January 10, 2011 Issue of JAMA Internal Medicine

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) wound infections after cardiac surgery have increased in recent years and carry significant morbidity and mortality. In our hospital, MRSA accounted for 56% of postoperative infections.MethodsPostoperative wound infection rates were compared for the 3 years before (baseline period) and after (intervention period) introduction of a comprehensive MRSA intervention program. The intervention included preoperative screening for MRSA colonization, administration of intravenous vancomycin prophylaxis for identified carriers, administration of intranasal mupirocin calcium ointment to all patients regardless of colonization status for 5 days beginning the day before surgery, and application of mupirocin to chest tube sites at the time of removal.ResultsPostoperative MRSA wound infections decreased by 93% (32 infections per 2767 cases in the baseline period vs 2 infections per 2496 cases in the intervention period; relative risk, 0.069; P聽<聽.001). Overall wound infection rates decreased from 2.1% to 0.8% (59 infections per 2769 cases vs 20 infections per 2496 cases; P聽<聽.001). During the intervention period, there was no change in the number of MRSA infections after noncardiac surgery.ConclusionThis MRSA intervention program, in which all patients receive intranasal mupirocin and patients colonized with MRSA receive vancomycin prophylaxis, has resulted in a near-complete and sustained elimination of MRSA wound infections after cardiac surgery.

Invited Commentary
The Bundled Approach to MRSA Surgical Site Infection Prevention: Is the Whole Greater Than the Sum of Its Parts?Comment on 鈥淪ustained Reduction in Methicillin-Resistant Staphylococcus aureus Wound Infections After Cardiothoracic Surgery鈥�
Catherine Liu, MD

Arch Intern Med

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Primary Care Clinicians' Experiences With Treatment Decision Making for Older Persons With Multiple Conditions

Terri R. Fried, MD; Mary E. Tinetti, MD; Lynne Iannone, MA

Abstract Full Text

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Arch Intern Med. 2011;171(1):75-80. doi:10.1001/archinternmed.2010.318

BackgroundClinicians are caring for an increasing number of older patients with multiple diseases in the face of uncertainty concerning the benefits and harms associated with guideline-directed interventions. Understanding how primary care clinicians approach treatment decision making for these patients is critical to the design of interventions to improve the decision-making process.MethodsFocus groups were conducted with 40 primary care clinicians (physicians, nurse practitioners, and physician assistants) in academic, community, and Veterans Affairs鈥揳ffiliated primary care practices. Participants were given open-ended questions about their approach to treatment decision making for older persons with multiple medical conditions. Responses were organized into themes using qualitative content analysis.ResultsThe participants were concerned about their patients' ability to adhere to complex regimens derived from guideline-directed care. There was variability in beliefs regarding, and approaches to balancing, the benefits and harms of guideline-directed care. There was also variability regarding how the participants involved patients in the process of decision making, with clinicians describing conflicts between their own and their patients' goals. The participants listed a number of barriers to making good treatment decisions, including the lack of outcome data, the role of specialists, patient and family expectations, and insufficient time and reimbursement.ConclusionsThe experiences of practicing clinicians suggest that they struggle with the uncertainties of applying disease-specific guidelines to their older patients with multiple conditions. To improve decision making, they need more data, alternative guidelines, approaches to reconciling their own and their patients' priorities, the support of their subspecialist colleagues, and an altered reimbursement system.

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From Disclosure to Transparency: The Use of Company Payment Data

Susan Chimonas, PhD; Zachary Frosch, BA; David J. Rothman, PhD

Abstract Full Text

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Arch Intern Med. 2011;171(1):81-86. doi:10.1001/archinternmed.2010.341

BackgroundIt has become standard practice in medical journals to require authors to disclose their relationships with industry. However, these requirements vary among journals and often lack specificity. As a result, disclosures may not consistently reveal author-industry ties.MethodsWe examined the 2007 physician payment information from 5 orthopedic device companies to evaluate the current journal disclosure system. We compared company payment information for recipients of $1 million or more with disclosures in the recipients' journal articles. Payment data were obtained from Biomet, DePuy, Smith & Nephew, Stryker, and Zimmer. Disclosures were obtained in the acknowledgments section, conflict of interest statements, and financial disclosures of recipients' published articles. We also assessed variations in disclosure by authorship position, payment-article relatedness, and journal disclosure policies.ResultsOf the 41 individuals who received $1 million or more in 2007, 32 had published articles relating to orthopedics between January 1, 2008, and January 15, 2009. Disclosures of company payments varied considerably. Prominent authorship position and article-payment relatedness were associated with greater disclosure, although nondisclosure rates remained high (46% among first-, sole-, and senior-authored articles and 50% among articles directly or indirectly related to payments). The accuracy of disclosures did not vary with the strength of journals' disclosure policies.ConclusionsCurrent journal disclosure practices do not yield complete or consistent information regarding authors' industry ties. Medical journals, along with other medical institutions, should consider new strategies to facilitate accurate and complete transparency.

Invited Commentary