Wonder Woman

via GruntDoc

ER doctor sounds siren for change | Houston Business Journal | 2.20.06

Even with a 76-hour-a-week work schedule and eight kids, Dr. Diana Fite finds time to tend to the trauma system.…

See GruntDoc’s post and read the article about Dr. Fite—amazing!

Primum Non Nocere

AMA Opposes Physician Involvement in Executions | AMA | 2.17.06

The American Medical Association (AMA) is alarmed that Judge Jeremy Fogel has disregarded physicians’ ethical obligations when he ordered procedures for physician participation in executions of California inmates by lethal injection.

…

The use of a physician’s clinical skill and judgment for purposes other than promoting an individual’s health and welfare undermines a basic ethical foundation of medicine—first, do no harm. Therefore, requiring physicians to be involved in executions violates their oath to protect lives and erodes public confidence in the medical profession.

As the voice of American medicine, the AMA urges all physicians to remain dedicated to our ethical obligations which prohibit involvement in capital punishment.

Another Hospital Myth

No ill effects found in hospital cellphone use | USA Today | 2.19.06

Despite signs in hospitals nationwide, little evidence exists that modern cellphone use interferes with medical equipment, and allowing doctors to use cellphones decreases medical errors, a paper in the journal Anesthesia and Analgesia finds.

…

According to an informal survey cited by the American Society for health care Engineering, about one-quarter of all hospitals ban cellphones entirely, half ban them from patient care areas, and the remaining quarter have no ban.

The bans go back to early reports from the 1980s that turning on a cellphone could turn off a ventilator or disrupt monitoring equipment.

But in surveying the engineering and medical literature on the topic, the researchers found that most incidents were single-case reports rather than widespread problems.

Modern digital cellphones use much less power than older analog models. And in 1979, the Food and Drug Administration created guidelines for shielding electronic medical devices, the paper notes.

…

Communication in Critical Care Environments: Mobile Telephones Improve Patient Care | Anesthesia & Analgesia | February 2006

Anesth Analg 2006;102:535-541

Most hospital policies prohibiting the use of wireless devices cite reports of disruption of medical equipment by cellular telephones. There have been no studies to determine whether mobile telephones may have a beneficial impact on safety.

…

The small risks of electromagnetic interference between mobile telephones and medical devices should be weighed against the potential benefits of improved communication.

Transparency

States want info about drugmakers’ gifts to doctors | USA Today | 2.16.06

From mugs and pens to expense-paid trips, the pharmaceutical industry’s largess to doctors and hospitals has come under increasing scrutiny in recent years. Now, a number of states want an even closer look.

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“If a doctor needs a Caribbean vacation or a mug or a pen, he or she is probably not very successful and needs to be in another business,” says state Sen. Mark Montigny, D-Mass., who sponsored the bill.

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“The No. 1 thing that keeps government and corporate officials honest is transparency,” Montigny says. “There ought to be, online, a report that everyone can see that says doc so-and-so has taken more than most.”

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State Sen. George Maziarz, R-N.Y., sponsored a bill to require such reporting after working in an office complex that also housed several doctors.
“They would show me their gifts: watches, leather jackets, golfing trips,” he says. “Someone is paying for that.”

…

States considering bills that would restrict or require reporting of gifts include^†:

1. California
2. Hawaii
3. Illinois
4. Massachusetts
5. Mississippi
6. New Hampshire
7. New York
8. Ohio
9. Pennsylvania

^† Dendrite International, National Conference on State Legislatures

Medical Students’ Exposure to and Attitudes About Drug Company Interactions | JAMA | 9.7.05

Conclusions Student experiences and attitudes suggest that as a group they are at risk for unrecognized influence by marketing efforts. Research should focus on evaluating methods to limit these experiences and affect the development of students’ attitudes to ensure that physicians’ decisions are based solely on helping each patient achieve the greatest possible benefit.

