Category Archives: General Health

“The future of gastrointestinal disease and symptom monitoring: biosensor, E-portal, and social media”

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At this year’s NASPGHAN meeting, the keynote lecture was given by Brennan Spiegel.  (Brennan Spiegel, MD (@BrennanSpiegel) | Twitter) This was a great talk!

This blog entry has abbreviated/summarized the presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Challenges in healthcare:

  • Time with patient is limited/poorly-timed in comparison to health care needs.
  • Care is reactive rather than proactive.
  • Care is expensive.

We spend all our time within walls of our clinic/hospital, but patients spend 99% time outside

 

How do we tailor care to the individual and make it more cost-effective? How do we get there?  Potential/Emerging Tools:

    • Patient provider portals (including mobile)
    • Social media
    • Wireless biosensors

 

Key question for patients: What is the most important goal for you/your family today?

How to improve communication with family? Electronic medical records often designed for billing rather than educating

MyGiHealth website/soon-to-be-app.  Here’s a link to YouTube video introduction.

  • HISTORY: Trained computer to interview patient re: abdominal pain –where, timing, risk factors for H pylori, etc.
  • Symptoms and severity: constipation, abdominal pain, gas/bloating, heartburn, diarrhea, dysphagia, incontinence, nausea/vomiting (Promise scales –percentiles).
  • Computer history looked better than history by physician (example below with fictional patient). If history obtained prior to physician coming into room, this would allow physician more time to communicate with patient rather than documenting (Related post: Aptly titled “The Cost of Technology” | gutsandgrowth)
  • Man vs Machine (Spiegel in press Am J Gastro 2014). History performed well with regard to billing complexity and completeness.
  • THIS IS COOL!
  • Physician still needed to analyze information and make diagnosis/treatment plan.
  • Also website/app with EDUCATION applicable to patient.
History by computer outperformed physicians

History by computer outperformed physicians

Obtaining information outside the confines of the office can help overcome Hawthorne effect. (Related blog post: Checklists -Helpful? Overhyped? Hawthorne Effect …). Passive vs Active monitoring.

Twitter: “What you say on twitter may be seen by everyone all over the word instantly”

  • Tool for epidemiologic data.
  • Marketing/advertising
  • Recruiting for clinical studies
  • Measure consumer sentiment
  • Educate patients/providers
  • Forge patient affinity groups
  • Monitor patients for clinical practice
  • Help to manage and direct care

Mayo clinic is studying the impact of social media.

Example of patients initiating research. “Spontaneous Coronary Artery Dissection: A Disease-Specific Social Networking Community-Initiated Study” Lead author: Marysia Tweet

Biosensors:

  • “91% of people keep their phone within 3 feet of themselves 24 hours a day.”
  • Can be used to track intake of food, air quality, movements etc
  • Current sensors: Fit bit, amigo (?sp), shine (?sp), Zeo (for sleep) others.
  • Fitbit: Calories, distance, active time, sleep time
  • More advanced sensors for athletes. Stride dynamics can predict marathon winner at mile 16!
  • Wireless sleep (eg. Zeo) monitor equivalent to formal sleep study
  • Q Sensor –can measure stress: physical ,cognitive, emotional (watching horror movie)
  • Hapi fork –can tell if you are eating too fast (correlated with BMI)
  • Proteus –monitors intake
  • Propeller –monitors MDI use for asthma (FDA approved)
  • AbStats Digestion Sensor –adheres to abdomen and can provide neurogastroenterology data. Green light –will tolerate feeds, Yellow light –will tolerate clears

75,000 health apps available at this time.

Recommended Reading by Dr. Spiegel: The Creative Destruction of Medicine by Eric Topol.  The Creative Destruction of Medicine: How the Digital …

 

“Decision Fatigue” & 1000 Posts

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This post is number 1000!  I don’t think this fact is related to “decision fatigue.”

From NY Times –here’s the link: Decision Fatigue for Physicians

Here’s an excerpt:

The phenomenon of “decision fatigue” has been found in judges, who are more likely to deny bail at the end of the day than at the beginning. Now researchers have found…As the day wears on, doctors become increasingly more likely to prescribe antibiotics even when they are not indicated.

