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美國認為pay for performance很重要…不過好的病人群才是拿高分的原因之一 有好原料才能燒好菜 不過衡量primary care physician的HEDIS指標，比起我們健保局的各項品質指標 實在是差太多了，健保局真是青出於藍勝於藍啊!! 但是，控制到了什麼呢? 指標是真相嗎? 拿慢箋開立率好了，為了達成這個目標，常常一拿三個月藥，multiple co-morbidities的病人哪有那麼易與的? 地區醫院還好住院容易，常常要幫醫學中心的病人cover倒是真的……嚴重妨害醫療品質，真是蛋頭指標，省錢指標… How can you judge a man by these stupid fiugures? 管理的目的不在此，蛋頭啊!! Clinical Performance Rankings of Primary Care Physicians Rankings are influenced by socioeconomic characteristics of patient panels. Physician quality measures are used increasingly for pay-for-performance and other clinical incentive programs. To assess how patient socioeconomic characteristics influence physician rankings, researchers reviewed records for 125,000 patients of 162 primary care physicians in a Massachusetts academic primary care network. Physicians were initially ranked in tertiles without adjustment, based on nine HEDIS (Health Effectiveness Data and Information Set) criteria, including screening for breast, cervical, and colon cancers, and ris...

不管DRG, 住院的 CAP一定會做這個東西 Current and Potential Usefulness of Pneumococcal Urinary Antigen Detection in Hospitalized Patients With Community-Acquired Pneumonia to Guide Antimicrobial Therapy Roger Sordé, MD; Vicenç Falcó, MD; Michael Lowak, MD; Eva Domingo, MD; Adelaida Ferrer, MD; Joaquin Burgos, MD; Mireia Puig, MD; Evelyn Cabral, MD; Oscar Len, MD; Albert Pahissa, MD Arch Intern Med. Published online September 27, 2010. doi:10.1001/archinternmed.2010.347 Background The role of pneumococcal urinary antigen detection in the treatment of adults with community-acquired pneumonia (CAP) is not well defined. We assessed the usefulness of pneumococcal urinary antigen detection in the diagnosis and antimicrobial guidance in patients hospitalized with CAP. Methods A prospective study of all adults hospitalized with CAP was performed from February 2007 through January 2008. To evaluate the accuracy of the test, we calculated its sensitivity, specificity, positive and negative predictive values,...

http://tinyurl.com/2wx7j8t 一個美國critical care physician 的感想，基本上和我們差不多 預立病危處理方式無法解決問題… Death & Dying in the ICU David Kaufman, MD, Critical Care/Intensive Care, 11:05AM Sep 9, 2010 I wish it were possible not to be so preoccupied with this theme, but it seems impossible to ignore the reality of the ICU (at least in my part of the USA). I just finished 2 weeks of ICU service, and it is striking how many patients come to the ICU to die, when, with a little careful examination, their dying process would be recognizable to their doctors, who could make it recognizable to the patients' loved ones. I feel like I lost count of the very elderly (85-plus years), emaciated, demented souls who came to us from nursing homes with sepsis, intubated in the Emergency Department, with only a small chance of getting off the ventilator. We often think that Advance Directives would be the answer, but at least in my state, Advance Directives only cover a limited range of situations. I am reminded of ...

http://www.medscape.com/viewarticle/728118_3 carbapenem resistant enterobacteriae 已經在美國很多了，要通報 但是NDM-1之所以引人注意是因為他和之前的carbapenemase不同來源 而且他可以在許多種plasmids上傳來傳去，傳得快 預計會造成Healthcare associated infection, 也可以造成community infection From Medscape Internal Medicine NDM-1 -- Making Resistant Bugs in New Ways Carol Peckham Posted: 09/13/2010 Introduction A report in Lancet Infectious Disease has described the New Delhi metallo-beta-lactamase 1 (NDM-1), a unique genetic mechanism identified in India, Pakistan, and the United Kingdom that has produced antibiotic-resistant gram-negative Enterobacteriaceae. [1] The strain was identified by the Centers for Disease Control and Prevention (CDC) in 3 isolates in the United States. To determine what threat this might pose, Medscape interviewed Alex Kallen, MD, and Brandi M. Limbago, PhD, both in the Division of Healthcare Quality Promotion, who provided perspective from Centers for Disease Control and Prevention (CDC). Alex Kallen, MD, is a Medical Office...

