Harmony and balance...a Frenchman and his horses

As we close 2006 and look forward to 2007, I wish y'all harmony and balance in your lives. Click here to view a short video on what is possible.

Salah ad Din Province CME

Click here for an interesting article on continuing medical education in Iraq.

More on suicide risk screening

"Anonymous" posted a comment on the TeenScreen item and so I am posting a link here to the December 2004 issue of the American Family Physician article which delineates the U.S. Preventive Services Task Force recommendations on screening for suicide risk.

Per the Centers for Disease Control, "For Americans ages 15 to 24, suicide is the third leading cause of death." Click here for the CDC's Injury Fact Book.

Simple measures...

An article in the Baltimore Sun discusses the findings of a study just published in the New England Journal of Medicine on the impact that simple infection control measures had on reducing Michigan hospital infection rates. It's not always a knowledge deficit, folks, health care is delivered in an environment (with its own culture) and the systems need to be in place to optimize the quality of care provided. Involve everyone on the health care team -- yes, provide them with the knowledge, but set up the systems so that they have the skills, resources, and tools to apply that knowledge!

Mental health screening program for teens

Since half of all serious psychiatric disorders surface sometime between the ages of 14 and 25, it makes sense to screen teens for mental illness. A recent article in the New England Journal of Medicine reports on the success of TeenScreen, in which more than 55,000 teens in 42 states were screened. Click here to read the abstract. Fyi, a pdf of the entire article is available free -- THANKS to the NEJM!

Medical gains and new challenges

This New York Times essay by Lawrence K. Altman, M.D. is definitely worth reading -- "So Many Advances in Medicine, So Many Yet to Come" -- it's a great history lesson on the past 50 years of medicine but also highlights, methinks, the importance of continuing medical education.
:)

German company wins pharmaceutical packaging award

Came across a news article about a European competition for pharmaceutical packaging. The winning company, Faller, won this award because its design not only met customer needs in terms of functionality but also included a "means for recording" when tablets are taken. Click here for the article.

"ACCME Asked to Provide U.S. Senate Finance Committee with Information Regarding CME"

Click here to read the ACCME's news release on this matter.

Pharma company to pay $499 million in settlement?

"Bristol-Myers Squibb Co. on Thursday said it has tentatively agreed to pay $499 million to settle a long-standing probe by the Department of Justice into its marketing and pricing practices." The company has agreed to enter into an agreement with the DOJ and and the Massachusetts U.S. Attorney's Office to settle this investigation. "In return, there will be no criminal charges filed against the company. Bristol-Myers added that the deal had not yet been finalized." Click here to read the entire MarketWatch article.

A new model for surgical skills training

Very good article just published in the New England Journal of Medicine "Teaching Surgical Skills — Changes in the Wind". The authors discuss the Fitts–Posner Three-Stage Theory of Motor Skill Acquisition as well as several training and assessment models. All good stuff for CME Providers to be well versed in, especially in light of the new ACCME accreditation criteria.

Take the food portion quiz!

Hate to do this just before those big dinners and all the holiday goodies, but I'm sharing this CNN online quiz "Portions, Past and Present" just in case it helps y'all even a little bit in 2007. FYI, I failed this quiz miserably.

Definitions count

Which is more important -- the Institute of Medicine's definition of a medical error or a patient's definition of a medical error? A study published in the January 2007 issue of the Joint Commission Journal on Quality and Patient Safety indicates that patients may have their own definition of what constitutes a medical "error" or "mistake":

“'The study underscores that patients and clinicians can have different views of the things that constitute a medical error,'” says Dr. Burroughs. “'For patients, clear communication and responsiveness are particularly important. If these are lacking, patients may view this as a medical error. It is important that clinicians recognize these differences, and the importance of communication and responsiveness.'”

Click here for the press release on this study.

An unintended consequence

The issue of a specific medical technology and its unintended consequence are discussed in this Washington Post article "Devices Can Interfere With Peaceful Death: Implants Repeatedly Shock Hearts Of Patients Who Cannot Be Saved". Frankly, I had never thought of this issue until I read this article!

"The implants -- small, internal versions of the paddles that emergency rooms use to shock patients' malfunctioning hearts -- are saving many lives. But in some cases they also are making the act of dying harder, forcing terminally ill patients and families to make wrenching decisions about turning them off. The devices subject some dying patients to painful jolts and can prolong suffering, traumatizing loved ones as the devices fire fruitlessly."

Henry Ford cracks down on vendors

Henry Ford Health System is the latest large health care system to formalize and implement policies and procedures "aimed at eliminating potential conflict of interest between relationships with vendors and employees." A novel component of Henry Ford's new P&Ps is a certification program for vendors. The cost of the certification program is $100 (per person?). Bottom line:

"Promotional products of any kind, food supplied by vendors or literature distributed by vendors, will no longer permitted at any Henry Ford site."

I think they mean "...will no longer be permitted..."; in any event, we get the point.

Has the "grand" gone out of rounds?

Read an interesting article in the New York Times, "Socratic Dialogue Gives Way to PowerPoint," written by Lawrence K. Altman, M.D. Doctor Altman describes the history of grand rounds and how they have changed:

"Precisely when and where grand rounds began is not known. There are many types of rounds where doctors learn from patients. For example, there are the daily working rounds as doctors walk through a hospital to visit and examine patients. In teaching rounds, more senior doctors supervise the work of residents, or house officers, at a patient’s bedside or in a clinic.

