You, the attending intensivist are worried about serious liver toxicity in this 17 year old young woman who has the potential to have a very big problem here. You recall somewhere a paper stating that the addition of Tagamet (cimetidine) may be of some value in the acute treatment of big league acetaminophen. Quick, like a bunny, You tap up some references from Medline:
Rolband GC et al:. Cimetidine in the treatment of acetaminophen overdose. J Clin Gastroenterol 1992 Sep;15(2):169-70 (snip)" A growing body of evidence suggests that cimetidine significantly reduces the hepatotoxicity of an acetaminophen overdose and that its hepatoprotective action may be additive to that of N-acetylcysteine"(snip).
And:
Speeg KV. Potential use of cimetidine for treatment of acetaminophen overdose. Pharmacotherapy. 7(6 Pt 2):125S-133S, 1987. (snip) "The H2-receptor antagonist cimetidine inhibits the cytochrome P-450 system, does not interfere with the administration or function of NAC, and therefore affords additive protection. That cimetidine protects against acetaminophen toxicity in animal models has been demonstrated on the basis of improved survival"(snip)
So you order some IV cimetidine to augment the effects of cysteine, hoping to head off disaster in this high risk patient.
Shortly thereafter the ICU gets a call from the clinical pharmacist, advising them that they can't have the cimetidine because:
1) It isn't on formulary (they actually found something CHEAPER than cimetidine).
and
2) They did their own search on their own Medline tap and came up with the following cites:
Burkhart KK. et al. Cimetidine as adjunctive treatment for acetaminophen overdose. Human & Experimental Toxicology. 14(3):299-304, 1995 Mar. (snip) "The addition of cimetidine therapy to standard N-acetylcysteine treatment did not provide additional hepatoprotection in acutely acetaminophen poisoned patients when treatment was started later than 8 h post overdose".
and:
Rudd GD et al:. Prevention of acetaminophen-induced hepatic necrosis by cimetidine in mice.Research Communications in Chemical Pathology & Pharmacology. 32(2):369-72, 1981 May. (snip) "When administered to mice after experimental acetaminophen overdose, cimetidine generally prevented the development of centrilobular necrosis, but did not prevent loss of glycogen or appearance of fat in the hepatocytes. The efficacy of cimetidine in preventing acetaminophen-induced hepatic necrosis should be further studied" (snip)
The clinical pharmacist says there is no reliable evidence that it works and they would have to go to too much trouble (and, of course, expense) to get it and so you can't have it.
Liver enzymes are climbing.
What do you do?
Dick Burrows:
Seems the odds are slightly more than even in favour of cimetidine but only by a nose and only on the basis of "more studies." Just like everything else these days! If I felt the burning need for the drug and the pharmacist is resisting I would ask him to come and see the patient and record his views in the notes and if he refused I would do it for him.
But the issue of whether it works or not is equivocable and you might just as well "throw the bones". It would be a pity to wind this up to a major war on that basis.
The real war surrounds the issue of clinical responsibility - where there is a dicey situation like this then the clinical responsibility must be yours to decide. After all you are going to be the one who gets screwed either way when things go awry.
If you were a pilot flying a bunch of passengers from A to B and the man on the ground said "I'm not sure whether or not you've got enough gas to get to the other side and you are almost at the point of no return - but you MUST continue" what would you say to him -"@#&* %&$" like as not. Believe it or not such issues affect them in the same way.
The issue of clinical responsibility is the issue here. And that is an issue which has been abrogated to the bean counters and now there is a danger of abrogating the responsibility to quasi medics (not even 'quacks' who at least usually see the patient) in the form of pharmacists who also know that they will have the support of the bean counters. In fact there is a danger of abrogating clinical responsibility to any prat with access to a computer and a subscription to Medline.
Clinical responsibility is all about making decisions in the face of uncertainty. That is precisely what you are fighting for.
I probably would not agree to the use of the drug but I would not criticise your using it and I would fight to the end for your right to decide to use it (Apologies to Voltaire).
