Archive for February, 2009

OMNI Postings of 2/28/09

by Paul Rega, MD — published on February 28th, 2009

A mother was sitting on the couch reading a book when one of her children walked up to her and said, “Mummy, why is my name Petal?”
The mother replied, “Because when you were born, a petal fell on your head.”

The next baby walked up and asked, “Mummy why is my name Rose?” she replied,

“Because when you were born, a rose fell on your head.”

The last baby walked up to her and said, “BLAS CLAFLAS YIFRASSAM TASSM POONNFFFIINRTY.”

The mother replied, “Please be quiet, Refrigerator.”

But I digress…..

This is a MMWR report from CDC about MVA stats. Did you know that in 2005, 45,520 deaths in the United States were related to motor vehicles? During 1999–2005, although annual age-adjusted motor vehicle–related death rates overall were nearly unchanged (range: 15.2–15.7 per 100,000 population), substantial differences were observed by state, U.S. Census region, sex, race, and age group. Among states, the average annual death rate ranged from 7.9 per 100,000 population in Massachusetts to 31.9 in Mississippi. Among regions, the rate ranged from 9.8 per 100,000 population in the Northeast to 19.5 in the South. The rate for men (21.7 per 100,000 population) was more than double the rate for women (9.4); the rate for American Indians/Alaska Natives (27.2) was nearly twice the rate for whites (15.7) and blacks (15.2), and the rate for persons aged 15–24 years (26.8) was 74% higher than the average annual rate overall (15.4).
http://omniphysicians.com/2009/02/26/mmwr-mva-deaths-in-us-1999-2005/

You take care of hypertension in dialysis patients, they don’t die as much. Go figure. Anyway, this review of a number of articles collected info on over 1600 dialysis patients with controls. Blood pressure lowering treatment was associated with lower risks of cardiovascular events (RR 0·71, 95% CI 0·55—0·92; p=0·009), all-cause mortality (RR 0·80, 0·66—0·96; p=0·014), and cardiovascular mortality (RR 0·71, 0·50—0·99; p=0·044) than control regimens. The effects seem to be consistent across a range of patient groups included in the studies.
http://omniphysicians.com/2009/02/26/dialysis-hypertension-death/

This report from MedScape came from a study that provided new evidence that women with strokes were more likely (43% more likely) than men to have mental status changes (disorientation, confusion, or loss of consciousness). The husbands of these women were more likely than controls to have big smiles on their faces!
http://omniphysicians.com/2009/02/26/isc-2009-women-with-stroke-tia-more-likely-than-men-to-report-mental-status-change/

The FDA has announced that long-term use of Reglan is so associated with tardive dyskinesia that there will be a boxed warning.

Tardive dyskinesia is characterized by involuntary, repetitive movements of the extremities, or lip smacking, grimacing, tongue protrusion, rapid eye movements or blinking, puckering and pursing of the lips, or impaired movement of the fingers. Funny, I got a lot of these symptoms when I was sitting next to Salma Hayek at the Oscars! http://omniphysicians.com/2009/02/26/chronic-metoclopramide-reglan-tardive-dyskinesia/

See ya,

Paul R.

Comments Off
categories: Emergency Medicine

Examples of Metaphors

by Paul Rega, MD — published on February 28th, 2009

Metaphors discussed in the article (Full Link: http://www.jpedhc.org/article/S0891-5245(07)00395-1/fulltext#sec3).

A 12-year-old girl, who considered her asthma as not severe, used a metaphor of a troll to describe her illness. She said, “The troll is a little man in a green suit with big boots and a top hat. He is not very nice. He is small and sleeps all day in the dark, like under a bridge—kind of hidden, until I wake him up by the activities I do. When he wakes up, he climbs up the ladder to tell the air it has to pay to come into my chest. He says, ‘You can’t go through until you pay. You need to pay.’ Sometimes the troll kidnaps your air (it seems as if the troll is asleep and you get air but he can wake up and kidnap the air). The troll can be controlled or destroyed by pushing him down the ladder. So far he has gone back to sleep only to wake up again. But one day he won’t wake up any more. The troll tells me in my ear when I’m getting ready to have asthma and I should calm down.”

Only she can hear the troll’s message. “It’s like nobody can hear it but me when it’s like starting… and then the troll starts tightening up my chest so it is hard to breathe.” In this metaphor, the troll and asthma are interchangeable. Here she uses the “it” in the first instance to talk about the troll and “it” in the second instant to talk about asthma.

An 11-year-old, who rates her asthma from not severe to moderately severe, said that asthma is like a chewed-up cracker—“like two little crackers that you chew up not really well. All these little pieces of crackers go everywhere, that’s how it is in your chest when you breathe. It gets your mouth all dry and you try and spit it out so you can breathe. When you breathe out, the crackers go out and when you breathe in the little pieces come back in. When you breathe you hear the sound of the little pieces of crackers in your chest. They are all crumbly and you hear the crumbly sounds cause you’re wheezing, a kind of cracker sound. If you take medicine, it kind of settles down the cracker pieces, so they don’t bother you. Otherwise the pieces go flying around and make you cough. Other medicines loosen up the cracker crumbs so you can cough them out.”

One precocious 11-year-old boy with moderately severe asthma said, “One has to have the capability or responsibility to treat your body right and prevent respiratory sickness from happening. You don’t want this to happen to you ’cause it is like a jellyfish, which has a deadly sting and vicious bit and tentacles which could squeeze your throat and make your bronchioles get smaller and make breathing harder. Or like a boa constrictor squeezing life out of you. To depend on yourself means no one else can help me but me. No one else can give me a warning. I might get a warning, like a tickle in my throat; no one else will know that but me. I have all the information, so I have to help myself. The tentacles of the jellyfish can brush up against you, that’s like a warning, it does not sting but you know that it is there.”

A quiet 12-year-old girl says that she is healed from having severe asthma. Much of her family’s activities revolve around a fundamental Christian church. The pastor prayed over her and asked others to pray for her, asking God that she be healed from asthma as he was when he was a young boy. She said, “Now I have a guardian angel who watches over me and cured me of my asthma. I no longer have to take medicine.” Things for this child are black or white; there is no in between. Her view is that “I am either not good enough to be cured, or I am. The guardian angel sent by God helps me to be good. However, if I mess up, I will get into trouble. My guardian angel does not protect me and can even take the air away. I use to not be able to catch my breath and then would breathe hard, which would hurt badly in my chest and I would be weak and tired. But now that I have been prayed over and have a guardian angel all that has ceased.”

