Category Archives: General Health

Better Discharge Planning Needed

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An interesting commentary in NY Times: Most Dangerous Time at the Hospital? May be When You Leave

An excerpt:

One-fifth of Medicare beneficiaries are readmitted within 30 days of discharge, and one-third are readmitted within 90 days. One studyfound that 20 percent of patients have a complication within three weeks of leaving the hospital — more than half of which could have been prevented or ameliorated. Thankfully most complications are minor, but some can be serious, leading to permanent disability or death. All told, Medicare spends $26 billion annually on readmissions, $17 billion of which is for readmissions that are considered preventable…

there’s often a rush toward the end of hospitalization — when a patient wants to leave or a rehab bed opens up — leading to a haphazard set of final conversations, appointments and prescriptions. And because the exact time of discharge is uncertain, the doctor discharging a patient may not be the one who knows the patient best.

It’s also often not clear exactly when a patient should be discharged….

the remaining diagnostics and treatments are often completed after discharge. But this is where we struggle most. Research suggests direct communication between hospital doctors and primary care doctorsoccurs infrequently and that discharge summaries — detailed records of a patient’s hospital course — are often unavailable at a patient’s first post-hospital visit. Almost 30 percent of patients are discharged with a plan to continue workups after hospitalization, but more than one-third of these are never completed. Similarly, more than 40 percent of patients have lab tests pending at the time of discharge — with 10 percent requiring action—but most physicians remain unaware of them.

My take: This is indeed an area where checklists and attention should be focused.  My top three:

  • Making sure a list of discharged medications is compared to admission medications
  • Identifying outstanding tests and arranging followup workup
  • Direct communication with outpatient physician(s)
Gibbs Gardens

Gibbs Gardens

Pharmaceutical Prescription Practices Tied to Pharmaceutical Payments to Doctors

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A recent buzz has developed regarding a ProPublica study showing an association between the amount of money physicians receive from pharmaceutical companies and their likelihood of recommending brand (rather than generic) prescription drugs.

Here’s a link to the full story: Now There’s Proof: Docs Who Take Company Cash Tend to Prescribe More Brand-Name Meds

“The more money doctors receive from drug and medical device companies, the more brand-name drugs they tend to prescribe, a new ProPublica analysis shows. Even a meal can make a difference.”

Here’s a link to NPR’s summary:  Drug-Company Payments Mirror Doctors’ Brand-Name Prescribing  An excerpt:

“A ProPublica analysis has found that doctors who receive payments from the medical industry do indeed prescribe drugs differently on average than their colleagues who don’t. And the more money they receive, the more brand-name medications they tend to prescribe.

We matched records on payments from pharmaceutical and medical device makers in 2014 with corresponding data on doctors’ medication choices in Medicare’s prescription drug program.

Doctors who got money from drug and device makers prescribed a higher percentage of brand-name drugs overall than doctors who didn’t, our analysis showed. Even those who simply got meals from companies prescribed more brand-name drugs, on average.”

My take: Prescription patterns vary widely among physicians and often for good reason.  At the same time, it is likely that in many cases variation in prescription patterns is influenced by frequent contact with pharmaceutical companies.  As a consequence, this has the potential to make patients question whether their physician always has their best interest in mind and the potential to increase healthcare costs.

Related blog posts:

Law Library Ceiling, Univ Michigan

Law Library Ceiling, Univ Michigan

21 Year Data for Cancer Survivors

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Most pediatric gastroenterologists see many children with pediatric cancers, so it is gratifying to see data showing improving long-term outcomes (GT Armstrong et al. NEJM 2016; 374: 833-42).  In addition, pediatric oncology serves as a model for improving therapy by enrolling virtually all of its patients in research protocols.

The authors evaluated late mortality among 34,033 patients in the Childhood Cancer Survivor Study.  All of these patients had survived at least 5 years after childhood cancer. During the study which had a median followup of 21 years, there were 3958 deaths and 1618 (41%) of these were attributable to health-related causes, including subsequent neoplasms (n=746), cardiac (n=241), and pulmonary (n=137).

