Archivi delle etichette: Evidence-based health care

HTA in Italia: pessimismo dell’intelligenza, ottimismo della volontà

Il 24 ottobre scorso sono stato invitato da Giovanni Morana, dinamico direttore della radiologia dell’ospedale di Treviso, ad un convegno sul tema della TAC Dual Energy. Il programma prevedeva una parte dedicata a questa interessante tecnologia ancora in fase di sviluppo e ricerca e una dedicata all’HTA.


L’incontro si è tenuto all’Ateneo Veneto, una fondazione istituita da Napoleone dopo il disfacimento della Serenissima Repubblica di Venezia, in uno splendido palazzo a fianco del Gran Teatro La Fenice.

Per un accidente della storia, il 9 ottobre 1996, nella stessa sede avevo organizzato un workshop, alla presenza dei politici e direttori generali della aziende sanitarie del tempo, dal titolo: “Razionamento o razionalizzazione dell’assistenza sanitaria – il ruolo dell’HTA”, starring Renaldo N. Battista al quale il collega direttore generale di Venezia (il compianto Carlo Crepas) aveva tributato gli onori che la Serenissima Repubblica tributava ai Capi di Stato e agli Ambasciatori in visita a Venezia: il corteo in barca lungo il Canal Grande.


L’invito di Giovanni Morana ha suscitato in me due sentimenti: il piacere di discutere oggi con i clinici (italiani, stranieri e un brillante giovane collega italiano che lavora a Charleston, Carlo De Cecco) e i produttori di tecnologia i metodi e le opportunità offerte dall’HTA; l’amarezza di toccare con mano la lentezza con la quale in questi vent’anni l’HTA si è diffusa in Italia!

Quanta strada ancora da percorrere! Se smettessimo di buttarci a pesce sulle cose urgenti e ci occupassimo un po’ di più delle cose importanti (De Gaulle) …..!!!

Il XXI secolo non ci ha portato ancora superare lo storicismo gramsciano: “Tutti i più ridicoli fantasticatori che nei loro nascondigli di geni incompresi fanno scoperte strabilianti e definitive, si precipitano su ogni movimento nuovo persuasi di poter spacciare le loro fanfaluche. D’altronde ogni collasso porta con sé disordine intellettuale e morale. Pessimismo dell’intelligenza, ottimismo della volontà”. (Q28, III)



Solving the high rates of hospital readmissions @kevinmd @Medici_manager @pash22

By  ,

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

  • Identifying high-risk patients early
  • Educating the patient and involving family members
  • Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

Science alone can’t make tough decisions for us @kevinmd @Medici_Manager @pash22


On April 14, The United States Preventive Services Task Force concluded that women with an elevated risk of breast cancer – who have never been diagnosed with breast cancer but whose family history and other medical factors increase their odds of developing the disease–should consider taking one of two pills that cut that risk in half. The Task Force is an independent panel of medical experts who review the medical literature to estimate the pros and cons of preventive interventions. This is the same Task Force that in recent years raised questions about the benefits of mammograms in 40 to 50-year-old women, and PSA tests for men of all ages, tests that screen respectively for breast and prostate cancer. Despite the popularity of both of these tests, the Task Force concluded that their harms often outweigh their benefits.

The irony now is that with this report on breast cancer prevention pills, the Task Force has switched from rejecting something patients believed in to endorsing something most patients will reject.

The seemingly strange way the Task Force ping-pong’s between popular and unpopular recommendations is inevitable, because these kinds of recommendations must necessarily go beyond the medical facts – it is impossible to decide what preventive measures people need without making value judgments.

To understand the way facts and value judgments get mixed together in these kinds recommendations, let’s take a closer look at these breast cancer prevention pills.

For many years now, doctors have been prescribing tamoxifen as secondary prevention to women who have already undergone treatment for breast cancer, in an attempt to thwart any breast cancer cells remaining in their body. In women whose breast cancer cells express “estrogen receptors”, tamoxifen reduces the chance that this cancer will recur, by attaching itself to those receptors, in effect crowding outestrogen. In breast cancer cells, any estrogen landing on these receptors will spur that cell to divide and multiply. But when tamoxifen lands on these receptor sites, it does not stimulate cell growth.

Raloxifene is a close cousin of tamoxifen, which has primarily been used to treat women with osteoporosis. Like tamoxifen, it competes with estrogen for the attention of estrogen receptors. Also like tamoxifen, it slows down breast cancer by preventing estrogen from stimulating cell growth. As it turns out, both raloxifene and tamoxifen also have the strange property that when they collide with bone cells, they don’t fight against estrogen, but seem to mimic estrogen, and thereby improve bone health. (Because these drugs and sometimes act like estrogen and other times act like anti-estrogen, they are called selective estrogen blockers.)

Two very similar drugs, then. Both slow down breast cancer cells while stimulating bone cells. Each drug has been shown to cut the risk of a first breast cancer in half for women with a high risk of experiencing this disease. In what is known as the P1 trial, for example, women who faced an average five year risk of breast cancer of 6% saw that risk drop to 3%, if they took tamoxifen.

Sounds like a good deal, yes? Take a pill for five years, and cut your risk of breast cancer in half. But keep in mind, most women do not face a 6% chance of breast cancer in the next five years. Women with this kind of risk are generally retirement age or beyond, and usually have a bad combination of family history, early onset of menses, and late age of first pregnancy. It is these women the Task Force believes should talk with their doctors about whether to take these medications. And how did the Task Force reach this conclusion? By determining that for some women, at least, the benefits of these pills outweigh their harms. Before looking at this harm benefit ratio more closely, let’s put this Task Force conclusion into context.

The Task Force essentially produces three kinds recommendations, which I have taken the liberty to name.

  1. NADA: When it concludes that the harms of an intervention outweigh the benefits, the Task Force recommends that doctors and patients avoid the intervention. Think: ultrasound screening for pancreatic cancer.
  2. OUGHTA: When the Task Force concludes that the benefits outweigh the harms, it pushes to make the intervention standard of care. For example: routine screening for colon cancer in people 50 years or older.
  3. UP TO THE INDIVIDUAL: When the Task Force concludes that the benefits of an intervention potential outweigh the harms, depending on the patient’s individual preferences, it leaves the decision up to individual patients and their doctors to weigh. This is the recommendation the Task Force made both for mammography in 40 to 50-year-olds, and for tamoxifen and raloxifene to prevent breast cancer.

When making NADA or OUGHTA recommendations, the Task Force essentially makes its own value judgment. It looks at the risks and benefits of an intervention, and concludes that no sensible person could decide differently from the Task Force. In this third type of recommendation, however, the Task Force concludes that reasonable people could make different choices, based on how they weigh the risks and benefits of the interventions.

