Appropriate use criteria updated for when to revascularize

Updated appropriate use criteria guide were released Jan. 30 to guide physicians and patients when to use an invasive procedure to improve blood flow to the heart and how to choose the best procedure for each patient. Clinical scenarios affirm the role of revascularization for patients with acute coronary syndromes and significant symptoms.

Prominent among the changes are a re-evaluation of the indications for the treatment of multivessel coronary artery disease by percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) as a result of data from the SYNTAX trial, which came out after the original criteria were published.

The new criteria appear online at the Journal of the American College of Cardiology.

Among the many changes:
--PCI is changed from inappropriate to uncertain for low burden left main disease, and from uncertain to appropriate for low burden three-vessel disease. This is meant to generate careful selection of high-risk surgery patients for PCI.
--Coronary artery bypass is appropriate for patient scenarios with coronary artery disease involving two vessels to include the proximal left anterior descendent coronary artery and all variations of three-vessel and left main coronary artery disease.
--PCI is appropriate in patients with coronary artery disease in all three heart arteries only if the severity of coronary artery disease burden is low.
--It is uncertain whether PCI is appropriate in patients with three- vessel coronary artery disease and an intermediate to high disease burden.
--PCI is also deemed uncertain in patients with blockages in the left main coronary artery, alone or with blockages in other arteries and low coronary artery disease burden.
--PCI is considered inappropriate in patients with blockages in the left main coronary artery with intermediate to high disease burden

The updated appropriate use criteria, drafted in conjunction with 10 major cardiovascular and thoracic medical societies, replace a previous set published in 2009. New clinical data led to the update. For example, publication of the SYNTAX trial called for the reexamination of clinical scenarios for multi-vessel coronary artery disease.

The 2009 appropriate use criteria outlines nearly 200 clinical scenarios that reflect common heart problems seen by cardiologists. The appropriate use criteria scenarios were developed to mimic patient presentations encountered in everyday practice and to address the rational use of coronary revascularization. The ratings take into account such factors as symptoms, medication, results of stress testing, severity of disease burden, and number of coronary blockages.

Labels: cardiology, PCI

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posted by Ryan DuBosar at 7:00 AM   0 Comments

Meaningful use core measure #13, the patient-generated clinical visit summary

One of the Meaningful Core Measures is to provide a clinical summary of the office visit to each patient. This a well-intended measure as we know that patients will often retain only a part of all the information that they received at the office visit. The summary needs to contain very important information about the visit and decisions made during the visit including patient instructions.

Patients when they leave the office often go out with a sheaf of papers and find it difficult to know which ones they really need to read.

I have been actually giving the patient the "task" of creating their own summary of the office visit. Once we have gone through the history and exam and labs, I will engage them in a discussion on next steps. Then I ask them to summarize the plans and action steps and write them down on a piece of paper. They write down what they agree to do instead of what I would tell them to do. They take this paper with them as a summary of the visit in addition to the EHR generated printed after visit summary.

This activity can take a couple minutes but is incredibly powerful. There is something about a patient's own handwritten plan that cannot be replicated by a physician generated print out.

This is a summary created by a hypothetical patient who was diagnosed with high blood pressure.

How different is it when a patient-physician discussion results in the patient writing down himself that he will cut back on the alcohol vs. a physician telling him to cut back and then handing him a printed patient instruction?

This process has another advantage. It gives the physician an idea about the patient's literacy level. This has to be addressed in a sensitive manner but is incredibly useful information that each physician should know but often does not. This may also not be appropriate for patients with writing disability (Parkinson's or rheumatoid). In these cases you can ask a patient to tell you what to write down.

If you want you can take scan the handrwitten document with an app on your iPhone or android and upload into the electronic health record (make sure your HIPAA police are OK with this. One option is not to have any patient identifiers on the image like the one above).

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

Labels: electronic medical records, guest post, HIPAA, meaningful use, Neil Mehta, patient communication, Technology in (Medical) Education

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posted by Neil Mehta, MD at 11:00 AM   1 Comments

Top 10 technologies a hospital might test this year

A top 10 list of important technologies and technology-related issues that hospital and health system leaders should pay close attention to this year questions each the need for each one based on economics, patient safety, reimbursement and regulatory pressures, as assessed by staff at the ECRI Institute.

