How Much Does a Doctor Visit Cost a Patient?

Posted on October 13, 2015 by gutsandgrowth

Opportunity Costs of Doctor Visits -YouTube Video

The study estimates that the typical visit to a doctor consumes 121 minutes of the patient’s time — 37 minutes in travel, 64 minutes waiting for care or filling out forms, and only 20 minutes face to face with the physician.

Based on the average sum a person could earn if working during that time, the researchers figure, it costs patients $43 in lost time for each medical visit — more than the average out-of-pocket cost for the care itself, which is about $32.

Mehrotra’s team drew their results from three national surveys, chiefly the 2003-2010 American Time Use Survey, administered by the Bureau of Labor Statistics. The survey asked randomly selected respondents to recall what they did from 4 a.m. on the previous day until 4 a.m. on the day of the survey. The researchers examined the experiences of the 3,927 respondents who had sought medical care during that 24-hour period.

The initial study: Opportunity Costs of Ambulatory Medical Care in the United States Kristin N. Ray, MD, MS; Amalavoyal V. Chari, PhD; John Engberg, PhD; Marnie Bertolet, PhD; and Ateev Mehrotra, MD, MPH. Published in American Journal of Managed Care (August 2015)

Targeted Therapy for PFIC type 2

Posted on October 12, 2015 by gutsandgrowth

Progressive Familial Intrahepatic Cholestasis, type 2, (PFIC2) is due to decrease (or absent) function of the bile salt export pump (BSEP) encoded by ABCB11 has been treated mainly in a symptomatic manner with medicines like ursodeoxycholic acid and sometimes biliary diversion. PFIC2 has been associated with increased risk for hepatocellular carcinoma (HCC).

A recent study (E Gonzales, et al. Hepatology 2015; 62: 558-66) indicates that newer therapies targeting the specific mutation may be effective.

In this study, treatment with oral 4-phenylbutyrate (4-PB) in four patients improved pruritus, serum bile acid concentrations, and liver function tests. 4-PB is considered a chaperone drug and may partially correct mistrafficking.

The associated editorial (pg 349-50) notes that 4-PB has an unpleasant taste and requires ingestion of a large number of pills. In addition, patients with complete loss of BSEP, 4-PB will not be effective. Finally, even in patients with a clinical response, it is unclear if this will lower the risk of HCC.

A second study (S Varma et al. Hepatology 2015; 62: 198-206) retrospectively studied 22 children with PFIC2. “Children with late-onset presentation, lower ALT, and intracellular BSEP expression are likely to respond, at least transiently, to nontransplant treatment.” Nontransplant treatment in this cohort included ursodeoxycholic acid in 19 (10 mg/kg thrice daily) and partial biliary diversion in 3. Higher ALT values were considered to be >165 IU/L. Another point in this study: response to treatment can be slow and take many months.

My take: These studies provide useful information about which patients with PFIC2 respond medically and introduce a new therapy, 4-PB.

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Is this really newsworthy? Perhaps next week: man with venomous snakes says they make great pets?

Perhaps next week the story will be: man with venomous snakes says they make great pets?

Exorbitant Drug Costs from USA Today

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Best Tweets Two #NASPGHAN15

Posted on October 10, 2015 by gutsandgrowth

One clarification -I do not think that Dr. Narkewicz is calling Dr. Balistreri a panda:

Best Tweets from Postgraduate Course: #NASPGHAN15

Posted on October 9, 2015 by gutsandgrowth

Since I am not at this year’s national meeting, I have followed some of the information on social media. Here are some of the best tweets:

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The Slow March of the Digital Health Revolution

Posted on October 8, 2015 by gutsandgrowth

A recent commentary (SD Dorn. Gastroenterol 2015; 149: 516-20) provides insight on the digital health revolution.

Key points:

“Amara’s law –that ‘we tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run’–seems to apply to digital health. Expect short-term gains to be incremental.”
The promise of ‘big data’ has not translated into big changes yet. “Many systems are not interoperable owing to cost, competition, privacy concerns, and technical barriers.”
Mobile health, mHeath, “is skewed toward those who need the least help: the young, the fit, and the educated.” And, there is “no evidence supporting the effectiveness of the vast majority of mHealth tools.”

What’s wrong with electronic health records?

“The overall evidence that EHRs improve safety and quality is spotty. Cost savings remain elusive.” Some reasons include that more time is needed and/or flaws in EHR design.
EHRs are not very usable –excessive clicks and scrolling.
EHRs “reduce productivity and can add hours to the busy clinician’s day”
Physicians “now spend up to two-thirds of a typical outpatient visit documenting.”
Clinical records may be more legible, but they are often less useful. “Template-generated notes frequently lack coherent narratives, are bloated with extraneous and repetitive information, and sometimes contain obvious errors that are copied forward from one note to another.”
“Physicians suffering from ‘alert fatigue’ may ignore potentially valuable clinical alerts.”
EHRs require frequent sign-ins and computers often have to be unlocked.
EHRs are expensive.
“In total, EHRs significantly worsen physician satisfaction.“

From a patient vantage, EHRs offer the possibility of patient portals to send physician messages, obtain test results, request medication refills, and schedule appointments. Telehealth offers the potential for expert advice from great distances.

Some integrated health systems, including the Veteran’s Health Administration and Kaiser Permanente, have shown that EHRs can be successful.

My take: The transition to digital technologies has great promise but could lead to a less personal approach. So far, the transition to digital health has been a bumpy slow road.

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Why D5 1/2NS was the Right Choice in the 1950s!

Posted on October 7, 2015 by gutsandgrowth

For many, a frequent practice is to order D5 1/2NS intravenous fluids for maintenance IVFs. An expert review (ML Moritz, JC Ayus. NEJM 2015; 2015: 373: 1350-60) of this topic explains why this was right in the 1950s but is usually the wrong choice today.

