Austin, Texas. Roger W. Bush, FACP, will serve on the Board as a representative of the American College of Physicians, and as an ex-officio member, Mark R. Chassin, FACP, serves on the board ex officio in his capacity as president of The Joint Commission.

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Tuesday, December 14, 2010

QD: News Every Day--CTs reassure patients, who may not know its risks

Emergency patients with acute abdominal pain feel more confident about medical diagnoses when a doctor has ordered a computed tomography (CT) scan, and nearly three-quarters of patients underestimate the radiation risk posed by this test, reports the Annals of Emergency Medicine.

"Patients with abdominal pain are four times more confident in an exam that includes imaging than in an exam that has no testing," said the paper's lead author. "Most of the patients in our study had little understanding of the amount of radiation delivered by one CT scan, never mind several over the course of a lifetime. Many of the patients did not recall earlier CT scans, even though they were listed in electronic medical records."

Researchers surveyed 1,168 patients with non-traumatic abdominal pain. Confidence in medical evaluations with increasing levels of laboratory testing and imaging was rated on a 100-point scale. Then, to assess cancer risk knowledge, participants rated their agreement with these factual statements: "Approximately two to three abdominal CTs give the same radiation exposure as experienced by Hiroshima survivors," and "Two to three abdominal CTs over a person's lifetime can increase cancer risk."

Median confidence in a medical evaluation without ancillary testing was 20 (95% confidence interval [CI], 16 to 25) compared with 90 (95% CI, 88 to 91) when laboratory testing and CT were included. About 75% of patients underestimated the amount of radiation delivered by a CT scan (assessed by comparing it to chest radiography) and cancer risk comprehension was poor. Median agreement with the Hiroshima statement was 13 (95% CI, 10 to 16) and with the increased lifetime cancer risk statement was 45 (95% CI, 40 to 45).

Further, only 3% of patients understood that CT scans increased a person's lifetime risk of cancer. Some estimates hold that 1.5-2% of all cancers in the U.S. may be attributable to the radiation from CT exams.

"Physicians use abdomen-pelvis CT scans because they have been demonstrated to increase certainty of diagnosis, decrease the need for emergency surgery, and avert up to a quarter of hospital admissions," said the study author. "At the same time, there is growing concern about the long-term consequences of CT scans, particularly in patients who receive many of these scans over the course of their lifetime."

And, they don't report that they've gotten previous CT scans. Of 365 patients who reported no previous CT, 142 (39%) had one documented in their electronic medical record.

There's plenty of circumstances in health care when testing is warranted, or even when unneeded tests can't be avoided. Consider this scenario involving a patient who transferred to a second hospital, and since the two facilities didn't use a common electronic medical record, the doctor had to order a duplicate X-ray for the work-up.

But scans aren't always a benefit. Use of CT scans has grown 16% over the years. Archives of Internal Medicine offers an short and excellent read on the subject in its "Less is More" section. The authors wrote, "Often, diagnostic tests are ordered without questioning how the result will or should change patient treatment. Instead, tests are ordered to 'reassure,' 'just to be sure,' 'just in case,' or 'just to know.'"

And then, one test result requires another, and another, or leads to an invasive test that resulted from a false positive. All this before the physician sees the patient.

"[T]here are safer ways to reassure patients," the authors wrote. "Physicians are (still) highly respected professionals, and patients value our advice. Talking with our patients should be our first choice for reassurance; tests should be reserved for cases in which the benefits can be reasonably expected to outweigh the risks."

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CT this

How and when do new medical technologies become the "standard of care?" A recent study showed that the use of CT scans in hospital emergency departments rose 16% between 1995 and 2007.

The only thing that surprises me about this is that it's not more. Way more.

I remember the first time I actually ordered a CT scan on a patient all by myself, in 1997. I remember signing the order in the patient's hospital chart, and feeling with some trepidation that I had just moved from the sidelines of the medical world into the main arena--the one floored and wallpapered with health care dollars.