Comments Off
categories: Emergency Medicine

Asthma and metaphors

by Paul Rega, MD — published on February 28th, 2009

For the full Text: Link: http://www.jpedhc.org/article/S0891-5245(07)00395-1/fulltext

Children’s Perceptions of Asthma: African American Children Use Metaphors to Make Sense of Asthma

Jane W. Peterson, RN, PhD, Yvonne M. Sterling, RN, PhD

published online 27 February 2008.

Abstract
Introduction
Children’s views of their illness often are absent in decisions that affect their lives. This research, which is a component of a larger study, reports how African American children described their asthma.

Method
The study’s design was descriptive and longitudinal, using an ethnographic approach. A subsample of 10 children diagnosed with asthma who resided in one of two study sites spontaneously described their asthma. The study was conducted in various settings where the researchers observed/participated in selected activities. Participants were interviewed several times, and field notes were recorded.

Results
The qualitative findings are from participant observation and interviews of 10 children ages 9 to 12 years. Four of the most developed metaphors are reported here. Out of their experiences, children created their own metaphors for asthma that are concrete, familiar, and multi-vocal, allowing for embellishment.

Discussion
Not all children use metaphors to explain or describe their asthma. Children who explain asthma in their own terms will feel valued and invested in their own health care as they find that their voices make a difference in decisions about their care.

Comments Off
categories: Emergency Medicine

Improving access to EMS

by Paul Rega, MD — published on February 26th, 2009

Modern HealthCare (2/25, Lubell) reported, “A bipartisan group of House and Senate members have reintroduced legislation to help improve access to emergency medical services.” The bill, called the “Access to Emergency Medical Services Act,” would create “a national bipartisan commission on access to emergency medical services to examine factors that affect the delivery of care in emergency departments.”

The proposal also calls for the Centers for Medicare and Medicaid Services “to develop standards, guidelines, and measures to address boarding and ambulance diversion.” Nick Jouriles, president of the American College of Emergency Physicians (ACEP), stated that the group has “every confidence that it will pass.” To that end, ACEP “plans to urge Congress to hold hearings on the access problems facing patients who visit emergency departments.”

Comments Off
categories: Emergency Medicine

Dialysis, Hypertension & Death

by Paul Rega, MD — published on February 26th, 2009

Source reference:
Lambers Heerspink HJ, et al “Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials” Lancet 2009; DOI: 10.1016/S0140-6736(09)60212-9.

Treatment reduced risk by 29% for both cardiovascular events and mortality (P=0.009 and P=0.044) and by 20% for all-cause mortality 20% (P=0.014), Vlado Perkovic, M.D., of the University of Sydney, and colleagues reported online in The Lancet.

  

Background

Patients undergoing dialysis have a substantially increased risk of cardiovascular mortality and morbidity. Although several trials have shown the cardiovascular benefits of lowering blood pressure in the general population, there is uncertainty about the efficacy and tolerability of reducing blood pressure in patients on dialysis. We did a systematic review and meta-analysis to assess the effect of blood pressure lowering in patients on dialysis.

Methods

We systematically searched Medline, Embase, and the Cochrane Library database for trials reported between 1950 and November, 2008, without language restriction. We extracted a standardised dataset from randomised controlled trials of blood pressure lowering in patients on dialysis that reported cardiovascular outcomes. Meta-analysis was done with a random effects model.

Findings

We identified eight relevant trials, which provided data for 1679 patients and 495 cardiovascular events. Weighted mean systolic blood pressure was 4·5 mm Hg lower and diastolic blood pressure 2·3 mm Hg lower in actively treated patients than in controls. Blood pressure lowering treatment was associated with lower risks of cardiovascular events (RR 0·71, 95% CI 0·55—0·92; p=0·009), all-cause mortality (RR 0·80, 0·66—0·96; p=0·014), and cardiovascular mortality (RR 0·71, 0·50—0·99; p=0·044) than control regimens. The effects seem to be consistent across a range of patient groups included in the studies.

Interpretation

Treatment with agents that lower blood pressure should routinely be considered for individuals undergoing dialysis to reduce the very high cardiovascular morbidity and mortality rate in this population.

 

Comments Off
categories: Emergency Medicine

MMWR: MVA Deaths in US (1999-2005)

by Paul Rega, MD — published on February 26th, 2009

Motor Vehicle–Related Death Rates: US, 1999-2005 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5807a1.htm?s_cid=mm5807a1_e)

In 2005, the most recent year for which data are available, 45,520 deaths in the United States were related to motor vehicles (1). A Healthy People 2010 objective calls for reducing the rate of deaths related to motor vehicles to 9.2 per 100,000 population from a baseline of 15.6 in 1998 (2). To assess progress toward the Healthy People objective and to examine characteristics of motor vehicle–related death rates, CDC analyzed data from the National Vital Statistics System (NVSS) for the period 1999–2005. This report summarizes the results of that analysis, which determined that, during 1999–2005, although annual age-adjusted motor vehicle–related death rates overall were nearly unchanged (range: 15.2–15.7 per 100,000 population), substantial differences were observed by state, U.S. Census region,* sex, race, and age group. Among states, the average annual death rate ranged from 7.9 per 100,000 population in Massachusetts to 31.9 in Mississippi. Among regions, the rate ranged from 9.8 per 100,000 population in the Northeast to 19.5 in the South. The rate for men (21.7 per 100,000 population) was more than double the rate for women (9.4); the rate for American Indians/Alaska Natives (27.2) was nearly twice the rate for whites (15.7) and blacks (15.2), and the rate for persons aged 15–24 years (26.8) was 74% higher than the average annual rate overall (15.4). Additional analysis and research to determine the causes of geographic and demographic variations in motor vehicle–related deaths might result in more effective targeted interventions among the states, regions, and populations at greatest risk.

NVSS data were obtained from CDC’s Web-based Injury Statistics and Query System, an interactive surveillance system that provides customized reports of injury-related deaths based on death certificate records from state vital statistics offices (1). CDC analyzed data on motor vehicle–related deaths for the period 1999–2005, the most recent years for which data were available, using codes† from the International Classification of Diseases, 10th Revision (ICD-10) (3). Because the mortality coding system in the United States changed significantly from ICD-9 to ICD-10 in 1999, analysis was limited to data for the period 1999–2005 to ensure appropriate comparisons of data from year to year (4). Bridged-race population estimates from the U.S. Census were used to calculate death rates. Rates were age adjusted to the 2000 standard U.S. population. Negative binomial regression was used to determine the statistical significance (p<0.05) of changes in rates from 1999 to 2005. Data were analyzed by state, census region, sex, race (regardless of Hispanic ethnicity), and age group.

