Archive for February 2009

Will Academic Medical Centers Show the Love to Their Faculty Quality Improvers?

When we launched our hospitalist program in 1995, I dreamed that many of our faculty would become leaders in quality and patient safety. That dream has come true, but we now must leap over two hurdles: getting these superb physicians paid and promoted. I think we can do it, but there are a bunch of issues to sort out, at UCSF and everywhere else.Traditionally, academic health centers have paid lip service to quality and safety. One could tell this by answering a few simple questions: Who were the academic Rock Stars? The great researchers. How was the promotional system structured? To support top-notch lab jocks and, to a much lesser extent, teachers. Where did the discretionary dollars go? To supporting discovery and education. Don’t get me wrong… academia wasn’t completely disinterested in its clinical enterprise, but the coin of the clinical realm was prominence and profitability, not quality and safety.…

Balloon kyphoplasty for vertebral fractures

In this randomized trial of over 300 patients with vertebral fractures, patients were randomized to balloon kyphoplasty or non-surgical treatment and followed up for a year. Kyphoplasty was superior in physical function, pain, and quality of life scores at 1, 3, and 6 months, but the differences between the groups diminished by a year (abstract). Based on this study, balloon kyphoplasty appears to be a reasonable treatment option to reduce short term pain and disability in patients admitted with vertebral fractures.

Radiation of coronary CTA

In this observational study of almost 2000 patients at 50 sites worldwide, researchers found the mean radiation dose of coronary CTA was 12 mSv (millisieverts), which is comparable to a nuclear stress test or an abdominal/pelvic CT (abstract). However, they did find tremendous variability (5mSv-30mSv) depending on protocol used, which reminds us to consider radiation exposure when weighing the risks and benefits of any radiologic diagnostic test.

Rapid ED discharge of chest pain with negative CTA

In this prospective single institution cohort of over 500 patients evaluated in the ED for chest pain, those at low risk for ACS (TIMI risk 0-2), underwent coronary CTA (1 group with immediate CTA and 1 group with CTA after short observation stay). Those with low risk CTA (calcium score <100 and no stenosis >50%) were discharged home. Those in the immediate CTA group were discharged at a median of 7 hours, and the observation group were discharged at a median of 21 hours. None of those discharged had a CV event or MI at 1 month follow up. This adds to the mounting literature of the safety of early triage and disposition of low risk chest pain patients with coronary CTA (abstract)

Are We Mature Enough to Make Use of Comparative Effectiveness Research?

Thanks to White House budget director Peter Orszag, a Dartmouth Atlas aficionado, $1.1 billion found its way into the stimulus piñata for “comparative effectiveness” research. Terrific, but – to paraphrase Jack Nicholson – can we handle the truth?In other words, are we mature enough to use comparative effectiveness data to make tough decisions about what we will and won’t pay for? I worry that we’re not. First, a bit of background. Our healthcare system, despite easily being the world’s most expensive, produces (by all objective measures) relatively poor quality care. Work begun 3 decades ago by Dartmouth’s Jack Wennberg and augmented more recently by Elliott Fisher has made a point sound-bitey enough for even legislators to understand: cost and quality vary markedly from region to region, variations that cannot be explained by clinical evidence and do not appear to be related to healthcare outcomes. In other words, plotting a 2x2…