Thursday, December 30, 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.

Labels: defensive medicine, electronic medical records, EMR, guest post, health care cost, health care reform, malpractice, medical errors, obesity, smoking

Changing the business of anticoagulation

[Editor's Note: This guest post origianlly appeared at DrDialogue.

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.

Labels: anticoagulation, community hospital, drugs, guest post, health care cost, hospital costs

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.

Labels: malpractice, medical errors, patient safety

Life at Grady: When I was an intern...

A version of the following post by Kimberly Manning, FACP, first appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect individuals' privacy.

Today I'm reflecting on my internship. . . 1996. . . .back in the day. . . (insert wiggly fingers here as we go back in time)

When I was an intern. . . .

•I didn't have an email address.
•Or a working cell phone that wasn't the size of a football or that didn't cost $500 per second.

When I was an intern. . . . .

•Clinical questions were explored in the big fat textbooks that sat on the shelves of every ward. ("Up-to-date"? Chile, please.)
•I read the Washington Manual so many times that I could tell you what page you could find "management of gastrointestinal bleeding" on without even opening the book.

(Click "more" below to continue reading this post.)

When I was an intern. . . .

•"Duty hours" was this obscure thing you heard of occasionally mentioned with regards to training programs in New York state. They allegedly had some rules about how long one could work (although no one I knew in New York state was following any kind of rules regarding them back then. . . .)
•Post-call (meaning: you've been up all night admitting sick patients) essentially meant very little to anyone besides you.
•Nobody cared if you were speaking in tongues or writing in hieroglyphics at 4:35 p.m. during post-call sign out rounds due to lack of sleep. (Or if you had clinic the following day.)
•"You okay with sticking around a bit longer?" was not an unusual thing to hear at 1 pm after being up all night-- when the only alternative to ekeing out a tiny "o.k." was to swallow hard and blink fast until you no longer wanted to fall to your knees in tearful exhaustion. ('Cause you knew that if you dared protest, you'd hear a soliloquy that starts with "When I was an intern. . . .")

When I was an intern. . . .

•I once (stupidly) took call two nights in a row because my co-intern and I both wanted an entire weekend off during our "one in three" call schedule month. (Translation: I worked more than 48 hours straight. Not. Smart.) That Sunday morning while rounding with my attending, I recall him saying, "Who's the on-call intern?" "Me." "Uh, okay. So where's the post-call intern?" "Also me." "Uhhh, can you do that?" "I think so." "Uh, okay. Who do we have first on our list?"
•I was so tired on that Sunday that I had to call a friend to come and drive me home.

When I was an intern . . . .

•I practiced presenting my patients in the car on the way to one of my ICU rotations because I was so intimidated by my take-no-prisoners attending that I felt it was 100% necessary.
•Case in point: That same attending in the ICU held his hand up to his ear in the middle of my patient presentation one day and said, "Ssssshhhhhh! Do you hear that? Listen." Everyone looked puzzled and tried to listen to whatever he was talking about. He then narrowed his eyes and exclaimed (yes, exclaimed), "It's the sound of your patient yelling around his endotracheal tube, 'Help me! Help me! This intern is trying to kill me!' " This was followed by a laugh that originated from so far in the deepest parts of his belly that I thought it would never end. Um, yeah, so that's why I was practicing my oral presentations on the way to work. . .
•The only comforting thing about that ICU month was that this same take-no-prisoners attending did not discriminate when divvying out the insults. One of my all time favorites remains: "Do you know what this patient would say if she could talk?" "No, sir." "She'd say, 'Somebody save me! I'm surrounded by a group of snot-nosed intern assassins!' "

When I was an intern. . . . .

•On my ER rotation in December of 1996, I was scheduled for twenty-two "twelve-hour" shifts. (My four clinic sessions were folded into two full-day sessions--on my OFF days. Nice.)
•Oh, in the aforementioned month? Nearly all of my shifts were from 2pm to 2am--exactly perfect for making certain that I had no time for any possible meaningful contact with anyone not requiring stitches, IV fluids or a splint.
•Whoops, I almost forgot. I did get one shift that wasn't from 2pm to 2am--Christmas Day--which was 10am to 10pm. Exactly perfect for guaranteeing that I would have no time to do anything remotely exciting before work or make anybody's celebration after getting off.