During 1999–2005, a total of 311,356 motor vehicle–related deaths occurred in the United States. The overall average annual age-adjusted rate for this period was 15.4 deaths per 100,000 population (range: 15.2–15.7 per 100,000 population); the annual death rate decreased by 1% from 15.3 in 1999 to 15.2 in 2005 (Table 1).

Of the motor vehicle–related deaths in the United States during 1999–2005, a total of 141,780 (46%) occurred in the South census region. The average annual death rate was highest in the South (19.5 per 100,000 population), followed by the Midwest (14.7), West (14.2), and Northeast (9.8). By state, the average annual death rate was highest in Mississippi (31.9 per 100,000 population), followed by Wyoming (27.7), Arkansas (25.6), Montana (25.6), and Alabama (25.1). In four states and the District of Columbia (DC), the average annual death rate was below the Healthy People target of 9.2 per 100,000 population: Massachusetts (7.9), New York (8.4), Rhode Island (8.5), DC (8.4), and New Jersey (9.0) (Table 1).

During 1999–2005, the average annual death rate for males (21.7 deaths per 100,000 population) in the United States was more than twice the rate for females (9.4) (Table 2). By race, the average annual death rate was highest among American Indians/Alaska Natives (27.2 deaths per 100,000 population), followed by whites (15.7), blacks (15.2), and Asians/Pacific Islanders (8.2) (Table 2).

By age group, the average annual motor vehicle–related death rate was highest among persons aged 15–24 years (26.8 deaths per 100,000 population) and persons aged >75 years (25.9) and lowest among persons aged < 14 years (4.0) (Table 3). From 1999 to 2005, the annual rate was flat (26.3 versus 25.9) among persons aged 15–24 years and increased by 8% among persons aged 45–64 years and by 4% among persons aged 25–44 years. The annual rate decreased by 18% among persons aged < 14 years and by 15% among persons aged >75 years.

Reported by: N Adekoya, DrPH, National Center for Public Health Informatics; Motor Vehicle Injury Prevention Team, Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note:

 

During 1999–2005, approximately 300,000 deaths in the United States were related to motor vehicle crashes; however, the overall annual death rate did not change substantially (range: 15.2–15.7 per 100,000 population). During an earlier period, from 1969 to 1992, the overall annual rate of motor vehicle–related deaths in the United States decreased 43%, from 27.7 per 100,000 population§ to 15.8 (1), a rate only slightly higher than the rate observed during 1999–2005. Motor vehicle–related deaths are preventable, and numerous factors have been credited for the decrease in the death rate during 1969–1992, including adoption of the 0.08 g/dL blood alcohol concentration limit for drivers; vehicle safety improvements, primary enforcement of seat belt and child restraint laws, an increased minimum legal drinking age, alcohol checkpoints, lower speed limits and increased enforcement, and increased availability of statewide trauma systems (5). Nonetheless, additional and vigorous measures are needed if the Healthy People 2010 national objective of 9.2 deaths per 100,000 population is to be met.

The findings in this report revealed substantial variation in motor vehicle–related death rates among states during 1999–2005. Some of this variation is explained by the extent of population exposure to the road environment, which was not part of this population-based analysis. Similar calculations using a denominator such as vehicle miles traveled can yield different variations among states. Motor vehicle–related death rates also can vary for other reasons, including the types of road users. In this analysis, rates might be higher in states with greater percentages of more vulnerable road users (e.g., pedestrians, bicyclists, and motorcyclists) than in states with more passenger vehicle occupants.

The South accounted for 46% of the deaths during the period studied but only 36% of the population. Reasons for this disproportion are unclear. In addition to variations in exposure to the road environment and type of road user, rates might be affected by the proportion of the population living in rural versus urban locations and greater distances traveled, differences in population demographics (e.g., income and education), and differences in safety behaviors such as safety belt use (6–8). However, regional differences also mask substantial state variability. For example, in the South, Alabama and Arkansas had rates approximately twice as high as Maryland and Virginia. The differences in death rates by sex, race, and age group observed in this analysis are consistent with other reports and again underscore the importance of identifying populations at greatest risk for targeted interventions (e.g., males, American Indian/Alaska Natives, and young adults) (9,10). Further studies should address reasons for the higher motor vehicle–related death rates in certain states to enable creation of strategies that directly address this concern.

The findings in this report are subject to at least two limitations. First, death certificates and population estimates might not accurately record race, resulting in overreporting or underreporting of deaths and rates for certain racial populations. Second, the Healthy People objective was based on unintentional deaths only. However, this study examined all motor vehicle–related deaths, including homicides and suicides, which accounted for 1,400 deaths, or approximately 0.45% of all motor vehicle–related deaths during the study period.

Motor vehicle crashes continue to be a leading cause of death and injury in every U.S. region and state. States should reexamine their unique demographic, geographic, and cultural risk factors to determine the extent to which they are contributing to motor vehicle crashes and injuries. In addition, state and local highway safety and public health officials should reconsider additional strategies that have demonstrated effectiveness in reducing the number of motor vehicle–related deaths and injuries. For example, when properly used, lap/shoulder safety belts reduce by 45% the risk for dying in a crash and by 50% the risk for moderate to serious injury (6). Currently, 49 states and DC have safety belt laws; however, 23 states have only implemented laws with secondary enforcement (i.e., allowing police to ticket motorists for not using safety belts only if they are stopped for another violation). Secondary laws are less effective at increasing safety belt use and decreasing fatalities than primary laws (10). States should reexamine their motor vehicle safety policies to ensure that they are implementing and enforcing measures with the greatest effectiveness. Information on the effectiveness of strategies to increase use of safety belts and child safety seats and reduce alcohol-impaired driving is available at http://www.thecommunityguide.org/mvoi/index.html.

