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Tag Archives: CMS

Should We COMMIT To This?

I try to keep up on current events in medicine, but sometimes discover that I miss things that may affect the manner in which I practice medicine. I attended a lecture on new treatments for STEMI and had a brief discussion with the lecturer afterwards regarding “Quality Measures” as determined by CMS. He mentioned a study that I had not read that goes by the acronym “COMMIT” – the Clopidogrel and Metoprolol in Myocardial Infarction Trial. This was a HUGE study that enrolled more that 45,000 patients in 1250 different hospitals. Patients suspected of having an acute MI were randomized to receive clopridogrel, metoprolol or placebo and were then continued on the medication until discharge or until they had been in the hospital for a week. Interesting point of the study was that patients who are given beta blockers “on arrival” had no difference in the primary endpoints of the study – death, reinfarction, or cardiac arrest. There was a 0.005 probability that the people receiving metoprolol would not experience ventricular fibrillation or reinfarction, but more than 1% of the patients receiving early beta blockers went into cardiogenic shock! As an aside, those on clopridogrel showed a significant improvement in the primary study endpoints. By getting early beta blockers, initially the patients did worse than those getting placebos. Over time, the reduction in reinfarctions and in ventricular fibrillation caused study participants to break just about even in terms of adverse events. The conclusion of the COMMIT study was that “it might generally be prudent to consider starting beta-blocker therapy in hospital only when the haemodynamic condition after MI has stabilised.” The COMMIT study results somewhat conflict with other studies cited by the American College of Cardiology and the American Heart Association in their joint 2004 guidelines for management of patients with acute ST-Elevation MI. Yet one of the “Hospital Compare” indicators for “quality care” in heart attack patients that the patient receive a “beta-blocker at arrival.” Even though the ACC/AHA recommendations are for patients with ST elevation MI, the Hospital Compare site does not make that distinction. Hospitals all over the nation brag about their statistics giving beta blockers at arrival. Cedars-Siani Hospital, Henry Ford Hospital, the Mayo Clinic, the Indiana Community Health Network, St. Luke’s Hospital in Missouri, and the University Health Care System in Georgia are just a few of the hospitals that I found posting their beta-blocker stats online. Is there conclusive evidence that we are helping, and not harming, patients by giving them beta blockers at arrival? I spent an hour online researching on PubMed, eMedicine, and MD Consult. I couldn’t find any studies showing a significant improvement in outcomes with “beta blockers at admission” for acute MI patients. I’m hoping that someone out there can post a link or two. The Beta Blocker Heart Attack Trial showed a significant improvement in outcomes when beta blockers were started 5-21 days after hospital admission, not “at arrival.” Even if there are some studies out there that do show a benefit, how do we reconcile the potential harm shown in the COMMIT study? If there is disagreement in the literature about the possible harm of a therapy, should hospitals get a bad “grade” for not giving that therapy? I would love to see data comparing the rates of death, reinfarction, etc. AFTER all of the CMS quality care measures were instituted. Couldn’t find that online, either. CMS is already making things worse for patients with pneumonia care. Now a huge study shows it may also be wrong with recommending early beta blocker administration. And there is no quality ...

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Hey CMS – Compare THIS

I’m away on a business trip and happened to read an article in the USA Today sitting outside my hotel room door that ticked me off. The feds spent $1.9 million in advertising to push their “Hospital Compare” web site. They want the public to compare different aspects of hospital care before deciding to go to the hospital. Another article on the topic from Yahoo is here. Supposedly the ads are to further the Bush administration’s goal to “increase transparency” in the health care system. Do the ads mention that the “quality” initiatives requiring that antibiotics be given within 4 hours of a pneumonia diagnosis actually “raises the risk of misdiagnosis and inappropriate use of antibiotics?” In other words, if doctors follow the initiatives, patients can potentially do worse. Do the ads mention that another initiative requiring doctors to perform blood cultures before giving antibiotics has absolutely no effect on clinical outcome? Do they mention that this requirement increases the length of stay by 4.5 days and increases the cost of hospitalization by over $5000 when “false positive” cultures are obtained (which occurs almost as often as “true” positives)? Of course not. They just pit one hospital against another – twisting the thumb screws to make one hospital look bad if it doesn’t adhere to some of these nonsensical quality measures. I still can’t figure out why CMS and the Bush administration have they excluded all the VA and military hospitals from their “hospital compare” web site if they are sooooo into transparency. Try searching for Walter Reed Army Medical Center or Tripler Army Medical Center on the site. Plug in the name of any of the VA hospitals in your area. Magically, according to the Hospital Compare database, government-run hospitals don’t exist. OK, CMS … you want other hospitals to shape up? Get your own house in order first. Put that $1.9 million to a better cause – like taking care of the soldiers who have sacrificed their lives and their health supporting this country’s initiatives instead of leaving them “stranded in unfit conditions,” “neglected,” and “waiting four months for the results of important medical tests”. Video testimony about the conditions in Walter Reed Hospital can be found here. “Do as I say and not as I do” doesn’t cut it. When you get the conditions at your hospitals in the top 10%, send me an e-mail. I won’t hold my breath.

