2010 Potpourri XXX

The Cochrane Collaboration puts out excellent evidence reviews on various health care treatments.  They recently released one on the use of structured telephone support and/or telemonitoring for heart failure patients.  They reviewed only very high-quality research, a total of 25 randomized clinical trials.  The review concluded that either intervention reduced all-cause mortality compared to usual care and reduced CHF hospitalizations.  Quality of life was improved and patients accepted the intervention well.  Overall costs were likely reduced.   (Cochrane Review)

A physician writes a perspective on the impact of quality of care reporting on the individual doctor in the New England Journal of Medicine.   (NEJM Perspective) The physician undoubtedly voices the frustration that many doctors feel when they receive reports regarding either processes of care or health status for their patients.  There are some natural feelings of inadequacy but also a sense of helplessness because there is only so much a physician can do to get patients to take care of themselves.  The author also appropriately points out that many of these measures take a condition in isolation, when real life patients tend to have multiple problems which must be treated as a whole.

In the same issue, the NEJM has an article praising the positive effects of quality measurement programs on quality of care, especially hospital care.  (NEJM Article) The authors, while in essence boasting of an achievement they had a role in, acknowledge that measuring and “improving” care processes is not the same as measuring and improving patients’ health or health outcomes.  They advocate moving more in the latter direction and ensuring that unintended consequences don’t occur.  An obvious example which they don’t mention is having almost every patient who leaves the hospital after a heart attack get a beta blocker.  Anyone who has been on a beta blocker can attest to the lower quality of life they cause and there is accumulating evidence that they have adverse effects.  Looking only at some process of care likely means that other processes and the overall goal of improving patients’ health get slighted.  This relentless focus on aggregate performance also means that individualization of patient care is being ignored.

The Journal of Telemedicine and Telecare carries a study examining the use of intercontinental hearing assessment.  This study showed that teleaudiology provided as good an assessment and diagnosis as in person audiology.  Since much of the world’s population lives in areas with few medical specialists, this capability greatly enhances access and appears to offer equivalent quality.   (JTT Abstract)

End-of-life care deserves substantial attention because it devours a very large proportion of our health resources and spending.  300,000 Americans a year are on prolonged mechanical ventilation, i.e. life support, and that number may double in a decade.  The prognosis is extremely poor for these patients, as documented in new research published in the Annals of Internal Medicine.   Almost half die in a year, and most die in the hospital.  Less than 20% had improved health outcomes over the course of the study and most of those were younger trauma victims.  These patients incurred an average of over $300,000 a year in costs.   That is $90 billion a year in total.  What is most disturbing is that coupling these results with most patients’ desire not to end up like this means that with proper advance directives much of this cost could be avoided, as could the distress to the patient.   (Annals Study)

While most telemedicine studies have positive results, that is not always the case.  Another Journal of Telemedicine article describes research on whether home telemonitoring for patients with chronic obstructive pulmonary disease could improve outcomes.  While telemonitoring was safe and accepted by patients, it did not appear to improve quality of life scores for the intervention group.  (JTT Abstract)