Grand rounds were showcases featuring the best clinicians, and the practice thrived in an era when doctors knew little more than what they observed at the bedside. Professors often demonstrated characteristics of physical findings like an enlarged thyroid, a belly swollen with fluid or another grotesque disfigurement that the audience could see. Those with a flair for showmanship were often the best teachers, adapting the predictable structure to their needs and talents."

Doctor Altman describes how grand rounds have evolved, and perhaps not for the better. In any event, I recommend y'all read the article...look for the Lollipop case.

It's the patient outcomes that count

Do hospitals that perform better on quality measures have the best patient outcomes? A study published in JAMA tried to determine just that...from the Washington Post article reporting on this study:

"Patients at hospitals that scored near the top on the quality-of-care measures did do better than those at hospitals near the bottom -- but not dramatically so.

For every 1,000 heart attack patients, there were about five fewer deaths at the better-performing hospitals than at the lower-performing ones, the study found. The figures were similar for patients with heart failure and pneumonia.

Rachel M. Werner, an assistant professor of medicine and the study's lead author, said the results point up the need for more meaningful quality measures."

New CME requirement for Dubai docs

Per a new ruling from the UAE Ministry of Health, physicians practicing in the public sector will now need 50 hours of CME every year in order to renew their medical licenses. The new ruling takes effect January 1, 2007:

"While many private sector hospitals already stipulate their own minimum number of CME hours doctors must attend, at present, there are no laws to ensure public sector medical practitioners - including doctors, dentists and nurses - do the same. And Dr Abdul Ghaffar Abdul Ghafoor, assistant undersecretary for curative medicine, at the Ministry of Health, said this move is vital to ensure Dubai’s doctors keep up-to-date with advances in treatment methods."

More on drug-eluting stents

An expert panel convened by the FDA has issued caution in the use of drug-eluting or drug-coated stents, indicating that both physicians and patients be fully informed of the risks associated with their use. See the New York Times article "Panel Urges Caution on Coated Stents" for additional information.
Also, see the Duke Med News article "Drug-Coated Stent Patients at Risk if Anti-Blood-Clotting Medication Discontinued" for an excellent description of the rather complex issues on the use of drug-eluting stents and why more research is needed.

Proposed JCAHO Patient Safety Goals 2008

The Joint Commission on the Accreditation of Healthcare Organizations has released their proposed 2008 Patient Safety Goals. A new topic area goal is sleep apnea:

"The problem for sleep apnea patients following surgery is they can’t wake themselves up under heavy sedation, according to Kevin Finkel, MD, an anesthesiologist at Barnes Jewish Hospital in St. Louis, MO, speaking to HCPro's Quality Improvement Report newsletter. About 90 percent of sleep apnea patients are undiagnosed, he said. For that reason hospital staff needs to look for signs of the condition and ask patients if they snore. Patients who are obese or have a neck circumference of more than 17 inches are also at more likely to have sleep apnea."

The JCAHO is seeking input on the proposed 2008 Patient Safety Goals.

Conflict of interest charge for NIH scientist

Dr. P. Trey Sunderland III is the first NIH official since 1992 to be charged by federal prosecutors with conflict of interest. According to the LA Times article, Sunderland, in charge of the NIH's geriatric psychiatry division, received money from Pfizer, Inc. from 1998 to 2003 without NIH's permission or knowledge. Alledgedly, Sunderland provided Pfizer, Inc. with spinal-tap samples from patients and "failed to note his company fees and additional expense reimbursements on annual NIH financial reports."

December issue of Medical Meetings magazine published

"Aiming High" is the title of the lead article on the new ACCME accreditation criteria. The writer of the article is the virtuoso with a pen (or is that a keyboard?), Sue Pelletier. The article is a timely read, as they say...
:)

American Academy of Pediatrics issues policy statement

Apparently, several Western countries as well as Denmark, Belgium and Greece, Sweden, and Norway limit advertising to children, but the United States does not limit such targeted advertising. That's why the American Academy of Pediatrics has issued a policy statement on advertising to children; this statement will appear in the December issue of Pediatrics. The statement is critical of:

"...alcohol ads that feature cartoonish animal characters; fast-food ads on educational TV shown in schools; magazine ads with stick-thin models and toy and other product ''tie-ins'' between popular movie characters and fast-food restaurants."

Let's hope that policymakers listen.

Participate in an international survey on patient safety

The World Health Organization (WHO) is calling for health care professionals and patient advocates from around the world to participate in an online survey on nine solutions relative to patient safety:

"The proposed Patient Safety Solutions address the issues of look-alike, sound-alike medications; correct patient identification; hand-over communications; wrong site, wrong patient surgery; use of concentrated electrolyte solutions; medication reconciliation; catheter and tubing misconnections; needle reuse and injection safety; and hand hygiene. The electronic Patient Safety Solution survey will be available online until February 16, 2007, at www.jcipatientsafety.org/survey."

Anemia drugs - emerging information and an FDA Alert!

