The Doctor's Channel - Business of Medicine

Alternative Medicine

2010-03-09T20:01:31+00:00

A new survey finds that most medical students think conventional medicine could benefit to some extent by integrating complementary and alternative medicine, also known as CAM. Supporters of CAM considered it to be a more holistic and highly individualized approach to patient care than conventional medicine.

For more information on Modern Physician, visit:
Modern Physician

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Information Technology Adoption

2010-03-09T19:59:09+00:00

If you’re looking for a word to describe the adoption of information technology by physician practices, “drip” would be more appropriate than “gush.” According to a new government study, the percentage of office-based physicians using electronic health record systems has increased, but the pace of adoption has slowed.

For more information on Modern Physician, visit:
Modern Physician

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The Reality of Electronic Medical Records

2010-03-09T19:52:54+00:00

When it comes to the power of electronic medical records to coordinate patient care, perception and reality are two totally different things. At least according to a new study published in the Journal of General Internal Medicine. The study suggests that the federal government should do more to ensure that the information technology it’s pushing through financial incentives gives physicians the tools they need to coordinate care for their patients.

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Modern Physician

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EMR rebate

2010-03-08T16:09:38+00:00

Micheal Swiernik, MD, Director, Medical Informatics, UCLA, discusses the considerations before purchasing an EMR that suits your workplace, and the costs associated with implementing this into your practice in a cost-effective manner.

Reading:
Terry AL, Chevendra V, Thind A, Stewart M, Marshall JN, Cejic S. Using your electronic medical record for research: a primer for avoiding pitfalls. Fam Pract. 2009 Oct 14.
Joe RS, Kushniruk AW, Borycki EM, Armstrong B, Otto T, Ho K. Bringing electronic patient records into health professional education: software architecture and implementation. Stud Health Technol Inform. 2009;150:888-92.
McGrath D. Using a phased-in incremental approach to EMR implementation. J Med Pract Manage. 2009 May-Jun;24(6):355-7.

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Quality Measures Reporting

2010-03-03T22:04:35+00:00

The concept seems simple enough, but even after several years in operation, Medicare's Physician Quality Reporting Initiative is still causing headaches for doctors.

Under this voluntary program, physicians receive a small bonus for reporting data on quality measures for services they provide. In 2008, the last year for which data was available, Medicare paid more than $92 million in incentives to doctors.

For more information on Modern Physician, visit:
Modern Physician

Views: 520
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Communication Challenges

2010-02-19T16:47:18+00:00

A new study of physician practices finds that while many physicians are having difficulty communicating with patients because of language or cultural barriers, even fewer are following the recommended steps to overcome those barriers.

For more information on Modern Physician, visit:
Modern Physician

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NT-proBNP measurement expedites chest pain management

2010-02-16T17:34:32+00:00

NEW YORK (Reuters Health) - In patients with chest pain of uncertain origin, emergency department evaluation combining clinical history and N-terminal pro-B-type natriuretic peptide (NT-proBNP) level, without exercise testing, safely reduces hospitalizations compared with a conventional strategy.

That’s according to randomized trial results reported by Spanish researchers in the American Heart Journal for February.

The practice of using exercise testing to determine whether chest pain patients should be admitted is often limited by restricted availability and patients’ inability to exercise, said lead author Dr. Juan Sanchis, at the University of Valencia, and his associates.

“In this setting, a simpler alternative tool to exercise testing seems to be justified,” they suggest. Clinical history alone cannot predict short-term events -- but NT-proBNP has been shown to provide additional prognostic information.

The research team compared two different strategies among 320 patients (160 in each study arm). Each patient had chest pain of possible coronary origin but with a nonischemic electrocardiogram and normal troponin levels.

The new strategy used a risk score accounting for pain, number of pain episodes in the previous 24 hours, age, insulin-treated diabetes, and prior percutaneous coronary intervention. Patients with a low clinical risk score and NT-proBNP < 110 ng/L (in a blood sample drawn 8 to 12 hours after pain onset) were directly discharged; otherwise they were admitted to the hospital.

In the usual care group, the decision to hospitalize was guided by the exercise test; patients with a contraindication to exercise were also hospitalized.

On the day of the index episode, the hospitalization rate was 56% with the new strategy and 69% with usual care (odds ratio 0.6, p = 0.03).

Usual care was also associated with more frequent revascularization at the index episode (18% vs 8%, p = 0.01), although the NT-proBNP-based strategy was associated with higher rates of planned postdischarge revascularizations (0.6% vs 5%, p = 0.04).

There were no significant differences between the usual care and new strategy groups, respectively, in rates of death (0.6% vs 1.3%), acute MI (6.9% vs 3.1%), or readmission for unstable angina (3.1% vs 3.8%) during 1-year follow-up.

Dr. Sanchis and his associates advise that “studies sized for clinical end points are needed to confirm the promising results of the present pilot study.”

Until then, they do not recommend the new strategy for routine clinical use.

Reference:
Am Heart J 2010;159:176-182.

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Google brain

2010-02-01T15:47:34+00:00

Gary Small, MD, Director, UCLA Center on Aging, University of California, Los Angeles, discusses a recent study, “Your Brain on Google” in which blood flow patterns were compared in internet - naïve brains before and after using the internet and found an increased brain activity in short-term memory and decision making.