References

 

  1. CDC. WISQARS (Web-based Injury Statistics Query and Reporting System). Available at http://www.cdc.gov/ncipc/wisqars.
  2. US Department of Health and Human Services. Injury and violence protection: objective 15-15. In: Healthy people 2010 (conference ed. in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov/document/pdf/volume2/15injury.pdf.
  3. World Health Organization. International statistical classification of diseases and related health problems: 10th revision (ICD-10). 3 vols. Geneva, Switzerland: World Health Organization; 1992.
  4. Anderson RN, Minino AM, Hoyert DL, Rosenberg HM. Comparability of cause of death between ICD–9 and ICD–10: preliminary estimates. Natl Vital Stat Rep 2001;49(2).
  5. Dellinger AM, Sleet DA, Jones BH. Drivers, wheels, and roads: motor vehicle safety in the twentieth century [Chapter 16]. In: Ward JW, Warren C, eds. Silent victories: the history and practice of public health in twentieth-century America. New York, NY: Oxford; 2007:343–62.
  6. National Highway Traffic Safety Administration. Traffic safety facts—2007 data. Occupant protection. Washington, DC: National Highway Traffic Safety Administration; 2008. DOT HS 810 991. Available at http://www-nrd.nhtsa.dot.gov/pubs/810991.pdf.
  7. National Highway Traffic Safety Administration. Traffic safety facts, 2005. A compilation of motor vehicle crash data from the Fatality Analysis Reporting System and the General Estimates System. Washington, DC: National Highway Traffic Safety Administration; 2006. DOT HS 810 631.
  8. O’Neill B, Kyrychenko SY. Use and misuse of motor-vehicle crash death rates in assessing highway-safety performance. Traffic Inj Prev 2006;7:307–18.
  9. CDC. Injury mortality among American Indian and Alaska Native children and youth—United States, 1989–1998. MMWR 2003;52:697–701.
  10. Shults RA, Nichols JL, Dinh-Zarr TB, Sleet DA, Elder RW. Effectiveness of primary enforcement safety belt laws and enhanced enforcement of safety belt laws: a summary of the Guide to Community Preventive Services systematic reviews. J Safety Res 2004;35:189–96.


 

                                                                                      

Comments Off
categories: Emergency Medicine

Chronic Metoclopramide (Reglan) & Tardive Dyskinesia

by Paul Rega, MD — published on February 26th, 2009

Link:  http://www.fda.gov/bbs/topics/NEWS/2009/NEW01963.html

FDA, 2/26/09:  FDA Requires Boxed Warning and Risk Mitigation Strategy for Metoclopramide-Containing Drugs

Agency warns against chronic use of these products to treat gastrointestinal disorders

The U.S. Food and Drug Administration announced today that manufacturers of metoclopramide, a drug used to treat gastrointestinal disorders, must add a boxed warning to their drug labels about the risk of its long-term or high-dose use. Chronic use of metoclopramide has been linked to tardive dyskinesia, which may include involuntary and repetitive movements of the body, even after the drugs are no longer taken.

Manufacturers will be required to implement a risk evaluation and mitigation strategy, or REMS, to ensure patients are provided with a medication guide that discusses this risk.

“The FDA wants patients and health care professionals to know about this risk so they can make informed decisions about treatment,” said Janet Woodcock, M.D., director of the FDA’s Center for Drug Evaluation and Research. “The chronic use of metoclopramide therapy should be avoided in all but rare cases where the benefit is believed to outweigh the risk.”

Current product labeling warns of the risk of tardive dyskinesia with chronic metoclopramide treatment. The development of this condition is directly related to the length of time a patient is taking metoclopramide and the number of doses taken. Those at greatest risk include the elderly, especially older women, and people who have been on the drug for a long time.

Tardive dyskinesia is characterized by involuntary, repetitive movements of the extremities, or lip smacking, grimacing, tongue protrusion, rapid eye movements or blinking, puckering and pursing of the lips, or impaired movement of the fingers. These symptoms are rarely reversible and there is no known treatment. However, in some patients, symptoms may lessen or resolve after metoclopramide treatment is stopped.

Metoclopramide works by speeding up the movement of the stomach muscles, thus increasing the rate at which the stomach empties into the intestines. It is used as a short-term treatment of gastroesophageal reflux disease in patients who have not responded to other therapies, and to treat diabetic gastroparesis (slowed emptying of the stomach’s contents into the intestines). It is recommended that treatment not exceed three months.

Metoclopramide is available in a variety of formulations including tablets, syrups and injections. Names of metoclopramide-containing products include Reglan Tablets, Reglan Oral Disintegrating Tablets, Metoclopramide Oral Solution, and Reglan Injection. More than two million Americans use these products.

Recently published analyses suggest that metoclopramide is the most common cause of drug-induced movement disorders. Another analysis of study data by the FDA showed that about 20 percent of patients in that study who used metoclopramide took it for longer than three months. The FDA has also become aware of continued spontaneous reports of tardive dyskinesia in patients who used metoclopramide, the majority of whom had taken the drug for more than three months.

Consumers and health care professionals are encouraged to report adverse events to the FDA’s MedWatch program at 800-FDA-1088, by mail at MedWatch, HF-2, FDA, 5600 Fishers Lane, Rockville, Md. 20852-9787, or online at: www.fda.gov/medwatch/report.htm

Comments Off
categories: Emergency Medicine

Clunk Redux

by Paul Rega, MD — published on February 26th, 2009

Date: 2/23/2009 1416 CST

Program: ARCH Air Medical Service
    2207 Scott Avenue
    St. Louis, MO  63103
   

Type: BK-117
Tail #: N122SL
Operator/Vendor: Air Methods Corp.

Weather: Clear. Not a factor

Team: Pilot, Flight Nurse, Flight Paramedic. No injuries reported. Patient on board.

Description:
    Please note some corrections to original bulletin: While transporting
    a patient to a St. Louis area tertiary care center, the pilot and med
    crew heard a loud sound which was followed by the complete loss of
    power on the number two engine. The pilot secured the engine and
    immediately diverted to St. Louis Downtown Parks Airport where a
    successful single engine run-on landing was performed. The patient and
    crew were then transported via ground ambulance to the receiving
    facility.

Additional Info:
    The following day, the number two engine was replaced and the aircraft
    was returned to service. The engine is now being sent to the
    manufacturer for further inspection to determine the cause of the
    failure.

Source: Matt Kasten, CMTE – Program Director

Comments Off
categories: Emergency Medicine

OMNI Postings of 2/26/09

by Paul Rega, MD — published on February 26th, 2009
Q: What do you have when you see a lawyer’s buried up to his neck in sand?
A: Not enough sand.
But I digress….
1)  You may have seen in this in the papers.  AHA guidelines, to a large extent, are not based on great research.  The investigators analyzed nearly 2,000 current recommendations. According to the researchers, 48% were based on opinions and case studies rather than rigorous scientific testing. The investigators found that “recommendations based on multiple studies that used the most reliable testing methods accounted for just 11 percent of the total.”  This post contains the abstract and there’s a link that will take you to the complete article.  So, I guess you can throw out the recommendation to sprinkle sanctified root beer on the corpse thirty seconds before you call a Code.
2)  This study will make the media rounds today.  Researchers wondered if certain types of diets with different combinations of fat, protein, and carbs do better than others in making one lose that eruption of lard around your waist and tuchas.  Bottom line:  Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.
3)  This is a concern every time you land or take off with the chopper.  Some ass decides to attack the helicopter.  It happened in this instance too.  A man starts running right up to the helicopter just as it was taking off from a hospital.  The co-pilot tackled him before any real problems.  They thought he was deranged until they realized that he was the patient they forgot to load from the ER!  Only kidding!
4)  You remember that University of Chicago policy to divert ER patients from the ER to other venues?  ACEP jumped all over that and now AAEM is coming out against the hospital tactics.  AAEM claims that the hospital is making fundamental changes without working with the physicians and nurses who work the ER.  “Not including emergency-room physicians and nurses … would be analogous to changing the way surgery is performed in an operating room without involving any surgeons,” said Dr. Larry Weiss, president of the academy.  Why aren’t the EMTALA gods weighing in on this yet?
All for now,
Paul R.
Comments Off
categories: Emergency Medicine