Due to the results of studies recently published in the New England Journal of Medicine (as reported in the New York Times), the National Kidney Foundation will be convening a panel of experts to review whether or not current anemia treatment guidelines for kidney dialysis patients need to be updated. The studies published in the NEJM indicated that aggressive treatment of anemia in kidney patients resulted in more deaths than expected. From the NYT's article:

"The foundation’s panel will probably meet in January or early February and could release new treatment recommendations for public review a few weeks later, the foundation said.

The anemia panel consists of 15 nephrologists who meet under the auspices of the foundation, a private nonprofit group based in New York that provides financing for kidney researchers. The panel is one of several panels sponsored by the foundation that make recommendations about how to improve treatment for kidney patients.

But some scientists complain that Amgen has until now had too much influence on the creation of the foundation’s guidelines. The most recent version of the anemia guidelines, released earlier this year, encourages more aggressive treatment than the Food and Drug Administration recommends."

The FDA has, in fact, issued an alert on this topic. CME Providers who are in the process of planning CME activities on this topic need to read this alert!

Painful statistics for Americans

Earlier this month, the Centers for Disease Control (CDC) released the results of their annual health survey of Americans. In the CDC Press Release, lead study author Amy Bernstein states that the study focused on pain issues because "'the associated costs of pain are posing a great burden on the health care system, and because there are great disparities among different population groups in terms of who suffer from pain.'" Here are some of the survey study findings on pain:

More than one-quarter of adults interviewed said they had experienced low back pain in the past three months.

Fifteen percent of adults experienced migraine or severe headache in the past three months. Adults ages 18-44 were almost three times as likely as adults 65 and older to report migraines or severe headaches.

Reports of severe joint pain increased with age, and women reported severely painful joints more often than men (10 percent versus 7 percent).

Between the periods 1988-94 and 1999-2002, the percentage of adults who took a narcotic drug to alleviate pain in the past month rose from 3.2 percent to 4.2 percent.

Superbug touchdown

Methicillin-resistant staphylococcus aureus (MRSA) has historically been an issue in the hospital setting; of late, it has encroached upon athletic facilities. This tiny microbe recently tackled Cleveland Browns player, Brian Russell. A preseason MRSA infection required Russell to be hospitalized and infected some of his team mates as well:

"Stories like Russell’s are becoming more common. Staph infections, in varying and sometimes deadly forms, are being reported in greater numbers across Ohio and nationwide as more virulent and resilient strains are infecting high school, college and professional athletes.

Football players, wrestlers and even fencers have contracted methicillin-resistant staphylococcus aureus, or MRSA, a serious superbug once isolated to hospitals and health-care settings that has found its way into locker rooms, weight rooms and athletic training facilities. Despite widely available information about the dangers of skin infections, staph has continued spreading."

Military investing in medical simulation training centers

As reported in the New York Times, the U.S. Army is in the process of building 18 new medical simulation training centers worldwide in order to optimize combat medic training. One of these training centers is located at Fort Drum. The four simulation rooms at Fort Drum can be used to present medics-in-training with not only medical dilemmas but with "psychological, emotional and moral dilemmas".

For CME providers interested in learning more about medical simulation, please click here to go to the Society for Simulation in Healthcare's website. This society was formed in January 2004 and is comprised of educators and researchers interested in using a "variety of simulation techniques for education, testing, and research in health care". It now has over 1,000 members!

"Gratitude unlocks the fullness of life.

It turns what we have into enough, and more. It turns denial into acceptance, chaos into order, confusion into clarity.... It turns problems into gifts, failures into success, the unexpected into perfect timing, and mistakes into important events. Gratitude makes sense of our past, brings peace for today and creates a vision for tomorrow."

- Melody Beattie

I wish y'all a Very Happy Thanksgiving!

Moody agrees with antidepressant defense

According to a Forbes.com article, U.S. District Judge James Moody Jr. agreed with defendant Patrick Henry Stewart, a Tampa executive who embezzled $1.8 million dollars from his employer, that an antidepressant he was taking made him commit this crime. Instead of sentencing Stewart to the 3 1/2 years in prison recommended by prosecutors (as part of a plea agreement), Moody sentenced Stewart to home confinement for one year and five year's probation. Wonder how much Stewart's copay was on that prescription for the antidepressant...not enough, I would venture.

White Coat Trust and Confidence

We've all heard about "white coat hypertension," but what other effect might formally attired physicians have on patients? Well, a good one...in an article just published in the American Journal of Medicine, the authors found that patients (both female and male) "reported that they were significantly more willing to share their social, sexual, and psychological problems with the physician who is professionally dressed". For a more personal slant on this issue, see the New York Times essay "When Young Doctors Strut Too Much of Their Stuff".

ACME Webinar on New ACCME Accreditation Criteria

Just finished listening to this ACME webinar; Murray Kopelow, MD, did a really nice job in going over the new criteria. My personal opinion is that these new accreditation criteria are simply more explicit "guidance" in moving CME to where it should have always been. That said, the criteria are in effect beginning with November 2008 ACCME decisions, and CME providers need to start making changes now if they will be seeking Level III accreditation. For some CME providers, this will be a sea change. Bottom Line: ACCME has certainly thrown down the gauntlet and I, for one, am very pleased about the new criteria.

Will prescription pill prices be pushed down?