Medical Student Exposure to Drug Company Interactions | JAMA | 1.18.06

Medicine is both an idealistic profession and a business. The profession is inextricably bound to the pharmaceutical companies, and most of our journals, conferences, and therapeutics would not be available without them. I believe the article’s conclusion that “research should focus on evaluating methods to limit theses experiences . . . ” is misplaced. Rather than attempting to limit these experiences, students and all physicians must learn to recognize the pervasiveness of these experiences and develop critical and even cynical ways to deal with them.

Medical Student Exposure to Drug Company Interactions—Reply | JAMA | 1.18.06

The fading boundary between medicine and drug companies is a huge problem because information presented by drug companies uniformly favors the sponsored product. As our article summarized, this is a problem that is magnified because physicians tend to deny that they can be influenced and often cannot recognize the bias, with negative consequences for patients and huge costs for society.

…

Pharmaceutical representatives will not visit if they are told not to…

TANSTAAFL, No Free Lunch, AMSA’s PharmFree and Counter-Detailing Intiative (Quicktime)

Helen Wilson

Grassley, Baucus Say Oregon Death Raises Safety Concerns at Specialty Hospitals, Question HHS on Hospital Approval, Oversight (PDF) | United States Senate Committee on Finance | 2.14.06

WASHINGTON - Sen. Chuck Grassley, chairman of the Committee on Finance, and Sen. Max Baucus, ranking member, are seeking to learn whether the federal government adequately oversees the licensing, safety and quality of physician-owned specialty hospitals. The senators said they are concerned about the oversight of specialty hospitals nationwide following an Oregon incident. An 88-year-old woman died soon after surgery at an Oregon specialty hospital that apparently opened during a federal moratorium on new specialty hospitals. The hospital did not have a doctor on site during her crisis and needed to call 911 for medical assistance.

“Congress imposed the moratorium because we needed to get a handle on whether these hospitals help or harm patients and federal health care programs,” Grassley said. “In at least one case, a patient suffered harm. We need to know whether that was an isolated incident or whether similar tragedies have happened or could happen because doctors aren’t present during emergencies. We also need to understand why this facility was allowed to open during the moratorium, whether other specialty hospitals also opened during this period, and whether federal oversight to protect patient safety and oversee this industry is up to par. If patients think they’re going to a full-fledged hospital, then they shouldn’t get treated like they’re at a clinic. And if specialty hospitals are putting physician profit before patient care, we have a problem.”

Baucus said, “It’s important to find out why a physician-owned specialty hospital was given the green light to open up shop during a federal moratorium on the opening of such hospitals. For the sake of patient safety and the wise use of federal health care resources, it’s vital that HHS provide answers and proper oversight on this issue.”

Grassley and Baucus outlined their concerns in a letter today to Health and Human Services Secretary Mike Leavitt. The text of the letter follows.

February 14, 2006
The Honorable Michael O. Leavitt
Secretary
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Dear Secretary Leavitt:

The United States Senate Committee on Finance (Committee) has exclusive jurisdiction over, among other things, the Medicare and Medicaid programs. As Chairman and Ranking Member of the Committee, we have a responsibility to protect these programs along with the more than 80 million Americans who receive healthcare from them.

Each year the Medicare and Medicaid programs spend in excess of $200 billion for in-patient healthcare services at America’s hospitals. Managed by the Centers for Medicare and Medicaid Services (CMS), Medicare and Medicaid cover many different procedures and services reaching virtually every hospital across the country, including physician-owned specialty hospitals. These physician-owned specialty hospitals have raised much controversy and debate over the past few years. Concerns over their dramatic growth, among other things, led Congress to enact section 507 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) — an 18-month moratorium on the construction of new physician-owned specialty hospitals. We write today to express serious concerns about both CMS’ administration of the specialty hospital moratorium and the quality of care and patient safety at physician-owned specialty hospitals.

Physicians’ Hospital (Physicians’) in Portland, Oregon, is in many ways the typical specialty hospital. Physicians’ focuses primarily on orthopedic and neurosurgical procedures and the primary investors are doctors who work at the hospital. However, Physicians’ differs from other specialty hospitals in that it appears to have opened its doors for business in December of 2004, during the 18-month moratorium Congress placed on specialty hospitals. This information was brought to our attention as a result of a tragic event which occurred this past summer at Physicians’.

