139 e-Letters

  • Physician Health in North America

    [This is a revision of a submission from earlier today that contains references.]

    To the editor:
    We read Weenink, et al.’s review of remediation and rehabilitation programs for healthcare professionals with interest.1 It is among the most systematic and certainly the most internationally focused reviews to date. The article noted, “the aim of these programs is two-fold: to help professionals with problems and to protect patients from professionals who are unable to perform adequately.” This important point is in direct alignment with the Federation of State Physician Health Program’s (FSPHP) philosophy of supporting our member programs in their mission of early detection of potentially impairing illness. As members of the leadership of the Federation of State Physician Health Programs (FSPHP), we laud this review and believe additional commentary is worthwhile.
    In the U.S. and Canada, each Physician Health Program (PHP) is unique in its scope of services, funding and the types of healthcare professionals served.2 In the U.S., we trace our roots back to a seminal paper that appeared in the Journal of the American Medical Association (AMA) in 1973.3 As Weenink, et al. noted, all programs provide services for professionals with substance use disorders and other mental health conditions. PHPs do not provide treatment, rather, we provide care coordination and monitoring for health professionals with impairing illness. The FSPHP brings together PHPs in the U....

    Show More
  • Reporting of adverse medical device events: From both sides of the Atlantic.

    Gagliardi and her Canadian colleagues must be commended for calling a spade a spade: “there may be little point in solely educating or incentivising individual physicians to report adverse medical device events unless environmental conditions are conducive to doing so”.(1) “Environmental conditions” being “healthcare system capacity and industry responsiveness”.(1) The French state of affairs illustrates the latter is not about unresponsiveness but deliberate obstructions.

    First, in March 2017, after serial warning letters, the French regulatory agency required withdrawal of YSY Medical’s medical devices within a 6 months delay as devices have been marketed without CE marking (Conformité Européenne _European Conformity, in 1985 France was a leader in the Union_ which is about basic safety standards (eg. no explosion, no electrocution …). YSY Medical challenged the decision before a regional administrative court which: a) considered the topic was in its jurisdiction; b) issued an emergency ruling to suspend the Agency’s decision. The Conseil d’Etat, France’s highest court, confirmed the ruling in 2018.(2)

    Second, after a suit by the Snitem (National Union of Medical Technologies Industries) and Medtech (an association of 40 companies), the Conseil d’Etat just cancelled a decree (#1716. 13 Dec 2016) requiring a summary of product characteristics for class III and implantable devices.

    However, France is improving. In 2009, the Agency’s director wrote “...

    Show More
  • Inappropriate antibiotic prescription for asymptomatic bacteriuria

    We read with great interest the original research done by Stagg et al where rates of unnecessary antibiotic use for asymptomatic bacteriuria (ASB) were decreased by implementing a two-step urine culture algorithm in the emergency department (ED). [1] We want to congratulate the authors for their successful research, and hope that algorithms such as the two-step ordering process will be implemented as widespread protocol to help decrease the overutilization of antibiotics for ASB.

    We have presented the findings of our own retrospective observational IRB-approved study performed at a 695-bed academic medical center to discern the downstream impact of routine urinalysis and urine cultures ordered from the ED on antibiotic prescribing. We hope these results will add to the growing body of evidence for stricter protocol regarding urine testing and subsequent treatment. The primary objective of our study was to evaluate the incidence of antibiotic treatment based on urinalysis and urine culture results with or without associated urinary symptoms. Secondary objectives included: incidence of symptoms documented in the medical record for patients who were ordered a urinalysis with or without urine culture, incidence of antibiotic treatment of ASB, and quantification of mean antibiotic dose given to patients with clinically defined ASB.

    Adult patients who had urinalysis with or without a urine culture performed in the ED were identified and randomized by reports genera...

    Show More
  • Pressure injury documentation: the case for using incident reports to inform quality improvement

    Pressure injuries are a largely avoidable adverse patient safety event, which are the focus of considerable global quality improvement efforts. Recent papers by Padula and Pronovost (1) and Squitieri et al. (2) highlight some of the challenges that exist with regards to efforts prevent and reduce the extent of patient harm arising from pressure injuries. These challenges include inconsistent reporting of the extent of pressure injury related harm as evinced by differences in the pressure injury related documentation from different care settings (1, 2) which are thought to be due to financial penalties for nosocomial pressure injuries (1). Padula and Pronovost (1) highlight the fact that the majority of the measurement and reporting of pressure injuries as well as the financial penalties for pressure injuries focus on hospital settings when pressure injury can arise at any point during a patient’s care trajectory. A number of possible solutions are put forward by Padula and Pronovost (1) to avoid underreporting the true extent of pressure injuries and to generate more accurate data that can be used to prevent and reduce the number of patients with pressure injuries in hospitals and other care settings. However, it is worth reflecting on the challenges of measurement and reporting for quality improvement and to considering what other routinely collected pressure injury related data can be used to inform improvement efforts.
    Establishing systems in which patient harm i...

    Show More
  • Pause before you nudge: ethical implications of behavioral economics and choice architecture in the health care setting

    The authors should be commended for highlighting some of the groundbreaking work on behavioral economics and touching on the potential for nudging in the clinical setting.1 Recently, others have advocated for the broad incorporation or nudge units within health systems.2 While the authors focus on physician-oriented nudges, for patient-directed nudges in particular, reflecting on the ethical implications of the nudge, and deciding to what degree patient autonomy is compromised, may be particularly important for physicians embarking on incorporating choice architecture into practice.

