Evidence-Based Medicine in the EMR Era

Students working with an artificial patient (F...Image via Wikipedia

Evidence-Based Medicine in the EMR Era

Jennifer Frankovich, M.D., Christopher A. Longhurst, M.D., and Scott M. Sutherland, M.D.
November 2, 2011 (10.1056/NEJMp1108726)

Many physicians take great pride in the practice of evidence-based medicine. Modern medical education emphasizes the value of the randomized, controlled trial, and we learn early on not to rely on anecdotal evidence. But the application of such superior evidence, however admirable the ambition, can be constrained by trials’ strict inclusion and exclusion criteria — or the complete absence of a relevant trial. For those of us practicing pediatric medicine, this reality is all too familiar. In such situations, we are used to relying on evidence at Levels III through V — expert opinion — or resorting to anecdotal evidence. What should we do, though, when there aren’t even meager data available and we don’t have a single anecdote on which to draw?
We recently found ourselves in such a situation as we admitted to our service a 13-year-old girl with systemic lupus erythematosus (SLE). Our patient‘s presentation was complicated by nephrotic-range proteinuria, antiphospholipid antibodies, and pancreatitis. Although anticoagulation is not standard practice for children with SLE even when they’re critically ill, these additional factors put our patient at potential risk for thrombosis, and we considered anticoagulation. However, we were unable to find studies pertaining to anticoagulation in our patient’s situation and were therefore reluctant to pursue that course, given the risk of bleeding. A survey of our pediatric rheumatology colleagues — a review of our collective Level V evidence, so to speak — was equally fruitless and failed to produce a consensus.
Without clear evidence to guide us and needing to make a decision swiftly, we turned to a new approach, using the data captured in our institution’s electronic medical record (EMR) and an innovative research data warehouse. The platform, called the Stanford Translational Research Integrated Database Environment (STRIDE), acquires and stores all patient data contained in the EMR at our hospital and provides immediate advanced text searching capability.1 Through STRIDE, we could rapidly review data on an SLE cohort that included pediatric patients with SLE cared for by clinicians in our division between October 2004 and July 2009. This “electronic cohort” was originally created for use in studying complications associated with pediatric SLE and exists under a protocol approved by our institutional review board.
Of the 98 patients in our pediatric lupus cohort, 10 patients developed thrombosis, documented in the EMR, while they were acutely ill. The prevalence was higher among patients who had persistent nephrotic-range proteinuria and pancreatitis (see tableResults of Electronic Search of Patient Medical Records (for a Cohort of 98 Pediatric Patients with Lupus) Focused on Risk Factors for Thrombosis Relevant to Our 13-Year-Old Patient with Systemic Lupus Erythematosus.). As compared with our patients with lupus who did not have these risk factors, the risk of thrombosis was 14.7 (95% confidence interval [CI], 3.3 to 96) among patients with persistent nephrosis and 11.8 (95% CI, 3.8 to 27) among those with pancreatitis. This automated cohort review was conducted in less than 4 hours by a single clinician. On the basis of this real-time, informatics-enabled data analysis, we made the decision to give our patient anticoagulants within 24 hours after admission.
Our case is but one example of a situation in which the existing literature is insufficient to guide the clinical care of a patient. But it illustrates a novel process that is likely to become much more standard with the widespread adoption of EMRs and more sophisticated informatics tools. Although many other groups have highlighted the secondary use of EMR data for clinical research,2,3 we have now seen how the same approach can be used to guide real-time clinical decisions. The rapid electronic chart review and analysis were not only feasible, but also more helpful and accurate than physician recollection and pooled colleague opinion. Such real-time availability of data to guide decision making has already transformed other industries,4 and the growing prevalence of EMRs along with the development of sophisticated tools for real-time analysis of deidentified data sets will no doubt advance the use of this data-driven approach to health care delivery. We look forward to a future in which health information systems help physicians learn from every patient at every visit and close the feedback loop for clinical decision making in real time.
Did we make the correct decision for our patient? Thrombosis did not develop, and the patient did not have any sequelae related to her anticoagulation; truthfully, though, we may never really know. We will, however, know that we made the decision on the basis of the best data available — acting, as the fictional detective Nero Wolfe would say, “in the light of experience as guided by intelligence.”5 In the practice of medicine, one can’t do better than that.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1108726) was published on November 2, 2011, at NEJM.org.


From the Division of Rheumatology (J.F.), the Division of Systems Medicine (C.A.L.), and the Division of Nephrology (S.M.S.), Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA.


