Fall 2011 - Volume 15 Number 4

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupOriginal Research and Contributions

Predicting Poor Outcomes in Heart Failure
David H Smith, RPh, PhD; Eric S Johnson, PhD; Micah L Thorp, DO, MPH; Xiuhai Yang, MS; Amanda Petrik, MS; Robert W Platt, PhD; Kathy Crispell, MD

Using data from electronic health records from a large health maintenance organization, the authors developed a model to predict the 5-year mortality or hospitalization risk for heart failure among 4696 patients who had an echocardiogram and a heart failure diagnosis from 1999 to 2004. They observed a 56% five-year risk of death or hospitalization for heart failure. The simple model includes demographic characteristics, blood pressure, renal function, and anemia status. The observed risk was three times higher in the highest-risk quintile than in the lowest-risk quintile.

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupNapa Immunization Study: Immunization Rates for Children with Publicly Funded Insurance Compared with Those with Private Health Insurance in a Suburban Medical Office
James C Cotter, MD, MPH

The immunization rates and health-access measures of 109 children ages 24 to 48 months, who had publicly funded health insurance (PFI) were compared with 300 children of the same age with private health insurance in the same medical practice. Children with PFI had lower rates of immunization and fluoride prescriptions; however the differences were only significant in the cohort of children age 2 years, and became similar by age 3 years.

A Single-Blinded, Direct Observational Study of PGY-1 Interns and PGY-2 Residents in Evaluating their History-Taking and Physical-Examination Skills
Sandeep Sharma MD, DrPH(c)

An independent medical observer used a yes/no checklist with 60 variables in a single-blinded observational study. Frequency tables were generated and results were based on descriptive statistics. In 7 categories aimed at chart review for accuracy, discrepancies were found between what medical interns and residents recorded in the patient's chart and the observed actions during the patient encounter. In 64%, the time spent on history taking was <7 minutes. In 72%, patients were not asked about family medical history.

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupEarly Detection of Colon Cancer—The Kaiser Permanente Northwest 30-Year History: How Do We Measure Success? Is It the Test, the Number of Tests, the Stage, or the Percentage of Screen-Detected Patients
David Moiel, MD; John Thompson, MD

This historical review of 5458 patients summarizes colorectal cancer screening strategies for 3 decades. The number of exams and disease-stage does not accurately reflect the effectiveness of screening efforts. A better measure is the percentage of screen-detected cases. Using a good test able to reach more people rather than the "perfect test" that reaches fewer transforms an ineffective program to a successful one when the strategy moves from testing to screening.

Centering Parenting: Pilot Implementation of a Group Model for Teaching Family Medicine Residents Well-Child Care
Pooja Mittal, DO

Leaders in child health care recommend primary care physicians use a parent-centered approach, with a focus on the parent–child relationship in the context of family, culture, and community. The family medicine residency program at the University of California, San Francisco is testing a parent-centered group-care model that over a year allows residents to experience comparative development as well as interactions among a group of parents and children, and forges a stronger bond between physician and parent.

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupRegional Expansion of Minimally Invasive Surgery for Hysterectomy: Implementation and Methodology in a Large Multispecialty Group
Esteban Andryjowicz, MD; Teresa Wray, MD

In the US each year, hysterectomy is the second most common major operation performed in women (600,000). This article reviews the steps that a large multispecialty group used to teach non-open hysterectomy methods to improve the quality of care and decrease inpatient procedures, and therefore costs. A structured educational intervention was delivered to 350 obsterician/gynelcologists at 12 medical centers, and their 26,055 hysterectomies (2005-2010) were studied. The rate of non-open hysterectomies increased 120% (from 38% to 78%) and the average length of stay decreased 31%. 

Review Articles

Quality Measurement and Improvement in General Surgery
Marisa Cevasco, MD, MPH; Stanley W Ashley, MD

Increasing emphasis is being placed on health care quality measurement and improvement in the US. Within general surgery, several sophisticated quality-measurement and outcomes systems have been developed. These include the National Surgical Quality Improvement Program, the use of selective referral and centers of excellence, the Surgical Care Improvement Project, and the World Health Organization Surgical Safety Checklist. This article reviews each of these quality-improvement initiatives, highlights their relative contributions, and discusses future directions of quality improvement within general surgery.

New Technology Review Process: The Laparoscopic Adjustable Gastric Band
Sandra Arthurs, MS, BME; Yerado Abrahamian, MHS; Elizabeth L Loughren, MPH; Jo Carol Hiatt, MD; Robin Cisneros; Jed Weissberg, MD

The Interregional New Technologies Committee (INTC) considers all available published evidence on a particular technology, surgical technique, or implantable device for a specific clinical indication and provides a recommendation on the sufficiency of the evidence for determining net medical benefit. This overview illustrates the INTC process and how it supports clinical decision making using implantation of laparoscopic adjustable gastric bands as an example.

Case Studies

A Case of an Abdominal Mass: Follicular Lymphoma
Tina L Walker, MD; Gabriel E Lopez, MD

Follicular lymphoma (FL) is the second most common subtype of non-Hodgkin lymphoma usually affecting older individuals (average 63.5 years). This report describes FL in a 38-year-old woman. Tumor grading, disease staging, and the Follicular Lymphoma International Prognostic Index score can be valuable aids in prognosis. These patients will likely first present to their primary care physicians.