AAEM questions U of Chicago’s Triage Policy

by Paul Rega, MD — published on February 26th, 2009

Link: http://www.chicagotribune.com/business/chi-wed-uofc-emergency-feb25,0,1573145.story

Chicago Tribune, 2/25/09

A second national emergency-room physicians group is questioning the reorganization plans for the emergency room at the University of Chicago Medical Center.

The American Academy of Emergency Medicine, which represents 5,000 emergency-room doctors and residents, says the U. of C. is making “fundamental changes” without the active participation of its own emergency-room physicians. The academy also said the U. of C. should “re-evaluate its triage and screening examination policies.”

The U. of C.’s initiative is aimed at clearing its ER of patients with non-urgent injuries and illnesses by redirecting them to community hospitals and clinics. Last week, the American College of Emergency Physicians called for a congressional investigation into the U. of C. initiative and whether it violates federal “patient dumping” laws.

“Not including emergency-room physicians and nurses … would be analogous to changing the way surgery is performed in an operating room without involving any surgeons,” said Dr. Larry Weiss, president of the academy.
The U. of C. maintains that its Urban Health Initiative and related emergency-room reorganization announced last week is about getting patients the right treatment at the appropriate location in a tough economic climate and that it does not violate the law. Since the restructuring, the U. of C. said it has been meeting regularly with physicians and staff, including emergency-room personnel.

“Like nearly every hospital in the country, the University of Chicago Medical Center is trying to make the best use of limited emergency-care resources,” the medical center said in a statement Tuesday night to the Tribune. “We are searching for effective ways to provide the right level of care for patients with widely varying needs. This process, still under way, involves the active participation of physicians and nurses.”
 

Comments Off
categories: Emergency Medicine

ISC 2009: Women with Stroke, TIA, More Likely Than Men to Report Mental Status Change

by Paul Rega, MD — published on February 26th, 2009

MedScape Link:  http://www.medscape.com/viewarticle/588640

MedScape: 2/24/09

Women who suffer a stroke or transient ischemic attack (TIA) are more likely than men to report nontraditional symptoms, particularly altered mental status, new research suggests.

Presented here at the American Stroke Association International Stroke Conference 2009, the prospective, observational study found women were 43% more likely than men to report nontraditional stroke symptoms, including pain, mental-status change, lightheadedness, headache, or other neurological and nonneurological symptoms.

When researchers examined these nontraditional symptoms individually, they found mental-status change — defined as disorientation, confusion, or loss of consciousness — was the main driver of this finding.

“Twenty-three percent of women reported mental-status change in comparison with 15% of men, and this was a significant difference between the genders,” study investigator Lynda Lisabeth, PhD, from the University of Michigan, in Ann Arbor, told reporters attending a press conference.

Recent evidence shows that there are a number of sex disparities in stroke care, including the fact that women take longer to get to the hospital, experience longer in-hospital delays, and are significantly less likely than men with ischemic stroke to receive tissue plasminogen activator (tPA).

Impact on Care?

“One of the ideas behind this is that perhaps women present in a different or a more atypical way and that this somehow impacts their care once they get to the hospital,” she said.

Furthermore, she added, a previous study conducted by investigators at University of Texas at Houston found that, in a nonurban Texas population of stroke patients, women were more likely to present with “nontraditional” stroke symptoms than men.

“We wanted to try to build on this study and better understand whether or not these results would confirm or refute the findings of the Texas study in a different stroke population,” said Dr. Lisabeth.

The study included 461 (48.6% women) cases of ischemic stroke/TIA presenting to the University of Michigan Hospital between January 2005 and December 2007. Prevalence of any nontraditional symptom and each symptom were calculated by sex.

Among women, 51.8% (116) reported the presence of at least 1 nontraditional stroke/or TIA symptom or more vs 44% (104) of men. Isolated nontraditional symptoms were extremely rare and occurred in 4% of women vs 3% of men.

Consistent Results

While the association of sex and nontraditional symptoms was of borderline significance (P = .07), Dr. Lisabeth said she believes this finding is meaningful, particularly in light of the fact that these findings support the previous results from the Texas study.

“I believe if we had a larger sample size, this finding would likely have been significant, and what convinces me is that the results were so consistent with the Texas study, which was conducted in a completely different patient population,” Dr. Lisabeth told Medscape Psychiatry in a follow-up interview.

Commenting on the study, American Stroke Association spokesperson Brian Silver, MD, from Henry Ford Hospital, in Detroit, Michigan, agreed that the study sends a signal that the finding of altered mental status in women is important.

“The point in this study is that all the numbers were trending in the same direction. When you see a trend like that, the implication is that there just wasn’t a large enough denominator to push it to statistical significance. Had there been a larger number of patients, it almost certainly it would have been statistically significant,” Dr. Silver told Medscape Psychiatry.

Changing Messages May Be Premature

Whether the current public stroke-education messages, including the “Give Me 5″ message endorsed by the American Stroke Association, should be tailored to address the possibility that women may also experience less typical symptoms, possibly in conjunction with traditional symptoms, is open to debate, said Dr. Lisabeth.

However, she pointed out that although rare, isolated nontraditional symptoms still affect 4% of the female population, which is still an important proportion of the stroke population.

Dr. Silver says at this point it may be premature to change the current stroke message. However, he added, the study highlights an important issue that warrants further study.

“It would be helpful to know whether adding nontraditional symptoms, and particularly altered mental status, to the [stroke] messaging would increase the diagnostic yield clinically and increase the percentage of individuals presenting early. These are 2 key questions that we don’t have the answers to at this point. However, if future data corroborate this finding, I think it would be a very reasonable change to make,” he said.

The study was funded by the University of Michigan. The authors report no financial disclosures.

