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Concern about Copper's Effectiveness in Preventing Hospital-Acquired Infections
Karen Appold’s cover story, “Copper,” in the September 2013 issue, offers an exciting and encouraging development in the struggle to prevent hospital-acquired infections, but I have two concerns. As copper tarnishes, it forms a surface patina of copper hydroxide and copper carbonate. Would this patina act as a physical barrier, preventing bacteria from coming into contact with elemental copper and inhibiting the antimicrobial effect? If so, the obvious solution is to polish the surface frequently enough to prevent tarnishing.
The second concern regards the use of copper-nickel alloys. Many people are sensitive to nickel, [with reactions that] usually manifest as contact dermatitis. A study by the North American Contact Dermatitis Group (NACDG), conducted between 1992-2004 and involving 25,626 patients who were patch-tested, showed a prevalence of nickel sensitivity of 18.8% in 2004, increased from 14.5% in 1992.1
With a current U.S. population of approximately 317 million, a prevalence of 18.8% would mean nearly 60 million people with nickel sensitivity. Extrapolating from the NACDG study, the rate is probably actually higher. Medical devices made with copper-nickel alloys that contact the patient’s skin would cause contact dermatitis, and implanted devices would have the potential for more severe allergic reactions.
I simply urge foresight and caution in the use of various copper alloys for medical applications.
Rod Duraski, MD, MBA, FACP, medical director, WGH Hospital Medicine, LaGrange, Ga.
Reference
Karen Appold’s cover story, “Copper,” in the September 2013 issue, offers an exciting and encouraging development in the struggle to prevent hospital-acquired infections, but I have two concerns. As copper tarnishes, it forms a surface patina of copper hydroxide and copper carbonate. Would this patina act as a physical barrier, preventing bacteria from coming into contact with elemental copper and inhibiting the antimicrobial effect? If so, the obvious solution is to polish the surface frequently enough to prevent tarnishing.
The second concern regards the use of copper-nickel alloys. Many people are sensitive to nickel, [with reactions that] usually manifest as contact dermatitis. A study by the North American Contact Dermatitis Group (NACDG), conducted between 1992-2004 and involving 25,626 patients who were patch-tested, showed a prevalence of nickel sensitivity of 18.8% in 2004, increased from 14.5% in 1992.1
With a current U.S. population of approximately 317 million, a prevalence of 18.8% would mean nearly 60 million people with nickel sensitivity. Extrapolating from the NACDG study, the rate is probably actually higher. Medical devices made with copper-nickel alloys that contact the patient’s skin would cause contact dermatitis, and implanted devices would have the potential for more severe allergic reactions.
I simply urge foresight and caution in the use of various copper alloys for medical applications.
Rod Duraski, MD, MBA, FACP, medical director, WGH Hospital Medicine, LaGrange, Ga.
Reference
Karen Appold’s cover story, “Copper,” in the September 2013 issue, offers an exciting and encouraging development in the struggle to prevent hospital-acquired infections, but I have two concerns. As copper tarnishes, it forms a surface patina of copper hydroxide and copper carbonate. Would this patina act as a physical barrier, preventing bacteria from coming into contact with elemental copper and inhibiting the antimicrobial effect? If so, the obvious solution is to polish the surface frequently enough to prevent tarnishing.
The second concern regards the use of copper-nickel alloys. Many people are sensitive to nickel, [with reactions that] usually manifest as contact dermatitis. A study by the North American Contact Dermatitis Group (NACDG), conducted between 1992-2004 and involving 25,626 patients who were patch-tested, showed a prevalence of nickel sensitivity of 18.8% in 2004, increased from 14.5% in 1992.1
With a current U.S. population of approximately 317 million, a prevalence of 18.8% would mean nearly 60 million people with nickel sensitivity. Extrapolating from the NACDG study, the rate is probably actually higher. Medical devices made with copper-nickel alloys that contact the patient’s skin would cause contact dermatitis, and implanted devices would have the potential for more severe allergic reactions.
I simply urge foresight and caution in the use of various copper alloys for medical applications.
Rod Duraski, MD, MBA, FACP, medical director, WGH Hospital Medicine, LaGrange, Ga.
Reference
Four Recommendations to Help Hospitalists Fight Antimicrobial Resistance
Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.
Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.
The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.
“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”
Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.
The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.
“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.
New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.
Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.
Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.
The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.
“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”
Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.
The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.
“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.
New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.
Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.
Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.
The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.
“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”
Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.
The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.
“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.
New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.