In the case of tamoxifen and raloxifene to prevent a first breast cancer, I expect the vast majority of women will conclude that the risks of the pills outweigh the benefits.  In the past two years, I have collaborated with a team of researchers at the University of Michigan (led by Angie Fagerlin, a decision psychologist in their medical school), to help women decide whether to take either of these pills. We developed an Internet-based decision aid, a tool designed to help patients weigh the pros and cons of their medical alternatives. (I write about the history of decision aids in my book, Critical Decisions.) Our decision aid provided women with individualized estimates of their odds of developing breast cancer in the next five years. We only directed women to the decision aid whose risk was high enough to have qualified for the P1 trial.

In the decision aid, we described the benefits of both drugs – the reduced risk of breast cancer and the strengthening of their bones. We also laid out the risks – a very small chance of endometrial cancer, a slightly larger chance of heart attack or stroke, a modest risk of cataracts, and finally a very strong likelihood of experiencing menopausal symptoms such as irregular menstrual bleeding and hot flashes. We actually provided them with precise numerical estimates of these side effects, with pictures illustrating the risks to make them easier to comprehend.

Women pondered the pros and cons and concluded, almost unanimously, that the side effects of these drugs outweighed the benefits.

The decision whether to take tamoxifen and raloxifene is no doubt a personal one, and the right choice will vary depending on how a given person weighs the respective risks and benefits of these medicines. For a woman with an extremely high risk of breast cancer over the next five years – say 10% or more – cutting that risk in half might very well be worth the hot flashes and the chance of experiencing blood clots. But very, very few women faced a five year risk is highest.

Consider, instead, a woman with a 3% chance of developing breast cancer over the next five years. That risk is much higher than average – most women face a five year risk of less than 1% – but is it high enough to justify taking one of these pills? For such a woman, tamoxifen and raloxifene only reduce that risk by 1.5%. Over five years. Five years with possible hot flashes. For a cancer women have not experienced yet. These modest benefits simply do not loom large enough to interest most women in these pills.

You might wonder at this point whether our decision aid biased women against these medications. As a physician trained in behavioral economics, I’m constantly on the lookout for decision biases. In the case of our study, however, we designed our decision aid in a manner that allowed us to test for well-known behavioral economic biases. For instance, research has shown  that when people face a choice between three options and two of the options are similar, they often opt for the more different alternative even if the other options are better. In other words, a person might believe that A > B, and A’ > B, but still choose B over A and A’, because they cannot decide between A and A’.

Aware of this problem, we created several different versions of our decision aid. In one version, we presented women with a choice between tamoxifen, raloxifene or no pill. Three choices in other words, two of which – the two medications – are quite similar to each other. In another version of the decision aid, we simply presented women with the choice between pill or no pill. We thought this simpler choice would increase women’s interest in these pills, by minimizing the difficulty of choosing between the two of them. But instead, this reframing of the decision did not increased women’s interest in either of these preventive medicines.

We also designed our decision aid to take account of another well-known decision bias, what are known as recency effects. When people learn about the risks of a medication and then learn about its benefits, that order of information leads them to look favorably upon the medication, because the information they remember best, the last information they receive, is about the pill’s benefits. By contrast, people who receive the same information about this medicine, but in the opposite order, like the pill less, because the last thing they learn about are the pill’s risks, and this information sticks in their minds. To make sure this recency effect was not influencing women’s decisions, we varied the order of information across women. We discovered that this did nothing to change their willingness to take either of these medications, mainly because whichever order women received information in, they did not like the idea of taking either pill.

If these pills are so unpopular among well-informed women, why would the Task Force come out in favor of them? It comes down to judgment. The Task Force concluded that a reasonable person could look at these risks and benefits and decide that the hot flashes and blood clots are acceptable prices to pay to reduce the chance of breast cancer. The majority of women don’t have to agree with this view for the Task Force’s recommendation to be correct. Even if only a small percentage of women decide these pills are worth taking, at least they have the freedom to make that choice. And at least they know that medical experts have concluded that such a decision is a reasonable one to make.

The same goes for whether to start mammograms before the age of 50 in women at normal risk of breast cancer. The Task Force never said that women shouldn’t start mammograms at this earlier age. They just said that it was a tough judgment call, and that some women, perhaps the majority even, might conclude that the harms of early screening – the anxiety caused by false negative tests, the pain caused by unnecessary biopsies – aren’t worth the modest benefits of screening at this age.

If the Task Force is going to leave all these tough decisions up to individual patients and their doctors, why should we care about their recommendations? For starters, you will have a hard time finding a more thorough and levelheaded evaluation of the pros and cons of these kinds of interventions. These people are very good at what they do. In addition, anyone reading through Task Force reports will be forced to recognize that science alone can’t make tough decisions for us. Ultimately, science can only provide us with the facts. The rest of us eventually need to make tough judgment calls. In effect, the Task Force is doing us a huge favor, by showing us which judgments are close calls, and which ones are no-brainers.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

Is the Future of Healthcare Delivery Guidelines or Personalized Medicine? @Medici_Manager @drsilenzi

By Dr. Joseph Kvedar

As we grapple with provider shortages, the surge in chronic illness and the quality to price (QPR as they say in the wine business) challenge in US healthcare delivery, it’s hard to imagine a future that does not include some sort of guideline or algorithm-driven care.  As providers take on more financial risk, one common strategy involves team-based care, and the attendant increase in decision-making and care delivery by non-physician clinicians.  If the je ne sais quoi feature of a quintessentially great doctor is clinical judgment and instinct, one of the challenges of this transition to team-based care is how to harness that trait and use it efficiently.

Care decisions that are unassailable at a population level (e.g., women should have regular, routine PAP smears or smoking is bad for your health) or are algorithmic in nature (e.g., titration of treatment for uncomplicated hypertension or therapy for mild to moderate teenage acne) can all be effectively reduced to guidelines.  This, in turn, allows a physician to delegate certain therapeutic decisions to non-physician providers while maintaining a high degree of care quality.  It is also thought that this type of uniformity of care delivery will improve the QPR too, by decreasing variability.

How do we come up with guidelines?  Typically they are based on large-scale, randomized, controlled clinical studies.  As is nicely articulated in a recent JAMA opinion piece by Drs. Jeffrey Goldberg and Alfred Buxton (JAMA, June 26, 2013—Vol 309, No. 24, pg 2559), guidelines are formulated based on the inclusion criteria for these trials.  This process gives us comfort that guidelines are based on rigorous science — and that is a good thing.  The challenge arises when we realize that individuals do not reflect populations exactly.  Clinical research is much more complex than wet lab work because people are complex and indeed unique.  Every clinician has had the experience of prescribing a therapy to a patient who fit guideline criteria exactly and having the opposite outcome of what the guideline predicts.

