Spring 2012 - Volume 16 Number 2

OrigKaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical Groupinal Research and Contributions

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupInfluence of Vascular Access Type on Sex and Ethnicity-Related Mortality in Hemodialysis-Dependent Patients
Karen Woo, MD; Janis Yao, MS; David Selevan, BS; Robert J Hye, MD

In an analysis of a database containing 6052 chronic hemodialysis patients between 2000 and 2008, age, male sex, prosthetic graft, tunneled catheter and diabetes are independent predictors of mortality. After controlling for these variables, when compared to Caucasians, African-American, Asian, Hispanic, and Pacific Islander ethnicity all demonstrate significantly decreased risk of mortality. Type of dialysis access is not responsible for gender and ethnicity-related mortality differences in this population.

Financial Implications of Increasing Medical School Class Size: Does Tuition Cover Cost?
Danny A Schieffler, Jr, PhD; Benjamin M Azevedo; Richard A Culbertson, PhD; Marc J Kahn, MD, MBA

To determine the financial consequences of increasing medical student enrollment, adjusted secondary revenue data are analyzed using linear regression to determine average fixed costs and variable costs per student. The best point estimate of the annual variable cost of educating a medical student is $62,877. Tuition and fees revenue from increasing enrollment will not increase overall revenue to medical schools.

Out-of-Plan Pharmacy Use by Members of a Managed Care Organization
Thomas Delate, PhD, MS; Gale Albrecht, MS, PharmD Candidate; Kari L Olson, PharmD, BCPS, FCCP

This retrospective health services investigation examined characteristics of patients in a managed care organization (MCO) who did and did not have a prescription written to an out-of-plan pharmacy (OOPP) from October 1, 2006 through September 30, 2010. A total of 10,353,283 prescriptions were included. Prescriptions written to an OOPP were more likely to be for chronic disease states. Patient age and MCO termination were associated with having a prescription written to an OOPP.

Association of Child and Adolescent Psychiatric Disorders with Somatic or Biomedical Diagnoses: Do Population-Based Utilization Study Results Support the Adverse Childhood Experiences Study?
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupT C R Wilkes, MB, ChB, M Phil, DCH FRCP(Edin), MRCPsych, FRCPC, FAPA; Lindsay Guyn; Bing Li, MA; Mingshan Lu, PhD; David Cawthorpe, PhD

From a randomly selected sample of 205,281 patients under age 18 years, on their index visit, this study examined the effect on somatic or biomedical diagnosis costs during a 16-year period. All physician billing records (8,724,714) from the study period were grouped on the basis of presence or absence of any International Classification of Disease diagnosis of psychiatric disorder. The somatic disorder billing costs (nonpsychiatric costs) were 1.8 times greater for those with psychiatric disorders. Somatic costs peaked before the age of 6 years and remained higher than the same-age groupings without psychiatric disorders in each age group.

Long-term Outcomes of Shamanic Treatment for Temporomandibular Joint Disorders
Nancy H Vuckovic, PhD; Louise A Williams, PhD; Jennifer Schneider, MPH; Michelle Ramirez, PhD, MPH; Christina M Gullion, PhD

Temporomandibular joint disorders (TMDs) are chronic pain conditions often refractory to treatment. Twenty-three women, ages 25 to 55 years, with a diagnosis of TMD were contacted at 1, 3, 6, and 9 months after treatment to record self-reported pain and disability outcomes and qualitative feedback. The improvements in usual and worst pain, and functional impairment at end of treatment persisted without change to 9 months.

Special Reports

The Kaiser Permanente Implant Registries: Effect on Patient Safety, Quality Improvement, Cost Effectiveness, and Research Opportunities
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupElizabeth W Paxton, MA; Maria CS Inacio, MS; Mary-Lou Kiley, MBA

The purpose of this article is to describe the Kaiser Permanente implant registries, which leverage the integrated health care system's administrative databases and electronic health records system. Data collection, quality control and validation, and statistical analysis for the registries are described. Areas discussed include: patient safety enhancement successes such as assistance during major recalls, identification of risk factors, risk calculator development, infection and adverse event surveillance, and research studies conducted using registry data.

Review Articles

Transanal Endoscopic Microsurgery for Rectal Tumors: A Review
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupHiroko Kunitake, MD; Maher A Abbas, MD, FACS, FASCRS

Since its introduction in 1983, Transanal Endoscopic Microsurgery has emerged as a safe and effective method to treat rectal lesions including benign tumors, early rectal cancer, and rectal fistulas and strictures. This minimally invasive technique offers the advantages of superior visualization of the lesion and greater access to proximal lesions with lower margin positivity and specimen fragmentation and lower long-term recurrence rates over traditional transanal excisions, with less morbidity, faster recovery, and greater potential cost savings.

Case Studies

Corridor Consult

False Estimates of Elevated Creatinine
Manpreet Samra, MD; Antoine C Abcar, MD

One of the most common reasons for a nephrology consult is an elevated creatinine. An elevation in the serum creatinine concentration usually reflects a reduction in the glomerular filtration rate (GFR). At times the elevation of the creatinine is not representative of a true reduction in GFR. Various causes of factitious elevation of creatinine include increased production of creatinine, interference with the assay and decreased tubular secretion of creatinine.

Corridor Consult

Management of the Athlete with Concussion
John K Su, MD, MPH; Joel F Ramirez, MD

The approach to and management of the athlete with concussion can be a challenging endeavor to physicians that care for athletes who have suffered a head injury—this group includes family physicians, pediatricians, internists, emergency medicine physicians, primary sports medicine physicians, orthopedic surgeons, neurologists, and neurosurgeons. Sometimes questions regarding the need for neurologic, psychologic, or radiographic imaging can make the decision for return to play unclear. New legislation will undoubtedly increase physician visits for these athletes to return to play.