1) Electronic health records: Hospitals will need not only IT infrastructure, but also the ability to integrate patient care device data into the electronic health record.
2) Minimally invasive bariatric surgery: Hospitals will need to develop interdisciplinary teams, invest in equipment, care setting and staffing models
3) 3D digital breast tomosynthesis: It requires more capital outlay and operational costs without a clear clinical benefit, and it doesn't replace full-field digital mammography.
4) New CT radiation reduction technologies: dose monitoring and measuring are critical to achieving lower radiation doses, and this aspect of the treatment is as important as the technology itself
5) Transcatheter heart valve implantation: hybrid cath lab models may be the ultimate destination for many of these procedures due to its lower cost and patient volumes. But this may happen only after procedures mature and proficiencies improve.
6) Robotic-assisted surgery: There's steady growth in the number and types of surgeries being done, despite a lack of definitive evidence for the superiority of it compared to traditional laparoscopic surgery.
7) New cardiac stent developments: A 60% use for off-label indications, high complication rates from treating bifurcated lesions with current stents, and higher-than-desired reocclusion and reintervention rates all signal the need for a more personalized approach to stents.
8) Ultrahigh-field-strength MRI systems: 3T systems offer better image resolution than their 1.5T counterparts, but cost about $1 million more than standard systems. Looming next: 7T systems.
9) Personalized therapeutic vaccines for cancer: The many new and high-cost pharmaceuticals and biotechnologies can cost $100,000 and more per patients, and they are all add-ons to existing therapy regimens.
10) Proton beam radiation therapy: Building these centers is a monstrous cost, as is running them. But no randomized controlled trials have proven to be more effective than photon beam treatments. And even newer (but just as expensive) regimens are also in development, carbon ions.

"Themes emerging on our 2012 list reflect ongoing impacts of healthcare reform initiatives and new technology developments that emphasize patient-centered care, including safety improvement, interconnectedness of technology, personalized medicine catering to individual care needs and preferences, and ever-increasing cost pressures," ECRI staff wrote in their white paper. "While the imperative to integrate health information technology with healthcare technology marches on, emerging devices, drugs, and procedures are tailored more than ever to individual patients' medical characteristics."

Labels: hospital costs, hospital leadership, new technology

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Life at Grady: The Old Man and the Knee

The following post, by Kimberly Manning, MD, FACP, is adapted from her blog, Reflections of a Grady Doctor. It is adapted with permission.

Hey there, Miss Manning!"

You announced that greeting to me while craning your head out of the door of a clinic room. Me, I was hustling and bustling through the hallways trying to get things situated for the afternoon session. I glanced back in your direction and couldn't help but slow down.

"Hey sir! What you know good?" I spoke to you in that easy and familiar language that we both know so well.

"Awww, I ain't no count!" And then you laughed out loud, slapped your knee, and then winced a bit. "Woooo! I bet' not stir ol' Arthur up."

Arthur. As in Arthur-itis.

I stopped in the doorway with a stack of papers in my hands and smiled at you. Today you were alone instead of with your daughter. This was fine because even though she sees about you, you "do for yah'self." Your dark leathery complexion has weathered the storm of your "eighty-some-odd" years quite well and I decide today that I love it all. Including those milky, bluish rings now filling the irises of your aging eyes. An interestingly beautiful contrast against that coffee-colored complexion.

Yes, I love it all because it represents so much of what I love about Grady. Storms weathered with beautiful contrasts.

(Click "more" below to continue reading.)

"I don't think I recall you havin' so much gray hair, Miss Manning!" You announced this in that unapologetic way that only the Grady elders can. "But tha's alright. I still think you a pretty little thang."

Pretty little thang? Ha. That's what I'm talking about.

I carefully watched you as your mouth moved. Cheeks with deeply chiseled lines and scarce remains of what was once a beard pasted around your chin and cheeks. The teeth in your mouth looked to be the ones you were born with; large and rectangular but now with a tannish hue and old school dental work gleaming from the sides. Your neck with its redundant skin is supported by shoulders that have remained unusually broad and strong.

"Chopping wood," you said. "Asked my grandson to do it, but he ain't no count." We both laughed again.

You've taken the liberty of removing your coat, folding it neatly on top of the plastic bag you'd carried in that day. And like the perfect patient that you are, you'd also removed every single one of your medication bottles from that same bag and lined them right up on the table.

"I stopped coloring it," I added in reference to the gray hair again. "Too much trouble, you know?"

"Yeah, I hear you. I never got too much gray but I thank I woulda took the gray over losing it all!" You cackled while rubbing your shiny hairless scalp. Then you slapped that knee again and woke ol' Arthur up again. "I jest went on and shaved on off. It never really came back after that."