"Six Ways Congress Could Hurt Big Pharma" is a Forbes.com article which discusses the six bills that are in Congress that could negatively affect pharma profits. Besides bills dealing with Medicare and Medicaid reform, drug importation, and drug safety, there are bills on patent reform and the Prescription Drug User Fee Act reauthorization in Congress. And with the Democrats in the majority next year:

"Wall Street is getting worried. In a note to investors, analysts at Prudential Equity Group fret, 'Democrats are well positioned to force action on drug prices, and contrary to conventional wisdom, a [presidential] veto is not a sure thing.'"

More changes to come in CME Land, methinks.

Public service announcements in movie theaters?

Just read an article about how St. Joseph's Healthcare will be advertising in southwestern Ontario (Canada) movie theaters about their services. Which got me to thinking (always dangerous)...wouldn't it be wonderful if the U.S. movie entertainment industry stepped up and included public service announcements (PSAs) at movie theaters (and on DVDs). After all, if they charge $8 to see a movie (and charge $29.99 for the new DVD of that movie), it seems the least they could do is devote some time to PSAs (hint: y'all could make them very brief and entertaining).

Deaths from falls have risen for the elderly...

The Washington Post reports that recently released Centers for Disease Control (CDC) statistics indicate a 55% increase over the past 10 years in deaths from falls among the elderly. Death from falls is now the 14th leading cause of death in the United States. Speculation is that because people are living longer with chronic diseases that as they age they more likely to fall due to vision and/or hearing problems as well as lack of muscular strength.

The CDC has a Home Fall Prevention Checklist available online that older adults (and their loved ones) can utilize to make their homes safer.

Pay for performance (P4P) -- the UK experience

I've finally (and thankfully) gotten a chance to read the web article by Robert Galvin: "Pay-For-Performance: Too Much Of A Good Thing? A Conversation With Martin Roland." Health Affairs, September/October 2006; 25(5): w412-w419.

Galvin interviews Martin Roland, an advisor to the "world’s most ambitious P4P program," the United Kingdom’s Quality and Outcomes Framework (QOF). Roland discusses the unexpected results and findings of the QOF and offers some advice to the United States. Even though the UK and US health care delivery systems differ, it is still very worthwhile information. One important point that Roland makes is that exception reporting "was introduced on the basis that if you have some form of evidence-based guideline, nobody would ever suggest that it should be applied to all patients. So, for example, if you’ve got a diabetic who’s dying of cancer, you’re not going to try and get his cholesterol down."

I encourage all who are involved in CME to read this important article; check with your medical librarian to see if your institution already subscribes to Health Affairs (or this article can be purchased online for a nominal fee).

What a boost to primary care in the UK!

What are the most beneficial and cost-effective preventive services?

According to a study performed by the National Commission on Prevention Priorities they are:

1. Aspirin chemoprophylaxis
2. Childhood immunization series
3. Tobacco-use screening and brief intervention

See the full results of this study at the AAFP website "Practice Guidelines:
Partnership for Prevention Ranks Preventive Services." Be certain to check out Table 2 which depicts current utilization rates (the current tobacco-use screening and brief intervention national utilization rate is only 35%) and the additional quality-adjusted life years saved if utilization rates were at 90%.

Massachusetts to require docs to report HIV-infected patients

Beginning on January 1, 2007, physicians in Massachusetts are required to report the names of patients who test positive for HIV to the state Department of Public Health. Apparently the state will keep the data confidential. The Boston Globe article points out that the Federal Government "is making financial assistance for HIV patients contingent on the reporting of names."

New Alliance for CME Board Members!

Mark Schaffer, Greg Paulos, Winnie Brown, Damon Marquis were recently elected to the ACME's board of directors. Congratulations to all!

Mark and I have worked together in the past and he is so knowledgeable and such a nice person. I am so pleased that he was elected to the board as I know he will help lead the Alliance to a bright future. Here is his position statement (from the Alliance website):

"Position Statement: Over the years the Alliance has grown in membership. However, as often happens with a growing, nationally (internationally) based organization, only a small portion of the members take full advantage of what the organization has to offer. I believe it is the responsibility of the members of the Board to build on what previous Boards have done to make the Alliance more inclusive, welcoming, and, above all, of value to the entire membership. Issues the Alliance must address:

• Provide more educational opportunities, especially to those who can’t attend the annual conference.
• Help members address the challenges of developing more relevant content in varied formats.
• Help members recognize the similarities rather than differences of provider types; break the 'silo mentality'; foster concrete ways to partner and share strengths and even resources.
• Identify and secure other sources of revenue."

A great resource on medication safety!

I am very pleased to highlight the services of a colleague of mine, John M. Kessler, Pharm.D., B.C.P.S., who is President and Chief Clinical Officer of SecondStory Health, L.L.C. John and I worked together at Duke University and he continues to be a great resource for me that I am now sharing with y'all. John has more than 20 years of experience in medication systems design, adverse drug event reporting and errors analysis, and JCAHO accreditation standards. Additionally:

"He has chaired the United States Pharmacopoeia's Advisory Panel on Mediation Errors and he has served as an ex-officio Member on the National Coordinating Council for Medication Error Reporting and Prevention. He has consulted with healthcare organizations and regulatory authorities in the United States, South Africa, Brazil and the Middle East on medication safety.

