Institute for Healthcare Improvement (IHI)

Author in the Room: Postlicensure Safety Surveillance for HPV Vaccine

October 2009 Author in the Room^® Teleconference

 

Author: John Iskander MD MPH

 

Article: "Postlicensure Safety Surveillance for HPV Vaccine"

 

Summary Points:

• Since quadrivalent HPV vaccine was licensed in June 2006, more than 23 million doses have been administered nationally.
• There were a total of 12,424 reports to the Vaccine Adverse Event Reporting System (VAERS) of adverse events following HPV vaccination through December 2008. The vast majority (94 percent) of adverse events reported to VAERS after receiving this vaccine have not been considered serious. The findings of this first published post-licensure safety review were generally not different from what is seen in safety reviews of other vaccines recommended for 9- to 26-year-olds.
• The most common events reported were syncope, local reactions at the site of immunization (pain and redness), dizziness, nausea, and headache.

Author in the Room: Attitudes of Physicians After A Mindful Communication Program

​November 2009 Author in the Room^® Teleconference

 

Author: Michael S. Krasner,  MD

 

Article: "Burnout, Empathy, and Attitudes of Physicians After A Mindful Communication Program"

 

Summary Points:

• Burnout is prevalent among physicians, and has untoward effects not only on the physicians themselves but also on the quality of the care they provide to their patients.
• Mindful communication training among a group of primary care physicians resulted in not only improvements in burnout and measures of well-being, but also improvements in markers of relationship-centered care to their patients.
• Mindful communication should be considered among a menu of continuing medical education opportunities available for physicians to enhance well-being, meaning, and interpersonal relationships in the practice of medicine.

Author in the Room: Rethinking Screening for Breast Cancer and Prostate Cancer

​December 2009 Author in the Room^® Teleconference

 

Author: Laura Essermand, MD, MBA

 

Article: "Rethinking Screening for Breast Cancer and Prostate Cancer"

 

Summary Points:

• The effectiveness of screening depends on the underlying biology of cancer. Routine mammographic screening works best for slow to moderate growth tumors, most common in women 50-74 and explains why the preventive services guidelines actually make sense.
• There are ways that we can improve screening today. Trained mammographers find the most cancers and have the fewest false positives. Offering follow up as an option for  low risk mammographic lesions will decrease false positives. Screening the populations who benefit most will also avoid false positives and overdiagnosis in those who benefit less from screening. The prostate cancer risk calculator is a good tool to use to determine whether to do a biopsy.
• We can and must do better. Mammography and PSA testing can detect very low risk cancers, and these cancers can be less aggressively treated. Tools are available to distinguish these low risk cancers. The most aggressive cancers often present between normal screens, so women with new masses, regardless of a recent normal mammogram should be evaluated. Men and women at high risk to develop breast and prostate cancer, should consider prevention interventions. Future screening should be developed to reduce mortality from the highest risk cancers

Author in the Room: Risk for Retinal Detachment

January 2010 Author in the Room^®Teleconference

 

Author: Hussein Hollands, MD

 

Article: "Acute Onset Floaters and Flashes: Is This Patient at Risk for Retinal Detachment?"

Summary Points:

• The most likely cause of acute onset monocular floaters or flashes is posterior vitreous detachment and if left untreated vitreous detachment complicated by retinal tear can progress to vision-threatening retinal detachment.
• A minimum approach to evaluating a patient with suspected posterior vitreous detachment should include a history of change in vision or curtain of darkness, measurement of visual acuity and assessment of confrontational visual fields.
• High-risk features for retinal tear in the setting of acute posterior vitreous detachment are subjective or objective visual acuity loss, monocular visual field loss (or curtain of darkness), and vitreous pigment or hemorrhage on slit-lamp examination and patients with any of these clinical findings should be referred for same day ophthalmology assessment. 

