Winter 2012 - Volume 16 Number 1

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

Are There Differences in Access to Care, Treatment, and Outcomes for Children with Appendicitis Treated at County versus Private Hospitals?
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupSteven Lee, MD, FACS, FAAP; Arezou Yaghoubian, MD; Rebecca Stark, MD; Roman M Sydorak, MD; Amy Kaji, MD

Among 7902 hospital patients (county = 682; private = 7220), children with appendicitis treated at a county hospital were of lower socioeconomic background and had higher appendiceal perforation rates, longer length of hospitalization, and higher costs than their counterparts at private hospitals but were more likely to undergo laparoscopic appendectomy and require less abscess drainage. Within the county hospital, ethnic and socioeconomic disparities were not apparent; thus, these differences between institutions might have been caused by underlying disparities in ethnicity, income, and health care access.

Supported Exercise Improves Controlled Eating and Weight through Its Effects on Psychosocial Factors: Extending a Systematic Research Program Toward Treatment Development
James J Annesi, PhD

Behavioral weight-loss treatments have been overwhelmingly unsuccessful. A systematic program of health behavior-change research based on social cognitive theory, applied to exercise and weight loss, is reviewed.  A field-based study of obese adults (n = 430) over 26 weeks is also reported showing greater effect with cognitive-behavioral methods than with standard nutrition education. Improved self-efficacy and self-regulation for exercise carried over to self-efficacy and self-regulation for controlled eating (b = 0.53 and 0.68, respectively).

"Our Culture Is Medicine": Perspectives of Native Healers on Posttrauma Recovery Among American Indian and Alaska Native Patients
Deborah Bassett, PhD; Ursula Tsosie, MSPH; Sweetwater Nannauck

American Indian and Alaska Native (Native) people experience more traumatic events and are at higher risk for developing posttraumatic stress disorder compared with the general population. The authors conducted in-depth interviews with six Native healers and categorized themes into: causes and consequences of traumatic injury; risk factors; protective factors; and barriers to care. Study implications include a need for improving cultural competence among health care and social services personnel working with Native trauma patients.

Pharmacist Glycemic Control Team Improves Quality of Glycemic Control in Surgical Patients with Perioperative Dysglycemia
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupKaren S Mularski, MD; Cynthia P Yeh, PharmD; Jaspreet K Bains, PharmD, BCPS; David M Mosen, PhD, MPH; Ariel K Hill, MS; Richard A Mularski, MD, MSHS, MCR

A Glycemic Control Team of pharmacists used a protocol, on consult, to manage perioperative dysglycemia during hospitalization. Using a pre–post, observational study design, the authors found that during the preimplementation period, 77.4% of postoperative patient days demonstrated good glycemic control versus postimplementation when control increased to 90.3%. The rate of hypoglycemia decreased from 8.6% to 4.6%.

How Do Adolescents Access Health Information? And Do They Ask Their Physicians?
George Ettel, III; Ian Nathanson, MD; Donna Ettel, PhD; Christine Wilson, PhD, ARNP; Paul Meola

Using a cross-sectional design, the authors administered an anonymous survey to high school students in grades 9 to 12. Surveys were completed by 497 of 705 students. All students were comfortable using the Internet, >90% used it at home and in school, a significant proportion reported trusting online information, and 22% modified their behavior. Topics included skin, nutrition, birth control, and sexually transmitted diseases. A significant number of students reported conducting e-mail conversations on health topics with their teachers versus only 5% with physicians.

The Power of the National Surgical Quality Improvement Program—Achieving A Zero Pneumonia Rate in General Surgery Patients
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupPascal R Fuchshuber, MD, PhD, FACS; William Greif, MD, FACS; Chantal R Tidwell, RN; Michael S Klemm, MD; Cheryl Frydel, RRT; Abdul Wali, MD, FACP; Efren Rosas, MD; Molly P Clopp, RN, MS, MBATM

The National Surgical Quality Improvement Program (NSQIP) provides risk-adjusted outcome measures for participating hospitals to use for performance improvement. This article summarizes its history and reports the two projects on postoperative respiratory complications—intubation >48 and pneumonia. It also explains the benefit of a several-hospital collaborative and describes
development of a "playbook."

Single-Incision Laparoscopic Surgery—Hype or Reality: A Historical Control Study
Maryam N Saidy, MD; Michele Tessier, PA; Deron Tessier, MD

The authors briefly review the history of single-incision laparoscopic surgery (SILS), its current applications, and potential pitfalls, and report a historical control study of 50 laparoscopic and 50 SILS cholecystectomies, all performed by one of the authors. Mean operative time for the noncholangiogram group (38) was 48 minutes, with mean estimated blood loss of 28 mL, and a 20% "conversion" rate (10). Although the only documented benefit is cosmetic, SILS is equivalent to conventional laparoscopy in all other respects.

