The Future of Medicine…is Defensive

At Northwestern University in Chicago, anyway – and probably externally valid to other institutions, as well.

This is a survey of 194 fourth-year medical students and 141 third-year residents regarding whether they observed or encountered “assurance” practice (extra testing of minimal clinical value) or “avoidance” practice (withholding services from patients perceived as high risk).  65% of medical students and 54% of residents completed the survey – decent numbers, but low enough to introduce sampling bias.

The numbers, of course, are grim – 92% of medical students and 96% of residents reported encountering “assurance” practice at least “sometimes” or “often”, while 34% of medical students and 43% of residents had encountered “avoidance” practice at least “sometimes” or “often” – nearly all of those being “sometimes”.  These behaviors are apparently learned from their superiors – approximately 40% of medical students and 55% of residents were explicitly taught to consider practicing defensive medicine.

Interestingly, medical students, internal medicine residents, and surgical residents all reported nearly identical levels of “often”/”sometimes”/”rarely” regardless of the behavior sampled – although surgical residents were more frequently taught to be defensive than medicine residents.

Must be a tough legal quagmire up in Chicago.

“Medical Students’ and Residents’ Clinical and Educational Experiences With Defensive Medicine”

Safety-Nets & ED Length of Stay

This is a relatively intriguing public policy article in JAMA following up in a timely fashion regarding the new CMS Emergency Department quality measures.  These new measures include various time-to-X measures, including length of stay, length of time to admission from bed request, etc.  There is some concern that these quality measures may be tied to federal funding, unfairly targeting “safety-net” hospitals that are not at baseline provided with the resources to address patient flow issues.

This article is a review of the NHAMCS database, a national probability sample survey of patient visits, looking at independent predictors of increased length of stay in patients admitted and discharged from the Emergency Department.  Based on the review of this sample, they do not see a significant difference in ED length of stay – and conclude that these quality measures should not be of concern to “safety net” EDs.  However, these general time-based measures mask most of the problems encountered in “safety net” institutions.
There are some baseline differences in patient characteristics between the safety-net and non-safety-net hospitals in their sample, and they tend to work in favor of safety-net hospitals.  The safety net hospitals in this sample tended to have younger patients with lower triage acuities, which should work in favor of reduced ED overall average length of stay.  My anecdotal experience suggests that, once the quality measures track more detailed ED transit times, I believe we will see more significant deficiencies drop out in the safety-net group.
“Association of Emergency Department Length of Stay With Safety-Net Status”

Big Pharma Is Behind The Money Hemorrhage

This is a research letter from the Archives of Internal Medicine that received a good deal of press recently, examining exactly where in the health system we were wasting money.

They focused on the ambulatory setting, used the NAMCS/NHAMCS database, and evaluated for the activities identified in the “Good Stewardship Working Group” identified by consensus to be low-yield and unnecessary.  They considered this to include antibiotics for afebrile/non-strep pharyngitis, routine EKGs, CT and MRI for uncomplicated low back pain, DEXA scans for young women, etc.  And they found – and this is where the big story comes in – $6.7 billion in these consensus not-recommended activities.

Fortunately for our Internal Medicine and Family Medicine colleagues, they actually weren’t ordering a lot of unnecessary tests – $175 million for low back pain and $527 million for DEXA are a lot of money, but still a drop in the bucket.  The majority of the unnecessary activities, $5.8 billion of the total $6.7 billion, was writing for a brand-name statin (atorvastatin or rosuvastatin) instead of one of the generics.

Certainly just the tip of the iceberg.  Drug reps are more than earning their salaries, apparently.

“‘Top 5’ Lists Top $5 Billion”

Predicting Poor-Performing Residents

This is an entertaining look into the residency training experience in the United States, which is renowned for its brutality in certain specialities.  As far as sleep-deprivation goes, it ranks right up there with some of the lowest quality of life professional jobs.

This is, basically, the quality-of-life information from the Internal Medicine in-service training examination, as reported in JAMA.  The authors have linked it to in-training examination results for the, probably predictable, association of poor work/life balance and poor in-training scores.

Interesting tidbits I noticed:
 – 15.3% of residents stated that life was as good as it could be.
 – PGY-1 and PGY-2 residents had nearly equal poor quality-of-life and work/life balance – which improves significantly PGY-3.
 – Over 40% of residents have >$100,000 in debts – and that was associated with poorer quality-of-life scores.
 – Improvements in quality-of-life for PGY-3 was mirrored by a corresponding increase in depersonalization.
Not a healthy experience, by a longshot.  Pity those whose residencies are longer than the bare minimum of 3 years.
“Quality of Life, Burnout, Educational Debt, and Medical Knowledge Among Internal Medicine Residents.”