American Stroke Association International Stroke Conference 2009: Abstract 82. Presented February 19, 2009

Comments Off
categories: Emergency Medicine

Heart Guidelines: Flawed

by Paul Rega, MD — published on February 26th, 2009

Intro:  A large proportion of the recommendations contained in American College of Cardiology and American Heart Association guidelines are based on weak evidence and expert opinion rather than multiple clinical trials or meta-analyses, a study has found. (http://www.medwire-news.md/news/article.aspx?k=38&id=81018)

Source:  JAMA 2009; 301: 831–841 (Full Text:  http://jama.ama-assn.org/cgi/content/full/301/8/831)

Abstract

Context  The joint cardiovascular practice guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA) have become important documents for guiding cardiology practice and establishing benchmarks for quality of care.

Objective  To describe the evolution of recommendations in ACC/AHA cardiovascular guidelines and the distribution of recommendations across classes of recommendations and levels of evidence.

Data Sources and Study Selection  Data from all ACC/AHA practice guidelines issued from 1984 to September 2008 were abstracted by personnel in the ACC Science and Quality Division. Fifty-three guidelines on 22 topics, including a total of 7196 recommendations, were abstracted.

Data Extraction  The number of recommendations and the distribution of classes of recommendation (I, II, and III) and levels of evidence (A, B, and C) were determined. The subset of guidelines that were current as of September 2008 was evaluated to describe changes in recommendations between the first and current versions as well as patterns in levels of evidence used in the current versions.

Results  Among guidelines with at least 1 revision or update by September 2008, the number of recommendations increased from 1330 to 1973 (+48%) from the first to the current version, with the largest increase observed in use of class II recommendations. Considering the 16 current guidelines reporting levels of evidence, only 314 recommendations of 2711 total are classified as level of evidence A (median, 11%), whereas 1246 (median, 48%) are level of evidence C. Level of evidence significantly varies across categories of guidelines (disease, intervention, or diagnostic) and across individual guidelines. Recommendations with level of evidence A are mostly concentrated in class I, but only 245 of 1305 class I recommendations have level of evidence A (median, 19%).

Conclusions  Recommendations issued in current ACC/AHA clinical practice guidelines are largely developed from lower levels of evidence or expert opinion. The proportion of recommendations for which there is no conclusive evidence is also growing. These findings highlight the need to improve the process of writing guidelines and to expand the evidence base from which clinical practice guidelines are derived.

Comments Off
categories: Emergency Medicine

Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates

by Paul Rega, MD — published on February 26th, 2009

Link to the complete NEJM atricle:  http://content.nejm.org/cgi/content/full/360/9/859?query=TOC

ABSTRACT
Background The possible advantage for weight loss of a diet that emphasizes protein, fat, or carbohydrates has not been established, and there are few studies that extend beyond 1 year. Methods We randomly assigned 811 overweight adults to one of four diets; the targeted percentages of energy derived from fat, protein, and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35%. The diets consisted of similar foods and met guidelines for cardiovascular health. The participants were offered group and individual instructional sessions for 2 years. The primary outcome was the change in body weight after 2 years in two-by-two factorial comparisons of low fat versus high fat and average protein versus high protein and in the comparison of highest and lowest carbohydrate content.

Results At 6 months, participants assigned to each diet had lost an average of 6 kg, which represented 7% of their initial weight; they began to regain weight after 12 months. By 2 years, weight loss remained similar in those who were assigned to a diet with 15% protein and those assigned to a diet with 25% protein (3.0 and 3.6 kg, respectively); in those assigned to a diet with 20% fat and those assigned to a diet with 40% fat (3.3 kg for both groups); and in those assigned to a diet with 65% carbohydrates and those assigned to a diet with 35% carbohydrates (2.9 and 3.4 kg, respectively) (P>0.20 for all comparisons). Among the 80% of participants who completed the trial, the average weight loss was 4 kg; 14 to 15% of the participants had a reduction of at least 10% of their initial body weight. Satiety, hunger, satisfaction with the diet, and attendance at group sessions were similar for all diets; attendance was strongly associated with weight loss (0.2 kg per session attended). The diets improved lipid-related risk factors and fasting insulin levels.

Conclusions Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.

Comments Off
categories: Emergency Medicine

NEJM: Investing in Health Care Reform

by Paul Rega, MD — published on February 26th, 2009

Link to complete NEJM article and graphs:  http://content.nejm.org/cgi/content/full/360/9/852?query=TOC

Indicating that health care reform is integral to his policy agenda, President Barack Obama has moved swiftly to incorporate elements of reform into his economic recovery bill and signed reauthorization of the State Children’s Health Insurance Program (SCHIP). Enactment of comprehensive reform, however, is likely to hinge on the development of a plan that is affordable to families, employers, and taxpayers. It will need to combine expanded health insurance coverage with investments designed to improve care and slow spending growth if it is to be sound and sustainable in the long term.

The Commonwealth Fund Commission on a High Performance Health System, in its new report, The Path to a High Performance U.S. Health System (Path proposal),1 has endorsed a set of health care policies that would produce savings for the system: the creation of a national health insurance exchange with a choice of private plans and a new public-plan option; investment in systemic changes, such as accelerated adoption of health information technology and health insurance benefits that are based on evidence of the comparative effectiveness of treatment options; realignment of incentives for health care providers under Medicare and the public plan to encourage accountability for patient outcomes and prudent use of resources; and public health measures, including increasing taxes on harmful products as a way of combating smoking and obesity. All these policies would require substantial changes in the financing and delivery of health care, and all would be politically difficult to accomplish. Estimates of the effect of this proposal on the trajectory of health care spending and coverage were prepared with the use of a health-benefits-simulation model and assumptions derived from the literature.2

Inclusion in the national insurance exchange of a public-plan option that would be open to businesses and individuals is key to achieving savings. Medicare has lower administrative costs and provider-payment rates than fee-for-service commercial insurers; if private plans did not bring down rates, a new public-plan option could offer premiums that would be 20 to 30% lower than commercial rates for similar benefits.1 To be competitive, private insurers would need to become more efficient and work with providers to integrate, coordinate, and redesign care to treat chronic conditions more effectively and avert preventable hospitalizations, complications, and readmissions.

Up-front investments that are key to long-term savings and improved performance include those designed to accelerate adoption of health information technology and evidence-based care. Under the Path proposal, an assessment on private insurers of 1% of premiums, plus an equal proportion of projected Medicare spending, would provide about $13 billion per year to assist safety-net, rural, and small medical practices in adopting information technology and establish a national electronic network to facilitate the exchange of patient health information. Similarly, an assessment on private insurers of 0.05% of premiums, along with the same proportion of projected Medicare and Medicaid spending, would generate about $14 billion through 2020 for research, undertaken by a newly established center for comparative effectiveness, to evaluate devices, drugs, procedures, and other treatments in order to encourage the use of cost-effective therapies.

