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Watching the Hospital Hand-Washing Watchers
Tweet Share on Facebook September 23, 2008 Comment (2)Thanks to fellow blogger Bob Wachter, a hospitalist at the University of California, San Francisco Medical Center, for taking note on his blog, Wachter's World, of a story in yesterday's ModernHealthcare.com about a development that very well might solve the low rate of hand-washing by hospital caregivers. Because the solution involves video monitoring, however, it raises a question or two of its own.
I've blogged here and here and here about the need for all healthcare workers to scrub their hands or use a hand sanitizer before touching or approaching patients. Rather surprisingly, no one can say with authority how much the number or rate of hospital-acquired infections would drop if hand-washing compliance shot up, but certainly it would be significant, considering the room for improvement. Because of all the attention recently devoted to hand-washing, Wachter writes, "many hospitals, including my own, have seen hand-cleansing rates skyrocket, from previously mortifying levels of 20 to 30 percent to merely embarrassing rates of 60 to 80 percent."
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The March of Alternative Medicine
Tweet Share on Facebook September 16, 2008 Comment (4)Another year, another report on the ostensibly growing embrace by hospitals of complementary and alternative medicine—or integrative medicine, as many practitioners prefer to call CAM because "alternative" has dubious vibes. The American Hospital Association has just released a new survey showing that about 37 percent of the hospitals that responded offer one or more CAM therapies such as acupuncture, massage therapy, and guided imagery, up from about 26 percent in an AHA survey in 2005.
I requested the survey and looked it over. I've walked the CAM beat for more than three decades, and my antennae are always sniffing for data true and false. Early this year, a cover story I wrote about CAM's spread into academic medical centers took heat from CAM detractors (for buying into a passel of woo-woo nonsense) and supporters (for mindlessly rejecting effective treatments just because they haven't passed conventional standards of evidence) alike. There's no middle ground with these folks.
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Colon Cancer Controversy
Tweet Share on Facebook September 9, 2008 Comment (2)A study released today in the Journal of the National Cancer Institute gives me a chance to bring up the phenomenon of a guideline that gets cemented into place as a hospital quality measure even if the premise behind it is controversial or shaky. The study shows that almost two thirds of hospitals fall short of such a standard that took effect last year: A minimum of 12 lymph nodes should be cut out and sent to the pathology lab in all patients who have a section of cancerous colon removed.
No surgeon challenges the absolute necessity to put lymph node tissue under the microscope to see whether cancerous cells have spread beyond the colon or other organ. The guideline, moreover, is based on studies that seem to show a clear relationship between long-term survival after such surgery and the number of nodes excised. The logical explanation is that the more nodes examined, the greater the chance of finding at least one that is positive for cancer, which triggers aggressive treatment involving radiation and chemotherapy. Therefore, it is important to look at a large number of nodes to maximize the odds of finding an elusive positive one.
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Hospital Parking, a Pain in the Purse
Tweet Share on Facebook September 3, 2008 Comment (1)How about that—parking fees will be eliminated at most hospitals in Scotland! My eye almost slid past this week's announcement from the British Medical Association. But a closer look and a little digging turned up an interesting story that many U.S. patients will appreciate. I'd like to hear from you if you're one of them.
I found that hospital parking charges in the United Kingdom have been something of a hot button for years with patients and doctors. Care is free through the National Health Service, so why should patients have to pay to park at NHS hospitals? The fees are "an indirect tax on healthcare," says the BMA. "A stealth tax on illness," echoes Macmillan Cancer Support, a patient group.
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A Dose of Lead or Mercury With Your Medicine
Tweet Share on Facebook August 27, 2008 Comment (5)Are we being pummeled with so many warnings about heavy metals in the food and water that we're starting to tune out? Not all of the media reports about a new study that found heavy metals such as lead and mercury in a sizable sample of traditional ayurvedic medicines of India have been as cautionary (a polite word for alarming) as I would have liked them to be. I'm not a physician or toxicologist or biochemist, but I've written about alternative medicine and read a few studies over the years, and the bottom line of this one, in the latest issue of the Journal of the American Medical Association, is about as subtle as a traffic cop's whistle.
Here it is: Out of 193 ayurvedic medicines purchased online—115 of them manufactured in the United States, 77 in India, and 1 in Canada—about 1 in 5 contained detectable amounts of lead, mercury, and arsenic. While some reporting has noted that the incidence was higher among U.S.-made products, the difference is trivial, 21.7 percent compared with 19.5 percent of medicines from India.