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Do Not Use These Medical Abbreviations!

I’m about fed up with the chart police dinging me for writing “unapproved abbreviations.” This whole “Do Not Use List” is another Medical Marijuana Advocates idea that has just gone too far. I can’t write “U” anymore because it could be mistaken for any of the following: “0,” “4” or “cc” I can’t write QD or QOD because the period after the Q might be mistaken for an “I” and the “O” might be mistaken for an “I” I can’t write “MS” for morphine sulfate because someone might confuse it for magnesium sulfate. Similarly, MSO4 and MgSO4 might be confused. We’re soon going to be blessed with even more additions to the “Do Not Use List”: Don’t write “> or <” because they could be mistaken for the number “7” or the letter “L” Don’t write “&” because it could be mistaken for the number “2” Don’t write “cc” because it could be mistaken for “U” (units) when poorly written. Instead we will have to write out the term “ml” instead. There are other “safety measures” to keep us from hurting ourselves, but these are the ones that stick out most in my mind. Now hold on a second while I get my soapbox. Tap tap tap. Is this thing on? There, that’s better. The “U” for units might get confused with a number “0” Maybe there could be some confusion. Now let me ask the nurses a question: If you get an order for “500 reg insulin SQ,” are you going to (a) question the order or (b) fill up a 30 cc syringe (HA! I wrote “cc” instead of “ml” – cc cc cc cc cc) with regular insulin and inject a bolus the size of a kiwifruit under someone’s skin? Would any medically trained person give “50 regular insulin” instead of “5 u regular insulin” to someone with a glucose of 250? I didn’t think so. So this rule must have been written for people who have no knowledge of how to use insulin – just in case the housekeeping staff wants to get into the act and start treating hyperglycemia on the sly. While I’m at it, will all of the communications from Medical Marijuana Advocates be required to go without the “cc” designation, too? What a waste of trees. Have to write a new letter to every addressee. We can’t use MSO4 and MgSO4 because someone might not know that MSO4 is morphine and MgSO4 is magnesium Would anyone question why a physician was giving a patient with a kidney stone 10 mg of Magnesium for pain? Considering that the dose of magnesium is usually 1000 mg, would it not set off a red flag in a normal person’s mind when you have to use a micropipette to get the proper dose of a medication and then administer three drops to medicate the patient? And what better way to terminate an episode of torsades de pointes than 1 gram of morphine IV over 30 minutes? Just think, junkies from miles around would figure out ways to put themselves into cardiac arrhythmias just to get treated in your ED! I can see them now: Hey! Wait a minute, JACK! NOOOObody said nothing about no motherf%#$ing shocks! The ampersand “&” might be mistaken for a “2” First, I want to know who even writes ampersands any more. Then I want to see how someone can morph an ampersand into a number 2. Right after that, they can go to my bank and turn the $155 dollars in my checking account into a king’s ransom. Not happening. “> ...

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Hospitals Getting Graded Using Wrong Test Questions

So the Department of Health and Human Services’ “report card” grading hospitals on how well the hospitals “care for all their adult patients with certain medical conditions” just keeps getting worse and worse. Now we’re seeing that the “quality indicators” the government is using are nothing of the sort. One recent study shows that at least one set of “quality indicators” Increases the likelihood of misdiagnosis, Causes patients to receive unnecessary antibiotics, Has no effect on patient length of stay or death rates Not mentioned in the article, but just as important – increases the costs that patients have to pay due to all the unnecessary antibiotics and blood cultures Jumping through all the government hoops makes patients more likely to be misdiagnosed and more likely to receive unnecessary antibiotics. And they’re the ones grading the hospitals? The HHS home page states “This information will help you compare the quality of care hospitals provide.” Funny thing . . . if you look around on the web site, it shows nothing about where the quality indicators came from or what scientific methods were used to come up with the indicators. This page lists all of the quality indicators that HHS uses to determine whether or not patients are receiving “quality care.” If you go to the Pneumonia “Process of Care Measures” you’ll see that HHS thinks that “quality hospitals” give antibiotics within 4 hours because “Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.” Great. So why the 4 hour time frame? There are no data on the web site to support the government’s “quality indicators.” Now at least one study shows that the 4 hour time frame may actually harm patients. And why does HHS equate quality of care with giving unnecessary antibiotics to patients with viral pneumonia? Some of the quality indicators are valid. But let’s not use smoke and mirrors to coerce hospitals into providing unnecessary and potentially harmful care so that they can be at the top of some report card. The patients in the US deserve better than this. On tap in the future – more than 100 new “quality indicators” by which hospitals will be expected to abide. Just how many of them will have a scientific basis? I’m not keeping my hopes up. This micromanagement is going to make healthcare in the US more expensive and less effective. One more thing – has anyone ever noticed that government-run hospitals aren’t on the HHS “Hospital Compare” website? Try searching for Walter Reed Army Medical Center or Tripler Army Medical Center, for example. If civilian hospitals are performing as well as government-run facilities, they should get a great grade, right? Why aren’t government-run hospitals available for comparison? Bottom line: If everyone ignores these indicators, they become meaningless. No quality indicators for the Department of Health and Human Services leadership . . . yet.

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