Under mandate by the FDA to answer lingering questions about long-acting beta agonists’ safety for treatment of asthma, four major pharma firms will launch five large randomized trials comparing inhaled corticosteroid / long-acting beta agonist combination products vs. ICS alone. The trials (4 in adults, 1 in kids) will enroll >50,000 people starting this year, [… read more]
Widespread beliefs among physicians that people with mental illness are more addicted, or less desirous or capable of quitting smoking, are wrong and perpetuate a deadly problem, argues J.J. Prochaska. You should nag mentally ill folks to quit smoking as you would anyone else, she urges. NEJM 2011;365:196-198. FULL FREE TEXT
In a great essay, Coller proposes re-engineering the health care system before Obamacare amplifies our skyrocketing cost problem under fee-for-service. Sounds like a twist on accountable care organizations, but more plausible and on its face politically palatable (after the bloody noses heal). JAMA 2011;306:204-205.
Particulate matter causes cardiovascular deaths, and also worsens respiratory illness. The Environmental Protection Agency plans to reduce acceptable levels of PM and ozone, a move that would force industry to pay for new upgrades. NEJM 2011;365:198-201.
The 18,000 clinical trials published each year aren’t doing much to improve human health, argues Peter Pronovost. Health delivery research can, by improving delivery and impact of already-proven interventions. But doing so will require cutting a slice of the funding pie for social scientists and other untouchables in the “omics”-loving academic caste system. JAMA 2011;306:310-311.
The Research Agenda in ICU Telemedicine: A Statement From the Critical Care Societies Collaborative. Kahn JM et al. CHEST 2011;140:230-238.
Why are big single center trial effects not often replicated in larger multi-center randomized controlled trials? Dechartres et al did a meta-meta-analysis on 48 meta-analyses comprising 421 randomized clinical trials. Across all their sensitivity analyses, reported treatment effects were consistently and substantially larger in single-center trials than in multi-center trials. No one knows why yet. [… read more]
Zager et al examined registry data on 38,917 patients admitted to Beth Israel and Brigham & Women’s hospitals between 1997-2007, and concluded that low socioeconomic status (as determined by census tract neighborhood of residence) did not influence 30- or 365-day mortality after admission to these hospitals’ ICU. CHEST 2011;139:1368-1379.
That’s what Banerjee et al argue, after retrospectively comparing ICU costs before/after implementation of 24-hour in-house intensivist coverage. They found that total costs for patients admitted at night declined by 61%, while daytime costs were unchanged. Crit Care Med 2011;39:1257-1262.
New York’s city council banned smoking in almost all public spaces on May 23. Colgrove et al raise the interesting point that because the risk from secondhand smoke outdoors is nil, the political move oversteps the mandate of public health, and is instead heavyhanded social engineering that will further stigmatize smokers, a sad and addicted [… read more]
Menthol doesn’t kill people — cigarettes that are tastier and easier to smoke because of menthol do. The FDA’s Tobacco Products Scientific Advisory Committee blandly concluded that removing menthol from cigarettes would improve public health, but in the current pro-economic recovery environment, there is no political will to take on Big Tobacco, Siegel, Benowitz and [… read more]
Pulmonary rehabilitation, realities in clinical practice. Birnbaum S, CHEST 2011;139:1498-1502. Having trouble finding a pulmonary rehab program to refer your COPD patient into? That may be because in 2011, according to Mr. Birnbaum, Medicare paid outpatient centers $28 per rehabilitation session, per patient.
Gershengorn et al retrospectively compared two MICUs at Beth Israel: one with “midlevels” (nurse practitioners and physician assistants during the day with attending coverage overnight) and one that was all house staff 24/7. There were no differences in important outcomes (mortality, MICU or hospital LOS), although the study was nonrandomized and subject to bias. CHEST [… read more]
The New York Times reported that hundreds of community hospitals frequently perform two chest CT scans back-to-back (one with, one without IV contrast), while academic centers almost never do. More than 70,000 patients were double-scanned; some hospitals did it >80% of the time on their Medicare chest patients. Defenders say they don’t do it to [… read more]
Free et al randomized 5,800 UK ready-to-quit smokers to get regular motivational text messages and help-line access, vs. placebo (texts thanking them for participating). At 6 months, those getting motivational text messages had biochemically-verified continuous abstinence of 11%, vs. 5% in the controls. Verification was by salivary cotinine at 6 months (& showed that 28% [… read more]
Sharma et al retrospectively observed >200,000 total patient-days for 9 months before and 27 months after implementation of a rapid response team at a single institution (U of Texas Galveston). Code rates and mortality did not change. CHEST 2011;139:1361-1367. Many cohort studies with historical controls over the past decade suggested benefits of RRTs, although others [… read more]
A brief historical and theoretical perspective on patient autonomy and medical decision making: Part II: the autonomy model. Will JF, CHEST 2011;139:1491-1497. ICU Ethics review.
Zinberg writes on predicted effects of the Affordable Care Act on reimbursements. As 30 million patients pour into the system, half onto Medicaid rolls, and cash-strapped state governments likely reduce payments for their visits (after federal prop-up payments shrink in 2016), Zinberg asks whether most physicians will see Medicaid patients at all, since many already [… read more]
Dyrbye & Shanafelt from Mayo sound a warning that the impending influx of 30 million newly insured patients into doctors’ offices after full implementation of health insurance reform, simultaneous with declining reimbursements, are likely to increase physician stress and burnout. They urge a lot of doctor-friendly policy measures (like a committee to set limits on [… read more]
Drug and device companies finance up to 60% of all CME in the U.S. Tabas et al surveyed 1,347 CME participants, 770 of whom responded. 88% felt that industry involvement biased their educational program…but only 42% said they’d be willing to pay higher CME fees to help reduce commercial influence. Participants almost universally (85-88%) underestimated the real [… read more]