Hospitalists Poised to Prevent, Combat Antibiotic-Resistant Pathogens
Describing formally for the first time the enormity of the problem of antibiotic resistance and warning of the “potentially catastrophic consequences of inaction,” the Centers for Disease Control and Prevention (CDC) announced in September that more than two million people a year are sickened by infections that are resistant to treatment with antibiotics.
Moreover, the CDC says 23,000 people die as a result.
And because those numbers are based only on the data available—and the agency assumes that many infections are not captured—the CDC says its estimate is a conservative one and the real number is probably higher.
The report is a call to action for hospitalists, who are in an almost ideal position to participate in efforts to prevent infections and control their spread once they’re discovered, says Jean Patel, PhD, deputy director of the office of antimicrobial resistance at the CDC.
“I think it’s a sobering number, and it indicates how far we have to go in combating this problem of antimicrobial resistance,” Dr. Patel says.
The medical community, she adds, cannot expect that new treatments will become available to fight all of these new infections.
“All of the drugs also are going to have some gaps in their range of activity, so there’s no drug coming that’s going to be effective against all the antimicrobial-resistant drugs that we face today,” Dr. Patel explains. “For that reason, we’re sounding the alarm that it’s important to pay attention to infection control and antibiotic stewardship practices.”
The report, “Antibiotic Resistance Threats to the United States, 2013,” creates three categories of antibiotic-resistant pathogens. In the “urgent” tier are Clostridium difficile, which the CDC estimates is responsible for 250,000 infections a year and 14,000 deaths; carbapenem-resistant Enterobacteriaceae, estimated to be responsible for 9,000 drug-resistant infections a year and 600 deaths; and drug-resistant Neisseria gonorrhoeae, at 246,000 drug-resistant infections.
These bacteria are considered an “immediate public health threat that requires urgent and aggressive action.”
There are 12 pathogens in the second category, described as “a serious concern” requiring “prompt and sustained action to ensure the problem does not grow.”
Of particular interest to hospitalists in this group, Dr. Patel says, is methicillin-resistant Staphylococcus aureus (MRSA). The CDC estimates that more than 80,000 severe MRSA infections and more than 11,000 deaths occur in the U.S. every year.
MRSA was not ranked as an “urgent” threat only because the number of infections is actually decreasing, especially in healthcare institutions, and because there are antibiotics that still work on MRSA.
“If either of those things were to change—for example, if the rate of infections were to increase, or if these isolates were to become more resistant—then we would have to think about changing this from a serious threat to an urgent threat,” Dr. Patel says.
Another infection in the serious category that should be on hospitalists’ radar is drug-resistant Streptococcus pneumoniae. A new vaccine is helping to decrease the number of these infections, but hospitalists should be vigilant about infections that could escape the vaccine and become resistant, Dr. Patel says.
The report estimates as much as $20 billion in excess healthcare costs due to antimicrobial-resistant infections, with $35 billion in lost productivity in 2008 dollars.1
Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious disease control committees at Emory University Hospital Midtown, says the sheer numbers are sure to get people to take notice.
“Two million is lots of patients,” she says. “It’s eye-opening, really, for many doctors and patients and society.”
The silver lining, she says, is that the field is moving toward diagnostic tools that will provide quick feedback on the type of infection at work.
It may be that hospitalists have no choice but to give an antibiotic to a patient because of the risk involved in not giving one; however, providers should quickly tailor that treatment to target the specific pathogen when more information is available.
—Ketino Kobaidze, MD, assistant professor, Emory University School of Medicine, Atlanta, member, antimicrobial stewardship and infectious disease control committees, Emory University Hospital Midtown
“The most important thing, I think, for hospital medicine and medicine anywhere, is to follow up with whatever you’re ordering and notice right away what happens with these tests. If it’s positive or negative, redirect your care,” Dr. Kobaidze says. “Time is really an important issue here.
“As hospitalists, we need to be extremely cautious not to give them something they don’t need.”
Dr. Kobaidze was particularly struck by gonorrhea being listed in the “urgent” threat category.
“It was so easy to treat before,” she says. “It was nothing, piece of cake. This makes me a little bit concerned.”
Robert Orenstein, DO, an infectious disease expert at Mayo Clinic, praises the report and says hospitalists have a key role to play.
“I think this has a clear impact on hospitalists, who are the primary caregivers of many of these ill patients,” he says. “We need to educate them and build systems that target antimicrobials to the infecting agents and limit their use. Hospitalists are also the people who can help protect patients from the spread of these in the hospital by following appropriate infection prevention guidelines and educating their colleagues of the importance of this.”
