Last week, a large part of the U.S. News staff busily churned out election coverage while a much smaller team—a couple of Webbies, as we affectionately call our online producers and programmers, plus a data specialist and I—raced to finish up the 2008-09 Best Health Plans rankings. Everything else, including this blog, had to wait at the crossing for the Best Plans train to pass, as all good things eventually must. Now that it has, I need to do a little catching up.
For today, I'll call your attention to "Rub a Dub Dub," a recent blog post in Aggravated DocSurg about showering before an operation. That's what it starts out as, anyway. The blogger is a general surgeon with an attitude, as the blog's name suggests, but the right kind—one of his pastimes is sniffing out claims and studies whose underpinnings are shakier than they seem. He's an informed skeptic. ("Experience is the name everyone gives to their mistakes," an Oscar Wildeism, is one of several quirky quotes at the top.)
Infections following surgery are a big target right now. The folks in Medicare have put a new rule in place withholding additional payments to hospitals that run up extra expenses because a patient develops certain preventable complications, one of which is a surgical site infection. (I blogged about the rule in September.) DocSurg reminds us that many surgeons used to tell patients to take a shower with a disinfectant soap before coming to the hospital. The reasoning was that even though patients would don their clothing and hours might pass before they were taken into the OR, the bacterial count on their skin was considerably lower than for patients who didn't shower with an antimicrobial soap. Fewer bacteria meant fewer surgical site infections, right?
Well, in 2006, an analysis of six different trials involving more than 10,000 patients found that the answer was simple: wrong. Fewer bugs on the skin as a result of showering with antimicrobial soap didn't equate to fewer infections following surgery. The preop shower was losing popularity anyway, writes DocSurg, but the review "sort of put a stake through its heart."
But then, just a few months ago, came another study, in the Journal of the American College of Surgeons , that redeemed the value of preop antimicrobial use. Or at least it seemed to. The goal of this study was to see how thoroughly an antiseptic, delivered as soap during a shower or in a cloth impregnated with the antiseptic, would be distributed on patients' skin. The cloth did much better, suggesting that perhaps showering is just the wrong way to go about things. However, the new study made no attempt to measure bacterial count before or after showering with an antiseptic soap. Nor were patients checked for postsurgical infections.
"What have we learned with this new study?" wonders DocSurg. "Unfortunately, nothing that we can state is clinically useful, because this study did not enter the real world of clinical results." So, he asks, "why do this kind of study in the first place?"
Could it be that the manufacturer of the disinfectant products provided the lead author with a research grant? It was used to buy the supplies, with leftover funds used for other research. The appearance (and too often reality) of conflict of interest has long haunted clinical trials sponsored by pharmaceutical manufacturers. There's nothing inherently bad about industry-funded research, and much, as DocSurg notes, that is good.
But the credibility of a study isn't exactly enhanced when it seems to be designed more to feature a particular product from a specific manufacturer than anything else. "Let's be brutally honest," writes DocSurg. "A study like this that gives us essentially no new information, but which throws the possibility of clinical relevance into its title and discussion, is really not helping anybody."
U.S. News's Avery Comarow has been editor of the America's Best Hospitals annual rankings since they first appeared in 1990. His reporting on clinical medicine, from the latest cholesterol guidelines to robotic surgery, has been driven by the question: What does this mean to patients? And that is the perspective he brings to his observations and commentaries on the increasing number of programs by hospitals and other healthcare providers to improve care and patient safety.
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