Why a Blog?

It’s not like you don’t have enough to read, or that I don’t have enough to do. So, why do I blog? And why should you read?

We are in the early days of a revolution in healthcare. The hospitalist field has grown from an idea – given breath by a handful of hardy pioneers – to a thriving specialty of more than 20,000 doctors: the fastest growing field in the history of American medicine. Hospitals have moved from assumed, reputational quality to a new kind of quality: measured, reported, and sometimes even paid for. Evidence-based medicine is rapidly supplanting eminence-based medicine. Patient safety wasn’t even in the lexicon a decade ago; now it seems to dominate every discussion. Housestaff work hours, nurse-to-patient ratios, the Joint Commission, medication reconciliation, CPOE, EMRs, PHRs….

What an incredibly exciting time to be in the middle of the storm. But it is also disorienting and a little bit scary; some days it feels like we’re in the carnival Fun House, the exit sign nowhere in sight.

Starting from my days as an intrepid college poly sci major, I found that I enjoyed – and maybe had a bit of talent in – analyzing complex situations and articulating my understanding to others. Since then, I’ve done work in healthcare policy, epidemiology, ethics, quality, safety, and medical education, and remain a (semi-) active clinician and teacher. Few things make me happier than dissecting and explaining healthcare issues, particularly when they’re clinically meaningful and politically and ethically charged, with passionate advocates and foes. Although I enjoy following healthcare Policy-with-a-capital-“P” (i.e., what happens inside the Beltway), my real interests lie closer to the ground: how changes in policies, practice, science, economics, and culture affect the way we care for patients, teach our trainees, and organize our work.

As I trolled around the World Wide Blogosphere, I found many terrific healthcare blogs, but none that approached our work from this particular angle: the policy and practice issues that affect real docs and nurses – and real patients – in real hospitals and clinics.

Ergo, this blog. Although I’ve written half-a-dozen books and 200 articles, these formats are a bit too formal, their time horizon a bit too elongated, to handle my daily impressions of the key issues of the day. Sometimes, I make a connection that helps illuminate my understanding of an issue, or stumble upon an article or a website that I find fascinating, or meet a colleague who educates me about something important and cool. In these circumstances, the idea of sharing it with my friends – or a few thousand of them – seems like the thing to do, as natural as breathing.

So I suspect I’ll be blogging a couple of times per week. I’ll really try not to waste your time or just blog for blogging’s sake. Most of my postings will represent my thoughts, though I welcome your comments and hope we can generate a lively dialogue. At times, I’ll act as a curator, bringing items that I think you’ll be interested in to your attention. But even then, I’ll try to place the pieces in context, not simply becoming a library or another daily update of the literature or news cluttering your In-Box.

And I’ll do my best to make it fun, interesting to read, and a bit contrarian and controversial. But never boring or wishy-washy.  

At least, that’s my goal. My 16-year-old son (who I hoped would be
impressed by “My Dad, The Blogger”), saw the title “Wachter’s World”,
rolled his eyes, and snorted, “I have an idea for your subtitle. How
about “Just Like Wayne’s World… Only Nerdier!”

Well, you can’t please everbody. I hope you enjoy the blog.

In any case, that’s quite enough editorial throat-clearing and knuckle-cracking. Here’s my first blog entry, on why pay-for-performance, Medicare-style, won’t have legs, but another kind of P4P will prove to be durable and transformative..

One Response to “Why a Blog?”

  1. Dr. Johnstone Sikulu Wanjala August 12, 2009 at 2:43 pm #

    Over 3000 children diagnosed with HIV in Bungoma after hospital introduces
    Implementing a policy of routine opt-out HIV testing led to the diagnosis of 3000 HIV infections in children admitted to hospital in Bungoma over an 18-month period, investigators report in a study published in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

    “Increased HIV testing has been proposed as an important component of HIV prevention and a pathway to support universal access to antiretroviral therapy”, write the investigators. “This is particularly important for infants where the rate of disease progression is extremely rapid, the risk of early death is high, and antiretroviral therapy can decrease mortality significantly in the first year of life”, they add.

    In an attempt to increase the number of diagnosed HIV-positive children in Bungoma Kenya, investigators at the University Teaching Hospital implemented a policy of offering routine HIV counselling and testing to all children admitted as inpatients.

    HIV prevalence amongst women attending antenatal services in Kenya is 25% and an estimated 28,000 infants are born each year in the country with HIV infection. The investigators therefore hypothesised that routinely offering HIV testing would identify large numbers of HIV-infected children.

    A total of 15,670 children of unknown HIV status were admitted to the hospital as in-patients between January 2007 and June 2009. Of these, 13,239 parents/caregivers (85%) received counselling for testing of their child and 11,571 children (87%) had an HIV test.

    In all, 3373 (29%) of children tested HIV-positive. Almost a third of children under six months of age were HIV-positive, as were 23% of children aged five and over. Nevertheless, two-thirds (69%) of children testing positive were under 18 months of age.

    Children admitted to the malnutrition ward had the highest prevalence of HIV infection (36%). After adjusting for possible confounding factors, the investigators found that children admitted to the malnutrition ward (adjusted odds ratio [AOR], 16.7; 95% CI: 13.7-20.4) and the diarrhoea/rehydration ward (AOR, 8.2; 95% CI: 13.7-20.4) were significantly more likely to test HIV-positive than children admitted to other wards.

    Approximately 4100 eligible children were not tested for HIV and 1668 (41%) received counselling but were not subsequently tested for the infection. The most common reason for not testing were the death of the child (44%), the refusal of the parent (12%) and early discharge (10%).

    “Many of the categories represent missed testing opportunities: early discharge, absconded, and weekend admission. The majority of children in these categories received no counselling. In contrast, parental refusal and waiting for husband’s permission represent situations where counselling was performed, but the child was not tested”, note the authors.

    As well as diagnosing over 3000 children, the investigators note secondary benefits of their programme of routine testing. “Parents and caregivers were offered HIV testing and, later in the programme, CD4 cell testing. HIV-positive adults were referred for care.” The investigators also write that parents were encouraged to bring other children in for HIV testing.

    “We successfully implemented a routine HIV counselling and testing programme for hospitalized paediatric patients”, conclude the investigators, “we propose that this programme is particularly relevant in settings with generalised HIV epidemics and should be replicated as a highly feasible way to identify children in need of HIV care and antiretroviral treatment.”
    I am looking forward to hearing from you.
    Best regards
    Dr. Johnstone Sikulu Wanjala
    Programme coordinator
    Sima Community based Organization
    PO BOX 1691, Kitale 30200
    Kenya.
    Cell +254 735754816

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