Arnold R. Eiser

Patients surviving 10 years of hemodialysis

Experience with 37 patients surviving 10 years of hemodialysis therapy was reviewed. These patients were compared with 103 patients who began hemodialysis between 1967 and 1971 and who subsequently died. Males had an excess risk of death. Patients with polycystic kidneys survived longer. There was more uncontrolled hypertension among a control group than in 10-year survivors. In survivors, the hematocrit level increased over time and averaged 30.4 percent at 10 years. Over 10 years, many complications arose including parathyroidectomy (24), pericarditis (13), gastrointestinal bleeding (11), myocardial infarction (10), septicemia (eight), and active tuberculosis (six). Despite complications, most patients are now stable. Between their eighth and 10th years they required an average of only one hospitalization with a mean stay of 9.7 days. Eighteen patients were not hospitalized. Excluding housewives, 67 percent of patients between ages 20 and 59 years are employed full-time and 10 percent part-time. Patients surviving 10 years are not progressively deteriorating and may look to the future with cautious optimism.

Reversible Nephrotic Range Proteinuria with Renal Artery Stenosis: A Clinical Example of Renin-Associated Proteinuria

Nephrotic range proteinuria occurred in a 60-year-old woman with renal artery stenosis and marked hyperreninemia. Treatment by nephrectomy produced resolution of both proteinuria and hypertension. The gradual resolution of the proteinuria postoperatively suggested the proteinuria, at least in part, came from the contralateral kidney. Foot process fusion in the nephrectomy specimen suggested it too was a source of proteinuria. A marked degree of hyperreninemia, as was present in this case, may be necessary before massive proteinuria occurs in renal artery stenosis.

Intestinal Mucormycosis in Hemodialysis Patients Following Deferoxamine

Two maintenance hemodialysis patients receiving deferoxamine to chelate iron and aluminum developed intestinal mucormycosis. One patient had pulmonary mucormycosis as well. The patients lacked the usual predisposing factors to mucormycosis, ie, diabetes and acidosis, but both had liver disease. The role of siderophores such as deferoxamine in promoting certain infections is discussed with reference to this particular clinical setting.

Does over-expression of transforming growth factor-beta account for the increased morbidity in African-Americans?: possible clinical study and therapeutic implications.

African-Americans experience an excessive prevalence of a number of apparently disparate disorders that all appear to be, at least in part, mediated by the over-expression or activation of transforming growth factor-beta (TGF-beta) signaling pathways, and that certain genotypes including the codon 10 polymorphism occur more commonly among African-Americans and appears to predispose to these disorders. These disorders, fibrosing in nature, include hypertension, focal glomerulosclerosis, diabetic nephropathy, end stage renal disease, sarcoidosis, uterine leiomyoma, keloids, myocardial fibrosis, and glaucoma. The specific polymorphism for TGF-beta, codon 10, has been implicated in glomerulosclerosis and diabetic nephropathy as well as cardiac transplant rejection. Although TGF-beta over-expression is not the sole factor in these disorders, it is suggested that by designing future clinical studies that consider genomic differences in TGF-beta expression, a more complete understanding of these clinical disorders will be possible. A more thorough understanding of the genetic basis of disease will like promote improved therapeutic regimens and may help reduce the disparate health outcomes for African-Americans as well as improve treatment of individuals of various and diverse ethnic backgrounds.

Patient-Physician Fit: An Exploratory Study of a Multidimensional Instrument:

Background. Patients face difficulty selecting physicians because they have little knowledge of how physicians’ behaviors fit with their own preferences. Objective. To develop scales of patient and physician behavior preferences and determine whether patient-physician fit is associated with patient satisfaction. Design. Two cross-sectional surveys of patients and providers. Setting. Ambulatory clinics at a university medical center. Participants. Eight general internists, 14 family physicians, and 193 patients. Measurements. Two instruments were developed to measure 6 preferences for physician behaviors: 1) considering nonmedical aspects of the patient’s life, 2) familiarity with herbal medicine, 3) physician decision making, 4) providing information, 5) considering the patient’s religion, and 6) treating what the patient perceives as his or her problem. Patients reported how they would prefer physicians to behave, and physicians reported how they preferred to behave. Patients also rated satisfaction with their physician. Results. Post hoc tests found that as a group, patients scored higher than physicians in preference for the physician to provide information and lower in preference for considering nonmedical aspects of the patient’s life and religious beliefs. As hypothesized, preference differences accounted for significant variance in satisfaction in overall tests (19% in the family medicine patients and 25% in internal medicine patients). Greater satisfaction was associated with fit between patient and physician preferences for physician decision making (in the internal medicine patients) and with fit in providing information and consideration of religion (in family medicine patients) Conclusions. Patients often prefer behaviors other than how their physicians prefer to behave. Preference fit is associated with enhanced patient satisfaction. Physicians should attend to whether patients want religion and other nonmedical aspects of their lives considered. Health plans may wish to provide tools to help patients choose physicians by fit

Warfarin, Calciphylaxis, Atrial Fibrillation, and Patients on Dialysis: Outlier Subsets and Practice Guidelines

