Dirigindo um hospital: um blogue diferente

Abaixo, reproduzo um dos posts do blogue Running a Hospital, de Paul Levy, diretor do Beth Israel and Deaconnes Medical Center, localizado em Boston. O texto copiado traz uma mensagem interessante relacionado ao sistema de faturamento. Mas, o mais interessante é o próprio blog.

O autor não poupa os próprios subordinados exigindo decisões mais incisas e rápidas.

Wednesday, September 17, 2008 Some ads I get Notwithstanding our excellent spam control program, I get tons of broadcast emails sent to me as CEO of a hospital, selling all kinds of services -- but especially services related to coding patient treatments to get the highest payment from insurers and Medicare. I suppose this is just a sign of the times and indicative of the structure of the health care industry.I confess that I do not understand many of these ads. I'm not saying that I don't understand why I get them. I am saying that I literally don't understand most of the terminology. Here are some excerpts from a small sample of those I received yesterday. I guess the one I really need is the last one listed . . .

Um relato no WSJ para entender a medicina defensiva

My nurse practitioner came to me with the case of a 40-year-old patient complaining about aches and pains from an auto accident. Just three days before, he had been released by the trauma center with instructions to see his family doctor. That turned out to be me. He was new to my practice. What impressed my nurse practitioner more than his injuries was the way he knocked the doctors and the hospital where he had been treated. Everything he said seemed negative, with a particularly hostile edge. "I wonder what he's going to say about us," my nurse practitioner said. So did I. An exam of the patient revealed some general soreness and a little extra tenderness in the abdomen. I ordered a CT scan. I wasn't all that worried about internal injuries. Still, the small chance of missing something on a dissatisfied patient was too big a risk for my professional comfort. His scan came back normal, as I expected. But doctors learn early to play defense. I've never been sued, but I've seen doctors accused of malpractice when there is a bad outcome, regardless of whether they seemed to have done anything wrong. There is an expectation after a patient does badly that the doctor should have ordered another test or done something else. But sometimes things go wrong no matter what you do -- or don't do. Defensive medicine is part of the cost of doing business, and also, unfortunately, a large part of the unnecessary expense of health care. In my experience, I'd estimate it accounts for 10% of the waste. Some days I think that's probably conservative. Unlike defensive driving where slowing down and being less aggressive saves lives, defensive medicine means doing more tests, ordering more consults from specialists and exposing patients to the risks of radiation, invasive tests and treatments. It transcends being cautious or careful for the patient's sake. It has everything to due with protecting the practice from the legal system. I try not to order expensive or risky tests to chase down minor lab or X-ray findings. Some physicians feel compelled to do this. One thing that we doctors hate almost as much as a faulty diagnosis is winding up in court to defend our decisions. Once a doctor has had his judgment questioned in a lawsuit, his documentation and test ordering will never be the same. A typical line of legal attack is that you didn't order a test or refer a patient to a specialist fast enough. A general surgical colleague used to handle elderly patients with higher medical risks. He was good at his job and never turned anyone away for lack of insurance. After being sued, he transferred many patients with problems he used to take care of himself to bigger hospitals for care. The change was expensive, adding ambulance or helicopter costs, and it delayed some surgeries. Another sign of the times can be found in patient files, which have become more suited to legal defense than medical communication. The modern medical chart often contains reams of normal data kept to satisfy auditors and show that doctors are comprehensive in taking a history and performing an exam. To ward off critics, we put in comments like, "The patient denies other complaints." Electronic medical records provide even more opportunities to pack in boilerplate entries. The notes from specialists about my patients are now four to five pages long, and I have to search for the nugget of useful information and advice, usually toward the end. Patients are defensive, too. They look up their symptoms on the Internet and then insist on testing and consultations for symptoms that can be safely observed and frequently go away on their own. What can we do? Building better relationships between doctors and patients would help, though that's a tall order given the brief visits that have become the norm. If you are going into the hospital, think about leaving your most confrontational family member at home. When the family questions every detail of care to the Nth degree, you're going to get more testing, more specialists poking you and more cost. If that type of evaluation and treatment is what you are after, most doctors will oblige. Just make sure to factor in the extra doses of radiation from scans, the extra medication you might be allergic to, and the extra procedures the specialist is likely to recommend. Speak up if you suspect a test is just being ordered to cover the doctor's derriere. The defensive among us will document your informed refusal and our estimation that your lack of compliance might hurt you. The rest of us would probably agree with you. Due to his schedule and the volume of email he receives, Dr. Brewer may not be able to respond to all reader email. He does participate in his forum, where readers are urged to post. His email address is thedoctorsoffice@wsj.com.