Rolando Berger:
I probably would not feel compelled to use ciumetidine on that patient (its efficacy is far too iffy at this point). That having been said, when evidence is equivocal and the issue is life-and-death, the decision is for the clinician assuming responsibility for the patient to make. No one else..... and certainly not someone who has personally cared and been responsible for exactly O patients!
Its the same issue with radiologists stating "an angiogram is not needed in this patient because I don't think he had a PE", or a blood bank doctor telling you to go ahead and do the transbronchial lung biopsy in the patient with a PT of 16 seconbds and platelets of 51 K without giviong FFP or platelets because "there is no controlled study showing it helps". I always bringing the chart and ask them to write exactly that, and sign their names, exactly below where I wrote that as the primary physician I strongly believe the opposite. No takers so far.... and I always get my angio and my FFP and platelets. ;-)
Seriously, of course this approach should apply only to SERIOUS situations and to issues that are truly equivocal and controversial. This is not a way for an MD to throw a temper-tantrum to try to get his/her own way.
Kresten Holk:
How much I hate to admit it, I tend to agree with your pharmacy.
1) Acetaminophen overdose is no rare disease. IF cimetidine had any SPECIFIC (unrelated to decreased acid excretion in the stomach) the mechanism would have been speculated on or found... and some company would have had i registered for this indication. Directors of ICUs worldwide would have implemented this cheap therapy in their guidelines as one spared liver transplant would make such a scheme cost effective.
2) A broad Medline search will always yield abstracts describing new therapeutic options in which further investigation is warranted...
If supportive therapy fails you call for a liver transplant. If you are really convinced that cimetidine is effective, you send a gopher to the nearest street pharmacy to get cimetidine. You then arrange an RCT (cimetidine vs placebo as supplement to standard therapy) which will bring you even more fame in case it is positive.
Wael M. R. Haddara:
Actually ,I would have to diagree. The mechanism for acetaminophen toxicity is through the metabolic pathway of acetaminophen. If I remember correctly, Acetaminophen is metabolised through the Cytochrome P450 system, isozyme 2E1. When there is a large metabolic load, the oxidative (glutathione) reserve is exhausted and you begin to form toxic by-products. Therefore, to prevent toxicity, you can do one of two things, either supply an oxidant eg. acetylcysteine OR inhibit the metabolicpathway ie Cytochrome P450 isozyme 2E1.
Cimetidine is a cytochrome p450 inhibitor, but it only inhibits 2C and 3A3/4/5 , but not 2E1. Believe it or not, the only known inhibitor of 2E1 (in clinical practice, not merely as a research tool) is ... yup the milk of amnesia - propofol ...
So, in fact there is a basis for using cimetidine, but not a very convincing basis.
I haven't really made up my mind yet on whether I would use Cimetidine, but the time frame issue is essential since it all depends on how much acetaminophen is **left** to go through the pathway. For some reason, the expression "closing the barn door after all the animals have left" comes to mind.
A lot of animal work is done in a very silly way (from a clinical standpoint) : the drugs are given **before** the insult ... this is so pervasive in SIRS and ARDS research and while it makes a mechanistic point it has little direct bearing on clinical practice.
Frederick Foss:
Transfer the patient to the pharmacologist's service. Did that once when was in the Air Force, when the pharmacist and I had an arguement about the use of vancomycin. The phrmacist went so far as to countermand my order. So, I went to the chart and transfered the patient's care to the pharmacist. I was called to the commander's office, who told me that that was not legal. I told him I knew that but did not appreciate the pharmacist changing my orders. I got my vancomycin with no further problems with that pharmicist.
Point is you are the on e trained and licensed to care for this patient and you have credible literature to back you up. If this patient dies you can be sure a lawyer will present your literature and not your pharmacologist's.
J.D. Forster-Coull:
I have been following this case over the weekend with great interest. As a clinical pharmacist practicing in both ICU and Respirology I have concerns about pharmacists acting as minions (read Drug police) of accountants. I see each patient in my unit and am acutely aware of their condition. If I or the attending doc feel that a "non-formulary" medication may be of benefit then we use it.
My ONLY concern is the best interest of the patient. I don't give a rat's ass about the formulary or restricted status of the drug.