For the study, published in JAMA Internal Medicine, scientists analyzed diagnoses of acute respiratory infections in 21,867 cases over 18 months in primary care practices in and near Boston.

In two-thirds of the cases, antibiotics were prescribed even though they were not indicated… Over all, compared to the first hour, the probability of a prescription for antibiotics increased by 1 percent in the second hour, 14 percent in the third hour and 26 percent in the fourth.

For pediatric gastroenterologists, what do you think happens more often (or less often) due to decision fatigue?  excessive/less testing? excessive/less use of medications (like proton pump inhibitors)?

For Halloween yesterday –some people had some great outfits.

That's Dinesh under that mask

That’s Dinesh under that mask

Wrongful Conviction: HCV Acquitted of Causing Diabetes & a Word on Ebola

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First about Ebola –here’s the Ebola recommendation from the NEJM editors regarding quarantine:

An excerpt:

The governors of a number of states, including New York and New Jersey, recently imposed 21-day quarantines on health care workers returning to the United States from regions of the world where they may have cared for patients with Ebola virus disease. We understand their motivation for this policy — to protect the citizens of their states from contracting this often-fatal illness. This approach, however, is not scientifically based, is unfair and unwise, and will impede essential efforts to stop these awful outbreaks of Ebola disease at their source, which is the only satisfactory goal…We should be honoring, not quarantining, health care workers who put their lives at risk not only to save people suffering from Ebola virus disease in West Africa but also to help achieve source control, bringing the world closer to stopping the spread of this killer epidemic.

Take-home message: Read the entire editorial why quarantine is not the right approach for asymptomatic returning health care workers.

Direct Ebola Risk to Health Care Workers

Direct Ebola Risk to Health Care Workers

Now in followup to yesterday’s post about HCV and diabetes:

Even Perry Mason would have had a difficult time proving hepatitis C virus (HCV) did not cause diabetes until a recent publication (Hepatology 2014; 60: 1139-49, editorial 1121-23).

In this study using population-based data from the U.S. National Health and Nutrition Examination Survey (NHANES) with 15,128 adult participants, the authors show that the prevalence of diabetes and prediabetes did not differ by HCV status.  The authors used standardized definitions for diabetes and prediabetes and adjusted for major confounders.  The authors did note a relationship between elevated alanine aminotransferase (ALT) with diabetes regardless of HCV status.  In their cohort, 56.7% had normal glucose, 32.8% had prediabetes, 3.2% had undiagnosed diabetes, and 7.3% had diagnosed diabetes.  The mean age progressively increased in these groups: 40.8 years, 51.9 years, 58.9 years, and 59.2 years respectively.

Among those with diabetes, 10.5% were HCV RNA-negative and 12.0% were HCV RNA-positive –unadjusted for ALT values; the unadjusted HCV antibody status was nearly identical at 10.5% and 10.2% respectively. After adjustment, the OR for being HCV RNA-positive was 1.06 (P=0.53) with confidence limits of 0.59-1.90.

In examining the evidence, the editorial and the discussion review previous evidence of a significant association between HCV infection, insulin resistance, and diabetes.  The odds ratio for this association (HCV and diabetes) was estimated to be about 1.7.  The problems with this association were the following:

  • Much of the work was reported from tertiary care centers
  • Advanced liver disease (of any type) is a well-established risk factor for type 2 diabetes (T2DM)
  • Many studies may have included patients with nonalcoholic fatty liver disease which is another risk factor for diabetes
  • These studies did not control for ALT values

Bottomline (from editorial): This study “calls one to reconsider the dogma on the role of IR [insulin resistance] in the pathogenesis of HCV infection and its association with T2DM.” If there is an association, it is much smaller than previous estimates.

Related blog post: Treating HCV Helps Diabetics | gutsandgrowth

Social Media -Why It is Useful for Physicians

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Just now, I participated in a 5K run to support The NASPGHAN Foundation.  My suggestion is to move this to a Saturday or Sunday next year to allow more support from the community at large.  That being said, I was pleased to be able to participate in this inaugural race.

Later today, I am giving a talk at our national pediatric gastroenterology meeting on social media.  On one of my first slides, I disclose that I have no financial conflicts and that I am not an expert on social media. The truth is that most teenagers are much more knowledgeable about social media than I am.  Perhaps the perspective that I lend to this area is that I have some experience on how social media can be helpful for physicians.