O sarampo nos Estados Unidos

Se ocorresse em Terra Brasilis, o que estaria acontecento na imprensa? Falência da Saúde Pública!!!

Mas, é na terra de Tio Sam. Notem que há crianças não vacinadas por crenças dos pais, filosóficas ou religiosas.

Measles Outbreaks Continue at Record Pace CDC Officials Warn of Increasing Levels of Viral Transmission By Cindy Borgmeyer 9/12/2008 In May, AAFP News Now reported on a series of measles outbreaks that had racked up a total of 64 cases between Jan. 1 and April 25 -- the most cases seen in the United States since 2001. According to CDC officials, that tally had reached 131 by the end of July -- the highest year-to-date number since 1996. As of the end of April, nine states had reported cases of the disease; now, 15 states and the District of Columbia have reported measles cases.But those figures only begin to scratch the surface of the problem. This boy with measles displays the characteristic red blotchy rash that typically appears on the third day of the illness. Of the 131 total cases reported to the CDC, 123 occurred in U.S. residents. Five of these residents had received a single dose of measles-mumps-rubella, or MMR, vaccine; six had received two MMR doses; and 112 were unvaccinated or had unknown vaccination status. Of those 112 cases, 16 occurred in patients who were too young to be vaccinated and one occurred in a patient who was born before 1957 and, therefore, was presumed to have immunity. Finally, of the 95 remaining patients eligible for vaccination, 63 had not been immunized because of their parents' philosophical or religious beliefs

Erros médicos: por que não notificar?

O blogueiro do The Wall Street Journal repercute matéria do Philadelphia Inquirer sobre a notificação de erros médicos. Alguns estados americanos adotaram a notificação de erros hospitalares. Lá, como cá há um pavor em dizer que há problemas nos processos de trabalho que levam a erros. Prova da estúpida onipotência do setor hospitalar e dos médicos.

Pennsylvania and New Jersey, like several other states, have passed laws in recent years requiring hospitals to report serious errors. But lots of important mistakes may still be going unreported, the Philadelphia Inquirer reports this morning. In New Jersey, for example, five of the state’s 80 hospitals didn’t report any preventable mistakes last year. And some Pennsylvania hospitals didn’t report any errors or near misses, which are also supposed to be reported. It’s unlikely the hospitals operated flawlessly. “I don’t know how many is enough, but zero is a bad number,” said James Bagian, head of the Department of Veterans Affairs’ National Center for Patient Safety, told the Inquirer. “Anybody that is supposed to report close calls and has zero reports is clueless. … Management is asleep at the switch and just waiting until they kill someone.” The laws are part of a nationwide push to recognize medical errors and improve patient safety by preventing them. But the laws aren’t in step with another big trend in medicine these days: transparency. In general, the error reports aren’t available to the public, and the agencies wouldn’t tell the Inquirer how many error reports each hospital had filed. The New Jersey Hospital Association supports reporting but opposes making the reports public. “It may present an unfair picture of what is actually going on . . . when we have some hospitals that are not reporting and other hospitals that are reporting,” a hospital association official told Inquirer.

