The Perils of Over-Treatment — diabetes and hypertension

excessToo much treatment is dangerous just like too little treatment.  Treating blood pressure too early or too aggressively increases the risk of death.  Treating elderly patients with diabetes with too much medicine increases episodes of low blood sugar that damage the brain and lead to broken bones from falling.

In 2014 the national guidelines for blood pressure treatment were changed to allow a higher blood pressure.  Similarly, a recent study found increased mortality for elderly patients treated too strongly for diabetes.

This is not rocket science.  Imagine a blood pressure medication that could lower the blood pressure to any level.  Knowing that zero blood pressure means you are dead, it stands to reason there is a point where treating blood pressure goes from helpful to dangerous.  Same for blood sugar.

Sometimes this problem is called “treating the test“.  In essence prescribers just look at the numbers and write a prescription, but ignore symptoms of weakness or spells of altered consciousness.  Hypertension and diabetes are good examples but this happens with lots of other conditions.

Examples of over-treatment include treating a sore throat with antibiotics, treating mild asthma with oral steroids, or treating an elevated lyme serology test with antibiotics.  It takes time to make a correct diagnosis and time to explain treatment to patients — some health care providers simply don’t take the time do do either.

Most drugs have a “therapeutic windowopenwindow.  As long as the window is open the patient gets benefit.  But, the window closes due to side effects and advanced age.

If a person is over 80 or in poor health excessive medical treatment is a substantial risk.  In this group even the thought of a low cholesterol diet is foolhardy.   It’s all about risks and benefits.

 

 

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2014 Health Rankings — Hawaii #1, Mississippi #50

State Quality of CareThe 2014 data from the United Health Foundation is in.  The graph rates health status of people in all 50 states .  Hawaii, the state with a virtual single payer, is #1 and Mississippi with poverty and poor access to care is #50.  The rankings aggregate 27 measures including physical inactivity, infectious diseases, immunizations, number of primary care physicians and disparity in health status.

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Addendum (2/26/15):  After creating the above graphic I realized it was virtually the same as one in a previous blog.  The first graph was from the Commonwealth Fund intended to show regions of poor quality care (e.g.patients not given adequate immunizations) and the second was from the United Health Foundation intended to show patients having poor health (e.g. patients not taking immunizations).  In the first it says the health care system is not doing enough, the second says the health care system is overwhelmed by problems.  I tend to side with the Commonwealth Fund. When you find yourself surrounded by alligators it is important to recall your first job was to drain the swamp, not to later just complain about alligators.  Good advice for the Mississippi legislature.

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Complications after Surgery — blame or improve?

carrot-stickThe long and difficult training for surgeons often leaves them with little intrinsic drive to improve surgical care.  Anyone who has had to discuss surgical quality with practicing surgeons is lucky to leave the discussion without a fear of losing their job.  So, with little intrinsic drive to improve quality, the government and insurance companies resort to the old carrot and stick methods.

For surgeons the carrot and stick are financial.   So, if a surgeon and associated hospital have patients that are readmitted within 30 days the hospital is penalized — the hospital is unhappy and verbally passes that unhappiness on to the surgeon.

A study just published “Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States” expresses surgeons’ negative opinions of the penalty saying it really won’t have much effect on surgeons – wow, what a stonewall attitude!

The argument is based on the findings that surgical patients return to the hospital because of an infection where the skin was cut or because of bowel problems from pain medication.  Somehow, the surgeons writing the article seem to think complications, coming to light after the patient leaves the hospital, are beyond their control — so the hospital should not be penalized.  In other words, complications are and ACT OF GOD.

Wrong answer!  Patients, families, insurance companies and Medicare do not want to further enrich surgeons and hospitals for bad outcomes.  A much better answer would be to double the efforts to improve quality and reduce complications and to have surgeons spend more time out of the operating room figuring how to improve surgery in the operating room.

Admiral David Farragut is attributed with the phrase “damn the torpedoes, full speed ahead” — was he really a surgeon in disguise?  We all know intrinsic motivation (dedication and innovation)  is much more effective than extrinsic motivation (carrot and stick).   Intrinsic motivation comes from training programs that place emphasis on quality and downplay personal profit.

The solution:  surgeons should be employees of the hospital (an ACO model) so they personally feel the financial pressure to minimize costly complications — not just watch as the hospital is penalized.  And, improve post-graduate surgical training to have more emphasis on quality.

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Do Hospital Amenities Impact Quality Care?

Acccrystalchandelierording to a study at Johns Hopkins (2/1/15) improving hospital amenities improve patient satisfaction with the facility but otherwise do not improve satisfaction with care.  This is important for two reasons:

  1. Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
  2. Patient satisfaction measurement is a powerful tool to assess medical care — if the patient’s expectations are met, it is likely good care is delivered.

The tremendous building boom for hospitals is strange given this bit of science  — are CEOs trying to improve quality by remodeling?   Now it seems clear CEOs should focus money and energy on improving hospital quality until the level of quality is very high then if there is money to spare consider improving the physical amenities.