He has experience in designing and implementing medication safety surveillance systems in large academic hospitals, small community hospitals and clinic environments. These surveillance systems have included:

• "triggers-based" concurrent monitoring system in a large academic hospital
• national drug information network to collect reports of adverse drug reactions
• voluntary reporting methods in hospitals and clinics
• observational methods and target-drug surveillance methods in hospitals
• computerized screening to identify adverse events in hospital diagnosis databases"

Please also keep John in mind if you are looking for an excellent speaker on medication safety!!

Unintentional medication error results in criminal charges

for a Wisconsin nurse. The medication error consisted of the nurse accidentally administering a bag of epidural analgesic intravenously rather than the intended penicillin. The 16-year-old patient, who was in labor, died as a result of this medication error. The nurse faces six years in jail and a $25,000 fine. This tragic accident and the nurse's subsequent criminal charges are discussed in a press release at the Institute of Safe Medication Practices website:

"While there is considerable pressure from the public and the legal system to blame and punish individuals who make fatal errors, filing criminal charges against a healthcare provider who is involved in a medication error is unquestionably egregious and may only serve to drive the reporting of errors underground. The belief that a medication error could lead to felony charges, steep fines, and a jail sentence can also have a chilling effect on the recruitment and retention of healthcare providers--particularly nurses, who are already in short supply."

100,000 nonaccident-related lower-limb amputations

are performed every year in the United States. Some 1.8 million Americans have undergone lower-limb amputations due to disease and medical conditions. From the New York Times article:

"Dr. Karel Bakker, a foot specialist who is a chairman of the International Diabetes Federation, believes that more effective foot care and patient education strategies would render up to 85 percent of these procedures unnecessary. Lower-limb ulcers are the most reliable harbingers of future amputation: according to a study published earlier this year in the journal Diabetes Care, nearly 9 in 10 nontraumatic foot and leg amputations come after the development of these infected sores, which can spread and quickly destroy surrounding tissue."

What a great QI project for CME providers!

San Diego CME Coordinators' Meeting

I just returned from having lunch with a great group of CME gals. The San Diego CME Coordinators' Meeting occurs on a quarterly basis and offers its "members" an opportunity to discuss what's new in CME and to share best practices. On the agenda today: ACCME New Criteria; CA AB487; and CA AB1195. I predict good things for this group! And I hope this gives y'all an idea about what you and your CME colleagues could be doing on a local level.

Three National Heart Attack Registries to be Combined

Three national heart attack registries are being combined into one registry, and the Duke Clinical Research Institute will play a leading role in the new registry which will be called the "National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network Registry." Duke cardiologists, Matthew Roe, M.D. and Eric Peterson, M.D. will serve as PIs for the new registry.

"Duke cardiologists were instrumental in the conception and implementation of one the three participating registries, known as CRUSADE. Started five years ago, this registry involves more than 500 hospitals in the United States and has collected clinical data on close to 200,000 patients.

The two other registries joining the collaboration are the National Registry of Myocardial Infarction, supported by Genentech, and the National Cardiovascular Data Registry, supported by American College of Cardiology Foundation.

Each of the three registries has collected detailed data on how patients with acute coronary syndrome were being treated in U.S. hospitals, with the goal helping hospitals stay current with the latest scientific findings."

KUDOS on the collaboration!

U.S. lagging in health care

Interesting article in the Washington Post regarding a study just published in Health Affairs. This study found that the U.S. is behind other countries on: 1) after-hours health care; 2) adoption of electronic medical records; and 3) investment in primary care systems.

"'Although the U.S. pays more for health care than any other country, we are under-investing in our primary care system,' Karen Davis, president of the Commonwealth Fund, the foundation that sponsored the survey, said in a statement. 'Other countries have made high-quality primary care a priority by putting into place the financial and technical systems that support access to, and delivery of, such care.'"

Piloting the way to patient safety

While some might say that delivering health care is so much more complex than flying planes, there are things that health care providers can learn from the airline industry. It seems a growing number of hospital administrators are bringing in aviation experts so that their medical staff members and employees can learn about prevention strategies. From the New York Times article "What Pilots Can Teach Hospitals About Patient Safety":

"'We’re where the airline industry was 30 years ago' when a series of fatal mistakes increased scrutiny and provoked change, said Dr. Stephen B. Smith, chief medical officer at the Nebraska Medical Center in Omaha, the teaching hospital for the University of Nebraska.

It is well established that, like airplane crashes, the majority of adverse events in health care are the result of human error, particularly failures in communication, leadership and decision-making.

'The culture in the operating room has always been the surgeon as the captain at the controls with a crew of anesthesiologists, nurses and techs hinting at problems and hoping they will be addressed,' Dr. Smith said. 'We need to change the culture so communication is more organized, regimented and collaborative, like what you find now in the cockpit of an airplane.'"

"Through the looking glass..."

It's Halloween, so here's something a bit off the med ed/public health track...a new study indicates that elephants exhibit mirror-recognition behavior and that they check themselves out in the mirror. Click here -- "Who's That Pretty Pachyderm?" -- for the full-length story.