Back then, quaint as it seems, we used to really deliberate about ordering tests like CT scans. They were deemed expensive and inconvenient, and in the [paradoxically-named] internist's armamentarium, it was a sort of Holy Grail of diagnostics--it lets us see your insides. [Quaint, too, in light of all the hoopla about airport body scanners.]

One of the faculty doctors who trained me had the following shtick that has stuck with me:

"Know what the most expensive thing is in health care?" he would mischievously ask.

MRIs?

Open heart surgery?

ICU care for moribund elders?

"The doctor's pen," was the answer, whereupon he'd pull out a Mont Blanc fountain pen and flash it around with panache.

The implication of future wealth coupled with fiduciary-medical responsibility was unmistakable.

Somewhere along the way, our collective reticence at using such "big guns" like CT scans and MRIs have fallen by the wayside. As the technologies have become faster, better, and more detailed, they have become altogether more commonplace, such that they are darn near routine.

In the ER with a headache? You're likely to get a CT scan. Abdominal pain? Belly CT, you betcha! [I don't mean to pick on the ER. Come to my office and there's a good likelihood the same fate awaits.]

Partly it's the legitimate fear of missing something, of being a bad doctor, and of course fear the fear of a lawsuit. It's also partly because patients have come to expect imaging tests because they've read about them, seen them on television, had their loved ones go through them. Heck, you can even get your own screening CT scan with no doctor's order necessary. [Please note the preceding link is just for illustrative purposes, and in no way an endorsement. In fact, I think screening CTs are overall a bad idea. So there. Fodder for a future post...]

Well, we're through the looking glass now. When everybody gets exposed to the amounts of radiation in a CT scan, bad side effects start getting reported. [These horror stories mostly occurred in the setting of improper use and repeated CT scans, mind you.]

I guess my point is, before asking for/being asked to get a CT scan, ask your doctor to really think through the need for the test "like they did in the old days."

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, 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 that inhabit them.

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Monday, December 13, 2010

QD: News Every Day--Health reform continues despite one judge's decision

A federal judge in Virginia has ruled that health care reform is unconstitutional and expects the Obama administration to honor that ruling while it's being appealed. But states and private companies are continuing to plan and budget for it nonetheless.

The court ruled that Congress exceeded its constitutional powers in compelling Americans to buy health insurance. Judges elsewhere have ruled the law is valid or dismissed the cases on procedural grounds, while a judge in Florida will hear another case later this week.

In the meantime, though, employers and health-care companies have to continue adjusting to the reform law's many provisions. States will continue to set up their health insurance exchanges, and they've already budgeted for the additional 16 million people who will qualify for Medicaid under the law. And the Obama administration is unlikely to stop what it's doing, since many of the provisions won't take effect until 2014.

A key of the lawsuit is "economic inactivity." The ruling says that while Congress can regulate interstate commerce, it can't regulate ... well, non-commerce, in this case the decision not to buy health insurance. The judge's decision is online. (Politico, Wall Street Journal, Associated Press, MSNBC)

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"Photograph 51," explores the life of Rosalind Franklin

Recently I snagged a last-minute ticket to see Photograph 51, a new play about the work and life of Rosalind Franklin. Her data, possibly stolen, enabled Francis Crick and James Watson to decipher and model the double-helix structure of DNA.

The intimate production, enacted by the small Ensemble Studio Theatre on the second floor of a nondescript building on West 52nd Street, affords a fresh look, albeit partly fictionalized, into important moments in the history of science. Most of the scenes take place in a research lab in post-war London, at King's College, where Franklin took on a faculty appointment.