He also stresses the importance of being aware of threats within your specific region.
“Many of these MDROs [multi-drug resistant organisms] have regional prevalence,” he says. “And it’s important to know which bugs are in your region so you can work with your institution and public health to tackle these.”
Tom Collins is a freelance writer in South Florida.
Reference
Describing formally for the first time the enormity of the problem of antibiotic resistance and warning of the “potentially catastrophic consequences of inaction,” the Centers for Disease Control and Prevention (CDC) announced in September that more than two million people a year are sickened by infections that are resistant to treatment with antibiotics.
Moreover, the CDC says 23,000 people die as a result.
And because those numbers are based only on the data available—and the agency assumes that many infections are not captured—the CDC says its estimate is a conservative one and the real number is probably higher.
The report is a call to action for hospitalists, who are in an almost ideal position to participate in efforts to prevent infections and control their spread once they’re discovered, says Jean Patel, PhD, deputy director of the office of antimicrobial resistance at the CDC.
“I think it’s a sobering number, and it indicates how far we have to go in combating this problem of antimicrobial resistance,” Dr. Patel says.
The medical community, she adds, cannot expect that new treatments will become available to fight all of these new infections.
“All of the drugs also are going to have some gaps in their range of activity, so there’s no drug coming that’s going to be effective against all the antimicrobial-resistant drugs that we face today,” Dr. Patel explains. “For that reason, we’re sounding the alarm that it’s important to pay attention to infection control and antibiotic stewardship practices.”
The report, “Antibiotic Resistance Threats to the United States, 2013,” creates three categories of antibiotic-resistant pathogens. In the “urgent” tier are Clostridium difficile, which the CDC estimates is responsible for 250,000 infections a year and 14,000 deaths; carbapenem-resistant Enterobacteriaceae, estimated to be responsible for 9,000 drug-resistant infections a year and 600 deaths; and drug-resistant Neisseria gonorrhoeae, at 246,000 drug-resistant infections.
These bacteria are considered an “immediate public health threat that requires urgent and aggressive action.”
There are 12 pathogens in the second category, described as “a serious concern” requiring “prompt and sustained action to ensure the problem does not grow.”
Of particular interest to hospitalists in this group, Dr. Patel says, is methicillin-resistant Staphylococcus aureus (MRSA). The CDC estimates that more than 80,000 severe MRSA infections and more than 11,000 deaths occur in the U.S. every year.
MRSA was not ranked as an “urgent” threat only because the number of infections is actually decreasing, especially in healthcare institutions, and because there are antibiotics that still work on MRSA.
“If either of those things were to change—for example, if the rate of infections were to increase, or if these isolates were to become more resistant—then we would have to think about changing this from a serious threat to an urgent threat,” Dr. Patel says.
Another infection in the serious category that should be on hospitalists’ radar is drug-resistant Streptococcus pneumoniae. A new vaccine is helping to decrease the number of these infections, but hospitalists should be vigilant about infections that could escape the vaccine and become resistant, Dr. Patel says.
The report estimates as much as $20 billion in excess healthcare costs due to antimicrobial-resistant infections, with $35 billion in lost productivity in 2008 dollars.1
Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious disease control committees at Emory University Hospital Midtown, says the sheer numbers are sure to get people to take notice.
“Two million is lots of patients,” she says. “It’s eye-opening, really, for many doctors and patients and society.”
The silver lining, she says, is that the field is moving toward diagnostic tools that will provide quick feedback on the type of infection at work.
It may be that hospitalists have no choice but to give an antibiotic to a patient because of the risk involved in not giving one; however, providers should quickly tailor that treatment to target the specific pathogen when more information is available.
—Ketino Kobaidze, MD, assistant professor, Emory University School of Medicine, Atlanta, member, antimicrobial stewardship and infectious disease control committees, Emory University Hospital Midtown
“The most important thing, I think, for hospital medicine and medicine anywhere, is to follow up with whatever you’re ordering and notice right away what happens with these tests. If it’s positive or negative, redirect your care,” Dr. Kobaidze says. “Time is really an important issue here.
“As hospitalists, we need to be extremely cautious not to give them something they don’t need.”
Dr. Kobaidze was particularly struck by gonorrhea being listed in the “urgent” threat category.
“It was so easy to treat before,” she says. “It was nothing, piece of cake. This makes me a little bit concerned.”
