2011 Potpourri XXIV

An article in the International Journal of Medical Informatics describes an observational study of EHR use for consults in the VA system.  The study found persistent use of paper instead of the electronic capability, workarounds, communication breakdowns and redundancies.  The staff were often frustrated by the system and had a large volume of requests for “enhancements” to fix the functionality.  Must be saving them a lot of money, being able to have everything all electronic like that!   (EHR Article)

Health care reform that expands coverage supposedly has as one of its benefits a reduction in utilization of expensive emergency room resources as a substitute for primary care.  While this theory always was dubious, research in Massachusetts indicates that ER usage has not declined at all several years after enactment of that state’s reforms.  Published in the Annals of Emergency Medicine, the study found that overall ER visits had increased.  Low-severity visits, those which presumably could have been treated elsewhere, declined very slightly and declined slightly more for the formerly uninsured and low-income patients compared to previously insured patients.  Just another indicator that insured status has little to do with ER use and perhaps laziness or ignorance is more of a factor.   (ER Study)

The American Society of Clinical Oncologists’ Annual Meeting has presentations of a vast body of cancer-related research.  This year a number of presentations focused on compliance with guidelines.  For many cancers, guideline adherence is 70% or less.  Some papers explored reasons for non-adherence and some looked at the outcome consequences of compliant versus non-compliant treatment.  These are the two important areas to explore in health care overall in regard to the expanding use of guideline-driven health care.  Given that cancer drugs are currently the second largest category in terms of pharmaceutical spending and likely will grow faster than other areas, development of good guidelines and compliance with them is particularly important.   (ASCO Abstracts)

A study on Canada’s population finds that there is a gap in the health related quality of life between higher and lower socioeconomic groups, but that the rate of decline in that quality of life is roughly equal across all groups.  The difference is health appears to be set early in life, according to the person’s income and education and to persist throughout time.  The rate of decline for men is not related to wealth or education but for high-income and upper middle-income women, the rate of decline is actually sharper than for poorer women.  No explanation is given for the initial gap in health quality of life–is it poorer access (unlikely with Canada’s universal coverage), poorer child-rearing practices or some other factor?   (Canada Study)

A meta-review of studies regarding the emotional effect of making health care decisions for others was published in the Annals of Internal Medicine.  This surrogate decision-making was typically in regard to end-of-life care.   The studies summarized found that at least one-third of decision-makers suffered emotional distress, often for months.  The negative emotional effects included stress, guilt and doubt about whether the right decisions were made.  Some decision-makers had a positive experience, usually because they felt they had supported the patient.  People were less likely to have a negative emotional experience if they knew and felt they acted in accordance with the patient’s preferences.  Health care providers should be aware of the possible emotional consequences to surrogate decision-makers and it seems they could lessen the burden by ensuring that the patient has articulated their care desires and that the surrogate is aware of those.  (Annals Study)

Research published in the Journal of the American Medical Association looked at whether ongoing ovarian cancer screening had an impact on mortality.  A usual care group was compared with one that had annual biomarker and transvaginal ultrasound screening.  Mortality was not reduced by the screening intervention, probably because screening did not detect cancers at an earlier stage.  More importantly, the screening produced a number of false positives, and those led to surgical interventions which resulted in some cases in serious complications.  Just another example of how “preventive” care sometimes leads to higher costs and no better quality.   (JAMA Article)