Franklin's story starts like this: She was born in 1920 to a Jewish family in London. She excelled in math and science. She studied physical chemistry at Cambridge, where she received her undergraduate degree in 1941. After performing research in photochemistry in the following year on scholarship, she joined the British Coal Utilisation Research Association and carried out basic investigations on the micro-structure of coal and carbon compounds, and so earned a Ph.D. from Cambridge University. She was a polyglot, and next found herself in Paris at the Laboratoire Central des Services Chimique de l'Etat, where she picked up some fine skills in X-ray crystallography.

You get the picture. She was smart, well-educated and totally immersed in physical chemistry before, during and after WWII. Single-minded and focused, you might say.

Franklin in Photograph 51 wears a simple brown dress with large black buttons straight down the middle of her lithe frame. Her lipstick and haircut seem right, but her three inch heels, even after a few years of experiencing the joie de vivre in Paris, or just being holed up in a research institute there, seem a tad too high for such a pragmatic soul. The lab set is perfect with its double-distilling glassware, wooden pegs on racks, tall metal stools with small, flat circular seats, light microscopes, heavy metal desks with file drawers and a contentious cast of characters.

As this narrative goes, Franklin spurns socializing with most of her colleagues. They find her difficult. She spends nearly all of her time and late hours using X-rays to generate crystallographic images of DNA and making detailed notes and related calculations. Eventually a lab assistant gives her key data, Photograph 51, to her colleague, Maurice Wilkins, who is inexpert in crystallography and cannot independently interpret the structure. While Franklin continues working at a measured pace, refusing to rush into publishing a model until she's sure of her findings and the implications, Wilkins shares the image with Watson and Crick. They move quickly, publish first in Nature and, later, win the Nobel Prize for the discovery. Meanwhile Franklin leaves Wilkins' lab and starts a new project on the structure of tobacco mosaic virus. She dies at the age of 37 of ovarian cancer, likely caused or effectuated by the radiation to which she exposed herself at work.

It's a sad story, but instructive, engaging and very well-done, so much that it's haunted me for days. Hard to know what's real.

According to a program note from Anna Ziegler, the playwright: "This play is a work of fiction, though it is based on the story of the race to the double helix in England in the years between 1951 and 1953." Ziegler refers to several books from which she drew material: The Dark Lady of DNA (by Brenda Maddox), The Double Helix (by James Watson) and The Third Man of the Double Helix (by Maurice Wilkins).

My favorite part is Franklin's statement at the beginning: "We made the visible, visible."

For a counterpoint to this play's version of events, you can take a look at Nobel Laureate James Watson's 2007 TED lecture on YouTube. "She was a crystallographer," he says of Franklin, and other things, before delving into his late-life happiness and current ventures in cancer genetics and autism studies.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She 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.

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Friday, December 10, 2010

QD: News Every Day--Medicare projects tie financial incentives to quality care

Results from three health care demonstrations for small or solo offices, large physician practices and hospitals demonstrate that offering providers financial incentives for improving patient care increases quality of care and can reduce the growth in Medicare expenditures.

The Centers for Medicare & Medicaid Services (CMS) outlined results from its demonstration models.

Overall, demonstrations give CMS the opportunity to work closely with providers to improve quality and efficiency, and their results and lessons help shape Medicare policies.

Small practices earn incentives
More than 500 small and solo physician practices are being rewarded for performance on 26 quality measures through the Medicare Care Management Performance (MCMP) Demonstration, which is in its second year. CMS is awarding approximately $9.5 million in incentive payments to promote the use of health information technology for chronic conditions among practices in California, Arkansas, Massachusetts and Utah. The average payment per practice is $18,100, but some practices earned as much as $62,500.

Doctors in small to medium sized practices who meet clinical performance standards on each measure are eligible to receive financial rewards under the MCMP Demonstration. The demonstration also provides an additional bonus to practices that report the data using an electronic health record (EHR) certified by the Certification Commission for Health Information Technology. Twenty-six percent of practices were able to submit at least some of the measures from a certified EHR.

Large physician groups create savings
Under the Physician Group Practice (PGP) Demonstration, physician groups earn incentive payments based on the quality of care they provide and the estimated savings they generate in Medicare expenditures for the patient population they serve.

