Archive for November 2014

Hey NEJM, where’s the beef?

  I opened the most recent copy of NEJM with anticipation.  At last, a review on severe alcohol withdrawal.  Perhaps a solution to the age old conflict between psychiatry (start benzo on Monday, decrease by 20-25% daily and discharge on Thursday or Friday) versus medicine (start benzo on Monday, and if they look like a rose on Tuesday, send them home).  No such luck. I did find this though: "The doses needed to control agitation and insomnia vary dramatically among patients and can be prodigious (e.g., >2000 mg of diazepam in the first 2 days in some patients); this underscores the advisability of providing treatment in a hospital, preferably in an ICU." UM.  You think?   (more…)

Century Old QI Lessons

Some days it seems like it would be easier to start from scratch. Maybe build your own hospital. [caption id="attachment_11486" align="alignright" width="210"] EA Codman[/caption] That’s what Ernest Codman decided to do. Codman was born in Boston, graduating from Harvard Medical School in 1891. This was before the Flexner report fundamentally changed medical education in the US, and around the time medicine in America was starting to come into its own. Codman was a passionate supporter of quality, for his patients, and the medical profession. He remains in the pantheon of great surgeons, though hidden behind many other giants in medicine. Various articles have been written about him over the years(by Berwick, Reverby, Donabedian, and a biography by Mallon), yet few know of his numerous accomplishments. Here are three Codman breakthrough ideas and lessons learned. ANESTHESIA RECORD Boston is the birthplace of anesthesia (unless you trained in Atlanta, like myself, and…

Ethics and Ebola

by Dr. Bartho Caponi MD, FHM The Ebola panic has died down; while many are under monitoring, there have been no further de novo U.S. cases since October 15, and only two more "imported" cases. Travelers are being screened and resources are heading to areas where they are needed. At my institution, Hospitalists have led the way; over half my division volunteered up-front to provide necessary care. I ended up in a lot of planning and policy meetings, where we internally crafted a comprehensive plan to deal with any Ebola-related eventuality. Nationally, the Centers for Disease Control and Prevention (CDC) have created many useful resources for people and institutions needing them. We now have guidelines for speaking to our children about Ebola and for taking care of Ebola-exposed pets, in addition to more trenchant issues. We now have "Ebola centers," hospitals capable of caring for suspected or confirmed Ebola patients…

2013: Did we pay more for inpatient care, or did we use more?

  The Health Care Cost Institute is not just another consulting firm or think tank.  They are a a non-partisan, non-profit clearinghouse for all things health care payment.  They obtain commercial and government data and generate reports on health spending direction. Their 2014 release analyzing 2013 commercial trends (think age 18-64 yo)  came out last week. The report has oodles of data and fun graphics covering many domains--but since we live on the inpatient side, you might also want to  take a look at the hospital end of things.  After all, hospital bottom lines live and die by employer sponsored insurance and the rates they pay (or hospitals accept). The verdict?  Inpatient use down, with care intensity and prices up (average price of a stay equals ~$18K). Have a look (page 7 of the report): (more…)

Pareto’s Principle in Hospital Medicine

There are certain universal laws that appear to govern the broader workings of the world around us. For those of you unfamiliar with Pareto’s Principle, it’s a concept that was first applied in economics and then found to be a governing rule in a whole host of different arenas. It’s no understatement to say that understanding and acting upon this concept can be transformative, not just in your work but also your personal life. [caption id="attachment_11495" align="alignleft" width="214"] source:[/caption] Pareto’s Principle also has become a popular area of focus in the world of business and management. Named after the 19th century Italian economist Vilfredo Pareto, in a nutshell the principle is as follows: 80 percent of effects always come from 20 percent of the causes. Pareto first observed this ratio when he realized that 80 percent of land and wealth in Italy was owned by 20 percent of the…