Here’s a link to my talk: StayingInformed WhyDoctorsNeedTwitter

If you have some suggestions, let me know soon.

Back to Basics: Acid-Base Disturbances

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A good review on acid-base disturbances: NEJM 2014; 371: 1434-45.  This is good reading for those needing a refresher on any of the following:

  • Metabolic acidosis: -high anion-gap vs. low anion-gap (Table 2)
  • Metabolic alkalosis -mainly due to loss of gastric fluid and use of diuretics.
  • Respiratory acidosis -associated with hypoventilation
  • Respiratory alkalosis -associated with hyperventilation

Here’s a link: http://www.nejm.org/doi/full/10.1056/NEJMra1003327

A few useful pointers:

  • Lactic acidosis  –“roughly half the patients with serum lactate levels between 3.0 and 5.0 mmol per liter have an anion gap within the reference range.”
  • Anion gap is affected by hypoalbuminemia.  “For every decrement of 1 g per deciliter in the serum albumin concentration, the calculated anion gap should be increased by approximately 2.3 to 2.5 mmol per liter.”
  • Low anion gap mainly due to loss of bicarbonate: GI conditions (like diarrhea or other GI fluid losses), renal losses of bicarbonate (RTAs, medicine-induced), decreased renal acid excretion, or other (eg. saline resuscitation, hyperalimentation (lysine, histidine, or argentine hydrochloride, cholestyramine, and other causes).
  • High anion gap: overproduction of acid (lactic acidosis, ketoacidosis –DKA, alcoholic).  Lactic acidosis can be due to D-lactic acidosis in short bowel syndrome or due to L-lactic acidosis (type A hypoxic, type B nonhypoxic -related to numerous medicines/intoxications/thiamine deficiency), advanced renal failure, impaired lactic clearance in liver failure, rhabdomyolysis, penicillin-derived antibiotics, and pyroglutamic acid.

Figure 1 provides an algorithm for sorting out acedemias including use of urinary anion gaps and Figure 2 does the same for alkalemias.

Scarier than Ebola -the Flu

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Scarier than Ebola  — From NY Times (an excerpt)

“Do me a favor. Turn away from the ceaseless media coverage of Ebola in Texas — the interviews with the Dallas nurse’s neighbors, the hand-wringing over her pooch, the instructions on protective medical gear — and answer this: Have you had your flu shot? Are you planning on one?

During the 2013-2014 flu season, according to the Centers for Disease Control and Prevention, only 46 percent of Americans received vaccinations against influenza, even though it kills about 3,000 people in this country in a good year, nearly 50,000 in a bad one….

On CNN on Monday night, a Dallas pediatrician was asked about what she had advised the families she sees. She said that she urged them to have their children “vaccinated against diseases that we can prevent,” and that she also stressed frequent hand-washing. Ebola or no Ebola, it’s a responsible — and frequently disregarded — way to lessen health risks.

So are these: fewer potato chips. Less sugary soda. Safer sex. Tighter restrictions on firearms. More than 30,000 Americans die from gunshots every year. Anyone looking for an epidemic to freak out about can find one right there.”

Deriving Measures of High Value Pediatric Care

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A recent article titled, “How does a gastroenterologist demonstrate value?” (linked to full text) DOI: http://dx.doi.org/10.1016/j.cgh.2014.08.021 provides some insight into what is in store for gastroenterologists as the shift from fee-for-service is influenced by value care initiatives.

Key points:

  • Value = Outcome/Cost
  • Healthcare value = Health of population/Cost
  • “AGA has spent the last 7 years developing measures that focus on outcomes and population management. They are available at http://www.gastro.org/practice/quality-initiatives/performance-measures.”This website provides several measures for hepatitis C, inflammatory bowel disease, endoscopy, and others.
  • For example, endoscopy measures:Measure # 1: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsMeasure #2: Surveillance Colonoscopy Interval for Patients with a History of Colonic Polyps- Avoidance of Inappropriate UseMeasure # 3: Comprehensive Colonoscopy Documentation

As a pediatric gastroenterologist, it is clear that more efforts will be needed for the pediatric population.  While the authors note that “financial pressures will intensify over time,” at the current time there is extremely wide variation on the use of common procedures; in fact, physicians are typically incentivized to perform procedures even in the setting of low yield.  So the first steps will be to define a high value pediatric GI practice.

