Most pediatric gastroenterologists would think that the acronym PEWS referred to “Pediatric Early Warning Score” which is used to identify patient deterioration (Sensitivity of the Pediatric Early Warning Score to Identify Patient …). This PEWS has been an important achievement in patient safety contributing to lower mortality, reduced codes, and shortened intensive care unit stays (Simple Scoring System and Action Algorithm Identifies Children at …).
PEWs acronym also refers to “physician evaluation websites.” These type of scores are growing in importance and may also reflect quality care. As such, a recent article highlights this emerging phenomenon (Am J Gastroenterol 2013; 108: 1676-85 -thanks to Ben Gold for this reference). While physicians are concerned about their reputations, these websites have not been widely embraced. This article makes several points about why physicians may need to reconsider.
- 35 websites met criteria to be included in this study: 18 were dedicated physician evaluation websites, 5 were health information websites, and 12 were general information websites (eg. Angieslist.com, kudzu.com, yelp.com).
- Frequent analysis/questions besides demographics/affiliations: punctuality, quality of staff (office/nursing), bedside manner, ability to make correct diagnosis, spent sufficient time, costs
- Five sites allow physician feedback and chance to respond to dissatisfied patients: docspot.com, doctorscorecard.com, healthgrades.com, ratemds.com, and your city.md
- Multiple charts indicate the huge traffic on these websites. For dedicated PEWs, healthgrades.com has the highest volume at over 5 million unique visitors per month (2011-2012).
- Most online evaluations are completed by females (with at least some college education) with a peak age between 45-65 years. Some smaller PEWs attract a younger crowd (eg. Zocdoc.com -4th most visited dedicated PEW).
- Most evaluations are positive. ”Site administrators…self-reported figures…ranged from 60-75% positive, 4-22% neutral, and 9-21% negative.”
- ucomparehealthcare.com (3rd most visited dedicated PEW) allows multiple physician profiles to be analyzed side-by-side.
- docspot.com compiles existing reviews from over 15 other websites.
- healthgrades.com (most visited dedicated PEW) allows users to rate physicians with a star scale but does not allow free response (avoids libelous comments).
- vitals.com -2nd most visited dedicated PEW.
- yourcity.md considered most “doctor friendly.” Prior to publicizing negative comments, this site allow doctors the option to respond publicly or privately; afterwards, the negative review can be revised. In addition, per user agreement, a negative claim which cannot be substantiated could result in the anonymous reviewer’s name being revealed to the physician or be removed.
One of my mentors told me that the key to patient care was the the 3 A’s: availability, affability, and ability. PEWs likely can help evaluate the first two A’s. PEWs allow for constructive criticisms but need to evolve to include other measures of physician performance. Ignoring PEWs would be a mistake for physicians –they are here to stay.
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As noted in several blog posts, there have been some important advances in the care of short bowel syndrome (SBS)/intestinal failure (IF) patients which have resulted in improved outcomes. A recent review of 28 children with ≤20 cm of small bowel has been published (J Pediatr 2013; 163: 1361-6, editorial 1243) and provides tangible evidence of these changes.
This retrospective study reviewed the charts of these children managed at Omaha’s intestinal rehabilitation program. 7 patients had NEC, 6 intestinal atresia, 6 had gastroschisis, 3 omphalocele, 5 had malrotation, and 1 patient had vascular disease.
- 27 survived (96%)
- 14 (50%) had at least one lengthening procedure; in this cohort, bowel lengthening was not associated with a greater rate of adaptation than native bowel.
- 13/27 (48%) achieved parenteral nutrition independence (“nutritional autonomy”) with their native bowel.
- Predictors of “successfully rehabilitated” patients: intact colon and ileocecal valve
- All patients had improvements in lowering PN requirements, total bilirubin, and growth z-scores.
- Serum transaminase levels did not improve in the nonrehabilitated patients
The main medical treatments at IRP include use of agents for control of bacterial overgrowth, reducing gastric acid production, lipid minimization, promotility and antimotility agents (eg. loperamide), and ethanol locks. The editorial comments on the “poor results” for surgical intervention, “particularly among those with ultra-short bowel.” This may be due to ‘marginal motility, ischemia, severe wall thickening, or due to adhesions.’
With regard to ethanol locks, the editorial supports them but states, “the main factor in prevention [of line infections] has been maintaining a consistent and strict protocol for catheter care.”
Previous related blog entries:
The link (from KT Park’s twitter feed): gastrojournal.org/article/S0016-5085(13)01521-7/fulltext …
Some of the key points/recommendations for adults with Crohn’s disease:
- In clinical practice, CD of moderate severity is defined as disease requiring systemic corticosteroids for symptom control.
