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Archive for August, 2011

Wednesday, August 31st 2011

Too Much Care

Trying to define what is appropriate care and what is appropriate cost effective care is the long sought goal. Even the government has gotten into the business. The online Medicare Hospital Compare Quality of Care shows reported ‘quality’ metrics as reported by hospitals that participate in Medicare. One of the new statistics they’ve made available is the number of lumbar MRI scans health systems perform for back pain before conservative therapies are attempted for the back pain. Here is the write up on the NPR Shots Blog,

Back surgery is one of the best documented examples of expensive medical treatments that drive up health care costs while not always helping patients, and sometimes even hurting them.

And the latest Medicare data show that doctors frequently order MRI back scans for patients who haven’t tried recommended treatments such as physical therapy. An MRI often prompts surgery.

In 2009, 32 percent of Medicare patients with lower back pain who received a spine MRI at a hospital outpatient imaging center hadn’t tried a more conservative — and cheaper — treatment than surgery, according to data published on Medicare’s Hospital Compare website this month.

The point made at NPR is a little misplaced. I’m not sure we should blame MRIs for creating unnecessary surgeries. And that’s conceding much of spine surgery is unnecessary. If we want to reduce the use of ineffective spine surgery the idea isn’t to reduce the number of MRIs, its to educate and disincentivize ineffective spine surgery.

That aside it remains that I agree that lumbar MRI is an overused test. Since the vast majority of axial back pain does not respond to surgical or procedural intervention there is probably very little gained from most lumbar MRIs in terms of directing therapy. A course of conservative therapies for back pain is probably in order prior to any MRI. IF that fails, if radicular symptoms develop or if symptoms worsen then a lumbar MRI may be considered.

Despite saying that I contribute to the problem of MRI overuse.

Data From HHS At One of The Teaching Hospitals I’m At

At some of the teaching facilities I’m at I review a number of outpatient consult requests for back pain. I routinely refuse consults until MRI scans are available. This is because I’m looking for surgically amenable disease which is really the only issue, as the spine surgeon consultant, I can comment on. But I personally know the vast majority of the lumbar MRIs I review will not have surgically amenable disease. What I should really probably be saying on consults that come to me without MR imaging is that conservative therapy is in order prior to a reconsult with an MRI.

Monday, August 29th 2011

Sutureless Vascular Anastamosis

During my intern year I did a non-clinical rotation focused on microsurgical skills in the lab. Much like the video above using the endoscopic tools trying to put together a “vascular” anastamosis.

It is a tough skill. And a tedious one. Imagine an external carotid to internal carotid bypass without the sewing; that might cut the operating time in half. A group at Stanford think they have proof of concept for a very neat non-suturing technique for putting blood vessels of all sizes together.

It isn’t what they use to put the vessels together. Apparently in the animal model they’re simply using Dermabond, used everyday as the final step in closing the skin by myself and thousands upon thousands of other surgeons. It’s essentially a surgical glue.

However keeping the vessel lumens patent and holding them together temporarily while you apply the Dermabond appeared to have been the challenge. The team at Stanford has a new use for a previous polymer which they place inside the vessels to hold them together, and then when heated breaks up harmlessly and reestablishes the lumen between the two vessels.

I’ll be honest, this is pitched as novel, I’m not sure if other research along the lines of this preceded this announcement by the scientists at Stanford, but if something simpler than the current suture techniques comes into clinical practice by the time I’m done with residency…well, that will be exciting for me.

Friday, August 26th 2011

Nocioception In The Back

As recently as 2008 back pain was the number one reason patients visited emergency rooms in the United States. That is incredible to consider.

Chronic lumbar back pain is an incredibly difficult condition to treat often. In some because identifying pain generators in the back is difficult.

I had an interesting discussion and lecture today on the innervation of the lumbar vertebral column.

In very basic terms the anterior portion of the vertebral column and the posterior part of the intervertebral disc are innervated by the sinuvertebral nerves which are recurrent coming off the ventral rami at each level. These nerves form extensive anastamoses with the sympathetic trunk.

The posterior aspect of the vertebral column, including the facet joints, is innervated by lateral, inermediate and medial brances of the dorsal rami. These branches as well enjoy connections with the sympathetic trunk.

