Comments on: Should We COMMIT To This? http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/ A blog from inside the emergency department Wed, 08 Feb 2012 14:07:09 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Rogue Medic http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3327 Rogue Medic Sun, 01 Jun 2008 17:31:31 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3327 The motivation to participate in a study is not something that would easily fit into a comment. I am not the person to write that, anyway. The patients were receiving the other standard treatments for heart attacks based on their presentation. On the other hand, why do we assume that the standard treatment is beneficial to patients? So much of the ACLS treatments are in the algorithms because, in the 1980s, some experts in 1980s medicine felt that these were the best treatments available and would lead to the best outcomes. The more we learn through research, the more we realize that a lot of these recommendations were not good for the patients. Is there any good reason to suppose that the standard treatment is better than placebo? If a study is done well, we should find out. If not, then your guess is as good as mine. The motivation to participate in a study is not something that would easily fit into a comment. I am not the person to write that, anyway. The patients were receiving the other standard treatments for heart attacks based on their presentation.

On the other hand, why do we assume that the standard treatment is beneficial to patients?

So much of the ACLS treatments are in the algorithms because, in the 1980s, some experts in 1980s medicine felt that these were the best treatments available and would lead to the best outcomes. The more we learn through research, the more we realize that a lot of these recommendations were not good for the patients.

Is there any good reason to suppose that the standard treatment is better than placebo? If a study is done well, we should find out. If not, then your guess is as good as mine.

]]> By: Angela http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3326 Angela Fri, 30 May 2008 04:08:19 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3326 How did the researchers convince patients to actually enroll in this study? I can't imagine that such a high number actually agreed to possibly receiving a placebo for treatment of an acute MI. Did they promise them Starbucks gift-cards? How did the researchers convince patients to actually enroll in this study? I can’t imagine that such a high number actually agreed to possibly receiving a placebo for treatment of an acute MI. Did they promise them Starbucks gift-cards?

]]> By: Dr. Greenbbs http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3325 Dr. Greenbbs Thu, 29 May 2008 23:40:33 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3325 I never give b-blocker to IWMI patients...usually the right sided component is too prohibitive for me to do so. Last night I had a guy with an anginal equivalent (new onset SOB) who had SBP of like 180...definitely benefited from the b-blocker and ntg. Just goes to show you....when non-doctors and the government get in the business of medicine, things just go to hell. I never give b-blocker to IWMI patients…usually the right sided component is too prohibitive for me to do so.

Last night I had a guy with an anginal equivalent (new onset SOB) who had SBP of like 180…definitely benefited from the b-blocker and ntg.

Just goes to show you….when non-doctors and the government get in the business of medicine, things just go to hell.

]]> By: TK http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3324 TK Thu, 29 May 2008 23:33:35 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3324 We have stopped routinely giving STEMI and ACS patients Beta blockers on arrival - and our cardiologists are on board with it. I personally only give it to people who are really tachycardic with a decent BP - and almost never to people with IWMI. <em> <strong>So what does your hospital administration say to your "Hospital Compare" grades? When competing hospitals show that they are 100% and you hospital is at 20%, it doesn't look good even if the metrics are bogus.</strong></em> We have stopped routinely giving STEMI and ACS patients Beta blockers on arrival – and our cardiologists are on board with it. I personally only give it to people who are really tachycardic with a decent BP – and almost never to people with IWMI.

So what does your hospital administration say to your “Hospital Compare” grades?
When competing hospitals show that they are 100% and you hospital is at 20%, it doesn’t look good even if the metrics are bogus.

]]> By: CardioNP http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3323 CardioNP Thu, 29 May 2008 23:16:28 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3323 I believe that this study (don't have the complete article handy right now) used very high dose beta-blockers at fixed doses w/o consideration for titration of HR/BP. My collaborating MD felt that this high dose of beta-blocker likely explained some of the worse outcomes in those on BB. I believe that this study (don’t have the complete article handy right now) used very high dose beta-blockers at fixed doses w/o consideration for titration of HR/BP.
My collaborating MD felt that this high dose of beta-blocker likely explained some of the worse outcomes in those on BB.

]]> By: scalpel http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3322 scalpel Thu, 29 May 2008 19:54:11 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3322 Our protocol is to give 600 mg Plavix on arrival to STEMIs, and I give beta blockers to patients who I think will benefit from them, namely patients whose BP and pulse suggest they will benefit from decreasing cardiac workload (and therefore cardiac oxygen consumption). Some STEMI patients with hypertension and pulses in the 60 range are more likely to benefit from early ACEI. Our protocol is to give 600 mg Plavix on arrival to STEMIs, and I give beta blockers to patients who I think will benefit from them, namely patients whose BP and pulse suggest they will benefit from decreasing cardiac workload (and therefore cardiac oxygen consumption). Some STEMI patients with hypertension and pulses in the 60 range are more likely to benefit from early ACEI.

]]> By: The Happy Hospitalist http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3321 The Happy Hospitalist Thu, 29 May 2008 18:23:58 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3321 interesting. Thanks Happy interesting. Thanks

Happy

]]> By: Teresa http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3320 Teresa Thu, 29 May 2008 15:40:06 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3320 <a href="http://www.americanheart.org/downloadable/heart/1115211365285COMMIT%20Beta%20Blocker%20FACT%20Sheet.pdf" rel="nofollow">This may have</a> reference to some studies on the goodness of β-blockers. It was too medical for me to understand, and besides, I find cardiology more boring than just about anything. But it is mercifully short, and it wouldn't take you doctors more than a minute to read and understand it. This may have reference to some studies on the goodness of β-blockers. It was too medical for me to understand, and besides, I find cardiology more boring than just about anything. But it is mercifully short, and it wouldn’t take you doctors more than a minute to read and understand it.

]]> By: shadowfax http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3319 shadowfax Thu, 29 May 2008 14:38:47 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3319 Bear in mind that the codes for the P4P measures are three-fold: Beta-blocker given, beta-blocker not given for patient factors, beta-blocker not given for hospital factors, or more simply: yes, contraindicated, no. Only the third code counts as a deficiency when they are crunching the numbers for analysis. While your point is EXTREMELY valid that the measures are dubious at best, there is at least this mitigating factor, that you can "opt out" of a given measure if in your judgment it is clinically appropriate. But you need to clearly and explicitly document it. <em><strong>Does it count if we say that the medical studies don't support it? ;-)</strong></em> Bear in mind that the codes for the P4P measures are three-fold: Beta-blocker given, beta-blocker not given for patient factors, beta-blocker not given for hospital factors, or more simply: yes, contraindicated, no. Only the third code counts as a deficiency when they are crunching the numbers for analysis.

While your point is EXTREMELY valid that the measures are dubious at best, there is at least this mitigating factor, that you can “opt out” of a given measure if in your judgment it is clinically appropriate. But you need to clearly and explicitly document it.

Does it count if we say that the medical studies don’t support it? ;-)

]]> By: pcb http://www.epmonthly.com/whitecoat/2008/05/should-we-commit-to-this/#comment-3318 pcb Thu, 29 May 2008 14:13:48 +0000 http://whitecoatrants.wordpress.com/?p=468#comment-3318 once you realize that P4P measures and quality rankings are more about creating a tiered payment system to save money for payors (private or govt) than they are about improving lives of patients, it will all make sense. once you realize that P4P measures and quality rankings are more about creating a tiered payment system to save money for payors (private or govt) than they are about improving lives of patients, it will all make sense.

]]>