Published in the April 2008 issue of Today’s Hospitalist
Federal go-ahead for ICU quality initiative
A FEDERAL AGENCY has reversed a ban that was holding up a quality improvement study that is of interest to hospitalists.
The Office of Human Research Protections (OHRP) had frozen a study examining how checklists could reduce catheter-related infections in ICU patients at 100 Michigan hospitals. While the study has been shown to successfully reduce infection rates in the ICU, the agency last fall ordered researchers to stop gathering data.
The problem was that the research team from Johns Hopkins, which organized the study, never submitted the protocols they were using to the review boards of the hospitals participating in the study. While that kind of review is a standard part of clinical research, quality improvement studies don’t always follow the same guidelines.
Critics of the agency’s decision predicted that the ban would have a chilling effect on all types of quality improvement studies. They complained that because the researchers were not examining experimental treatments, those guidelines didn’t apply to the study.
In a statement explaining their decision to reverse course, agency officials said that they don’t want to stand in the way of quality improvement activities that pose minimal risk to patients. The agency is reportedly examining rules that govern studies involving human subjects.
Since 2003, the Hopkins team, led by Peter Pronovost, MD, has studied the use of checklists in the Michigan hospitals. The checklists have been so successful that they have become entrenched in the hospitals’ ICUs.
According to research published in the Dec. 28, 2006, New England Journal of Medicine, the initiative reduced catheter-related infections by two-thirds within 18 months.
New scorecard on PQRI’s first year
THE RESULTS FOR MEDICARE’S first public reporting initiative targeting physicians show that the program was embraced by a relatively small number of clinicians.
About 99,000 clinicians participated in the 2007 Physician Quality Reporting Initiative, better known as PQRI, between July and November 2007. That’s about 16% of the clinicians who were eligible, a group that includes physicians, PAs, physical therapists and NPs.
The Centers for Medicare & Medicaid Service (CMS), which administers the program, estimated that about half of those clinicians will receive a bonus of 1.5% this spring. The agency also said that because 2007 reports were being accepted through Feb. 29 of this year, the participation rate is expected to climb.
To participate in the PQRI program, physicians must report data on at least three measures that pertain to them, and they must report data on at least 80% of the patients to whom those measures apply. Among the 2007 program’s 74 measures, 11 have reporting specifications that apply to hospitalists.
While the CMS declined to identify participation in the program by specialty, it did note that three specialties “anesthesiology, emergency medicine and ophthalmology “had above average participation rates.
In 2008, the PQRI program has been expanded to track 119 measures, which supporters hope will encourage greater participation. Skeptics, however, question whether a bonus payment of 1.5% is enough to get physicians’ attention.
ISMP highlights issues with methadone
AFTER RECEIVING numerous reports that patients being treated with methadone have suffered serious harm, including death, the Institute for Safe Medication Practices (ISMP) has released a warning about the complexities of using the drug.
In its Feb. 14 Medication Safety Alert, the ISMP noted that problems have been reported in both patients who have been switched to methadone after being treated for pain with other opioids, and in patients just starting to use methadone for pain control.
Because there is so much variability in the drug’s absorption, metabolism and potency as an analgesic, methadone requires a very personalized approach. Particular vigilance is needed during the initiation of treatment and titration.
The ISMP identified the following problems that physicians need to consider when prescribing methadone:
- Opioid conversions. Because there is incomplete cross tolerance between methadone and other opioids, dosing during opioid conversion can be complex. Patients who have a high degree of tolerance to opioids are not immune to an overdose of methadone.
- Half life. While methadone is effective as an analgesic for four to eight hours, about the same as morphine, its half life is eight to 59 hours, significantly longer than morphine, which has a half life of one to five hours. In opioid-tolerant patients, methadone’s half life is about 24 hours. In opioid-naÃ¯ve patients, however, methadone’s half life is about 55 hours.
Due to methadone’s long half life, patients may not feel its full analgesic effects until three to five days after they’ve started using the drug. As a result, physicians must titrate methadone more slowly than other opioids.
- Side effects. Methadone’s respiratory depressant typically peaks later and lasts longer than its analgesic effects.
No link found between resident burnout and error rates
WHILE DEPRESSION APPEARS to lead to more errors among pediatric residents, there doesn’t appear to be a similar relationship with burnout.
A study in the March 1 British Medical Journal found that pediatric residents who were depressed made 6.2 times as many medication errors per month as residents who weren’t depressed. Depressed residents made 1.55 medication errors per month, compared to 0.25 for non-depressed residents.
When researchers looked at residents suffering from burnout, however, they found no statistically significant difference in error rates. Burnt out residents made 0.45 errors per month, compared to 0.53 for residents who weren’t burnt out.
Researchers found it interesting that burnout didn’t seem to affect the residents’ error rate. In previous studies, burnt out physicians have said that they make significantly more errors than their counterparts who do not feel burnt out.
Researchers found that of the 123 residents they studied in three pediatric residency programs, 20% met criteria for depression and 74% met criteria for burnout. The study notes that the rate of depression in the residents studied is roughly twice what they would expect to find in the general population.
Researchers also found that half of residents were unaware that they were depressed, and that only a small number were receiving treatment.