Errors in diagnosis place a heavy financial burden on an already costly health care system and can be devastating for affected patients. Strengthening certain aspects of a new and evolving model of comprehensive and coordinated primary care could potentially address this highly relevant, but under emphasized safety concern, say Mark Graber, M.D., of Stony Brook University Medical Center, and Hardeep Singh, M.D., M.P.H., of Baylor College of Medicine, in a commentary published in the July 28 issue of the Journal of the American Medical Association (JAMA).

In the commentary, Drs. Graber and Singh point out that diagnostic errors are the single largest contributor to malpractice claims (about 40 percent) and cost approximately $300,000 per claim. They discuss a unique model of primary care, called the patient-centered medical home, and outline five principles that the model needs to incorporate in order to reduce the incidence of diagnostic errors. The principles of the patient-centered medical home were developed and endorsed by the American Academy of Family Physicians, the American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association.

The model facilitates partnerships between individual patients, their personal physicians and, when appropriate, the patient’s family. Care is assisted by physician ‘extenders,’ nurse empowerment, information technology and other means to assure that patient get care when and where they need and want it in a culturally and linguistically appropriate manner.

“The great majority of diagnostic errors have root causes that derive from the properties of the healthcare setting, organization and practice,” says Dr. Graber, Associate Chair of Medicine at SBUMC and Chief of Medical Service at the Northport Veteran Affairs Medical Center. “By working together, cognitive scientists, informaticians, clinicians, and human factors engineers have a unique opportunity to decrease the likelihood of diagnostic error to the extent that the five principles we outline in JAMA can be incorporated into every new medical home.”

In the commentary, Drs. Graber and Singh define the five principles as Right Teamwork, Right Information Management, Right Measurement and Monitoring, Right Patient Management, and Right Safety Culture.

Right Teamwork

The medical home model places emphasis on team-based care, and primary care teams could include not only physicians but also nurses, allied health professionals and personnel, the authors explain.

“Task delegation with the ‘team’ has to be done correctly to avoid errors related to patient follow-up, a common breakdown in the process,” says Dr. Singh, Assistant Professor of Medicine and Health Services Research at the Veterans Affairs Health Services Research and Development Center of Excellence and Baylor College of Medicine. “The physician could take a leadership role, while the entire group collectively takes care of the patient.”

For example, monitoring test results, referrals and appointments to ensure appropriate follow-up could be performed by other team members under physician supervision.

Through innovative team-training programs, care should be undertaken to ensure that the new model of care does not introduce ambiguous responsibility between team members. Individual accountability and ownerships of patients should continue to be emphasized, the researchers wrote.

Right Information Management

Breakdowns in information management, such as communication and coordination of care, are the root of many diagnostic errors, Drs. Singh and Graber wrote.

“Electronic health records can help facilitate information transfer but this information then needs a required follow-up action for the task to be considered completed,” they note. “The information loop needs to be closed.”

Major issues affecting safe information management are the unclear responsibility for patient follow-up between the primary care physician and subspecialist or team member, as well as the overwhelming volume of alerts, reminders and other diagnostic information in electronic health records.

If information management problems (technological and non-technological) are not addressed now, they are likely to worsen when medical homes are fully implemented, the authors wrote. “Comparative effectiveness studies should be conducted to evaluate which features and functions of electronic records are more effective in reducing diagnostic errors in medical homes.”

Right Measurement and Monitoring

Improving the current performance monitoring strategies of providers’ competence are also necessary, the researchers wrote, including better measurement processes and outcomes related to compliance with preventive measures and key indicators of diagnostic performance (i.e. appropriate management of diagnostic test results).

“Newer methods that include electronic surveillance and monitoring techniques could be used to detect diagnostic errors proactively. These approaches could be accompanied by feedback to clinicians about specific prevention strategies,” they wrote.

Right Patient Empowerment

Drs. Singh and Graber point out that patients are key partners in the medical home team. “Encouraging ‘activating’ questions should become part of the patient centered medical home commitment to reduce errors.”

