Doc Burnout and Patient Outcomes; Joint Injections for Arthritis: It’s PodMed Double T!

Allergies & Asthma

PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include removing blood clots for cerebellar bleeds, clinician burnout and patient quality outcomes, keeping people with COPD out of the hospital, and joint injections for osteoarthritis.

Program notes:

0:51 Provider burnout and quality of care

1:47 Single study as benchmark

2:52 Studies are all over the board

3:46 New treatment for osteoarthritis

4:46 Looked at cartilage with MRI

5:46 Change in cartilage 0.05 mm

6:31 Intensive management of COPD and ED visits, hospitalizations

7:31 Actually showed harm

8:31 Don’t have good evidence on how to prevent rehospitalization

9:31 Related to a different medical condition

10:01 Removing cerebellar hematoma and outcomes

11:01 Evacuating didn’t improve neurological function

12:06 End


Elizabeth Tracey: Can we keep people with COPD out of the hospital with an intensive intervention?

Rick Lange, MD: Does removing a clot in a person that’s had a cerebellar bleed improve their outcome?

Elizabeth: What’s the impact of healthcare provider burnout on patient safety?

Rick: Can we modify osteoarthritis by doing joint injections?

Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on October 11th, 2019.

Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, with your permission, I’d like to start with Annals of Internal Medicine. This is a look at this impact of provider burnout and quality of care, which is, of course, probably the most important outcome relative to anything in healthcare as far as I’m concerned. As so many of their studies are, this was a meta-analysis and they finally boiled it all down to 123 publications with 142 study populations, including 240,000+ healthcare providers in their analysis. They were looking at a number of factors. There were five categories: best practices, communications, medical errors, patient outcomes, and safety. And they were looking at this relationship between burnout and quality of care.

They finally ended up with a metric that they called “excess significance.” That was where they kind of overstated the results of the studies and here’s what they used as a benchmark, and I’d like to hear your thoughts about this. They identified just one single study among this whole group they included in the meta-analysis that had a low risk of bias and they felt was a precise study. They used that study to benchmark everything else against that and that’s where they came up with this metric they thought overstated the impact of physician burnout or clinician burnout on patient outcomes, and I’m not sure I’m really persuaded by that. Ultimately, they decided, “Well OK, what we really need is better studies.” What are your thoughts?

Rick: This is a real issue because it’s estimated that 50% of healthcare providers are experiencing burnout. That’s a result of increased regulations and electronic medical records and other things — healthcare systems that make it very difficult to practice quality care. The concern is we know that burnout increases provider care dissatisfaction, the risk of suicide, and it increases the risk of actually leaving the profession, but the question is does it affect quality of care to the patients? That’s what these authors tried to address with this particular study.

What they noticed was the studies are all over the board. The second thing is, how do you assess quality of care? By the way, these studies looked at different healthcare providers. Some were physicians. Some were nurses. Some were other types of healthcare providers. What they concluded was there does seem to be some relationship between healthcare provider burnout and quality of care, but right now it’s very difficult to quantify. And so I agree with their findings.

Elizabeth: What did you think about the strategy of singling out one study that, in their estimation, had this low risk of bias and using it as the benchmark?

Rick: Usually you have, in a group like this, 123 studies, maybe 40 or 50 that are high-quality studies. In this particular case, they could only identify one, but what it tells us is there’s a lot we don’t know. We suspect, and the evidence strongly suggests, there’s a relationship. We need to do good quality studies to get to the bottom of this.

Elizabeth: We’re going to turn now to the Journal of the American Medical Association. We’re going to spend the rest of our time there. Which of those studies that you’re going to be talking about would you like to go to?

Rick: Let’s talk about potential to modify osteoarthritis. Osteoarthritis most commonly affects the knee joints and is characterized by loss of cartilage. That causes the joint to remodel and also causes inflammation. Currently, all we have is symptomatic treatment, either taking medications to decrease the pain or actually doing interarticular injections to do that. We don’t have very many things currently on the market that are disease-modifying drugs, but there’s one that’s recently been available called sprifermin. It’s a recombinant human fibroblast growth factor 18. It actually increases cartilage in joints.

So what these authors did was a phase 2 trial of almost 550 participants and these are people that have known osteoarthritis, and they had symptoms. They received two different doses over a 6- or 12-month period where they received weekly injections for 3 weeks either at 6 months, or at 6 months and 12 months, and followed them for 2 years looking at the amount of cartilage by MRI. Among the individuals that received the highest dose of the sprifermin, there was a very, very minimal increase in cartilage width. However, patients didn’t have a better quality of life or didn’t have less pain. So it looks like the highest dose of this disease-modifying drug may give a slightly increased cartilage, but the functional benefit of that is really unknown at this time.

Elizabeth: I thought in this study they didn’t really assess a lot of the quality-of-life factors. They basically just said, “Yep, OK, we have objective evidence that it does slightly and there’s a linear relationship, a dose response between how much of the drug was injected and how much the cartilage got thicker.” But there wasn’t really a big assessment of functional status.