Robert Orenstein, DO, an infectious disease expert at Mayo Clinic, praises the report and says hospitalists have a key role to play.
“I think this has a clear impact on hospitalists, who are the primary caregivers of many of these ill patients,” he says. “We need to educate them and build systems that target antimicrobials to the infecting agents and limit their use. Hospitalists are also the people who can help protect patients from the spread of these in the hospital by following appropriate infection prevention guidelines and educating their colleagues of the importance of this.”
He also stresses the importance of being aware of threats within your specific region.
“Many of these MDROs [multi-drug resistant organisms] have regional prevalence,” he says. “And it’s important to know which bugs are in your region so you can work with your institution and public health to tackle these.”
Tom Collins is a freelance writer in South Florida.
Reference
Describing formally for the first time the enormity of the problem of antibiotic resistance and warning of the “potentially catastrophic consequences of inaction,” the Centers for Disease Control and Prevention (CDC) announced in September that more than two million people a year are sickened by infections that are resistant to treatment with antibiotics.
Moreover, the CDC says 23,000 people die as a result.
And because those numbers are based only on the data available—and the agency assumes that many infections are not captured—the CDC says its estimate is a conservative one and the real number is probably higher.
The report is a call to action for hospitalists, who are in an almost ideal position to participate in efforts to prevent infections and control their spread once they’re discovered, says Jean Patel, PhD, deputy director of the office of antimicrobial resistance at the CDC.
“I think it’s a sobering number, and it indicates how far we have to go in combating this problem of antimicrobial resistance,” Dr. Patel says.
The medical community, she adds, cannot expect that new treatments will become available to fight all of these new infections.
“All of the drugs also are going to have some gaps in their range of activity, so there’s no drug coming that’s going to be effective against all the antimicrobial-resistant drugs that we face today,” Dr. Patel explains. “For that reason, we’re sounding the alarm that it’s important to pay attention to infection control and antibiotic stewardship practices.”
The report, “Antibiotic Resistance Threats to the United States, 2013,” creates three categories of antibiotic-resistant pathogens. In the “urgent” tier are Clostridium difficile, which the CDC estimates is responsible for 250,000 infections a year and 14,000 deaths; carbapenem-resistant Enterobacteriaceae, estimated to be responsible for 9,000 drug-resistant infections a year and 600 deaths; and drug-resistant Neisseria gonorrhoeae, at 246,000 drug-resistant infections.
These bacteria are considered an “immediate public health threat that requires urgent and aggressive action.”
There are 12 pathogens in the second category, described as “a serious concern” requiring “prompt and sustained action to ensure the problem does not grow.”
Of particular interest to hospitalists in this group, Dr. Patel says, is methicillin-resistant Staphylococcus aureus (MRSA). The CDC estimates that more than 80,000 severe MRSA infections and more than 11,000 deaths occur in the U.S. every year.
MRSA was not ranked as an “urgent” threat only because the number of infections is actually decreasing, especially in healthcare institutions, and because there are antibiotics that still work on MRSA.
“If either of those things were to change—for example, if the rate of infections were to increase, or if these isolates were to become more resistant—then we would have to think about changing this from a serious threat to an urgent threat,” Dr. Patel says.
Another infection in the serious category that should be on hospitalists’ radar is drug-resistant Streptococcus pneumoniae. A new vaccine is helping to decrease the number of these infections, but hospitalists should be vigilant about infections that could escape the vaccine and become resistant, Dr. Patel says.
The report estimates as much as $20 billion in excess healthcare costs due to antimicrobial-resistant infections, with $35 billion in lost productivity in 2008 dollars.1
Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious disease control committees at Emory University Hospital Midtown, says the sheer numbers are sure to get people to take notice.
“Two million is lots of patients,” she says. “It’s eye-opening, really, for many doctors and patients and society.”
The silver lining, she says, is that the field is moving toward diagnostic tools that will provide quick feedback on the type of infection at work.
It may be that hospitalists have no choice but to give an antibiotic to a patient because of the risk involved in not giving one; however, providers should quickly tailor that treatment to target the specific pathogen when more information is available.
—Ketino Kobaidze, MD, assistant professor, Emory University School of Medicine, Atlanta, member, antimicrobial stewardship and infectious disease control committees, Emory University Hospital Midtown
“The most important thing, I think, for hospital medicine and medicine anywhere, is to follow up with whatever you’re ordering and notice right away what happens with these tests. If it’s positive or negative, redirect your care,” Dr. Kobaidze says. “Time is really an important issue here.