Lots more details exist obviously. The most interesting detail however may be that, at least in some animal studies, for all the sinuvertebral and lateral, intermediate and medial branches at all the levels they all eventually “return” through the L1 and L2 dorsal ventral rami.

That means that nocioceptors through a broad area are all returning the same. Is this signal coming from L4 or L1? It may help explain the visceral nature of much back pain and the difficulty in localizing the pain generator at times.

Or maybe I just don’t stand the implications of such. That’s always a possibility as well.

Wednesday, August 24th 2011

Urinary Incontinence With Back Pain

In my twenty six months in residency I’ve been called perhaps a couple dozen times by staff in the emergency room for suspected cauda equina. The usual cabal of symptoms are:

  • Back pain
  • Possible bilateral lower extremity radiating pain
  • Possible subjective weakness
  • Bowel and/or bladder incontinence

It is the last one that usually gets those physicians and physician extenders who are triaging the patients in the emergency astiring.

The cauda equina are the nerves that continue, after the end of the spinal cord, down to the legs and the sacrum. They provide for movement of the legs, urination, defecation, feeling to the legs and the perineal and “saddle” regions. Compression of these nerves, the majority of the time by a centrally herniated disc, is a neurosurgical emergency and known as cauda equina syndrome. Symptoms of cauda equina syndrome include: numbness or tingling to the inner thighs and perineum thought of as the “saddle” region, weakness especially a foot drop, inability to urinate or deficate, the opposite to include bowel or bladder incontinence, back pain.

Now, I’m sure I don’t get consulted with the vast majority of individuals who come into the emergency room with back pain. Even those individuals who have pain radiating from their back into their legs. But as soon as someone complains that they’re involuntarily urinating that seems to almost guarantee me a call.

Often times it seems that those triaging these patients seem to believe that involuntary urination or defecation has some high sensitivity for identifying patients suffering from cauda equina syndrome when combined with other symptoms as described above.

It turns out however that very few of these individuals have true neurogenic bowel or bladders.

In the perhaps two dozen of these patients I’ve seen I think two or three of them have had true cuada equina.

The question is then, if there is not something organic making these individuals urinate or defecate involuntarily then what is going on with the majority of patients I see who complain of such?

As one paper describes it, I truly believe there is an association between low back pain and urinary incontinence,

A rare association between severe low back pain and urgency incontinence of urine, not explained on the basis of any conventional neurologic or genito-urinary pathology, should be recognized.

For an unexplained reason there is a described association between pain and involuntary urination and defecation. And indeed, in my limited experience the vast majority of patients with both back pain and either bowel or bladder incontinence do not have neurogenic bowels or bladders or cauda equina syndrome.

Indeed, amongst these cabal of symptoms, urinary retention is likely much more sensitive a symptom for cauda equina pathology. With all the back pain that must be seen i the emergency room it’s probably an important point for staff to realize.

Tuesday, August 23rd 2011

Litigation And Complaints And Malfunctioning Hips

A New York Times article looks at rising complaints concerning metal on metal hip implants.

Now excuse my ignorance on the subject but it appears the major offenders in this piece had experiences that pre-dated their availability in the United States without incidence. What I mean is that it appears the high rate of complications and failures is limited to the United States as compared to, say, Europe. That may reflect some clinical difference such as surgeon training or patient selection or something along those lines.

But I wonder how much the litigious culture of the United States works to either:

One, bring these issues truly to light so that perhaps the complications with these hips happen just as frequently elsewhere but it goes under reported without the culture of broad civil court


Two, how much these problems are made hyperbolic by the same culture.

There are literally dozens of these videos on YouTube. Is there something comparable in say, Germany?

Monday, August 22nd 2011

On The RVS Update Committee

Brian Klepper and David Bibbe have an interesting piece on The Health Care Blog about a legal challenge to the American Medical Association’s RVS Update Committee.

I’ve commented on criticism of the RUC before.

As a brief refresher however the RUC is a committee made up largely of representatives from the members of the American Board of Medical Specialties. The RUC makes recommendations on how much Medicare’s fee schedule, known as the Relative Value Resource Based System, should pay for any given physician service. To be a little clearer, it spells out how much each physician activity should be worth as compared to other physician activities. For instance, how much should a doctor get paid for a craniotomy as compared to a primary care office visit.

