12 minute read
When ‘less is more’: Study of lung-collapse treatment draws international attention
Dr. Peter Hahn
Treating patients at Metro Health – University of Michigan Health for certain types of sudden lung collapse, the three doctors noticed something interesting: Less-invasive treatments appeared just as effective as the usually recommended approach.
Seeing an opportunity to update treatment guidelines, they launched an ambitious review of 70 years of studies. Coauthors Dr. Sri Mummadi, Dr. Jennifer de Longpre’ and Dr. Peter Hahn, CEO of Metro Health, published their findings earlier this year in the Annals of Emergency Medicine.
The study has since attracted widespread attention for commentary in other leading medical journals: the British journal BMJ, the New England Journal of Medicine’s NEJM Journal Watch and an upcoming issue of Ontario-based ACP Journal Club, published by the American College of Physicians. The review in NEJM Journal watch wrote that the study “serves as notice that the available evidence favors a ‘less is more’ approach.”
When air leaks from the lung and gets trapped in the chest wall, the pressure prevents the lung from inflating completely. It becomes impossible to fully inhale. When this occurs without an injury such as blunt trauma, it is called spontaneous pneumothorax – the focus of the study.
Patients who are suffering spontaneous pneumothorax usually end up in the emergency room with chest pain and shortness of breath. Noting that the condition accounted for $1.4 billion in inpatient charges as recently as 2014, the authors observed that previous guidelines for the best initial treatment strategy were outdated and inadequate.
When the three doctors worked together at Metro Health – University of Michigan Health, they saw success with innovations such as using very small chest tubes, as narrow as a coffee straw, to remove air pressure inside the chest of spontaneous pneumothorax patients. At the time, American guidelines favored largediameter chest tubes.
“Obviously, from a patient’s point of view, having a coffee straw inside the chest is much more easily tolerated than having a garden hose,” Mummadi said.
At the other end of the spectrum, British guidelines recommended removing the air with needle aspiration. This approach is less invasive but has a drawback: Patients must be observed for six hours or more before being discharged. This is not practical in an American emergency room setting.
1,880 published papers 12 selected studies 781 patients 3 treatments
Inspired to measure the different approaches, the three doctors undertook a meticulous worldwide search of medical studies. They reviewed 1,880 published papers, including some that had to be translated from Chinese and Korean. They focused on randomized controlled studies, the gold standard in science, finally selecting 12 for review. The studies involved 781 patients. The doctors then compared outcomes of the three treatments – needle aspiration, narrow-bore chest tube and large-bore chest tube – based on:
Efficacy – which treatment produces the most success
Safety – which treatment carries the least risk of complication
Using innovative Bayesian statistical techniques to blend the data, they found little difference in success rates. However, the researchers discovered that needle aspiration and narrow-bore chest tubes outperformed large-bore chest tubes on the safety metric.
They propose that future studies undertake a direct comparison of needle aspiration and narrow-bore tubes.
However, Mummadi also noted that modern narrow-bore tube design offers an additional advantage over the other two treatments. They can be fixed to the chest, allowing the patient to be discharged for later follow up in an outpatient setting.
“Due to the improved design of these devices, we are able to discharge these patients from the ER without admitting to the hospital,” he said. “This means reduced risk of complications resulting from hospital stay.” In 2018, Drs. Mummadi and Hahn were the first in North America to publish the results of a novel centralized pathway for all patients with pleural disease. Their findings were widely cited and incorporated into textbooks worldwide.
Dr. Mummadi is now on faculty at the Cleveland Clinic. Dr. de Longpre’ joined Mercy Health Muskegon after completing her internal medicine residency at Metro and Dr. Hahn is a former Mayo Clinic pulmonologist and served as chief medical officer at Metro Health before becoming CEO. Hahn congratulated his co-authors for exploring opportunities for more patient-centric treatments.