Medicina: a ciência das verdades transitórias, transformadas em dogmas para fins didáticos

No blogue auxiliar Ensaios Clínicos , postei os dois abstracts publicados hoje no The New England Journal of Medicine. Trata-se da continuidade de dois ensaios clínicos sobre diabetes encerrados e publicados há dez anos, o UKPDS (United Kingdom Prospective Diabetes Study). Agora, eles avaliam o efeito do ensaio sem a intervenção, dez anos depois. Os resultados praticamente mudaram o publicado inicialmente, o que implica discutir cada vez mais o mundo dos ensaios clínicos e o mundo real. Fica para outro momento.

O título do post é homenagem ao filósofo, médico, endocrinologista e diabetólogo, Arnaldo Caleiro Sandoval, autor dessa e de outras máximas.

Quem é mais citado?

Um artigo simples, de fácil realização, publicado no Circulation pela equipe da Harvard Medical School revela que artigos financiados pela indústria são mais citados do que aqueles por outras fontes, independente da qualidade. O mesmo vale para artigo mostrando que a proposta nova é mais efetiva do que a existente.

Leitura obrigatória em seminários de médicos-residentes e pós-graduandos.

Differential Citation Rates of Major Cardiovascular Clinical Trials According to Source of Funding. A Survey From 2000 to 2005

David Conen MD, Jose Torres BA, and Paul M Ridker MD* Background—Prior work indicates that therapeutic trials funded by for-profit organizations are more likely to report positive findings than trials funded by not-for-profit organizations. What impact, if any, funding source has on subsequent dissemination of trial data is uncertain. To address this issue, we used the number of citations per publication per year to assess differences in trial dissemination according to funding source. Methods and Results—We assessed 303 consecutive superiority trials of cardiovascular medicine published between January 1, 2000, and July 30, 2005, in the Journal of the American Medical Association, The Lancet, and the New England Journal of Medicine. The primary outcome measure was the number of citations per publication per year up to December 31, 2006. Overall, the median number of citations per publication per year was 46 for trials funded exclusively by for-profit organizations, 37 for trials jointly funded, and 29 for trials funded by not-for-profit organizations (P=0.0007). Higher citation rates for trials funded by for-profit organizations were consistently observed in analyses stratified by journal and various trial design features and were most striking when the new intervention was favored over the standard of care; in this subgroup, the median number of citations per publication per year was 52 for trials funded by for-profit organizations compared with 25 for trials funded by not-for-profit organizations (P=0.0006). In marked contrast, in analyses limited to trials in which the new intervention was significantly worse than the standard of care, an inverse pattern was observed with fewer citations per publication per year for trials funded by for-profit organizations compared with not-for-profit organizations (33 versus 41; P=0.048). Higher citation rates were observed for industry-funded trials than for federally funded trials even when the trials dealt with similar issues and were published back-to-back in the same journal. Conclusions—Dissemination of clinical trial results is important for clinical practice but appears to be biased in favor of for-profit entities. Consideration should be given to more extensive promotion of clinical trial results that are funded by not-for-profit organizations.

Não fui embora !

Reforma do Pronto-Socorro do Hospital, estrutura nova para ambulatórios de especialidade, relatórios e proposições a agências de pesquisas, aulas e seminários, início do ELSA, submissão de manuscritos... O blog ficou sozinho..