For example, I have used ondansetron in patients refractory to standard anti-emetics such as, dimenhydrinate, prochlorperazine or metoclopramide. By decree, at our hospital ondansetron is restricted to nausea/vomiting from chemo/radiation. Since I knew the patient and observed firsthand the pt's profound discomfort (actually a little too firsthand in this case) I thought ondansetron was worth a try because of its unique mechanism.
The attending doc and I talked about it, we tried it, it worked. Yes the pharmacy department ate the cost of the ondansetron but the patient benefited.
My point is that formulary's are guidelines, patients are individuals. I take great exception to pharmacists who mess with patients without actually seeing them first and reviewing the situation with the attending doc. When a non- formulary medication is ordered at my hospital the pharmacist discusses the case with the doc and if the doc feels that the formulary drug is not appropriate then we bring the non-formulary drug in. One of course can't get too carried away since you can eat away at your other program budgets if you aren't careful with your drug budget. In general the docs are quite reasonable and understand the budgetary constraints of the hospital.
Of note this is the second case that FL has crafted about back door medicine, the last one was about flumazanil infusions. I agree with Wael Haddera that just because you have a Pharm.D. does not make to competent, just like in any profession there is a bell curve of skills. I intend no disrespect to the pharmacists at FL's hospital however I think as ICU boss he needs to sit down with the Director of Pharmacy and chat.
Just a few thoughts from a friendly neighbourhood Canadian. Hopefully I won't be "offed" by any accountant or pharmacy hit squads in the mean time.
Robert Aucoin:
Every so often, actually quite regularly, I get called down to the cave and have to answer as to why I let such and such be used in such and such case when there was no literature to support it. Or better still, I get a call with the "do you know how much this stuff cost?" screamed at me. Or I get accused of having my own formulary and satellite outside of the nine dots (long explanation). The main reason for the calls, accustations and dress downs is that I AM on the unit and I DO see the children and the parents and all the carnage that goes with it. Trying to explain to someone how to add KCl to a burretrol because of a child's crashing K+ is difficult if the person on the other end of the line doesn't know what a burretrol is. (poor grammar here)
In my little corner of the world 75% of the drugs are not approved for infant use. 98% of my collegues have only "run" through PICU while making deliveries. I have had to give directions to our Pharm.D. because they had never been to my office IN PICU.
Its a question of frame of reference. I'm clinical. They are not. I will argue and get into fist fights for meds for our kids.
I do not want the last word on therapy. I don't have the background and they don't pay me enough money to do that. I will assist and argue with you anywhere, anytime but in the end YOU will make the final decision.
My job is to improve the outcome of pharmacotherapy. My job is to protect the patient from mis-adventures in pharmacetical practice. My job is make sure no one does anything dumb that may endanger one of my patients. I get pissy about them, they're not big enough to do it themselves. I am. Now then let me get my resume out and brush it up. What's the other thing? Flame retardant suit. I wonder if my old job on the Tug boats is still open?
Dick Burrows:
If you are there then I have no gripe with you and anyway I would not dream of flaming you. I am very well aware of the medical ego and probably have more than my fair share!
But the point quite simply is that all too often decisions are made by people who have sweet FA to do with the patient.
And the distance breeds contempt not fondness.
I appreciate the fact that the pharmacist has a valuable place to play - in fact everybody in the loop has a place to play.
When I go to do my ward round tomorrow those of us who are there (doctors, nurses, physios, pharmacists etc) will discuss the problems of each person in turn. We will seek second opinion where necessary and consult with the relatives. We will make very real decisions by consensus which, depending on the circumstances, will dramatically affect a life.
They are not easy decisions and they are not lightly taken but when, after all the discussion and heartache, somebody else comes up with a contrary decision which is taken - more with an eye on sleep or questionable economics - then I throw a real wobbler.
I am open to reasonable discussion and if the pharmacist on my ward round says 'I dunno but let me look into it" I am more than happy to accommodate. But when people resort to scoring points by way of a quick search on Medline I get really pissed off.
Ego comes into it. Of that there is no doubt but at least let all egos play out their games at the bedside! - which you have already said you do.