  1. 1
    Lowe HJ, Ferris TA, Hernandez PM, Weber SC. STRIDE — an integrated standards-based translational research informatics platform. AMIA Annu Symp Proc 2009;14:391-395
  2. 2
    Prokosch HU, Ganslandt T. Perspectives for medical informatics: reusing the electronic medical record for clinical research. Methods Inf Med 2009;48:38-44
    Web of Science | Medline
  3. 3
    Gunn PW, Hansen ML, Kaelber DC. Underdiagnosis of pediatric hypertension — an example of a new era of clinical research enabled by electronic medical records. AMIA Annu Symp Proc 2007;11:966-966
  4. 4
    Halevy A, Norvig P, Pereira F. The Unreasonable Effectiveness of Data. IEEE Intelligent Systems, March/April 2009:8-12.
  5. 5
    Stout R. In the best families. New York: Viking Press, 1950:71.

Why hospitals and physicians should get serious about patient-centered care

QuikSCAT image of Hurricane Katrina on August ...Image via Wikipedia

Source: Kevin MD

Health care professionals are a cynical lot.   We joke about the “fad or buzzword of the month,” usually some vague concept heralded by the powers on high.   Our job is to promote the idea, knowing full well that the “next big thing” is probably right around the corner.
Take “patient-centered.” It sure feels like a buzz word.   I suspect most hospital and physician executives, and their ad agency partners, would agree.  But this time things are very different.
Here are reasons why hospitals and physicians should get serious about patient-centered care.
1. Patients are starting to discover that their doctors and hospitals are not nearly as good as they should be.
“Pay no attention to that man behind the curtain.” This line comes from the Wizard of Oz where little Toto rips the curtain back to show the great and powerful Oz is merely an old medicine show marketer from Kansas.
The analogy is a good one.  Patients across the U.S., and other countries, are “doing a Toto” as they pull back the curtains on doctors and hospitals only to learn that they are often not getting the quality of care they expected.
People every day hear about some story that undermines their confidence in the health care system.  Doctor Smith at XYZ hospital amputated the wrong limb again, Sally down the street was given the wrong medication, Mr. Patel’s opinion was ignored by his doctor, and so on.  Unlike years past when such stories were infrequent and seemed to occur in some other city… stories now appear daily, occur in my city, and are instantly shared with people around the world via the internet.
2. Patient-centered care is the right thing to do, and it’s not that hard
I think most would agree that today’s health care system is still very provider-driven.  That means that the care that is delivered, how it is delivered, who delivers it, and how outcomes are measured are all defined from the providers’ perspective (physicians, hospitals and payers ).   Patient-centered care simply means looking at these same issues but from the perspective of individual patients.   Notice nowhere here did I equate patient-centered care with smile training, customer service training or pianos in attractive lobbies.  Patient-centered care means involving patients in the planning, delivery and evaluation of health care where it really counts in terms of outcomes, patient adherence, cost reduction and fewer re-hospitalizations.
Being patient-centered is like doing a market research study and then implementing the findings.  Patient-centered care does not give absolute control to patients, it simply invites them into the party and gives them a place at the table.  As providers, we don’t do a good job of listening to patients.  We do an even worse job when it comes to acting on what patients tell us they want.
3. Patient-centered care will make any hospital or doctor stand out from the crowd.
Like a beautiful rainbow, patients and providers will recognize patient-centered care when they see it.   Like rainbows, example of patient-centered care are few and far between, but here are some tell-tale signs:
  • Providers and patients know each others’ names
  • Patients’ opinions are actively sought, listened to and honored where possible (no, a suggestion box, patient satisfaction survey or mission statement constitute being patient-centered — if you think they are then you aren’t patient-centered)
  • Patients tell you that their doctors and other team members really listened to what they had to say (again if you think satisfaction surveys qualify you aren’t there yet)
  • Patients are treated as the most important member of their health care team and taught how they can best contribute to the team’s success
  • Providers feel that their patients are actively involved in their own care
  • You see a significant improvement in patient health status, adherence, engagement, level of utilization and patient/provider experience
If these aren’t good enough reasons to give patient-centered care another look at your organization then just think about this.  Beginning in 2013, 30% of hospital Medicare reimbursement will be determined based upon patient experience.  Eventually commercial payers will follow suit.
Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs atMind The Gap.

Critical Moments — Doctors and Patients

Lenore M. Buckley, M.D., M.P.H.
N Engl J Med 2011; 365:1270-1271October 6, 2011

I lost myself in the very properties of [my patients‘] minds, for the moment at least, I actually became them . . . so that when I detached myself from them at the end of intense concentration over an illness that was affecting them, it was as though I was awakening from sleep. For the moment I myself did not exist, nothing of myself affected me. As a consequence, I came back to myself as if from any other sleep, rested.

