Archive for March 2009

Average vs. Threshold Encounter Volume

John Nelson writes... Daily encounters are a good metric for financial analyses, but I think they’re not so good when thinking about quality of care or hospitalist career longevity. Most groups track the average number of encounters per hospitalist each day (or rounding) shift.  And everyone wants to know what it the right or SHM recommended average number of daily encounters.  When does an increasing average encounter volume begin to impair quality of care?  (more…)

Statins and primary prevention of VTE

In a follow-up study from the JUPITER trial (which randomized >17,000 older adults with LDL<130 and CRP >2 to rosuvastatin or placebo), after a median of 2 years, the rosuvastatin group had a lower risk of incident VTE (HR 0.57, CI 0.37-0.86). Although it would be premature to use statins for primary prevention of VTE, it is intriguing, and will likely results in studies evaluating the role of statins in preventing recurrent VTE (abstract).

CT or Cxray for pneumonia diagnosis

In this small single-center retrospective analysis of patients with a diagnosis of pneumonia, of those who had both CT and Cxray performed, 27% had a negative (or non-diagnostic) Cxray, and a CT consistent with pneumonia (infiltrate / consolidation). This indicates that in patients with clinical signs / symptoms of pneumonia and a normal / non-diagnostic Cxray, CT is warranted (abstract).

Unfractionated heparin dosing; hard to get it right

This analysis is from a large prospective trial of over 20,000 patients with STEMI who were randomized to unfractionated (UFH) or low molecular weight heparin (LMWH). UFH was dosed bythe ACC/AHA weight based nomogram, with centrally monitored aPTTs (60 U/kg bolus and 12 U/kg/hour gtt). Despite 99% adherence to the nomogram, only 34% of initial aPTT's were therapeutic. Markedly low aPTT's (13%) were associated with increased risk reinfarction (OR 2.2), and markedly high aPTT's (16%) were associated with minor or major bleeding (OR 2.1). Markedly high aPTT's were more likely in patients that were older, female, lower weight, or with renal dysfunction. Unfortunately, even in the best of circumstances, we achieve therapeutic initial levels only 1/3 of the time, reminding us to remain vigilent despite protocols, especially in patients with the above risk factors (abstract).

ICU Glycemic Control: Another Can’t Miss Quality Measure Bites the Dust

A disconcerting pattern has emerged: a blockbuster study finds that a certain practice leads to improved outcomes. Large national organizations codify the practice into a quality measure, forcing widespread adoption. Later studies prove the practice to be unhelpful, perhaps even dangerous. Oops.Think about it – we’ve now seen quality measures that prompted the use of boatloads of unnecessary antibiotics (“door-to-antibiotic time” in patients with suspected community-acquired pneumonia), “can’t miss” quality measures that proved wrong (giving beta blockers to every perioperative patient), quality measures that promote gamesmanship and box-checking as a surrogate for meaningful action (smoking cessation counseling), and quality measures that trade efforts to prevent one kind of harm (preventing falls) for another (tethering some elderly hospitalized patients to their beds, leading to deconditioning and pressure ulcers). Let’s now add tight glucose control in critically ill patients to the Hall of Hiccups. A multicenter study of ICU patients in Australia…
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