"Everything has got a moral if you can only find it."
- Lewis Carroll

The role of alcohol in crime and accidents is underreported

A study to be published in the November 2006 issue of the Journal of Studies on Alcohol estimates that alcohol plays a role in about one-third of homicides and one-third of fatal non-traffic accidents. Interestingly, the study found that the media underreports this association:

"While alcohol is linked to 34 percent of motor vehicle accidents, only 12.8 percent of television stories, 19.2 percent of newspaper articles, and 22.2 percent of magazine articles about such accidents mentioned the use of alcohol, the study revealed. For stories about fatal accidents not involving motor vehicles, alcohol was mentioned in 1.4 percent of television reports, 4.8 percent of newspaper stories and 13.6 percent of magazine articles. However, statistics suggest 31 percent of these accidents involve the use of alcohol. The link between violent crime and alcohol use was also rarely acknowledged."

Food for thought...(certainly not drink for thought).

"Full court press"

If you missed 60 Minutes last night then you missed an excellent report on combat medicine. The good news is that you can read about it here "A Fighting Chance."

"CME" intervention on DVT prophylaxis in France

An Archives of Internal Medicine article by French doctors reports that provider education on evidence-based guidelines for the prevention of DVT was successful. What made the difference? As reported in the heartwire article, the lead author, Doctor Elodie Sellier (University Hospital, Grenoble, France) states that the decrease in DVTs (from 12.8% preintervention to 7.8% postintervention) was due primarily to an increase in the use of graduated compression stockings. Furthermore:

"Rates of minor bleeding and thrombocytopenia were similar in the two patient groups, and no major bleeding was observed, note Sellier et al, suggesting that the educational intervention reduced the incidence of DVT without compromising patient safety."

Sellier E, et al. Effectiveness of a Guideline for Venous Thromboembolism Prophylaxis in Elderly Post–Acute Care Patients. Arch Intern Med. 2006;166:2065-2071.

Just curious, do articles like this get into the CME literature database even if there are no keywords like "continuing medical education"?

More research needed on use of CT scans to screen for lung cancer

In a recent Duke News release, Duke Professor, Edward F. Patz Jr., M.D., (James and Alice Chen Professor of Radiology, Professor of Pharmacology and Cancer Biology, Professor of Pathology, Director, Molecular Diagnostics Laboratory) indicates that additional research needs to be completed before CT scans are routinely used to screen for lung cancer:

"Patz said the New England Journal of Medicine article raises awareness of the potential of CT scans for improving lung cancer diagnosis. But he said the study did not compare the use of CT scans against a control group of patients who received chest X-rays or no imaging at all. Such a comparative study is essential if the medical community is to prove whether CT scans decrease lung cancer deaths, the ultimate goal of a screening program, he said.

Because of these factors, Patz said, it is important to await the results of an ongoing randomized clinical trial comparing chest X-rays against CT before concluding that screening will save lives. The study, called NLST, is being conducted at over 25 sites nationally and is funded by the National Cancer Institute."

CDC releases guidance on drug-resistant infections

In an effort to stem the continuing rise of drug-resistant infections, the Centers for Disease Control has issued the "Management of Multidrug-Resistant Organisms in Healthcare Settings" guidelines. These guidelines were developed by experts in collaboration with the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC). The guidelines recommend the followings steps for hospitals and healthcare facilities:

• Ensure that prevention programs are funded and adequately staffed.
• Carefully track infection rates and related data to monitor the impact of prevention efforts.
• Ensure that staff use standard infection control practices and follow guidelines regarding the correct use of antibiotics.
• Promote best-practices with health education campaigns to increase adherence to established recommendations.
• Design robust prevention programs customized to specific settings and local needs.

CME Providers, what a great opportunity for you -- contact your Infection Control folks!

More on the drug-eluting stent issue!

Visit www.theheart.org (registration is required) for additional information on a proposed standard definition of stent thrombosis. Using this standard definition, "the cumulative incidence of stent thrombosis might be no greater in patients treated with a drug-eluting stent than in those treated with a bare-metal stent." From the article:

"The new ARC protocol should standardize the definition of stent thrombosis and provide consistency in the reporting of future trials, explained Cutlip. The Food and Drug Administration (FDA) has requested that the drug-eluting-stent companies use this new definition when they present data at an FDA meeting on stent safety in early December. The proposed ARC definition includes patients with definite/confirmed stent thrombosis, probable stent thrombosis, and possible stent thrombosis."

Employee Benefit Research Institute survey shows

that "fewer than two in 10 Americans are satisfied with the cost of health insurance and with costs not covered by insurance. More than half are 'not too satisfied' or 'not at all satisfied.'" There was no change in satisfaction ratings with the quality of care. While increases in health care insurance premiums have slowed over the past few years, it is still approximately double the rate of increase in Americans' earnings and twice that of the rate of inflation. The EBRI phone survey indicated that Americans are not able able to save as much for retirement due to rising health care costs. While this survey only interviewed 1,000 Americans, its findings are interesting. The good news:

"Americans also have changed their behavior — seeking out generic drugs, trying to take better care of themselves and talking to their doctors more carefully about treatment options, the study found."

Interesting news release on "Pharmaceutical CME..."

Cutting Edge Information has a new research report available, "Pharmaceutical CME: Measuring Program Effectiveness in the Compliance Environment." Here's the link to the news release. I'd love to hear your thoughts on this news release (and the full report if you happen to purchase it).

Another source of preventable medical errors?