William Carlos Williams, M.D.

A pale, thin, anxious 9-year-old boy sits in front of me. As I start to talk to him, I realize that he is in pain, stoic, and not very verbal. I glance down and notice a markedly swollen ankle. He has been losing weight and uncomfortable for months, his anxious parents report. The pain seems to come and go, but now it’s so severe that he has trouble getting off the bus.
I gently probe for more information. “Have you had diarrhea?” I ask the boy. Yes, he nods. His mother looks startled; he has obviously never mentioned it to her. “Any blood in the diarrhea?” He nods again, and now we’re both startled. The boy looks even more anxious, and I’m aware of his parents’ escalating panic. It’s then that I realize that this is one of those critical moments. I’ll confess that most of the time, I’m not the slow, thoughtful, organized, wise physician with an endless fund of knowledge that I always imagined I’d become. More often, I’m the harried, absent-minded doctor who rushes into the room an hour late and tries to organize her thoughts in front of you as you remind her who you are and why you’re there. But at moments like this, I become completely focused. William Carlos Williams, the poet and primary care physician, eloquently described these moments and the intensity of the relationship between doctors and patients as they embark on the treatment of a serious illness.
Such moments occur at most a few times a month, usually when I least expect them. I walk into an exam room prepared to hear about a straightforward problem or to see a child with pain “everywhere” who’s struggling with the social challenges of middle school, and then, as I listen, I realize that the person in front of me is seriously ill. Sometimes the patient or the parents already know; sometimes they have no idea. The dawning of this realization is followed by a call to full attention. In the next hour and over the next few months, what I do (or don’t do) will change the life of this child and family; what I say and how I say it will be critical, providing the information, reassurance, and hope to keep everyone moving forward.
With this boy, Sam, my questions and exam follow the usual order, and then it’s time to talk. I remind myself of my responsibilities — education, treatment, support, advocacy. I look into Sam’s eyes and try to describe, in language he can understand, general concepts that will give him a sense of what’s happening in his body. This basic explanation is usually adequate for the parents as well, who are often in a state of shock; we’ll have more time to talk later.
I explain it to Sam first, respecting the fact that it’s his body and he is able to understand — and needs to know — what’s happening. It’s an important step in showing him respect and giving him back some control. We’re beginning a relationship, and obtaining his trust will be key to getting his cooperation. I want him to know that I see who he is, care about what he thinks, and will be his ally.
As I talk, I envision myself building a protective wall around him and his parents to hold back the wave of fear, vulnerability, and loss of control that is rushing in as they realize something serious has occurred. I look into his eyes and explain with confidence and reassurance that things will get better. I offer hope: “We know what this is, and together we will get you better.” We are now a team, and he’s the most important team member. We discuss the possible diagnoses, treatment, the need for a GI referral, and how to reach me over the next few days.
As I leave the room, I feel like I’m rising to the surface of the water after a deep dive. I have been in another world, where outside sounds are muffled and time slows. Now I reemerge in the noisy, fast-paced world of outpatient medicine. I’m an hour behind schedule, and the nurses — and my next patient — are understandably annoyed. A long day awaits. But somehow the rest of the day is easier. The world comes into better focus. I have been reminded of why I’m here and how lucky I am to be doing what I do.
In the afternoon, I pass the pediatric gastroenterologist, who reassures me he will see Sam quickly, and within a week he’s diagnosed with Crohn’s disease and starts treatment.
I see Sam regularly over the next few months. I smile when I go into the room, look at him first as I say hello, and ask how things are going. I’ve learned to warn my patients about the ups and downs of glucocorticoid treatment: first, there’s relief when the medicine finally controls the symptoms, then there’s discouragement about side effects and changes in appearance and mood, followed by the struggle to discontinue them as the other medications begin to work. It’s an emotional roller coaster, and it’s my job to prepare them.
Sam has followed this path. There’s the visit at 4 weeks when the diarrhea has stopped and the joints are not painful. He is still quiet but looks relieved. When he returns at 8 weeks, he is markedly cushingoid, embarrassed, and dejected — it’s not easy to have a pumpkin face with acne in elementary school. Again, I sit next to him and look directly into his eyes. Sometimes this is not so easy with teens and preteens, who tend to stare down at the floor. In an attempt at humor, I bend down and turn my head up so I can see his face. “It will be better,” I reassure him. “A few more weeks.” He smiles. I walk him through the treatment plan again. I explain what’s happening to his body and go over the timelines.
By the 12th week, he is still cushingoid but surprisingly chatty and looks straight into my eyes as he reports what’s happened since the last visit. He seems to understand now that I am here to see and talk to him, and he is proud of his role in managing the illness. He looks more hopeful. The prednisone dose has been reduced, and he knows the tapering schedule well enough to correct his father, who is momentarily confused about the gastroenterologist’s treatment plan. He sees the light at the end of the tunnel.
Sam and his parents are at the beginning of a long journey. This illness will influence who Sam will become — affecting his self-image, relationships, and aspirations. His parents face one of life’s most difficult challenges. The course of their lives and their relationship shifted, almost imperceptibly, at that first visit. How their story will play out is still unclear to me, although I’ve seen hundreds of other versions of it over the years.
This time, I’ve been lucky enough to be there from that critical moment at the beginning, to be a part of the story’s evolution and, I hope, acceptable resolution. All physicians experience these moments. They shape our lives, inform our values, and educate and prepare us for the next patient who needs our help. The expectation of these moments and the satisfaction they bring keep us moving forward through difficult times. The challenge is to continue to notice them — to remember the personal impact of the diagnoses we make and our ability and obligation to soften the blows, to build that protective wall.
The name of the patient has been changed to protect his privacy.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.