Goldberg and Buxton point out the collision of this guideline-based care delivery model with the burgeoning area of personalized medicine.  I was immediately drawn to their definition of personalized medicine: “The tailoring of medical treatment to the individual characteristics of each patient.  It does not literally mean the creation of drugs or medical devices that are unique to a patient, but rather the ability to classify individuals into subpopulations that differ in their susceptibility to a particular disease or their response to a specific treatment.”  I always felt like there was too much emphasis on the genetic components of personalized medicine.

Our vision at the Center for Connected Health (which is backed up by our experience to date) is that we will get far richer and complex data from multiple phenotypic inputs such as physiologic monitoring data, mood and motivation-related data than is represented by genomic data.  The genome is an incredibly important anchor for devising a personalized medicine profile, but the profile will change over an individual’s lifetime according to these phenotypic inputs.

We’ve done some preliminary work on this and found that indeed we can map individuals phenotypic data over time as they go through an intervention designed, for example, to improve activity level.  During a six month period of tracking activity and motivation, we have seen dynamic changes in these two variables.  Think about it over a lifetime.

The collision with guidelines is multifactorial.  We are all individuals and none of us are completely representative of the composite patient who is defined by the inclusion criteria for the clinical trial that lead to the guideline.  Thus, some of us are bound to be poor candidates for the prescribed intervention (I hate to mention it, but we’ve all seen examples of Uncle Harry who smoked two packs per day, lived into his 90s and died of causes unrelated to smoking).  If that wasn’t enough, there is the fact that we change over time and though we might fit a guideline today, we may not in a year.

Really, when you think about it, ‘clinical judgment and instinct’ is the 20th century (and earlier) embodiment of personalized medicine.  Those of us who are clinicians can all point to experiences where we’ve said, “I can’t tell you why, but I really think we should do it this way” (this way being contrary to conventional wisdom) and it has generated a positive outcome.  Of course we also have experiences where the outcome is not good or where we make mistakes that could have been prevented by adherence to guidelines.

How to make sense of this complex and contradictory situation? Here’s my take:

  1. Personalized medicine, however you define it, is still in the very early stages. We have decades to go, probably on both the genetic and phenotypic fronts, before we can comfortably replace guidelines.
  2. We should welcome the sharing of decision-making across the care team and maximize the use of non-physician clinicians. Guidelines give us the state-of-the-art way to do this.
  3. The best form of personalized medicine today is still clinician instinct and judgment.  This does not mean deferring all clinical decisions to the most senior or most highly trained person on the team.  The care delivery culture can be modified to maximize appropriate personalization of care while adhering appropriately to guidelines. This requires an open culture where inquiry is encouraged.  Each care team member must be comfortable with what he or she doesn’t know, with spotting exceptions to norms and engaging other team members in a learning dialogue around these exceptions.

This should enable guidelines to be appropriately applied while surfacing exceptions for discussion.  In the meantime, we and others will be working as fast as we can to create the framework for personalized medicine from both the genetic and phenotypic perspective.

The Importance of Teaching Value-Added Care @Medici_Manager @muirgray @WRicciardi @pash22

By Richard M. Schwartzstein, M.D. and Grace Huang, M.D.

Richard M. Schwartzstein, M.D., Executive Director of the Carl J. Shapiro Institute for Education and Research, Vice President for Education at Beth Israel Deaconess Medical Center, and Faculty Associate Dean for Medical Education at Harvard Medical School

Grace Huang, M.D., Director of Assessment at the Shapiro Institute and Assistant Professor of Medicine at Harvard Medical School

No topic is more timely or relevant to the current political climate than cost-effective care. We at the Shapiro Institute for Education and Research prefer to frame the concept as “value-added care,” which incorporates patient-centered outcomes, including potential harm and discomfort from diagnostic testing. In the face of data that demonstrate wasteful testing and treatments contribute significantly to our rising health care costs, practicing physicians are under pressure to be part of the solution.

The lay public clearly is attuned to this crisis as expressed in the popular press and media reports and is demanding to know why physicians are not taught to consider the value and cost of the tests and treatments they recommend. Changing physician behavior, however, requires more than knowledge-based instruction; rather, we must identify and address the cultural factors that contribute both to patients’ demands and expectations and to physicians’ actions.

Our historical model for training physicians has neglected to incorporate contemporary principles of resource utilization, harm from diagnostics, and cost considerations into medical education curricula. The medical, physical, and emotional consequences of false-positive testing are not real to medical students. Even in the hospital environment, where trainees become increasingly aware of delivery issues—such as readmission rates, observation status, and case management—they still operate under assumptions that tests and services are fully reimbursed and that hospitals are profitable. Consequently, when residents enter the workforce, they are unprepared for the economic realities of our health care system and typically lack the tools necessary to navigate an optimal patientcentered, cost-conscious approach to the evaluation and management of their patients.

Topics such as epidemiology, evidence-based medicine, and diagnostic reasoning represent the cornerstones of the preclerkship curriculum for medical students. But the hidden curriculum and test-ordering practices of attending physicians (who often drive the ordering decisions of trainees) hinder the effective application of these theoretical principles during actual clinical experiences. Most faculty members are neither trained in high value care nor able to identify “best teaching practices.” Academic doctors, particularly those practicing in tertiary medical centers, strive to teach their students and residents the breadth and depth of medicine. The longer and more intricate the differential diagnosis, the better, and supervising physicians often are loath to stifle the curiosity of their trainees.

Patient expectations fuel excessive testing. The fear of malpractice litigation may incentivize health care professionals to pursue diagnostic certainty even at the cost, both financial and human, of multiple tests and procedures. Physicians may assume that patients will seek alternate care if their doctor is reluctant to pursue whatever test the patient thinks is necessary, regardless of the cost. Physicians also may opt for the perceived “easy way out” by giving the patient what he or she wants, rather than entering into a thoughtful, but timeconsuming and potentially difficult, conversation about the reasons for avoiding that diagnostic pathway.

There have been positive steps to reduce waste and contain costs. Campaigns such as Choosing Wisely at the American Board of Internal Medicine have spurred professional societies to highlight unnecessary tests for their specific specialties, while the High-Value Care Curriculum at the American College of Physicians (ACP) provides the knowledge elements and tools to deliver content. But these initiatives, although incredibly valuable starting points for these discussions, may not sufficiently address our medical culture, which demands diagnostic certainty. One key question remains: If we want to influence the actions of future physicians, how do we optimally teach these principles to our current trainees?