The Case of Helen Wilson

On July 27, 2005, Helen Wilson, an 88-year-old woman with a history of hypertension and diabetes, was admitted to Physicians’ for elective back surgery. While in recovery, Ms. Wilson was given an injection of the pain medication hydromorphone, and suddenly went into cardiac arrest. The nursing staff at Physicians’ immediately began CPR, but there was no doctor available to assist. According to the investigative report filed by the Health Care Licensure and Certification Office of the Oregon Department of Human Services.

“[T]here was no physician in the hospital at the time of the incident. The hospital does not have an emergency department. The respiratory therapists are not permitted to intubate patients. The hospital’s [Physicians'] policy is to call 911 in the event of a patient code.”

The nurses followed procedure and called 911 for emergency help. Upon arriving at Physicians’, paramedics were able to intubate and resuscitate Ms. Wilson and transport her to a neighboring hospital capable of providing a higher level of care. Unfortunately, it was too late. Ms. Wilson passed away four days later, after her family made the decision to remove life support.

The investigative report indicated that a review of documentation and interviews with hospital staff revealed that “the hospital failed to ensure that the medical staff was accountable for the quality of care provided to all patients.” The report raises questions regarding whether the admitting physician actually assessed the patient prior to surgery, whether the surgery was still necessary, and whether it was appropriate given the patient’s abnormal laboratory values prior to surgery. The report also finds that a nurse made “multiple unsuccessful calls to several physicians between the hours of 1655 and 1720,” just before the patient stopped breathing.

The events surrounding the death of Helen Wilson are tragic, and illustrate some of the drawbacks of the limited scope of work performed at specialty hospitals. This incident raises concerns about quality of care and patient safety. Additionally, it raises questions regarding how Physicians’ was allowed to open during the 18-month MMA-mandated moratorium.

{Questions for Dr. Leavitt}

1. How many physician-owned specialty hospitals have policies, either written or verbal, that do not require a physician to be on duty or on call when patients are present?
   1. Do any of these physician-owned specialty hospitals provide a disclaimer to their patients informing them that a doctor may not be there in the event of a life-threatening emergency?
   2. In the event that CMS does not track or have records that would allow CMS to answer the aforementioned questions, please provide a written response regarding CMS’ position as to whether or not CMS believes Medicare and Medicaid funds should be paid to specialty hospitals that lack either a physician on duty or a physician on call.
2. How many physician-owned specialty hospitals have policies directing hospital staff to call 911 in case of a patient emergency?
3. Since its opening in December 2004, have there been any other patient deaths at Physicians’? What are the circumstances surrounding these deaths?
4. Was Physicians’ Hospital reimbursed by Medicare or Medicaid for any services rendered during or after the physician-owned specialty hospital moratorium (November 18, 2003 - Present)? If so, please provide a list of the payments, including the type of procedure and the total amount of money reimbursed.
5. Was Physicians’ granted a new provider agreement to receive Medicare and Medicaid payments?
   1. If so, please provide an explanation why CMS issued a provider agreement to a new physicianowned specialty hospital during the moratorium.
   2. If not, please state in detail how Physicians’ was able to seek reimbursement for services to Medicare and Medicaid patients.
6. Is CMS aware of any other physician-owned specialty hospitals that have received provider agreements during the moratorium without applying for the required advisory opinion? If so, please provide a list of the hospitals and a reason why CMS granted a provider agreement.
7. Does CMS know of any other physician-owned specialty hospitals similar to Physicians’ that may have opened during the moratorium utilizing a provider agreement from a facility that existed prior to the moratorium? If so, please provide a list of such facilities and provide a detailed explanation as to why CMS approved them during the moratorium.
8. Provide a list of all specialty hospitals that received any payment from Medicare and Medicaid from November 18, 2003, through June 8, 2005. This list should include the name of the facility, the location, and contact information for that facility. Please separate this list by state and identify the total amount of Medicare and Medicaid funds received by each facility.