From Virginia Commonwealth University School of Medicine, Richmond.

The New Language of Medicine

Pamela Hartzband, M.D., and Jerome Groopman, M.D.
N Engl J Med 2011; 365:1372-1373October 13, 2011

During our first year of medical school, we spent countless hours learning new words, memorizing vocabulary as if we were studying a foreign language. We discovered that some words that sounded foreign actually represented the familiar: rubeola was measles, pruritus meant itching. Now, we find ourselves learning a new language of medicine filled with words that seem familiar yet feel foreign. Patients are no longer patients, but rather “customers” or “consumers.”1 Doctors and nurses have been transmuted into “providers.” These descriptors have been widely adopted in the media, medical journals, and even on clinical rounds. Yet the terms are not synonymous. The word “patient” comes from patiens, meaning suffering or bearing an affliction. Doctor is derived from docere, meaning to teach, and nurse from nutrire, to nurture. These terms have been used for more than three centuries.
What precipitated the increasing usage of this new vocabulary in medicine? We are in the midst of an economic crisis, and efforts to reform the health care system have centered on controlling spiraling costs. To that end, many economists and policy planners have proposed that patient care should be industrialized and standardized.2 Hospitals and clinics should run like modern factories, and archaic terms such as doctor, nurse, and patient must therefore be replaced with terminology that fits this new order.
The words we use to explain our roles are powerful. They set expectations and shape behavior. This change in the language of medicine has important and deleterious consequences. The relationships between doctors, nurses, or any other medical professionals and the patients they care for are now cast primarily in terms of a commercial transaction. The consumer or customer is the buyer, and the provider is the vendor or seller. To be sure, there is a financial aspect to clinical care. But that is only a small part of a much larger whole, and to people who are sick, it’s the least important part. The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain. Furthermore, the term “provider” is deliberately and strikingly generic, designating no specific role or type or level of expertise. Each medical professional — doctor, nurse, physical therapist, social worker, and more — has specialized training and skills that are not recognized by the all-purpose term “provider,” which carries no resonance of professionalism. There is no hint of the role of doctor as teacher with special knowledge to help the patient understand the reasons for his or her malady and the possible ways of remedying it, no honoring of the work of the nurse as a nurturer with unique expertise whose close care is essential to healing. Rather, the generic term “provider” suggests that doctors and nurses and all other medical professionals are interchangeable. “Provider” also signals that care is fundamentally a prepackaged commodity on a shelf that is “provided” to the “consumer,” rather than something personalized and dynamic, crafted by skilled professionals and tailored to the individual patient.
Business is geared toward the bottom line: making money. A customer or consumer is guided by “caveat emptor” — “let the buyer beware” — an adversarial injunction and hardly a sentiment that fosters the atmosphere of trust so central to the relationship between doctor or nurse and patient. Reducing medicine to economics makes a mockery of the bond between the healer and the sick. For centuries, doctors who were mercenary were publicly and appropriately castigated, the subjects of caustic characterization in plays by Moliere and stories by Turgenev. Such doctors betrayed their calling. Should we now be celebrating the doctor whose practice, like a successful business, maximizes profits from “customers”?
Beyond introducing new words, the movement toward industrializing and standardizing all of medicine (rather than just safety and emergency protocols) has caused certain terms that were critical to our medical education to all but disappear. “Clinical judgment,” for instance, is a phrase that has fallen into disgrace, replaced by “evidence-based practice,” the practice of medicine based on scientific data. But evidence is not new; throughout our medical education beginning more than three decades ago, we regularly examined the scientific evidence for our clinical practices. On rounds or in clinical conferences, doctors debated the design and results of numerous research studies. But the exercise of clinical judgment, which permitted assessment of those data and the application of study results to an individual patient, was seen as the acme of professional practice. Now some prominent health policy planners and even physicians contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints, written by experts.2 These guidelines for care are touted as strictly scientific and objective. In contrast, clinical judgment is cast as subjective, unreliable, and unscientific. But there is a fundamental fallacy in this conception. Whereas data per se may be objective, their application to clinical care by the experts who formulate guidelines is not. This truth, that evidence-based practice codified in clinical guidelines has an inescapable subjective core, is highlighted by the fact that working with the same scientific data, different groups of experts write different guidelines for conditions as common as hypertension and elevated cholesterol levels3 or for the use of screening tests for prostate and breast cancers.4 The specified cutoffs for treatment or no treatment, testing or no testing, the weighing of risk versus benefit — all necessarily reflect the values and preferences of the experts who write the recommendations. And these values and preferences are subjective, not scientific.5
What impact will this new vocabulary have on the next generation of doctors and nurses? Recasting their roles as those of providers who merely implement prefabricated practices diminishes their professionalism. Reconfiguring medicine in economic and industrial terms is unlikely to attract creative and independent thinkers with not only expertise in science and biology but also an authentic focus on humanism and caring.
When we ourselves are ill, we want someone to care about us as people, not as paying customers, and to individualize our treatment according to our values. Despite the lip service paid to “patient-centered care” by the forces promulgating the new language of medicine, their discourse shifts the focus from the good of the individual to the exigencies of the system and its costs. Marketplace and industrial terms may be useful to economists, but this vocabulary should not redefine our profession. “Customer,” “consumer,” and “provider” are words that do not belong in teaching rounds and the clinic. We believe doctors, nurses, and others engaged in care should eschew the use of such terms that demean patient and professional alike and dangerously neglect the essence of medicine.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.