    There is an important distinction between engaging in what the original proponents of nudging termed “libertarian paternalism” (e.g., encouraging smoking cessation),3 and self-serving nudging (e.g., encouraging patients to choose a particular procedure or treatment, which may also benefit the physician or health care system).4 Indeed, concerns abound regarding the ethics of nudging the informed consent process, and pharmaceutical companies’ reliance on similar heuristics to improve sales is well established.5,6

    It is also worth highlighting that nudges are often experimental; as such, it is not always clear that they will have the desired effect, further stressing the need for an ethical pause. While these concerns are implicitly acknowledged by the authors, given the potential impact of nudges, and the lack of patient-facing transparency in developing choice architecture—a defini...

    Show More
  • Health technology: boon or bane?

    I read this paper1 first published on 5 March 2018 in your journal with great interest.

    The great pace of health information technology (health IT) advancement in recent decades held promise in improving patient safety and quality of care, but unfortunately there has since been inadvertent consequences and carry-over effects of technology-related safety concerns in its use and implementation.2 This paper has further fuelled the boon or bane debate of health IT.3

    Ironically, the implementation of a national, multifaceted, quality improvement (QI) programme of ‘de-implementing’ electronic health record (EHR) notifications to primary care physicians (PCPs) has shown some benefit.1 This has, in some way, proven that being too reliant on technology in healthcare may yet rear its ugly head.

    The paper has shown that high volume of EHR notifications can overwhelm PCPs;1 the proposed measure of breaking these down into “low-value” and “high-value”, and enforcing certain mandatory ones, may merely be an intermediate stopgap technique. Determining which is which, by its nature, is difficult to do and standardise.

    Further, implementing a nationwide programme such as this poses certain challenges that the authors have not considered – will there be a difference between urban and rural healthcare facilities in its implementation, given resource limitations?4 Will technology have improved or changed by the time this programme is fully implemented nationwide?...

    Show More
  • Letter to the Editor

    To the editor,

    Sexton et al describe an observed association between leadership WalkRounds (WR) with feedback and improved levels of safety culture within healthcare settings.1 This work builds on previous data from this group evaluating WR in building a safety culture.2 These encouraging findings spur the need for understanding the robustness of evidence that the WR concept is built on in order to evaluate if continuation and expansion of the WR concept should be promulgated.

    The research data that WR are based on are largely observational sets or pre and post studies without control groups or objective outcome measures.3 This is fertile ground for bias and confounding that will undermine the probity of the findings. Sources of bias relate to institutional incentives around WR programs succeeding and the want held by individuals to be seen to be implementing initiatives that improve quality. In the present study described by Sexton et al, the cross sectional observational nature of the data collection is exposed to confounding with clinicians involved in a WR program potentially working in an environment with a superior safety culture regardless of the presence of regular WR (with or without feedback).1 Self-selection bias will also be at play as it is with any voluntary survey method as will be recall bias with culturally high achieving environments and poorly functioning settings over and under estimating their performance respectively, and perhaps ascribi...

    Show More
  • People with intellectual disabilities and Patient decision aids

    The population with intellectual disabilities have multiple morbidities and greater health needs compared with the general population. This population experiences health and healthcare inequities and inequalities. To reduce the health inequality gap people with intellectual disabilities should be involved as partners in their healthcare. This will require access to relevant information and the development of tools that support collaboration, such as tailored patient decision aids (PDA) (1).
    The population with intellectual disabilities is rarely considered or involved (2)at the guideline development stage. The consequent failure of clinical guidelines to adequately address the health needs of people with intellectual disabilities exacerbates already poor access to health and healthcare. An examination of clinical guidelines from seven countries(3) found that most clinical guidelines failed to address people with intellectual disabilities as being at high risk for particular conditions when appropriate.
    Guidelines and PDAs developed with the general population in mind may not reflect the complexity and multi-morbidity of individual patients with intellectual disabilities and their ‘real world’ lives. Many people with intellectual disabilities have visual, hearing, mobility, memory and dexterity difficulties. Clinicians and guidelines developers may not be aware of the complexity of the task their ask their patients with intellectual disabilities and their...

    Show More
  • Authors' conclusions not supported by results

    Authors do not acknowledge some of the most common criticisms of these studies:

    (1) Physician health program (PHP) data may be suspect because PHPs benefit from presenting a rosy picture of their effectiveness.

    (2) Self-reports from those being evaluated by PHPs, which have much to lose from responding to surveys in ways that criticize these programs, may not be reliable.

    (3) There are considerable reasons to doubt that "programme completion," "return to practice," and "no relapse/recurrence" reflect treatment efficacy. Unwarranted referrals may also result in coerced treatment for physicians who do not have a substance use disorder or problematic performance, making "graduation" not meaningful for the purposes of drawing conclusions about PHP treatment effectiveness.

    Other concerns with this research will be addressed in forthcoming publications by the commentator.

  • What about compassion fatigue?

    Thank you for this article it summarises the situation well but omits to mention compassion fatigue in any detail . This is an important concept in organisations who need to change and recognise individual coping skills and support people to make positive changes in their own lives. Without self compassion we cannot be compassionate towards others. So whatever changes are made to the organisation it will not make any difference if people are not supported to change themselves. See this article - When Caring Stops Staffing Does Not Really Matter - https://www.nursingeconomics.net/necfiles/staffingUnleashed/su_ND10.pdf Or see my blog for more discussion on self compassion - http://drmarjorieghisoni.edublogs.org/