David Crippen:
I presented this case, which by the way is (mostly) real, to illustrate the point that "evidence based medicine" is only as good as individual interpretations of the evidence." Most respondents so far have fallen into my trap as I expected them to (loud cackle).
For different reasons, the physician in this case interpreted the evidence in a favorable light and the pharmacist interpreted it in a radically different light. Why? All other factors being equal, the physician had an incentive to "do the right thing" for the patient and consider cost and bureaucratic hassles a secondary effect. The pharmacist's incentive is to save money for their boss, the hospital that hired them with the expressed intent to cost-cut. Out of the existing array of evidentiary data, both these guys made decisions according to the dictates of their own opinion, and then used selected data bases to support those decisions.
Back in the old days, power figures in medicine made policy decisions on thinly veiled personal whims, frequently not knowing or even caring about evidence. Enter "Managed Care". Now power figures in medicine make decisions on personal whims and support them by reference to "evidence" specifically crafted to support their whims. "Care Managers " have figured this out and now have collected their own data bases that support their whims as well. Otherwise, little has changed(chortle).
Now that I have rendered a big chunk of the CCM-L "scientists" completely apoplectic, let me twist the knife a little and finish off the rest. Otis Rush is wailing on the tubes and I'm in that kind of mood.
The fight for who should have the right and privilege to "practice medicine" has escalated to higher echelons of empowerment vs. obstruction. In the managed care arena, physicians cannot be trusted to conserve scarce resources because they have an incentive to create demand for their services, and they share in expended resource allocation. Accordingly, Care Managers have figured out two methods of keeping them (us) in line.
First is simply to make them part of the system. Throughout history, social and political change has mainly been fomented by those who have nothing to lose and something to gain by bucking the system. This is why a bunch of scruffy kids could bring down a President and stop a war. Astute managers figured this out and simply absorbed potential recalcitrants into a system that rewards them for going along with the party line and corrects them when they deviate. Recall Lou Brusco stating a while ago that his reluctance to go along with hospital cost cutting measures would quickly impact his "performance review" and subsequent salary and benefits. It's as simple as that.
Secondly, the system hires para-health care practitioners to maintain checks and balances on physicians, and empowers them to make patient care decisions from the back door. Instead of empowering them to practice medicine, they empower them to restrict the practice of medicine. So, if a clinician with seven years of residency and fellowship after medical school and 25 years at the bedside makes a decision to "do something", that decision is only good until as the decision of a 25 year old kid with an college level expertise in drugs and drug interactions to withhold that treatment on the basis of standing orders from the Boss to "cut costs".
So, then, one could describe "managed care" as a method of blunting the incentives of physicians to expend scarce resources on individual patients and standardize them to means that have been "proven" cost effective in larger groups. Toward that end, it is necessary to empower non-physicians to practice medicine by impasse rather than commission. Slick trick, Eh? Who said bureaucrats were dumbasses.
So, as you might have gathered, I am less than impressed with the concept of "Evidence Based Medicine" as I see it practiced in the trenches. I am sure than Gordo the Doig can and will set me straight on how it should be practiced. But the action that I see translated at the front line is not what it was conceived to be by the Ivory Tower. Let me take a classic example and dissect it just a little. Al Connors, start itching.
There is no objective evidence that I know of that the placement of a pulmonary artery catheter results in improved outcome, and some recent evidence that it may do the opposite. Yet, as I sit here grooving on numerous Otis' riffs, I will emphatically tell you that, despite the evidence, I passionately believe that PA lines are a gift from God in selected patient and DIRECTLY improve outcome. In selected patients. The reason that there is no evidence for the benefit is simply because most people that use PA lines don't know how to select patients or interpret the resultant data. Current methods of obtaining data only measure the ability for all comers to integrate with large groups of patients.
The (potential) tyranny of Evidence Based Medicine (EBM). If benefit cannot be proven for all comers for large populations, individualized benefit cannot be condoned. My evidence is better than your evidence. My statistician can beat up your statistician. And so we have the potential to lose this beneficial thing because we can't construct a trial that demonstrates its benefit in experienced hands for patients selected by those hands. But Evidence Based Medicine will be our salvation. It will cut out all the crap that can't be proven to be effective.