Activating questions may include: “How do I make sure I hear about all my test results?” “Do I need another opinion?” and “How and when should I get back to you if I’m not better?”

Right Safety Culture

The current conversation about the patient-centered medical home is focused on reimbursement and chronic disease care, Drs. Singh and Graber note. “But patient safety must be a central, organizing principle and not just an afterthought,” they said. “From a practical standpoint, this necessitates an appropriate infrastructure and skill set to ensure effective implementation of the four rights described above.”

Mark Graber, M.D., is Professor and Associate Chair of the Department of Medicine at Stony Brook University Medical Center and Chief of Medical Service at the Northport VA Medical Center. His research focuses on patient safety and diagnostic errors. Dr. Graber convened and chaired the first two international conferences on “Diagnostic Error in Medicine” in 2008 and 2009.

Source:
Stony Brook University Medical Center
via MedicalNewsToday

New US research on mice suggests that bone plays a key role in insulin regulation and helps cells of the body take up glucose; as both these processes are impaired in people with type 2 diabetes the researchers suggest this discovery could lead to new diabetes drugs.

Dr. Gerard Karsenty from Columbia University Medical Center, New York, and colleagues found that the process of bone resorption, when old bone breaks down to make way for new growth, releases a hormone called osteocalcin that turns on insulin production and also helps cells take up glucose.

You can read about the research that led to these findings in a paper published online on 23 July in the journal Cell.

There is great curiosity among scientists in the field about what influences the regulation of insulin, because the insulin receptor appears to be everywhere in the body, including osteoblasts, cells responsible for bone formation and releasing osteocalcin, which Karsenty and his team first linked with glucose regulation in 2007.

Back then they found that once uncarboxylated (when the protein loses the COOH carboxyl terminus, a way of switching signals on and off), osteocalcin switches on insulin production in the pancreas and improves the ability of cells in the whole body to take in glucose: both of which are impaired in people with type 2 diabetes.

In this study they found that as osteoblasts begin the resorption process, the cell environment becomes more acidic which favors decarboxylation and thereby activates more osteocalcin, which in turn stimulates insulin production.

But they also found that insulin favored bone resorption, so the process appears to be a “feed-forward” loop where insulin signals osteoblasts to start resorption, which in turn releases more osteocalcin, which in turn releases more insulin.

“Insulin is a street-smart molecule that takes advantage of the functional interplay between bone resorption and osteocalcin, to turn-on the secretion and synthesis of more insulin,” said Karsenty.

The researchers suggest their finding strengthens the idea that diabetes could be treated by regulating levels of osteocalcin in the body.

They also raised an important question that warrants further research: bisphosphonates, the most common drugs for treating osteoporosis, work by slowing down bone resorption, so could they also inhibit osteocalcin activation and cause some patients to become glucose intolerant?

“This research has important implications for both diabetes and osteoporosis patients,” said Karsenty:

“First, this research shows that osteocalcin is involved in diabetes onset; secondly, bone may become a new target in the treatment of type 2 diabetes, the most frequent form of diabetes, as it appears to contribute strongly to glucose intolerance; and, finally, osteocalcin could become a treatment for type 2 diabetes.”

And secondly, said Karsenty, although more research is needed to study this further, there is a concern that an osteoporosis patient with borderline glucose intolerance who is then treated with bisphosphonates could be pushed into “fully-fledged” diabetes onset.

Another paper (Fulzele et. al.) in the same issue of Cell, describes how researchers found that insulin signaling helps bone formation by suppressing Twist2, a protein that inhibits osteoblast development and enhances expression of osteocalcin.

Writing in a preview article about the significance of the two studies, Drs. Clifford J. Rosen and Katherine J. Motyl of the Maine Medical Center Research Institute suggested that together they add to the growing evidence that the skeleton plays an important role in metabolic homeostasis: it would seem that bones are key players in keeping a steady throughput of energy through every cell of the body.