When I was an intern. . . . .

•I burst into tears on rounds after my attending kept pumping me on obscure pharmacology questions post-call.
•I cut the back of my hair with a pair of Fiskars from my sewing kit because I didn't have enough time to go to a professional. (And actually had such a distorted view of style that I thought it looked pretty darn good.)
•Blinked out my left contact lens every single time I intubated someone. ("Eyes on the vocal cords. . . steady, steady. . . . and I'm in!" Blink. "Damn.")

When I was an intern. . . .

•I fell asleep in my car in the parking lot post call. In Cleveland, Ohio. In the winter. (Fortunately, a security officer tapped my window and woke me up before I developed frostbite.)
•I called my chief resident after the first big snow and asked what I should do about coming in. My chief laughed so hard that I was sure he would tear an intercostal muscle somewhere. That was the answer to that question.

When I was an intern. . . .

•I learned so much that I thought my head would explode.
•I was often more terrified than I had ever been in my entire life.
•I made some really, really great friends who sometimes carried me away from the battlefield on those days when I could no longer walk for myself.

When I was an intern. . . .

•I cried so hard when I lost my first patient that I wondered if I was cut out for this profession.
•I sometimes wasn't sure I'd make it.
•I prayed. A lot.

Funny how much has changed since I was an intern. New rules, new war stories. . . . but some things remain the same no matter when you trained or how gruesome your personal version is of the "When I was an intern. . . ." saga.

You learn. You try. You grow. You cry.
And if you're lucky. . . this doesn't end when you finish your internship. :)

Labels: hospital medicine, internship, Life at Grady

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."

Labels: cardiology, costs, defensive medicine, health care cost, hospital costs, patient safety

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.

Labels: costs, defensive medicine, Glass Hospital, guest post, health care cost, hospital costs

Medicare project ties financial incentives to quality care

Results from a demonstration project for show that offering providers financial incentives for improving patient care increases quality of care and can reduce the growth in Medicare expenditures.

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.

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

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

Labels: cardiology, heart failure, pneumonia, quality measures, quality reporting

Hospital fashion steps forward

[Editor's Note: This guest column was written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College.]

The November AARP Bulletin highlights a promising development in hospital couture: trendsetter Diane von Furstenberg has designed new, unisex gowns ready for wearing in hospitals. The new gowns provide style and full coverage, with options for opening in front or back according to the Bulletin. A trial is underway at the Cleveland Clinic.

Turns out Newsweek ran a more detailed feature on the von Furstenberg hospital gowns last August. For those of you who missed the medical fashion story of last summer, here's the scoop.

In May, 2010, the Cleveland Clinic held a Patient Experience Summit with a bifocal theme of "empathy and innovation." There, on Day 2, the gowns were unveiled. Jeanne Ryan, a nurse who leads the redesign team, gave a presentation. In sum: the garments should be comfortable to wear, provide dignified coverage, allow ease of access for medical examination, and meet the needs of both ambulatory and bedbound patients. And cheap--the gowns cost about $9 each, according to Newsweek.

The magazine provides some history on hospital gown innovation: "... In 1999 the Hackensack University Medical Center in New Jersey redid its gowns with the help of designer Nicole Miller. In 2004 the Maine Medical Center in Portland introduced a floor-length option to accommodate the requests of female Muslim patients, and in 2009 the Robert Wood Johnson Foundation offered $236,110 to the College of Textiles to work on designing, producing and marketing a new style of gown ..."

It's not obvious to this reviewer what will be so much better with the new DvF wraps, but I'm encouraged by the Clinic's efforts to get this right.

Initial feedback has been good, according to Cleveland.com. Some men find the print a bit feminine, so the team may change the color scheme. Also, because the fabric shrinks upon washing, the gowns may need lengthening.

The team painstakingly chose a fabric not too heavy so as to be warm or uncomfortable for patients lying in bed, but not so light as to be transparent. The gown incorporates the Cleveland Clinic's diamond logo in a von Furstenberg signature, repetitive kind of pattern. There's an elastic waistband, a wrap-around closure, and a wide V-neck. The gown is functional while preserving modesty. "Physicians can open the gown to expose the part they need to access without exposing the patient completely," Ryan told Newsweek.