In this context, the Shapiro Institute convened an invitational Millennium Conference on Teaching Value-Added Care, co-sponsored by the AAMC and in partnership with the ACP. This spring, teams from six medical schools—Drexel University College of Medicine, Dalhousie University Faculty of Medicine, Geisel School of Medicine at Dartmouth, Case Western Reserve University School of Medicine, Penn State College of Medicine, and Mayo Medical School—joined the Harvard/Shapiro team to consider challenges of the learning environment, propose best instructional practices, and engage in a structured dialogue to build consensus on how to teach value-added care across the medical education continuum.

We will detail our findings in future proceedings. A preliminary summary includes the following highlights.

Value is not strictly about cost; it comes from the patient’s perspective. As such, we must teach and serve as models for the behaviors that elicit patient concerns and preferences about the many nonmedical factors that influence their perceptions of health care. To explain why a particular study highlighted in the media does not apply to an individual patient requires not only knowledge of study design and biostatistics, but also the ability to translate that information to a patient who may not fully understand the study results. Discussing the complications of testing, particularly the consequences of false-positive findings, is challenging and requires a range of communication skills.

Teaching value does not necessarily require significant amounts of extra time.When a test of questionable value is ordered, ask the student or trainee, “How will the results affect what we will do with this patient?” At the end of patient rounds, consider adding questions that foster appropriate test ordering, such as, “Is there anything we ordered today that the patient does not need?” During the traditional morbidity and mortality conferences, add a discussion of hospital costs incurred.

Tackle the hidden culture head-on. The clinical learning environment is typified by routine daily labs, unnecessary diagnostic evaluations, and repeat imaging. Foster a reward system that values cost-effective care by discouraging extensive differential diagnoses that include diseases that are obscure and have a low probability of producing the patient’s clinical picture. Train a core faculty with demonstrated expertise in teaching these topics. Incorporate practice audits of ordering behavior into the teaching competencies of faculty.

The deliberations and recommendations of the committed faculty who attended the Millennium Conference 2013 are only the beginning of our efforts to enhance the teaching of value-added care. We hope our findings will stimulate additional initiatives across the United States and Canada.

More Treatments Equal Better Care? @Medici_Manager @pash22 @helenbevan


American HealthScare : 

How the healthcare industry’s scare tactics have screwed up our economy — and our future

There are multiple lines of evidence that doing more things to patients doesn’t always result in better health. I summarize a few examples here.

Dartmouth Studies

Researchers at Dartmouth University examined the relationship between medical resources used and the resulting health outcomes in people nearing the end of their lives in two California regions, Los Angeles and Sacramento.

In Los Angeles, the patients used 61% more hospital beds, 128% more intensive care unit (ICU) beds, and 89% more physician labor in the management of chronically ill patients during the last two years of life compared to Sacramento. In spite of this intense use of medical resources, the quality of care for patients with heart attacks, heart failure, and pneumonia was worse in Los Angeles. Patients did not enjoy this aggressive care either. Patients rated 57% of Los Angeles hospitals as below average compared to 13% of Sacramento hospitals.

What are the cost implications of the overly aggressive care in Los Angeles? If the Los Angeles hospitals had functioned at the same level as the Sacramento hospitals over the five years of the study measuring these differences, the savings to the Medicare system would have been approximately $1.7 billion.

Brain Aneurysms

Researchers studied immediate family members of patients who had symptomatic brain aneurysms. The researchers wanted to know if finding and surgically fixing aneurysms in the healthy family members who had no aneurysm symptoms would prevent strokes and deaths. The results were basically that many people were injured as a result of the surgery, which the researchers didn’t feel justified the few saved lives.

The Medical Outcomes Studies

In the late 1980s and early 1990s a series of studies called the Medical Outcomes Studies were completed. Their purpose was to measure differences in medical resources used and health outcomes in patients with common conditions who saw different kinds of doctors. They wanted to know if ologist care led to better health compared to primary care, and how the doctors differed in practice styles. The researchers studied patients with high blood pressure and diabetes.

For high blood pressure, patients of cardiologists had more office visits, more prescriptions, more lab tests per physician visit, and were more likely to be hospitalized. There was no difference between the three physician types for average blood pressure, complications, or physical function.

For diabetes, patients of endocrinologists were found to have higher hospitalization rates, more office visits, more prescription drugs, and more lab tests per physician visit than family physicians. There was no difference between the three physicians for average sugar levels, physical functioning, and almost all diabetic complications.


These are just a few examples of how more aggressive medical care doesn’t always result in better health. All of the GIMeC members typically support the notion that more is better. Overcoming this aggression bias will be one of our big challenges in reforming our healthcare system.


Wennberg DE, Fisher ES, Goodman DC, Skinner JS, Bronner KK, Sharp SM. Taking care of patients with severe chronic disease: the Dartmouth atlas of health care 2008. The Dartmouth Institute for Health Policy and Clinical Practice Center for Health Policy Research [online]2008 [cited 2009 May 2]. Available from:

Risks and benefits of screening for intracranial aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage. N Engl J Med. Oct 28 1999;341(18):1344-1350.

Vernooij MW, Ikram MA, Tanghe HL, et al. Incidental findings on brain MRI in the general population. N Engl J Med. Nov 1 2007;357(18):1821-1828.

Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA. Mar 25 1992;267(12):1624-1630.

Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. JAMA. Nov 8 1995;274(18):1436-1444.

Smokers will be asked to quit before undergoing surgery under new medical guidelines @Medici_Manager

Grant McArthur

SMOKERS will be asked to quit before undergoing surgery and be referred for help while on waiting lists under new medical guidelines.

A strengthened smoking policy from the Australian and New Zealand College of Anaesthetists will require all elective surgery patients to be asked if they smoke, and for tobacco users to be given referrals to help them quit before their operations.

The policy will not give practitioners the power to delay or cancel surgery. But ANZCA president Dr Lindy Roberts said the guidelines would offer smokers the best chance to avoid life-threatening complications by providing them with support.

The hope is to convince and help smokers to quit four to six weeks before surgery, while they are already on the waiting list, which can greatly cut the risks of serious complications during recovery.

“Smokers are at greater risk of complications such as pneumonia, heart attacks and wound infections,” Dr Roberts said.

“When you are coming into hospital for something like an operation, it does provide you with an opportunity to think about your health more generally, and the benefits of giving up smoking for your health are in the longer term as well as relating to surgery and anaesthesia.

“It may be that when presented with the risks for a certain procedure that the surgery is delayed to allow somebody to improve their health prior to the surgery.

“From time to time a decision may be made between the anaesthetist, the surgeon and the patient to delay the surgery if there is something that can be improved to make them fitter for surgery.”