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If Medicine Is So High-Tech, Why So Much Illness?
Tweet Share on Facebook August 26, 2008 Comment (5)"Early in my ER career I decided I would not press my medical opinions on people who did not request them," writes Robert Martensen in the quietly compelling A Life Worth Living: A Doctor's Reflection on Illness in a High-Tech Era, which will be published next month. Being closemouthed isn't easy for physicians, drilled from the start of their training to absorb, recall, and recite information. The context in the book is a 40-year-old patient named Marguerite. Martensen had tentatively diagnosed inflammatory breast cancer in Marguerite, who had asked to come to his ER because she knew him casually and she wanted him, not an unfamiliar doctor, to check out a tender spot in one breast. His diagnosis subsequently was confirmed, and she was about to enter the hospital for a bilateral mastectomy. "We're going to lick this thing!" her husband, Eduardo, told Martensen.
"I wanted to say and ask many things, but I did not," writes Martensen, who was no longer involved in Marguerite's care. "My job, if I had one, involved being supportive.... To do otherwise, I told myself, to attempt to insert myself into their intimate life, would be disrespectful. The last thing they needed was for me or any outsider to sow doubt."
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The Wild West of Medical Care Abroad
Tweet Share on Facebook August 22, 2008 Comment (16)Take a quick look at these two emblems. Displayed online, both are supposed to convey trustworthiness to patients considering a trip to another country for medical care. Do they look similar?
The sources of the seals are very different. The seal on the right is from the Joint Commission International (JCI), which accredits hospitals abroad for safety and quality. It's an arm of the Joint Commission, which is tasked by Congress with accrediting U.S. hospitals. The other is from the Medical Tourism Association (MTA) a trade group based in West Palm Beach, Fla. Its members include foreign hospitals, health insurers, and "facilitators," a specialized category of travel agencies that arrange and book medical trips abroad.
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Hospital Deaths Go Public
Tweet Share on Facebook August 21, 2008 Comment (4)How well thousands of individual U.S. hospitals do on the ultimate test of hospital competence—whether very sick patients live or die—is now revealed on the Web for all to see, in hard numbers. The Hospital Compare page maintained by the Centers for Medicare & Medicaid Services (CMS) this week began displaying actual hospital death rates for heart attack, heart failure, and pneumonia patients. Until now, only relative performance had been shown—whether mortality for such patients at a particular hospital was about the same as the national average, better than average, or worse than average.
This is a big step forward. The death rates, says Harlan Krumholz, director of the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital, which developed the mortality measure, "provide insights into where hospitals are compared to where they should be."
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How Involved Should Patients Be?
Tweet Share on Facebook August 5, 2008 Comment (3)"Patient-centered care," which stripped of all its fuzziness I take to mean that patients should be equal partners (or more) with the physicians who treat them, is a current hot topic in healthcare. At its heart lies a fundamental and fascinating question: Are patients the best judges of their own care? Hospitalist Robert Wachter's current discussion of patient-centered care on his blog, Wachter's World, is long, but it's a great read, touching on almost everything that makes me a little uncomfortable with the concept.
Wachter sets out generally agreed-upon principles of patient-centered care: Patients' preferences should be respected; caregivers should attend to patients' emotional needs—their context, comfort, and significance; patients should be engaged and empowered; there should be shared decision making that promotes patient autonomy; family and friends should be involved in care decisions where appropriate; and care should be coordinated within and across systems. As Wachter says, well, sure.
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Fatal Drugs, Uneducated Patients
Tweet Share on Facebook July 29, 2008 Comment (7)"Abuse?" Or "mistake?" As reported widely today the death rate from perfectly legal medications, both prescription and over the counter, jumped 360 percent between 1983 and 2004. Many of the deaths involved a mix of alcohol and drugs, which has led some of the coverage to refer to drug abusers.
That's wrongheaded. In the first place, the researchers who analyzed all of the nearly 50 million U.S. death certificates filed from 1983 to 2004 excluded deaths caused by street drugs alone, such as heroin, methamphetamine, and crack cocaine. The aim was to find out whether the steadily growing numbers of patients taking multiple medications—many of which originally were available only by prescription but then moved to the other side of the counter—and getting less medical supervision were suffering the consequences of this potentially deadly combination. They were, especially when alcohol was involved; deaths from medications plus alcohol rocketed from 92 in 1983 to 3,792 in 2004, a bounce of nearly 3,200 percent.
Comarow On Quality
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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