Rick: They used what’s called the Ontario McMaster University Osteoarthritis Index Scores. It assesses things like functionality, pain, and also whether people are using pain medications. Those were no different between the groups. By the way, the change in cartilage was .05 millimeters. That was at 2 years and there’s some suggestion that it wasn’t as significant at 3 years. Statistically significant increase in cartilage width, but whether that’s functionally beneficial still remains to be seen.

Elizabeth: I think worth noting also is that virtually 100% of the patients complained of arthralgias at the injection site. Some of them also had sort of the swelling and all that other stuff that was rather troubling. I guess on the other hand, though, I would say we don’t have anything that really modifies the disease course in osteoarthritis, so I at least am glad that there’s some investigation of this going on.

Rick: Exactly. This goes to just not treating the symptoms, but actually trying to modify the osteoarthritis, so I agree.

Elizabeth: Speaking of benefits, let’s turn to one that originated here at Johns Hopkins. This was a look at if we do a rather intensive intervention with folks who have COPD [chronic obstructive pulmonary disease], can we impact on their subsequent visits to the ED [emergency department] or subsequent hospitalizations? They took a look at 120 people who had been hospitalized for COPD and they put them into a comprehensive 3-month program to basically educate them and their family caregivers about “Look, what do you need to pay attention to as far as your self-management is concerned?” and also increasing their vigilance with regard to “My symptoms are getting worse and I need to do some kind of an intervention.”

The intervention was given by nurses. The upshot of this whole trial, and there was a lot of sound and fury around it, [was] because [when] they submitted this paper initially, it looked like it showed a benefit as a result of this intervention — and then they re-crunched everything. They found that not only didn’t it show a benefit, it actually showed a harm in that the people in the intervention group were hospitalized more often and went back to the ED more often than the people who didn’t receive the intervention. And there’s been a lot of speculation both on the part of the authors and editorialists about why that might be the case, but certainly disappointing for people with COPD.

Rick: A couple things are interesting about this. When this study came out, it initially told individuals that these interventions helped. Unfortunately, when they went back and looked at it, somebody had entered the data incorrectly, and when they went to analyze it, it was just the opposite. Kudos, first of all, to the authors who noticed this, and wanted to get the truth out, and also to JAMA for publishing this with a retraction. This is a great example of trying to preserve scientific integrity.

The other issue — this is all in response to the hospital readmission reduction program of the CMS [Centers for Medicare & Medicaid Services], which financially penalizes hospitals that have a high 30-day readmission rate for things like COPD. Despite what CMS says, we don’t really have good evidence on how to prevent COPD rehospitalizations. What they’ve done is actually force us to provide interventions that not only are not helpful, but actually may make the situation worse as well.

Elizabeth: I thought some of the patient characteristics were interesting, and some of the speculation relative to why did these folks come back into the hospital more often. There were more men in the group who actually came back in. One of the potential reasons I saw about that was that it increased their vigilance. All of a sudden these guys became more aware of “Wow, if I’ve got this particular symptom, maybe I ought to seek care faster.” The other thing was comorbidities, which they did not exclude folks with comorbidities. We know that’s very, very common among people with COPD. And so what’s that interaction? Is that the thing that drives them to come back to the hospital?

Rick: Exactly. In fact, most of the readmissions aren’t related to an exacerbation of their COPD again. It’s to a different medical condition. You shouldn’t be penalized for that.

Elizabeth: The other one thing I will add about this is that the one piece of self-management that was not available to them were drugs. In previous studies, they have shown if people have access to that and can self-administer that, that does seem to have an impact on ED visits and hospitalizations.

Rick: If our goal is to decrease readmissions, we need more studies to figure out how best to do that.

Elizabeth: Let’s turn to your final one — another one that’s somewhat disappointing. If you take out the blood clot when somebody has got this giant bleed into their cerebellum, it doesn’t really help.

Rick: I can remember being taught in medical school that if someone has an intracranial hemorrhage of bleeding in the brain, the treatment for that is to evacuate it surgically. That’s been around for decades. They had a pool of about 6,600 patients derived from four different large intracranial cohort studies. And from those, they identified that about 10%, about 580 patients actually had a cerebellar intracranial hemorrhage.

Some were treated medically, and some had surgical evacuation of the hematoma, and they were able to match those two groups. They had about 152 in each group. What they discovered was although the patients who underwent surgical hematoma evacuation had a slightly higher 3-month survival, 78% versus 61%, there was no difference at all in the proportion of patients that had a favorable, functional outcome. This dispels one of the more commonly held beliefs that evacuating an intracranial cerebellar hematoma is helpful.

Elizabeth: One thing I would note about this is that only about 10% of intracranial bleeds meet this particular criteria.

Rick: Right. When one has intracranial hemorrhage in other parts of the brain, particularly in the cerebrum and it’s large, surgical evacuation has been shown to be helpful. That appears to be distinctly different than the cerebellar hemorrhage, which as you say, occurs in about 10% of all intracranial hemorrhages, but that still means about 10,000 patients in the United States each year have a cerebellar hemorrhage. That accounts for about 1.5% of all strokes.

Elizabeth: So I think it’s great to look very carefully at these different locations and what the impact of surgical evacuation is.

Rick: Right. Now, it may be in the future we may be able to identify a small cohort of individuals that do benefit, but right now we don’t have that answer.

Elizabeth: On that note, then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.


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