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Showing posts with label The New England Journal of Medicine. Show all posts
Showing posts with label The New England Journal of Medicine. Show all posts

Monday, December 30, 2013

Common Knee Surgery Does Very Little for Some, Study Suggests

A popular surgical procedure worked no better than fake operations in helping people with one type of common knee problem, suggesting that thousands of people may be undergoing unnecessary surgery, a new study in The New England Journal of Medicine reports.

The unusual study involved people with a torn meniscus, crescent-shaped cartilage that helps cushion and stabilize knees. Arthroscopic surgery on the meniscus is the most common orthopedic procedure in the United States, performed, the study said, about 700,000 times a year at an estimated cost of $4 billion.

The study, conducted in Finland, involved a small subset of meniscal tears. But experts, including some orthopedic surgeons, said the study added to other recent research suggesting that meniscal surgery should be aimed at a narrower group of patients; that for many, options like physical therapy may be as good.

The surgery, arthroscopic partial meniscectomy, involves small incisions. They are to accommodate the arthroscope, which allows doctors to see inside, and for tools to trim torn meniscus and to smooth ragged edges of what remains.

The Finnish study does not indicate that surgery never helps; there is consensus that it should be performed in some circumstances, especially for younger patients and for tears from acute sports injuries. But about 80 percent of tears develop from wear and aging, and some researchers believe surgery in those cases should be significantly limited.

“Those who do research have...
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Friday, December 27, 2013

Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear

Today's post was shared by NEJM and comes from www.nejm.org

Background

Arthroscopic partial meniscectomy is one of the most common orthopedic procedures, yet rigorous evidence of its efficacy is lacking.

Methods

We conducted a multicenter, randomized, double-blind, sham-controlled trial in 146 patients 35 to 65 years of age who had knee symptoms consistent with a degenerative medial meniscus tear and no knee osteoarthritis. Patients were randomly assigned to arthroscopic partial meniscectomy or sham surgery. The primary outcomes were changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure.

Results

In the intention-to-treat analysis, there were no significant between-group differences in the change from baseline to 12 months in any primary outcome. The mean changes (improvements) in the primary outcome measures were as follows: Lysholm score, 21.7 points in the partial-meniscectomy group as compared with 23.3 points in the sham-surgery group (between-group difference, −1.6 points; 95% confidence interval [CI], −7.2 to 4.0); WOMET score, 24.6 and 27.1 points, respectively (between-group difference, −2.5 points; 95% CI, −9.2 to 4.1); and score for knee pain after exercise, 3.1 and 3.3 points, respectively (between-group difference, −0.1; 95% CI, −0.9 to 0.7). There were no...
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Thursday, December 26, 2013

You may not be better off after knee surgery

Today's post is shared from cnn.com 

(CNN) -- Patients who underwent simulated knee surgery fared just as well as those who got the real deal, according to a new study that's raising eyebrows about the most common orthopedic procedure performed in the United States.

The findings, published Thursday in the New England Journal of Medicine, add to a string of papers suggesting that arthroscopic partial meniscectomy fails to help many patients. The operation typically is performed to relieve knee pain, whether from wear or from an injury.

But other doctors say it's still too soon to draw sweeping conclusions.

The study, which was conducted in Finland, followed 146 patients between the ages of 35 and 65 with symptoms of degenerative wear and tear of the meniscus, a disk-shaped piece of cartilage that acts as a shock absorber between the shinbone and thighbone. They had no detectable arthritis, suggesting that any pain was due to a problem with the meniscus.

About half the patients underwent an arthroscopic meniscectomy, in which a surgeon inserts a blade through a tiny incision in the knee, and essentially shaves down the rough, frayed edges of the meniscus.

The other half underwent an elaborately staged "sham" surgery, in which the doctor made an incision and poked around without any actual manipulation, shaving or cutting.

A year later, there was no significant difference in the knee pain reported by patients in each group. Nearly two-thirds on each side said they were happy with the results, and most said...