Malpractice Risk in Emergency Medicine

I was actually surprised by these statistics – I expected Emergency Medicine to be higher.  After all, we’re meeting people with potentially unrealistic expectations, suffering long wait times, without continuity of care, and potential bad outcomes lurking everywhere.

But, really, our claims against and claims with payout are really pretty much average across specialties.  Neurosurgery and Thoracic Surgery are the nightmare specialties, where nearly a 5th of physicians practicing in those specialties has a claim filed against them each year.  Another interesting statistic was that Gynecology, only a little above average in claims filed against, has the highest percentage of payouts.

Neurosurgery, Neurology, and Internal Medicine lead the way in median payout, but Pediatrics, Pathology, and Ob/Gyn lead the way in mean payout – apparently skewed by the occasional massive award.

Given the legislation pending in many states these days giving additional protections to Emergency Physicians and physicians on-call to Emergency Departments, it’s really not a bad time to be in EM, from a liability standpoint.

“Malpratice Risk According to Physician Specialty”

5% of Patients Spend 50% of Our Healthcare Dollars

Per-capita spending doubled from 1997 through 2009 from $4100 to $8100 – with 5% of patients spending $35,800 on average annually to account for 47.5% of healthcare spending.  Overall, the five most expensive conditions are heart disease, cancer, trauma, mental disorders, and pulmonary conditions.

Unsurprisingly, people over 55 made up the majority of the high spending groups.  Unhappily enough, the authors note a “flattening” of the distribution of spending, where younger individuals are responsible for a greater proportion of the spending.  This is not due to more cost-effective care in the elderly, it’s a result of increasing disease prevalence in the young, primarily attribute to obesity-related diseases such as hypertension, diabetes, hyperlipidemia.

May you live in interesting times, indeed.

“Understanding U.S. Health Care Spending – NIHCM Foundation Data Brief July 2011”

Ambulance Diversion Kills People? Maybe?

This article got a ton of press – but it tries to take far too simple an approach to far too complicated an issue.  I’ve done research like this, where you use zip code centroids and calculated distances to nearest hospitals, and it’s just one way a blind man describes an elephant.

These authors look retrospectively at all the acute MIs in four California counties, then looked at hospital daily diversion logs for each day from each of those hospitals – and tried to merge them together to prove that if your nearest hospital was on diversion for a lot of the day you had your acute MI, you had worse outcomes.

Their final analysis says, basically, there’s a 3-5% difference in 30-day, 90-day, and 1-year mortality if your nearest hospital is on diversion >12 hours in a day vs. if your nearest hospital is on diversion <6 hours per day.  The between 6-12 hour diversion cohort performed identically to the <6 hour per day cohort.  So, I don’t know exactly what to make of this.  Their 95% CI almost crosses zero.  Something magical happens at 12 hours that changes your acute MI mortality risk.  So, yes, what the authors are trying to prove is probably true – but this article’s data mining and massage can only hypothesize the association, and doesn’t prove anything.

“Association Between Ambulance Diversion and Survival Among Patients With Acute Myocardial Infarction.”

Prehospital STEMI Diversion to PCI

Time is muscle and the earlier you get to PCI the more muscle you can save.  So, we should just drive by all the critical access hospitals and go straight to PCI-capable centers?  The Dutch, in this retrospective study, think we should.  Everything in their protocol hinges on EMS reading a computer interpretation of the EKG, and, if it says STEMI, they go to the PCI center.  At the end of the day, everyone who went to the PCI capable center first rather than the spoke hospital first had a mortality benefit between 2% and 2.6% at one year.  

What they really don’t discuss much are the outcomes of the 5.7% of their intention-to-treat analysis that had false positives.  False positives, at least, are typically not harmful to the patient – the alternative diagnoses for chest pain that would benefit from immediate treatment at one of their non-PCI “spoke” hospitals are probably not that frequent – aortic dissections and submassive PEs tend to be the sorts of things that would benefit.  But, even if they did a true intention-to-treat analysis, they’d probably still have a mortality benefit.  The other problem with false positives is the financial costs associated with unneeded cath lab activation and the costs to the system associated with taking EMS out of service.  It’s obvious that treating patients for their disease in the most timely fashion for certain diseases improves outcomes – but we must always beware of the unintended consequences.

This is actually a big deal sort of topic in EM right now as it relates to the regionalization of care, which is something that the Academic Emergency Medicine consensus conference is dealing with right now.  Attempting to mirror what’s happened with trauma networks, they’re trying to extend the benefits to other acute conditions that otherwise benefit from transfer to higher levels of care.  Clearly, a myriad of life-threatening conditions benefit from the resources of tertiary referral centers – but the logistics and political issues associated with centralizing care for different conditions remains a significant barrier.