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Archive for the ‘CMS’ Category

Choosing a Doctor

Tuesday, December 23rd, 2008

selecting-physicianThe December 29th edition of American Medical News has an article about how patients choose physicians.

For primary care physicians, more than half of patients choose their doctor by word of mouth and another third choose their doctor based upon a referral from a health plan or from another health professional.

With specialists, a vast majority of patients choose them based upon a referral from the primary care doctor or another physician.

Almost 90% of the time a hospital is chosen based upon where a patient’s physician has privileges or based upon the recommendation of another physician. Friends and co-workers often ask me where they should go for treatment.

One of the interesting things about this survey – which was a national survey of more than 13,500 adults – was that very few patients chose physicians based upon internet sites and only a little more than 4% of patients chose hospitals based upon either the internet or upon “books, magazines, or newspapers.”

The Cliff Note’s version is as follows:
1. If you are a primary care physician, be nice to your patients and take good care of them. Not only will they stay your patients, but they will help you build your practice.
2. If you are a specialist, be nice to the primary care physicians. They account for more than two thirds of your business.
3. If you are a hospital administrator, see #1 above. Invest in your patients and your docs and the rest will follow.
Oh, and all that advertising isn’t doing much to gain you market share. Likewise, no one is paying much attention to that comparison bullhokey at www.hospitalcompare.whatever.com. Stop worrying so much about “quality indicators” that have no basis in science and start worrying more about being good to your patients and your staff physicians.

Word of mouth will get you a lot farther than that ad in the paper.

Sticking Blood Cultures and “HospitalCompare”

Monday, December 1st, 2008

Nice study in the Journal of Emergency Medicine by Shapiro et al. showing that many of the blood cultures performed in the emergency department are low-yield.

At one institution the study was able to decrease the number of blood cultures by 27% and therefore decrease the health costs by nearly $125,000.

At this single study institution’s emergency department, there were 3901 blood cultures drawn over a 1-year period. The study analyzed patient characteristics and determined which patient characteristics were associated with a greater likelihood of bacteremia or “bloodstream infections.”

The symptoms more likely to be associated with bacteremia were divided into “major” and “minor” criteria.
Major criteria included temperature > 39.5°C (103.0°F), indwelling vascular catheter, or clinical suspicion of endocarditis.
Minor criteria included temperature 38.3-39.4°C (101-102.9°F), age > 65 years, chills, vomiting, hypotension (systolic blood pressure < 90 mm Hg), neutrophil% > 80, white blood cell count > 18 k, bands > 5%, platelets < 150 k, and creatinine > 2.0.

If a patient has either one major criterion or two minor criteria, then blood cultures were indicated. Otherwise, patients were considered “low risk” and did not need blood cultures.

Using study criteria, the researchers were able to reduce the number of blood cultures by 27%, resulting in  approximately 1053 fewer cultures per year. At an estimated cost of $15.91 per culture and a charge of $118 per culture set, there was a potential savings of $16,758 in costs and $124,286 in charges at ONE HOSPITAL.

In addition to preventing low yield blood cultures, the study also noted additional cost savings. Nearly 5% of patients in the study had false positive cultures, meaning that the cultures grew out an organism when there really wasn’t an organism present. In other words, the samples were accidentally contaminated. The study cited another study showing that patients with contaminated blood cultures have a hospital stay that is an average of 4.5 days longer and costs an average of $4385 more.

Contamination is one of those problems that it is difficult to guard against. Skin is cleansed with iodine and alcohol, but you can’t eradicate every single organism on the skin that could contaminate the needle. The more cultures you draw, statistically speaking, the more contaminated specimens you are going to get.

This study enrolled 3730 patients. Out of those 3730, only about 8% had true bacteremia and more than half that many – almost 5% – had false positives.

Using the study criteria, the researchers were able to identify more than 99% of patients who had positive bloodstream infections. Only 3 of the 3730 patients studied had infections in the blood that were not caught by using these criteria.

Yet, the government requires that we draw blood cultures before starting antibiotics on every patient that might have pneumonia.

I previously commented about how the CMS “Hospital Compare” website is a bunch of hooey.

It doesn’t allow people to compare government hospitals with all the other hospitals.
It purports to show which hospitals meet “quality” measures by performing certain tasks in a timely manner, yet many of the indicators it uses have little scientific basis.

