Hospitalist Blog: February 2010

Wednesday, February 24, 2010

Conflics of interest prevent AMA from accurately representing physicians' views

Some thoughts from Daniel Palestrant:

"...the AMA has been completely sidelined in this healthcare debate. It’s been clear that the AMA’s decisions were based more on the ﬁnancial incentives that it gets from the US government as opposed to truly advocating for physicians or patients."

"Today, the AMA has reached a point where it will not publicly talk about its membership base. The most optimistic estimates say that less than one in ﬁ ve US physicians are AMA members, but most people on the inside will tell you that there are less than 60-80,000 physicians who are actually paying AMA members.

"The AMA’s revenue in 2008 was nearly $300 million, with just about $40 million coming from membership dues (http://tinyurl.com/ye39cgf). A big chunk of the AMA’s revenue comes from its monopoly on billing codes, which is something that the government has granted them, meaning that the AMA gets a lot of money from insurance companies; and physicians as it turns out, are adamantly against those billing codes. So, to me it’s a fundamental conﬂ ict that you could have an organization that is ostensibly advocating for physicians but is getting the majority of its money from the insurance industry."

"The physician community has been very consistent on what it wanted to see in the healthcare reform process, and yet none of those things have been achieved. The reason why the AMA wasn’t able to achieve those things is because it has no leverage. The politicians know that the AMA doesn’t really represent the physicians, and all the politicians have to do is threaten the AMA with removing its CPT license. That would make the AMA’s revenue disappear, and there are thousands of people whose jobs depend on that special arrangement with the government. Because of that fundamental conﬂ ict, there’s no possible way the AMA can truly advocate for physicians.

"The AMA came out and endorsed the House version of the bill within, I think, 36 hours of the bill coming out (http://tinyurl.com/y939a24). In the 72 hours following that, more than 11,000 physicians logged in to Sermo and voted on whether they supported the House version of the bill, with more than 90% saying they did not. The AMA’s position was, “We’re doing these things because we think we need to have a seat at the table and we want to achieve our two primary goals,” which are malpractice tort reform and repeal of the Sustainable Growth Rate (SGR), neither of which the AMA has been able to achieve. In the current push for healthcare reform pretty much everyone got a deal—the insurance industry, the pharma industry—yet the AMA has managed to accomplish absolutely nothing for America’s physicians."

Read the rest.

The best way to empower patients and physicians is to diminish the power of third parties.

Saturday, February 20, 2010

Thinking about starting a rural hospitalist program?

Here’s my advice:

Only administrations that appreciate physician billing as a small component of determining success of a program will survive. If your administration believes that physician billing is the most important sign of success and they make their decisions accordingly, the program is doomed to failure.
Don’t under staff. Many programs try to skimp by. When one doc leaves (and they will), it puts the others on the road to burnout real quick. If you can’t fully staff with enough physicians plus buffer for growing pains and the quitters, then start the program part time. Perhaps no weekends or no nights. Whatever, if you don’t have enough physicians to run the program, it’s doomed to failure from the start.
Be flexible. The larger your pool of candidates, the more successful you will be in starting the program.
Keep lines of communication open between docs and administration. Hospitalist jobs are everywhere. Administration in rural America must understand that they don’t run the show, the docs do. Why? because the docs can leave and land a job just about anywhere they want. It’s a buyers market for hospitalist medicine. It will be for quite some time. We are only getting started.
You’re going to have to pay more than you think. It’s rural. And it’s hospitalist. Think big.

From the Happy Hospitalist.

A Hospitalist’s Lament

Notes from Dr. RW...

"...[B]ecause the [hospitalist] role has not been carefully defined it is morphing into that of a jack-of-all-trades house doctor, a career few of us signed up for.

"Uncritical enthusiasm for some nebulous notion of 'comanagement' has blurred the boundaries of responsibility among hospitalists and other specialists and forced hospitalists into clinical encounters way beyond the scope of their training, pushing them out of their comfort zones and creating liability concerns.

"Under the rubric of comanagement some hospitalist programs are being made to function as H&P and discharge planning services in which they perform the clerical scut work on surgical and subspecialty patients who have no need of their clinical expertise.

"Hospitalists are increasingly coming to be viewed as administrative and business solutions more than clinicians. Not exactly what a candidate looks for in a career.

"These factors may increase the risk of burnout, increase turnover in hospitalist programs and exacerbate the shortage in the work force."

Continued...