An unintended, but predictable, consequence of cream skimming—this is the very tip of a very large and dirty iceberg. Value is always a balance between quality and cost—no doubt Helen Wilson was informed about the cost “advantages” of the specialty hospital, but was she informed about the inferior quality that ultimately claimed here life? There is something fundamentally wrong with a hospital that utilizes the EMS system to provide a critical service.

Patronizing Dribble

In Emergency Medicine, we’re pretty use to being patronized by the other specialties—but I don’t expect it from within the specialty or from the putative leading organization representing emergency physicians. Patronizing dribble? Fluff piece?

Symptoms May Mask Meth Cases in ED | ACEP News | February 2006

Emergency physicians have a lot of catching up to do on their knowledge of the symptoms of methamphetamine addiction, according to Dr. Mark B. Mycyk.

Right, on the most prevalent intoxicant (excluding alcohol of course) in most urban ERs. Where have you been for the past 10 years? Of course, I may be jaded working in Northern California— the meth capitol.

“Maybe it’s because they don’t know what to do about it, or maybe it’s because they are so focused on traditional drugs of abuse, like cocaine, marijuana, and PCP.

Right, you certainly are showing your regional prejudice—cocaine and PCP have been displaced for several years by methamphetamine use.

“It’s a [consequence] of meth use where they’re picking at their skin,” she said, adding that this disorder is also known as “meth mites.”

How about pseudopediculosis and formication? C’mon, “ER doctors” can learn polysyllabic terms!

Patients addicted to methamphetamine (also known as “crystal meth”) also may have the typical IV drug users’ skin infections and abscesses, he continued.

D’oh! It may be “crystal meth.” It may be many other things— many many adulterants may be included in the “product.”

The most important thing emergency physicians can do when they see someone clearly under the influence of a drug of abuse is to “ask the tough questions and ask if they’re using some of the newer drugs,” Dr. Mycyk said.

“It’s easy to get a tox screen for heroin, but if that is negative and the patient is clearly high on something, you need to ask, ‘Have you used methamphetamine?’ ” explained Dr. Mycyk.

“Ask the tough questions” and “have you used methamphetamine”—you have got to be kidding, has this guy worked in an urban ER? You can ask all the questions you like, but denial and outright lying are part and parcel of the drug use culture. Excuse me, but confusing the high of heroin with the high of methamphetamine—we’re “ER docs” not morons!!!

The rest of the article is a pharmaceutical swill plug: “Dr. Torrington is an investor in and consultant to Hythiam, Inc.” Including a discussion of a proprietary detoxification regime (that most meth addicts will not be able to afford and which most payers, including governmental payers, will not cover) and flumazenil, a drug still in search of an indication.

Bottomline, “ER docs” really don’t know what they are doing AND please inquire about investing with Hythiam, Inc. and their “product” Prometa™—for the treatment of alcohol, cocaine, and methampethamine.

Pharmaceutical ad guissed-up as patronizing dribble…how refreshing…thanks ACEP!

Cream Skimming, Souring

Should Doctors Own Hospitals? | BusinessWeek | 2.20.06

Controversy builds over a fast-growing, profit-driven business

Buried in the deficit-reduction bill that President George W. Bush signed on Feb. 8 was a mandate that could put the kibosh on a hot trend in health care: hospitals that are partly owned and run by doctors.

For years critics have complained that when doctors invest in hospitals, conflicts of interest arise that could endanger patients and threaten the survival of general hospitals.… In 2003, Congress placed a moratorium on enrolling such facilities in Medicare and Medicaid while it examined the criticisms. The suspension was supposed to end on Feb. 15, but the signed budget bill requires that the Centers for Medicare & Medicaid Services extend the moratorium as much as six more months, while it prepares a report for Congress.

