Once again a study challenges dogma - POISE Published, Debate on Perioperative Beta Blockers Continues

Publication of the landmark Perioperative Ischemic Evaluation (POISE) trial online May 12, 2008, in the Lancet has triggered another heated debate about the pros and cons of using beta blockers perioperatively in noncardiac surgery [1]. In one corner are the authors of POISE, which was first reported at the American Heart Association (AHA) 2007 Scientific Session and which found that beta blockers do more harm than good in this setting; and in the other, two accompanying editorialists, who suggest that it is the POISE protocol—specifically, the doses of beta blocker used and timing of initiation of therapy—that explains the findings and that a different protocol might shift the risk/balance back in favor of using beta blockers in this setting [2].

"What POISE says is that in the dosing we used, we see beta blockers have substantial risk in the perioperative setting," Dr Philip J Devereaux (McMaster University, Hamilton, ON) told heartwire. "And until someone demonstrates with a clear and large randomized controlled trial that an alternative dose is both effective and safe, it’s just not rational, not in people’s best interests, to be assuming—that’s how we got into this trouble in the first place."

I have not done preoperative and perioperative management for many years, and have not followed this literature carefully.  I did know that most experts thought that beta blockers markedly decreased MI risk during and after non-cardiac surgery.  So as a more casual observer, this article surprised me.

Devereaux first reported POISE—a randomized controlled trial in more than 8000 patients undergoing noncardiac surgery who were not on beta blockers, randomized to either the beta blocker metoprolol or placebo—at the AHA meeting last year. The results showed that the beta blocker reduced the risk of myocardial infarction (MI) but increased the risk of severe stroke and overall death in patients undergoing noncardiac surgery. It suggested that for every 1000 patients treated, metoprolol would prevent 15 MIs, but there would be an excess of eight deaths and five severe disabling strokes.

Devereaux told heartwire that the new analysis featured in the Lancet "helps to explain why death went up and stroke went up [with metoprolol]. Death was clearly driven by a hypotensive state, leading to shock, which we’ve recognized is so common in the perioperative setting, and that’s what tipped the balance and why we saw the excess death. Also it’s not that simple to predict who will develop shock, and many people who are going to get it are the same people who are going to get a heart attack also."

He and his coinvestigators conclude: "Patients are unlikely to accept the risk associated with perioperative extended-release metoprolol. Current perioperative guidelines that recommend beta-blocker therapy to patients undergoing noncardiac surgery should reconsider their recommendations in light of these findings."

I take several messages from this study.  First, we really do not know answers to complex clinical questions until we careful prospective studies, especially randomized controlled clinical trials.  Second, the performance indicator and safety movement which has a "ready, fire, aim" philosophy, must reevaluate their strategies.  One must wonder if our current push towards performance measurement has caused strokes and death in some patients.  Finally, 30 years after finishing my residency, I continue to reshape my medical knowledge.  As new knowledge appears we must quickly adjust our practice.  I am interested in the ability of the performance movement to adjust.  Of course, they will shrug off the unintended consequences that they caused here. 

Regular readers know that I consider making the proper diagnosis the epitome of internal medicine (as well as many other specialties.)  We know that we often miss diagnoses, but we often do not know why.  I have often recommended Jerome Groopman’s book - How Doctors’ Think - as a primer on medical cognition.  Currently he has a regular column in the ACP Internist.  The current article gives a classic example of medical diagnostic error - Beware of ‘search satisfaction,’ a common cognitive error .

Dr. Ginsberg told us that he viewed this case as “a horse masquerading as a zebra.” Why didn’t we see the horse? To help answer the question, Dr. Ginsberg sent us this picture of how the mind may not perceive a visual abnormality.

If you see nothing wrong, try again. It took us several tries.

The current American Journal of Medicine has an interesting article on diagnostic error - Overconfidence as a Cause of Diagnostic Error in Medicine.  This article is long and detailed.  I recommend it only for those who want to study this problem in depth.

How important is diagnostic accuracy?  I would argue that if we could measure accuracy we would have the best single measure of physician quality.  However, we are forever challenged with developing a measure, because we have difficulty knowing the correct answer - that in fact is the problem.

Clearly, we should encourage physicians to take the time to think about diagnosis.  Perhaps, we could actually help patients through the act of spending money on cognition.  Perhaps, but then who would pay for me to think?

Was It the Drinking Binge?

Solution to "Was It the Drinking Binge?"

Becoming a better ward attending: Ten modifiable behaviors

This exploration is published in ACP Hospitalist.  We (db and Lisa Willett) developed the paper as part of a faculty development program conducted at the Southern Society of General Internal Medicine.  We are now using this framework for short (1-1.5 hour) teaching workshops.

For those who teach and learn, we would love your comments.

I have moved into cell phone technology.  Through a site called Wirenode, I now have cell phone friendly access.  I have an advertisement in the side bar, but here is the mobile phone web address -  http://medrants.wirenode.mobi

Please let me know if this addition has value.

The Experience of Pay for Performance in English Family Practice: A Qualitative Study

PURPOSE We conducted an in-depth exploration of family physicians’ and nurses’ beliefs and concerns about changes to the family health care service as a result of the new pay-for-performance scheme in the United Kingdom (Quality and Outcomes Framework [QOF]).

