Saturday, January 9, 2010

Screening for Potential Surgical Site Infections

The NEJM has an article this month about the prevention of surgical site infections by identifying and treating those patients who are colonized with staphylococcus aureus. It's a randomized trial that used PCR assays of nasal swabs to identify patients colonized with methicillin susceptible staoh aureus. Those patients noted to be positive were then treated with mupirocin nasal ointment and a chlorhexidine soap scrub prior to elective surgery. Infection rates were halved compared to the placebo group.

Interesting paper but it ought to be noted that these patients were carriers of the methocillin susceptible strain of staph aureus rather than the more virulent MRSA. It would be interesting to see if the results were as profound if we treated all MRSA carriers.

Furthermore, as with any paper, we have to ask ourselves what we're supposed to do with the data accumulated. How ought it to change clinical practice? Do we need to start screening all elective surgery patients? Should every carrier be treated, no matter what the operation to be performed is?

I've done close to 500 inguinal hernia in my brief career as a general surgeon. I've never had a wound infection. (Knocking on wood.) Do I really need to be checking all my patients for staph? PCR assays cost money, as do treatment regimens with mupirocin. Is it cost effective to implement MSSA/MRSA screening for all elective surgery? Or just certain operations (like heart surgery, bowel cases, ortho procedures, etc.)

Thursday, January 7, 2010


A paper that extrapolates data from the American College of Surgeon's NSQIP database demonstrates that infectious complications in general surgery cases rise linearly with increased duration of operating times.

The lesson as always: Don't dick around. Don't waste time or motion. Get in and get out.

Never Events: Cost Savings?

We're all familiar by now with the concept of "never events". These are the in-hospital complications (such as line infections, urinary catheter infections, DVT's, and decubitus ulcers) that the Center for Medicaid and Medicare Services has deemed entirely preventable and, thus, will not compensate hospitals for their treatments.

The idea behind such a mandate is twofold. Number one, it promotes safe practices that will hopefully improve patient care and in-hospital outcomes. If a hospital is being financially penalized because of high urinary tract infection rates, you can be sure that systemic QA review of how nurses and aides insert Foley catheters is just around the corner. That seems like a good thing to me. Unfortunately, not all infections or blood clots are preventable. (Try finding an article in the medical literature describing how one is supposed to reduce the incidence of DVT's to zero).

The other motivation of "never event" designation is to ostensibly bend the cost curve downward. Non-payment of "avoidable" events will, over the long haul, reduce overall health care spending. So they aver.

There's an interesting article examining the validity of this claim in the journal Health Affairs from last September. The study examined 767,995 acute inpatient Medicare discharges from 2006. Upon review of the charts, a so-called never event was idenified in only 828 patients. The savings from reduced payments for these events would have been about a hundred grand or so. Extrapolated nationwide, savings come to a little under $3 million---a pittance compared to Medicare's half trillion dollar annual budget.

The problem with "never event" non-payment is not that it is fundamentally evil and unjust but that it is irrelevant from a pragmatic perpsective (the cost reduction is negligible). The problem is with the inflammatory nature of the terminology. Never event. Think about it. If you were a patient and you saw on your hospital bill a charge that was deducted secondary to denial of payment by Medicare and then you found out that the reason it was denied was that it was a complication that is never supposed to happen, wouldn't you feel that you had been wronged to some extent? That something was inflicted on you during your hospital stay? If I'm a trial attorney, I love this terminology.

So it's simple---change the terminology. Call them "potentially avoidable complications". There are no "never events" in medicine. Absolutism is just as invalid and as damaging in medical practice as it is in politics, religion, and philosophy. As physicians, we ought always to strive for better practice but to insist on perfection is a pipedream doomed to end in disillusionment.

Tuesday, January 5, 2010

ALS Entrapment

Very much worth your while to read Tony Judt's poignant reflections on living with ALS (Lou Gehrig's Disease). Every night for him devolves into a nightmarish trial of fortitude as, essentially quadriplegic but with complete sensation, he is forced to endure sleeping in the same position in bed until the breaking of the dawn. All those subtle little shifts in body position-- the mindless scratch to alleviate an itch, the pulling of the covers, the unconscious roll to the side-- are lost to Mr. Judt. And alone he must bear the unbearable motionless imprisonment; the itch that screams, the leg cramp, the throbbing back all through the night. He writes beautifully of the mental gymnastics he puts himself through in order to distract his mind from the torment:
My solution has been to scroll through my life, my thoughts, my fantasies, my memories, mis-memories, and the like until I have chanced upon events, people, or narratives that I can employ to divert my mind from the body in which it is encased. These mental exercises have to be interesting enough to hold my attention and see me through an intolerable itch in my inner ear or lower back; but they also have to be boring and predictable enough to serve as a reliable prelude and encouragement to sleep. It took me some time to identify this process as a workable alternative to insomnia and physical discomfort and it is by no means infallible. But I am occasionally astonished, when I reflect upon the matter, at how readily I seem to get through, night after night, week after week, month after month, what was once an almost insufferable nocturnal ordeal. I wake up in exactly the position, frame of mind, and state of suspended despair with which I went to bed—which in the circumstances might be thought a considerable achievement.

I had a patient like this once. An older guy with advanced ALS (he could move his arms somewhat) who presented with toxic megacolon from c difficile colitis. He recovered physiologically quite well from the subtotal colectomy but he was a difficult patient nonetheless. He would stare through people, seemingly not even listening to what doctors or nurses had to say. These bright blue piercing eyes, sunken in his wan, pale, haggard, desperate face. You'd go into his room and it was an endless stream of requests and demands. I want water. I'm cold. Roll me. Bring me water. The pleading eyes and this low monotone voice, over and over, day after day. It was depressing. You'd bring him some water and then there would be another thing he needed. And then another. He'd been reduced by the disease to a series of instantaneous wants and desires, a shell of human dignity. It was horrible.

Monday, January 4, 2010

The Paradox of Private Insurance and Universal Coverage

Great article from James Surowiecki in the New Yorker last week about the difficulty in reconciling the overwhelming public support for granting equal health insurance opportunities to all comers, regardless of pre-existing conditions, with the equally vehement public opposition to "single payer" or "governement run" health care systems. Key paragraph:
Congress’s support for community rating and universal access doesn’t fit well with its insistence that health-care reform must rely on private insurance companies. After all, measuring risk, and setting prices accordingly, is the raison d’ĂȘtre of a health-insurance company. The way individual insurance works now, risk and price are linked. If you’re a triathlete with no history of cancer in your family, you’re a reasonably good risk, and so you can get an affordable policy that will protect you against unforeseen disaster; if you’re overweight with high blood pressure and a history of heart problems, your risk of becoming seriously ill is substantial, and therefore private insurers will either charge you high premiums or not offer you coverage at all. This kind of risk evaluation—what’s called “medical underwriting”—is fundamental to the insurance business. But it is precisely what all the new reform plans will ban. Congress is effectively making private insurers unnecessary, yet continuing to insist that we can’t do without them.

And of course the health care insurance industry is totally on board with the pending reform legislation---makes one wonder what sort of backroom deals were cut to guarantee future insurance industry profits and therefore seal its support...