In theory this isn’t new money; the RUC doesn’t recommend that the RVRBS pay a certain amount to physicians for certain activities but merely just recommend comparatively how much each physician activity should be worth.

“You should pay physicians ten times as much for a lithotripsy as for a pap smear.” I just made that up right now, but you get the idea hopefully. They’re just recommending how to divide up the Medicare pie.

The RVRBS was created by Medicare and came into play in 1991. Part of the reasons behind it being to close the income gap between primary care physicians and specialists. However, in the past two decades that gap has actually grown. This has become the source of chagrin from many sides, as demonstrated by Drs. Klepper and Bibbe’s piece.

The role of the RUC in failing to close the primary care – specialist income gap is a constant criticism of it. Major criticisms include the fact the majority of its members represent specialists, the secrecy under which it works and the fact that it’s recommendations are by and large accepted and implemented by CMS.

These criticisms are fair enough and I won’t go into a full fledged defense of the RUC. However I do have two concerns with attacks on the RUC:

First, it appears that the compensation between all procedures and E/M services such as office visits has actually narrowed per unit since the deployment of the RVRBS. See former RUC chairman Dr. William Rich’s letter in the Annals and pre-RVRBS commentary data on physician reimbursement here and here and elsewhere.

Second, this seems to imply and, at least cursory there appears evidence, that the growth in the primary care – specialist gap is largely based on volume and not the RVUs themselves.

If true that seems to excuse, not in full, but certainly in part the RUC. To be sure it appears fair to criticize that the RUC has not fully accounted for the time involved in each RVU for which they make recommendations. The RVUs are obviously supposed to account for the fact a colonscopy can be done in 20 minutes while a level 4 office visit takes substantially more time. However, there appears to be a much larger issue in physician reimbursement, well beyond the scope of the RUC. Perhaps attention is better focused on broader reform than RUC criticism.

Anyway go read the article at The Health Care Blog. It is thought provoking, as always when Dr. Klepper and others discuss the RUC.

Monday, August 22nd 2011

Does Limiting Physician Hours Help Patients?

New physicians, known as interns, entering residency, which is the training physicians go through after medical school, can no longer take overnight call in the hospital without supervision from a more advanced resident or from a faculty physician. In addition they cannot work more than 16 hours straight. This as of July 1st.

For me this means a situation in which I’m taking essentially the same amount of overnight call as I did last year but, if the interns were part of the overnight call pool I’d be taking substantially less. Let this stand as my disclosure for this post.

The rules for interns are part of new regulations on resident physician work hours from the Accreditation Council for Graduate Medical Education.

For the past decade, the move to limit resident working hours has been a constant debate and struggle. I’ve written about it in the past here and here. Part of the situation is that it has become accepted that longer duty hours, less sleep for resident physicians, who are intimately involved with patient care at teaching facilities, leads to iatrogenic harm and worse patient care.

In moves to improve patient care and, in no small measure, to stem any public outcry and to make sure that resident duty hour regulation remains part of medicine’s self govern mandate the rules on resident work hours have become subsequently more restrictive through three iterations.

The problem is however that no matter how intuitive it may seem that limiting the amount of time resident physicians can work should mean they’re more rested should mean fewer mistakes when treating patients, it turns out that the evidence for such was highly circumstantial when resident work hours were first implemented and has not been borne out since the implementation.

It’s true that there are witnessed attentional mistakes in medicine that lead to patient harm. And it’s true that there is evidence from studies outside of medicine, and our own everyday anecdotal experience, that fatigue worsens attentional mistakes.

A very small 2004 study in the New England Journal of Medicine, 24 interns partook, randomized but did not blind the schedules of these physicians-in-training to a traditional schedule with 30 hour call shifts, where the residents routinely but not always worked over 80 hours a week, and to a float system where the residents worked 16 hour shifts and did not work over 80 hours a week. The interns working more and working longer shifts, made more errors.

But since implementation of resident physician work hour restrictions almost no change in patient’s harmed by errors or in patient outcomes has been seen. This from multiple large retrospective studies looking at data from millions of patient visits to teaching hospitals.

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