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Specialty hospitals may also drive up aggregate health-care costs by spurring demand for pricey elective surgeries, according to a Jan. 25 survey by the Center for Studying Health System Change in Washington

…

With the suspension likely to be extended, the onus is now on the Centers for Medicare & Medicaid Services to deal with the conflict. The agency, says a CMS official, will prepare a report that addresses conflict-of-interest concerns by scrutinizing how physician-ownership deals are structured and examining how such hospitals treat uninsured patients. Based on those findings, Congress may decide to revamp the rules for physician-owned care. Legislators are facing a tricky task, says Stuart Gutterman, senior program director at the Commonwealth Fund’s Program on Medicare’s Future in Washington: “They’ll have to balance the physicians’ desires with the concerns of patients and communities.”

Cream Skimming

Present System, Future Disaster

Dr. David Seaberg Testifies Before Subcommittees Of House Committee On Homeland Security | ACEP | 2.8.06

Washington, DC - David C. Seaberg, MD, a member of the Board of Directors of the American College of Emergency Physicians (ACEP), today testified before a joint hearing of subcommittees of the U.S. House Committee on Homeland Security.

…

Dr. Seaberg proposed the following 10-Point Plan to increase capacity, alleviate overcrowding and improve surge capacity in the nation’s emergency departments:

{emphasis added}

1. We must increase the surge capacity of our nation’s emergency departments by ending the practice of “boarding” admitted patients in emergency departments because no inpatient beds are available. This will require changing the way hospitals are funded to allow for inpatient and intensive-care unit surge capacity to manage this burden.
2. We must implement protocols to collect and monitor real-time data for syndromic surveillance, hospital inpatient and emergency department capacities and ambulance diversion status. Collection of this data is vital to developing appropriate protocols.
3. Homeland Security agencies on the federal, state, and local levels need to understand that hospitals and emergency departments are part of the community’s critical infrastructure. We cannot have response and recovery in a disaster without fully functioning, protected, and connected health resources.
4. We must require hospitals and communities that are severely affected by a natural or man-made disaster, or even a severe influenza outbreak, to postpone elective admissions until the crisis has abated. We must develop a way to compensate those facilities for their loss of revenue.
5. Command and control of disaster medical response must be more coordinated across federal, state and local agencies and departments.
6. We must establish a committee of stakeholders and disaster medicine experts from the public- and private-sectors and academic institutions to develop and/or refine national medical preparedness priorities and standards. We must change the national preparedness culture to one which is consensus-driven and evidence-based.
7. We must provide federal and state funding to compensate hospitals and emergency departments for the unreimbursed cost of meeting their critical public health and safety-net roles to ensure these emergency departments remain open and available to provide care in their communities.
8. We must establish a sustainable funding mechanism for disaster preparedness for hospitals, emergency departments and emergency management that is tied to national benchmarks and deliverables.
9. To ensure emergency physicians and nurses play a primary role in disaster planning and are considered in any national allocation of resources and protective measures, Congress should continue to include them in any definitions regarding first responders to disasters, acts of terrorism and epidemics.
10. Congress should pass H.R. 3875, the “Access to Emergency Medical Services Act,” which provides incentives to hospitals to reduce overcrowding and provides reimbursement and liability protection for EMTALA-related care.

Failure to…

Eliminating Conflicts in Medical Treatment | WSJ | 2.8.06

Medicare Tests Program to Better Coordinate Care for Multiple Ailments

Suffering from diabetes, arthritis and osteoporosis, 68-year-old Carol Spalding shuttled between four different doctors and a hospital in Maryland, struggling to manage her own care and cope with two wounds that refused to heal. Now, thanks to a new Medicare pilot program, she has two nurses to coordinate her doctor visits, explain her medications, and lift her spirits when she cries in pain and frustration.

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The Centers for Medicare and Medicaid Services, which is looking to cut more than $30 billion in costs, says patients with five or more chronic conditions account for 23% of its beneficiaries but 68% of its spending, seeing an average of 13 different doctors and filling 50 prescriptions a year. They struggle with combinations of diabetes, heart disease, glaucoma, asthma, lung disease and cancer, among other ailments.

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At the root of the problem, many agree, is a reimbursement system that pays doctors to treat illness and perform procedures, but provides no incentives for better preventive care or keeping patients out of the hospital. “We need to reorient the way Medicare looks at care, and focus on prevention and the coordination of care,” says Herbert Kuhn, the director of the Center for Medicare Management, which is overseeing the health support pilot. The system is full of “perverse incentives,” he says, “and there’s got to be a better way to do it.”