“As hospitalists, we need to be extremely cautious not to give them something they don’t need.”
Dr. Kobaidze was particularly struck by gonorrhea being listed in the “urgent” threat category.
“It was so easy to treat before,” she says. “It was nothing, piece of cake. This makes me a little bit concerned.”
Robert Orenstein, DO, an infectious disease expert at Mayo Clinic, praises the report and says hospitalists have a key role to play.
“I think this has a clear impact on hospitalists, who are the primary caregivers of many of these ill patients,” he says. “We need to educate them and build systems that target antimicrobials to the infecting agents and limit their use. Hospitalists are also the people who can help protect patients from the spread of these in the hospital by following appropriate infection prevention guidelines and educating their colleagues of the importance of this.”
He also stresses the importance of being aware of threats within your specific region.
“Many of these MDROs [multi-drug resistant organisms] have regional prevalence,” he says. “And it’s important to know which bugs are in your region so you can work with your institution and public health to tackle these.”
Tom Collins is a freelance writer in South Florida.
Reference
Culture Shift Required to Defeat Defensive Medicine
Hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, sees defensive medicine as a source of unnecessary costs—and a threat to patient safety.
In fact, he and his colleagues offered an oral presentation at HM13 earlier this year titled, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists.” In a survey of 1,020 hospitalists, it was reported that defensive medicine was practiced in 37% of pre-operative evaluations and 58% of syncope cases.
Dr. Kachalia says he understands the pressures that can lead physicians to order unnecessary tests, particularly when patients request them. So what does he say about those requests?
“The answer is a simple one but takes time and effort: If you don’t think that something is clinically indicated, you should talk with the patient, explaining to them why you don’t think it’s necessary,” he says. “And, hopefully, you can come to mutual agreement. Ordering things just for the sake of preventing legal liability is just not the right thing to do.”
Dr. Kachalia says he believes that a paradigm shift in how medical liability is handled in this country is needed to change those habits.
But culture change also takes time.
Bryan Weiss, MBA, managing director of the consulting services practice at Irving, Texas-based MedSynergies, says the first step of that change may be having physicians admit that few doctors know a lot about malpractice issues, because they are typically negotiated, arranged, and paid for by their employers, whether that’s a hospital or large management companies.
“It’s not me versus them,” says Weiss, a Team Hospitalist member. “As a specialty, we need to be in this together, to push the education and awareness that it’s OK not to know, so let’s work together to make it better. But it’s not going to happen overnight.”
Hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, sees defensive medicine as a source of unnecessary costs—and a threat to patient safety.
In fact, he and his colleagues offered an oral presentation at HM13 earlier this year titled, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists.” In a survey of 1,020 hospitalists, it was reported that defensive medicine was practiced in 37% of pre-operative evaluations and 58% of syncope cases.
Dr. Kachalia says he understands the pressures that can lead physicians to order unnecessary tests, particularly when patients request them. So what does he say about those requests?
“The answer is a simple one but takes time and effort: If you don’t think that something is clinically indicated, you should talk with the patient, explaining to them why you don’t think it’s necessary,” he says. “And, hopefully, you can come to mutual agreement. Ordering things just for the sake of preventing legal liability is just not the right thing to do.”
Dr. Kachalia says he believes that a paradigm shift in how medical liability is handled in this country is needed to change those habits.
But culture change also takes time.
Bryan Weiss, MBA, managing director of the consulting services practice at Irving, Texas-based MedSynergies, says the first step of that change may be having physicians admit that few doctors know a lot about malpractice issues, because they are typically negotiated, arranged, and paid for by their employers, whether that’s a hospital or large management companies.
“It’s not me versus them,” says Weiss, a Team Hospitalist member. “As a specialty, we need to be in this together, to push the education and awareness that it’s OK not to know, so let’s work together to make it better. But it’s not going to happen overnight.”
Hospitalist Allen Kachalia, MD, JD, of Brigham and Women’s Hospital in Boston, sees defensive medicine as a source of unnecessary costs—and a threat to patient safety.
In fact, he and his colleagues offered an oral presentation at HM13 earlier this year titled, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists.” In a survey of 1,020 hospitalists, it was reported that defensive medicine was practiced in 37% of pre-operative evaluations and 58% of syncope cases.
Dr. Kachalia says he understands the pressures that can lead physicians to order unnecessary tests, particularly when patients request them. So what does he say about those requests?