The whole blood culture requirement is just one of the site’s many big failures.

Performing blood cultures before giving antibiotics in pneumonia patients has absolutely no effect on clinical outcome.
False positive cultures increase the length of stay by 4.5 days and increase the cost of hospitalization by nearly $5000.
Now researchers have come up with a way to decrease the number of blood cultures performed in the emergency department by 27%.

Yet, the Department of Health and Human Services and its “Hospital Compare” web site just keep the “stay the course” attitude. Looking for those “bugs of mass destruction” when finding them costs millions of dollars and has no effect on clinical outcome.

I’m sure that not all blood cultures are done on pneumonia patients. If we say that half of blood cultures were done for pneumonias, we would be able to save an average of $60,000 in costs in each of the 5,708 hospitals in the US … actually … lets just round down to 4,000 hospitals so that we underestimate costs … we’d save $240 million in costs.

Some of the ill-conceived indicators on the Hospital Compare web site are causing laypeople and hospital administrators to pressure physicians into practicing bad medicine. The NEJOM study is just one more reason why neither administrators nor the lay public should put much credence in the HospitalCompare statistics.

Just think, we’d save almost a quarter billion dollars per year by ignoring just one inaccurate statistic.

How much could we save if we just took the whole “Hospital Compare” site off the web?

Clostridium difficile Not A Medical Error?

Thursday, October 30th, 2008

According to this article in American Medical News, researchers at McGill University in Montreal discovered that less than half of 836 patients with Clostridium difficile infections had been exposed to antibiotics in the 45 days prior to their hospitalizations. The study is in CMAJ, but the link isn’t working at the time of this post. The study also showed that, just like MRSA, the rate of community-acquired Clostridium difficile is rising. The rate per 100,000 person-years among people 65 and older in Quebec rose from 0.5 in 1997 to 57.2 in 2004.

If Clostridium difficile infections occur more than half the time without any preceding antibiotic therapy, what exactly is the “error” that needs to be corrected to cease the occurrence of this “never event”?

“Never events” aren’t about patient safety. Never events aren’t about evidence-based medicine.

Never events are all about the Benjamins.

The joke’s on CMS, though. Now we’re going to spend so much money testing hospitalized patients for “C. diff” that the money CMS saves by not paying for the few positive instances of this “never event” will pale in comparison.

Addendum
The link to the CMAJ article is here. Commentary about the article is here.
Factiods from these two articles include:

  • C. difficile can be “cultured from the stool of 3% of healthy adults and up to 80% of healthy newborns and infants.” Is the birth of a health child with C. difficile in its colon the next “never event”? Will all healthy newborns be given Flagyl and Vancomycin to eradicate these organisms?
  • Admitted patients may have C. difficile, but will not all have symptoms of C. difficile-associated diarrhea during their hospital stay. In other words, people might have C. diff prior to admission, but might not develop symptoms until after they’re hospitalized. Hospital gets dinged for an “error” that wasn’t its fault.
  • In addition to antibiotic use, C. difficile is also associated with use of a proton pump inhibitor, presence of inflammatory bowel disease, presence of irritable bowel syndrome, and presence of renal failure. What are we going to do with people who take Prilosec and have Crohn’s disease? Refuse to admit them to avoid the “never event”?

Yet Another Patient Dies Waiting For Emergency Care

Thursday, September 25th, 2008

Michael Herrera, who founded many Tex-Mex restaurants across North Texas, went to the Parkland Hospital emergency department after a golf game. He was having severe stomach pains.
Unfortunately for Mr. Herrera, 270 other people also checked into the Parkland Hospital emergency department that day.
Mr. Herrera waited 19 hours for care and still had not seen a doctor when he went into a cardiac arrest and died.
Mr. Herrera was uninsured and Parkland Hospital is reportedly the only hospital in the Dallas area to provide care for patients without insurance (I do not know this to be a fact, but am stating this due to several comments in the comment sections of the articles below).
Here are some other articles about the story from Dallas News, Pegasus News, Fort Worth Star Telegram, and WFAA.com from Dallas/Fort Worth.

Still think funding for emergency care is unimportant?
Still think socialized medicine and “free” care is the way to go?
We’re going to see more and more people die waiting for care until our lawmakers increase funding for emergency care and create a system that provides adequate reimbursement to medical providers while protecting everyone from jackpot justice.