As someone who's experienced one-size-fits-all sizes that span from to basketball player, in pre-surgical outfits, and who's spent weeks lying in hospital beds barely clad while all kinds of people came in and out without knocking, and who even in this year felt embarrassed in a revealing "gown" that was supposed to cover me as I walked down a hall to a room for an X-ray but didn't, in front of other patients and sometimes former colleagues, I see this as definite progress, or at least a step in the right direction.

These gowns needn't (and shouldn't) be expensive, and I have some concerns about the V-neck, which sounds too open for a post-mastectomy style and for frail patients who might catch cold, or pneumonia. (Will Diane design matching scarves?) But in general I think this is a favorable trend, or at least a start, that some hospitals are noticing how patients are treated--apart from the meds and procedures and strict nursing care--affects their experience and, potentially, their wellness.

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.

Labels: hospital costs, patient satisfaction

Atrial fibrillation: 3 notable studies, 3 important questions

In treating atrial fibrillation (AF), this year has witnessed some real excitement. And not all the good news has to do with new pills. Recently, there has been a flurry of encouraging and objective news on ablating AF. Here are some comments on three notable studies that address three important questions:

1. What are the "long-term" success rates of AF ablation?
On this important question comes an American Heart Association (AHA) abstract from the highly-regarded lab of Dr. Karl-Heinz Kuck in Hamburg. They report on a relatively young cohort of 161 patients who underwent AF ablation (using standard pulmonary vein isolation techniques) in 2003-2004. At an average of five years of follow up, more than 80% were either AF-free or "clinically improved."

Real-world impression: Although late recurrences of AF years after successful ablation have been reported, my impression (having started with AF ablation in 2004) is that most who are AF-free off drugs after one year have remained AF-free thus far.

2. Should AF ablation be offered as first-line therapy to younger patients?
Presently, the guidelines (circa 2006) for AF treatment recommend ablation as second-line therapy for those who have failed at least one trial of drug treatment. These "ancient" guidelines were conceived in an era when AF ablation was done laboriously and mostly in arrhythmia "institutes." Times have changed, and it isn't just one blogger's opinion that AF ablation is getting easier.

In the good-news-for-AF-patients' bucket goes this 1,500-patient Circulation publication from the University of Pennsylvania on the efficacy and risk of AF ablation in young patients. They analyzed AF-ablation results on the basis of age quartiles. Remarkably, all age groups had success rates in the 80% range, but the quartile of patients less than 45 years old also had no major complications--as in zero.

Incorporating the well known fact that young AF patients tolerate drug therapy poorly, these well-regarded researchers concluded that in the younger AF patient, ablation may be considered as a first-line option.

Real-world impression: This is a similar experience as ours. Since younger patients with AF frequently have low resting blood pressure and heart rate , they often do not tolerate the rate-slowing effects of most AF-drugs. Additionally, young patients tend to have smaller atria with less structural disease and more often than not, have focal drivers of AF. Less intrinsic atrial disease (like dilation of heart chambers) means less risk of procedural complications. More focality of AF "nests" means more chance of isolating the drivers with encircling RF lesions. These facts, in conjunction with the favorable long-term data from Hamburg, argue strongly that ablation should be considered a reasonable first-line option in young, otherwise healthy AF patients.

3. In patients with long-standing AF and congestive heart failure (CHF), how does AF ablation compare to amiodarone?
As background, it is well known that AF worsens outcomes in CHF. And this combination is common: AF and CHF are two of the most frequently cited in-patient cardiac diagnoses. It is also known that AF ablation is less successful in patients with long-term AF. So, in treating this common scenario (CHF and AF), there are two schools of thought in cardiology. As is often the case with emerging novel therapeutics, there are the old-schoolers, who in this example cling to the 1990s-vintage, once-daily amiodarone, and there are the new-agers, who believe catheter ablation deserves consideration.

Although one abstract does not unequivocally bury the rotary-phone guys, this amiodarone-versus-ablation study provides an early glimpse into the future. From the well-endowed "Italy-in-Texas" arrhythmia institute comes preliminary results of the AATAC trial. The trial randomized 105 patients with CHF, previously implanted ICDs and permanent or long-standing persistent AF to either amiodarone or AF ablation(s). (Having ICDs allowed researchers a window on true AF-suppression as ICDs have reliable AF-detection algorithms.) At only 10 months of follow-up, 75 percent of the ablation group ("after two ablation procedures") versus 46% of amiodarone group were AF-free.

