Ambulatory Surgery Centers — where’s the data?

undertherugAmbulatory Surgery Centers (ASC) are adept at hiding problems.  Just try to find death rates, numbers of transfers to hospitals, organ punctures, and surgical procedures required to correct errors.  Nope – you won’t find those crucial bits of data for public view.  Here is a link to statistics collected for “internal” review:  Quality Reporting Program.

As with most health care entities the public expression of “quality”  is “certification” — which means an outside reviewer thinks the organization has the right programs and procedures so nothing stands in the way of quality care.  Likewise, nothing usually stands in the way of a student getting an A+ on a test — but A+ is not always the grade.  As Confucius says: “there are always greater and lesser”.

So, as a patient, what should you look for; what questions should you ask?

  • Is the ASC certified?  If not, find another ASC.
  • How many patients does the surgeon treat at the ASC  — expect at least 10 per week.
  • How often does the surgeon do the procedure you need at the ASC — expect at least 10 per month.
  • Will you be sedated? — if so, make sure an anesthesiologist or nurse anesthetist will be monitoring you while sedated — if not — find a different ASC.
  • How close is a hospital if you have one of those serious complications listed in the consent-for-surgery form?  If an ambulance would take more than 10 minutes to get you to the hospital consider another ASC.
  • If you have severe heart or lung problems (like a history of congestive heart failure or COPD) consider having your procedure at a hospital rather than at an ASC.
  • Ask if a pre-op check list, like the one the World Health Organization recommends, is used for all surgeries — if not, quality is a questionable.  If the surgeons says they don’t need a check list find a different surgeon.  Keep this in perspective — every airplane pilot must follow a pre-flight checklist, is your surgery any less important?
  • The person that comes with you needs to write down what the surgeons says after the procedure.  Patients who have been sedated, even if they seem fully awake, will have impaired memory for many hours.  Have the person with you write down what was found at surgery — what is the diagnosis and what are the specific instructions.
  • Absolutely avoid late afternoon surgery — because you will be shipped to the hospital for minor complications — the ASC will close and they don’t have staff to provide care after closing.

 

 

 

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Something Less than an Ambulance — will it fly?

ambulanceER doctors never ask the question but often think: “Why did you call an ambulance for a sore throat?!”  The trip costs at least $1000 and stands a chance of not being covered by insurance.  The ambulance crew feels bad they don’t have a more appropriate option but if you call an ambulance — you get an ambulance.

Kaiser Health News reports the South Metro ambulance company in a suburb of Denver Colorado is trying a new service.  An ambulance that is basically an ER in a box.  Equipped with lab tests, bandages, sutures and a few medications they go to a home to treat a problem rather than transport a person to the ER.  It costs about $500 — at this point, it is something insurance will not cover.

Here are two extremes:

  1. A single parent picks up their child from a family member after working 2 jobs at fast food restaurants.  The parent just got the jobs after 3 months of being unemployed.  The primary care doctor’s office is closed and the parent is expected at work in about 7 hours.  But, the child has a fever and a sore throat. The bus they usually catch to go to the hospital does not run after 8 PM.  The parent calls an ambulance.
  2. A woman drops a martini glass and cuts her finger.  Her husband thinks she needs stitches but he has some after hours stock trading to do before bed.  He tells the butler to call an ambulance and get the problem resolved.

The first case is common for Medicaid families.  No resources, no car, and not much to lose by calling an ambulance.  But, something to gain by not missing time at a new job and it helps the child on both counts.  The ambulance and ER visit may cost Medicaid over $1000.  But, during the day a visit to primary care might only cost $50.

The second case is crying for concierge care.  The family has the cash to pay for someone to come to the house and put a few stitches in a finger.  But, instead the problem clogs up the ER that should be dealing with heart attacks and car wrecks.  Again, if the problem happened earlier in the day a primary care office or urgent care clinic could have solved the problem.

One could see Medicaid having a fleet of mobile treatment units just to limit the financial losses in the ER.  Actually, a good idea.  Both cases might have solved their problems by taking a taxi to an urgent care clinic — if one was open.

Will the “ER in a box” find a place? — at least a place where someone will pay them?  The idea leans toward the concierge model.  No insurance is going to pay for an ambulance when a taxi will work.  No insurance company will pay extra just for the convenience of one patient.

Nice idea, but it’s not likely to fly financially.

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Psychology of Unhappy Doctors — unmet expectations

ocdDoctors are unhappy because the medical world  is not what they expected (or dreamed about).

An essay in the Wall Street Journal today “Why Doctors Are Sick of Their Profession?” describes the feelings of many doctors.   What are those feelings?  What do they mean?