More ED patients, less available EDs, more medical providers getting fed up with practicing emergency medicine. Hospitals trying to stay afloat by limiting care to indigent patients.

First it’s Beatrice Vance
Then it’s Esmin Green
Just today, Kevin MD linked to another story about Brian Sinclair who died in Winnipeg after waiting 34 hours to be seen in a Canadian emergency department. See another version of the story here.
Now Michael Herrera is dead.

Think about this question when you enter the voting booths this November:

How many people have to die waiting for medical treatment before our elected leaders address funding for medical care?

We’re getting what we pay for.

It is sad that some people are getting it sooner than others.

Boy am I glad I’m a doctor.

Picture credit here

UPDATE SEPTEMBER 30, 2008
An autopsy showed that Mr. Herrera died from complications due to diabetes, heart disease, and morbid obesity.
“I would suspect that with his presentation, he would have been attended to and sent home,” said Dr. Ron Anderson, president and chief executive officer of the Parkland Health and Hospital System.

Pay Up Or Else

Friday, August 22nd, 2008

I was going to take the day off from blogging today, but Sam had an interesting comment that made me want to start writing. Even as I type this, I’m not sure how I feel about the whole situation.

If you read through Sam’s blog, he has had a lot of things happen in his life that he didn’t deserve. The latest problems seems to have been a sudden medical event that caused him a significant amount of medical debt. Now he is in the process of filing bankruptcy because he did not have health insurance. Despite all this, with help from God, he has persevered and seems to have a close loving relationship with his kids.

His case reminds me of another blogger, Steph, who I wrote about back in February. She, too had a tremendous amount of medical debt and was trying to climb out of her “debt hole.” Unfortunately it looks like she has fallen upon harder times as well.

The plight of these bloggers is not uncommon. Hospitals seem more and more willing to sue for medical debts. Should hospitals be able to force people into bankruptcy for the medical services that they provide?

A hospital is a business. Without money, the business goes bankrupt.
If you walk into a lawyer’s office, many times you’ll need a retainer or the lawyer won’t take your case. If the retainer runs out and you don’t pay, then the lawyer stops providing services.
If you walk into a supermarket, fill up your basket, and leave without paying, you’ll be arrested for theft.
Stop paying the guy to cut your lawn and you’ll have to do it yourself.
Why do people expect that medical care should be free if they don’t have any money?

Part of the answer to that question appears to be the sentiment that some people get medical care for free, so therefore I should get medical care for free. No one walks into the supermarket and walks out without paying for their groceries, so the general public does not expect that they should be able to do the same. People don’t regularly get free services from their accountants or their attorneys, so the public doesn’t expect that going to an accountant or an attorney should be free. On the other hand, a lot of people get “free” medical care. Those in similar financial situations but who are forced to pay for their medical care then feel cheated.

That idea seems to be at the center of the deportation issue I wrote about yesterday. If you look at the comments to the Chicago Tribune article, you’ll see that many people state things to the effect that “these people pay nothing into the system and take everything out of the system” and “we have to take care of our own citizens before we take care of foreign nationals.”

I agree. The “system” has to be more equitable.

The problem is that for all the beliefs that “we” have as individuals and that “we” project to others as moral directives, “we” don’t want to be personally involved in advancing those beliefs.
There are many homeless people that deserve shelter, but “we” don’t offer them a place to stay in our basement because although “we” believe the homeless deserve a place to live, “we” don’t want to be personally involved. In fact, “we” don’t even want a homeless shelter anywhere near us because that would affect our property values. It’s OK to provide these services as long as it isn’t in our back yard.
More and more families are finding it difficult to put food on the table. Food at food pantries is drying up. “We” believe that no one should go hungry, yet “we” don’t offer the food we purchase to others because although it is morally correct to feed the hungry, technically “we” think it is someone else’s job.

Medical care is different, though.

People in emergencies “need” medical care and they need it immediately. It is morally objectionable to risk people’s lives and health by refusing to provide services because people can’t afford to pay for those services.

That’s the crux of the problem.

Medical care is a business, but it is a different business.

Hospitals are in the business of fixing people, and some people need to be fixed immediately – money or not. Who pays for the increasing number of people with little or no money?

