Saturday, July 29, 2017

Computerized physician order entry: a negative factor in physician productivity and morale



Abstract:

Objectives: To examine the impact of clerical support personnel for physician order entry on physician satisfaction, productivity, timeliness with electronic health record (EHR) documentation, and physician attitudes.

Methods: All seven part-time physicians at an academic general internal medicine practice were included in this quasi-experimental (single group, pre- and postintervention) mixed-methods study. One full-time clerical support staff member was trained and hired to enter physician orders in the EHR and conduct previsit planning. Physician satisfaction, productivity, timeliness with EHR documentation, and physician attitudes toward the intervention were measured.

Results: Four months after the intervention, physicians reported improvements in overall quality of life (good quality, 71%–100%), personal balance (43%–71%), and burnout (weekly, 43%–14%; callousness, 14%–0%). Matched for quarter, productivity increased: work relative value unit (wRVU) per session increased by 20.5% (before, April–June 2014; after, April–June 2015; range −9.2% to 27.5%). Physicians reported feeling more supported, more focused on patient care, and less stressed and fatigued after the intervention.

Conclusions: This study supports the use of physician order entry clerical personnel as a simple, cost-effective intervention to improve the work lives of primary care physicians.

This would represent going back to what we had before meaningful use, not a new intervention.

Thursday, July 27, 2017

A recent review of the latest Surviving Sepsis guidelines suggests that we go back to early goal directed therapy


Low value systems update: CPOE based insulin order sets didn’t help with glycemic control


Systematic review of non invasive positive pressure ventilation (NIPPV) in acute exacerbation of COPD with hypercapnic respiratory failure



Main results

We included in the review 17 randomised controlled trials involving 1264 participants. Available data indicate that mean age at recruitment was 66.8 years (range 57.7 to 70.5 years) and that most participants (65%) were male. Most studies (12/17) were at risk of performance bias, and for most (14/17), the risk of detection bias was uncertain. These risks may have affected subjective patient-reported outcome measures (e.g. dyspnoea) and secondary review outcomes, respectively.

Use of NIV decreased the risk of mortality by 46% (risk ratio (RR) 0.54, 95% confidence interval (CI) 0.38 to 0.76; N = 12 studies; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 9 to 23) and decreased the risk of needing endotracheal intubation by 65% (RR 0.36, 95% CI 0.28 to 0.46; N = 17 studies; NNTB 5, 95% CI 5 to 6). We graded both outcomes as 'moderate' quality owing to uncertainty regarding risk of bias for several studies. Inspection of the funnel plot related to need for endotracheal intubation raised the possibility of some publication bias pertaining to this outcome. NIV use was also associated with reduced length of hospital stay (mean difference (MD) -3.39 days, 95% CI -5.93 to -0.85; N = 10 studies), reduced incidence of complications (unrelated to NIV) (RR 0.26, 95% CI 0.13 to 0.53; N = 2 studies), and improvement in pH (MD 0.05, 95% CI 0.02 to 0.07; N = 8 studies) and in partial pressure of oxygen (PaO2) (MD 7.47 mmHg, 95% CI 0.78 to 14.16 mmHg; N = 8 studies) at one hour. A trend towards improvement in PaCO2 was observed, but this finding was not statistically significant (MD -4.62 mmHg, 95% CI -11.05 to 1.80 mmHg; N = 8 studies). Post hoc analysis revealed that this lack of benefit was due to the fact that data from two studies at high risk of bias showed baseline imbalance for this outcome (worse in the NIV group than in the usual care group). Sensitivity analysis revealed that exclusion of these two studies resulted in a statistically significant positive effect of NIV on PaCO2. Treatment intolerance was significantly greater in the NIV group than in the usual care group (risk difference (RD) 0.11, 95% CI 0.04 to 0.17; N = 6 studies). Results of analysis showed a non-significant trend towards reduction in dyspnoea with NIV compared with usual care (standardised mean difference (SMD) -0.16, 95% CI -0.34 to 0.02; N = 4 studies). Subgroup analyses revealed no significant between-group differences.

Authors' conclusions

Data from good quality randomised controlled trials show that NIV is beneficial as a first-line intervention in conjunction with usual care for reducing the likelihood of mortality and endotracheal intubation in patients admitted with acute hypercapnic respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease (COPD). The magnitude of benefit for these outcomes appears similar for patients with acidosis of a mild (pH 7.30 to 7.35) versus a more severe nature (pH less than 7.30), and when NIV is applied within the intensive care unit (ICU) or ward setting.


Wednesday, July 26, 2017

Normalization of testosterone levels following replacement therapy associated with a decreased incidence of atrial fibrillation


Abnormal p wave axis is a risk factor for stroke



Conclusions—aPWA is independently associated with ischemic stroke. This association seems to be stronger for cardioembolic strokes. Collectively, our findings suggest that alterations in atrial electric activation may predispose to cardiac thromboembolism independent of atrial fibrillation.

Tuesday, July 25, 2017

Disclosing conflicts of interest to patients


Here is another article from JAMA’s theme issue on COI.

Negative cost incentives as COIs have received relative little attention in the past but are dealt with in this piece:

Physicians and hospitals can also participate in financial agreements in which they generate more revenue if less health care or less expensive medications or devices are used…

..considerable evidence suggests that these financial relationships may exert unconscious influences on physician behavior, particularly when the cost of care, rather than patient clinical outcomes, is involved.

That is a real concern and should present a huge problem to those among our leadership who advocate for the “new professionalism” under which the doctor is to simultaneously advocate for the patient and the population. That puts the individual clinician right in the middle of the conflict which, when disclosed (and disclose we must in this age of transparency) has the potential to undermine trust.

Sunday, July 23, 2017

Capillary leak syndrome


From a recent review:

In various human diseases, an increase in capillary permeability to proteins leads to the loss of protein-rich fluid from the intravascular to the interstitial space. Although sepsis is the disease most commonly associated with this phenomenon, many other diseases can lead to a "sepsis-like" syndrome with manifestations of diffuse pitting edema, exudative serous cavity effusions, noncardiogenic pulmonary edema, hypotension, and, in some cases, hypovolemic shock with multiple-organ failure. The term capillary leak syndrome has been used to describe this constellation of disease manifestations associated with an increased capillary permeability to proteins. Diseases other than sepsis that can result in capillary leak syndrome include the idiopathic systemic capillary leak syndrome or Clarkson's disease, engraftment syndrome, differentiation syndrome, the ovarian hyperstimulation syndrome, hemophagocytic lymphohistiocytosis, viral hemorrhagic fevers, autoimmune diseases, snakebite envenomation, and ricin poisoning. Drugs including some interleukins, some monoclonal antibodies, and gemcitabine can also cause capillary leak syndrome. Acute kidney injury is commonly seen in all of these diseases. In addition to hypotension, cytokines are likely to be important in the pathophysiology of acute kidney injury in capillary leak syndrome. Fluid management is a critical part of the treatment of capillary leak syndrome; hypovolemia and hypotension can cause organ injury, whereas capillary leakage of administered fluid can worsen organ edema leading to progressive organ injury. The purpose of this article is to discuss the diseases other than sepsis that produce capillary leak and review their collective pathophysiology and treatment.

Background here.