…

Failure to Communicate {modified graphic/table}

Percentage of people with chronic conditions reporting problems:

• 14%: received different diagnoses from different providers
• 16%: received information about drug interactions upon filling prescriptions
• 17%: received conflicting information from providers
• 18%: had duplicate tests or procedures

…

Failures to communicate, to coordinate, to align incentives…

Diversions, a Nosocomial Infection

Crowded ERs often send away ambulances | Philadelphia Inquirer | 2.7.06

ATLANTA - An ambulance is diverted every minute, on average, to a different hospital because emergency rooms in the United States are so overcrowded, one of the first national studies of the issue suggests.

The study did not measure how the delays in getting to hospitals affected patients’ survival, but experts said it could not have been for the better.

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About half a million ambulances were diverted from their original destinations because the receiving hospitals’ emergency departments were too overcrowded, the survey data from 2003 indicated. The study, released yesterday, is published in the Annals of Emergency Medicine.

…

Effects of Hospital Closures and Hospital Characteristics on Emergency Department Ambulance Diversion, Los Angeles County, 1998 to 2004 | Ann Emerg Med | 2.7.06

Study objective

We assess the effects of nearby hospital closures and other hospital characteristics on emergency department (ED) ambulance diversion.

Methods

The study design was a retrospective, multiple interrupted time series with control group. We studied all ambulance-receiving hospitals with EDs in Los Angeles County from 1998 to 2004. The main outcome measure was monthly ambulance diversion hours because of ED saturation.

Results

Our sample included 80 hospitals, of which 9 closed during the study period. There were increasing monthly diversion hours over time, from an average of 57 hours (95% confidence interval [CI] 51 to 63 hours) in 1998 to 190 hours (95% CI 180 to 200 hours) in 2004. In multivariate modeling, hospital closure increased ambulance monthly diversion hours by an average of 56 hours (95% CI 28 to 84 hours) for 4 months at the nearest ED. County-operated hospitals had 150 hours (95% CI 90 to 200 hours) and trauma centers had 48 hours (95% CI 9 to 87 hours) more diversion than other hospitals. Diversion hours for a given facility were positively correlated with diversion hours of the nearest ED (0.3; 95% CI 0.28 to 0.32). There was a significant and positive interaction between diversion hours of the nearest ED and time, suggesting that the effects of an adjacent facility’s diversion hours increased during the study period.

Conclusion

Hospital closure was associated with a significant but transient increase in ambulance diversion for the nearest ED. The temporal trend toward more diversion hours, as well as increasing effects of the nearest facility’s diversion hours over time, implies that the capacity to absorb future hospital closures is declining.

The single greatest real threat to the U.S. healthcare system is the inability to surge capacity—almost all urban settings nationwide are affected. Present healthcare funding and “competition” has stripped any ability to surge capacity—leaving our healthcare system truly lean and mean. Contrary to the old adage about the “bird-in-hand,” our attention and our ambulances are all diverted. Ambulances are diverted solely because that is the only surge in capacity the hospitals can control. Plain and simple, diversions are a sign of diseased hospitals—stricken with the disease of too little beds, too little staff, or a combination of both. Like ambulances, and the EMS system in general, the Emergency Department (ED) becomes the next stricken victim of this true nosocomial disease.

Those first stricken, like victims of scourges past, are perceived as the cause and are punished for their shortcomings. As in ages past, the truth is much more subtle and pervasive—ambulance, EMS, and EDs are just low hanging fruit on the diseased trees. Ambulances will cease to be diverted only when EDs cease to close, and EDs will cease to close only when the hospitals are cured of their insidious inability to meet healthcare demands.

One final point of clarity, the term should never be ambulance diversions or EMS diversions or ED diversions—it should be hospital diversions, because it is far more preferable and logical to name a disease after its cause, instead of its victims…else, what should we call the “bird flu?”

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