“We” pay.

“We” pay taxes. The taxes we pay are no longer sufficient to fund the care “we” think that “we” deserve. In addition, those taxes are going to a thousand other places because “we” believe that those thousands of other things are more important than providing medical care to “ourselves.” In fact, “we” are finding more and more devious ways to cut payments for medical care to “ourselves” in the form of “never events,” payment cuts for programs to train new doctors, and payment cuts to medical providers in general.

One of the ways that hospitals earn money is by charging inflated prices to those who can afford to pay for their medical care. Unfortunately this game has become ridiculous.  I wrote about the high cost of medical care in a previous post. Read it – maybe it will help you if you need to negotiate with the hospital about a bill. $129 for a box of Kleenex? $90 for a 70 cent IV line? My recent surgery ended up costing $72,000. Medicare’s payment for the same procedure is $6,500.

When payments dry up, medical providers have to make a decision – find other sources of revenue or close up shop. More and more providers are choosing the latter option. But some of the hospitals that are trying to stay open are suing to get their money and making the lives of those with limited incomes a living hell.

What’s the right answer?

All this rambling and I still don’t know the right answer.

I do know that “we” need to start taking better care of “us,” though. “We” need to pass meaningful health care reform. “We” need to talk to our legislators about improving the state of health care in this country. “We” need to vote for elected officials who make the medical care of the citizens in this country a priority. E pluribus unum.

But most of the people reading this are young and healthy and this issue probably doesn’t apply to them, right?

Think again.

Catastrophic events happen regularly. I see them all the time. You’re just a clogged artery, a busted blood vessel, a blown tire, or a drunken driver away from becoming the next case of medical bankruptcy.

Just ask Sam.

Picture credit here

More On Medicare Never Events

Thursday, August 14th, 2008

I have to stop reading Kevin’s blog.

Lately, every time I read through his posts, I get all riled up over something. The most recent thing to get my blood boiling was Kevin’s link to a nice rant on Buckeye Surgeon’s blog about these looming Medicare “Never Events.” There’s a journalist in Cleveland named Diane Suchetka who published a “blind leading the blind” article about “never events” in the Health News section of Cleveland.com.

I know that I’ve beaten this whole “never event” horse before, but the whole concept is just so remarkably brain dead that I had to get my whip out again.

The thing that concerns me the most about the “never event” concept right now is that many members of the general public are jumping on this bandwagon. Like foie gras ducks being force-fed corn, the citizens of this country are being force fed the notion of “never events” by the government and insurance agencies. Even more disconcerting is that the feeble minded among us actually believe that all of these “never events” should never happen. Just look at the comments to Ms. Suchetka’s article.

After reading the article and the comments, I added my own comment:

It is unfortunate that someone so misinformed about the effects of “never events” on the practice and accessibility to medical care is allowed to publish an article like this. It is even more unfortunate that so many of the members of the general public support Ms. Suchetka’s ramblings.
First of all, look at the contradictions contained within this article itself. She quotes someone from “SHIC” as saying that “If hospitals were to set up efforts to follow these longstanding practices, the vast majority of these medical errors and infections could be prevented.” Wait a second. “Vast majority?” I thought that these were “never events.” Shouldn’t Captain Obvious have stated that the events would “never” happen if the policies were followed?
Medicare calls the “errors” “reasonably preventable.” If they are “never events,” shouldn’t they be called “entirely preventable”? If they are “never events” then I want to see the people who came up with that term treat patients for a year and show me their results in preventing them.
There are other misstatements. Realitynurse states that “C. diff is a medical mistake.” Uninformed and untrue statement. C. diff is an organism that lives and grows just like every other organism on this planet. Antibiotic use may increase the prevalence of C. diff, but antibiotic use does not “cause” C. diff. Your statement is akin to saying “mosquitoes are a mistake” or “uninformed nurses are a mistake.”
Why has C. difficile become so ominous? Up to 20% of people prescribed clindamycin can develop C. difficile. What exactly should we do to make sure that not one single patient ever develops a C. difficile infection? Go on. I want all you smart people to tell me. Stop prescribing all antibiotics? Sounds like a plan. Then Medicare will deem all the other infections as “never events,” too.
If any of the people reading this column want to avoid never events, here’s how to do it: Don’t go to doctors and stay away from hospitals. That’s right. Boycott us. If you want to create a manual on how to provide perfect medical care while you’re treating yourself for a ruptured appendix, I’d be happy to read it.
Ms. Suchetka is right that these Medicare rules will affect all of us, but she has the wrong reasoning. They will affect all of you that develop these conditions because physicians and hospitals will avoid you like the plague. If you are prone to falling, good luck finding a doctor to treat you. Immunocompromised and likely to develop infections? Better read up on those medical journals. You’ll be treating yourself soon.
“Medicaid expenses could drop”? Get a clue. They won’t drop, they’ll increase. No one will accept Medicaid patients with predispositions to these conditions and the patients will end up in the emergency department where the care is really inexpensive. Maybe Medicaid should focus its efforts on reigning in those that misuse their access to health care in order to score some pain meds. That would save a lot more money than this all this hogwash about those things that are and are not preventable.
Hospitals are “get[ting] the message” alright. They’re closing. Doctors are getting the message, too. Fewer and fewer specialists are treating patients from emergency departments because they don’t want to deal with people who expect perfection and who then try to sue when they don’t get it.
When your local hospital closes down or when the wait for care is so long that you or a loved one develop a bad outcome because of it, you can thank people like Ms. Suchetka for putting pablum to paper.
Boy am I glad I’m a doctor.
WhiteCoat