Ten physician practices participating in the PGP Demonstration achieved benchmark performance on at least 29 of the 32 measures reported in year four of the demonstration. Three groups, Geisinger Clinic in Danville, Penn., Marshfield Clinic in Marshfield, Wis., and Park Nicollet Health Services in St. Louis Park, Minn., achieved benchmark performance on all 32 performance measures.

All 10 physician groups achieved benchmark performance on the 10 heart failure and 7 coronary artery measures. Over the first four years of the demonstration, the physician groups increased their quality scores an average of 10% on 10 diabetes measures, 13% on the seven heart failure measures, 6% on the seven coronary artery disease measures, 9% on two cancer screening measures, and 3% on three hypertension measures.

Five physician groups will receive performance payments totaling $31.7 million as part of their share of $38.7 million of savings generated for the Medicare Trust Funds in the demonstration's fourth year.

CMS is moving the physician groups into the shared savings program established in health care reform.

Hospitals continue to improve
The Hospital Quality Incentive Demonstration (HQID) began in 2003 with hospitals in 38 states to test whether paying hospitals for performance on an array of quality metrics would shift the performance upward across the group.

The hospitals participating in the demonstration improved performance across the board. CMS is awarding incentive payments totaling $12 million in the project's fifth year to 212 hospitals for top performance, top improvements and overall attainment in the six clinical areas. Through the first five years, CMS awarded more than $48 million to top performers. After the initial 3 years of the demonstration, CMS extended the project for three additional years to test new incentive models and ways to improve patient care.

An independent evaluation suggests that the demonstration contributed to quality increases. However, quality also increased substantially for similar hospitals that were not participating in the demonstration but had reported quality information on Hospital Compare. Only 10% to 17% of the increase in quality for hospitals that did participate in the demonstration can be attributed to the pay for performance incentives. Participants that received incentive payments raised their quality score by an average of 18.3% over 5 years. Even the participating hospitals that did not meet their benchmarks and did not receive incentive payments improved their average quality score by 18%.

Hospitals were measured and scored based on their performance on more than 30 standardized and widely accepted care measures for patients in six clinical areas: heart attack, coronary bypass graft, heart failure, pneumonia, hip and knee replacements, and the Surgical Care Improvement Project.

The HQID is sponsored by Medicare in partnership with Premier Healthcare Alliance, a national health care performance improvement organization.

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Thursday, December 9, 2010

QD: News Every Day--Year-long 'doc fix' likely to pass this week

UPDATE: The year-long doc fix, which cleared the Senate by unanimous consent, has been also passed by the House, and will move to the President for signature. He had already said he'll sign the legislation. But Medicare's reimbursement system was flawed the day it became law. Is a year long enough to find a solution? (Los Angeles Times, WhiteHouse.gov)

In case you missed it ...
Female doctors are increasingly going into colon and rectal surgery as a career. 31% of colon and rectal surgeons under 35 years of age were women in 2007, compared to 12% of those ages 45 to 54 and 3% of those ages 55 to 64. The specialty is attractive to women because it's growing, and colonoscopies are scheduled events that give them ample control over their day, reports the Wall Street Journal's work-life columnists. One woman's story supports this: gastroenterologist Carol Semrad, MD, who graduated from medical school in 1982. She told Northwestern University's Medill Reports, "In medical school I liked internal medicine. I thought it was mentally the most challenging and comprehensive study of disease. If you knew the pathophysiology of how disease presents, anything else like surgery, was more mechanical. I was more interested in primary-disease processes." (Wall Street Journal, Medill Reports)

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Changing patient behavior with two power words

"I recommend." These are two word which, when spoken by a physician to a patient have tremendous power to change behavior. That assumes of course a trusting relationship between patient and physician (but that's a topic for another day.)