Key points:

Use of hypotonic maintenance fluids (sodium concentration <130 mmol per liter), “has been associated with a high incidence of hospital-acquired hyponatremia and more than 100 reports of iatrogenic deaths or permanent neurologic impairment related to hyponatremic encephalopathy.”
Acutely ill patients have “disease states associated with excess arginine vasopressin.”
Recommendations on the use of hypotonic fluids were “based on theoretical calculations from the 1950s, before the syndrome of inappropriate antidiuresis was recognized as a common clinical entity.”
“More than 15 randomized, prospective trials involving more than 2000 patients have evaluated the safety and efficacy of isotonic fluids…most of these studies involved children…isotonic fluids were superior.” Limitations: these studies were typically <72 hours and excluded patients with renal disease, heart failure, and cirrhosis.
The authors also note potential problems with 0.9% NS for rapid infusion, perhaps related in part to the polyvinyl chloride bags which lowers the pH. “0.9% saline, as compared with balance salt solutions, may produce a hyperchloremic metabolic acidosis, renal vasoconstriction, an increased incidence of acute kidney injury requiring renal-replacement therapy, and hyperkalemia.”
Hypotonic fluids may be appropriate in the setting of established hypernatremia or a clinically significant renal concentrating defect (with free-water losses).

My take: D5 1/2 NS and other hypotonic fluids should not be used commonly as a maintenance fluid.

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Nutrition Support for Intestinal Failure

Posted on October 6, 2015 by gutsandgrowth

A recent blog post by Kipp Ellsworth (The Pediatric Nutritionist) highlights a recent lecture by Conrad Cole that provides several useful points. The post includes a link (embedded talk) to 76 slides. Here are a few:

Iodine deficiency: Dr. Cole “typically orders a TSH level every six months, also ordering a spot urine iodine if a significant TSH uptrend emerges.”
Lipids: “Dr. Cole reviewed evidence revealing the restriction of soy-based lipids to 0.5 gm/kg/day as nearly efficacious as the use of fish-oil infusion (Omegaven) in preventing PNALD.” Daily use of 0.5-1 gm/kg/day is less error-prone than using lipids 3-4 times/week.
Formula: “breastmilk constitutes the touchstone of enteral nutrition choices for the intestinal rehab patient, conferring a host of benefits beyond those associated with formula alone… the medium-chain triglyceride component of many oligomeric and monomeric formulas constitutes a therapeutically valuable source of nutrition, increasing the proportion of calories absorbed.”
Formula for toddlers: “Dr. Cole continues transitioning his patients to oligomeric and monomeric formulas such as Elecare Junior, Pediasure Peptide, and Peptamen Junior upon reaching toddlerhood.”
Fiber: “Dr. Cole recommended the use of a sc-FOS product such as NutraFloraas optimal for the short bowel syndrome population. Dr. Cole initially doses soluble fiber at 1 gm/100 mL of formula and advances as tolerated to a maximum of 2 gm/100 mL formula. He typically does not use supplemental fiber to control ostomy output in patients without a colon in continuity”
Enteral fish oil: “Dr. Cole remains unconvinced of the therapeutic value of enteral fish oil supplementation pending further research studies on the subject.”

Funding for his talk was provided by Abbott Nutrition.

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Medical Progress for Intestinal Failure Associated Liver Disease

Posted on October 5, 2015 by gutsandgrowth

A recent review (WS Lee, RJ Sokol. J Pediatr 2015; 167: 519-26) provides a good explanation of the role of various intralipids and intestinal microbial dysbiosis in the setting of intestinal failure-associated lipid disease (IFALD).

The review discusses criteria for IFALD (e.g. conjugated bilirubin ≥2 mg/dL & parenteral nutrition ≥14 days), the epidemiology, and the pathogenesis. Potential risk factors and level of evidence for these risk factors is noted in Table 1.

Table 2 describes the evidence supporting suggested strategies for the prevention of IFALD. The effectiveness and recommendation levels for these strategies are generally very low and weak based on reviews by ASPEN and the American Pediatric Surgical Association. Among the strategies, reduction of lipid emulsion to ≤ 1 g/kg/day has some of the strongest support in this table but is still regarded as level III evidence and described as “probably effective.” Other strategies reviewed included ethanol locks, multidisciplinary team management, use of ursodeoxycholic acid/bile acid supplementation, cycling of parenteral nutrition, use of prokinetics, removal of manganese and copper from parenteral nutrition, and antibiotic use to prevent bacterial overgrowth.

With regard to alternative intravenous lipids (eg. fish oil, or SMOF mixture):

“Although a properly powered randomized controlled trial has not been conducted, current evidence suggests that the use of FO-ILE [fish oil -intravenous lipid emulsion] is effective in reversing the established cholestasis associated with IFALD, but there is insufficient evidence for a preventative effect in neonates.”
“Most studies have been retrospective, used a historical comparison group, used different doses of lipid, and were conducted in patients with quite advanced IFALD.”
Use of FO-ILE improves biochemical parameters, but has not been shown to “improve other important long-term clinical outcomes, such as severity of hepatic fibrosis.”
In addition, reduced ILE and FO-ILE may result in other sequelae such as cognitive developmental delay. “Recently, lower brain weight and alterations of brain PUFA content were demonstrated in newborn piglets receiving total PN with reduced dose SO-ILE or FO-ILE compared with normal dose SO-ILE.”

My take: This review underscores how little is known about the approaches often recommended for management of IFALD.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Why We Vaccinate: Life after Polio

Posted on October 4, 2015 by gutsandgrowth