Category Archives: General Health

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

Desperate for a Kidney Transplant

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A recent NY Times article delves into the issues of kidney trafficking: NY Times Kidney Trafficking

Here’s an excerpt:

In the United States, the number of kidney transplants has remained static for a decade at 16,000 to 17,000 a year. During the same period, the waiting list for kidneys from deceased donors has nearly doubled, passing 100,000 this year. The median wait time for an adult [for a kidney transplant] is more than four years, and more than 4,000 die waiting each year.

Some physicians and ethicists question the relative morality of allowing thousands to die just because the means of saving them is considered repugnant. A regulated marketplace, they say, could all but eliminate the shortage. It is no accident, they argue, that the only country that allows compensation for donors — Iran — effectively has no waiting list.

Experts list China, Egypt, India, Pakistan, Sri Lanka, Turkey, Eastern Europe and the former Soviet republics as hot spots for organ trafficking. But illicit transplants usually go undetected unless there is a surgical mistake or a payment dispute. Prosecutions are thwarted by false affidavits, toothless laws and lack of international cooperation, particularly regarding extradition.

What Happens with Cost Transparency in Medicine?

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While it is true that some tests, like MRI and CT scans, may be performed better (better images, better contrast administration, etc) at some locations than others, many times the test is similar but the costs to the patient may be widely divergent.  Yet, for most patients the exact costs are not known until the bill arrives in the mail.  A recent study shows that many patients will consider the costs of these expensive tests if they are provided beforehand.  Here’s the NY Times link, MRI study,  and an excerpt:

A study released Monday in the journal Health Affairs suggests we are smarter than that.

The insurer WellPoint provided members who had scheduled an appointment for an elective magnetic resonance imaging test with a list of other scanners in their area that could do the test at a lower price. The alternative providers had been vetted for quality, and patients were asked if they wanted help rescheduling the test somewhere that delivered “better value.”

Fifteen percent of patients agreed to change their test to a cheaper center. “We shined a light on costs,” said Dr. Sam Nussbaum, WellPoint’s chief medical officer. “We acted as a concierge and engaged consumers giving them information about cost and quality.”

The program resulted in a $220 cost reduction (18.7 percent) per test over the course of two years, said Andrea DeVries, the director of payer and provider research at HealthCore, a subsidiary of WellPoint, which conducted the study. It compared the costs of scanning people in the WellPoint program with those of people in plans that did not offer such services.

Related blog posts:

Using Preoperative Aspirin to Prevent Postoperative Problems –Negative Study

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A recent study has looked at whether giving aspirin prior to surgery can help those who take aspirin and also those who do not (NEJM 2014; 1494-503).  This trial called POISE-2 (Perioperative Ischemic Evaluation 2) was undertaken to determine if low-dose aspirin, as compared to placebo, would affect 30-day risk of death or nonfatal myocardial infarction.

The relevance of this study relates to aspirin’s known potential for preventing venous thromboembolism and the fact that “one-third of patients undergoing noncardiac surgery who are at risk for major vascular complications receive perioperative aspirin.”

The study enrolled 10,010 patients and employed a 2-by-2 trial design to account for whether they had been taking aspirin.  The study took place between 2010-2013 at 135 hospitals and 23 countries.  Mean age was 68 years in both groups.

Results:

  • The rate of death was similar in both groups: 7.0% for aspirin and 7.1% for placebo (hazard ratio 0.99)
  • Major bleeding was more common with aspirin than placebo: 4.6% vs. 3.8% (P=0.04).

Bottomline: Perioperative aspirin had no significant beneficial effect.

Related study: NEJM 2014; 370: 1504-13.  Conclusion: “Administration of low-dose clonidien in patients undergoing noncardiac surgery did not reduce the rate of” death or nonfatal myocardial infarction.  Patients who received clonidine had more frequent hypotension and nonfatal cardiac arrest.