An article in the Washington Post today reports on a study published in the Journal of the American Board of Family Medicine which indicates that, on an annual basis, between 2 million and 5 million patients call their doctors' offices after hours or on the weekend. Answering services routinely ask these patients "'Is this an emergency?'" The study found that 90% of the calls were put through as emergencies and investigated the 10% that were not:

"...among the 10 percent whose calls were not forwarded because they said the matter was not urgent was a man with chest pain radiating down his arm, another who had trouble breathing, and a pregnant woman leaking amniotic fluid -- situations that require prompt medical attention because they could be life-threatening."

The article reports on some good strategies to assure that a clinician decides what constitutes an emergency.

Duke develops genomic test panel to improve selection of chemotherapy

A genomic test panel was developed at Duke University's Institute for Genome Sciences & Policy. The panel of tests can be utilized to analyze the "unique molecular traits of a cancerous tumor" and determine "which chemotherapy will most aggressively attack that patient's cancer":

"In experiments reported in the November 2006 issue of the journal Nature Medicine, the researchers applied the genomic tests to cells derived from tumors of cancer patients. They found that the tests were 80 percent accurate in predicting which drugs would be most effective in killing the tumor.

The Duke team plans to begin a clinical trial of the genomic tests in breast cancer patients next year."

How cool is that!

NIH senior scientists allege that Eli Lilly

provided financial support for the development of sepsis guidelines in order to market their product, Xigris. From the Boston Globe article:

"'Dr. Peter Q. Eichacker , a senior investigator in NIH's critical care medicine department and primary author of the paper, said patients and physicians deserve guidelines that are free of industry bias and based on 'the best research and clinical experience available.'

Instead, Eichacker and his co authors wrote, pharmaceutical companies see medical guidelines as 'a potentially powerful vehicle for promoting their products.'

Lilly, in a prepared statement, said it was 'proper' to provide funding for the Surviving Sepsis Campaign. `'We do not believe that Lilly had any role in the development of guideline content, beyond funding the initiative,' the company said. 'The campaign worked independently and autonomously, and our funding for these grants was openly disclosed.'"

Apparently this drug has been hotly debated ever since the FDA approved it in 2001 "based largely on a single late-stage study showing it extended survival by 28 days."

Study finds that severe outpatient drug events are common

We've all heard the statistics on adverse drug events in the hospital setting; however, a new U.S. government study indicates that outpatient drug reactions send over 700,000 Americans to Emergency Rooms every year:

"Accidental overdoses and allergic reactions to prescription drugs were the most frequent cause of serious illnesses, according to the study, the first to reveal the nationwide scope of the problem. People over 65 faced the greatest risks.

'This is an important study because it reinforces the really substantial risks that there are in everyday use of drugs," said patient safety specialist Bruce Lambert, a professor at the University of Illinois at Chicago's college of pharmacy."

"What's new in medical education"

Check out Anne Taylor-Vaisey' blog for the latest in medical education. She just updated it today!
Anne, thanks!
:)

"Turnabout is fair play"

Perhaps in response to the increasing practice of health plans in grading providers on practice performance measures, the American Academy of Family Practice (AAFP) is conducting a survey of its members asking them to assess health plans. Participating AAFP members will grade health plans in eleven categories, some of which are:

• Payment rates (whether they are adequate or too heavily discounted);
• Timeliness of payments (whether clean claims are paid within an appropriate amount of time);
• Accessibility, knowledge and responsiveness to your practice's concerns (whether payer representatives are easy to reach, helpful, etc.);
• Formularies (whether the information is easy to access, how often it changes, etc.);
• Prior authorization (how often it is required, how reasonable the decisions are, etc.);
• Physician performance data (whether data is accurate, valid and used fairly);
• The contracting process (whether the payer is willing to negotiate, disclose its fee schedule, etc.).

It will be interesting to see the results of this survey and if it prompts other specialty societies to conduct similar surveys.

Institute of Medicine (IOM) news release

The IOM released information last month that is worth another look! The IOM was asked by the FDA and the Department of Health and Human Services to convene a committee to examine the FDA process and make recommendations for improving said process. The recommendations of this committee were released on 9/22/06; copies of the full report, The Future of Drug Safety: Promoting and Protecting the Health of the Public can be purchased at the IOM website. Some of the recommendations from the committee include:

• Labeling requirements and advertising limits for new medications
• Clarified authority and additional enforcement tools for the agency
• Clarification of FDA's role in gathering and communicating additional information on marketed products' risks and benefits
• Mandatory registration of clinical trial results to facilitate public access to drug safety information
• An increased role for FDA's drug safety staff
• A large boost in funding and staffing for the agency

Additionally, the committee report recommends "that a substantial majority -- at least 60 percent -- of advisory committee members be free of significant financial involvement with companies whose interests may be affected by their deliberations. FDA should issue waivers for the other committee members very sparingly." Yes, Virginia, a zero tolerance policy on financial relationships with industry just isn't practical, is it?

Fish oil: risks and benefits

A recent meta-analysis article in JAMA "Fish Intake, Contaminants, and Human Health Evaluating the Risks and the Benefits" concludes that:

"For major health outcomes among adults, based on both the strength of the evidence and the potential magnitudes of effect, the benefits of fish intake exceed the potential risks. For women of childbearing age, benefits of modest fish intake, excepting a few selected species, also outweigh risks."

Since the authors found that "modest consumption" of fish results in a 17% drop in total mortality, I'd say that's a rational conclusion.

