Commentary on medical news by a practicing physician.

  • Epocrates MedSearch Drug Lookup


    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
    -Robert Ehrlich, drug advertising executive.

    "Opinions are like sphincters, everyone has one." - Chris Rangel

    email: medpundit-at-ameritech.net

    or if that doesn't work try:


    Medpundit RSS

    Quirky Museums and Fun Stuff

    Who is medpundit?

    Tech Central Station Columns

    Book Reviews:
    Read the Review

    Read the Review

    Read the Review

    More Reviews

    Second Hand Book Reviews


    Medical Blogs


    DB's Medical Rants

    Family Medicine Notes

    Grunt Doc




    Code Blog: Tales of a Nurse

    Feet First

    Tales of Hoffman

    The Eyes Have It


    SOAP Notes


    Cut-to -Cure

    Black Triangle



    Kevin, M.D

    The Lingual Nerve

    Galen's Log



    Doctor Mental



    Finestkind Clinic and Fish Market

    The Examining Room of Dr. Charles

    Chronicles of a Medical Mad House



    Health Facts and Fears

    Health Policy Blogs

    The Health Care Blog

    HealthLawProf Blog

    Facts & Fears

    Personal Favorites

    The Glittering Eye

    Day by Day


    The Business Word Inc.

    Point of Law

    In the Pipeline


    Tim Blair

    Jane Galt

    The Truth Laid Bear

    Jim Miller

    No Watermelons Allowed

    Winds of Change

    Science Blog

    A Chequer-Board of Night and Days

    Arts & Letters Daily

    Tech Central Station





    The Skeptic's Dictionary

    Recommended Reading

    The Doctor Stories by William Carlos Williams

    Pox Americana: The Great Smallpox Epidemic of 1775-82 by Elizabeth Fenn

    Intoxicated by My Illness by Anatole Broyard

    Raising the Dead by Richard Selzer

    Autobiography of a Face by Lucy Grealy

    The Man Who Mistook His Wife for a Hat by Oliver Sacks

    The Sea and Poison by Shusaku Endo

    A Midwife's Tale by Laurel Thatcher Ulrich



    American Academy of Pediatrics

    General Health Info

    Travel Advice from the CDC

    NIH Medical Library Info



    Wednesday, December 13, 2006

    Mismeasure of Medicine: A study in today's JAMA says that meeting "quality measures" mandated by third party payers doesn't necessarily translate into quality care:

    The study examined 2004 data from 3,657 hospitals, comparing their performance on quality-of-care measures for treating heart attacks, heart failure and pneumonia with the death rates for the same patients. The quality measures charted such matters as whether patients who had a heart attack received aspirin within 24 hours of being admitted and how soon patients with bacterial pneumonia were given antibiotics.

    Patients at hospitals that scored near the top on the quality-of-care measures did do better than those at hospitals near the bottom -- but not dramatically so.

    For every 1,000 heart attack patients, there were about five fewer deaths at the better-performing hospitals than at the lower-performing ones, the study found. The figures were similar for patients with heart failure and pneumonia.

    The study looked at the rates of compliance with the following evidence based medicine recommendations:

    For heart attack patients - Did they receive aspirin on admission and did they go home with the advice to take aspirin once a day? Did they get beta-blockers on admission, and go home with a prescription for one? Did they get an ACE inhibitor if their heart wasn't pumping quite up to par?

    For heart failure patients- Did they have an echocardiogram to assess how well their heart pumps? Did they get an ACE inhibitor if it wasn't pumping so well?

    For pneumonia patients- Did they have their oxygen saturations checked? Did they receive a pneumonia vaccine, or document when their last pneumonia vaccine? Did they get antibiotics in a timely fashion?

    All of the above measures are supposed to improve survival, at least according to studies. And they do, when applied to research populations. However, the improvement is not a large one. For example, in this study of ACE inhbitors in heart failure, the ACE inhbitors improved survival by
    four percent. That's not a dramatic difference, which is probably why the study failed to find dramatic differences in hospitals who met the standards and those who didn't.