The move follows the success of a Frankston Hospital program in which all smokers entering the surgery waiting list were sent a quit pack – prompting 13 per cent to act and contact Quitline. Australian Medical Association Victorian president Victoria president Dr Stephen Parnis said the college’s quit-smoking stance was a positive move, balancing the need to advise patients without discriminating.

“This is not about banning people, this is about giving them the best chance to benefit,” Dr Parnis said. “When you weigh into account the procedure they need and their health, if there is a benefit to delaying the procedure then we would do that.”

Tough choices: how to rein in Australia’s rising health bill @Medici_Manager @pash22

With health costs rising and costly medical innovations on the horizon, it’s crunch time for health funding. In the lead up to the May budget, The Conversation’s experts will explore the options for reining in costs – but warn governments must make some tough decisions.

Medical schools signal readiness for revolution @Medici_Manager

A robust response to an AMA initiative underscores the fact that medical schools recognize the need for a necessary update of how they educate physicians.

Posted March 18, 2013.

Educator Abraham Flexner’s 1910 report evaluating American and Canadian medical schools is generally credited with transforming medical education into its current modern age. Flexner shined a light on the importance of a more rigorous education so that future physicians could be trained in — and have a sharp mind for — the rapid scientific and technological advances coming out of the Industrial Revolution.

Over the last decade, numerous studies have looked at one question: Should the Flexner model be updated so medical education can adapt to the rapid scientific and technological advances of today’s information revolution? The answer is uniformly, yes, and the call for change isn’t coming only from medical and educational observers. Recently, striking evidence has surfaced that the schools themselves are ready to make a change — one as revolutionary as anything Flexner envisioned.

That evidence is their overwhelming response to a $10 million initiative by the American Medical Association called “Accelerating Change in Medical Education.” Before a Feb. 15 deadline, 115 out of 141 U.S. medical schools sent five-page concept proposals explaining what transformative changes they would like to make in teaching future physicians. Changes might include new ways of teaching and assessing core competencies, or more of a focus on patient safety or quality improvement. The proposals reflect a changing health care delivery system transformed by technology so that the skill of finding and applying information is as important — or more so — than memorizing it. Of those proposals, 20 to 30 will be chosen to write a longer request for a proposal that is the equivalent of applying for a National Institute of Health grant. From there, eight to 10 schools will be announced at the AMA Annual Meeting in June as sharing in the $10 million to help implement their ideas.

The AMA helped bring Flexner’s report to bear, with its Continuing Medical Education division. It rated medical schools at the time and solicited the Carnegie Foundation for the Advancement of Teaching — which chose Flexner — for further efforts in improving physician education. This was at a time that many schools’ quality was poor, and there were few, if any, standards for training doctors.

The AMA again has stepped to the forefront, not only with its $10 million offer but also with other efforts to promote initiatives to improve education, publishing papers on change in medical education and organizing high-level discussions in which experts talk about what the future of medical schools should be.

But unlike 100 years ago, when substandard schools closed or fired faculty to catch up to Flexner’s standards, the relationship between medical schools and agents of change is markedly more symbiotic.

Schools already are part of the discussion about accelerating the pace of instruction to three years instead of four, as a way to train more doctors and confront the current crisis of a looming physician shortage.

They have recognized the impact that the Internet and mobile technology have had as a means for doctors to quickly and easily review treatment guidelines and look up information on diseases, pharmaceuticals and procedures. Business tracks have been added at some schools to help future physicians learn about how to manage the complex insurance and financial environment they will face. There are now programs where physicians are taught how to work not only in an individual practice setting but also as leaders and members of teams that stretch across different professions, locations and practice settings.

The AMA’s “Accelerating Change in Medical Education” program indeed will fund individual schools with particularly compelling ideas, schools that a panel of experts will choose to reflect a variety of regions and projects. But the goal is not merely to promote transformations at a few schools. By including those schools in a medical education consortium, by sharing their ideas with all medical schools, and also by sharing other worthy ideas from schools that weren’t selected, the hope is that the AMA program helps facilitate creative thinking and out-of-the-box ideas across the spectrum of medical education.

The reason the AMA emphasizes “accelerating” change is that incremental changes aren’t enough to ensure that future doctors get the training they need in a world in which rapid business, population and technological changes have made being a doctor a much more dynamic profession. These have to be systemic changes, as bold and far-reaching in our time as they were in the wake of the Flexner report.

Flexner’s triumph stemmed from an era when there were many medical schools unworthy of the name. This next revolution starts from strength, solid opportunities and a well-demonstrated willingness to embrace change.


“Accelerating change in medical education,” American Medical Association (link)

I grandi ospedali sono più sicuri @Medici_Manager @WRicciardi

17 maggio 2013 di Denis Rizzoli

Il rischio di morte per un intervento chirurgico è significativamente più alto negli ospedali di piccole dimensioni. È il risultato di uno studio condotto dall’ Agenzia sanitaria per i servizi regionali(Agenas) e il Dipartimento di epidemiologia del Lazio. Si chiama Volumi di attività ed esiti delle cure: prove scientifiche in letteratura ed evidenze scientifiche in Italia e vuole dimostrare quali sono le malattie curate meglio negli ospedali con alti volumi di attività. Le conclusioni parlano chiaro. Farsi operare in una struttura che svolge poche operazioni potrebbe essere fatale per almeno 14 diverse patologie: l’aneurisma dell’aorta addominale non rotto, l’angioplastica coronarica, l’artoplastica del ginocchio, il bypass aortocoronarico, il tumore del colon, del pancreas, del polmone, della prostata, dello stomaco e della vescica, la colecistectomia laparoscopica, l’endoarterectomia carotidea, la frattura del femore e l’infarto. Per dimostrarlo, hanno svolto una ricerca sistematica negli studi internazionali pubblicati. Questi risultati sono stati poi confrontati con i dati del Programma Nazionale Esiti 2012, già pubblicati da Wired nella mappa interattiva #doveticuri con le performance di tutti gli ospedali italiani, cliccabile qui sotto.

Quali sono gli interventi più sicuri in un grande ospedale? 
L’ infarto è una delle patologie che fa più vittime con una media nazionale elevata: il 10,28% dei pazienti è morto entro 30 giorni dall’intervento, nel 2011. In questo caso, tuttavia, l’ospedale in cui si viene operati può fare la differenza.