Most physicians cope very well and are quite successful in society.  Clearly, they do not have a psychiatric disorder as a group.  Yet, the WSJ article lists certain symptoms.  These are feelings of:

frustration, failed aspirations, malaise, worthless sacrifice, loss of control, conspiracy of lawmakers and insurance companies, devalued work, and recurrent intrusions of unpleasant thoughts.  Lawyers (the scum of the earth) make more money than they do.  And, oppression is keeping them from doing things the “right way”.

If a patient complains of those symptoms the diagnosis would be: depression with underlying obsessive-compulsive and narcissistic traits.  For doctors it may just be the world is not what they expected when they started 15 years of training.   The job is basically good and it’s too late to start over.

Is money an issue?   If a distraught patient says their anxiety has nothing to do with a “recent divorce” … it really has everything to do with the divorce.  If a doctor say it “has nothing to do with money” … it’s the money.

As a group doctors have a huge capacity for delayed gratification.  They go through difficult years of training by thinking it will get better later — the salary will go up, all the testing will stop, professors will go away, long hours will improve, and no one will question their decisions.  Welcome to the real world:  stagnant salaries, maintenance of certification tests, professors who set evidence based guidelines, long hours and insurance companies that question decisions.

Medical training is mostly to blame.  It’s too long, often unfocused, minimizes teamwork and shuns consistency.  The fight for doctors to follow evidence based guidelines is undermined by the constant drum beat of “cook book medicine”.  In fact, most medical treatment is by the book — a stunning revelation to most.  If physician expectations were better managed during training the dissatisfaction after training would not be an issue.

Many employees find their job the least stressful part of the day.  Stressed physicians need to focus on their job of diagnosis and treatment — it is very rewarding.  Extraneous worries can drive you crazy.

Accountable care organizations reduce physician stress by focusing physicians on the job of taking care of patients while business professionals manage the business.  Perhaps increasing the structure of medical care is the solution for physicians, not the enemy.

 

 

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Medication Expiration Dates — add 5.5 years

drugexpireIt’s likely the actual shelf life of your medications is much longer than the date printed on the box.  Medications required “as needed” often sit in the bottle for a long time — patients wonder when they should be discarded but really don’t want to pay for another expensive prescription.  Heidi Mitchell of the Wall Street Journal describes this problem in her story 8/25/14 “Are Expired Medications OK to Take?

The military has the shelf-life problem on a large scale — numerous doses of medications are stockpiled in case of an emergency.   Fortunately, in 2006 the military commissioned the FDA to study the problem — just as we all suspected, most medications last much longer than the expiration date — on average 5.5 years longer.

Medications fail the shelf-life tests if there is a significant loss of potency, leakage, crumbling of pills, loss of pressure within an inhaler, mold growth or bacterial contamination.  The latter two problems are mostly with liquid medications and are manifest by a cloudy or discolored appearance.

Although most medications last much longer than expected there are some cautionary notes:  Don’t keep medications for emergency life-saving situations beyond the expiration date.  This would include insulin, nitroglycerin and injectable epinephrine.  Also, medications requiring refrigeration should not be kept beyond the expiration date.  Many medications exposed to high temperatures (such as in an automobile glove compartment for several summer days) may deteriorate rapidly and are probably best discarded.

All medications, stockpiled or not, need to be kept out of the reach of children.

Medications don’t become poisonous with storage but they can become less potent.  A pain pill that is 10% less potent is actually not much of a problem — most people can’t notice a 10% change.

So, if the military stockpiles medications 5 1/2 years beyond the expiration date so can you — save some money!

 

 

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Good & Bad Patient Portals — improving communication

patientportalA good patient portal is wonderful; a bad patient portal is a waste of time.  A recent post by Dr. Yul Ejnes suggested portals may not be patient centered and don’t get much use.

An alternative view is that all patient portals NOT are the same.  Some have great features and are supported by the providers offering them.  Other portals are not much more than advertising — generally something a patient does not revisit.  Sadly, many businesses have the latter type of portal — no wonder people don’t flock to medical portals.

Check out your health care provider’s portal.  If it does not really provide a benefit then TELL THE PROVIDER, complain, and say other providers do a better job.

Admittedly, a poorly functioning provider office will likely have a poorly functioning portal.  Just because the portal lets you send a message to the nurse or provider is no guarantee the response will be helpful.

Large vertically integrated health systems or ACOs have the best chance of a good patient portal.  The portal needs monitoring and rules for providers — rules that require questions to be answered the same day.  And, that the portal will display lab results within 48 hours, regardless of whether the provider has or has not seen the results.  Responses from nurses need to be monitored for accuracy and timeliness — the lazy but profitable response to just make an appointment is not adequate.  Integration of pharmacy functions is essential.