Um idéia excelente: compartilhar banco de dados

Towards a Data Sharing Culture: Recommendations for Leadership from Academic Health Centers. (texto completo, clique aqui) Sharing biomedical research and health care data is important but difficult. Recognizing this, many initiatives facilitate, fund, request, or require researchers to share their data. These initiatives address the technical aspects of data sharing, but rarely focus on incentives for key stakeholders. Academic health centers (AHCs) have a critical role in enabling, encouraging, and rewarding data sharing. The leaders of medical schools and academic-affiliated hospitals can play a unique role in supporting this transformation of the research enterprise. We propose that AHCs can and should lead the transition towards a culture of biomedical data sharing. Benefits of Data Sharing for Academic Health Centers The benefits of data sharing and reuse have been widely reported. We summarize them here, from the perspective of an AHC. The predominant benefit of data sharing is accelerated scientific progress. Advances are clearly valuable to an AHC when translated into improved patient outcomes, reduced research costs, and decreased time in moving discoveries from the bench to the bedside. Of more immediate benefit to AHCs and their researchers, sharing data increases the visibility and relevance of research output. Sharing data generates opportunities for additional publications through collaboration, and may increase the citation rate of primary publications. Since publication history and citation impact are often considered in future funding decisions, these benefits are likely to accelerate research programs, and thus enhance the reputation of the academic institutions. Data sharing can also benefit an AHC in its roles of educator and employer. Health care professionals trained in clinical informatics benefit from exposure to real-world data. By embracing data sharing goals, an AHC becomes more appealing to cutting-edge researchers, and thereby more able to recruit the talent required for future successes. Finally, the widespread adoption of a data sharing culture needs leaders, and thus provides an opportunity for AHCs to demonstrate excellence. A Leadership Role Despite the anticipated benefits, sharing research data has yet to be widely adopted in biomedicine. Through their interwoven roles in education, research, and policy, AHCs can lead the development of best practices for establishing a data sharing culture. Practical steps with potentially powerful impact are discussed below and summarized in Box 1. Box 1: Recommendations for Academic Health Centers to Encourage Data Sharing Commit to sharing research data as openly as possible, given privacy constraints. Streamline IRB, technology transfer, and information technology policies and procedures accordingly. Recognize data sharing contributions in hiring and promotion decisions, perhaps as a bonus to a publication's impact factor. Use concrete metrics when available. Educate trainees and current investigators on responsible data sharing and reuse practices through class work, mentorship, and professional development. Promote a framework for deciding upon appropriate data sharing mechanisms. Encourage data sharing practices as part of publication policies. Lobby for explicit and enforceable policies in journal and conference instructions, to both authors and peer reviewers. Encourage data sharing plans as part of funding policies. Lobby for appropriate data sharing requirements by funders, and recommend that they assess a proposal's data sharing plan as part of its scientific contribution. Fund the costs of data sharing, support for repositories, adoption of sharing infrastructure and metrics, and research into best practices through federal grants and AHC funds. Publish experiences in data sharing to facilitate the exchange of best practices.

Agora é polícia que mostra a máfia das ações judiciais.

Ações Judiciais para liberação de medicamentos. Quando ninguém falava, eu denunciei. Recebi de um médico, uma ação no CREMESP que foi arquivada e, outra em Conselho de Ética. Outra ação movida contra mim , na esfera do Judiciário foi retirada de início. Agora, somente cabe ler os jornais e, observar detalhes da maior drenagem de dinheiro público na área da saúde ocorrida nos últimos tempos.

Folha de S.Paulo e Datafolha restauram a geografia em São Paulo

A Folha de S.Paulo publica há cinco domingos, pesquisa do Datafolha e dados demográficos sobre as regiões da cidade de São Paulo. O destaque fica pela reintrodução da geografia em contraposição à definição ideológica de bairros com sotaque carioca. Tudo que é bom seria na zona sul, o que não fosse seria zona norte, leste, oeste etc... A própria Folha, mais Estadão, Vejinha sempre classificavam os Jardins como Zona Sul, o mesmo para o Morumbi e, até o Alto de Pinheiros! O Ipiranga que fica na zona sul era classificado como zona leste. A geografia agradece à Folha de S.Paulo, que aprendeu a não brigar com os mapas.

Agora, será a vez dos cardiologistas brasileiros aprenderem que o Brasil está no Ocidente do planeta. Quem nunca leu "com a ocidentalização dos hábitos dos brasileiros....? "(uma tradução idiota de "life style westernization" aplicada à China, Japão, India).