Does My Patient Have Asthma?
Eric Macy, MD, MS

A 57-year-old woman, initially seen in primary care, had diagnoses of steroid-dependent "asthma," obesity, depression, reflux, sleep apnea, pollen allergy, hypertension, hyperlipidemia, and prediabetes. The diagnosis of asthma should be confirmed by pulmonary function tests before and after bronchodilator use to document reversible airflow obstruction or should undergo a methacholine or mannitol challenge.

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupSuppressed Wound Healing In a Patient with Rheumatoid Arthritis Taking Leflunomide (Arava)
D Miller Wise, MD

Although patients with rheumatoid arthritis taking disease-modifying antirheumatic drugs (DMARDs) are monitored for various medication adverse events, DMARDs, and leflunomide in particular, have effects that are not observed clinically, specifically adverse effects on wound healing.

Clinical Medicine

ECG Diagnosis: Pulmonary Embolism
Joel T Levis, MD, PhD, FACEP, FAAEM

The S1Q3T3 sign (prominent S wave in lead I, Q wave and inverted T wave in lead III) is a sign of acute corpulmonale (acute pressure and volume overload of the right ventricle because of pulmonary hypertension) and reflects right ventricular strain. This electrocardiogram finding is present in 15% to 25% of patients ultimately diagnosed with pulmonary emboli.

Image Diagnosis: Ultrasound in Right Lower Quadrant Pain
L Paige Sokolsky, MD; Gus M Garmel, MD, FACEP, FAAEM

Ovarian torsion is classically described as an acute onset of severe lower quadrant abdominal pain, typically unilateral. Doppler ultrasound is the imaging modality of choice as an enlarged, torsed ovary with peripherally displaced follicles because of vascular congestion. Because the ovary is supplied by both the ovarian and uterine arteries, a torsed ovary may have arterial flow, and medial displacement of the ovary compresses the uterus and bladder.

Dermatology Image: Erythema Multiforme
Joel T Levis, MD, PhD, FACEP, FAAEM

Erythema multiforme is a type of delayed hypersensitivity skin reaction triggered by infection or by certain drugs. It consists of a polymorphous eruption of macules, papules, and characteristics target lesions (central bullae or vesicle with surrounding concentric rash) distributed with a propensity for the distal extremities, and minimal mucous membrane involvement with less than 10% epidermal detachment.

Commentary

Physician-Assisted Suicide and Euthanasia: Can You Even Imagine Teaching Medical Students How to End Their Patients' Lives?
J Donald Boudreau, MD

In the peer-reviewed literature there is a paucity of commentary on the interface of euthanasia and physician-assisted suicide with medical education. Medical students and residents would inevitably and necessarily be implicated. This paper explores potential implications for medical education of a widespread sanctioning of physician-inflicted and physician-assisted death. Through a consequential-basis analysis, the author concludes that euthanasia, when understood to include physician aid in hastening death, is incommensurate with humanism and the practice of medicine that considers healing as its overriding mandate.

Bridging Physician-Patient Perspectives Following an Adverse Medical Outcome
Mark Montijo, PhD; Kathleen Nelson, RN, MPA; Mark Scafidi, JD; Dave St Pierre, MHROD; Dorothy Tarrant, LCSW, MPA; Jocelyne Vistan, MA; Maureen Whitmore, MA

During the course of physician-patient interactions in today's increasingly complex health care environment, conflict inevitably arises. Physicians are held to very high standards, sometimes leaving them and their patients ill-equipped to cope with medical complications and unexpected outcomes. In the aftermath of an unanticipated adverse outcome, how health care professionals deal with errors has gained greater importance and attention.

Editorial

Patient-Centered Research from Electronic Medical Records
Mikel Aickin, PhD

Many important scientific discoveries were made not by minor modifications of previous research, but by rethinking fundamentals. Currently, perhaps the largest collection of unresolved or poorly resolved medical issues are the kinds patients present in primary care. The fundamental to rethink is whether the information in electronic medical records (EMRs) is there, if we reach. A new electronic section of the journal, dedicated to publication of EMR-based research, is now open for article review. Encouraged article characteristics include: assessment of therapies as they are actually provided, inclusion of all relevant patients, and new analytic methods.

Narrative Medicine

Humanity before Science: Narrative Medicine, Clinical Practice, and Medical Education
Samir Johna, MD; Simi Rahman, MD

It appears from the available literature that Narrative Medicine is promising in addressing some of the flaws of Flexner's model of medical education, and may be the answer to the current crisis in the physician-patient relationship. Its impact extends beyond empathic and compassionate delivery of care to patients; it extends well into physicians' own wellness. Medical educators should consider incorporating narrative writings as early as medical school education and all the way into residency and fellowship education.

Soul of the Healer

Angles and Edges
J Richard Gaskill, MD

A Bare Tree in Winter
Mary T Shannon, MSW, MS

Meditation on the Beach
Mohamed Osman, MD

Tranquil Journey on the Yangtze
Karen C Kwock, RN

On the Cover

Dead Vlei
Stuart Hahn, MD

Circulation

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Letters

Articles, editorials, letters to the editor, and other material represent the opinion of the authors. Send your comments to permanente.journal@kp.org.


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