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US healthcare

William C Cayley: Social history on the back roads

31 Oct, 14 | by BMJ

bill_cayley_2Social context and relationships may shape what drives our patients, but sometimes the best way to ponder these is on a drive!

En route to a home visit today, I was met at the edge of town by a road crew doing last-minute sealing work before the onset of winter (despite what you may have heard, Wisconsin only has two seasons—winter and road construction!). As I sat mildly frustrated at the wait until they let us pass, I found myself wondering how many of the road crew, might actually be my patients. (In the end, no faces were familiar, but still it left me thinking).

The home visit was actually relatively straightforward, nothing new going on, no new needs requiring attention. On departing, I decided to both avoid another road construction delay, and take some back roads into town that I seldom explore.

more…

William Cayley: Overdiagnosis, uncertainty, and epistemology

29 Oct, 14 | by BMJ

bill_cayley_2Many thanks to Anita Jain for reporting on the “Overdiagnosis” session at the Cochrane Colloquium—I wish I could have been there.

The suspicion that overdiagnosis (or at least over testing) is driven in part by the quest for certainty, is corroborated by an implementation study of the Vancouver chest pain rule. When the Vancouver chest pain rule was implemented as a triage protocol, the number of patients presenting for emergency care of acute chest pain who could subsequently be discharged early for outpatient follow-up was almost doubled. more…

William Cayley: Social history consultations and patient time vs patient time

23 Oct, 14 | by BMJ

bill_cayley_2Who are you, what do you need, and how do I figure out how to care for you?

Fundamentally, those are the questions that drive every encounter between a doctor and a patient. A recent article in the New England Journal of Medicine calls for us to expand the “social history” facet of this to include six domains: individual characteristics, life circumstances, emotional health, perceptions of healthcare, health related behaviors, and access to and utilization of health. more…

William Cayley: Thinking about Ebola from the sidelines

7 Oct, 14 | by BMJ

bill_cayley_2Recently I was staring at two dramatically different bits of “news” on my computer screen. Yet another story on the spreading Ebola outbreak was in one window, and the latest update on our practice’s clinical performance metrics was in the next window. News of an out of control plague, juxtaposed with little red and green numbers telling me how well (or poorly?) I’m doing at “keeping” enough of my patients “in control” with their blood pressures, lipids, and the like. more…

William Cayley: Facing uncertainty

2 Oct, 14 | by BMJ

bill_cayley_2The first case of Ebola in the United States, a cluster of cases of “acute neurologic illness with focal limb weakness of unknown etiology in children,” and ongoing concern over enterovirus D68 in the US. As if economic uncertainty and ongoing conflicts around the globe were not enough to put one on edge, there is now a near daily stream of news about spreading infectious disease threats.

As physicians it seems we are at least implicitly expected to deal primarily with certainties. What is the right diagnosis? What is the risk threshold above which one should take a statin to prevent vascular “bad things?” What medication will prevent my patients getting badly ill from an influenza-like illness? What interventions will ensure my older patients don’t fall or get depressed?

How do we navigate the dicey waters between the scary bad things, and the desire for certainty in diagnosis and prevention? more…

The BMJ Today: A new era in transparency

2 Oct, 14 | by BMJ

A new era in openness and transparency—and arguments over data—has begun with the publication of the first tranche of data made available under the US’s Sunshine Act. The act makes all drug, device, or biological manufacturers declare money they give to doctors (if it’s above $10), including cash in kind, i.e. food or drinks, even if that money is routed to a charity.

It will take months to look through everything as the full data aren’t available yet (these first 4.4m payments only cover half of 2013). The Centers for Medicare and Medicaid Services aren’t happy with their completeness, and there are concerns from physicians that the data are misleading or incorrect. Read our first look at the data, Open Payments goes live with pharma to doctor fee data: first analysis, to find out about some of these problems and see some of the top line figures. more…

Richard Smith: Using data to improve care and reduce waste in health systems

30 Sep, 14 | by BMJ

richard_smith_2014Annual expenditure on healthcare in the United States is currently $2.8 trillion, and about a third of it is wasted, says the Institute of Medicine. The sum wasted is about five times the GDP of Bangladesh, a country of 160 million people. This is waste on a spectacular scale, and reducing it while improving the quality of care is the main aim of the information technology developed by Optum, the services part of the UnitedHealth Group, said Richard Migliori, a former transplant surgeon and chief medical officer of the UnitedHealth Group. I don’t come to tell you what to do, said Migliori speaking last week to the Cambridge Health Network, but I hope to at least elicit your sympathy. more…

Hugh Alderwick: The ups and downs on the road to health service improvement

19 Sep, 14 | by BMJ

hugh_alderwickParallels between the successful transformation of the Veterans Health Administration (VA) in the United States and the changes needed in the NHS in England have been made for a number of years. But recent troubles at the VA offer some important lessons for the NHS in the future, as explored in a roundtable discussion held at the King’s Fund last week.

The story of the transformation of the VA is familiar to many. Once a fragmented and hospital centred public healthcare system, changes made in the late 1990s helped the VA to become an organisation renowned for providing high quality, affordable care. more…

William Cayley: My Chief Complaint

18 Sep, 14 | by BMJ

bill_cayley_2My chief complaint . . . is with the chief complaint.

One of the hallowed concepts in medical history taking and documentation is the “chief complaint.” Supposedly a way to set the agenda for a medical visit, in current practice it often gets both distorted and treated as a boundary setter.

Ideally, in medicine, we hope to address our patients’ medical problems and cure their ills; and thus we obviously want to know why someone is spending his or her time coming to see us. In modern computer enhanced, team based care, however, the “chief complaint” often becomes further and further removed from what is actually on the patient’s mind. more…

Stuart Buck: Are scholars or journalists more to blame when correlation and causation are confused?

15 Aug, 14 | by BMJ

Stuart_BuckNews stories about everything from nutrition to epidemiology to family behavior often confuse correlation with causation. Drink coffee, we are told, and you will lower your risk of dying (or perhaps raise it, depending on the week). Get married, and you will have stronger bones.

Sophisticated news consumers in the know understand that it’s best to discount such stories, which do not report on randomized experiments or any other statistical model that could show causation. The articles are invariably about correlations—akin to demonstrating that sunburn goes up along with accidental drowning, which is true not because either one causes the other, but because both occur in the summer. more…

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