Ensaios Clínicos: um site de ensino

Quem acessar o site Ensaios Clínicos verá uma seleção de resumos dos mais relevantes ensaios clínicos publicados ou comentários relacionados à terapêutica. Na faixa ao lado, também é possível acessá-lo. Desde o início do ano utilizo a secção Ensaios Clínicos em Cardiologia para orientar os residentes de Clínica Médica no preparo de seminários sobre terapêutica que ocorrem todas segundas-feiras. Agora, o objetivo é incentivar os residentes a postarem comentários sobre os temas por eles desenvolvidos para permitir um debate público, incluindo obviamente a imensa comunidade extra-universitária. Depois disso, como as apresentações estão cada vez melhores, a intenção será disponibilizar os diapositivos no site para conhecimento geral.

A demografia não perdoa a falta de planejamento

Uma semana fora do ar. Não foi vírus no computador ou no blogueiro, mas o excesso de atividades em reuniões do ELSA, EMMA, relatórios, análises de projetos, preparo de aulas, revisão de manuscritos, enfim a vida acadêmica na sua intensidade máxima.

Hoje, o Estadão discute a questão da saúde em São Paulo, considerada questão eleitoral mais mais crítica. Na verdade, a saúde do paulistano, como a do brasileiro, melhora ano a ano. Todos os indicadores são positivos, mesmo aqueles relacionados a epidemias como a dengue. O que continua muito ruim é a organização do sistema e, a incapacidade do sistema de saúde (vale para todas políticas públicas, principalmente na educação) em se adaptar às mudanças demográficas e epidemiológicas da sociedade brasileira. Hoje, em São Paulo, sobram leitos de pediatria e obstetrícia, mas faltam de clínica médica e ortopedia. A culpa deve ser compartilhada tanto pelo SUS como pelas escolas médicas.

ELSA no ano 1 saúda os 60 anos do "vovô" Framingham Heart Study

Em breve, o Framingham Heart Study completará 60 anos. Esse estudo iniciado em 1948 com mais de 5 mil pessoas na cidade do mesmo nome, próxima a Boston representa um dos grandes legados da epidemiologia à ciência e saúde pública. Impossível falar em fatores de risco cardiovascular sem os resultados de Framingham.

Essa semana, os quatros primeiros participantes terminaram os exames iniciais do Estudo Longitudinal de Saúde do Adulto, na sede paulista do projeto localizado no Hospital Universitário da USP. Na foto, a coordenadora, professora Isabela Benseñor e técnica Angelita trocam a placa no primeiro dia do estudo. O ELSA examinará 15 mil pessoas em SamPa (5 mil), BH (3 mil), Salvador (2 mil), Rio (2mil), PoA (2mil) e, Vitória (1 mil). Trará informações sobre os determinates do diabetes e da doença cardiovascular em uma população brasileira. Trata-se do grande empreendimento dos epidemiologistas brasileiros que aproveitam o momento para saudar o aniversário do "vovô" Framingham.

Vacina para o HPV: custo-benefício discutível

O PharmaBlog faz um resumo abaixo muito bom do artigo sobre a custo-efetividade da vacina para o HPV. Esse é recidivante nesse blogue, basta clicar aqui para ver o debate nos Estados Unidos a conduta do nosso Ministério da Saúde.

Eu volto a repetir o post de 19/01/07: "... quem precisará da vacina, não terá acesso e, fará uso quem tem risco mínimo de câncer de colo uterino. É o fenômeno descrito na Inglaterra por Julian Tudor- Hart chamado "inverse care law". O Ministério da Saúde precisa ser rigoroso e, impedir a liberalização total de venda da vacina? Sim, porque (1) somente o Ministério poderá comprar a vacina e, quem tomar em clínica particulares irá deduzir o valor pago no imposto de renda. Ou seja, por compra direta ou por renúncia fiscal, a conta será do erário; (2) existirá em breve, alternativa da Glaxo, que poderá ser mais barata e efetiva. Por isso, se o Ministério facilitar a venda do produto da Merck estará "matando" o concorrente que poderá ser ou não a melhor opção (não há dados confiáveis) entre as duas estratégias de prevenção. No entanto, a prioridade de aplicação em termos de faixa etária, região e categoria social deveria ser do Ministério. Porque, se com certeza, a moça de 15 anos moradora em Brasília Teimosa em Recife se beneficiará mais da vacina, do que a senhora de 35 anos moradora no plano piloto de Brasília, não preciso ser advinho para saber quem terá e, quem não terá acesso à vacina, casos as "leis de mercado" prevaleçam."