在美國威斯康辛的資料如是說 2009H1N1 的嚴重性被overblown How Bad Was the 2009 H1N1 Epidemic? In one state, it looked much like usual flu, except that it struck a younger age group. The hubbub surrounding pandemic 2009 H1N1 "swine" flu has died down, soon to be replaced, no doubt, with a similar 2010 version. Meanwhile, just how severe was 2009 H1N1 epidemic influenza compared with ordinary seasonal flu? Researchers evaluated symptomatic residents in a cluster of Wisconsin zip codes during three periods in 2008–2009, including the summer and fall of 2009 when pandemic 2009 H1N1 was circulating but before the vaccine was widely available. The 545 participants with culture-confirmed pandemic 2009 H1N1 were on average much younger than the 632 people with seasonal influenza A H3N2 (median age, 10 vs. 25 years), but about the same age as the 221 people with seasonal (nonpandemic) H1N1. Symptoms were similar in all groups, although symptoms among both children and adults with pandemic H1N1 were perce...

測兩次母血的DAP level和將來小朋友的觀察分數有相關 但是證據尚嫌薄弱 和之前 http://pediatrics.jwatch.org/cgi/content/full/2010/602/1 的那篇文章倒是有點相關。但ADHD是不是被過分誇大了呢? Is Prenatal Exposure to Organophosphate Pesticides Associated with Attention-Deficit/Hyperactivity Disorder? Maternal prenatal pesticide levels were associated with attention problems in 5-year-old boys. Organophosphate pesticides inhibit acetylcholinesterase activity and thereby increase levels of acetylcholine in the central nervous system. Recent studies suggest that fetal exposure to organophosphates is associated with abnormal neonatal reflexes and poorer performance on infant mental development scales. To explore this association further, investigators measured dialkyl phosphate (DAP) metabolites of organophosphate pesticides in maternal urine at two time points during pregnancy in 348 Mexican American women (mean age, 26) who delivered healthy newborns in a California agricultural community. Attention was measured by maternal report (Child Behavior Che...

CP的風險在GA 40 wks 最低 ，37wk or >42wk 最高 我們該因此改變小朋友的delivery timing嗎? 尚無定論 Gestational Age and Risk for Cerebral Palsy: A Surprising Discovery Among term and postterm newborns, CP prevalence is lowest at 40 weeks' gestation and highest at 37 and ≥42 weeks' gestation. Cerebral palsy (CP) is a nonprogressive motor encephalopathy characterized by impairment of movement or posture and is presumed to be the result of injury or anomaly in the developing brain. Prevalence of CP has remained at 1.5 to 2.5 per 1000 live births for several decades. Although the etiology in most cases is unknown, the strongest risk factor for CP is preterm birth ( Follow-up through 2005 indicated that 1938 children with CP were registered in the national health insurance system. Prevalence of CP was lowest among infants born at 40 weeks' gestation, and risk was higher with earlier or later delivery (see the table). In a subset of infants with ultrasound measurements of gestational age, the association...

http://www.medscape.com/viewarticle/727593?src=mp&spon=32&uac=62514FX 一台血糖機一個人用，可以減少cross cintamination? 若請病人自備血糖機，誰來監測reliability? FDA原文 是說，採血工具一定要single use, 測量工具如果不太可能一人一機，要按照機上的指示disinfection August 27, 2010 — In the war against the transmission of bloodborne pathogens such as hepatitis B virus, the US Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA) recommended yesterday that fingerstick devices should never be used with more than 1 person. They issued similar guidance for point-of-care (POC) blood-testing devices such as glucometers and instruments for insulin administration. The 2 federal agencies said the shared used of blood lancing and POC testing devices has led to a steady rise in reports of bloodborne-pathogen infections — mostly involving hepatitis B virus — during the past 10 to 15 years. Such communal bloodletting occurs in settings that range from public health fairs to physician offices, but the problem is most ser...