    Here's what counts for quality in hospitals - cleanliness and good nursing care. Hospitals don't measure those parameters, though. It's much harder to measure the worth of a nurse than to send someone around to check off documentation points on a chart. You can enact every principle of evidence based guidelines and it won't do squat for the patient if they are only attended by a nurse's aid with six weeks of training who can't recognize a turn for the worst, while the fully trained nurses are pre-occupied with fulfilling the documentation requirements.

    We have vastly over-rated the improvements we get from easy pharmacological fixes while simultaneously under-rating the value of basic medical care and judgment. And with the coming of pay for performance, the mismeasure will only get worse.

    posted by Sydney on 12/13/2006 09:07:00 PM 6 comments


    The article forget to point out something very important- the actual scores that were in the top and bottom deciles. They are so close that even the bottom ten or twenty percent still have compliance rates of over 90% for most measures.

    For example: Acute MI Management composite score (sept, 2006):

    Top twenty percent: 98.65
    Bottom twenty percent: 91.30

    Basically, most hospitals deserve an "A" , but CMS grades on a curve. To get an A from CMS for an acute MI you need a score of 99.57%. The study should have looked at hospitals who don't follow to protocols or indicators, but of course, those hospitals don't exist.

    By Anonymous Danie, at 2:41 PM  

    I didn't actually make my point, which is this:

    The outcomes don't differ by much because the scores don't differ very much. Using deciles is misleading statistically and demoralizing for the hospitals, IMHO.

    By Anonymous danie, at 2:44 PM  

    This reminds me of a story I read some time ago. An American couple were traveling in the UK when she had a heart attack. Taken to the emergency room she was treated and after she was stable and the worse was over she was moved to a room.

    Her drug therapy quickly became aspirin. Her husband was given unlimited access and she was encouraged to do as much as she wanted for herself. In a short time, with someone making sure she was safe, she would bathe, dress herself, and then the couple would slowly walk down to the pub for lunch or tea. He said it was very obvious that phone calls were going back and forth and someone knew where they were at all times.

    She quickly recovered to the point that they could return to the States. Here she was wired, plumbed, pumped full of drugs after the fact, and placed in a cardiac unit where he husband had no access. She was left isolated and with no advocate. Her cloths were removed and she was left to the whims of a physical therapist with a busy schedule. She was released about a week later.

    Reflecting upon their experience they were warmed by the support and caring attitude of the UK experience. They were also able to measure progress on a daily basis.

    While recognizing the greater technology of the US experience they were left cold and drained. They felt they were sucked up by a big money making machine, and given the six figure bill for her one week, along with a followup physical therapy schedule that would disrupt their lives for months, they knew they had fallen into a system where they were not important.

    I hope if I ever have a little heart attack I am in the English countryside.

    Steve Lucas

    By Anonymous Anonymous, at 7:13 PM  

    Nice blog.

    I'm sure now the CMS will completely abandon P4P, right? In addition to Danie's excellent point, I've had concerns about being at the mercy of the data collectors at our particular institution. I've caught at least two mistakes on my own chart audits...

    By Anonymous Anonymous, at 2:21 PM  

    The role of measurement should be to determine what adds value -- tracking that, and ignoring the rest. If good nursing care is more significant to outcome effectiveness than medical methodology, then do what you want, medically; just have good nurses. And if good nursing care can't be quantified, you have to rely on anecdotal evidence. Surely, you're not proposing either?

    By Blogger bill, at 7:54 AM  

    I agree. Trying an easy fix like this is likely to create more controversial issues without yielding much benefit.

    By Anonymous docwrite, at 8:20 PM  

    Post a Comment

    This page is powered by Blogger, the easy way to update your web site.

    Main Page


    Home   |   Archives

    Copyright 2006