Medical record

Death: How and When to Start a Conversation About It.

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Hospitalized patients and their families complain about the quality of end-of-life care, and a review in the Canadian Medical Association Journal offers guidance on talking with patients and their families about their preferences and what to expect.

The review suggests that such conversations about death should be thought of as a process rather than a single event; and if you would not be surprised that the patient died within the next year, it’s best to start that process. In doing so, the authors advise that family members be invited to the conversation.

The physician should be prepared to offer prognostic estimates (the authors provide links to helpful online estimators) while acknowledging uncertainty. As important, learn the patient’s values and record them clearly in the medical record.

The authors offer two seemingly less important, perhaps obvious points for these discussions: first, sit down, and second, make eye contact.

Source: CMAJ 

Medicare’s Efficiency Measure for Head CT for Atraumatic Headache Is Profoundly Flawed.

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A multicenter review of medical records shows that the measure is wildly unreliable, invalid, and inaccurate.

As part of their initiative to publically report and eventually pair reimbursement with specific quality and efficiency measures, the Centers for Medicare and Medicaid Services (CMS) developed an efficiency measure to evaluate use of brain computed tomography (CT) for emergency department (ED) patients who present with atraumatic headache. The measure (CMS OP-15) uses administrative billing data for patients with a final diagnosis of nonspecific headache. A CT scan is not included in the calculation (i.e., considered appropriate) if the patient has any of the following exclusions, which were derived based on guideline review and expert opinion: headache associated with lumbar puncture, dizziness, paresthesia, lack of coordination, subarachnoid hemorrhage, complicated or thunderclap headache, focal neurologic deficit, pregnancy, HIV, tumor or mass, or CT scan related to reason for admission. The National Quality Forum (NQF), which typically reviews and approves all measures for the CMS, rejected the proposed measure because it lacked scientific validity. The CMS implemented the measure despite the NQF finding.

These authors assessed the reliability, validity, and accuracy of the measure in a retrospective review of medical records for a convenience sample of 748 patients deemed by the CMS as having received inappropriate head CT because no exclusions were documented. The authors determined that exclusions were documented in the medical record for 489 patients (reliability, 35%) and that universally accepted indications for head CT (according to expert consensus, society guidelines, and literature) were present for 123 of 259 patients without exclusions documented in the medical record (validity, 48%). Overall accuracy of the measure was 17%.

Comment: CMS OP-15 should be immediately discontinued because it is fatally flawed: it was not validated with chart review and was implemented against the recommendation of the National Quality Forum, thus discrediting both organizations. Implementation of CMS OP-15 is unjustifiable and inexcusable and represents a complete abandonment of patient safety and quality of care in favor of thoughtless reduction of reimbursement for CT scans, which, according to national guidelines, are indicated and appropriate. In addition, implementation of this ill-conceived measure raises concerns about the ability of the CMS to police itself or anything else.

Source: Journal Watch Emergency Medicine