For Induction of Remission:
- We Suggest Against Using Thiopurine Monotherapy to Induce Remission in Patients With Moderately Severe CD (Weak Recommendation, Moderate-Quality Evidence)
- We Suggest Against Using Methotrexate to Induce Remission in Patients With Moderately Severe CD (Weak Recommendation, Low-Quality Evidence)
- We Recommend Using Anti–TNF-α Drugs to Induce Remission in Patients With Moderately Severe CD (Strong Recommendation, Moderate-Quality Evidence)
- We Suggest Using Anti–TNF-α Drugs in Combination With Thiopurines Over Anti–TNF-α Drug Monotherapy to Induce Remission in Patients Who Have Moderately Severe CD (Weak Recommendation, Moderate-Quality Evidence)
Maintenance of Remission:
- We Recommend Using Thiopurines Over No Immunomodulator Therapy to Maintain a Corticosteroid-Induced Remission in Patients With CD (Strong Recommendation, Moderate-Quality Evidence)
- We Suggest Using Methotrexate Over No Immunomodulator Therapy to Maintain Corticosteroid-Induced Remission in Patients With CD (Weak Recommendation, Low-Quality Evidence)
- We Recommend Using Anti–TNF-α Drugs Over No Anti–TNF-α Drugs to Maintain Corticosteroid- or Anti–TNF-α—Induced Remission in Patients With CD (Strong Recommendation, High-Quality Evidence)
- We Make No Recommendation for or Against the Combination of an Anti–TNF-α Drug and a Thiopurine Versus an Anti–TNF-α Drug Alone to Maintain Remission Induced by a Combination of These Drugs in Patients With CD (No Recommendation, Low-Quality Evidence)
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Using a UK National registry with 106,013 children, investigators determined that there was no overall risk of cancer among children born after assisted conception during a 17-year study period (NEJM 2013; 369; 1819-27).
Among individual cancers, this cohort had an increased risk of hepatoblastoma and rhadomyosarcoma, though the absolute risk was quite low. The risks for these cancers may be related to chance or indirectly related to parental infertility through mechanisms like low birth weight or imprinting disorders.
A recent review (JPGN 2013; 57: 543-49) provides information about the relationship between neonatal environment and subsequent inflammatory gastrointestinal disease.
While most of the review, focuses on physiology and pathophysiology, the most interesting part is the assertions (with references) in Table 1 which include the following:
- Breastfeeding reduces risk of IBD
- Cesarean section increases the risk of celiac disease, cow’s milk allergy, and other IgE-mediated food allergies
- Many chronic adult diseases have been shown to have origins in neonatal life, particularly cardiovascular disease/metabolic syndrome
Here’s the view of the NY Times (nyti.ms/1b7nTbl ) about the new therapies for Hepatitis C:
Medicine may be on the brink of an enormous public health achievement: turning the tide against hepatitis C, a silent plague that kills more Americans annually than AIDSand is the leading cause of liver transplants. If the effort succeeds, it will be an unusual conquest of a viral epidemic without using a vaccine.
“There is no doubt we are on the verge of wiping out hepatitis C,” said Dr. Mitchell L. Shiffman, the director of the Bon Secours Liver Institute of Virginia and a consultant to many drug companies.
Over the next three years, starting within the next few weeks, new drugs are expected to come to market that will cure most patients with the virus, in some cases with a once-a-day pill taken for as little as eight weeks, and with only minimal side effects.
That would be a vast improvement over current therapies, which cure about 70 percent of newly treated patients but require six to 12 months of injections that can bring horrible side effects.
The latest data on the experimental drugs is being presented at The Liver Meeting in Washington, which ends Tuesday [11/5/13]
But the new drugs are expected to cost from $60,000 to more than $100,000 for a course of treatment.
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According to a recent editorial (NEJM 2013; 369: 1180-81), 45,000 American adults die each year because they have no medical coverage (Am J Public Health 2009; 99: 2289-95).
The editorial which describes a late diagnosis of colon cancer in an adult who had been chronically uninsured despite working full-time makes a couple of key points:
- Lack of insurance can be lethal
- Underinsured also have higher mortality rates One example: insurance status, not race, was associated with mortality after an acute cardiovascular event in Maryland (J Gen Intern Med 2012; 27: 1368)
While the rollout for the Affordable Care Act (ACA) has been bad, the underlying reason for it remains sound. In addition, though the ACA expands coverage, I am skeptical that it will control problems with skyrocketing costs. As such, many other difficult changes in medical care delivery will ultimately be needed.
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Life in the balance (book) | gutsandgrowth