Source:
MedicalNewsToday

A team of European researchers have found that reducing meat consumption may be a key factor in losing weight and maintaining an healthy body weight. The researchers wrote in The American Journal of Clinical Nutrition that meat intake, because of its high energy and fat content might be linked to weight gain.

According to some previous observational studies, the researchers wrote, meat consumption is positively linked to weight gain. However, intervention studies had not revealed a clear picture.

The team, from the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London and other European institutions, set out to evaluate the link between total meat, red meat, poultry and processed meat consumption and weight gain after a follow-up of 5 years, involving over 370,000 individuals who participated in the European Prospective Investigation into Cancer and Nutrition-Physical Activity, Nutrition, Alcohol, Cessation of Smoking, Eating Out of Home and Obesity (EPIC-PANACEA) project.

Between 1992 and 2000, 103,455 males and 270,248 females, aged between 25 and 70 were recruited from 10 different European countries.

Country-specific validated questionnaires were used to assess their baseline diets. Their weights and heights were measured at the start; and were subsequently asked to report their weight after five years.

In general, the team discovered that meat intake was linked to weight gain in both sexes; even after factoring in such variables as average calorie intake, physical activity and other confounders.

The researchers wrote:

Total meat consumption was positively associated with weight gain in men and women, in normal-weight and overweight subjects, and in smokers and nonsmokers. With adjustment for estimated energy intake, an increase in meat intake of 250 g/d (eg, one steak at 450 kcal) would lead to a 2-kg higher weight gain after 5 yrs. (95% CI: 1.5, 2.7 kg). Positive associations were observed for red meat, poultry, and processed meat.

The authors concluded that:

Our results suggest that a decrease in meat consumption may improve weight management.

The first team of registered nurse volunteers from California, Michigan, and Washington State will depart for Haiti Wednesday morning with the Department of Defense’s Continuing Promise, National Nurses United (NNU), the nation’s largest organization of registered nurses, announced. The volunteer RN team will be treating patients in Haiti and Columbia during their month long deployment.

The group is part of a continuous series of assignments of volunteer RNs from NNU’s Registered Nurse Response Network (RNRN) which included working onboard the USNS Comfort, the critical Navy relief effort that cared for the most seriously injured following the disaster, and Hopital Sacre Coeur (HSC), the largest private hospital in northern Haiti.

Teams of RN volunteers will be based aboard the USS Iwo Jima, a Navy amphibious ship, in one-month rotations from July to November. They will be working in makeshift clinics on the shores of Haiti, Colombia, Costa Rica, Guatemala, Nicaragua, Panama, Guyana, and Suriname.

“I had been traveling in Haiti with another nurse and we had left the day before the earthquake,” said Brook Casipit, an RN from Seattle, Washington with previous disaster relief experience in Central America who is part of RNRN’s first Continuing Promise team. “We had just arrived in the Dominican Republic when we heard about the disaster and tried desperately to return to volunteer, but were not able to find an organization on the ground to work with. I am delighted to finally be able to volunteer my service through RNRN.”

The first team consists of NP’s and RNs with a background in women’s health, disaster relief experience, and many have recent experience in Haiti including:

Cherie Thurner, an RN from Michigan, who went with RNRN to Sacre Coeur Hospital and has been on 13 medical mission trips to Haiti over the last 13 years. She has been on two medical missions in the country following the January earthquake and worked disaster relief following Hurricanes Katrina and Rita in 2005.

Amanda Howard, an RN from the San Diego area, who spent six weeks in Haiti after the earthquake and established pre- and post-natal care in an existing clinic.

Jane Ernstthal, a San Francisco Bay Area women’s health nurse practitioner with clinical experience in Malawi, Kenya, Chile, Ecuador, Mexico, and Haiti, where she conducted family planning trainings for local clinicians.

