July 2nd, 2012

Selections from Richard Lehman’s Literature Review: July 2nd

CardioExchange is pleased to reprint selections from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.

JAMA  27 June 2012  Vol 307

Pay for Performance (pg. 2595): Of all the things that made me glad to retire from general practice two years ago, pay for performance must top the list. Here’s a Viewpoint piece from the USA which explains why: “Focusing on specific outcomes does not reward skills or result in managing complexity, solving problems, or creativity. Indeed, Pink suggests such reward systems will undermine these desirable attributes.” Good old Pink: I like the cut of his jib. “Translating the ideas of Trisolini and Pink into a clinical medicine context leads to several recommendations: pay physicians a rewarding yet reasonable salary rather than piecework rewards, provide a direct ability to influence patient outcomes, and offer a continual sense of accomplishment and recognition. These would represent a more effective approach to motivating performance than specifically paying for production functions.” Good old Trisolini, too: nice jib. And here is the last paragraph of this excellent piece by Christine Cassell and Sachin Jain: “Efforts to assess physician performance are here to stay. The current system of care has invested a great deal in these measures, both financially and intellectually, and the goals they seek to achieve are critical to a high-functioning health care system. To reach sustainable quality goals, however, close attention must be given to whether and how these initiatives motivate physicians and not turn physicians into pawns working only toward specific measurable outcomes, losing the complex problem-solving and diagnostic capabilities essential to their role in quality of patient care, and diminish their sense of professional responsibility by making it a market commodity. Rewards should reinforce, not undermine, intrinsic motivation to pursue needed improvement in health system quality.” Amen.

Berwick’s Commencement Address (pg. 2597): And now from the man who has worked harder than anybody to improve health service quality – Donald Berwick’s address to Harvard medical graduates as they set out: “You will soon learn a lovely lesson about doctoring; I guarantee it. You will learn that in a professional life that will fly by fast and hard, a hectic life in which thousands of people will honor you by bringing to you their pain and confusion, a few of them will stand out.” The one who stands out for him is called Isaiah. He was a black child, addicted to cannabis at 5, crack at 14, by which time he had already done his first armed robbery. Berwick saved him from acute lymphoblastic leukaemia. He was found dead in the street 18 years later. “Society gives you rights and license it gives to no one else, in return for which you promise to put the interests of those for whom you care ahead of your own. That promise and that obligation give you voice in public discourse simply because of the oath you have sworn. Use that voice. If you do not speak, who will?”

tPA for Ischaemic Stroke in Warfarin-Treated Patients (pg. 2600): And now back to the kind of medicine that gets published in journals. A lot of people who get ischaemic stroke are taking warfarin, usually for atrial fibrillation. Is it safe to give these people intravenous tissue plasminogen activator (tPA) if they get an ischaemic stroke? The bottom line seems to be yes: “Conclusion: Among patients with ischemic stroke, the use of intravenous tPA among warfarin-treated patients (INR ≤1.7) was not associated with increased symptomatic intracranial haemorrhage risk compared with non–warfarin-treated patients.” But read that again. These patients were not being meaningfully anticoagulated with warfarin: their INRs were all 1.7 or less. Had their warfarin been properly monitored, they would probably never have had their stroke in the first place.

NEJM  28 June 2012  Vol 366

Surgery for Infective Endocarditis (pg. 2466): Infective endocarditis is a pleasing diagnosis to make, but not a good one to receive. Ever since I first read it at the age of 18, I’ve been haunted by this scene from the memoirs of Alma Mahler: “Chantemesse, who was a celebrated bacteriologist, now made a culture from Mahler’s blood and after a few days he came to us in great delight with a microscope in his hand. I thought a miracle had happened. He placed the microscope on the table. ‘Now, Madame Mahler, come and look. Even I – myself – have never seen streptococci in such a marvellous state of development.’… But I could not listen. Dumb with horror, I turned and left him.” In the trial reported here, patients with left-sided infective endocarditis, severe valve disease, and large vegetations were randomly assigned to early surgery (37 patients) or conventional treatment (39). The primary end point was a composite of in-hospital death and embolic events that occurred within 6 weeks after randomization. It was a small trial, but an easy win for surgery done within 48 hours.

Lancet  30 June 2012  Vol 379

The American Healthcare System (pg. 2412): Appalled by the prospect of the Supreme Court declaring Obama’s health act unconstitutional, Richard Horton is moved to fill the whole of Offline this week with an eloquent, coherent, historically informed view of America’s strange relationship with its health providers, and how this distorts the whole of global health provision. I never thought to write such praise of Offline; but I still prefer Victor Montori on Twitter: “Health care is a human right. Societies must protect and promote it. Debate how, not whether.”

BMJ  30 June 2012  Vol 344

Record Number of RECORD Studies: Those of us who are interested in the full disclosure of all data from clinical trials are not all paranoid geeks by nature. It has taken me the best part of fifteen years to realize how biased and incomplete the evidence base for common interventions can be, despite the efforts of the regulatory agencies. A classic case was rosiglitazone (Avandia) where cardiovascular harms were suspected from the start but were supposedly laid to rest in the open-label RECORD trial, sponsored by the manufacturers; in fact there is clear evidence of biased adjudication in this study, presented to the FDA two years ago and never explained since. I was therefore stunned to see the RECORD study appear in this meta-analysis of new oral anticoagulants following hip and knee replacement, again in the context of a seemingly biased adjudication. To quote in full: “However, major bleeding rates reported in the four pivotal RECORD (Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycaemia in Diabetes) studies with rivaroxaban were 7-8 times lower than those in the enoxaparin groups of the remaining studies, which was attributed to the exclusion of most wound bleedings from the definition of major bleeding, as previously reported. This issue prevented the pooling of data on major bleeding reported in the publications of the RECORD studies. However, the major bleeding rates in the RECORD studies without excluding major wound bleedings were reported in an FDA review, and were similar to the major bleeding rates of the remaining studies.” Hmm. I thought there was only one RECORD study, which was nothing to do with rivaroxaban. In fact there are four others, sponsored by Bayer and Johnson and Johnson, in which the acronym stands for Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Venous Thrombosis and Pulmonary Embolism. It is time for the BMJ to set the RECORD straight. As for the meta-analysis, it proves that it’s swings and roundabouts with dabigatran, rivaroxaban and apixaban for preventing VTE: the new oral agents may be slightly more protective than enoxaparin, but at the cost of slightly more bleeds.

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