Take the colonoscopy. The U.S. Preventive Services Task Force (USPSTF) recommends that adults aged older than 50 years get a colonoscopy every 10 years. In 2005, 50% of adults aged more than 50 years in the U.S. had been screened according to these recommendations. Not surprisingly, the rate of colonoscopy screening is much lower than that of other recommended adult preventive services. I was curious: Why?

Here are two interesting facts:
1. Studies show that patients cite "physician recommendation" as the most important motivator of colorectal screening. In one study, 75% to 90% of patients who had not had a colonoscopy said that their doctor's recommendation would motivate them to undergo screening.
2. In that same study, in 50% of patients where a colonoscopy was appropriate but not done, the reason given was that the physician simply did not "bring up" the subject during the visit. Reasons included lack of time, visit was for acute problem, patient had previously declined or forget.

What the doctor says makes a difference
Turns out that the highest colonoscopy screening rates were highest among physicians who were more adamant about the need for screening. These doctors framed the recommendation (message) to the patient as coming from them self, e.g., "I recommend" or "we recommend." Doctors who framed the recommendation as coming from someone else, e.g., "they recommend" or "organization X recommends" had lower screening rates.

The following table provides examples of the different ways that physicians in this study framed their recommendation to patients for colorectal cancer screening:


A word of clarification

In these days of patient-centered care and shared decision-making, some may question the use of physician-centric directives like "I recommended." For one thing, a strong physician recommendation is what some patients want. For patients who want more than just the physician's recommendation, the physician can provide them with information to help them make their own informed decision about getting a colonoscopy.

I recommend that you give this approach a try!

Resources:
Levy, B., et al. "Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study." Journal of the American Board of Family Medicine. 2007;20:458–468.

Guerra, C., et al. "Barriers of and Facilitators to Physician Recommendation of Colorectal Cancer Screening." Journal of General Internal Medicine. 2007; 22(12):1681–8.

This post by Steven Wilkins, MPH , appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, December 8, 2010

How often should bone density testing be done?

How often should bone density testing be done? Not as often as you think, even though Medicare may be willing to pay for it every two years. Via Science Daily:
"Now a new study led by Margaret L. Gourlay, MD, MPH of the University of North Carolina at Chapel Hill School of Medicine finds that women aged 67 years and older with normal bone mineral density scores may not need screening again for 10 years.

"If a woman's bone density at age 67 is very good, then she doesn't need to be re-screened in two years or three years, because we're not likely to see much change," Gourlay said. "Our study found it would take about 16 years for 10% of women in the highest bone density ranges to develop osteoporosis. That was longer than we expected, and it's great news for this group of women," Gourlay said.

The researchers suggest that for T scores greater than -1.5, repeat testing needn't be done for 10 years. Women with T scores between -1.5 and -2.0 can be re-screened in 5 years, and those with T scores below -2.0 can have every other year testing as is done now.

To be honest, I've been spacing out bone density testing in woman with good baseline scores for some time, but not knowing how long I can go. This is great information for me and for my patients.

This post by Peggy Polaneczky, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--Physician pay pits Medicare's funding against health care reform

The Senate formally introduced a year-long "doc fix" Tuesday night, giving them a year to find a permanent solution to fixing the way Medicare pays physicians.

Modern Physician reported that the measure will extend current Medicare payments for all of 2011. It will cost nearly $15 billion over the next 10 years. The costs would be offset by changing how beneficiaries of a health care tax credit might pay back their benefit if they earn more than expected, such as if they found employment in the course of a year. As the Associated Press points out, much of health care reform was funded by changing Medicare. Now, Medicare is drawing back funding by changing provisions in health care reform.

Although physicians have threatened to stop treating Medicare beneficiaries if Medicare rates were to be cut, as National Public Radio reports, to date Medicare patients have less trouble finding physicians and scheduling appointments than privately insured people, according to a new Medicare Payment Advisory Commission (MedPAC) survey.