"Less trouble though, right?"

"Reckon it is!"

I saw your cane leaning against the wall. Weathered but still quite functional. Just like you.

"Knee still giving you a lot of trouble?"

"You know? Not as bad since they inject that medicine in it. But you know, these ol' knees been good to me so I manage just fine. This right one like to get stiff in the mornings. He get to loosenin' up as I get up and around though." The pronoun reference to your knee warmed my heart. You warmed my heart even more. I knew I could stand there talking to you all day so I decided to move on.

"Alright then, sir. Your doctor is checking your lab work and will be in here in a few minutes."

"Okay then, baby. Good seeing you, alright?"

"You, too, sir."

"And Miss Manning? Keeping a smile on your face make you look prettier than any old hair dye can any day."

That's what I'm talking about.

One of the nurses overheard that part as she came in to check supplies in the room. I looked over at her from the doorway. "You hear that? That was a good word, huh?"

She laughed and replied, "Ummm hmmm. But I think I'm gonna smile AND dye my hair."

Ha.

This day was a good day.

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Providing health care in the wild via technology on a shoestring budget

Students in our medical school have since 2009 "adopted" a village in rural Peru. They go there for a month at a time accompanied by faculty members to provide various health services.

While there are many challenges, technology is a big help.

One key challenge was to learn about the population and document this and pass it on to the next group of students using an electronic medical record system. This would help them plan on bringing appropriate supplies (e.g. eye glasses, education material, etc.)

Solution:
OpenMRS: This is an excellent, robust open source electronic medical records system that was developed out of a partnership (Regenstrief Institute @ Indiana University and Partners in Health).

It lets you create custom fields, forms and reports. We wanted to capture the data at the point of care at the clinic where we would work. This would save the time of entering data from paper forms to the database and hopefully decrease errors.

One problem we have in rural Peru is a reliable power supply. So we decided to create an ad-hoc wireless network using a laptop as a server or host and tablet computers as the data entry devices. The plan is to take some extra extended batteries for the laptop so it can run constantly for about eight to 10 hours, and the tablets should last for at least six to eight hours if we don't use them for anything else. We would charge everything overnight at the hotel be set for the next day at the clinic.

Another challenge is language; the folks there speak Spanish.

Solution:
The students and faculty are getting a crash course in Spanish from some of the students who are quite fluent in this. Luckily there is a free medical Spanish app.

Another challenge is checking the visual acuity so we can give the correct eyeglasses. We have an ophthalmologist in the group who is training all the students. But getting them to learn refraction using retinoscopy may not be feasible.

Solution:
Just saw this amazing video of a $2 device that can be attached to a smartphone that lets you measure the refractive error in a few seconds. Am hoping to get in touch with the genius inventor to see if we can get one or two of these devices to help the cause.

It is quite amazing how we are getting to a point where the portable devices are going to be able to change the world, a model where the health care provider goes to the patient rather than the other way around! This may seem like something we need in rural and underserved areas in third world countries, but why can't we use this right here in the U.S.? Is it because of our financial models or the legal system?

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

Labels: guest post, medical education, Neil Mehta, new technology, residency training, Technology in (Medical) Education

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posted by Neil Mehta, MD at 11:00 AM   0 Comments

Google tracks flu peaks faster than the CDC

Google can calculate flu incidence peaks a week faster than other diseases surveillance systems, including that of the Centers for Disease Control and Prevention. With hospitals already stretched to capacity and using just-in-time logistics to serve patients, the seven extra days of warning could help them during a pandemic, researchers concluded.

Google Flu Trends uses search engine query data to estimate influenza activity. By counting how often Google sees 45 flu-related search queries, it estimates how much flu is circulating in different countries and regions around the world.

The data are available in near real time, unlike previously developed surveillance systems such as call volume to telephone triage services, over-the-counter drug sales and volumes of emergency department patients with influenza-like illness.

Researchers studied correlation of Google data to influenza and crowding from an inner-city emergency department at an urban academic hospital in Baltimore from January 2009 through October 2010. Data were collected weekly for the emergency departments, the CDC, laboratory-confirmed influenza data and emergency department crowding (patient volume, number of patients who left without being seen, waiting room time, and length of stay for admitted and discharged patients). Pediatric and adult data were analyzed separately when compared to Google Flu Trends.

Results appeared online Jan. 8 at Clinical Infectious Diseases.