最近看完ER season 14 ER DVD 一直出，現在剩下第15季了 Dr. House 出到第四季就不動了 anyway，ER visit is the society's safety net CDC很好笑，專收人球(sorry for this term)的ER是safety-net EDs。這類safety-net EDs數量激增 41%，同時期ED number 減少 5%( 1997-2007)，套句本國方言，這叫做庶民ER。全台灣的ER大概只有和信的不是庶民ER The number of EDs that met the CDC definition for safety-net EDs (>30% of total visits by patients with Medicaid, >30% of visits by patients with no insurance, or >40% of visits by patients with Medicaid or no insurance) increased from 1770 in 2000 to 2489 in 2007 (41% increase). 本研究在金融海瀟開始前結束，不然會更難看 Emergency Department Visits on the Rise The largest increase is among patients with Medicaid. In the U.S., emergency departments (EDs) provide access to care to all persons, regardless of ability to pay. Researchers used data from the National Hospital Ambulatory Medical Care Survey to examine trends in U.S. ED visits for subgroups by insurance status from 1997 through 2007. The total annual number of visits increased from 95 million to ...

身為一個披著CM外皮的一般科醫師 常常在門診碰到好像gout又不是gout的病人也是很合理的 雖然病人指天發誓他是gout 我們難道就信他了嗎? 全台灣有多少gout是抽關節液診斷的? 這篇文章好!! 可是，要到8分以上還有點難度耶。 Monoarticular Arthritis: Which Patients to Treat for Gout? A new clinical score supports decision making. Researchers at an academic rheumatology department in the Netherlands prospectively developed a diagnostic rule for gout using data from 381 consecutive patients with monoarticular arthritis who were referred by family physicians. Within 24 hours of visits to family practitioners, patients underwent joint aspiration, examination of synovial fluid for monosodium urate (MSU) crystals, physical examination, and laboratory testing. Researchers, who were blinded to the family practitioners' diagnoses of gout or nongouty arthritis, analyzed predefined potentially diagnostic variables in logistic regression models; variables that were significantly associated with presence of MSU crystals were weighted and used to develop a clinical prediction model. The best-fit model...

"treating 1000 people with calcium supplements for 5 years would prevent only 26 fractures but would cause an additional 14 MIs." 這種meta-analysis的文章可以相信嗎? Calcium Supplementation Is Associated with Excess Risk for Myocardial Infarction Marginal-to-moderate bone benefits must be weighed against cardiovascular risks. Evidence suggests that calcium supplements hasten vascular calcification and increase mortality in patients with kidney failure and raise risk for myocardial infarction (MI) in healthy older women. To further investigate the association between supplemental calcium and adverse cardiovascular events, researchers conducted a meta-analysis of 15 double-blind, randomized trials in which participants (mean age at baseline, >40) received calcium supplements (≥500 mg daily) or placebo. Patient-level data were available for five trials involving >8000 participants (77% women; median follow-up, 3.6 years). MIs occurred in 143 participants randomized to calcium supplem...

說是rapid TB diagnosis in low-income countries 台灣也很需要啊!! 優點是人員不需要太多training, 不太會有染污的問題 一般檢驗室就可以做 缺點是貴，一個cartrige大概是600元新台幣，一台是80萬台幣 但大量使用後可望降價 不然等一個TB culture要等6-8星期 病人就是燒給你看 還沒確診給他吃TB藥，副作用出來你就嗝屁了 這種19世紀的檢驗方法不符合21世紀病人和社會的期待…… 我不想被關10個月啊!! Rapid Tuberculosis Diagnosis in Low-Income Countries An automated molecular test for Mycobacterium tuberculosis and rifampin resistance demonstrated excellent sensitivity using untreated sputum from patients with suspected pulmonary infection. The acid-fast bacillus smear has been critical in the rapid diagnosis of pulmonary tuberculosis (TB) in resource-limited countries. However, the sensitivity of this technique is limited, and more-useful tools such as molecular tests have not been an option due to the cost of training and equipment. In a partially industry-funded, multinational trial involving 1730 patients with suspected pulmonary TB, researchers examined the performance of an automated molecular test for Mycobacterium tuberculosis (MTB) and resis...