About Metro Health – University of Michigan Health
As an affiliate of University of Michigan Health, Metro Health provides a world-class system of leading-edge healthcare services with its patient-centric, holistic approach. The 208- bed hospital anchors Metro Health Village in Wyoming, Michigan, serving more than 250,000 patients annually. More than 61,000 emergency patients are treated each year at the hospital, a Verified Level II Trauma Center. Primary and specialty care services are provided at 30 locations throughout West Michigan. More than 500 staff physicians provide state-of-theart treatment for a full array of health needs, including for cancer, heart and vascular disease, stroke and trauma. As a certified Comprehensive Stroke Center and accredited Chest Pain Center, Metro Health provides specialty services that include neurosciences, pulmonology, gastroenterology, cardiology, endocrinology, OB/GYN, bariatrics, orthopedics and wound care. In 2020, Metro Health was the only Grand Rapids area hospital included among the "101 Best and Brightest Companies to Work For" by the National Association of Business Resources. The hospital is committed to promoting health and wellness through the Metro Health Hospital Foundation, Live Healthy community outreach classes and educational programs. For more information visit www.metrohealth.net, follow us on Twitter @MetroHealthGr and like the hospital on Facebook.com/MetroHealth
JOIN OUR COMPASSIONATE TEAM
Advancing care where it matters most.
This is the best of both worlds. A trusted local health provider is now part of a world-class health system. A place where patients are treated like people; where top specialists are making game-changing advances; and where our focus is bringing the right care to the right place. Our story has only just begun.
metrohealth.net/recruiting
ETHICAL ISSUES THE RISK MANAGER SHOULD CONSIDER IN A COVID - 19 WORLD, PART I
By Josh Hyatt, DH.Sc., MHL, MBE(c), DFASHRM, HEC-C
As news of international response to COVID-19 gets reported,
bioethicists are beginning to look at some critical responses and comment on the significant impacts they represent. These ethical dilemmas have a natural alignment with our strategic and operational duties as risk managers. Risk managers are being put on the front line of responding to ethical dilemmas, which may be challenges never faced before. With the news from Italy and other countries managing massive outbreaks, there are lessons risk managers should be aware of and prepare for in the U.S.
Rationing
As we see the rates of infections climb, we can extrapolate there will be an increased need for medical treatment in which space, qualified personnel, and equipment will become coveted resources and fought for by providers, patients, families, and the community. It has been projected that at its current trajectory, the U.S. may need as many as 100,000 more ICU beds to manage the pandemic in the near future. In two weeks, Italy went from 322 confirmed c ases o f c oronavirus t o 10,149 (number as of 3/11/20) and is facing unprecedented pressure on their healthcare resources. They are running out of staff to manage the volume and ventilators to manage the suffering of those experiencing respiratory distress. As resources dwindle, physicians are being forced to implement battlefield t riage t echniques a nd r ation medical treatment. As a result, the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) published rationing guidelines that encourage distributing dwindling resources to those who are more likely to benefit and have the highest opportunity for recovery. This rationing includes lifesaving equipment, space in ICUs, human resources, and clinical time focused on those fortunate patients (continued).
Click here to read more on how ethical issues e ffect risk managers and physicians alike.
FREE TO MOA MEMBERS: AOA - QUALIFYING ONLINE COURSES, OFFERED THROUGH COVERYS’ EDUCATION RESOURCE, MED - IQ. VISIT DOMOA.ORG/MEDED FOR ACCESS.
Polypharmacy in the Elderly: Navigating Complexities in Care
Overview:
This interactive case-based activity discusses strategies to reduce inappropriate polypharmacy in the geriatric population. Links to useful resources are provided to help participants make clinical decisions for the patient, and expert faculty offer their perspectives on the latest evidence for deprescribing management decisions.
Expires 10/28/20 Recent Changes in Newborn Screening: What, When, How, and Why
Overview:
This 15-minute, accredited CME publication reviews the current state of newborn screening (NBS) for lysosomal storage disorders (LSDs) and explores available methods for LSD analysis, focusing on Pompe disease (PD) and mucopolysaccharidosis type I (MPS I), the most recent LSDs added to the Recommended Uniform Screening Panel (RUSP).
Expires 2/18/21
Duke Perspectives From the American Academy of Orthopaedic Surgeons 2020 Annual Meeting
Overview:
This publication summarizes relevant abstracts and findings that were shared at the virtual American Academy of Orthopaedic Surgeons 2020 annual meeting. In addition, Samuel B. Adams, MD, associate professor of orthopaedic surgery at Duke University School of Medicine, provides expert insight on presented studies.
