geoffrey modest medical blogs

editorial in the new york times (similar to my prior emails on the subject, but i thought raised the pay-for-performance in a broader context). raises a few issues regarding new york city proposal to pay doctors in public hospitals based on the quality of their work: 1. pay-for-performance (P4P) does not work (i sent out a BMJ article on this a few months ago), at least at the low reward levels offered (there are certainly many things we could do better, which would improve care and decrease costs, such as making sure that hospitalized patients have appropriate followup, med reconciliation, multidisciplinary approaches including nutrition counseling, physical therapy, etc.  Unfortunately, many of the currently incentivized items are not necessarily as useful but are easy to measure, such as whether an A1C has been checked according to a prescribed schedule which may not make much sense for many individual patients). in addition, those providers who work in wealthier institution

striking article in BMJ about the image and reality of pharmaceutical research and development (see  pharmaceutical R&D bmj 2012  in dropbox).  the $400 billion/yr drug industry has promoted an "innovation crisis" myth that they are too strapped to do the very expensive R&D. reality is that overall there has been a constant rate of new drugs over the past 60 years. the real innovation crisis is in the fact that the percentage of new medications which really offer important therapeutic advantage is on the order of 15% (ie, vast majority of new drugs are "look-alikes", ie yet another ACE inhibitor, statin, etc). this has not changed since i saw data in the 70s. the authors of the BMJ note "since the mid-1990s, independent reviews have also concluded that about 85-90% of all new drugs provide few or no clinical advantages for patients". and still, of the large amount of money spent on R&D, 80% of basic research comes from public sources. they also

there have been an array of articles recently on hospital readmissions and length-of-stays, one in the annals and several in the latest JAMA. 1. the question has come up that by our attempts to decrease hospital length-of-stay, are we creating more hospital re-admissions and perhaps increased mortality ?  (see hospital LOS and readmission rate annals 2013  in dropbox).  big study in the VA system o f  129 hosp it als from 1997-2010 with >4M admissions, looking at 2 chronic diseases (chf, copd) and 3 acute dz (acute MI, comm-acq pneumonia, GI hemorrhage). results:     --LOS decreased from 5.44 to 3.98 days overall     --LOS also decreased for the 5 target admissions above, e s p ecially  for acute MI (dec 2.85 days) and pneumonia (2.22 days)     --during this 14 year period, the 30-day readmission rate decreaesd from 16.5% to 13.8%, including in these 5 target diagnoses (greatest reduction in MI from 22.6% to 19.8% and COPD from 17.9% to 14.6%).     --all-cause mortality

article in the lancet on patie nts  with treatment resistant depression. (see  depression resistant and CBT lancet 2013  in dropbox). 469 pts aged 18-75 on antidepressants for >6 weeks but with persistent depression (Beck depression inventory BDI score >=14) in the UK.  randomized to usual care (without any restrictions on treatment options) vs adding cognitive behavioral therapy (twelve 50-60 minute sessions) to usual care. primary outcome was response with at least 50% decrease in depressive symptoms at 6 months compared to baseline. baseline BDI score was 32 (severe depression is 29-63).   results:     -- 90% were followed up to 6 months, 84% for  a year     -- 46% of the usual care plus CBT vs 22% in the usual care group met criteria for response at 6 months. 55% vs 31% at 12 months.  93% of both groups were taking antidepressant meds at 6 months, 88% of the CBT and 92% of the usual care were at 12 months.     -- full remission rates (BDI <10) in 28% vs 15% afte