Real-world impression: Way back in 2004 in the New England Journal of Medicine (NEJM), it was shown that restoration and maintenance of sinus rhythm by catheter ablation in patients with CHF was beneficial, at least in Bordeaux. The question now, though, is whether AF ablation has progressed sufficiently to supplant drug therapy in advanced cases of AF and heart disease. AF ablation has come a long way in half a decade--it's easier, but not easy. But neither is taking anti-arrhythmic drugs long term.

As for approaching AF with catheter ablation, I see us in a similar transition that we went through in the 1990s when ablation for SVT moved to first-line. Since ablating AF is much harder than SVT, the transition to non-drug therapy will be longer than it was with the one-burn-and-done SVT.

For sure, in climbing the AF-ablation mountain we are getting closer to the top, but there are still some steep pitches left.

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.

Labels: cardiology, guest post, heart failure

Life at Grady: Jedi nose tricks

A version of the following post by Kimberly Manning, FACP, first appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect individuals' privacy.

"Hmmm. . . .fruity. . ." I overheard one of the senior infectious disease attendings say to a medical student one day on the wards. He waved his fingers around his nose in circles like a maestro, and then nodded his head. "Pseudomonas," he then said with the kind of confidence one uses when they tell you the sky is blue or the grass is green. Pseudomonas.

The student looked from left to right, and then did a quick scan of the area. She shrugged and looked back at the attending with a puzzled expression. I could tell she wanted to say, 'Huh'?

Here's the thing: It's not like I overheard this exchange in or even near a patient room. This all went down at the nurses' station, easily thirty feet or more away from the nearest hospital bed. The infectious disease consult team had just emerged from the stairwell and had made a pitstop right by where I was writing my patient notes.

The minute I caught a glimpse of the senior faculty member leading a team of five other people of various levels of training, I immediately placed my pen down. Some of my best medical knowledge acquisitions have taken place via eavesdropping around the I.D. team. (Matter of fact, I'm convinced that this alone scored me at least four correct questions on my board recertification.) No matter where you trained, everyone knows that you can always count on the I.D. doctors to drop some random clinical pearls of wisdom even in idle chatter. And don't let it be one of the senior gurus--it's a veritable mother lode.

(Click "more" below to continue reading this post.)

"Do you mean fruity like when people have diabetic ketoacidosis?" the student inquired. Nice, I thought, but clearly a rookie suggestion. Nice, though. I rested my chin in my hand and buckled my seatbelt for the ride.

You could tell that the ID Maestro was already foaming at the mouth with the beautifully packaged teachable moment he'd just been handed. He smiled wide. "No. . . this is a different kind of fruity. Almost like. . .a pleasant strawberry smell. Very distinct and quite different from that chemicaly-fruity smell that's often appreciated in ketoacidosis. This is more. . .how can I describe it. . . .fruity-fruity." Chemicaly-fruity? Fruity-fruity? Man, I can't wait 'til I'm senior faculty.

So, for my non-medical friends, I don't need to tell you that the hospital is teeming with all sorts of smells. When someone says "hospital smells," most layfolks probably think of typical unpleasant odors like vomit or urine, shuddering at the idea that hospital personnel are pretty much desensitized to such things. The truth is that, yeah, we are pretty much desensitized to the fumes of bodily excrement; matter of fact, those don't even count as "hospital smells" because they're a given. I'm talking about the other smells. The ones that no-way, no-how would the average person be able to assign an origin other than, "Sheeesh! What is that?"

Sometimes they waft by and disappear like vapor, and other times they accost you and tackle you to the ground. Most will tell you that the longer you work in the hospital, the more discerning your snout becomes (at least that's the going line we give to students.) To some degree, I'd say that's true. For example, the smell of a bloody bowel movement is one you only need to experience one time to get the gist of, but over time gets fine tuned. I'm pretty sure that some of my gastroenterologist friends can tell you just how much blood and even how many units of blood you'll need to transfuse to bring the blood count back to normal--all with one whiff.