Oh, all right. Have at it. I'm sitting here sucking on some Single Barrel Bourbon that Streat is coming all the way to Pittsburgh for, without any flame proof suit at all. I'm an easy target (but I have mean, vengeful friends) :-)
Gordon Doig:
In a system where budgets are not constrained and resources are infinite, we could easily argue that all should be done that does not cause harm. But since budgets are limited, using expensive, unproven therapies based on ego or belief does cause harm. Perhaps to the patients you care for directly, perhaps to those you will care for in the future.
The bottom line is, if you have good solid evidence to prove that a therapy works, it should be available. If however, the evidence is controversial (see 'quackwatch'), we should take a step back and assess it objectively.
Dick Burrows:
But that is precisely the point - where is the good solid evidence? You cannot demonstrate it and yet and in spite of the lack of good solid evidence Western medicine persists with unproven therapies in just the same way as alternative practitioners persist with theirs - but at least they don't spread a thin patina of science on their arguments. Instead of putting forward the very real argument that such therapies cannot be proven, and therefore of little value, you resort to large multicentre trials which in turn generate their own confounding variables.
Furthermore there is a great deal of difference between controversial evidence and what you are referring to as quackery.
The quack is dangerous because he is out for self gain at the expense of the patient and doesn't care how he gets his gain. Such an attitude is unfortunately no less likely in Western medicine as opposed to alternative medicine and I by no means imply that practitioners of alternative techniques indulge themselves in quackery. It is the standard of care that is important here. Quite rightly techniques should be evaluated but you do not necessarily throw out something merely because it doesn't seem to work according to your Westernised approach.
Wael M. R. Haddara:
1. What you described in the case study is not Evidence Based Mecicine (EBM)
The two references found by the physician are not primary papers. One of the references cited by the pharmacist is an animal study. So, the "strength" of the evidence immediately plummets. Therefore, clinical experience/n=1 trials and pathophysiolgoy can play a good role ....
2. "Abusum non tollit usum" - abuse is not an argument for disuse.
Evidence Based Medicine (EBM) is a bandwagon. As such, there are a lot of people on that bandwagon who (a) do not understand what EBM is; and/or (b) just want to be "hip". As Dr. Gord Guyatt once put it so eloquently,".. in the absence of a good Randomized Controlled Trial (RCT), your clinical experience is good evidence." (or words to that effect) That point is lost on a lot of people ...
3. "Reason will never be lacking when the strong wish to oppress the weak."
Sure, perhaps the managed care bosses are using quasi-EBM lingo to support their cut-backs. So what ? If they EBM didn't serve their purposes, they'd find something else.
4. "If you can't beat them, join them."
If the managed care bosses are attempting to neutralize the physicians by absorbing them into the system, why don't you do the same with those "para-health care professionals" ... involve the pharmacists in the clinical decision making by making them part of the team.
Arthur Morgan:
If benefit cannot be proven for all comers for large populations, individualized benefit cannot be condoned. My evidence is better than your evidence. My statistician can beat up your statistician. And so we have the potential to lose this beneficial thing because we can't construct a trial that demonstrates its benefit in experienced hands for patients selected by those hands. But Evidence Based Medicine will be our salvation. It will cut out all the crap that can't be proven to be effective.
AJM:A large STRATIFIED controlled trial would be needed to show that pulmonary artery catheters kill more people than they save, and at huge financial cost - why bother, no-one would believe it anyway? The cost of the trial may be more than the money saved. Can some-one please explain to me the important difference of knowledge based upon fact (="evidence") that we learned at university , and EVIDENCE that proves something works or not , and will now govern our practice.
David Crippen:
Someone said: When people had to be laid off because of the budget cuts (mostly nurses, unfortunately) everyone suddenly realized that controlling the drug budget was in everyone's benefit.
I just heard this identical argument from a local hospital pharmD less than 48 hours ago and I sense a trend here. I am much more impressed that this Pharmacy budget: nurse employment is a cleverly contrived ploy by those trying any way possible to justify such actions in a manner calculated to impress the most vulnerable population of those most sensitive to it.