The comments on the blog have to be approved by the blog owner and at this point Ms. Suchetka or whoever “owns” the blog has still not “approved” my comment about her uninformed article.

I just decided that I’m not finished yet. Now you’re getting both barrels, lady.

A DVT will soon be a never event. Indirectly what CMS is saying is that blood should never clot. If blood should never clot, then why doesn’t CMS make Coumadin ingestion mandatory for every person in the United States? We’ll just put rat poison in the water supply and force everyone to go for their monthly INR checks. Oh, wait – maybe it’s only that blood should “never” clot in the legs. Where do I get my own set of government-issued Ted Hose? And another thing – all you airlines better give me upgrades to first class or I’m not paying for my flights. What’s fair for medicine is fair for the travel industry. “Never” means never.

C. difficile and Staph aureus infections are also going to be considered “never events.” Think about the idiocy of this classification. Mircoorganisms should “never” happen. You sonofabitches in the government give us a vaccine to eradicate smallpox but you’re holding out on the C. diff vaccines so you can avoid paying for medical care, aren’t you? How long before strep throat, otitis media, pneumonia, H. pylori gastritis, and urinary tract infections will also be never events? Ooops. UTIs already are never events. Don’t forget about tooth decay, either. Stinking peptostreptococcus bugs. Oh yeah – yeast infections, too. Monistat will soon be mandatory for all women. The human body should be absolutely sterile.

“Never events” are and always have been “all about the Benjamins.” Look at this news release. The “background” section states that the “never events” were “required” pursuant to Section 5001(c) of the Deficit Reduction Act. Medicare wants to stop paying for things not because they “should never happen” but because it’s trying to save money. The whole “never event” moniker is just a spin they put on the cuts to make it look like someone else’s fault. Do “never events” never occur at government run hospitals? We’ll never know because CMS doesn’t even include government run hospitals on the “hospital compare” list.

Am I the only one that finds it odd that CMS is so willing to judge others but is so unwilling to allow others to judge it?

Just like the guy that cuts your lawn, your attorney, or any other entity that performs services for you – once you stop paying for the services, you stop getting the services. Medical care will be no different. Economic forces will make it more and more difficult to find care if you are predisposed to a “never event.”

In addition, medical providers will find loopholes in the “never event” system that will drive up the costs of care instead of decreasing it. Maybe your doctor will transfer you to another hospital for “specialist care” after you develop a “never event” so that the new hospital can bill for it. Maybe you’ll suddenly develop some other medical condition that the hospital can bill for while you are treated for the uncompensated “never event.” Trust me – medical providers are a helluva lot more creative than the people working at the Medicare National Bank.

Rest assured that whatever happens, the laws of unintended consequences will increase the costs of treating “never events” and Medicare’s inevitable decline into bankruptcy will occur even more quickly because of it.

Other countries must just be watching us, smirking, and shaking their heads.

Get your healthcare while you can. If you still believe that never events should never occur, you better get your treatment for delirium quickly – delirium is one of the conditions on the “never event” hit list.