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Thursday, November 28, 2013

Saving Academic Medicine from Obsolescence

Today's post was shared by NEJM and comes from blogs.hbr.org
by Benjamin P. Sachs, Ralph Maurer, Steven A. Wartman and Marc J. Kahn  |   10:00 AM November 8, 2013
The United States spent 17.9% of the GDP on healthcare in 2012. Academic medicine, which makes up, approximately, 20% of these costs ($540 billion), is under profound threat. Teaching hospitals and medical schools are faced with declining clinical revenue, dwindling research dollars and increasing tuition costs. To meet these challenges, we believe academic medicine must embrace disruptive innovation in its core missions: educating the next generation of health professionals, offering comprehensive cutting-edge patient care, and leading biomedical and clinical research.  Medical schools and academic health centers will need to significantly adapt in each of these areas in order to ensure the long-term health of the medical profession. The following are a few examples of disruptive innovations Tulane School of Medicine has embraced.        
Medical information doubles roughly every five years, making it impossible for physicians to stay current. Computing power has also increased to the point that machines like IBM’s Watson, first programed to play chess and Jeopardy, are now used to diagnose and recommend treatment for patients.  Mary Cummings, one of the first women aviators to land a plane on an aircraft carrier, faced a similar situation when she left the navy; a computer was replacing...
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Sunday, November 24, 2013

A Remedy for Fragmented Hospital Care

Today's post was shared by NEJM and comes from blogs.hbr.org

Fragmented hospital care has been associated with higher hospital mortality and length of stay, and failures of communication and teamwork are the most commonly identified sources of “sentinel events” in hospitals — unexpected occurrences that result in actual deaths or the risk of deaths, or physical or psychological injuries.
Organizational Context
To address this problem, Emory Healthcare (EHC), the clinical delivery arm of the Robert W. Woodruff Health Sciences Center of Emory University and the largest and most comprehensive health system in Georgia, launched its Care Transformation initiative in 2009.
Through the strength of this initiative, in 2012, EHC became the first and only health system in the nation to have two hospitals — Emory University Hospital and Emory University Hospital Midtown — simultaneously in the top 10 in the University HealthSystem Consortium (UHC) Quality and Accountability ranking of U.S. academic medical centers. In 2013, these two hospitals were ranked in the top five.
The Care Transformation initiative at EHC has influenced the organization in many ways, one of which was the creation of an environment where the redesign of care models was encouraged.
This piece focuses on the development of a collaborative care model called the Accountable Care Unit (ACU), which became a re-imagining of hospital care inspired by core principles of EHC’s Care Transformation initiative: patient-and-family...
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Wednesday, November 13, 2013

Professionalism and Caring for Medicaid Patients — The 5% Commitment?

Today's post was shared by NEJM and comes from www.nejm.org

Interview with Prof. Sara Rosenbaum on the health care safety net, Medicaid expansion, and access to care.
Interview with Prof. Sara Rosenbaum on the health care safety net, Medicaid expansion, and access to care.
Medicaid is an important federal–state partnership that provides health insurance for more than one fifth of the U.S. population — 73 million low-income people in 2012. The Affordable Care Act will expand Medicaid coverage to millions more. But 30% of office-based physicians do not accept new Medicaid patients, and in some specialties, the rate of nonacceptance is much higher — for example, 40% in orthopedics, 44% in general internal medicine, 45% in dermatology, and 56% in psychiatry.1 Physicians practicing in higher-income areas are less likely to accept new Medicaid patients.2 Physicians who do accept new Medicaid patients may use various techniques to severely limit their number — for example, one study of 289 pediatric specialty clinics showed that in the 34% of these clinics that accepted new Medicaid patients, the average waiting time for an appointment was 22 days longer for children on Medicaid than for privately insured children.3
Physicians have good reasons for not accepting Medicaid patients, as I learned from direct experience as a member of a nine-physician primary care practice in California. We accepted Medicaid patients, but it was difficult. Medicaid's payment rate was very low — we lost money on each Medicaid visit. When referrals were necessary, we often had to personally ask specialists to accept our patient....
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Saturday, September 21, 2013