I am not convinced that these two phenomenon have any relationship to each other at all. The ICU is the repository of the sickest batch of patients in the hospital, patients that require minute to minute titration frequently on a 1:1 basis with the most skilled nurses in the hospital. Why is the ICU the logical place to practice draconian cost cutting and why does the ICU pharmacy budget have anything specifically to do with the nurses? My internal bullshitometer is off the scale.
Someone said: Develop a consensus process, Use evidence, Make exceptions when necessary
I think these three processes are the key. However, the "system" (for want of a better term) really only pays lip service to them. When any of these things actually break the threshold, some way is quickly found to negate them. The point is cost cutting, and the people responsible for it are those most loyal to the cost cutters, not necessarily the patients. Toward that end, all these things are only in place to give the appearance of flexibility. It's like asking your kid if he wants to get a haircut. If he says no, he's going to get a haircut anyway. You have only given him the illusion that he has some input to make him feel better about it if he happens to choose the right option.
Gordon Doig and others said What you described in the case study is not Evidence Based Medicine (EBM)
That is correct. However, what EBM is conceived to be in the lofty towers where the first iterations brew, is not the same as what it ends up as in the trenches where the enemy is fought with tooth and claw. I would hazard a guess that MOST practicing physicians at the "trench" level, cannot evaluate all the things necessary to make for "evidence Based Medicine", even if they had time and energy to do so. They read abstracts, and predigested synopses of the literature. Like the famous line from "The Jerk" when Steve Martin's father gives him the lesson on how to survive in a hostile world:
"Son, (proffers one hand with large turd in it) This is shit.....(opens other hand with shoe polish can)...and this is Shinola.....if you can tell the difference you will always be successful". And there is a lot of shit out there...and it appears in peer reviewed journals, frequently as thinly veiled advertising.
To wit:
Brand X sedative works just great in the ICU: You should all be using it!!
By: Doctors X, Y and Z
Objective: To give Brand X to a lot of patients and see if they get sedated.
Design: We gave Brand X to all the patients that looked like they needed sedated.
Setting: A hospital ICU, Natch
Patients: Ones that thrashed around or grimaced a lot.
Measurements: Nurses looked at 'em, then we looked at 'em, then we looked at each other.
Results: They all did great.
Conclusions: Brand X works great and it's cheaper than Brands Y and Z. We should all be using Brand X allatime.
(This study supported by an unrestricted grant from the makers of Brand X).
Otherwise learned members of MY department have touted "evidence" similar to the above in Journal Club to justify their own notions about how savings can occur most effectively. if you build it, they will come. As long as the pressure is on to be cheap, evidence will be generated to justify cheap.
Gordon Doig said But since budgets are limited, using expensive, unproven therapies based on ego or belief does cause harm.
Then, I ask, the burden of proof is on whom to decide what is harm and what is benefit? The ego of the physician or the ego of the hospital employee reporting to the hospital's cost effectiveness policy.
Angela Foehl:
I hung back on this one, reading with interest the comments. There are 2 basic issues here--1) how much stock should anyone place in quick Medline searches and abstracts in patient treatment decisions and 2) whose decision governs if the treating physician and pharmacist disagree.
Now it's my turn--this is only on issue #1 to save time:
1) Always remember that abstracts are not necessarily well-reflective of the actual study methods, results, etc. They should never be relied upon in the absence of the actual full-text studies for treatment decisions. Do you really want to tell the jury--"Well, I didn't have time to read the whole article"?
2) The search string input will provide different search results, depending on the wording--it is possible to miss quite a few pertinent studies if you do not exhaust various permutations of the search terms used. (I have experienced this many times.) So, don't rely on just one or two search strings and think you've found it all. Pertinent findings can often be found as subsidiary study findings, which may come using analogous or related search terms.
3) When analyzing the full-text articles, it is essential to identify the study population and its relationship to your patient (if any), whether the study population was large enough to provide statistically significant results, whether the hypotheses are articulated well and how they relate to the stated results, whether the stated results in the conclusions match the actual results, and which questions the study should have asked or answered.