Expires 6/7/21
domoa.org/HCPM
A PHYSICIAN PRACTICE IS A SMALL BUSINESS
BY EWA MATUSZEWSKI, CEO, MEDNETONE
The emergence of a best practices playbook for physician practices following this pandemic is likely as close as any primary care physician practice has come to having a strategic plan. Of course, a playbook or return-towork strategy is not a strategic plan. It is focused on health and safety for patients, practice teams, vendors and anyone who sets foot in a physician’s office. But if you haven’t considered adopting a broader strategic plan as an offshoot of a playbook, it’s advisable to do so now.
Learn from other industries.
I was in the trenches with PCPs as they struggled with financial issues, staff layoffs, insufficient personal protection equipment and other COVID19 induced threats to a practice’s viability. Prior to the recent availability of guidance from national and state medical agencies and professional medical associations, which came far too late in my opinion, I turned to social media as part of my information gathering process to create our own back-to-work manual. That’s where I “met” Gary Johnson, Chief Manufacturing and Labor Affairs Officer at Ford Motor Company.
I don’t know Mr. Johnson, but I requested permission via LinkedIn to utilize the Ford Motor Company COVID-19 Playbook. He gave me permission and I incorporated some of the Ford Playbook foundational approaches into the primary care practice playbook made available to members of the Michigan Osteopathic Association. To pay it forward, this playbook, and a 12-minute video are now available online for use by physicians, dentists, other physician organizations, and the healthcare community at large. Lesson? In developing a strategic plan, look beyond healthcare to learn from industry titans like Ford, Lear and other companies who are emerging as back-towork leaders.
“In developing a strategic plan, look beyond healthcare to learn from industry titans like Ford, Lear and other companies who are emerging as back-to-work leaders.” Create a new inventory mindset.
Inventory isn’t just an added expense. It’s a lifeblood of your practice in the new era.Maintain a minimum 30-day supply of PPE and hand soap, hand sanitizer and janitorial supplies, including bleach and surface disinfectants. Welcome your cleaning company as a new member of your practice team. Some cleaning companies will not be able to make the transition to the new cleaning protocols. If yours can’t, find a new supplier and evaluate their service level regularly.
Commit to training and education.
A major change to your current physician organization’s membership requirements might be mandatory adherence to a playbook and any other best practice regulations that are instituted for patient and practice team safety and third-party payor reimbursement, which is likely to expand payment of new or enhanced services as it did with telehealth visits. Change is coming rapidly in all directions.
It’s a smart business decision to assess your team’s strengths and weaknesses
…CONTINUED FROM PAGE 23 domoa.org/HCPM
and develop a training and education strategy accordingly. Continuing medical education is a given, but no longer sufficient. Find the gaps in your collective team’s ability to help run the business side of the practice; cross-train and upskill as necessary.
Get on board with EHRs and Telehealth.
Speaking from the vantage point of a professional organization, the majority of physician offices with two or more providers have modern practices with electronic health record systems and HIPAA-compliant virtual consult capabilities. Moving forward, I ultimately see such technologies as being required. Seemingly overnight, a doctor’s practice has gotten significantly more complex and physicians need to be prepared and responsive.
Formalize a business recovery plan.
Many physician practices got through the initial onset of this pandemic on a wing and a prayer. It wasn’t strategic – and for most it didn’t work well. Be
website, social media, and
prepared for the next business disruption; whether it just hits your office (e.g. a fire, flood or death) or a pandemic that takes down whole sectors, document now everything that needs to be done to stay open or promptly re-open. From IT and billing to communications via website, social media and direct patient outreach, be ready for a disaster with a business recovery plan that minimizes disruption to patient care and the financial viability of your practice. This is also a good time to ensure that your legal and business advisors are meeting your needs. Your practice may need an attorney or CPA with deep experience in physician practices. Lastly, expect physician groups to deploy care managers to perform practice audits and questionnaires for both the clinical providers and practice team to ensure compliance with new guidelines.
We still need the old school touch of a physician, but the new normal demands business acumen, modern tools, multi-disciplinary teams, a focus on in-practice learning, and incorporation of measures that identify and respond to the social determinants of health. Payors and employer groups will be looking for these enhancements – and such actions will prepare us for future catastrophes.
Ewa Matuszewski is the founder of Practice Transformation Institute, an IACET-accredited
teaching and training organization. IACET is the only standard-setting organization approved by
the American National Standards Institute (ANSI) for continuing education and training.