The improvement in treatment regimens have included reductions in radiotherapy and anthracycline exposure.  The graph below shows survival rates 20 years after being cancer-free (15 years after being cancer-free for 5 years).

My take: This study confirms that these improved regimens have long-lasting effects on mortality.  Through cooperative research, we can do better in oncology and in all of pediatrics.

Incidence of death from any cause from patients treated between 1970-1999.

Incidence of death from any cause from patients treated between 1970-1999.

CDC Guideline for Prescribing Opioids for Chronic Pain

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Full Text: CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016

D Dowell et al. JAMA. Published online March 15, 2016. doi:10.1001/jama.2016.1464 .

Excerpts:

  • No evidence shows a long-term benefit of opioids in pain and function vs no opioids for chronic pain with outcomes examined at least 1 year later (with most placebo-controlled randomized clinical trials ≤6 weeks in duration).

  • Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury).

  • Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacologic therapy, with less harm.

CDC: “We know of no other medication routinely used for a nonfatal condition that kills patients so frequently,”

1st Six Recommendations (12 total)

1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. (Recommendation category: A; evidence type: 3)

2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. (Recommendation category: A; evidence type: 4)

3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy. (Recommendation category: A; evidence type: 3)

4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. (Recommendation category: A; evidence type: 4)

5. When opioids are started, clinicians should prescribe the lowest effective dosage.  (Recommendation category: A; evidence type: 3)

6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed. (Recommendation category: A; evidence type: 4)

Other points:

  • Avoid concurrent benzodiazepines
  • Review state prescription drug monitoring program to look for dangerous combination therapies and prior opiod dosing
  • Consider risk mitigation strategies (eg. naloxone)
  • Suggests urine screening at start to screen for illicit substance abuse which increases risk

USAToday’s review of these guidelines: CDC issues new guideline on opiods

Bottomline: This report is very important for those who prescribe opiods for chronic pain.

Law Library, Univ of Michigan

Law Library, Univ of Michigan

Drug Waste Costing Billions. Who benefits? Pharmaceutical Companies

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From NY Times: Waste in Cancer Drugs Costs $3 Billion a Year

Here’s an excerpt:

The federal Medicare program and private health insurers waste nearly $3 billion every year buying cancer medicines that are thrown out because many drug makers distribute the drugs only in vials that hold too much for most patients, a group of cancer researchers has found…

If drug makers distributed vials containing smaller quantities, nurses could pick the right volume for a patient and minimize waste…according to researchers at Memorial Sloan Kettering Cancer Center, whopublished a study on Tuesday in BMJ…

“Drug companies are quietly making billions forcing little old ladies to buy enough medicine to treat football players, and regulators have completely missed it,” said Dr. Peter B. Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering and a co-author of the study…

Some non-cancer drugs also generate considerable waste, includingRemicade, an arthritis drug sold by Johnson & Johnson for which an estimated $500 million of the drug’s $4.3 billion in annual sales comes from quantities that are thrown away, researchers found.

My take: this is another indictment of our pharmaceutical companies willful neglect of medication costs or cynical manipulation of our healthcare system.

Related blog posts:

Why Georgia Cannot Provide More Healthcare

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RE: Georgia Senate Resolution 756.

From Jay Bookman: Ga. can’t afford health care for its people, but tax cuts? Sure!..

Here is an excerpt:

Medicaid cannot be expanded in Georgia, extending much-needed health insurance to some 400,000 of our fellow citizens, because the state budget is under too much strain.

Sure, expanding Medicaid would save lives and improve the quality of life for many others, many of them lower-income working people whose jobs don’t include health coverage. Sure, it would bring billions of new federal dollars into the state and help rescue a health-care delivery system that is now collapsing in much of rural Georgia. Sure, it would create thousands of jobs, and sure, federal tax money would no longer be flowing out of Georgia to subsidize Medicaid coverage for people in other states…

Yet on Monday, a supermajority of the state Senate voted to slash the state income tax by an amount roughly equivalent to that needed to fund Medicaid expansion.

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My day on the beach is about to get worse

My day on the beach is about to get worse. Flamenco beach.

NPR: Understanding “Sleep Munchies”

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From NPR: Sleep Munchies: Why It’s Harder to Resist Snacks When We’re Tired

An excerpt:

There’s lots of evidence that getting too little sleep is associated with overeating and an increased body weight.

The question is, why? Part of the answer seems to be that skimping on sleep can disrupt our circadian rhythms. Lack of sleep can also alter hunger and satiety hormones.

Now, a new study finds evidence that sleep deprivation (getting less than five hours of sleep per night) produces higher peaks of a lipid in our bloodstream known as an endocannabinoid that may make eating more pleasurable.

So, what’s an endocannabinoid? If you look at the word closely, you may already have a clue. The prefix endo means inner, or within. And cannabinoid looks like … you got it: cannabis.

My take: Another good reason to avoid being on call -it could lead to sleep deprivation/weight gain.

Old San Juan

Old San Juan

Worried About the Zika Virus

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While Zika virus infections may not be seen frequently by pediatric gastroenterologists, this infection will be a common concern for the families we treat and we may end up taking care of children with feeding problems/neurologic impairment due to congenital infection.

I attended a recent Georgia American Academy of Pediatrics board meeting.  One of the topics discussed was the Zika virus.  An update was given by Dr. Harry Keyserling, chair of the infectious disease committee (who has given permission for me to share some of his slides).  Some of the important points from his talk:

  • The Zika virus shares some similarities with the Dengue virus. The Zika virus is a single-stranded RNA flavivirus. Incubation period is 3 days to a few weeks.  It can be acquired from mosquito bites, spread sexually, transplacentally or intrapartum.  It may be transmissible via blood, organ donation or possibly breastmilk.

 

History of Zika Virus

History of Zika Virus

Most are asymptomatic. The clinical spectrum in those with symptoms are noted above.

Most are asymptomatic. The clinical spectrum in those with symptoms are noted above.

  • 80% of infected individuals are asymptomatic.
Approximate distribution of mosquito vector

Approximate distribution of mosquito vector

  • Due to the geographic distribution of the vector, it is likely that there will be many more cases in Georgia.

Screen Shot 2016-03-02 at 6.57.28 PM

US DATA 1

US DATA 2

  • The most alarming association has been with microcephaly.  In some locations, there have been recommendations to avoid pregnancy until 2018.  After natural infection has spread, it is likely to lead to immunity and then should be safe to become pregnant.

Prevention

  • Zika can be acquired through sexual-transmission which indicates that pregnant women in endemic areas could need to avoid sex.

More resources:

My take: Because the Zika virus is going to continue to spread and the methods for prevention are not entirely effective, the next few years are going to present a lot of challenges.  This will continue until some population immunity develops (following infection or perhaps after development of an effective vaccine).

Surgery Resident Sleep & Flexibility in Training

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A recent study (KY Bilimoria et al. NEJM 2016; DOI: 10.1056/NEJMoa1515724) indicates that some flexibility in training hours did not result in increased adverse outcomes and improved continuity of care. This study examined the care of nearly 140,000 patients.

For a 2 minute quick take -video available at this link along with full-text and abstract: National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training

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Emergency Medical Information -Easy Access on Your iPhone

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When I purchased a new iPhone, one of my sons was eager to show me all of the cool features.  If you do not have a teenager (i.e. house IT specialist) in the house, you may not have taken advantage of the health app built into the iPhone 6.  This can be very useful for you and your patients.

Screen Shot 2016-01-31 at 12.14.08 PM

One feature of the health app is that it allows you to store emergency contact information and health information that’s accessible from your device’s Lock screen. First responders or good Samaritans will be able to call the emergency contacts listed in Medical ID.  This health app also can function as an activity tracker.

Screen Shot 2016-01-31 at 12.12.38 PM

Here’s a link with additional information: How to set up your emergency medical ID