From Beth Israel Deaconess Medical Center and Harvard Medical School — both in Boston.

Designing a Smarter Patient

[medical]Edel Rodriguez

When given clearer information, patients weigh risks and benefits differently from their doctors.

“I’m comfortable with that,” or “No, it wouldn’t be comfortable for me.”
That’s what our patients often tell us when faced with a choice about taking a medication or undergoing a procedure. And the discussion usually stops there.
But what makes someone comfortable or uncomfortable with one treatment or another, or with no treatment at all? Where do these views come from? And how can patients make better decisions?
For answers, we spent four years interviewing scores of patients of different ages. We found that a host of powerful and often hidden influences, inside and outside the patient’s mind, can sway thinking and distort judgment. We also discovered that, by unmasking those influences, it is possible for patients to gain greater confidence and control over their medical decisions.
Consider the case of Susan Powell (not her real name), a nurse’s assistant now in her 50s. She had been healthy all her life, but when she turned 45, she decided to see a primary-care doctor. Susan ate healthy foods and was physically active, but she was a bit overweight, and her blood tests showed that she had high cholesterol. Her doctor prescribed a statin drug and asked her to come back in a month.

Statins are among the most commonly prescribed medications in the world. In the U.S. alone, more than 25 million people take the drugs to lower their cholesterol, which is a key factor leading to heart attack and stroke.
Soon after seeing her doctor, Susan spoke with an acquaintance at church who had developed muscle pain after starting to take a statin. Susan also thought of her father, who had high cholesterol and never took any medication for it. “People take too many pills,” he often told his children. He lived a long, full and active life.
Susan decided not to take the statin.
Many people decline treatment because they know someone who suffered from side effects or someone who lived well into old age without treatment. Stories deeply affect all of us, and they can make real the risks and benefits that might otherwise seem abstract—but they can also distort our vision by making the rare appear routine.
Statistics can help to put lessons drawn from stories into a larger context, letting us make a more considered choice than we possibly could by using narratives alone.
At Susan’s follow-up appointment a month later, her doctor told her that “by taking a statin pill, you’ll reduce your risk of a heart attack over the next 10 years by as much as 30%.” The risk of side effects, she continued, was very small, and the benefits far outweighed the risk. Susan promised to give it serious thought.
She continued to search for information, reading everything she could about cholesterol. What caught her eye was a government-sponsored link to a “10-Year Heart Attack Risk Calculator.”
She entered her age, total cholesterol number of 240, and “good” cholesterol (HDL) of 37. She was not a smoker, her blood pressure was fine, and she was on no medications. The result: “Risk Score: 1%: Means 1 of 100 people with this level of risk will have a heart attack in the next 10 years.”
This means that 99 of 100 people like me won’t have a heart attack in the next 10 years, Susan told herself. She started to feel much better. She had found a key number in health literacy: her risk for disease without treatment.
Without treatment, Susan’s risk for a heart attack was 1 in 100. If 1 in 100 women has a heart attack, that means 2 in 200 do, or 3 in 300. The statin treatment reduces risk by 30%, or about one-third.
Let’s apply that benefit to a group of 300 women like Susan, where three would have a heart attack without taking statins. If we treat them all, we would prevent one heart attack—because we protect one-third of those three. The other two women would still have a heart attack despite taking the medicine. The remaining 297 would not have had a heart attack even without the medication, so they wouldn’t benefit from taking it.
This statistic comes as a surprise to many people. When you hear that a statin lowers Susan’s risk by 30%, it sounds as if she is at a 100% risk of suffering a heart attack if she doesn’t take the medication.