È bastato incrociare la percentuale di decessi per infarto in ogni struttura (sull’asse verticale) con il numero di casi trattati nello stesso ospedale (sull’asse orizzontale) – escludendo però i centri con meno di 6 casi l’anno perché statisticamente fuorvianti. La curva risultante mostra che il numero di morti crolla fino a circa 100-150 casi l’anno e continua a diminuire al crescere dei ricoveri, come mostra il grafico tratto dallo studio di Agenas. È errato tuttavia parlare di una soglia di interventi oltre la quale si può ritenere un ospedale sicuro. “ Nei casi che abbiamo studiato, la mortalità continua a diminuire al crescere dei volumi quindi non è possibile trovare un punto esatto, una soglia minima”, spiega Marina Davoli del Dipartimento epidemiologia del Lazio. Forse non è un caso se tra gli ospedali con l’indice di rischio per infarto più alto (66,67%) nel 2011 ci siano strutture con un volume di 7 casi l’anno, come l’Ospedale Civile di Giaveno, in provincia di Torino, oppure l’ Ospedale di Pieve di Cadore, Belluno, con un volume di 9 interventi annuali. Tra i centri più virtuosi, invece, c’è una struttura con 891 casi l’anno, l’ Azienda Ospedaliera-Universitaria Careggi di Firenze, che ha un indice di rischio del 6,47%.

Anche per i malati di tumore si presenta un rischio analogo. Per esempio, il 5,88% dei pazienti operati di cancro allo stomaco sono morti nel 2011 ed è una delle malattie oncologiche più pericolose. Anche per questo intervento si è più sicuri in un grande centro.

I dati sulla mortalità di ogni struttura sono stati collocati sull’asse Y, mentre il numero di interventi effettuati sull’asse X. I pazienti che non sopravvivono dopo 30 giorni dall’intervento si riducono drasticamente negli ospedali che operano fino a circa 20-30 casi all’anno e la curva continua ad abbassarsi al crescere dei volumi di attività. Anche qui, uno dei centri con l’indice di rischio particolarmente alto (50%) è l’ospedale Rummò di Benevento con volume di 8 casi, mentre tra i più virtuosi c’è il Policlinico Universitario Agostino GemelliRoma, con una mortalità dell’0,62% e un volume di 96 interventi l’anno.

Passando alla frattura del femore, non ci sono sorprese rispetto ai casi precedenti. Questo intervento ortopedico è piuttosto pericoloso per i pazienti più anziani. Nel 2011, sono deceduti in media il 5,91%.

Il rischio di morte entro 30 giorni diminuisce a picco nelle strutture che operano fino a 100 interventi all’anno e continua a diminuire lievemente fino a stabilizzarsi.

Perché gli ospedali piccoli sono più pericolosi?
Riguardo ai motivi per cui il rischio di morte cala negli ospedali con più ricoveri gli esperti sembrano essere tutti d’accordo. “ È una relazione già ampiamente documentata dalla letteratura internazionale – spiega Carlo Perucci, direttore di Agenas – nella chirurgia c’è una linea d’apprendimento riguardo alla manualità e alle competenze. Più si lavora, più si diventa bravi”. Anche la numerosità delle equipe è un fattore determinate. “ Oltre alle abilità del singolo medico, c’è anche l’organizzazione. Un ospedale grande ha affrontato più casi particolari e quindi ha più medici specializzati in singole variazioni della stessa patologia”, illustra Stefano Nava, primario di pneumologia all’ Ospedale Sant’Orsola diBologna. Infine, anche il maggior numero di attrezzature sembrano giocare a favore dei grandi centri. “Solo le strutture con alti volumi, possono avere tutta l’infrastruttura necessaria per affrontare il problema”, prosegue Perucci. “ Se un paziente ha un trauma cranico e va nell’ospedale più vicino che non ha imaging o il radiologo non è reperibile, è chiaro che perde tempo. Il fattore tempo è fondamentale per molte patologie”, conclude Nava.

La mappa # doveticuri di Wired, dove sono contenuti le performance di tutti gli ospedali italiani, è stata scelta tra le finaliste dei Data Journalism Award, il premio del  Global Editors Network (Gen) dedicato alle migliori inchieste di data journalism. Da quest’anno anche i lettori possono esprimere la loro preferenza sul sito datajournalismawards.orgFate sentire la vostra voce.

Incidentalomas: The real cost of ordering tests @Medici_Manager @SIHTA_Italia @kevinmd


I recently read a very good article in the New York Times about a patient found to have the classic incidentaloma, a small mass in the adrenal gland.  This is estimated to be seen in 4% of abdominal CT scans, and is rarely serious but typically leads to recommendations for additional testing and follow up CT scans to assure that it is not either a metastatic cancer from another area or a hormone secreting tumor of the adrenal gland itself. It is so common that the NIH has a formal recommendation article to guide physicians on how to manage a small adrenal mass found on imaging modalities, what they refer to as adrenal incidentaloma, and even have an acronym “AI.”

The term incidentaloma is a tongue-in-cheek to denote an incidental finding on an imaging test.  –oma is the suffix used in the name of any tumor or enlargement.  Examples are lipoma, condyloma, meningioma, teratoma, and dozens of others. The root of the term obviously refers to the fact that it was an incidental finding on a test looking for something else altogether.

Classic incidentalomas include:

  • Tiny solitary pulmonary nodules. Commonly on chest x-ray or chest CT scan a small pulmonary nodule is seen.  Most times these are the result of a prior fungal infection or previous inflammation, but often require follow up imaging.
  • Small ovarian cysts seen on pelvic ultrasound.  The ovaries of women of child bearing age form an ovulatory cyst each month, and commonly these normal cysts, or other small cysts of questionable importance are noted on pelvic ultrasounds done for evaluation of uterine fibroids, evaluation of abnormal bleeding, or other concerns where ovarian cyst or cancer is not the primary concern.  Follow up ultrasounds, occasional surgery, and lots of emotional angst are the most common outcomes.
  • Renal cysts. Abdominal CT scans often show “lesions” in the kidney that require further evaluation to determine if they are simple renal cysts or possibly solid tumors.  They usually are cysts, but are common incidental findings on CT scans done to look for kidney stones, diverticulitis, or other problems. Again additional evaluation with ultrasound and sometimes monitoring over time or even biopsy are done to further evaluate these incidentalomas.
  • Lab test abnormalities, though not referred to as incidentalomas are other common incidental findings that often lead to a cascade of follow up testing.  The most common example in my practice is minor elevation of liver enzymes called transaminases, or liver function tests.  When abnormal these are usually repeated along with testing for viral hepatitis C and B.  If they remain abnormal liver imaging, sometimes liver biopsy are often done.  The usual outcome is a diagnosis of fatty liver, with advice to stop drinking alcohol, and lose weight.  This is advice that could have been given without even knowing the liver enzymes were elevated.

The whole incidentaloma problem is just one example of the real cost of ordering tests, especially tests like CT scans and MRIs that are so sensitive that they often find insignificant minor abnormalities or normal variants that lead to yet more expensive and sometimes invasive evaluation.

