Urine Microalbumin
Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn. Yes, theeee Mayo Clinic. He wrote a recent opinion piece in Internal Medicine News that you may find intriguing. You see, he has been following yearly urinary microalbumin in his patients with diabetes even though they are already on an ACE inhibitor or an angiotensin receptor blocker. Why? Because he was “supposed” to even though he didn’t know what to do with the results. Why is he like every other doctor? Because like lemmings, we have believed in these stupid quality indicators, which, by the way, are unproven but “somewhere along the line, an annual microalbumin has been incorporated into performance measures and clinical algorithms” As Dr. Ebbert points out, the American College of Physicians just published a clinical guideline on the “Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease” (Ann. Intern. Med. 2013 Oct. 22 [doi:10.7326/0003-4819-159-12-201312170-00726]) and it “recommends against testing for proteinuria in adults with or without diabetes who are currently taking an angiotensin-converting enzyme inhibitor or an angiotensin II–receptor blocker.”
Dr. Ebbert ended his piece by asking,” How long it will take for clinical practice to catch up and remove this as a performance measure remains to be seen.”
I bet years!
This is one more reason metrics, quality indicators and pay-for-performance is WRONG for medicine.
I like that guy! If they spill protein the nephro isn’t going to get too yanked unless it’s 1000mg. 500mg? You’re O.K. Cripes they’ll just decide whether they want to do a kidney biopsy or not. If on the ACE/ARB already and spilling, “Turf ’em Daniel.”
How about pneumovax? If one is so decrepit that a run of the mill strep can kill’em, if
they’ve had the pneumovax, plenty of other more vicious bugs are going to give ’em the dirt nap.
Only one case in 28 years I’ve seen pneumovax help. A person with marginal zone lymphoma got strep pneumonia “alot” in spite of a single pneumovax shot. I started giving him one shot every three months for a year, every 4 months for a year, twice a year and then once a year thereafter. When I started that, he never had a strep pneumonia again. It’s called teasing an amnestic response from an impaired immune system. The guy was in pretty good shape otherwise but the strep pneumo would knock him down every few months.
Obamacare has provisions to reduce this type of thing. It is estimated the 1/3 of all tests and diagnostic procedures are “unnecessary”. Depends on you definition of unnecessary, by my definition it is over 2/3.
How can they reduce this if they are using them as a way to bonus doctors with pay-for-perfomance indicators?
On the nose, Doug.
And make sure you put the word “bonus” n quotation marks, since all they are dong is giving back money they stole in the first place.
This is just like the ACE levels used for certain autoimmune disorders. Ask a physician what it means and they tell you it doesn’t really tell them anything, but everyone uses it as an index of inflammation.
Like they said in residency: “Don’t do the test if the results won’t change your treatment.”
I do as few tests as possible, and I feel good about that.
What the hell am I supposed to do about an isolated trace blood, or an elevated CRP or ESR anyway?!?