Special Reports

A Case of Baffling Fatigue With a Spectral Twist
Kate Scannell, MD, FACP

Mr Gee had increasingly experienced "episodes" of abrupt elevations of systolic blood pressure beyond 200 mmHg that occurred at night, when he also had headaches, tinnitus, nausea, and fear of a stroke. Laboratory and radiographic tests were negative. Encouraging a patient to frame his illness within his own experience of its beginning, its current middle, and its imagined ending will often expose clarifying diagnostic clues. This case study illustrates clinical empathy in action.

Gathering the Patient's Story and Clinical Empathy
Jodi Halpern, MD, PhD

Until the 1990s, physicians have been skeptical about empathy, assuming that it would interfere with clinical objectivity and effectiveness. This has shifted as research has shown that empathy plays a fundamental role in both diagnostic accuracy and treatment effectiveness. Often confused with compassion, sympathy, and other benevolent emotions, clinical empathy involves emotional resonance, but is distinguished by curiosity. Helping patients tell their stories is one way to "practice" empathy.

Review Articles

Transparency Matters: Kaiser Permanente's National Guideline Program Methodological Processes
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupCarrie Davino-Ramaya, MD; L Kendall Krause, MD, MPH; Craig W Robbins, MD, MPH; Jeffrey S Harris, MD, MPH; Marguerite Koster, MA, MFT; Wiley Chan, MD; Gladys I Tom, MS

The practice-guideline process of collecting, critically appraising, and synthesizing available evidence, then developing expert panel recommendations based on appraised evidence, makes it possible to do the best for patients at the point of care. A multidisciplinary group of stakeholders conduct high-quality systematic reviews either of acceptable external guidelines, then an internal search for relevant reviews, meta-analyses, and original studies, which are then appraised using GRADE. Recommendations are disseminated through the e-Clinical Library.

Case Studies

Altered Mental Status in an Elderly Woman with Concurrent Takotsubo Syndrome and Polymyalgia Rheumatica: A Case of Treatable Geriatric Delirium
Hien Nguyen, MD; Connie Le, MD; Hanh Nguyen, MD; Nam-Tran Nguyen

The authors describe a unique case of a patient, aged 80 years, who presented with delirium and takotsubo syndrome, known as "broken heart syndrome" because it often follows emotional stress. Though difficult to distinguish from myocardial infarction, it is associated with favorable prognosis for complete recovery. This is the first case reported in an elderly patient, who also had coexistent polymyalgia rheumatica.

Patient Safety in Surgical Residency: Root Cause Analysis and the Surgical Morbidity and Mortality Conference—Case Series from Clinical Practice
Samir Johna, MD; Taylor Tang, MD; Maryam Saidy, MD

The surgical morbidity and mortality conference currently focuses mainly on human errors rather than system failures. Root cause analysis can be an effective way of analyzing system failures and of finding possible solutions for them. Having both perspectives—human errors and systems failures—enhances surgical education, improving quality assurance, and improving patient safety.

Clinical Medicine

Image Diagnosis: Perilunate and Lunate Dislocations
Jennifer A Newberry, MD, JD; Gus M Garmel, MD, FACEP, FAAEM

In perilunate dislocation, the distal and proximal carpal rows overlap and the radial styloid may be completely fractured, with dorsal dislocation of the capitate. It is most commonly seen in young men (teens to 20s), from a high-energy hyperextension mechanism, often caused by falling on an outstretched hand. In lunate dislocation, it displaces volar (the "spilled teacup sign"), and the capitate is dorsal to the lunate.

Commentary

Peer Review: Innovating Change
Antonio Salud II, MD; David Shapiro, MD; Tom Rampulla, MSMI; Karen Reddin, RN, MSN

Medicine has traditionally focused on specialty and subspecialty expertise, which subsequently leads to fragmentation, inefficiencies, and lack of accountability. The Institute methodology fosters accountability rather than blame, focuses on system failures rather than on individual ones, and results in a peer-review process built on strong interdisciplinary relationships.

Editorial

The Physician as Storyteller & Poet: Quick Writes from East Bay Writers' Workshops
Tom Janisse, MD; Betty Lin, MD

In this article, the authors review the importance of reflective writing and present 15 stories and 2 poems written in 10 minutes by physicians and practitioners at 2 writing workshops designed to use creativity as a means of dealing with the stress of a medical career, enhancing coping skills, strengthening the ability to attend empathetically to a patient's experience of illness, and improving well-being.

Soul of the Healer

"Green Bridge—Florence, OR"
John Davenport, MD, JD

"Leopard"
Calvin Weisberger, MD

"Butterfly"
Thomas Paluch, MD

On the Cover

"Yosemite National Park"
Gary Larsen