Google Flu Trends correlated with number of positive influenza test results (adult ED, r=0.876; pediatric ED, r=0.718) and number of emergency department patients presenting with influenza-like illness (adult ED, r=0.885; pediatric ED, r=0.652). Pediatric but not adult crowding measures, such as total emergency department volume (r=0.649) and leaving without being seen (r=0.641), also had good correlation with Google Flu Trends. Adult crowding measures for low-acuity patients, such as waiting room time (r=0.421) and length of stay for discharged patients (r=0.548), had moderate correlation.

Researchers concluded that Google Flu Trends provides near-real-time surveillance data seven to 10 days before the CDC's U.S. Influenza Sentinel Provider Surveillance Network, correlating well "but not perfectly" with flu activity.

The imperfection was that Google Flu Trends was prone to spikes caused by news coverage rather than sick people seeking information.

One flu peak was not detected by Google Flu Trends, "possibly because of the previous month's flurry of Internet activity surrounding the news coverage of the H1N1 outbreak," the authors wrote. Another flu peak recorded by Google was not mirrored in the number of patients with flu-like symptoms or positive influenza tests, and instead was probably caused by news coverage of the CDC declaring H1N1 as a national public health emergency.

Labels: emergency room, influenza, new technology

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posted by Ryan DuBosar at 7:00 AM   0 Comments

Life at Grady: The Two Gradys

The following post, by Kimberly Manning, MD, FACP, originally appeared on her blog, Reflections of a Grady Doctor. It is reprinted with permission.

Today is January 15, 2012. My name is Kimberly D. Manning and I am a medical doctor. I received my medical degree from Meharry Medical College in Nashville, Tennessee. For the past ten years, I have had the honor of teaching Emory University medical students and training Internal Medicine resident physicians at Grady Memorial Hospital in Atlanta, Georgia.

And I am a black female.

Fifty years ago today the date was January 15, 1962. Dr. Martin Luther King, Jr. was somewhere blowing out thirty three candles on his birthday cake. During that time, the vast majority of black physicians in the United States were educated at either Meharry Medical College or Howard University School of Medicine--both historically black institutions. In January of 1962 more than a quarter of the population in Atlanta, Georgia was black.

And Grady Hospital was segregated.

"White" Grady and "Colored" Grady. Known by most during those times as "The Gradys"; this plurality serving as the perfect descriptor for these separate but not-so-equal hospitals within one hospital. Yes, in 1962, Grady hospital was segregated.

(Click "more" below to keep reading)

Not only segregated. On January 15, 1962, there were no black physicians with staff privileges there. None. As a matter of fact, during that time there were approximately 4,000 hospital beds at hospitals in the Atlanta area. But physicians who looked like me could only practice in less than 500 of them. 438 to be exact.

Fifty years ago today.

If an African-American patient that I cared for as a primary care provider was hospitalized fifty years ago today, yes, they could be admitted at Grady. However, I would have to give up all patient care privileges at the moment they hit the door. Because, you see, while black people could receive care on the segregated C and D wings of the hospital, they could not receive that care from physicians of their same race.

No, they could not.

In January of 1962 there were groups picketing in front of Grady Hospital. Groups like SNCC and others in the community inspired by a thirty-three year old preacher who had become the face of the Civil Rights Movement. The same preacher who preached around the corner from Grady Hospital at Ebenezer Baptist Church. So there they stood. The Student Nonviolent Coordinating Committee withstanding hateful stares and venomous words. Young people bravely holding up signs criticizing the inequity of the care offered to "negro" patients at Grady Hospital -- and also the fact that black physicians weren't allowed there.

Fifty years ago today.

Other than it being just wrong, there were other problems with that whole no-black-doctors thing. See, just like it is now, Grady was the hospital that served the indigent patient population in Atlanta. And just like now, many of those patients were black. With segregation like it was, many of those folks were cared for by black physicians in the community. And back then, your primary doctor was usually who cared for you in the hospital, too.

Unless, of course, you needed to be admitted at Grady. Regardless of your wishes, that nice black doctor of yours would likely have been called a "boy" and sent on his way.

Or "gal" or "nigra" had it been me.

Fifty years ago today.

I guess it was good that there was at least the "colored" Grady. I mean, it could have been worse. In addition to Grady, at least there was Hughes Spalding Hospital (the colored hospital) across the street. Across the street. Yeah. So fifty years ago today, your negro doctor caring for you across the street from Grady couldn't come to care for you there. No, he or she could not. Oh, and if you weren't poor enough to be considered "indigent"? That made it even more complicated.