Edward Pullen is a family physician who blogs at

Alla ricerca dell’informazione di qualità @Medici_Manager

La buona informazione è la migliore medicina. “La disponibilità di informazioni affidabili e validate – considera Carlo Favaretti – può generare valore aggiunto solo se questa disponibilità viene ‘catturata’ da tutti coloro che, nella pratica quotidiana, devono combinare al meglio le risorse disponibili con i bisogni e le domande dei cittadini”. Ben venga quindi una guida come La ricerca documentale, rivolta a tutte le figure professionali sanitarie, su come trovare nel mare magnum web-based l’informazione di cui si ha bisogno in una prospettiva evidence-based oriented.

La presentazione di Carlo Favaretti go

Acquista il libro a soli 12 € go

Vaccines and Autism: CDC Study Says No Connection @Medici_Manager @WRicciardi

Frank DeStefano, MD, MPH

New CDC Study of Vaccine Doses and Autism

Concerns about childhood vaccinations and the risk for autism persist for many parents and some members of the public. A new CDC study published in the Journal of Pediatrics [1]addressed a current concern about the relationship between autism spectrum disorder (ASD) and vaccination, which centers on the number of vaccines and vaccine antigens given to infants and children, according to the recommended childhood immunization schedule.

The study evaluated the association between the level of immunologic stimuli received from vaccines during the first 2 years of life and the development of ASD. The findings showed that neither the number of antigens from vaccines received on a single day of vaccination, nor the total number of antigens received during the first 2 years of life, is related to the development of autism.

About This CDC Study

This study is the first of its kind to evaluate the issue of “too many vaccines too soon” and the development of ASD. The study was conducted in 3 managed care organizations (MCOs), involving 256 children with ASD and 752 control children matched by birth year, sex, and MCO. In addition to ASD, researchers evaluated autistic disorder and ASD with regression and found no relationship with the number of vaccine antigens received in either of these categories.

Study data were obtained from immunization registries and medical records. The data used in this study had been collected and analyzed previously.[2] Children eligible for the study were born between January 1, 1994, and December 31, 1999, and were 6-13 years old at the time of data collection.

Each child’s total vaccine antigen exposure was determined by adding the number of different antigens in all vaccines that each child received in 1 day, as well as all vaccine antigens each child received up to 2 years of age. The number of vaccines and number of vaccine doses administered according to type of vaccine are shown in the Table.

Table. Antigens in Vaccines and Total Doses Administered by Vaccine Type

Vaccine Type Antigens per Dose Dosesa
Diphtheria toxoid/tetanus-diphtheria (DT/TD) 2 14
Diphtheria-tetanus-pertussis (DTP) 3002 235
DTP – Haemophilus influenzae type B (Hib) 3004 1659
Diphtheria-tetanus-acellular pertussis (DTaP) 4b 1165
DTaP 5b 789
DTaP 6b 492
DTaPHepatitis B 6b 3
Influenza 10 95
Hib 2 2123
Hepatitis A 4 22
Hepatitis B 1 3085
HepatitisB-Hib 3 215
Measles, mumps, rubella (MMR) 24 1093
Measles 10 2
Meningococcusc 2 285
Mumps 9 1
Pneumococcusd 8 698
Polio 15 3385
Rabies 5 1
Rotaviruse 14 57
Rubella 5 2
Typhoid 3000 4
Varicella 69 917
Yellow fever 11 1
aTotal vaccine doses administered in the study population from birth to 2 years of age
bNumber of antigens in DTaP vaccines varied by manufacturer
cMeningococcal C conjugate vaccine administered as part of a clinical trial at 1 MCO
dPneumococcal conjugate (7-valent) vaccine; some doses administered in a clinical trial at 1 MCO
eRotaShield® (no longer marketed)

The number of vaccine antigens has decreased in recent years although the number of recommended vaccines has increased. The routine immunization schedule in 2013 contains more vaccines than the schedule of the late 1990s. The maximum number of vaccine antigens that a child would be exposed to today by 2 years of age is 315, compared with several thousand in the late 1990s. This is the result of changes in vaccines that allow them to more precisely stimulate the immune system. For example, the older whole-cell pertussis vaccine induced the production of approximately 3000 different antibodies, whereas the newer acellular pertussis vaccines (such as DTaP) stimulate the production of 6 or fewer different antibodies.

This study strengthens the conclusion of a 2004 comprehensive review by the Institute of Medicine of the scientific evidence that favored a rejection of the causal association between certain vaccines types and autism.[3]

Knowledge, Attitudes, and Beliefs About Vaccines and Autism

Some parents are concerned that there is a link between vaccines (such as MMR) or certain vaccine ingredients (such as thimerosal) and autism. However, several large and reliable studies of MMR vaccine have been done in the United States and other countries.[3,4] None has found a link between autism and MMR vaccination. Furthermore, research[2] does not show a link between thimerosal in vaccines and autism. Although thimerosal was taken out of childhood vaccines in 2001, autism rates have continued to climb.

Although scientific evidence shows that vaccines do not cause autism, a 2012 HealthStyles survey showed that slightly more than 15% of parents are concerned that they do (LaVail K, Fisher A, CDC; unpublished data). Data from the survey found that 22.8% of parents are concerned that children receive too many vaccines at a single doctor’s visit, and 22.8% of parents are concerned that children receive too many vaccines by the age of 2 years. The vaccines, they believe, can cause learning disabilities, such as autism. In another recent survey,[5] more than 1 in 10 parents of young children refuse or delay vaccinations in the belief that delaying vaccines is safer than giving vaccines according to the CDC-recommended immunization schedule. Children do not receive any known benefits from delaying vaccines. Delaying vaccines puts children at risk of becoming ill with vaccine-preventable diseases.

What Clinicians Can Do

CDC research with parents about their vaccine attitudes and vaccination behaviors has found that most US parents believe that vaccines are important, and they vaccinate their children. In fact, coverage for most of the routine childhood vaccines remains at or exceeds 90% in children aged 19-35 months. CDC and other agencies and organizations continue to conduct research to learn more about the causes of autism.

Healthcare professionals are the main determinants of parents’ decisions about whether to vaccinate their children. This study provides evidence that clinicians can use to reassure parents that the number of vaccines received early in life is not associated with the development of autism. Clinicians can help parents to learn the signs of ASD and act early so that action can be taken to help their children reach their full potential. Online resources, tools, and educational materials for clinicians to use to communicate with parents and caregivers are found at the end of this article.