Achieving substantial savings in care delivery will require payment reforms in both the public and private sectors. The Path proposal would increase payment for primary care services by 5% through revision of the Medicare fee schedule; encourage adoption of the “medical home” model to promote coordinated care; implement a global case rate for episodes of acute hospital care, including follow-up care; and correct overpayments for prescription drugs and other services to align payments with value.

Substantial savings could be achieved by eliminating excess payments to Medicare Advantage plans relative to the costs of traditional Medicare.3 Prices that are paid for prescription drugs in the United States continue to be well in excess of those paid in other countries.4 In addition, other countries are more advanced in assessing the cost-effectiveness of treatments and basing prices on the lowest-cost treatment with equivalent effectiveness.5

The Path proposal also calls for strategies to improve public health, including increasing the federal excise tax on cigarettes by $2 a pack, instituting a new federal tax on sugar-sweetened soft drinks of 1 cent per 12 oz, and increasing the federal excise tax on beer by 5 cents per 12-oz can and on other alcohol products by proportional amounts. A portion of these tax revenues would be used to fund state and local public health initiatives.

Our analysis of these proposals indicates that reform that simultaneously improves coverage, quality, and efficiency can lead to better health and economic security for American families. The inclusion of an individual mandate to obtain coverage, along with income-related assistance in paying premiums and expanded coverage under Medicaid and SCHIP, would lead to near-universal coverage, with only 4 million people, or 1% of the U.S. population, uninsured in 2020, instead of a projected increase to 61 million under current policies.1

Equally important, the projected growth in annual national health expenditures through 2020 would slow from 6.7% to 5.5% — resulting in cumulative savings of $3 trillion over 11 years. These savings, while representing approximately 7% of the $42 trillion in health care spending that is currently projected through 2020, would reduce expenditures in that year from 21% of the gross domestic product to 18%.

The cumulative cost to the federal budget of expanding coverage alone is $1.9 trillion over the same 11-year period (see Table 1). Though difficult to achieve, the above-mentioned reforms — in the context of a coverage expansion that broadened the potential effect by increasing the number of patients to whom the reforms apply and eliminating the need for cross-subsidies and a patchwork of public policies now used to offset the costs of care for the uninsured — could offset more than two thirds of the incremental costs in the federal budget. At the same time, employers, state and local governments, and households would realize net savings totaling $3.6 trillion. In light of these savings, the balance of $600 billion in federal-budget costs could be offset in a number of ways. For example, design features, such as the level of the public-plan premium or premium assistance, could be calibrated to achieve greater federal-budget savings while leaving substantial savings for employers and households. The return on federal investment in reforms would accrue to all payers (see Table 2), and ongoing financing could then be shared more broadly by all organizations that realize gains. Although payers would benefit from the reduction in spending growth (as well as from greater access and more effective care), providers would continue to benefit from a growing health care system: even under the Path policies, national health care spending in 2020 is projected to be $4.6 trillion — 80% higher than in 2009. The simultaneous achievement of universal coverage, better health outcomes, and slowed spending growth requires changing the way public policy is shaped, as well as rapid experimentation and learning. Currently, the secretary of health and human services does not have sufficient flexibility to test and fine-tune savings strategies on a statewide or regional basis. I believe that the secretary should be given far greater authority, with accountability to the President and Congress — perhaps with the advice of a council of independent experts — to act as a prudent purchaser, test new payment and system reforms, and rapidly spread and implement promising reforms. It is time to change “business as usual” and to invest in the health care reforms that will benefit the public and patients and put our nation on a sounder economic footing.

 

No potential conflict of interest relevant to this article was reported.
Source Information

Dr. Davis is the president of the Commonwealth Fund, New York.

This article (10.1056/NEJMp0900309) was published at NEJM.org on February 19, 2009.

References

 

  1. The Commonwealth Fund Commission on a High Performance Health System. The path to a high performance U.S. health system: a 2020 vision and the policies to pave the way. New York: Commonwealth Fund, February 2009. (Accessed February 4, 2009, at http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=815367.) 
  2. Path to a high performance health system: technical documentation, Washington, DC: Lewin Group, February 2009.
  3. Budget options. Vol. 1. Health care. Washington, DC: Congressional Budget Office, December 2008.
  4. Accounting for the cost of U.S. health care: a new look at why Americans spend more. Washington, DC: McKinsey Global Institute, November 2008. (Accessed February 4, 2009, at http://www.mckinsey.com/mgi/publications/US_healthcare/.)
  5. Davis K. Slowing the growth of health care costs — learning from international experience. N Engl J Med 2008;359:1751-1755. [Free Full Text]

Comments Off
categories: Emergency Medicine

Slowing the Growth of Health Care Costs — Lessons from Regional Variation

by Paul Rega, MD — published on February 26th, 2009

Link to complete article and graphs:  http://content.nejm.org/cgi/content/full/360/9/849?query=TOC

The expansion of health insurance coverage in the United States is likely to be on the front burner of health care reform efforts in the new presidential administration. But boiling on the back burner is perhaps the most serious threat to Americans’ access to care: rapid growth in health care costs.

Pessimism abounds. Most observers see rising costs as an inexorable force, blame advancing technology, and conclude that only by rationing beneficial care or making draconian price cuts can we slow the growth of health care costs.

But a careful look at variations in spending growth and spending patterns among U.S. regions reveals a more optimistic picture. By learning from regions that have attained sustainable growth rates and building on successful models of delivery-system and payment-system reform, we might, with adequate physician leadership, manage to “bend the cost curve.”

The graph shows per capita Medicare spending from 1992 through 2006 in five U.S. hospital-referral regions. During this period, overall Medicare spending, adjusted for general price inflation, rose by 3.5% annually. But there was considerable variation among regions. Per capita inflation-adjusted spending in Miami grew at an annual rate of 5.0%, as compared with just 2.3% in Salem, Oregon, and 2.4% in San Francisco. In dollar terms, the growth in per capita Medicare expenditures between 1992 and 2006 in Miami ($8,085) was nearly equal to the level of 2006 expenditures in San Francisco ($8,331). A total of 26 hospital-referral regions (including Dallas) had more rapid spending growth than Miami, and 18 regions (including San Diego) had slower growth than Salem. Three of the regions included in the graph — Boston, San Francisco, and East Long Island, New York — started out with nearly identical per capita spending, but their expenditures grew at markedly different annual rates: 2.4% in San Francisco, 3.0% in Boston, and 4.0% in East Long Island. Although such differences may appear modest, compounding leads to enormous differences in spending levels over time. By 2006, per capita spending in East Long Island was $2,500 more than in San Francisco — which translates into about $1 billion in additional annual Medicare spending from this region alone.