Reading:
Small GW, Moody TD, Siddarth P, Bookheimer SY. Your brain on Google: patterns of cerebral activation during internet searching. Am J Geriatr Psychiatry. 2009 Feb;17(2):116-26.
van Gerven M, Farquhar J, Schaefer R, Vlek R, Geuze J, Nijholt A, Ramsey N, Haselager P, Vuurpijl L, Gielen S, Desain P. The brain-computer interface cycle. J Neural Eng. 2009 Aug;6(4):041001. Epub 2009 Jul 22. Review.
Kircher T, Blümel I, Marjoram D, Lataster T, Krabbendam L, Weber J, van Os J, Krach S. Online mentalising investigated with functional MRI. Neurosci Lett. 2009 May 1;454(3):176-81. Epub 2009 Mar 14.

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Biomarker-guided treatment of infection reduces antibiotic exposure in ICUs

2010-01-28T16:43:58+00:00

NEW YORK (Reuters Health) - The biomarker procalcitonin can help guide treatment of severe bacterial infections in the intensive care unit (ICU), French investigators report online in The Lancet on January 23.

They suggest that procalcitonin-guided therapy can cut treatment duration and perhaps reduce the emergence of antibiotic-resistant strains.

Serum levels of procalcitonin have been used to diagnose bacterial sepsis, the authors explain, and its use has been shown to reduce antibiotic exposure in patients with acute respiratory tract infections. However, the few ICU trials were small and “underpowered for safety, which in this setting is of the utmost importance.”

In the prospective, open-label PRORATA trial, Dr. Michel Wolff at Hopital Bichat-Claude-Bernard in Paris and colleagues compared procalcitonin-guided treatment with standard care in 8 ICUs. In patients randomized to the procalcitonin group, levels were measured each day, and 0.5 mcg/L was the threshold for starting antibiotics. Physicians were urged to stop treatment when procalcitonin dropped below 80% of the peak concentration or when the absolute concentration was < 0.5 mcg/L.

In both groups, all treatment decisions were left in the hands of the treating physicians.

According to the report, the patients had a wide range of infections; 40% had septic shock, and close to 70% were on mechanical ventilation.

Mortality did not differ significantly between the 307 patients in the procalcitonin group and the 314 controls at day 28 (21.2% vs 20.4%, respectively) or at day 60 (30% vs 26.1%, respectively), the investigators report, demonstrating non-inferiority of the procalcitonin algorithm. None of the deaths was related to infection relapse.

During the first 4 weeks, antibiotic treatment lasted an average of 10.3 days in the procalcitonin group and 13.3 days in the control group, for a 23% relative reduction in days of antibiotic exposure (p < 0.0001). Days of antibiotic exposure per 1000 inpatient days totaled 653 and 812, respectively (p < 0.0001).

Rates of physician adherence to the treatment algorithm were 47% in the procalcitonin group and 55% in the control group. However, findings were similar for patients strictly managed according to study algorithms.

After the 28th day, 39% of patients in each group had not been discharged, but only 17% of the procalcitonin group and 14% of the control group were still in the ICU.

The authors found no differences between the groups in most secondary outcomes, including rates of relapse or superinfection, number of days without mechanical ventilation, ICU or hospital length of stay, and percentage of emerging multidrug-resistant bacteria.

They note that their findings cannot be extrapolated to surgical patients, who represented about 10% of the study cohort, or to those needing long-term antibiotics or who are neutropenic or infected with high-risk pathogens.

Still, the researchers believe their conclusions are likely to be generalizable to most other non-surgical ICU patients, including those who are immunocompromised.

Furthermore, they add, “A procalcitonin-guided strategy could reduce antibiotic selective pressure with potential benefits in the era of multiresistance.”

Reference:
Lancet 2010.

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Early discharge feasible for low-risk patients after STEMI angioplasty

2010-01-27T23:13:20+00:00

EW YORK (Reuters Health) - Low-risk patients with ST-segment elevation myocardial infarction (STEMI) treated with angioplasty can be discharged within 72 hours, Canadian investigators suggest.

Although STEMI patients are usually hospitalized for 5 to 7 days to monitor for serious complications, Dr. Madhu K. Natarajan and colleagues at Hamilton Health Sciences-General Site in Hamilton, Ontario, were able to safely target low-risk patients for early discharge followed by close nursing follow-up.

Within 24 hours of percutaneous coronary intervention (PCI), participants were randomized to discharge within 72 hours or standard care. Patients were eligible for the study if they had a Zwolle score of 3 or less, with no obvious contraindication to early discharge at the time of randomization.

"We find the Zwolle score particularly useful," the authors write in the January issue of the American Heart Journal. The Zwolle Primary PCI Index takes into account Killip class, postprocedural TIMI (Thrombolysis In Myocardial Infarction) flow, age, 3-vessel disease, site of infarction, and ischemic time. Patients with a score of 3 or less (out of 16) have a 30-day mortality risk of 0.5% and a 0.2% risk of malignant ventricular arrhythmias after 48 hours.

In their report, the researchers describe a prospective pilot study in 54 patients conducted from January to October 2007.

In fact, the authors found, "length of stay was short in all study patients" - a median of 55 hours overall. There was no difference between the groups either in length of stay or rate of rehospitalization at 6 weeks (8% with early discharge and 4% with standard care). No patient from either group died.

The intervention group met all prespecified criteria for feasibility, including 74% discharged within 72 hours and at least three follow-ups with the nurse, the first being within 3 days of discharge.

Among patients who could not participate in the trial because they were being transferred back to their referring hospital after PCI, the median length of stay was 78 hours (p = 0.0003). Therefore, the authors recommend, "It may be preferable to discharge these patients directly from the hospital where PCI was performed."

Am Heart J 2010;159:117e1-117e6.

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