Picture credit here

P.S. I’m still glad that I’m a doctor.

Should We COMMIT To This?

Thursday, May 29th, 2008

I try to keep up on current events in medicine, but sometimes discover that I miss things that may affect the manner in which I practice medicine.

I attended a lecture on new treatments for STEMI and had a brief discussion with the lecturer afterwards regarding “Quality Measures” as determined by CMS.

He mentioned a study that I had not read that goes by the acronym “COMMIT” – the Clopidogrel and Metoprolol in Myocardial Infarction Trial. This was a HUGE study that enrolled more that 45,000 patients in 1250 different hospitals. Patients suspected of having an acute MI were randomized to receive clopridogrel, metoprolol or placebo and were then continued on the medication until discharge or until they had been in the hospital for a week.

Interesting point of the study was that patients who are given beta blockers “on arrival” had no difference in the primary endpoints of the study – death, reinfarction, or cardiac arrest. There was a 0.005 probability that the people receiving metoprolol would not experience ventricular fibrillation or reinfarction, but more than 1% of the patients receiving early beta blockers went into cardiogenic shock! As an aside, those on clopridogrel showed a significant improvement in the primary study endpoints.

By getting early beta blockers, initially the patients did worse than those getting placebos. Over time, the reduction in reinfarctions and in ventricular fibrillation caused study participants to break just about even in terms of adverse events. The conclusion of the COMMIT study was that “it might generally be prudent to consider starting beta-blocker therapy in hospital only when the haemodynamic condition after MI has stabilised.”

The COMMIT study results somewhat conflict with other studies cited by the American College of Cardiology and the American Heart Association in their joint 2004 guidelines for management of patients with acute ST-Elevation MI.

Yet one of the “Hospital Compare” indicators for “quality care” in heart attack patients that the patient receive a “beta-blocker at arrival.” Even though the ACC/AHA recommendations are for patients with ST elevation MI, the Hospital Compare site does not make that distinction.

Hospitals all over the nation brag about their statistics giving beta blockers at arrival. Cedars-Siani Hospital, Henry Ford Hospital, the Mayo Clinic, the Indiana Community Health Network, St. Luke’s Hospital in Missouri, and the University Health Care System in Georgia are just a few of the hospitals that I found posting their beta-blocker stats online. Is there conclusive evidence that we are helping, and not harming, patients by giving them beta blockers at arrival?

I spent an hour online researching on PubMed, eMedicine, and MD Consult. I couldn’t find any studies showing a significant improvement in outcomes with “beta blockers at admission” for acute MI patients. I’m hoping that someone out there can post a link or two. The Beta Blocker Heart Attack Trial showed a significant improvement in outcomes when beta blockers were started 5-21 days after hospital admission, not “at arrival.”

Even if there are some studies out there that do show a benefit, how do we reconcile the potential harm shown in the COMMIT study? If there is disagreement in the literature about the possible harm of a therapy, should hospitals get a bad “grade” for not giving that therapy?

I would love to see data comparing the rates of death, reinfarction, etc. AFTER all of the CMS quality care measures were instituted. Couldn’t find that online, either.

CMS is already making things worse for patients with pneumonia care. Now a huge study shows it may also be wrong with recommending early beta blocker administration.

And there is no quality care measure for  giving clopridogrel (Plavix) — a medicine that is proven to reduce morbidity and mortality in acute MIs.

Isn’t one of the tenets of medicine to “first do no harm“?

What gives?

Picture credit here

Hey CMS – Compare THIS

Wednesday, May 21st, 2008

I’m away on a business trip and happened to read an article in the USA Today sitting outside my hotel room door that ticked me off. The feds spent $1.9 million in advertising to push their “Hospital Compare” web site. They want the public to compare different aspects of hospital care before deciding to go to the hospital. Another article on the topic from Yahoo is here.

Supposedly the ads are to further the Bush administration’s goal to “increase transparency” in the health care system.

Do the ads mention that the “quality” initiatives requiring that antibiotics be given within 4 hours of a pneumonia diagnosis actually “raises the risk of misdiagnosis and inappropriate use of antibiotics?” In other words, if doctors follow the initiatives, patients can potentially do worse.