Web Resources

CDC. Developmental Milestones

CDC. Autism Spectrum Disorders. Screening and Diagnosis for Healthcare Providers

American Academy of Pediatrics. Community Pediatrics. Act Early on Developmental Concerns: Partnering with Early Intervention

Frank DeStefano, MD, MPH, is Director of the Immunization Safety Office of the Centers for Disease Control and Prevention (CDC). He is a graduate of Cornell University and the University of Pittsburgh School of Medicine. He received training in public health and preventive medicine in the Epidemic Intelligence Service and preventive medicine residency at CDC. He obtained a Masters of Public Health degree at Johns Hopkins University School of Hygiene and Public Health. He has had extensive epidemiologic research experience at CDC, the National Institutes of Health, and at non-governmental research organizations. His areas of research have included immunizations, autism and other developmental disabilities, reproductive health, veterans’ health, diabetes, cardiovascular diseases, and other chronic diseases. Dr. DeStefano is an author on over 150 publications in leading scientific and medical journals. For the past 16 years Dr. DeStefano has had a focus on vaccine safety.

Reactions to Choosing Wisely® @Medici_Manager @muirgray

On February 21st, seventeen medical specialty societies announced new lists of things physicians and patients should question as part of the ABIM Foundation’s Choosing Wisely campaign. This marks the second release of lists from the campaign; at least 18 societies will release new lists later in the year.

In addition to the announcement of new lists, Consumer Reports—which has worked with the medical specialty societies to create patient-friendly translations—published new brochures that now cover more than 30 specific topic areas.

The National Business Coalition on Health and Pacific Business Group on Health also unveiled new a Choosing Wisely Employer Toolkit to help employers educate their employees about steps they can take to avoid overused or unnecessary tests or procedures.

The announcement of new society lists was covered widely in the media and inspired reactions ranging from cautiously optimistic to skeptical that the campaign could achieve its goals.

A brief sampling:

The New York Times’ The New Old Age Blog For the Elderly, Medical Procedures to Avoid
“It is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments. It took an elegantly simple approach: By working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify ‘Five Things Physicians and Patients Should Question.’”

Huffington Post Choosing Wisely, Indeed
“This long overdue and welcome effort is launched to inspire conversations between patients and doctors about the necessity—or lack thereof—of many commonly-ordered diagnostic tests and medical approaches.”

Modern Healthcare Curbing Overuse (subscription required)
“We have created a medical ecology based on overprescription and overconsumption on the part of both physicians and patients,” Dr. Blair Erb said. “What Choosing Wisely has done is legitimize our ability to cut back on what’s unnecessary.”

Stand Up For Health Care Blog “Just in Case” Can Mean More Money and No Benefit
Choosing Wisely is something we can all do to improve our own care and improve our health care system at large.”

Albany Herald Staff Editorial: More Isn’t Always Better in Medicine
“For American health care to be what it should be, its core has to reside in truthful communication between a patient and the doctor he or she trusts.”

Akron Beacon Journal Editorial: The Doctors’ List of Don’ts
“The premise of Choosing Wisely is that good information, presented in language that the average layman can grasp, will lead to intelligent conversation and good decisions about appropriate treatment. The project is appealing as an ongoing exercise in determining what is worth the money in medical care. It is especially appealing because when the recommendations come from practitioners themselves, it helps to strip a sensitive discussion of the toxic exaggerations so often the currency of the political arena.”

The Economist: Democracy in America Waste Lots, Want Lots 
“The Choosing Wisely campaign is bravely entering the fray, but its ambition is modest. It hopes to convey that not all care is good care. Slowly, the culture among physicians and patients may change. But the campaign has no teeth. Its suggestions are phrased in the gentlest possible manner, listing treatments that ‘patients and physicians should question.’”

For updates on the campaign, follow #ChoosingWisely on Twitter (@ABIMFoundation), “Like” us on Facebookand subscribe to The Medical Professionalism Blog.

Antimicrobial resistance—an unfolding catastrophe @Medici_Manager @bmj_latest

Fiona Godlee, editor, BMJ

At the end of the 1960s, the then US surgeon general William H Steward famously declared: “The war against infectious diseases has been won.” His optimism might well have been justified at the time. The discovery of antibiotics and their widespread introduction had transformed both medical practice and life expectancy.

Antibiotics still transform lives, but—as with so many of the world’s resources—we now know that they are not limitless, and that unless we are careful, their beneficial effects will run out. We have become so accustomed to the availability of antibiotics that a world without them is almost inconceivable. Yet this is the world that England’s chief medical officer, Sally Davies, demands we contemplate in the second volume of her annual report (doi:10.1136/bmj.f1597). The causes of this unfolding catastrophe are many: overuse of existing antibiotics, increasing resistance to them, a “discovery void” regarding new drugs, and a change in the types of organisms presenting the greatest threat. “If we don’t get this right we will find ourselves in a health system not dissimilar to the early 19th century,” she says.

Is Davies being overdramatic? Sadly not. Her decision to focus on antimicrobial resistance has been broadly welcomed. And this week we publish a report from Richard Smith and Joanna Coast, long term analysts of the economics of resistance (doi:10.1136/bmj.f1493). They suggest that the picture she paints may even be too rosy. “Resistance is said to present a risk that we will fall back into the pre-antibiotic era,” they say. “However, this is perhaps optimistic.”

Their argument is that we have badly underestimated the cost of resistance. Studies that have tried to estimate the economic impact have looked at the extra cost of treating a resistant infection compared with a susceptible one. But this ignores the bigger picture. The whole of modern healthcare, including invasive surgery and immunosuppressive chemotherapy, is based on the assumption that infections can be prevented or treated. ”Resistance is not just an infectious disease issue,” they say. “It is a surgical issue, a cancer issue, a health system issue.”

Their revised assessment of the economic burden of resistance encompasses the possibility of not having any effective antimicrobial drugs. Under these circumstances they estimate that infection rates after hip replacement would increase from about 1% to 40-50%, and that about a third of people with an infection would die. It seems likely that rates of hip replacement would fall, bringing an increased burden of morbidity from hip pain.

The CMO’s 17 recommendations include better hygiene measures and surveillance, greater efforts to preserve the effectiveness of existing drugs, and encouragement to develop new ones. As Anthony Kessel and Mike Sharland point out, only one or two new antibiotics that target Gram negative organisms are likely to be marketed in the next decade (doi:10.1136/bmj.f1601). Recognising this as a global problem, the CMO’s report also calls for antimicrobial resistance to be put on the national risk register and taken seriously by politicians internationally.

As for the cost of such action, Smith and Coast see it as an essential insurance policy against a catastrophe that we hope will never happen. And they share the CMO’s urgency. “Waiting for the burden to become substantial before taking action may mean waiting until it is too late.”


Cite this as: BMJ 2013;346:f1663

Footnotes Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest