Category Archives: General Health

Medication Manager Apps

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From Cincinnati Children’s Staff Bulletin: A review of medication manager apps

My take: I have not tried the apps below.  I do think ‘old school’ products like weekly pill boxes can be very useful.

An excerpt:

For some families, medication apps can help them establish a routine of taking medication at the same time each day. For others, the app acts as a reminder every once in a while when the family has a really busy day and may have forgotten otherwise.

Possible Features
 MyMedScheduleMobile Mango Health Medication Manager
 MedCoach Medication Reminder MediSafe Meds & Pill Reminder
Alerts you to take meds  X X X
Prescription refill reminders  X
Connect with pharmacy to refill prescriptions  X  X
Track progress  X  X
Create medication schedules  X  X
Create list of medications for doctor  X  X
Synchronizes with other family members  X
Drug interaction warnings  X
Gives points and rewards  X
FREE  X  X  X  X

 

Looking at the ‘Less is More’ Narrative

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There is a widespread claim that up to 30% of health care dollars are wasted.  This claim is similar to other claims of fraud and abuse often extolled in political campaigns.  The questions, at least in medicine, is whether this claim is accurate and even if it is, is there a way to improve health care spending.

A recent commentary (L Rosenbaum. NEJM 2017; 377: 2392-7) tackles the “Less-Is-More-Crusade” in medicine.  Some of the key points:

  • The 30% waste figure is often attributed to Dartmouth investigators ((http://www.dartmouth.atlas.org/keyissues/issue.asp?con=1338)
  • This figure has many limitations including inadequate control for severity of illness, regional price differences, and the possibility that variation is due to underuse as well as overuse.
  • Confounders: difficulty controlling for sicker patients
  • “Other research suggests that higher spending is actually associated with better outcomes.”

Dr. Rosenbaum describes how MIT economists identified what worked out to be a randomization experiment of health care.  These economists examined hospital performance among patients transported by ambulance.  Since the ambulance companies had hospital preferences, the “patients [were] essentially randomly assigned to hospitals.”  Key finding: “hospitals that spend more during hospitalizations for various acute conditions have lower mortality rates at 1 year post-hospitalization than lower-spending-hospitals, a relationship driven largely by inpatient treatment intensity” (J Pol Econ 2015; 123: 170-214).

Another recent analysis found that Medicare beneficiaries discharged from EDs in “hospitals with the lowest admission rates were 3.4 times as likely to die within a week” as their counterparts at hospitals with the highest admission rates.  In addition, “low-admitting EDs tended to serve generally healthier populations.”

Dr. Rosenbaum points out that while many attribute physician greed as a driver of excess testing/overdiagnosis in a fee-for-service model, there are many other explanations.  Physician expertise and desire for more certainty are relevant factors.

My take: This commentary provides a lot of nuance.  Yes, there is certainly waste but there is a lot of underuse in medicine. Like in areas outside of medicine, “eliminating fraud and abuse” is an oversimplification and will be difficult to achieve.

Grand Canyon basin

 

Reminders and Hard Stops -One Way to Improve Care Using an Electronic Medical Record

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A recent study (MA Konerman et al. Hepatology 2017; 66: 1805-13) provides a tangible example of how an electronic medical record (EMR) could be helpful in improving care.

Implementation of EMRs has been a source of consternation for many physicians.  Some of the concerns include spending inordinate amounts of time completing documentation and how they can make the patient encounter less personal.

Nevertheless, with a good EMR, there is the potential for better care.  One way to implement a specific improvement is to place a “hard stop” or a reminder.  A hard stop can prevent completing documentation until an issue is addressed.  A reminder can pop up for appropriate patients to query whether a specific problem is being addressed.  In theory, both could be helpful; though, too many reminders can trigger alarm fatigue and too many hard stops can be quite annoying and further slow delivery of patient care.

In the above-mentioned study, the authors placed a reminder (“best practice advisory”) that encouraged screening for hepatitis C virus (HCV) among patients born between 1945-65 who lacked a prior HCV diagnosis and lacked prior testing.  This resulted in an increase in HCV screening in a primary care setting from 7.6% to 72% (one year after implementing).  Of the 53 newly diagnosed patients, all were referred for specialty care.  11 had advanced fibrosis or cirrhosis.

My take: Using EMR tools, specific screening goals can be achieved.  Before placing hard stops and/or reminders, we need to make sure that these goals are carefully selected to generate a net benefit.

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South Kaibab Trail, Grand Canyon

 

Deprescribing Initiative

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A recent article (Gastroenterol & Endoscopy News, October 2017; 64-66) described an effort to reduce the problem of “polypharmacy.”  While this is clearly a problem for adult medicine, increasingly, this is an issue with pediatrics as well.

Key points:

  • In 2015, 35.8% of adults were taking at least 5 medications (JAMA 2016; 176: 473-82)
  • More medications increase the risk of adverse events, drug interactions, and costs
  • The deprescribing initiative (http://deprescribing.org/) encourages active review of medications and removing those with questionable risk-benefit trade-off
  • If stopping medicines, generally remove one at a time

 

Deaths and Morbidity from Childbirth –U.S. with Highest Rate in the Industrialized World

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Previously the issue of maternal mortality has been discussed on this blog: Take Two: Mushroom poisoning and maternal death with childbirth

An update on this topic from NPR: Full Link  Nearly Dying In Childbirth: Why Preventable Complications Are Growing In U.S.

For the past year, ProPublica and NPR have been examining why the U.S. has the highest rate of maternal mortality in the industrialized world. That relative high rate of death, though, has overshadowed the far more pervasive problem that experts call “severe maternal morbidity.” 

Each year in the U.S., 700 to 900 women die related to pregnancy and childbirth. But for each of those women who die, up to 70 suffer hemorrhages, organ failure or other significant complications. That amounts to more than 1 percent of all births. The annual cost of these near deaths to women, their families, taxpayers and the health care system runs into billions of dollars

In the News …Hepatitis A Outbreak in California Linked to Homelessness

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From NEJM: Full Link: Hepatitis A Outbreak in California — Addressing the Root Cause

On October 13, 2017, Governor Jerry Brown of California declared a state of emergency in response to a hepatitis A outbreak that began in the homeless population in San Diego. In the past year, more than 649 people throughout California have been infected, 417 have been hospitalized, and 21 have died from hepatitis A, making this the largest outbreak in the United States in the past 20 years. The vast majority of those affected have been homeless. Like two thirds of people who experience homelessness in California, most were unsheltered.

The environmental conditions associated with homelessness — overcrowding in encampments and emergency shelters, exposure to the elements, and limited access to facilities for hygiene and food preparation and storage — facilitate infectious-disease transmission..Infectious diseases are one of many health threats faced by homeless people. Poorly controlled chronic diseases, complications of substance use disorders and smoking, and unintentional injuries and violence are prevalent, difficult to manage, and often severe among homeless adults.

A Call to Arms for Health Care Professionals

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A recent editorial published simultaneously in NEJM (DB Taichman et al. 2017; 377: 2090-91), Annals of Internal Medicine, PLOS Medicine and JAMA urges physicians:

  • “Don’t be silent. We don’t need more moments of silence to honor the memory of those who have been killed. We need to honor their memory by preventing a need for such moments.”

A short list of how health care professionals can help:

  • “Educate yourself”
  • Contact your local, state, and federal legislators.  “And do it again at regular intervals.”
  • Attend public meetings. “Demand answers, commitments, and follow-up”
  • “Go to rallies.”
  • “Join, volunteer for, or donate to organizations fighting for sensible firearm legislations.”
  • Vote for candidates “with stances that mitigate firearm-related injury.”

My take: I’m proud of my friends who have been trying to make a difference.  If any other medical problem exacted the toll of firearms, it is hard to imagine such complacency/resignation.

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Sunrise over South Rim of Grand Canyon

“Data-free Zone” and mHealth

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A recent study (J Kamgno et al. NEJM 2017; 377: 2044-52) used an innovative cell-phone-based device (the LoaScope) to improve treatment of onchocerciasis (river blindness).

Background (summarized in editorial: pg 2088-90): Ivermectin has been distributed in Africa since 1988 to treat onchocerciasis; in fact, the 2015, Nobel Prize in Medicine was shared by the discoverers of ivermectin.  However, in 1996, it was recognized that central nervous system adverse events were occurring in ivermectin-treated patients with coexistent Loa loa infection.

Kamgno et al show that not treating patients with L loa counts >20,000 microfilariae per mL helps target ivermectin to those who will benefit.  The LoaScope identified 340 persons who were at high risk for serious adverse events; the authors estimate that 62 serious central nervous system complications and 8 deaths were avoided with this approach.

Despite the apparent success of this mobile Health (mHealth) application, a separate editorial cautions that most mHealth has little data to support its use (A Roess.  NEJM 2017; 377: 2010-11). Key points:

  • To date, more than 1200 mHealth tools or apps have been catalogued
  • Determining which are effective is difficult  With breastfeeding, there are >340 apps, yet only “15 had any evidence supporting their use, and that was from pilot evaluations.:
  • Most apps involve data collection and delivering health education messages.  The latter are usually one-way messages. “The evidence to support their rapid and widespread use is limited.”
  • mHealth in remote areas may enhance collaboration; though, practical infrastructure problems like poor wireless networks and unreliable electricity hamper their utility.
  • mHealth could improve point-of-care diagnostics. Current products include blood-glucose monitors, blood-pressure monitors, and electrocardiography
  • While many have suggested these apps will be cost-effective, these analyses typically do not evaluate the costs of misinformation and the diverse workforce requirements needed for implementation

My take (with help from editorial): mHealth tools are here and increasing.  Advances like the LoaScope for treating river blindness has been shown to improve outcomes.  Before recommending other mHealth tools, we need to insist on adequate evaluation or we will “arrive in an increasingly fragmented mHealth landscaped littered with poor-quality, unproven apps.”

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Sunrise at the Grand Canyon’s South Rim