I lifted my nose skyward and inhaled. Fruity? Nope. I couldn't smell anything. I inhaled again. No fruity, no fruity-fruity, no chemical-fruity, no nothin'. I took a few more careful, inconspicuous nasal breaths inward, this time flaring my nostrils. Still got nothin'. I decided that I would immediately stand and sniff in the same place where the Maestro was standing the minute he left.

Turns out I wasn't the only one with faulty senses. "I can't smell anything," saidoke one of the fellows on the consult team. He squinted his eyes, inhaled, and then shook his head. "Nope."

The Maestro waved his hand again, welcoming the scent to his nares (which I am totally going to do when I am senior faculty whether I smell something or not.) "You can't smell that? That fruity scent? It's so distinct," he queried emphatically. "Like strawberries." Uhhh, or not.

After a few more moments of smelly chatter, the ID team disappeared into a patient room. I quickly jumped out of my seat and stood in the Maestro's exact place. Big inhale. Wait for it...wait for it...Nada! Another big inhale. Nothin'. Dang.

Fifteen minutes later, the ID consult team filed out of the room and immediately formed a semicircle around the Maestro (who was in the midst of an infectious disease teaching symphony.) "That odor is classic. Any time you smell that coming from a wound, think Pseudomonas. And that green exudate! Classic. Great case."

"But you smelled it the minute we stepped out of the stairwell! You didn't even need to see the pus in the wound!" said the student incredulously. "Once we removed the dressing I could smell what you were talking about, but how did you notice that from all the way over there?"

The Maestro offered a knowing smile, kind of like Yoda in Return of the Jedi. Because I am the Jedi Master, Young Luke. (At least that's what I thought he should have said.) Instead he leaned on the nurses' station and replied, "After a while you just sort of know. I guess it comes with experience." (Told you that's what we tell the students.) They exchanged a few more comments/teaching points and then left to see the rest of their patients. Finally, the coast was clear.

I stood up and sniffed. I took two steps closer to the patient's room and sniffed again. Still nothing. Hmmm. Maybe 14.5 years out of medical school is not enough time to achieve Jedi olfaction. Hmmm. Suddenly, a thought popped into my head. It was from a discussion I'd had with my faculty mentor, Neil W. during one of our meetings. He was telling me about how, more than once, he's literally had his nostrils quickly tickled with that chemicaly-fruity smell of diabetic ketoacidosis during fleeting, 30-second patient encounters. Most of them were there for completely different reasons, but just one whiff was enough to change the game plan. That was all it took to make him stick the person's finger for a blood glucose and have his hunch confirmed.

"The nose knows," he proudly said that day. That afternoon we debated for a half hour about whether the clinical smell thing is a matter of Jedi-level experience or simply a skill that some folks are born with. The jury is still out.

Sniff. . .sniff. . .sniff. . .sniff. . .

Eventually I found myself standing directly in front of the doorway that the Maestro and company had just departed. I knew that actually entering the room would border on a HIPAA violation, so this was the end of the road for me. I pinched my nose to get it ready and then took one last big sniff. Nose don't fail me now! Iiiiinnnnn--and . . . .wait! I smell something! I folded my arms and leaned toward the doorjamb, taking one more whiff just to be sure. Undeniable. Like the Maestro, no further evaluation needed.

I looked down the hall to Mr. Stanley, the nurse caring for the patients in that room. "Um, Mr. Stanley?" I uttered once he looked my way.

"Hey there, Dr. Manning! You need something?"

"Uuhhh, I don't, but I'm pretty sure someone else does. Mr. Stanley, I think someone in this room needs to be changed." I gestured into the doorway with my thumb.

"Really?" he asked, "I don't think so, doctor. I was just in there."

I stuffed my notes in my pocket, stood up tall, and patted Mr. Stanley on the shoulder. Pointing to my nose, I laughed, "Just trust me on this one, Mr. Stanley. Trust me."

Labels: hospital smells, Life at Grady

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internist and 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.

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.

CasesBlog
Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients.

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.

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

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
ACP Member Mike Aref, MD, PhD, ACP Member, 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.

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, ACP Member, 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.

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).

Musing of an Internist
Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident.

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.

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.

White Coat Underground
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.

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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