Do the ads mention that another initiative requiring doctors to perform blood cultures before giving antibiotics has absolutely no effect on clinical outcome? Do they mention that this requirement increases the length of stay by 4.5 days and increases the cost of hospitalization by over $5000 when “false positive” cultures are obtained (which occurs almost as often as “true” positives)?

Of course not. They just pit one hospital against another – twisting the thumb screws to make one hospital look bad if it doesn’t adhere to some of these nonsensical quality measures.

I still can’t figure out why CMS and the Bush administration have they excluded all the VA and military hospitals from their “hospital compare” web site if they are sooooo into transparency. Try searching for Walter Reed Army Medical Center or Tripler Army Medical Center on the site. Plug in the name of any of the VA hospitals in your area. Magically, according to the Hospital Compare database, government-run hospitals don’t exist.

OK, CMS … you want other hospitals to shape up? Get your own house in order first. Put that $1.9 million to a better cause – like taking care of the soldiers who have sacrificed their lives and their health supporting this country’s initiatives instead of leaving them “stranded in unfit conditions,” “neglected,” and “waiting four months for the results of important medical tests”. Video testimony about the conditions in Walter Reed Hospital can be found here.

“Do as I say and not as I do” doesn’t cut it. When you get the conditions at your hospitals in the top 10%, send me an e-mail.

I won’t hold my breath.

Do Not Use These Medical Abbreviations!

Sunday, November 4th, 2007

I’m about fed up with the chart police dinging me for writing “unapproved abbreviations.” This whole “Do Not Use List” is another Medical Marijuana Advocates idea that has just gone too far.

  • I can’t write “U” anymore because it could be mistaken for any of the following: “0,” “4″ or “cc”
  • I can’t write QD or QOD because the period after the Q might be mistaken for an “I” and the “O” might be mistaken for an “I”
  • I can’t write “MS” for morphine sulfate because someone might confuse it for magnesium sulfate. Similarly, MSO4 and MgSO4 might be confused.

We’re soon going to be blessed with even more additions to the “Do Not Use List”:

  • Don’t write “> or <” because they could be mistaken for the number “7″ or the letter “L”
  • Don’t write “&” because it could be mistaken for the number “2″
  • Don’t write “cc” because it could be mistaken for “U” (units) when poorly written. Instead we will have to write out the term “ml” instead.

There are other “safety measures” to keep us from hurting ourselves, but these are the ones that stick out most in my mind.

Now hold on a second while I get my soapbox.
Tap tap tap. Is this thing on?
There, that’s better.

The “U” for units might get confused with a number “0″
Maybe there could be some confusion.
Now let me ask the nurses a question: If you get an order for “500 reg insulin SQ,” are you going to
(a) question the order or
(b) fill up a 30 cc syringe (HA! I wrote “cc” instead of “ml” – cc cc cc cc cc) with regular insulin and inject a bolus the size of a kiwifruit under someone’s skin?
Would any medically trained person give “50 regular insulin” instead of “5 u regular insulin” to someone with a glucose of 250? I didn’t think so.
So this rule must have been written for people who have no knowledge of how to use insulin – just in case the housekeeping staff wants to get into the act and start treating hyperglycemia on the sly.
While I’m at it, will all of the communications from Medical Marijuana Advocates be required to go without the “cc” designation, too? What a waste of trees. Have to write a new letter to every addressee.

We can’t use MSO4 and MgSO4 because someone might not know that MSO4 is morphine and MgSO4 is magnesium
Would anyone question why a physician was giving a patient with a kidney stone 10 mg of Magnesium for pain? Considering that the dose of magnesium is usually 1000 mg, would it not set off a red flag in a normal person’s mind when you have to use a micropipette to get the proper dose of a medication and then administer three drops to medicate the patient?
And what better way to terminate an episode of torsades de pointes than 1 gram of morphine IV over 30 minutes? Just think, junkies from miles around would figure out ways to put themselves into cardiac arrhythmias just to get treated in your ED! I can see them now: Hey! Wait a minute, JACK! NOOOObody said nothing about no motherf%#$ing shocks!

The ampersand “&” might be mistaken for a “2″
First, I want to know who even writes ampersands any more. Then I want to see how someone can morph an ampersand into a number 2. Right after that, they can go to my bank and turn the $155 dollars in my checking account into a king’s ransom. Not happening.