Increasing the distance a nurse must walk to see patients results in decreasing nursing visits.  This seems simple enough, but the current trend in hospital remodeling is to eliminate rooms with multiple patients.  The trend reduces RN visits, increases the need for nursing assistants, increases hospital cost and may increase falls for elderly patients.

The hospital that looks like a nice hotel seems to be the desire of hospital CEOs.  This may be fine for obstetrics but may be wrong for geriatrics.   A multi-bed ward with 4 patients allows one nurse to check on 4 patients quickly.  4 times the number of nursing visits makes it much easier to prevent falls.  When nurses still wore those pointy white hats they had this figured out.

Progress marches on.  American health care quality is as low as many 3rd world countries but at least we have nice surroundings in which to suffer the complications.

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Hospitals fail to stop IV fluids for CHF — poor quality care

ivfluidsHospitals are responsible to rescue patients from inappropriate treatment — especially when the need to intervene is obvious.   The hospital has a board of directors responsible for the care delivered in a hospital. They hire the CEO who hires a quality manager.  When bad quality management hurts or kills patients it is the hospital’s fault.

An article by Dr. Behnood Bikdeli and colleagues (JCHF. 2015;3(2):127-133) describes a huge study at 346 hospitals about treatment of patients with congestive heart failure (CHF).   Here is the essence:

  • CHF is life-threatening condition where the body collects too much fluid, usually due to a weak heart.  The fluid gets into the lungs and causes shortness of breath.
  • The treatment for CHF is to remove fluid from the body and give medications to improve heart and kidney function.
  • The absolutely wrong thing to do is to give extra fluid by the veins.
  • The study found about 12% of patients with CHF were treated with 1 to 2 liters of fluid in the veins during the first 2 days of hospitalization.  AND, most alarming, compared to similar patients not treated this way, they were more likely to end up in intensive care or die.
  • The most telling statistic is how often various hospitals let this dangerous use of intravenous fluid happen:  0% to 71%.  This means some hospitals did not let it happen (0%).  Some hospitals let it happen a lot (71%) — just hope your grandmother did not go to that hospital!

It is not rocket science to say fluid overload is not treated with extra fluid.  This is easy to detect when the admitting diagnosis is CHF and the doctor orders say “NS IV at TKO” (translation:  give salt water in the veins at a rate to make sure the veins stay open).  NO NO NO the patient does not need extra fluid.  This should not happen and there are lots of ways to prevent it or even rescue patients when Dr Welby writes such an order (or tries to use leaches).

Solutions:

  1. Mandate doctors use standard orders for treatment of CHF — there is plenty of latitude to customize such orders.  But, IV fluid is not one of the choices without stating why.
  2. Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
  3. Educate staff that IV fluid is not a cure-all.  Fluid would help a dehydrated patient but not others.
  4. Nurses do a double check before admitting a patient from the ER with the question:  does this patient have CHF and an order for IV fluids — if so, call the physician to clarify the situation or to change the order — no clarity=no admit.
  5. All CHF patients should be weighed daily — if the weight is going up it means more fluid is being retained — the patient needs to be rescued.  Fix the problem or find someone who can, NOW.

Attention patient and family.  This is easy to spot.  The admitting doctor says the diagnosis is congestive heart failure but you see IV fluids being pumped into yourself or your family member.  SPEAK UP!  “Why is fluid treatment needed?”  do not accept the answer of “everybody gets an IV”.

Attention hospital board members:  do you know what your hospital is doing to prevent this obvious problem?  Quality is your responsibility, you must do something besides listen to financial statements.  Is your hospital the one with 0% or 71% record of treating CHF with IV fluids?

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High Medical Cost in Winter Havens — unnecessary testing

mctestswithlegend

Snowbirds:  watch out for high medical costs in Florida, Texas, Arizona and California.  According to Elisabeth Rosenthal in the New York Times 2/1/15 “Patients Find Winter Havens Push Costs Up”.  She points out providers in Florida are the worst offenders — the same place notorious for Medicare fraud!

Ms. Rosenthal highlights one patient from New York wintering in Florida who had a checkup for his pacemaker but did not have any new symptoms.  Many in-office tests were ordered by the substitute cardiologist — tests the patient’s regular cardiologist said were unnecessary.

To be very blunt:  cardiologists, and other providers, who order in-office tests make a lot of money from those tests.  Many studies show providers who profit from tests do more tests than providers who don’t profit from tests.  A medical license is not a license to take advantage of patients or Medicare — profit motivation seems to blind some providers to this distinction.

The lure of profit is made greater by a patient not having any new symptoms, not having any record of previous tests, and not having plans for follow-up visits.  It is like the patient has a sticker pinned on their back:  “TEST ME”.   The choice for the cardiologist is simple: either pay the nurse to spend time getting out-of-town records OR make money by repeating tests.  Make money, right!

