Tuesday, July 17, 2018

Stop Antibiotics When You feel Better!

First, a special thank you to Emily Styslinger, my summer research student (Colgate University) for passing this article on to me.

The idea that stopping antibiotic treatment early promotes antibiotic resistance is simply not supported by evidence.

This article, published in the British Medical Journal, neatly explores the idea that 'complete the course' of antibiotics may not be the best option for limiting antibiotic selective pressure.  We are learning that shorter courses of antibiotics for select bacterial infections (community-acquired pneumonia, pharyngitis, healthcare associated pneumonia) are as effective as the time honored 14 day course of treatment.

It is now time for us to aggressively question the duration of all antibiotic courses.  

We need research that best defines duration limited yet effective treatment regimens for bacterial infections. This must be coupled with a clear patient centered message, as suggested in the paper: Stop antibiotics when you feel better. 

I love it.

Sunday, July 15, 2018

My Month-long, Multi-modal Football (Soccer) Binge Has Mercifully Ended!








The World Cup has finally ended as has my multi-modal, month-long binge of football (soccer). Mercy!

As predicted, my productivity was much reduced by (nearly) watching all of the matches in their entirety.The World Cup is an important and relevant event that serves to bring us together, as explored here in today's New York Times.

The month-long experience came to an end this weekend first with a visit to the new DC United football ground, Audi Field, for its inaugural match (DC United  FC vs Vancouver Whitecaps FC), with the debut of English football legend Wayne Rooney.Today was capped off with the World Cup Final, France vs. Croatia.

Over the last 30 days, I managed to read two noteworthy books on football. Masters of the Modern Game, by Grant Wahl, neatly delves into the tactics, personalities and philosophies of current day football. The second, What We Think About When We Think About Soccer, by philosopher and Liverpool FC fanatic, Simon Critchley, explores the experience of football through the lens of phenomenology (the study of consciousness and the objects of direct experience)- how we live, feel, hear, watch, identify, collectivize,individualize, glorify and despise the 'beautiful game'. A unique read.

Back to the World Cup. During the final I cheered for neither France nor Croatia, but for Nestor Pitana, the referee, my Argentine compatriot. Croatia played well but France prevailed, worthy champions. 

Yes, my love of football is an ongoing childhood obsession. I am not ashamed nor am I alone.

Back to more mundane matters for the next 4 years.

Tuesday, July 10, 2018

Holding Providers (and Programs) Accountable for Healthcare Outcomes: Four Critical Criteria

Source: Randomagonline.com
The Joint Commission has this week landed at VCU health!

This visit got me thinking on the topic of provider and program accountability which led me to this opinion article, published by the Joint Commission, in Annals of Internal Medicine. I highly recommend giving it a perusal.

The four critical criteria for accountability measures that address health outcomes are as follows:

  1. Strong evidence should exist that a particular intervention or bundle leads to an improvement in the outcome
  2. The outcome should be measurable with a high degree of precision
  3. A risk adjustment methodology should exists and include and accurately measure the risk factors most strongly associated with the outcome
  4. Implementation of the outcome measure must have little chance of causing adverse consequences
So how well do we fare when applying the above criteria to proposed outcomes?  Not so great.  Check out table 2 in the manuscript. Central line bloodstream infection outcomes meets the criteria as does NSQIP surgical site infection reduction programs.

In my opinion, Clostridium difficile outcome measures fall far short on criteria #1.

As for CMS Hospital Compare data it systematically violates criteria # 3, risk adjustment.  
A major flaw.

We need to be cautious when outcomes drive accountability.

Friday, July 6, 2018

End of Public Reporting? Stop, Not So Fast.

This news article published in USA Today reports how the Trump administration may propose legislation that will stop the Center for Medicare and Medicaid Services (CMS) from publicly disclosing data on healthcare associated infections (HAIs). 

Although the body of literature assessing the impact of public HAI reporting is limited, there is some evidence to suggest that publicly reported data heightens awareness and enhances focus on risk reduction practices.  A recent report can be found here in Health Services Research.

I recall a time when awareness, focus and resources for actually implementing HAI risk reduction practices in the hospital was limited.  Healthcare epidemiology was more a descriptive discipline that focused on defining HAI risk factors.  

Now, we both describe and act on HAIs-through risk reduction implementation science.
This is both the present and future- we 'describe' and 'do'.

Removing external oversight and public reporting would allow hospital administration to toggle the support and executive oversight of hospital infection prevention down the ladder of priority.

The likely result: more patient harm.

Monday, July 2, 2018

It's July, The New Interns Are Here! Be Patient, Unlike Dr. House

For those of us in academic medicine we know this time of year very well: it is July, the new interns are here.

I am back on the infectious diseases consult service this week and the number of phone calls/pages is nothing short of astounding.  It is the new interns and wow are they green.

The potential safety ramifications of new trainees are significant as reported here in the Journal of General Internal Medicine, where increases in fatal medication errors were observed in July, exclusively in teaching hospitals.

As a consultant, I commonly experience poorly communicated consult questions and mistakes in care coordination and follow up.

When I find myself getting upset, which is often, I do my best to pause and simply remember:  I was once an intern too.

Be patient, unlike Dr. House.