Brooke Casipit, a Seattle, Washington recovery room RN who has trained local midwives in Guatemala, Dominican Republic, Haiti, and Nicaragua. “We have learned from our experience in Hurricane Katrina that the kind of skills needed in the weeks and months following a disaster are nursing skills,” said Bonnie Castillo, RN, director of RNRN. “The kind of care that’s needed is everyday care, and things are exacerbated by the lack of medication and basic first aid. Wounds fester and spread. Something that was preventable ends up a life-threatening situation. Nurses are the heart of a long-term recovery effort.”

Source: California Nurses Association

“The private doctor’s practice – long considered a mainstay of American medicine – could be going the way of the independent bookstore and locally owned pharmacy,” The Detroit News reports. “Crushed by mounting economic pressures, more midcareer physicians in Michigan and across the country are giving up their solo practices and joining large and better-financed hospital systems as salaried employees. And an increasing number of young doctors graduating from medical school are forgoing private practice in favor of hospital jobs with steady paychecks and regular hours. … The shift is ushering in a new era in medicine that improves the coordination of patient care between doctors and hospitals and further consolidates the health care industry. But it also means the steady demise of a venerable tradition: the autonomous doctor” (Rogers, 7/20).

As doctors join hospitals and shun private practice, primary care doctors are also getting harder to find, The Boston Globe reports. “Massachusetts has the highest ratio of doctors per population in the country, but that doesn’t mean its residents can find a primary care physician who is accepting new patients. It got harder to secure a slot after 2006, according to one of three reports on health care released by the state today.” Only 60 percent of doctors practicing family medicine were accepting patients in 2009, according to the Massachusetts Division of Health Care Finance and Policy. “Last year only 44 percent of internal medicine practices were accepting new patients, down from 66 percent in 2005.” Fewer residents there don’t already have a primary care doctor, however – only 11 percent in 2008 don’t (Cooney, 7/19).

In the meantime, nurses are also coming under greater scrutiny. ProPublica has a story and list regarding discipline actions taken with nurses in locations across the country. “Each state has a different process for investigating and disciplining nurses and for making licensing information available to the public.” ProPublica has charts that allow the public to verify a nurse’s license and has stories about the practice of allowing nurses who are sometimes allowed to practice in one state though they were disciplined in another because of a multi-state agreement allowing them greater practice mobility (Ornstein and Weber, 7/20).

Source:
www.kaiserhealthnews.org
© Henry J. Kaiser Family Foundation. All rights reserved.

The number of women diagnosed with womb cancer is at its highest for over 30 years according to new figures published by Cancer Research UK which show more than 7,530 people now* develop the disease each year in the UK.

Experts believe the reasons for the continuing rise in womb cancer include more women being overweight or obese and women having fewer or no children.

In 1975, 13 in every 100,000 women were diagnosed with womb cancer but over 30 years later the rates have risen to more than 19 women being diagnosed in every 100,000.

The incidence rates of womb cancer peak in women aged 60-79. And these age groups have seen the largest increases with rates nearly doubling since 1975 – rising from around 40 women in every 100,000 to over 75 in every 100,000 in 2007.

Womb cancer is the fourth most common cancer in UK women and in 2008 1,741 women died from the disease.

In the last 10 years – of the top 10 most common cancers in women – incidence rates for womb cancer have risen the second fastest, after malignant melanoma skin cancer.

Sara Hiom, Cancer Research UK’s director of health information, said: “These figures show that we’re still seeing a year on year rise in the number of women diagnosed with womb cancer and more needs to be done to tackle this. Women can reduce their risk of developing the disease by keeping a healthy weight and taking regular exercise.

“All women should be aware of the symptoms of womb cancer which include abnormal vaginal bleeding – especially for post-menopausal women, abdominal pain and pain during sex. Although these symptoms don’t usually mean cancer, as they could be signs of other diseases like fibroids or endometriosis, it’s still vital to get them checked by a doctor. The earlier the disease is diagnosed, the more likely treatment will be successful.”