“> or <” could be mistaken “7″ or “L” and “cc” could be mistaken for “U” (units) when poorly written

I understand how an order to give “10 cc insulin SQ if BGL 7 350″ would be confusing. I routinely dose insulin by “cc” instead of “units” and I frequently see blood glucose levels more than 7000 in my daily practice (the normal glucose level is between >0 and 110). I thought long and hard about this one, though, and have come to the conclusion that we should probably stop using the “ml” term also. Because if written poorly, “ml” might actually appear to be the number “11111″ which could accidentally increase the dosage of any medication by 11111-fold.
See?ml.gif Instead, I propose that we use the symbol from the Artist Formerly Known as Prince:prince_symbol.gif
Think of how many times we could avert the tragedy of some poor patient getting a 50011111 bolus of saline.

A period in Q.D or the letter “O” in QOD might be mistaken for an “I”
Good point. But because they are so confusing, we shouldn’t just stop at using “.” and “O” with Q.D. and QOD, we should stop using them altogether. By doing so, we would avoid confusing orders such as “STIP patient’s ciumadin NIW”
And this whole thing just gives me flashbacks about one time when I narrowly escaped ordering emergency dialysis for a patient whose potassium level looked like it was “315″ on the computer printout. Boy was I embarrassed. Oh, and I almost forgot the time I nearly intubated a patient whose pH appeared to be 7144. Phew!

Attention Medical Marijuana Advocates …
Here’s a patient safety measure for you:
If health care providers are so incapable of determining whether a dose of medication is 100 times more than it should be and are at such a loss of medical knowledge that they can’t remember whether to use morphine or magnesium for pain management, they either need to call the physician to clarify the order or they need to find another profession.

Maybe they could work for the Joint Commission. Betcha they’d fit right in.

Update:
Want to see one solution to the medical abbreviation problem? Check out this post on physician handwriting.

Hospitals Getting Graded Using Wrong Test Questions

Sunday, July 29th, 2007

So the Department of Health and Human Services’ “report card” grading hospitals on how well the hospitals “care for all their adult patients with certain medical conditions” just keeps getting worse and worse. Now we’re seeing that the “quality indicators” the government is using are nothing of the sort. One recent study shows that at least one set of “quality indicators”

  1. Increases the likelihood of misdiagnosis,
  2. Causes patients to receive unnecessary antibiotics,
  3. Has no effect on patient length of stay or death rates
  4. Not mentioned in the article, but just as important – increases the costs that patients have to pay due to all the unnecessary antibiotics and blood cultures

Jumping through all the government hoops makes patients more likely to be misdiagnosed and more likely to receive unnecessary antibiotics. And they’re the ones grading the hospitals?

The HHS home page states “This information will help you compare the quality of care hospitals provide.” Funny thing . . . if you look around on the web site, it shows nothing about where the quality indicators came from or what scientific methods were used to come up with the indicators. This page lists all of the quality indicators that HHS uses to determine whether or not patients are receiving “quality care.” If you go to the Pneumonia “Process of Care Measures” you’ll see that HHS thinks that “quality hospitals” give antibiotics within 4 hours because “Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.” Great. So why the 4 hour time frame? There are no data on the web site to support the government’s “quality indicators.” Now at least one study shows that the 4 hour time frame may actually harm patients. And why does HHS equate quality of care with giving unnecessary antibiotics to patients with viral pneumonia?

Some of the quality indicators are valid. But let’s not use smoke and mirrors to coerce hospitals into providing unnecessary and potentially harmful care so that they can be at the top of some report card. The patients in the US deserve better than this.

On tap in the future – more than 100 new “quality indicators” by which hospitals will be expected to abide. Just how many of them will have a scientific basis? I’m not keeping my hopes up. This micromanagement is going to make healthcare in the US more expensive and less effective.

One more thing – has anyone ever noticed that government-run hospitals aren’t on the HHS “Hospital Compare” website? Try searching for Walter Reed Army Medical Center or Tripler Army Medical Center, for example. If civilian hospitals are performing as well as government-run facilities, they should get a great grade, right? Why aren’t government-run hospitals available for comparison?

Bottom line: If everyone ignores these indicators, they become meaningless.

No quality indicators for the Department of Health and Human Services leadership . . . yet.

(more…)

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