Thursday, February 18, 2010

Stress Testing

Myocardial perfusion imaging: Society of Nuclear Medicine

MPI: American Society of Nuclear Cardiology (includes ICD-9 and CPT codes)

Exercise Stress Test: Family Practice Notebook

Stress Echocardiogram: Family Practice Notebook

Pharmacologic Stress Test: Family Practice Notebook

Stress Myocardial Perfusion Imaging: Family Practice Notebook

Radionuclide Imaging: Merck

Cardiac Imaging: Family Practice Notebook

Framingham Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (MI and Coronary Death)

Duke Treadmill Score

Monday, February 15, 2010

Discontinuation of Mechanical Ventilation

A simple daily assessment screen can identify patients who may be considered for successful tracheal extubation. This includes:

Adequate gas exchange (e.g. PaO2/FiO2 greater than 150 to 200; level of positive end expiratory pressure (PEEP) less than 5 to 8 cm H2O; FiO2 less than 0.4 to 0.5; and pH greater than 7.25);
Hemodynamic stability as defined by the absence of active myocardial ischemia and the absence of clinically significant hypotension (i.e., a condition requiring no vasopressor therapy or therapy with only low-dose vasopressors such as dopamine or dobutamine, less than 5 mcg/kg/min); and
Appropriate neurological and muscular status allowing the capability to initiate an inspiratory effort.

Indicators of failure of spontaneous breathing trials

Inadequate gas exchange
Arterial oxygenation saturation less than 85-90 %
PaO2 less than 50-60 mmHg
pH less than 7.32
Increase in PaCO2 greater than 10 mmHg
Unstable ventilatory pattern
Respiratory rate greater than 30-35 breaths/minute
Respiratory rate change over 50%
Hemodynamic instability
Heart rate greater than 120-140 beats/minute
Heart rate change over 20%
SBP greater than 180 mmHg, or
SBP less than 90 mmHg
Blood pressure change greater than 20%
Vasopressors required
Change in mental status
(e.g. somnolence coma, agitation, anxiety)
Signs of increased work of breathing
(e.g. use of accessory respiratory muscles, nasal flaring, paradoxical breathing movements)
Onset or worsening of discomfort, diaphoresis

More here.

Friday, February 12, 2010

Rheumatoid Arthritis Decision Tree

Click to enlarge

The American College of Rheumatology (ACR) developed diagnostic criteria for recognizing RA. Their list enabled determination of RA based on the presence of 4 of 7 listed criteria, and has been the standard method used by rheumatologists. These criteria include morning stiffness lasting longer than 30 minutes, arthritis in 3 or more joint areas, arthritis of hand joints, symmetric arthritis, and rheumatoid nodules. At least 4 of these criteria must have been observed by the clinician for 6 weeks after initial presentation.

However, early diagnosis and treatment in RA is vital, because a delay of as little as 4 to 6 months in treatment initiation can result in long-term joint damage. Therefore, in order to diagnose RA as early as possible, it has recently been recommended that a provisional diagnosis and referral to a rheumatologist should be made on the basis of more than 1 swollen joint in the context of other typical symptoms and signs.

***

Don't Forget: Live virus vaccines should be avoided in patients on immunomodulatory therapy. These include intranasal influenza, zoster, mumps/measles/rubella, yellow fever, and

Conditions That Can Adversely Affect SMBG Results

Conditions That Can Adversely Affect SMBG Results

Condition	Outcome
Patient has poor hygiene.	Failure to wash hands before testing or keep the meter clean can commonly cause errors¹⁸ as well as potential contamination.¹⁰
Test strips are not specific to the meter in which they are used.	A mismatch between meter and strips will produce inaccurate results.¹⁰
The expiry date on the test strips has passed.	Outdated test strips can produce inaccurate results.¹⁰
Test strips are exposed to humidity, high temperatures, or strong light; test strip container is left open.	Humidity and high temperatures can deteriorate the enzyme on the test strip that interacts with glucose to produce the result, producing a falsely elevated number.¹⁹
Test is done at high altitude.	Can adversely affect results, particularly in low temperatures.²⁰
Patient does not assess accuracy of new meter or test strip batch using control solution.	The patient should test each new meter and each new package of test strips with control solution. Prescriptions should include control solutions as well as meters and strips.¹⁰
Patient does not properly calibrate meter as required.	Patients must properly calibrate their meters for each new set of test strips.¹⁰ Coding errors can produce inaccurate results that can in turn lead to insulin dosing errors.²¹ Alternatively, patients can be advised to choose meters with automatic calibration, which significantly reduces the possibility for these types of errors.²¹
Patient has variable hematocrit levels (eg, smokers, patients living at high altitudes, dehydrated patients, or patients with sickle-cell anemia, polycythemia, or end-stage renal failure).¹⁵	Abnormally high hematocrit can artificially depress the glucose result; abnormally low hematocrit levels can artificially elevate the glucose result²²; this occurs because the higher concentration of red blood cells blocks the plasma from adequately diffusing through the strip layers.¹⁰
Patient is receiving a treatment containing a sugar (eg, xylose, maltose, icodextrin, galactose).	Test strips that use the enzyme glucose dehydrogenase pyrroloquinolinequinone or glucose-oxireductase can give falsely elevated readings in patients who are also receiving treatments containing other sugars.²³ In rare instances, this has caused death and has been the subject of an FDA warning.²⁴ Not all glucose meters use this enzyme, and the test method used is identified in the package insert for the glucose strips.
Patient is taking acetaminophen, ibuprofen, ascorbic acid, dopamine, L-dopa, methyl dopa, tetracycline, ephedrine.	These substances (among others) can potentially influence the reliability of blood glucose test results.¹⁰