The survey was part of a report to MedPAC commissioners that assessed beneficiary access to physician services, ambulatory care quality, private insurer rates compared to Medicare rates and volume growth. The analysis also examined how costs are likely to change in 2012 and discussed a payment update recommendation. Although it drew from resources and reports between 2007 and 2009 (and before Congress underwent five different "doc fix" votes this year alone, some of them retroactively) it acknowledges that this year's temporary patches frustrated doctors. While health care reform offers incentives for primary care, "more levers should be explored," the report said.

MedPAC polled Medicare beneficiaries and privately insured people 50 to 64. According to the results, Medicare beneficiaries are less likely than privately insured ones (ages 50-64) to report delays in getting appointments. 75% of Medicare beneficiaries reported "never" having delays, compared to 72% of privately insured. 83% reported never experiencing a delay getting an appointment for an illness or injury, compared to 72% of privately insured.

Also, Medicare beneficiaries were less likely to report problems finding a new primary care physician. It was "no problem for 79% of Medicare patients and 69% of the privately insured, and a "big problem" for 12% of Medicare patients and 19% of the privately insured.

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Tuesday, December 7, 2010

QD: News Every Day--Repeal the whole but keep each part

Americans want to repeal health care reform but keep its individual provisions, reports a survey. The schizophrenic divide might be explained by a lack of understanding of the law's specifics, or the overarching fears that the law will cost more or result in less health care.

Among other findings:
--40% of adults wanting to repeal health care reform
--31% want to keep it, and
--29% are undecided.

When delving into the reasons why:
-- 81% believe it will raise taxes,
--77% believe that it will reduce the quality of care, and
--74% believe that it will ration health care.

But, respondent also like the individual provisions of health care reform. Nearly two-thirds of respondents like preventing insurers from denying coverage for pre-existing conditions, 60% want to keep tax credits for small businesses that provide health insurance to employees, and more than half want to allow children to remain on their parents insurance until they are 26.

The poll by market researchers Harris Interactive and news syndicate HealthDay surveyed 2,019 adults online just before Thanksgiving. The complete findings are online.

The conflicting views will give Republicans plenty of ammunition when they take over the U.S. House in January. Different tactics are being trotted out for how Republicans will approach health care reform, including holding the doc fix over legislator's heads, touting state's rights to defund health reform, and calling for outright insurrection.

One method being mulled is to fund the 'doc fix' by defunding health reform. It would cost $19 billion to fund Medicare reimbursement rates for one year, the time period being considered that would allow Congress time to create a permanent solution to how Medicare reimburses physicians. It also gives Republicans a dollar amount to offset from funds dedicated to health care reform, such as the Prevention and Public Health Fund, which sets aside $15 billion over 10 years for bike paths and farmers markets. One physician and clinic chief said, "Ideally, this is not a political party issue; it's a quality and fiscal issue,” and suggested that Medicare Part B is a likely target for budget offsets. [Note: Since this story was first published, Senate leaders have proposed a one-year doc fix and intend to introduce it to the rest of the Senate for consideration. While few details are available, costs would be offset by changing how much money health care subsidy recipients would have to re-pay if their eligibility changes in the middle of a tax year. Democrats may agree to this before control of the U.S. House converts to Republican leadership.]

Meanwhile, a Republican plans to introduce legislation that would allow state officials to challenge proposed federal regulations during their open comment periods. Sen. Roger Wicker said the bill is a reaction to health care reform. States could file constitutional legal challenges requiring the responsible federal agency to certify that a regulation doesn't violate the 10th Amendment (powers not granted to the federal government are retained by the states) and then post that certification on that agency's website.

But for U.S. Representative Michele Bachmann, only complete repeal is acceptable. The incoming House Majority Leader, Eric Cantor, agrees, although the incoming Speaker of the House, John Boehner, didn't commit to the issue. (HealthDay, Politico, Modern Healthcare, The Hill, Cybercast News Service)

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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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