Another component of health literacy is understanding the risks of a therapy. Statins cause muscle pain in 1% to 10% of people who take them. However, if we “flip” the frame, the number without any side effects is 90 to 99 out of 100, a much more reassuring statistic.
Advertisements for drugs may include statistics, but fundamentally these ads are designed to communicate a compelling tale. Over the weeks that followed her appointment with her physician, Susan paid particular attention to ads for statins. Once she started looking for them, they seemed to be everywhere.
In 2007, a team of researchers from the UCLA Medical Center and other medical centers studied prescription drug ads broadcast on national networks. They found that the average American TV viewer sees over 1,000 prescription drug ads in the space of a year. That’s 16 hours all told—much more time than the average person spends with his or her primary-care physician.
The study concluded that the large majority of TV ads fail to fulfill an educational purpose. But they clearly work, at least from the point of view of sales: Every $1,000 spent on advertising translated into 24 new prescriptions, according to an analysis by the House Energy and Commerce Committee.

Another illuminating study, conducted by researchers at the Dartmouth Institute for Health Policy and Clinical Practice, examined the impact of printed drug ads on patient preferences. One group was given actual ads. A second group received the same ads, except that the brief summary at the end of the text was replaced by a “drug-facts box.” The box presented information in a clear, accessible fashion, similar to the way we recalculated the benefits and risks of a statin for Susan.
The results of the Dartmouth research are impressive. Nearly two-thirds of the group that saw the original ads overestimated the benefits of the treatment. They believed it was 10 times more effective than it actually was. But nearly three-quarters of the participants who saw the information in the drug-facts box correctly assessed the actual benefits of the treatment.
Even more striking was another finding. When people were given readily understandable information about the statin’s actual benefit in preventing future heart disease, nearly twice as many said they wouldn’t take the drug in light of its side effects. When given clearer information, the patients weighed the risks and benefits differently from their doctors and were less likely to take the medication.
Susan Powell’s decision was not simple. More than five years later, her doctor continues to encourage her to take the drug, and she continues to say no—but now, at least, she can more fully explain why.

—Dr. Groopman and Dr. Hartzband are on the faculty of Harvard Medical School and the staff of Beth Israel Deaconess Medical Center, both in Boston. This essay is adapted from their new book, “Your Medical Mind: How To Decide What Is Right for You.

Health Alliance for prudent antibiotic prescribing in patients with Respiratory Tract Infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

example of selection for bacteria by antibioti...                                     Image via WikipediaFelicitaciones a nuestros colegas de Misiones que participaron de este estudio y en particular a la Dra. Lidia Caballero. Fue publicado en PLoS.  

Source: http://www.biomedcentral.com/1471-2296/12/52

Research article

Health Alliance for prudent antibiotic prescribing in patients with Respiratory Tract Infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

Lars Bjerrum email, Anders Munck email, Bente Gahrn-Hansen email, Malene PLEJDRUP Hansen email, Dorte EJG Jarbol email, Gloria Cordoba email, Carl Llor email, Josep Maria Cots email, Silvia Hernandez email, Beatriz GONZALEZ Lopez-Valcarcel email, Antonia Perez email, Lidia Caballero email, Walter von der Heyde email, Ruta Radzeviciene email, Arnoldas Jurgutis email, Anatoliy Reutskiy email, Elena Egorova email, Eva Lena Strandberg email, Ingvar Ovhed email, Sigvard Molstad email, Robert VANDER Stichele email, Ria Benko email, Vera Vlahovic-Palcevski email, Christos Lionis email and Marit Ronning email

BMC Family Practice 2011, 12:52doi:10.1186/1471-2296-12-52

Published: 20 June 2011

Abstract (provisional)


Excessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.


GPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.


A total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.


A multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.

In Memorian: Barbara Starfield

Con profunda tristeza los médicos generales y de familia recibimos la noticia del fallecimiento de Barbara Starfield. Comprometida con la atención primaria, las palabras huelgan y copio aqui, para quienes no la conocieron, su pagina de profesora en John Hopkins, la misma Universidad donde nació el modelo flexneriano y que ella combatió. Tuve el honor de, si bien no conocerla personalmente, leerla en la lista de “Social Determinats of Health”, e intercambiar opiniones a través de e-mails. Hemos perdido a un simbolo de la Atención Primaria, pero su pensamiento seguirá vivo. Mi condolencia también a su amigo, quien me dió la noticia, Juan Gervas.

Barbara Starfield


Academic Degrees
Departmental Affiliation
Health Policy and Management
Affiliation Type:
Primary Care Policy Center
Population, Family and Reproductive Health
Affiliation Type:
Departmental Address
452 Hampton House
Contact Information
Personal Website
Research and Professional Experience
Determinants of health and equity in health; effectivenss and equity of health services; assessment of population health; co-morbidity and case mix; primary care and specialty care and their interrelationships; continuity (longitudinality) of care and its effects; comprehensiveness and coordination of care

Honors and Awards
David Luckman Memorial Award, State University of New York, Downstate Medical Center, 1958. The 1967 Award of The Enuresis Foundation for “significant contribution to knowledge and understanding of enuresis.” Research Scientist Development Award (K02 HS 46225) from the National Center for Health Services Research and Development, 1970-75. Member, Institute of Medicine, National Academy of Sciences. Elected 1977. The George Armstrong Award for Work in Advancing the Goals of Improved Patient Care, Teaching, and Research in Ambulatory Pediatrics. The Ambulatory Pediatric Association, May 1983. First Annual Research Award for Contributions to Research in Child Health. The Ambulatory Pediatric Association, May 1990. Residential Scholar, Bellagio Study Center, Rockefeller Foundation, June 9 – July 13, 1990. Special Recognition Award for the Secretary for Health and Human Services (Task Force to Develop Child Health Indicators, 1990), May 1991. First National Primary Care Achievement Award, Pew Charitable Trusts/Health Resources and Services Administration (DHHS), 1994. Distinguished Investigator Award, Association for Health Services Research, 1995. American Public Health Association‘s Martha May Eliot Award, 1995. AHSR (Association for Health Services Research) Distinguished Fellow, 1996. Maurice Wood Award for Lifetime Contribution to Primary Care Research, North American Primary Care Research Group (NAPCRG), 2000. Honorary Fellow, Royal College of General Practitioners (UK), 2000. Lifetime Achievement Award, Ambulatory Pediatric Association, 2002. Morehouse School of Medicine Excellence in Primary Care Award, 2002