Author in the Room: Medical Care for the Final Years of Life

February 2010 Author in the Room^®Teleconference

 

Author: David Reuben, MD, MSc 

 

Article: "Medical Care for the Final Years of Life"

 

Summary Points:

• For a conventional evidence-based approach is modified by three important caveats: prognosis, insufficient evidence, and patient goals and preferences.
• Conceptually, the care of older persons can be divided into three time frames: short-term, which focuses on remediating the current problems; mid-range, focusing on preventive and foreseeable problems; and long-range, which focus on eventual decline and living arrangements.
• Individual providers need to structure their practices to efficiently and comprehensively accommodate the diverse needs of elderly patients.

Author in the Room: Heterogeneity and Lessons from Improvement

March 2010 Author in the Room^® Teleconference

 

Author: Frank Davidoff, MD

 

Article: "Heterogeneity Is Not Always Noise: Lessons from Improvement"

 

Summary Points:

• A clinical trial is a powerful tool for showing whether an intervention works, but the heterogeneity of trial participants means it’s a mistake to assume that the overall (or group) benefit of an intervention found in such a trial is the same for every participant
• The absolute benefit of an intervention is greater for trial participants — and for patients, generally — whose baseline risk for a bad outcome is high than it is for those whose baseline risk is low
• A quality improvement program in any one organization is like an individual patient, in the sense that it’s highly complex, is unstable (i.e., changes over time), and its local circumstances are unique, all of which make it hard — although not impossible — to judge whether a quality improvement program in any particular setting actually works, and to know whether it would work elsewhere.

Author in the Room: The Patient Who Falls

April 2010 Author in the Room^® Teleconference

 

Author: Mary Tinetti, MD

 

Article: "The Patient Who Falls"

 

Summary Points:

• Falls are common health events that cause discomfort and disability for older adults and stress for caregivers. Previous falls; strength, gait and balance impairments; and medications are the strongest risk factors for falling.
• The most effective strategy for reducing the rate of falling in community-living older adults may be intervening on multiple risk factors including strengthening and balance exercises through physical therapy, medication reduction, environmental modifications to reduce fall hazards, cataract surgery. Vitamin D has strong evidence of benefit for preventing fractures among older men at risk and probably of preventing falls in all at risk older adults.
• While challenges and barriers exist, fall prevention strategies can be incorporated into clinical practice.

Author in the Room: Identifying Patients at Risk for Disabling Low Back Pain

May 2010 Author in the Room® Teleconference

 

Author: Roger Chou, MD

 

Article: "The Rational Clinical Examination: Will This Patient Develop Persistent Disabling Low Back Pain?"

 

Summary Points:

• A small proportion of patients with acute low back pain (LBP) go on to develop chronic LBP; these patients account for a very high proportion of costs, services, and suffering.
• The most helpful items to predict persistent disabling low back pain are presence of maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities.
• Early identification of patients with these risk factors could help guide early use of psychological therapies and exercise therapy to reduce the likelihood that they will go on to develop chronic disabling low back pain.​

Author in the Room: The Older Adult Driver with Cognitive Impairment

June 2010 Author in the Room^® Teleconference

 

Author: David Carr, MD

 

Article: "The Older Adult Driver with Cognitive Impairment"

 

Summary Points:

• Know how to assess a cognitively impaired older driver in the office setting
• Know how and where to refer at-risk cognitively impaired older drivers
• Know how to counsel cognitively impaired older drivers in regards to driving retirement

Author in the Room: Alcohol Consumption in Older Adults and Health Effects

July 2010 Author in the Room^® Teleconference

 

Author: Kenneth J. Mukamal, MD, MPH, MA

 

Article: "A 42-Year-Old Man Considering Whether to Drink Alcohol for His Health"

 

Summary Points:

• Careful alcohol histories are needed for all patients, particularly to identify binge drinking, which is frequent among moderate and especially younger drinkers.
• Even moderate alcohol consumption has important and plausible health effects based on short-term trials and observational studies, including lower risk of heart disease presumably via higher HDL-cholesterol and higher risk of breast cancer (presumably via higher levels of estrone and DHEA sulfates).
• Given these points, even controlled alcohol consumption is unlikely to benefit younger drinkers, but is a reasonable point of discussion for middle-aged and older adults, especially as a launching point for education about problem drinking and the potential risks and benefits of including alcohol as part of a healthy diet in older age.