METHODS Using a semistructured interview format, we interviewed 21 family doctors and 20 nurses in 22 nationally representative practices across England between February and August 2007.

RESULTS Participants believed the financial incentives had been sufficient to change behavior and to achieve targets. The findings suggest that it is not necessary to align targets to professional priorities and values to obtain behavior change, although doing so enhances enthusiasm and understanding. Participants agreed that the aims of the pay-for-performance scheme had been met in terms of improvements in disease-specific processes of patient care and physician income, as well as improved data capture. It also led to unintended effects, such as the emergence of a dual QOF-patient agenda within consultations, potential deskilling of doctors as a result of the enhanced role for nurses in managing long-term conditions, a decline in personal/relational continuity of care between doctors and patients, resentment by team members not benefiting financially from payments, and concerns about an ongoing culture of performance monitoring in the United Kingdom.

CONCLUSIONS The QOF scheme may have achieved its declared objectives of improving disease-specific processes of patient care through the achievement of clinical and organizational targets and increased physician income, but our findings suggest that it has changed the dynamic between doctors and nurses and the nature of the practitioner-patient consultation.

Those who champion P4P make an unfortunate assumption.  They believe that you can push one button, and only impact the desired outcome.  They are obsessed with measurement, and believe that measurement will improve health care.  They are so dangerous.

I will state that those who champion P4P are mistaken in the most dangerous way.  Unless we carefully study the impact of incentives we could cause more harm than good.

Bob Wachter talked about this eloquently in March - The Great Quality Debate: Berwick’s Plea for Action vs. Evidence-Based Medicine. 

On the other hand, in our zeal to “do something,” vigorously promoting or mandating practices with weak evidence risks squandering scarce resources, diverts us from better strategies, and subjects the safety field to the whims of opinions and biases. Berwick worries that our EBM pushback gives intellectual ammo to the dark forces of status quo. This is a reasonable concern. But given the public interest in quality and patient safety, I worry more that the distance between “this seems like a good idea” to “let’s include it as part of a campaign” to “let’s make it a new Joint Commission standard” to “let’s make it a state law” is perilously short. Accordingly, we should require awfully strong evidence that we’re doing the correct thing as we traverse that path, particularly when practices are complex and expensive.

The Annals of Family Medicine article raises many legitimate questions about Great Britain’s P4P experiment.  We should learn from their experience. 

Gut-wrenching

When I think of abdominal pain evaluation, I think of Cope’s Early Diagnosis of the Acute Abdomen

What does one say about the 21st edition of an authoritative clinical text first published in 1921? This revised edition by the eminent surgeon William Silen clearly demonstrates the beauty of succinct medical writing and the durability of clinical pearls. The previous edition was published in 2000 and the march of technology has continued relentlessly, threatening to overwhelm even the most ardent medical student’s or resident’s desire to obtain a complete history and perform a rigorous physical examination on patients presenting with symptoms and signs consistent with an acute abdomen.

Abdominal pain in many ways represents the epitome of history, physical exam and diagnostic testing.  Lisa Sanders writes about a challenging story of abdominal pain in an adolescent.  As usual she writes the story beautifully, and as a reader I kept trying to solve the story.

You will need a high speed connection to view this talk.  I gave this talk at UC Davis, and they kindly archived it. 

Long time readers will not be surprised by my comments, but I hope this discussions brings many ideas into focus.

Guidelines - a skeptic’s viewpoint

A premed student writes:

We see a trend that people are starting to say NP’s and CRNA’s, particularly in rural settings, are helping control costs while providing general care and limited anesthesia. I also see a trend that a lot of MD’s ad MD anesthesiologists are ranting that these types of advanced practice nurses are ruining general/family care and cannot and never will have the necessary training do to such a role without having been through med school - though not so much ranting about crna’s so long as they practice under an anesthesiologist and not solo.
So then nursing profession pumps out "Doctorate of Nursing Practice" to fill the void of internal medicine physicians.. though this is not a PhD role for academic/research settings.. it is for clinical settings. The AMA flips out again claiming ‘Dr. Nurse’ will confuse patients and cause problems.

Do you think advanced practice nurses like crna, fnp, nnp, etc., are doing an adequate job for their scope of practice..? Calling in the md for exceptional or issues out of their scope?
What do you think of crnas practicing solo without an md.. this seems to be a ‘problem’ in rural areas.

There is no doubt there is a shortage of health care professionals.. even down to lpns.. 

Being a medical professor and MD, what do you think?

Activated Vitamin D Associated with Mortality Drop in Chronic Kidney Disease

For patients with moderate-to-severe chronic kidney disease and hyperparathyroidism, activated vitamin D appears to lower the risk of death over two years, an observational study found.

The 429 patients with stage 3 or 4 disease who took oral calcitriol had a 26% reduced risk of death (P=0.016) and a 20% reduced risk of death or long-term dialysis (P=0.038) compared with 989 patients who did not take oral calcitriol, Bryan Kestenbaum, M.D., of the University of Washington here, and colleagues reported online in the Journal of the American Society of Nephrology. The results will be published in the August print issue.

These data have great importance to generalists and nephrologists.  These data support the hypothesis that the secondary hyperparathyroidism Is a major problem for these patients.