Clinical Medicine

ECG Diagnosis: Hypokalemia
Joel T Levis, MD, PhD, FACEP, FAAEM

The earliest electrocardiogram change is a decrease in the T-wave amplitude. As potassium levels decline further, ST-segment depression and T-wave inversions are seen. The U wave is described as a positive deflection after the T wave, often best seen in the mid-precordial leads (eg, V2 and V3). When the U wave exceeds the T-wave amplitude, the serum potassium level is < 3 mEq/L.

Image Diagnosis: Abdominal Wall Hematoma
Jasmine K Dhaliwal, MD; Gus M Garmel, MD, FACEP, FAAEM

Abdominal wall hematoma is uncommon, but may be a life-threatening condition. Risk factors include older age, female sex, systemic anticoagulation, abdominal wall trauma, pregnancy, and impaired renal function. Clinical manifestations include abdominal pain, abdominal wall ecchymosis, drop in hematocrit, and a positive Carnett's sign indicating the abdominal wall and not the abdominal cavity as the source of pain.

Commentary

The Familiar Foundation and the Fuller Sense: Ethics Consultation and Narrative
Craig Nelson, PhD, CLS

The intention of this essay is to examine "ethical expertise" and the idea of clinical ethics "consulting." The author's position champions the use of two tools: "familiar foundation" and "fuller sense." The "familiar foundation" represents a body of knowledge. Through a deep analysis of patient narrative found in the "fuller sense," the ethicist sharpens focus and achieves a richer understanding of the patient's situation in life. In using both tools, patients and families are better served.

A Retirement and A Reservation: A Retrospective Autobiography
Sok K Lee, MD, MA

For 37 years, the author was a healing professional, a breadwinner, and a working spouse. After retirement, he felt like a jobless loner, an inactive pensioner, and a homebound spouse. In this retrospective autobiography, he suggests professional, financial, social, and familial points to help younger colleagues better their upcoming retirement. To overcome Erikson's identity crisis, he volunteered to be a (wounded) healer at Warm Springs Indian Reservation.

The Health Care Professional as a Modern Abolitionist
Michael G O'Callaghan, DDS

Health care professionals are in a unique position to identify and to assist victims of human trafficking, which today occurs both domestically and globally. It manifests in many forms, including adult and child forced labor, involuntary domestic servitude, adult and child sexual slavery, involuntary servitude, debt bondage, and child soldiers. This article offers insight into modern human trafficking and ways health care professionals can be activists.

Can Kawasaki Disease Be Managed?
Alberto Coustasse, DrPH, MD, MBA, MPH; Julius Larry, DDS, JD, MPH; Doohee Lee, PhD

Kawasaki Disease (KD) is the leading cause of acquired cardiovascular disease among children, most commonly among Asians and Pacific Islanders. In 2006, over 5500 KD cases were reported in the US. Because the etiology remains unknown, and there is no specific laboratory test, timely and accurate diagnosis remains difficult. Developing a specific registry or a surveillance system may be necessary for increasing awareness and decreasing complications related to misdiagnosis.

Editorial

Medical Education—the Challenge of Distinguishing Actual Costs versus Charges (Tuition)
William L Toffler, MD

The author of this editorial writes that Scheiffler et al (page 10) use a creative "back door" approach to assess whether or not tuition covers medical school costs. It may provide insight into the true cost, if, and only if, two basic underlying assumptions are correct: 1) the funding coming from these sources does correlate with true costs, and 2) the estimated percentage actually allocated to education is correct. In conclusion, like all good research, the authors' published work raises more questions than have been answered.

Letters to the Editor

Dear Editors: Re: Boudreau JD. Physician-Assisted Suicide and Euthanasia: Can You Even Imagine Teaching Medical Students How to End Their Patients' Lives?

Considering that physician-assisted suicide and euthanasia is a sensitive and controversial topic, the reductionism and the lack of objectivity of the question asked and of its discussion are intriguing. It is clear that the author and advisers wished no answer but their own. It is not usual for scholars to be reluctant to confront their views with others.

Dear Editor: Re: Ettel G III, Nathanson I, Ettel D, Wilson C, Meola P. How do adolescents access health information?

As a Pediatric and Adolescent Gynecologist I have struggled with the fact that the electronic medical record (EMR) cannot be accessed by adolescents. I worked at the Kaiser Permanente Los Angeles Medical Center for 14 years and am now at Group Health in Washington State using the Epic EMR. I am quite frustrated by the fact that my teenage patients cannot exchange e-mails with me regarding their care.

Book Reviews

Lost Lives. The Pandemic Violence Against Children
Einar A Helander
Review by Anna Luise Kirkengen, MD, PhD

Scared Sick. The Role of Childhood Trauma in Adult Disease
Robin Karr-Morse, assisted by Meredith S Wiley
Review by Anna Luise Kirkengen, MD, PhD

Soul of the Healer

Original Visual Art

"Birney Creek"
Stephen Jacobs

"Focus on the Physical"
Marilyn Mitchell

"Hearing Loss"
Mohamed Osman, MD

"Genetic Engineering"
Mohamed Osman, MD

On the Cover

"Ancient Magnolid"
Latifat Apatira, MD

Circulation

25,000 print readers per quarter, 6900 eTOC readers, and in 2015, 1.4 million page views on TPJ articles in PubMed from a broad international readership

Subscriptions

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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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