Calciphylaxis is an uncommon disorder that occurs predominantly in patients with end-stage renal disease and portends a high mortality (40%-80%). Studies have implicated a potential causal relationship to the prescribing of warfarin in patients on dialysis and the development of calciphylaxis syndrome. Under the influence of hyperphosphatemia in end-stage renal disease, vascular smooth muscle cells can take on properties similar to osteoblasts and can calcify under the influence of vitamin D. Matrix GLa protein normally inhibits such calcification from occurring, but it is a vitamin Kedependent protein and thus is diminished when warfarin, an inhibitor of vitamin K, is administered. Because this is the era of pay-for-performance programs, adherence to certain practice guidelines will determine the quality measures of care and thus a proportion of reimbursement under the pay-for-performance programs. The dominant practice guideline for the management of atrial fibrillation is the one developed by the American College of Chest Physicians entitled, “Antithrombotic Therapy for Atrial Fibrillation,” which makes use of the CHADS2 7 and CHA2DS2-VASc 8 risk model scoring systems for anticoagulation decision-making to prevent stroke in atrial fibrillation. The guideline does not make any specific mention of patients with end-stage renal disease not being enrolled in any of the studies cited in the practice guideline development or suggest that this guideline does not apply to the clinical subset of patients with end-stage renal disease. Pulmonologists, epidemiologists, and cardiologists who contribute to this important practice guideline were not considering patients on dialysis, a small subset of the total patient population with atrial fibrillation, or that the guideline might be applied to this unique clinical subset of patients in whom smooth muscle cells act more like osteoclasts when vitamin K is inhibited. The intricacies of biological science can trump the best of human intentions through unintended clinical consequences.

Electronic communication in ethics committees: experience and challenges

Experience with electronic communication in ethics committees at two hospitals is reviewed and discussed. A listserver of ethics committee members transmitted a synopsis of the ethics consultation shortly after the consultation was initiated. Committee comments were sometimes incorporated into the recommendations. This input proved to be most useful in unusual cases where additional, diverse inputs were informative. Efforts to ensure confidentiality are vital to this approach. They include not naming the patient in the e-mail, requiring a password for access to the listserver, and possibly encryption. How this electronic communication process alters group interactions in ethics committees is a fruitful area for future investigation.

Rationale, principles, and educational approaches of organizational transormation

Weaving through the drama we call managed care are three distinct plots that are playing out against a backdrop of escalating health care costs, uneven access to care, and a delivery system that frequently aggravates its users. The first plot concerns money and ownership: What will be the respective roles of the for-profit and not-for-profit sectors in providing the capital needed to rebuild the health care system? Who will own the system? What form of ownership leads to the best system performance? The second plot concerns the control of medical management: Will it be payers or providers who make the ultimate decisions about what care is given, how, and by whom? Although these two plots are of great importance, and certainly receive most of the publics attention, they cannot be adequately addressed without a thorough understanding of the third plot: the reorganization of health care delivery into integrated systems. It is this third plot that is the most revolutionary and the most fundamental; it is also the most obscure. Many, perhaps even most implementations of managed care fail to attend adequately to the restructuring of health care delivery. Rather, they superimpose new financial arrangements and external control mechanisms on the traditional, nonintegrated structures of fee-for-service medicine. In short, they manage costs, not care. Not only are such internally inconsistent efforts doomed to fail, but the stress and frustration they create for both patients and clinicians poison the waters for more sincere, creditable implementations. For precisely this reason, it is vital that we understand the organizational transformation that is at the heart of managed care, that we know how to distinguish the real thing from inadequate or even disingenuous implementations, that we not lose the baby with the bath water. Equipped with such understanding, we can help steer the changes in health care in a favorable direction, toward the emergence of new and more capable approaches to health care delivery that make it easier for clinicians to provide higher-quality, more efficient care. In this article, we describe the rationale and mechanisms for the creation of integrated health care systems. We also present ideas for educators about how to prepare future physicians for their roles in integrated systems. Finally, we reconsider the themes of money and control, and find that they are but subplots of the theme of reorganization. New forms of financial and medical management will be judged by their contribution to the performance of integrated systems and, ultimately, to improvements in the health of the community.

The Role of Bioethics and Business Ethics

Managed care represents a profound transformation in the architecture and process of health care delivery. Whether motivated by the economics of health care and the widely perceived need for cost containment1, 2 or by the quality improvements that a systems approach potentially permits,3, 4 managed care organizations represent a new level of organization in health care delivery. Formerly the fundamental unit of health care delivery was the individual clinician whose focus was principally the individual patient. Now the fundamental unit is a health care organization, and its focus is its covered population. Thus, an organizational perspective is being created alongside that of the individual, with considerable potential for conflict.

Integrating Quality Improvement Into Continuing Medical Education Activities Within a Community Hospital System

The integration of the Mercy Health System’s quality improvement (QI) and continuing medical educational (CME) activities is described. With the implementation of computerized medical data, the opportunities for QI-focused CME are growing. The authors reviewed their regularly scheduled series and special CME programs to assess their impact on quality care processes. Clinical improvements were affected by combining national guidelines and advancements with local clinical data and interactions with physicians within interdisciplinary as well as specialty conferences. Case-based, multidisciplinary conferences lent themselves to this process to a greater extent than didactic conferences. The latter also could lead to QI when the topics were focused on specific quality initiatives that often are part of a national QI initiative. Although the authors consider these efforts to be at an intermediate stage of development, they have observed several QI/patient safety process improvements.