Another reference with regard to value care (J Pediatr 2014; 165: 650-51) discusses how infectious disease consultations improve outcomes, can decrease costs (length of stay, complications) and improve usage of appropriate antimicrobials.  Another helpful point: “Although common, curbside consultations have been shown to be associated with inferior patient outcomes compared with official bedside consultations.”  This is often due to incomplete or inaccurate data.

Related blog posts:

Unexpected Out-of-Network Charges ($117,000)

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A recent NY Times articles details a financial problem that really is a disgrace —unexpected out-of-network charges.

Here’s an excerpt:

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving…

He was blindsided, though, by a bill of about $117,000 from an “assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did not recall meeting…

In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives…

In recent years, unexpected out-of-network charges have become the top complaint to the New York State agency that regulates insurance companies…

Out-of-Network Rates Drive Unexpected Medical Costs

When out-of-network physicians perform hospital procedures, hefty charges can be added to medical bills. Insurers often pay the full amount or large portions, which provides an incentive for doctors to include out-of-network colleagues.

Difficult Boundaries in Patient Care

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An interesting article in the NEJM (here’s link to full text: No Appointment Necessary?) explores the ethical and practical challenges of being asked to help in the care of friends and families.  These issues are definitely not abstract.  I would be surprised if most physicians have not received multiple requests for advice or for prescriptions.  Some of the potential problems listed include the following:

  • feeling pressured to practice outside their area of expertise
  • lack of complete information about the problem
  • not asking for sensitive information
  • emotional investment/loss of perspective
  • conflict of interest
  • potential for guilt/remorse if clinical error
  • poor documentation

The article notes that “the very first code of medical ethics drafted by the American Medical Association (AMA) in 1847 recommended against physicians treating family members, stating that “the natural anxiety and solicitude which he [the physician] experiences at the sickness of a wife, a child . . . tend to obscure his judgment, and produce timidity and irresolution in his practice.”

Yet, in practice, “a 1991 study showed that 99% of surveyed physicians reported having received requests from family members for medical advice, diagnosis, or treatment, and 83% had prescribed medications for relatives.6  Physicians cite convenience as a key reason to provide this care, but other explanations have included a wish to save the relative money as well as a belief that ‘I provide the best care.’”

Take-home message (from the authors): It is our hope that providers will think through the potential ethical conflicts before offering informal care. We also urge providers who are involved in medical education to help trainees understand the ethical boundaries of care as part of their professional role and encourage them to refrain from treating friends, family members, and themselves.

 

Business of Blood in Decline

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With refinements in surgery, including minimally invasive techniques, and studies showing that transfusions are not needed in many conditions until patients have bigger drops in their hemoglobin, there has been a big drop in the need for blood transfusions.  I was unaware of how much of a drop until I read this article from the NY Times: Blood Industry Shrinks

An excerpt:

Changes in medicine have eliminated the need for millions of blood transfusions, which is good news for patients getting procedures like coronary bypasses and other procedures that once required a lot of blood.

But the trend is wreaking havoc in the blood bank business, forcing a wave of mergers and job cutbacks unlike anything the industry, which became large scale after World War II, has ever seen.

Transfusions are down almost one-third over the last five years, to about 11 million units last year from about 15 million units, according to the American Red Cross, which has about 40 percent of the market. With “minimally invasive” techniques like laparoscopic surgery and other shifts in medicine, demand for blood continues to drop despite population growth and a soaring number of people over 65, who have the most surgeries requiring blood.

Blood bank revenue is falling, and the decline may reach $1.5 billion a year this year from a high of $5 billion in 2008.

Other useful points included the following:

  • The decline in demand is opportune given the growing list of exclusions
  • Red blood cells have a shelf life of 42 days; platelets 5 days
  • While blood is donated, hospitals pay $225-240 per unit and patient may be charged ~$1000 per unit.  Hospitals have been trying to lower their costs given the changes in supply and demand.

Related blog post:

Transfusion strategy in acute GI bleeding | gutsandgrowth