All that was going on on this day in 1962.

In January of 1962, my father was a freshman in college at Tuskegee Institute. He had graduated from high school in Birmingham, Alabama that previous year and, like many black folks back then, was the first person in his family to go to college. But also like many black folks back then, he wasn't the first smart person in his family.

No, he was not.

My paternal grandmother valued education. She celebrated my father for his academic achievements and applauded his decision to get higher education. Like me, my father excelled at science and things involving interpersonal skills. He enthusiastically told his counselor in 1961 that he wanted to major in Biology and go to medical school. Unfortunately, that counselor discouraged him. Shot down that dream quick, fast and in a hurry telling him that it was too much of a gamble. If a black man is going to go to college and he wants a job, he needs to go get an engineering degree. And let go of this pipe dream of being a doctor.

"What if you don't get into medical school? Then what?"

Going to college was already a big deal. And it wasn't like there was a doctor in the family for him to call for advice or to counter with, "But what if you do get in, son? What if you do?"

Yep.

So fifty years ago today, on January 15, 1962, my gifted-in-science father was struggling in math and engineering classes at Tuskegee Institute where it would take him more than six years to graduate. Because that's where the world was back then. Race and gender clearly dictated decisions and created ceilings made of a hell of a lot more than glass.

Me? I chose to go to Meharry Medical College because it was a good fit for me. Not because there was no other option or other place willing to let me fit. But had I thought of medical school on January 15, 1962, my medical education story would be different. It would have been Meharry or Howard or bust.

Or perhaps, for a woman, nothing at all.

Fifty years ago today.

Today I'm reflecting on how far things have come on what would have been Dr. Martin Luther King, Jr.'s eighty-third birthday. I am imaging a life for me in his world, a life at Grady Hospital some fifty years ago. And what I am realizing is that I wouldn't have had any kind of life there. At least, not as a doctor. And damn sure not as a teaching physician at Emory.

Oh, did I forget to mention? 1962 was also the first year Emory University integrated its student body. 1963 marked the admission of the first black student in Emory's School of Medicine-- a young man named Hamilton E. Holmes. As for the faculty part, I'm not sure when that part fully changed. I do know that Dr. Asa Yancy Sr. was the first brother-faculty member appointed at Emory which technically took place in the late 1950's (even though he still couldn't get privileges at Grady.) Something tells me that it probably took a little more time to get some sister-doctors on the roster.

But that's just my guess.

So yeah. A lot has gone down in fifty years. So instead of posting the "I Have a Dream" speech or even discussing some of the annoying criticisms that have come up about Dr. King after his death or talking about President Obama or even ranting about how black history should be discussed in more than just the winter months . . . .I am simply sitting here quietly feeling thankful. Thankful that I am right here right now and not fifty years ago today.

And even more thankful that people like Dr. King and my daddy were there.

Sometimes I feel angry that the doors open to me were shut in my father's face. But when I see how proud he and my mother are of their children and what we have become, I feel a little better. And when I listen to his stories of growing up poor, black, and one of eleven children in the epicenter of the Jim Crow era--and I see what he has become--I feel proud, too.

I literally get to be a Grady doctor because somebody wasn't afraid to be spit at and hosed down and hit across the head with a brick. I get to be a Grady doctor because some surely terrified individuals put themselves in harm's way on Freedom riders' buses and some peaceful young person in my own father's neighborhood got attacked by German shepherds just for standing up. Because of them I get to be where I am right now. A doctor. At Grady.

So to all who lived through it, I say thank you. For every time you had to stand there and hear someone call your grown-ass father a boy or a ni**er or your beloved matriarch a gal or a ni*ra, thank you. To those who bravely went against the grain when it would have been much easier to hunker down in some false sense of pink superiority, thank you, too. Because I know that there was a lot more moving in that movement than just black folks.

Today is January 15, 2012. My name is Kimberly D. Manning and I am a medical doctor. I received my medical degree from Meharry Medical College in Nashville, Tennessee. For the past ten years, I have had the honor of teaching Emory University medical students and training Internal Medicine resident physicians at Grady Memorial Hospital in Atlanta, Georgia.

And I am a black female.

Happy Birthday, Dr. King.

Labels: civil rights, Life at Grady, MLK JR

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posted by Jessica Berthold at 7:00 AM   0 Comments