Here is a checklist of possible portal features — how does your provider’s portal stack up?

  • Responses to online requests take less than 24 hours
  • Ask a medical question
  • Ask medication related question
  • Make a follow up appointment
  • Make a same day urgent care appointment
  • Get refills on a chronic medication
  • Get a message from your provider about test results
  • Report drug side effects or drug allergies
  • Send a picture of a skin rash.
  • Diabetics can send blood sugar results
  • Asthmatics can send peak-flow measurements
  • Look at your list of medical diagnoses both active and inactive
  • See a list of current medications and the diagnosis for which they are prescribed
  • Links to drug information about the drugs on the medication list
  • Review the providers notes
  • Review any test, x-ray or consultation report
  • Your provider can send questions to specialists and forward the response to you
  • You can print your lab, pathology and x-ray reports
  • See your most recent medical summary including past medical history, social history, family history, medications list allergies — and be able to print the report if needed for consultations or to take on trips.
  • Request a summary of billing and payment information  — including when bills are sent to insurance and when payment is received.
  • Pay your bills on-line
  • Links to reliable on-line information sources about tests, treatments, drugs, immunizations and diseases.  Include a symptom checker — a computerized diagnosis based on symptoms — something to discuss with your doctor.
  • Provider office provides training to use the portal.

A provider might say:  “I’m not paid for running a portal or answering questions”.  That is very true for many providers in the US health care system.  But, in systems without fee-for-service billing then portals are a huge driver of efficiency.  If a patient’s questions or problems can be resolved via the portal so much the better for both the provider and the patient.  The handwriting is on the wall — fee for service is going to go away — the efficiency of portals will be a strong driving force.

 

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Wrong Aspirin Dose After MI — frequent errors

ASA81Highly educated and experienced cardiologists just can’t get it right:  the correct dose of aspirin after a heart attack is 81 mg (called low-dose), NOT 325 mg (called high-dose).  The current prescribing error rate is 60.9%  as published by the American Heart Association in 2014.

Personal communication with several cardiologists elicits the comment:  the higher dose is needed because of the risk of another heart attack — and “in my experience” it just works better.   It’s hard to believe this clinical error in this age of quality assurance.  The problem is BLEEDING not heart attacks!  The stomach BLEEDS due to aspirin and the higher the dose the higher the risk of BLEEDING.

bloodinsinkJust imagine the risk and strain for a recent heart attack victim who vomits blood, needs a transfusion and must undergo a stomach scope — some patients die.  From a cardiology standpoint: “they died from something unrelated to the heart attack” — great thinking.

Cardiologists completely and totally get it wrong when they simultaneously prescribe high dose aspirin and the anticoagulant warfarin – the ghastly mistake happens 40% of the time.

The chemical reaction of “acetylation” is caused by aspirin within small blood cells called platelets.  Acetylation of platelets is responsible for the favorable heart effects of aspirin.  It has been known for at least 30 years that 81 mg of aspirin completely acetylates every platelet a person has — more aspirin does no more.   According to the 2012 TRITON-TIMI trial:

“We observed no difference between patients taking a high dose versus a low of aspirin as it relates to cardiovascular death, heart attack, stroke or stent thrombosis,” according to Payal Kohli, MD involved in the study and quoted in Science Daily.

Hospital quality improvement programs need the “guts” to just say NO.  325 mg is not correct.  Cardiologists are the sweetheart doctors making millions of dollars for hospitals — it should not matter, JUST SAY NO.

It’s almost impossible for even the most proactive patient to question the great doctor that just saved their life.  So, hospital quality assurance has an even greater responsibility than usual.  The prescribing error needs to be corrected — hospital pharmacists and quality improvement departments need to be strongly involved – this error has gone on far too long.

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Discharge Drug Errors — 50% mistakes

manymedsMedication mistakes are common.  A recent study by Amanda Mixon following discharge from the hospital pegs the error rate at an astounding 50%.  The study focused on whether instructions given to patients at the time of discharge from the hospital matched what the patient later took at home.

The study is  biased by assuming all the errors are caused by patients – not the providers.  The authors point to patient problems of low health literacy and a poor facility with numbers.  Illegible instructions, poor communication skills, excessive complexity of medical regimens,  conflicting instructions, and giving verbal instructions to the wrong person are all provider or institutional issues.

Even a simple phone  call after discharge might have cleared up patient confusion — perhaps the study would have been better with a phone call and no phone call comparison.

The article conclusion is to apply more effort to find those high risk patients.  Another conclusion would be to find those high risk hospitals having difficulty telling patients what drugs to take.  The study was done at a VA facility affiliated with Vanderbilt — a good place to start the search.

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