Selected Publications
Gervas J, Starfield B, Heath I. Is clinical prevention better than cure? Lancet 2008; 372:1997-9. Starfield B. Refocusing the system. N Engl J Med 2008; 359(20): 2087, 2091. Lee TH, Bodenheimer T, Goroll AH, Starfield B, Treadway K. Perspective roundtable: redesigning primary care. N Engl J Med 2008; 359(20): e24. Starfield B. Commentary: Access, primary care, and the medical home: rights of passage. Med Care 2008; 46: 1015-16. Starfield B. The biggest bang for the buck: a conversation with Barbara Starfield, M.D., M.P.H. Interview by Sallie Rixey. Md Med 2008; 9(3): 11-3. Rawaf S; De Maeseneer J; Starfield B. From Alma-Ata to Almaty: a new start for primary health care. Lancet 2008; 372(9647): 1365-7. Starfield B. An evidence base for primary care. Managed Care 2008; 17(6): 33-26, 39. Starfield B, Hyde J, Gérvas J, Heath I. The concept of prevention: a good idea gone astray? J Epidemiol Community Health 2008; 62: 580-83. Alonso J, Urzola D, Serra-Sutton V, Tebe C, Starfield B, Riley AW, Rajmil L. Validity of the health profile-types of the Spanish Child Health and Illness Profile – Adolescent Edition (CHIP-AE). Value in Health 2008; 11: 440-9. Starfield B. Editorial: The importance of primary care in health systems. Hong Kong Practitioner 2008; 30: 1-2. Starfield B. Comment: Quality and outcomes framework: patient-centred. Lancet 2008; 372: 692-4. Starfield B. Commentary: Primary care in Canada: coming or going? Healthc Pap 2008; 8: 58-62; discussion 64-7. Starfield B. Social gradients and child health. In Heggenhougen HK, Quah SR (eds.). International Encyclopedia of Public Health, Vol 6, pp. 87-101. San Diego, CA: Academic Press, 2008. Gervas J, Starfield B, Violan C, Minue S. GPs with special interests: unanswered questions. Br J Gen Pract 2007; 57: 912-7. Starfield B, Fryer GE Jr. The primary care workforce: ethical and policy implications. Ann Fam Med 2007; 5: 486-91. Starfield B, Birn A-E. Income redistribution is not enough: income inequality, social welfare programs, and achieving equity in health. J Epidemiol Community Health 2007; 61: 1038-41. Starfield B. Global health, equity, and primary care. J Am Board Fam Med 2007; 20(6): 511-3. Gérvas J, Starfield B, Minué S, Violan C, Seminario de Innovacion en Atencion Primaria 2007. [Some Causes (and Solutions) of the Loss of Prestige of General Practitioners/Family Doctors. Against the Discrediting of Heroes.]. Aten Primaria 2007; 39(11): 615-8. Beasley JW, Starfield B, vanWeel C, Rosser WW, Haq CL. Global health and primary care research. J Am Board Fam Med 2007; 20(6):518-26. Pueyo M-J, Serra-Sutton V, Alonso J, Starfield B, Rajmil L. Self-reported social class in adolescents: validity and relationship with gradients in self-reported health. BMC Health Services Research 2007; 7:151. Pasarin MI, Berra S, Rajmil L, Solans M, Borrell C, Starfield B. [An instrument to evaluate primary health care from the population perspective]. Aten Primaria 2007; 39 (8): 395-401. Forrest CB, Shadmi E, Nutting PA, Starfield B. Specialty referral completion among primary care patients: results from the ASPN Referral Study. Ann Fam Med 2007; 5: 361-7. Starfield B, Horder J. Interpersonal continuity: old and new perspectives. Br J Gen Pract 2007; 57 (540): 527-9. Starfield B. Pathways of influence on equity in health. Soc Sci Med 2007; 64 (7): 1355-62. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv 2007; 37(1): 111-26. Starfield B, Gervas J. Family medicine should encourage its clinicians to specialize: negative position. Chapter 10 in Buetow SA and Kenealy TW. Ideological Debates in Family Medicine, pp. 107-119. New York, NY: Nova Science Publishers, 2007. Starfield B, Shi L. Commentary: Primary care and health outcomes: a health services research challenge. Health Serv Res 2007; 42(6 Pt 1): 2252-6. Valderas JM, Starfield B, Salisbury C. Definitions of chronic health conditions in childhood. JAMA 2007; 298: 1636. Valderas JM, Starfield B, Roland M. Multimorbidity’s many challenges: A research priority in the UK. BMJ 2007; 334(7604): 1128. Starfield B, Shi L. Commentary: The impact of primary care and what states can do. North Carolina Medical Journal 2007; 68: 204-7. Starfield B. Editorial: Co-morbidity and its challenges for quality of primary care. Rev Port Clin Geral 2007; 23:179-80. Starfield B. Pathways of influence on equity in health: A rejoinder to Braveman and Wilkinson. Soc Sci Med 2007; 64(7): 1371-2.

HiRes 90K Cochlear Implant Device: Recall – Malfunction

MedWatch logo MedWatch - The FDA Safety Information and Adverse Event Reporting Program HiRes 90K Cochlear Implant Device: Recall – Malfunction
[Posted 11/27/2010]
AUDIENCE: Audiology, Patients
ISSUE: Advanced Bionics (AB) announced that it will voluntarily recall its HiRes 90K cochlear implant device and is retrieving all unimplanted devices in distribution. This action is being taken in response to two confirmed instances where the product experienced a malfunction requiring explantation. These recipients experienced severe pain, overly loud sounds and/or shocking sensations at 8-10 days after initial activation of their device.
BACKGROUND: AB is continuing to evaluate the root cause(s) of the problem and is working closely with the FDA to address their questions and concerns, and institute changes to the product to ensure that the HiRes 90K has the highest quality for patients who use the device. This voluntary action is being taken to ensure continued patient safety and product quality.  The risk of any significant adverse medical events appears to be remote at present. 
RECOMMENDATION: Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program:

  • Complete and submit the report Online: www.fda.gov/MedWatch/report.htm
  • Download form or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178

Read the complete MedWatch Safety Alert at:  : http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm235009.htm

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