Winter 2008 - Volume 12 Number 1
Original Articles
The Dartmouth Atlas Applied to Kaiser Permanente: Analysis of Variation in Care at the End of Life
Matt Stiefel, MPA; Paul Feigenbaum, MD; Elliott S Fisher, MD, MPH
The Dartmouth Atlas method for examination of variation in care at the end of life was replicated by Kaiser Permanente (KP). Although KP inpatient care use rates were 25% to 30% lower and hospice use rates were higher than in the surrounding communities, there was still two- to four-fold variation in inpatient care use across KP geographic areas. Results reinforced emphasis on palliative care for patients with chronic conditions and earlier transitions to hospice.
Puentes Clinic: An Integrated Model for the Primary Care of Vulnerable Populations
Lawrence Kwan, MD; Cheryl J Ho, MD; Charles Preston, PhD; Viet Le, MD, PhD
This integrated model to address the needs of a medically vulnerable population of homeless and injection-drug users emphasizes open access, outreach, groups, and a team approach to care. Emergency Department and urgent care visit rates decreased, simultaneous with increased primary care visits.
Myocardial Infarction and Its Association with the Use of Nonselective NSAIDs: A Nested Case-Control and Time-to-Event Analysis
T Craig Cheetham, PharmD, MS; David J Graham, MD, MPH; David Campen, MD; Rita Hui, PharmD, MS; Michele Spence, PhD; Gerald Levy, MD; Stanford Shoor, MD
In a study of 8143 cases and 31,496 matched study control subjects, indomethacin and naproxen were associated with increased odds of adverse cardiovascular outcomes--myocardial infarctions and sudden cardiac death. These events occurred early in therapy.
Home Hospice Acupuncture: A Preliminary Report of Treatment Delivery and Outcomes
Karen Kaufman, PhD, LAc; Ellen J Salkeld, PhD
The increasing incorporation of complementary and alternative medicine modalities into hospice care prompted a preliminary exploration of the process of offering acupuncture to ameliorate undesirable side effects from needed analgesic and sedative medications. Excellent or good results were noted in the charts of 34% of patients whose chief complaint was pain and in 31% of patients with anxiety.
Review Articles
Laparoscopic Colorectal Surgery
James Yoo, MD
The use of minimally invasive techniques in colorectal surgery has lagged behind its application in other surgical fields, even though important new studies have demonstrated the benefits and safety of laparoscopic colorectal surgery, making it now the preferred approach.
Sporadic rather than familial, 80% to 85% of cases of primary hyperparathyroidism are caused by a solitary parathyroid adenoma. Diagnosis is made by hypercalcemia, elevated parathyroid hormone level, and a normal or high 24-hour urine calcium excretion. Multiple studies have demonstrated symptomatic and metabolic benefits of parathyroidectomy in "asymptomatic" patients.
Case Studies
"The Other Side of the Fence": A Geriatric Surgical Case Study of Error Disclosure
Robert Formanek, Jr, MD; Doug Bonacum, MBA, CSA
An unanticipated adverse event after the surgical repair of a hip fracture lead to an exploration of a patient's care experience, through panel discussion, commentary, and excerpts from a letter entitled The Other Side of the Fence, written by the daughter of the 90-year-old patient
Two cases of a rare manifestation of diverticulosis illustrate the clinical presentation and surgical management, which is curative and in select cases can be carried out laparoscopically.
Clinical Medicine
Improving Chronic Care: The "Guided Care" Model
Chad Boult, MD, MPH, MBA; Lya Karm, MD; Carol Groves, RN, MPA
In a new model now being tested by Kaiser Permanente in the Baltimore-Washington, DC area, a registered nurse works in a practice with several primary care physicians conducting eight clinical processes for 50-60 multimorbid patients.
The use of methamphetamine is highly prevalent among populations at risk for acquiring HIV infection, especially men who have sex with men. A novel intervention tool--the "video doctor"--significantly reduced high-risk behaviors.
In two case examples, use of an evidenced-based diagnostic algorithm to rule out pulmonary embolus seeks to reduce the significant radiation exposure to a patient. A single CTA is equivalent to 400 chest x-rays.
Commentary
Culture and Medicine: Reflections on Identity and Community in an Age of Pluralism
Sylvestre Quevedo, MD, MPH
This narrative account of a physician-patient relationship explores the meanings and relevance of race, ethnicity, and cultural diversity in the practice of medicine and in our general society.
Prominent leaders talk about: developing an integrated system with community clinics and neighborhoods; and, for an ever larger, diverse, and immigrant population, a new simultaneous translation system; and training future doctors by involving them in the hospital's quality improvement committees and clinical projects.
Factors outside traditional health care delivery--community-based social determinants of health such as environment, pollution, job opportunities, education, income, and support for healthy lifestyles--play equally important roles in disparities improvement by health systems.
Health plans, in fulfilling their obligation to provide a reliable, safe, and secure system of care to millions of users, must also assume a leading role in demonstrating a commitment to abrogate the destructive role of racism and social injustice upon the health care of all Americans.
There has been real progress in controlling this infection--in the US and in the developing world --however, men having sex with men continues to represent the majority of new infections. Despite tremendously effective medication, poor adherence by patients is all too common.
All narrative shares the common function of someone telling something to someone about something. For decades American medical students have memorized the familiar acronym--S.O.A.P--which identifies patient as subjective and physician as agent of objective fact. Narrative medicine challenges this slippery assumption about a clean division between subject and object. Physicians and patients are immersed in the act of storytelling.
Soul of the Healer
Original Visual Art
On the Cover
James McCormick, MD
