Ambulatory/Primary Care

“Mr. Obama, Tear Down These (Hospital) Walls”: Readmissions in Context

I like readmissions. Well, that didn’t come out quite right, did it? What I mean is that I like focusing on readmissions as a potentially actionable quality measure. I believe that it’s possible to prevent many readmissions, thereby improving quality and lowering costs. And compared to mortality (the other hot outcome measure), the need for case-mix adjustment is a bit less critical, and there is no such thing as "a good readmission."I also like DRGs. Paying hospitals a fixed fee for a given diagnosis has created the only corner of sustainable capitation in our healthcare system, one that is otherwise awash in inappropriate expenditures driven by the dominant fee-for-service payment structure. But the DRG system created a big black hole, and it is time to fill it. It’s called the post-discharge period. And one large part of the detritus emerging from that hole is readmissions.You probably saw this week’s NEJM…

The PSA Story: The Triumph of Science Over Common Sense

My father, who celebrated his 79th birthday yesterday, is many things: eccentric, nearly deaf (though he attributes this to my mom being a “low talker”), hilarious, crotchety, and a true mensch. But he’s neither incontinent nor impotent.It might have been otherwise. Like most men over 50, he began having yearly PSAs checked about 20 years ago, and, in the late-1990s, one came back in the 8 ng/mL range (normal is below 4). The usual stuff ensued: a transrectal ultrasound, multiple biopsies, and a small focus of prostate cancer with a lowish Gleason score. So now what?Although a local urologist recommended surgery, he received second (and third and fourth – courtesy of “my son, the doctor”) opinions from three superb academic urologists – Peter Carroll of UCSF, Peter Scardino at Memorial Sloan-Kettering, and later, Mark Soloway of the University of Miami. All three told him the same thing: there is no…

Today’s NEJM Hospitalist Study: What’s the News?

A paper in today’s New England Journal proves what we all know – the hospitalist field is the only thing growing faster than the national debt. Even though that’s not news, this elegant biopsy of the Medicare database offers some new insights about our field, the fastest growing specialty in medical history.Briefly, the study used a methodology developed by Sanjay Saint a decade ago: by examining evaluation and management (E&M) codes submitted by general internists to Medicare, one can determine which physicians do virtually all their E&M work in the hospital, which have traditional general internist practices (part-inpatient, part-outpatient), and which do virtually no inpatient work (“ambulists” or “officists” – somebody will ultimately need to settle on a term). The NEJM authors defined a hospitalist as a general internist who cares for over 100 Medicare patients per year and whose E&M codes are at least 90% hospital-based. This is a…

My Colonoscopy… And Dave Barry’s

When I launched this blog, I vowed not to dwell on personal matters – you’ve heard nothing about my older son's lab work (remarkable), my younger son’s cartooning (awesome), or my golf game (never mind). But I simply must tell you about my colonoscopy today.Well, actually I won’t. But I wanted to raise the topic to implore you to do two things:Most importantly, if you’re due for one, go ahead and get it. It could save your life. Remember, the evidence supports a colonoscopy at age 50 if you are at average risk, and age 40 (or 10 years before the earliest age of diagnosis in a first degree relative with colon cancer) if you have a strong family history. Former White House press secretary Tony Snow, who died last month at age 53, should have begun screening in his late 20s, since his mother died of colon cancer at…

Is “Patient-Centeredness” a Healthcare MacGuffin?

Last week’s ABIM Foundation Summer Forum focused on patient-centered care… and who could be against that? But is patient-centered care just a healthcare MacGuffin?What’s a MacGuffin, you ask? In a spectacular talk at the Forum, Michael Richardson of Chicago’s Hines VA reminded us that the MacGuffin was one of Alfred Hitchcock’s favorite directorial strategies. Hitchcock defined the term this way:MacGuffin: a plot device that motivates the characters or advances the story, but the details of which are of little or no importance otherwise.I loved Richardson’s analogy when I heard it, but its utter aptness became clear only as the conference proceeded. Let’s start with the areas of general agreement (thanks to Jim Naughton, Chair of the ABIM Foundation, for articulating these points):Patients’ preferences should be respected.We should attend to patients’ emotional needs, context, comfort and meaning.Patients should be engaged and empowered.There should be shared decision-making that promotes patient autonomy.Family and…
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