The Hazards of Evidence-Based Medicine Assessing Variations in Care

JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 08/2011; 306(7):762-3. DOI: 10.1001/jama.2011.1181
Source: PubMed


Assessing quality of care frequently involves using measures of processes of care, such as Medicare's 25 quality metrics.1 Adherence to these processes is thought to lead to improved outcomes. For example, the Surgical Care Improvement Project was introduced in 2006, with the goal of reducing surgical complications by 25% by 2010.2 Based on observational studies demonstrating associations between process and outcomes, experts concluded that adherence to this series of process measures would result in better care. Medicare adopted these and published them on its Hospital Compare Web site1 as measures of hospital quality. However, for some process measures, studies have shown that adherence to these measures is not necessarily associated with improved outcomes. This has been the case for perioperative antibiotic use and postoperative wound infection3 and for acute myocardial infarction, heart failure, and pneumonia.4 More worrisome is that in some cases, adherence to the prescribed process measure may be associated with considerable harm, such as with tight glucose control in critically ill patients.5

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    ABSTRACT: Recently, multiple regulations and recommendations for safe infection control practices and safe injection and medication vial utilization have been implemented. These include single dose and multi-dose vials for a single patient and regulations. It is a well known fact that transmission of bloodborne pathogens during health care procedures continues to occur because of the use of unsafe and improper injection, infusion, and medication administration. Multiple case reports have been published illustrating the occurrence of infections in interventional pain management and other minor techniques because of lack of safe injection practices, and noncompliance with other precautions. However, there are no studies or case reports illustrating the transmission of infection due to the use of single dose vials in multiple patients when appropriate precautions are observed. Similarly, the preparation standards for simple procedures such as medial branch blocks or transforaminal epidurals have not been proven to be essential. Further, the effectiveness or necessity of surgical face masks and hats, etc., for interventional techniques has not been proven. To assess the rates of infection in patients undergoing interventional techniques. A prospective, non-randomized study of patients undergoing interventional techniques from May 2008 to December 2009. An interventional pain management practice, a specialty referral center, a private practice setting in the United States. All patients presenting for interventional techniques from May 2008 to December 2009 are included with documentation of various complications related to interventional techniques including infection. May 2008 to December 2009 a total of 3,179 patients underwent 12,000 encounters with 18,472 procedures. A total of 12 patients reported suspicion of infection. All of them were evaluated by a physician and only one of them was a superficial infection due to the patient's poor hygienic practices which required no antibiotic therapy. Limitations include the nonrandomized observational nature of the study. There were no infections of any significance noted in approximately 3,200 patients with over 18,000 procedures performed during a 20-month period in an ambulatory surgery center utilizing simple precautions for clean procedures with the use of single dose vials for multiple patients and using safe injection practices.
    Full-text · Article · Sep 2011 · Pain physician

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