It is possible to go on, but the point is that a quick & dirty Medline search (and, remember, Medline is not all-inclusive--there are other databases out there) may give you good questions to ask yourself or others (i.e., a pharmacist) about, but is no substitute for a thorough meta-analysis of the relevant literature and cannot be done under extreme time pressure.
Erkan Hassan:
I believe this all started with the case of the acetaminophen overdose and the possible use of cimetidine in this patient as discussed between a physician and pharmacist.
IMHO, the best way to approach the case has already been pointed out by a number of list members (physicians, pharmacists, attorneys). To summarize and interject my views, I think we need to remove the professional designations. It doesn't matter if the 2 people involved were physician/pharmacist or pharmacist/nurse, or nurse/respiratory therapist, or someone from central supply and the janitorial crew. The main point is the behavior and how it affects patient care. In this light, THEY WERE BOTH WRONG!! I make this statement based on 2 areas of the case (and again issues that have been brought up by others)
A. ANYONE who initiates, withholds or withdraws therapy to a critically ill patient based on reading only abstracts (and I don't care how many of them they read) is wrong. When someone makes a decision in this manner, the next sound they hear should be that of their professional license going through the paper shredder.
B. When ANYONE initiates, withholds or withdraws a NEW therapy to a critically ill patient without going to see the patient at the bedside...rev up the paper shredder.
Angela Foehl:
Here are some excerpts from a research paper I did a few years ago on cost-control of antibiotics in hospital environments. I assure you, the relationship between the cost of antibiotics and nurses is tenous, at best. Antibiotics comprise one of the most expensive category of drugs and the newest, most powerful antibiotics are exhorbitantly expensive, compared to penicillin, for instance. The longterm overuse of antibiotics in treatment of humans and in animal feeds have contributed to the mutation of antibiotic-resistant microbes. So has the upsurge in tuberculosis cases in AIDs and/or homeless patients, which is often poorly treated, if at all. These resistant microbes require multiple-drug regimens, which also increases per-patient costs of antibiotic administration.
Here are the excerpts from my paper:
"The effect of resistant microbial strains also incurs higher treatment costs as multiple drug therapies must often be employed before an infection is under control. One estimate is that this adds from $100 million to $200 million to total U.S. medical costs. This is, of course, a financial boon for the pharmaceutical companies, whose sales of antibiotics to drugstores and hospitals alone have risen in five years from a "mereo/oo $3.7 billion in 1988 to $5.6 billion in 1993. These figures do not even include sales to HMOs, clinics and other purchasers.
The health and financial implications of antibiotic prescribing patterns in our country are serious. Infection of hospitalized patients with antibiotic-resistant bacterial strains annually "increases the nation,s (U.S.) health care costs by as much as $4 billion. Antibiotic expenditures alone can comprise "30% to 50% of a hospital,s total drug budget.o/oo
Formularies have been used to control drug costs for many years and other methods of prescription reviews and so forth have been found useful, as well in meeting this goal.
Restricting comments just to the concept of Evidence-Based Medicine--there are numerous interpretations and applications for what this means. Most current allopathic medical treatments are, in one way or another, evidence based--this is nothing new. What is new is quick, easy & nearly ubiquitous access to medical studies by physicians in the trenches. It is the also the first time in history that epidemiological evidence on treatment methodologies and outcomes is easily available to see whether treating 2 populations with the same disorders but different treatment modalities have significantly different outcomes in cost-effectiveness, patients' life quality, etc. So, it is computerized access to information that now alters patient treatment decisions on the micro and macro levels.
The question then becomes, how best can this information be incorporated into treatment decision-making? Practitioners and managed-care managers must all find scientifically acceptable and practical ways to do this. Sure, some people will use epidemiological evidence toward their own politicized or money-grubbing ends, as always. But, there is unprecedented opportunity to compare old-standby treatments to study data to decide whether or not a change in treatment methods is wise. Some studies on East and West coast hospitals, i.e., on CABG, have yielded very useful results that have led to changes in patient treatment methods.