“The answer is a simple one but takes time and effort: If you don’t think that something is clinically indicated, you should talk with the patient, explaining to them why you don’t think it’s necessary,” he says. “And, hopefully, you can come to mutual agreement. Ordering things just for the sake of preventing legal liability is just not the right thing to do.”
Dr. Kachalia says he believes that a paradigm shift in how medical liability is handled in this country is needed to change those habits.
But culture change also takes time.
Bryan Weiss, MBA, managing director of the consulting services practice at Irving, Texas-based MedSynergies, says the first step of that change may be having physicians admit that few doctors know a lot about malpractice issues, because they are typically negotiated, arranged, and paid for by their employers, whether that’s a hospital or large management companies.
“It’s not me versus them,” says Weiss, a Team Hospitalist member. “As a specialty, we need to be in this together, to push the education and awareness that it’s OK not to know, so let’s work together to make it better. But it’s not going to happen overnight.”
Data Mining Expert Explains Role Performance Tools Will Play in Future
Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company
Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company
Click here to listen to more of our interview with Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company
The Why and How Data Mining Is Applicable to Hospital Medicine
Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.
Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.
Click here to listen to excerpts of our interview with Dr. Deitelzweig, chair of SHM’s Practice Analysis Committee.
Learn How Best To Avoid Some of Data Mining’s Potential Pitfalls
Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.
“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.
A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.
Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.
Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.
ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”
The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH
Bryn Nelson is a freelance medical writer in Seattle.
Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.
“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.
A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.
Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.
Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.
ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”
The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH
Bryn Nelson is a freelance medical writer in Seattle.
Ensuring data quality and equivalency can present major challenges in data analytics, especially given the field’s dearth of uniform standards.
“The joke is that the great thing about health-care data standards is that there’s so many to choose from,” says Brett Davis, general manager of Deloitte Health Informatics. If data integration remains a big challenge, however, Davis says the cost and complexity of the technology is dropping rapidly.
A lack of electronic health records (EHR) can limit more advanced data-mining functions. But that’s no excuse for not exploring the technology, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine at Ochsner Health System in New Orleans and chair of SHM’s Practice Analysis Committee.
Deployment of that partial prerequisite also seems to be happening quickly around the country. The Office of the National Coordinator for Health IT (ONC) estimates that hospital adoption of at least a basic EHR system more than tripled between 2009 and 2012, to 44% from 12%. Meanwhile, an estimated 85% of hospitals were at least in possession of certified EHR technology by 2012.
Despite the falling barriers, Davis cautions that users should have clear goals in mind when setting up a new system. “There is the risk of building bridges to nowhere, where you just integrate data for the sake of integrating data but not knowing what questions and insights you want to glean from it,” he says.
ONC spokesman Peter Ashkenaz agrees, citing governance within a hospital or health center and education of all participants as important elements of any data-analytics plan. Among the questions that must be addressed, he says, are these: “Have we collected the right information? Are we doing so efficiently and securely with respect to privacy requirements? Are we sharing the data with the appropriate parties? Are we doing so in a way that is easily understood? Are we asking the right questions about how to use the information?”
The most fundamental question, Dr. Deitelzweig says, may be whether a hospitalist group, hospital, or health system is truly committed to using the technology. “If you’re going to make the investment in such things, then you really better be dedicated to understanding them and how best to utilize them. And give it some time,” he says. “I think people want solutions fast, and often they don’t take the time to individualize it or customize it.” TH
Bryn Nelson is a freelance medical writer in Seattle.
MARQUIS Highlights Need for Improved Medication Reconciliation
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.1
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website. TH
Larry Beresford is a freelance writer in San Francisco.
Reference
1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.1
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website. TH
Larry Beresford is a freelance writer in San Francisco.
Reference
1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.1
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website. TH
Larry Beresford is a freelance writer in San Francisco.
Reference
1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.
Hospitalists Should Take Wait-and-See Approach to Newly Approved Medications
Wait-and-See Approach Best for Newly Approved Meds
I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?
–David Ray, MD
Dr. Hospitalist responds:
I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.
I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.
Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.
This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.
In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.
In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.
In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
Wait-and-See Approach Best for Newly Approved Meds
I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?
–David Ray, MD
Dr. Hospitalist responds:
I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.
I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.
Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.
This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.
In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.
In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.
In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
Wait-and-See Approach Best for Newly Approved Meds
I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?
–David Ray, MD
Dr. Hospitalist responds:
I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.
I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.
Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.
This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.
In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.
In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.
In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
Hospitalists as Industrial Engineers
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].