What’s going on? It is highly unlikely that these differences in growth could be explained by differences in health. Marked regional differences in spending remain after careful adjustment for health, and there is no evidence that health is decaying more rapidly in Miami than in Salem.

The variations allow us to rule out two overly simplistic explanations for spending growth. First, “technology” is clearly an insufficient explanation: residents of all U.S. regions have access to the same technology, and it is implausible that physicians in the regions with slower spending growth are consciously denying their patients needed care. Indeed, evidence suggests that the quality of care and health outcomes are better in lower-spending regions and that there have been no greater gains in survival in regions with greater spending growth.1 Second, it is difficult to blame regional differences entirely on the current payment system, since all our evidence on regional growth comes from populations in the fee-for-service system. Other research has emphasized the role of managed care in moderating the growth of costs,2 but this story cannot explain the rapid growth in Miami, where roughly half of Medicare enrollees are covered by Medicare Advantage plans.

The causes must therefore lie in how physicians and others respond to the availability of technology, capital, and other resources in the context of the fee-for-service payment system. A recent study by researchers in our group provides further insight.3 Using clinical vignettes to present standardized patient care scenarios to physicians throughout the country, the researchers found that physicians in high- and low-spending regions were about equally likely to recommend specific clinical interventions when the supporting evidence was strong. Those in higher-spending regions, however, were much more likely than those in lower-spending regions to recommend discretionary services, such as referral to a subspecialist for typical gastroesophageal reflux or stable angina or, in another vignette, hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit the latter patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family. Differences in the propensity to intervene in such gray areas of decision making were highly correlated with regional differences in per capita spending. What do these findings suggest in terms of approaches to reducing health care costs? First, physicians have an opportunity to lead. Physicians are still almost entirely responsible for determining what treatments their patients receive and where they obtain their care. And although the increasingly commercial behavior of some physicians may threaten the public perception of the profession, patients still largely trust their own doctors. Leadership is needed at three levels. In their practices, physicians can help patients understand when a more conservative path is likely to be as safe as a more intensive and higher-cost path. In their communities, physicians have the credibility to argue against the need for further growth — whether through hospital expansion, the construction of new imaging centers, or the recruitment of more specialists to oversupplied regions (www.dartmouthatlas.org provides spending, hospital, and workforce data for each U.S. hospital-referral region). And physicians can support changes in the health care system that will help their patients and communities get the best possible care at the lowest possible cost.

But physicians will need help from payers and policymakers. Under the current payment system, physicians cannot afford the time it takes to help patients understand why a test or procedure is not needed. Hospitals lose money when they improve care in ways that reduce admissions, and they lose market share when they don’t keep pace in the local medical arms race. In this race there are no financial rewards for collaboration, coordination, or conservative practice.

To slow spending growth, we need policies that encourage high-growth (or high-cost) regions to behave more like low-growth, low-cost regions — and that encourage low-cost, slow-growth regions to sustain their current trends. Our ongoing research program (funded in part by the National Institute on Aging) suggests that there are two broad and closely linked strategies for accomplishing these aims: fostering the growth of more organized systems of care and implementing fundamental payment reform. Consensus is emerging that integrated delivery systems that provide strong support to clinicians and team-based care management for patients offer great promise for improving quality and lowering costs. Most physicians already practice within local referral networks around one or more hospitals, which could form local integrated delivery systems with little disruption of practice.4 Policymakers would need to remove legal barriers to collaboration and offer incentives — such as larger payment updates or subsidies for implementing electronic health records — to providers who were willing to establish real or virtual accountable care systems.5 Our volume-based payment systems could then be changed to incorporate partial capitation, bundled payments, or shared savings, thereby fostering accountability for overall costs and quality of care. Although much remains to be learned about aligning reforms in delivery systems with payment reforms, early results from demonstration projects have been promising and could provide the foundation for national reform.

The good news is that small changes in annual per capita growth rates have enormous implications for the long-term solvency of Medicare and the sustainability of expanded insurance coverage. Using data from the 2008 Medicare trustees’ report on projected revenues and total Part A and B spending, we estimate that Medicare will be $660 billion in the hole by 2023. Reducing annual growth in per capita spending from 3.5% (the national average) to 2.4% (the rate in San Francisco) would leave Medicare with a healthy estimated balance of $758 billion, a cumulative savings of $1.42 trillion.

Such a change would not solve the country’s long-term fiscal challenges. But it suggests that if we focus reform efforts on current areas of overspending — overuse of hospitals and unnecessary visits, consultations, tests, and minor procedures — we may be able to bend the cost curve while continuing to enjoy the benefits of technological advances.

 

No potential conflict of interest relevant to this article was reported.
Source Information

Dr. Fisher is a professor of medicine and of community and family medicine, Dr. Bynum an assistant professor of medicine and of community and family medicine, and Dr. Skinner a professor of economics and of community and family medicine at Dartmouth Medical School, Lebanon, NH, where Dr. Fisher also directs the Center for Health Policy Research, Dartmouth Institute for Health Policy and Clinical Practice.

References

 

  1. Skinner JS, Staiger DO, Fisher ES. Is technological change in medicine always worth it? The case of acute myocardial infarction. Health Aff (Millwood) 2006;25:w34-w47. [Free Full Text]
  2. Chernew ME, Hirth RA, Sonnad SS, Ermann R, Fendrick AM. Managed care, medical technology, and health care cost growth: a review of the evidence. Med Care Res Rev 1998;55:259-288. [Free Full Text]
  3. Sirovich B, Gallagher PM, Wennberg DE, Fisher ES. Discretionary decision making by primary care physicians and the cost of U.S. health care. Health Aff (Millwood) 2008;27:813-823. [Free Full Text]
  4. Bynum JP, Bernal-Delgado E, Gottlieb D, Fisher E. Assigning ambulatory patients and their physicians to hospitals: a method for obtaining population-based provider performance measurements. Health Serv Res 2007;42:45-62. [CrossRef][ISI][Medline]
  5. Shortell SM, Casalino LP. Health care reform requires accountable care systems. JAMA 2008;300:95-97. [Free Full Text]


Comments Off
categories: Emergency Medicine