Why Health Care Is Stuck — And How to Fix It

Medical costs approximate the largest majority of costs in workers' compensation claims. Today's post was shared by NEJM and comes from blogs.hbr.org


20130918_2

The pressures for fundamental change in health care have been building for decades, but meaningful change has been limited while the urgency of change only grows. The moment of discontinuity has arrived. Already unsustainable costs, an aging population, advances in medicine, and a growing proportion of patients in low reimbursement government programs have made the status quo unsustainable. Change is inevitable.

There is only one real solution, which is to dramatically increase the value of health care. Value is the outcomes achieved for patients relative to the money spent. Without major improvements in value, services will need to be restricted, the incomes of health care professionals will fall, and patients will be asked to pay even more.

In our October Harvard Business Review article “The Strategy That Will Fix Health Care”we describe the strategic agenda that is necessary to create a high value health care delivery system. We believe that there is no longer any doubt about how to increase the value of care. The question is whether providers can make the necessary changes.
Why has it been so hard for health care organizations to improve outcomes and efficiency, despite their best intentions? With so many good, smart people working so hard? With patients’ needs so obvious and so compelling? And with such deep societal concerns about health care spending? The...
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Sunday, September 15, 2013

Worrisome or not? Lung nodules identified on initial LDCT lung cancer screening

Today's post was shared by NEJM and comes from blogs.nejm.org


Long the domain of astrologers and tarot card readers, prediction has recently become downright fashionable. While quant-minded individuals like Billy Beane and Nate Silver have achieved fame and fortune using probabilistic forecasting, dozens of smartphone apps deliver the predictive insight of clinical risk scores to doctors’ fingertips. Why all the enthusiasm? Accurate predictions allow us to prepare for the future.

Testing their predictive mettle in this week’s NEJM, Dr. Annette McWilliams (British Columbia Cancer Agency, Vancouver, Canada) and colleagues ask a deceptively simple research question: If a low-dose computed tomography (LDCT) lung cancer screening test detects a lung nodule, can we use the information at hand to accurately predict if it is malignant?

Using clinical and LDCT data from 1871 current or former smokers in the PanCan study, the investigators developed a model to predict when a newly discovered nodule was cancerous. Model variables included age, family history of lung cancer, and the presence of emphysema as well as nodule size, type, and location. Next, the investigators tested this prediction model in a cohort of 1090 current and former smokers enrolled in several British Columbia Cancer Agency chemoprevention trials. They found their model successfully discriminated between higher-risk and lower-risk nodules even within this validation cohort (AUC = 0.97, 95%CI 0.95-0.99), suggesting that the model can also be generalized to other...
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Sunday, April 3, 2011

Vermont Single Payer System Called the Dawn of A New Era

The proposed state based Vermont Single-Payer health care system, that would embrace workers' compensation medical care, is gaining momentum. A recent article in the New England Journal of Medicine, citing increased costs and the failure of the workers' compensation systems to provide a medical delivery system for occupational injuries, has embraced the proposal as a "Dawn of a New Era."

Saturday, March 12, 2011

Daylight Savings Time Switch May be Hazardous to Your Health

Time change at the end of Daylight Saving TimeImage via Wikipedia

The semi-annual tradition of changing the clock an hour ahead and an hour back has been reported to result in a high incident of work-related illness. A study in the New England Journal of Medicine reports, "More than 1.5 billion men and women are exposed to the transitions involved in daylight saving time: turning clocks forward by an hour in the spring and backward by an hour in the autumn. These transitions can disrupt chronobiologic rhythms and influence the duration and quality of sleep, and the effect lasts for several days after the shifts." This may result in an increase of work-related accidents in the days following the time adjustment.