WIHI - A Podcast from the Institute for Healthcare Improvement

Which way forward for the quality improvement and patient safety movements? Join IHI's President and CEO, Donald Berwick, for a series of conversations with Senior Communications Strategist, Madge Kaplan. Each monthly installment offers Dr. Berwick?s latest thinking on the major issues of the day and how health care professionals, health care leaders, and patients and families can bring about significant reform.

Most cancer screening guidelines do not recommend screening elderly persons in poor health who have limited life expectancies because the harms of screening (which occur immediately) outweigh the potential benefits (which occur many years in the future). PSA screening rates among elderly men with limited life expectancies should be much lower than current practice to avoid harming these men with unnecessary tests and procedures. Guidelines should be more explicit about how life expectancy is defined and provide tools to help clinicians identify men with poor prognoses who are most likely to be harmed by PSA screening, considering both age and the presence of severe disease.

For the general population, the health benefits of fish intake far outweigh the risks. Women of childbearing age, nursing mothers and young children should eat up to two servings of fish per week as the benefits of fish intake still outweigh the risks. Given the magnitude of the benefits, physicians should regularly give dietary advice to patients for cardiovascular disease prevention.

Wait-and-See Prescription (WASP) is a viable approach to managing children with acute otitis media. Compared with the standard prescription group, the WASP group filled the antimicrobial prescription much less frequently and had equivalent clinical outcomes. Within the WASP group, fever and ear pain were associated with filling the prescription demonstrating that parents are able to make appropriate care decisions when given clear guidance. In the management of acute otitis media, important points for clinicians are first to make right diagnosis and then to provide sufficient analgesia. Adequate pain control allows parents to better manage their sick child and use antimicrobials judiciously while also reducing the risk of medical side effects and antibiotic resistance.

There is a new and novel pharmaceutical approach to treating nicotine addiction that helps smokers quit by specifically targeting nicotine receptors. Efficacy for varenicline was three-to four times that of placebo and twice that of bupropion at the end of 12 weeks of treatment, but abstinence rates in all groups declined after drug treatment ended. The launch of a new smoking cessation medication will likely drive patient demand for smoking cessation services. Medical practices should be prepared to respond to this demand by having a clear, systematic approach to smoking cessation.

Even though we have long assumed that clinicians should ask patients directly about intimate partner violence, this study shows that self-complete methods for soliciting such information are preferred by women, and may be more efficient. The prevalence rate for intimate partner violence differs by setting and population and varies significantly from approximately 4% to approximately 18%. While this study provides evidence on the best methods to solicit information on intimate partner violence, it doesn't tell us if collecting this information improves outcomes for women exposed to such violence. A randomized controlled trial evaluating the effectiveness of screening women for intimate partner violence in health care settings is currently underway.

Raloxifene is as effective in reducing the risk of invasive breast cancer in postmenopausal women who are at increased risk of the disease. The safety profile of raloxifene is more favorable than tamoxifen with fewer hysterectomies, uterine malignancies, serious thrombotic events, and cataracts. Both physicians and patients are familiar with raloxifene and its use for preventing and treating osteoporosis, and there is a long experience with its use in healthy women.

This week: Dr. Callahan discusses standard protocols that primary care practices have to offer a patient with Alzheimer Disease and their caregivers. He describes how the quality of care of many geriatric syndromes, including Alzheimer Disease, can be improved by implementing a collaborative care model.

This week: The complex set of components involved in the decision to screen (or not) for colon cancer includes input from both the doctor (e.g., data about what might happen and how likely the possibilities are) and the patient (e.g., how the patient weighs the relative desirability of the various possible outcomes that result from the possible decisions). Embedded in experts' recommendations for colorectal cancer screening are nearly impossible demands on primary care clinicians to discuss the pros and cons of various modalities for screening with each patient and to assess risk even to the detail of learning the pathology of the biopsy of relatives' colonoscopies (e.g., adenomatous vs. hyperplastic polyps).

This week: All or none measurement more closely reflects the interests and likely desires of patients than other approaches to measurement such as composite or item-by-item. All or none measurement forces a system perspective and offers a more sensitive scale for assessing improvements.

This week: Dr. Taddio explains how infants feel pain during central line placement and this pain can be reduced with analgesics. IV Morphine used alone or in combination with Tetracaine Gel is more effective than Tetracaine alone or no treatment. IV Morphine and Tetracaine Gel are associated with expected side effects.

This week: Dr. Johnson discusses how men who have few if any symptoms from their inguinal hemia, can safely delay having it fixed. When symptoms develop, especially if the symptoms worsen suddenly, they should visit a surgeon and request a repair. If the hernia suddenly becomes incarcerated, painful, and signs of a bowel obstruction develop (vomiting, abdominal cramps), an operation should be done immediately.

This week: Recent reports suggest an increasing occurrence and severity of Clostridium difficile associated disease. The authors found that the use of acid-suppressive therapy, particularly proton pump inhibitors, is associated with an increased risk of community-acquired C difficile and state that the unexpected increase in risk with nonsteroidal anti-inflammatory drug use should be investigated further.

This week: Dr. Samore discusses how clinical decision support systems(CDSS) are feasibly implemented in practice settings that lack electronic medical records (including rural communities) but need to be integrated with tools that save clinicians time to be sustainable.

This week: Dr. Flum discusses how following a bariatric (obesity) surgery, patients ages 65 and up as well as Medicare medically disabled patients, have a much higher risk of early death than other patients. However, more experienced bariatric surgeons can lower that risk of death for older patients.