Pharma Blog » 2008 » August » 21 Gardasil Isn’t Worth The Cost For Women Over 18 By Ed Silverman // August 21st, 2008 // 8:05 am That’s the conclusion of a new study that is going to make life much harder for Merck to wring needed sales out of its controversial HPV vaccine. The study, which appears in the New England Journal of Medicine, comes as the drugmaker is already struggling to convince college-age and older women to get the vaccine, which costs about $360 for a three-dose regimen. The vaccine, which is approved for girls and young women ages 9 to 26, makes economic sense for preteens because they are less likely to have the sexually transmitted virus that causes cervical cancer, according to the study. But the cost-benefit depends on how long Gardasil’s protection will last, although Merck contends the vaccine is cost effective for women through age 24. The analysis predicted that life expectancy gained by giving Gardasil to women older than 18 doesn’t outweigh the expense. “We aren’t saying older women can’t benefit. We are just saying that from a societal perspective there might be a better use of this investment in money,” Jane Kim, an author on the study and an assistant professor of health decision science at Harvard University, tells Bloomberg News. “You are getting diminishing returns.” The researchers compared the price of the vaccine and other expenses involved in getting the shot along with regular pap smears to the cost of pap smears. A pap smear, which detects abnormal cell change that could signify cervical cancer, costs about $38.68 and is recommended at least once every three years for women ages 21 through 64, according to the National Institutes of Health. To wit, Gardasil cost about $43,600 per “quality-adjusted life year” gained when administered to 12- year-old girls. This falls below the $50,000 per QALY benchmark used by many researchers as a maximum for cost-effectiveness, although other researchers cite $100,000 per QALY. It would cost $97,300 per QALY, however, to vaccinate girls and women through age 18; $120,400 per QALY for girls and women up to age 21, and $152,700 for girls and women up to age 26. However, the cost becomes more attractive when considering protection against genital warts - the cost per QALY when given to 12-year-olds falls 20 precent to $34,900, and to $133,600 for a program through age 26. Current data has only looked at Gardasil’s ability to stop HPV for up to five years. It is unknown whether Gardasil can reduce overall rates of cervical cancer and deaths, Charlotte Haug, editor-in-chief of the Journal of the Norwegian Medical Association, wrote in a separate editorial also published in the New England Journal. “There is good reason to be cautious about introducing large-scale vaccination programs,” Haug tells Bloomberg. “Instead, we should concentrate on finding more solid answers through research rather than base consequential and costly decisions on yet unproven assumptions.” It is routine for vaccines to be used after five years of efficacy data and it would be unfair to patients keep the product off the market while researchers study its long-term effects, Rick Haupt, Merck’s executive director of Gardasil clinical research, tells Bloomberg. Merck may present data this year on the effects of the vaccine over nine years. Gardasil protects against the HPV strains 16 and 18, which are responsible for 70 percent of cervical cancers, and HPV strains 6 and 11, which cause 90 percent of genital warts. While many of the sexually transmitted infections caused by HPV are resolved naturally, others develop into genital warts and cervical cancer. The CDC recommends girls be vaccinated at age 11 or 12.

Blog do Karl corrige os dois posts anteriores

O JAMA deu antes. 16 de Abril 2008. Ver http://jama.ama-assn.org/cgi/content/full/299/15/1813.