"Fixing America's Hospitals" - Newsweek article

In the October 16, 2006 issue of Newsweek, Claudia Kalb reports on the innovations of ten hospitals. The innovative approaches to improving patient care and patient safety delineated in the article are as varied as the institutions themselves. I encourage you to read this important article and see if you, as a CME professional, can work with others at your institution who might be working on similar improvement projects. An excerpt:

"This year, more dire news: medication errors harm at least 1.5 million people and cost some $3.5 billion per year. What goes wrong? Missed diagnoses, incorrect drug dosing, failure to treat promptly. Experts agree that doctors, nurses, pharmacists and technicians will always make mistakes—it's the safety net around them that needs to be fixed. ''No matter how good people are, they suffer from being human and they're going to screw up,' says Jim Conway, senior vice president at Boston's Institute for Healthcare Improvement. 'We have to put systems in place that stop that error from causing harm.'"

"Therein lies the rub..."

Interesting posting at Sue Pelletier's CAPSULES blog about a new website, www.sermo.com, for physicians. Apparently, physicians subscribe to this website and then post their comments about their experiences with devices and drugs. The "rub" is that investment firms have access to their comments. To read Sue's wonderful blog, www.medicalmeetings.net

"Our romance with technology..."

Great phrase (and now blog headline) from a very recent editorial by Sanjay Kaul, M.D. and George A. Diamond, M.D., F.A.C.C. which is posted at www.cardiosource.com. The authors discuss the findings of major studies on the use of drug-eluding stents (DES), and they question the efficacy, risk and economics of DES use over that of bare metal stents. This is a great read and, hopefully, will generate much discussion on the more general issue of "our romance with technology..." and the closely aligned off-label use issue. An excerpt from the editorial:

"The FDA statement that 'coronary DES remain safe and effective when used for the FDA-approved indications' ignores the nearly 80% off-label use of these devices in the 'real world.' Although the FDA does not have the mandate to impact medical practice, it should nevertheless leverage its relationships with medical professional societies and device sponsors to collaborate on the development and implementation of new tools and programs that help mitigate unnecessary risk and promulgate best practice standards."

Irish CME system dubbed ineffective...

In the October 13, 2006 issue of "Irish Medical Times," Greg Baxter reports that consultant cardiologist Doctor John Clarke feels that CME credits (called "points" in Ireland) are "easy to come by...and doctors do not always learn something." It will be interesting to see if and when there is reform of the Irish CME point system.
http://www.imt.ie/displayarticle.asp?AID=11776&NS=1&SID=1&CAT=18

For women, the most violent place is home

A new W.H.O. study has confirmed (as reported in the New York Times) that violence against women by their intimates is a common, worldwide phenomenon. W.H.O. conducted interviews in 10 countries at 15 different sites to ascertain the rates of violence against women. From the NY times article:

"...the World Health Organization found that rates of partner violence ranged from a low of 15 percent in Yokohama, Japan, to a high of 71 percent in rural Ethiopia."

How sad.

Could it happen?

Richard L. Reece, M.D., a pathologist, is the author of an interesting article on health care in the United States in the year 2020. (He is also the author of a to-be-published book "Innovation-Driven Care: 36 Key Concepts for Transformation"). What "brave new world" does Doctor Reece envision in 2020?

"The commitment
The U.S. has committed to a health system promising greater wellness, longer lives, affordable prices, quick access, universal coverage, and uniform conformity.

Bipartisan politicians and neutral business coalitions now reign over a good society. They have reined in health spending and capped costs at 20 percent of Gross National Product, more than 16 percent in 2006, but less than 25 percent projected for 2030.1 In 2006 David Cutler, a Harvard economist, released a study showing health gains from 1960 to 2000 had been worth the spending.2 Still, in 2006, waste was rampant, duplication was constant, fraud was blatant.

Good health for all
In 2020, Americans brim with good health and delay disease until late in life. For good reasons:
All U.S. citizens have free genomic profiles at birth predicting future diseases and instructing how to prevent and circumvent these ailments."

For the entire article (registration required): http://www.healthleadersmedia.com

Take two aspirin...

How well do physicians explain to their patients how to take the medications that they prescribe for them? A study published in the Archives of Internal Medicine and headlined in the New York Times today answers that question...apparently, not very well...excerpt from the Times article:

"Although there were variations, depending on the type of medicine prescribed, 74 percent of the doctors mentioned the trade or generic name of the medicine, and 87 percent stated its purpose. Sixty-six percent said nothing about how long to take the medicine, 45 percent did not say what dosage to take and 42 percent failed to mention the timing or frequency of doses. Physicians mentioned adverse side effects only 35 percent of the time."

CME providers...take note!
:)

We're all in this together...

An article appeared today in the New York Times entitled "Overattentive Families May Be Underrated." While health care professionals sometimes find questions from a patient's family member(s) irritating and taking up too much of their time (not that I've ever personally encountered this); family members can and do contribute a great deal to the well being of their loved ones. The article (written by a physician) concludes:

"The most effective families, it seems to me, are those who genuinely appreciate the efforts of frequently overwhelmed health care providers and who seek to work with them to help care for their relatives. At the same time, as a concerned family member, you may know the patient better than anyone else, and if you see something that doesn’t seem right, speak up. The doctors may not thank you, but perhaps they should."