Suggestions:

  • If you are on vacation and have a sudden health problem your best bet is an urgent care center.  They can send you to a specialist, if needed.
  • If you have health problems and will be spending several weeks or months away from home:
    • Talk to you primary care provider:  they may want you to call in and give a report on the phone (diabetes is a good example).  If so, no office visit may be needed while away.
    • Get enough medication to last the trip.  Or, get prescriptions with refills at WalMart or Target and have the prescription transferred to a store near your winter location.
  • Identify a doctor to see in your vacation area before you leave.  Ask friends or other people who winter in the area for a recommendation.  Call the distant provider office and get a FAX number so records can be sent.
  • If your primary care provider thinks you need a health care visit while you are away then make an appointment and have your records sent before you leave home — also take a paper copy!
  • If tests or surgery are recommended then call your regular doctor’s office to see if they agree.
  • Give any provider you see your regular provider’s name, address, phone number and FAX number (a business card is good).  Request that results of visits, tests or hospitalizations be faxed or sent to them — and make sure it happens.  Fill out a release of information form while you are at the office or other facility.

Bon Voyage!

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Checklist for the Kidneys — a disease without symptoms

checklistIf your doctor says your kidneys are not working 100% …  is that a problem?  ABSOLUTELY!  You need your kidneys in order to stay alive and when blood tests begin to show kidney problems it means you have lost a lot of kidney function already — at least 50%.  So, the wise doctor and the informed patient need to run a checklist to do the right things.  If you wait until you have symptoms of complete kidney failure, it’s too late.

The main blood test for kidney function is serum creatinine — abbreviated Cr.  The kidneys have a large reserve capacity; in fact, a person can donate a kidney and still have the creatinine (Cr) blood test be “within normal limits”.

Many things can go wrong with the kidneys that range from the fairly simple to the terribly complex.  For instance, kidneys can be damaged simply by the bad effects of high blood pressure or by esoteric autoimmune diseases (“friendly fire” where the body’s defense against germs is accidentally directed at healthy kidney tissue).

You need to know 4 things to estimate your kidney function:

  1. Serum Creatinine (Cr) as measured on a blood sample.
  2. Your age (in years)
  3. Your race (black or not-black)
  4. Your gender (male or female)

Then you calculate another number called eGFR (estimated glomelular filtration rate) based on the items 1 – 4.  Often, this is automatically calculated by the lab — if not get the answer from many online web sites like the National Kidney Foundation eGFR calculatorThe normal value is 100 but it’s not considered abnormal until it is below 90.

STAGE eGFR DESCRIPTION TREATMENT (also see tables below)
1 90+ Normal kidney function but urine findings or structural abnormalities or genetic traits point to kidney disease. Observation, control of blood pressure.
2 60-89 Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease Observation, control of blood pressure and risk factors.
3A or3B 45-59
30-44
Moderately reduced kidney function Observation, control of blood pressure and risk factors.
4 15-29 Severely reduced kidney function Planning for endstage renal failure.
5 below 15 or on dialysis Very severe, or endstage kidney failure (sometimes called established renal failure) Dialysis or transplant.

Now to the checklist mentioned above (Clin J Am Soc Nephrol 9:1526-1535,2014.):  All is well if you have no known kidney problems, the eGFR is above 90, the urinalysis (U/A) is normal, and you have no genetic predisposition to kidney disease (like a family history of polycystic kidney disease). Otherwise, you have stage 1-4 kidney disease so check off the items below to make sure important tests and treatments are obtained.
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Slow the progression.

checked_checkbox Keep blood pressure below 140/90
checked_checkbox Check HbA1c and keep below 7% for diabetics.
checked_checkbox Every year check urine microalbumin/Cr ratio.
checked_checkbox If ratio is above 30 start ACE or ARB drugs.
checked_checkbox Work to stop smoking.
checked_checkbox Avoid NSAIDS (aspirin like products) or other toxins.
checked_checkbox Keep LDL cholesterol below 100.
checked_checkbox Get pneumonia vaccination every 5 years.
checked_checkbox Get Influenza vaccination each year.

Find and treat complications.

checked_checkbox Check hemoglobin and Iron — keep in satisfactory range.
checked_checkbox Check calcium, phosphate and PTH — keep in satisfactory range.

Referral to nephrologist.

checked_checkbox eGFR is below 30.
checked_checkbox Protein remains in urine despite initial treatment.
checked_checkbox Persistent elevated potassium.
checked_checkbox Can’t keep blood pressure below 140/90.
checked_checkbox eGFR falls by 30% in 4 months without explanation.
checked_checkbox Cause of kidney problems is unclear.
checked_checkbox Anemia needs treatment with erythropoietin stimulating drugs.
checked_checkbox Elevated phosphate or PTH.

So, this seems complicated?  TRUE.  That is precisely why a checklist is needed.  And, that is why the informed patient needs to go over this checklist with the primary care provider.  Print a copy of this post and take it with you to an appointment to start the discussion.

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