Reference

Cancer Research UK statistics, 2007

Source:
MedicalNewsToday

A universal influenza vaccine – so-called because it could potentially provide protection from all flu strains for decades – may become a reality because of research led by scientists from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

In experiments with mice, ferrets and monkeys, the investigators used a two-step immunization approach to elicit infection-fighting antibodies that attacked a diverse array of influenza virus strains. Current flu vaccines do not generate such broadly neutralizing antibodies, so they must be re-formulated annually to match the predominant virus strains circulating each year.

The research, led by NIAID scientist Gary J. Nabel, M.D., Ph.D., appears online ahead of print July 15 issue of Science Express.

“Generating broadly neutralizing antibodies to multiple strains of influenza in animals through vaccination is an important milestone in the quest for a universal influenza vaccine,” says NIAID Director Anthony S. Fauci, M.D. “This significant advance lays the groundwork for the development of a vaccine to provide long-lasting protection against any strain of influenza. A durable and effective universal influenza vaccine would have enormous ramifications for the control of influenza, a disease that claims an estimated 250,000 to 500,000 lives annually, including an average of 36,000 in the United States.”

In parallel experiments with mice, ferrets and monkeys, Dr. Nabel and his colleagues first primed the animals’ immune systems with a vaccine made from DNA encoding the influenza virus hemagglutinin (HA) surface protein. After being primed with DNA vaccine, the mice and ferrets received a booster dose of the 2006-2007 seasonal influenza vaccine or a vaccine made from a weakened cold virus (an adenovirus) containing HA flu protein. Monkeys were boosted with the seasonal flu vaccine only.

This prime-boost vaccine stimulated an immune response to the stem of the lollipop-shaped hemagglutinin of influenza virus. Unlike HA’s head – which mutates readily, allowing the virus to become unrecognizable to antibodies – the stem varies relatively little from strain to strain. In principle, Dr. Nabel explains, antibodies generated against the stem of HA should be able to recognize and neutralize multiple flu strains.

Although the DNA in the priming vaccine was derived from a 1999 circulating flu virus, all the animals made antibodies capable of neutralizing virus strains from several other years. Mice and ferrets produced antibodies not only against virus strains dating from before 1999, including a strain that emerged in 1934, but also against strains that emerged in 2006 and 2007.

Moreover, although the prime-boost vaccines were both made from H1 subtypes of influenza A virus, the antibodies they generated neutralized other influenza subtypes, including H5N1 (avian influenza) virus. This indicates that a prime-boost strategy potentially could confer immunity to many or all subtypes of influenza A, says Dr. Nabel.

In another set of experiments, the scientists measured how well the prime-boost vaccine protected mice and ferrets from infection with deadly levels of flu virus. Three weeks after receiving the boost, 20 mice were exposed to high levels of 1934 flu virus, and 80 percent survived. Mice receiving DNA only, seasonal flu vaccine only or a sham prime-boost vaccine all died.

The researchers saw similar results when they tested several prime-boost combinations in ferrets, which are considered a good animal model for predicting flu vaccine efficacy in humans. All four ferrets that received a DNA prime-seasonal boost were protected from infection with a 2007 virus strain, while all six ferrets that received the DNA prime-cold virus boost combination were protected from the 1934 influenza virus.

Collaborators on these studies included Terrence Tumpey, Ph.D., of the Centers for Disease Control and Prevention.

“We are excited by these results,” says Dr. Nabel. “The prime-boost approach opens a new door to vaccinations for influenza that would be similar to vaccination against such diseases as hepatitis, where we vaccinate early in life and then boost immunity through occasional, additional inoculations in adulthood.”

Trials of prime-boost influenza vaccines assessing safety and ability of the vaccine to generate immune responses are already under way in humans, Dr. Nabel adds. The information from the new research will be valuable in selecting candidates to move forward into large-scale trials, he says. “We may be able to begin efficacy trials of a broadly protective flu vaccine in three to five years.”

Source:
MedicalNewsToday