Archive for March, 2015

Switch to Generic Medications — no problem!

genericmedSwitching from a brand name medication to an available generic medication is safe, easy and will likely save you a lot of money.  Thanks to the work of the FDA, generic medications in the United States are quite safe.  Patients in the US take more generics than in other countries.

When a patient starts a new brand-name drug (e.g. Lipitor) there is a risk of a side effect or allergy to the active ingredient.   But, when a patient switches to a generic medication (e.g. atorvastatin) the patient already knows the active ingredient agrees with them so the chance of a reaction is as close to zero as medical science can make it.

Prescribers are well aware that some generic medications may come in different forms (tablets or capsules) and different strengths — this is not a problem, the prescription just has to be adjusted to match what the patient needs.  Most care providers are quite willing to make the change to help lower the cost of treatment — patients tend to take medications they can afford!

The Wall Street Journal had a story today based on the opinion of a “pharmacist-economist” who has been a lead author on only one paper in the past 20 years and who thinks tablets and capsules of the same medication are distinct entities (yes, but it makes no practical difference).  The WSJ is clearly interested how the switch to generics affects the economics for big pharma — it would not be good and the stocks could go down — such a disaster.  However, if you have stock in a brand-name company you could use your stock dividends to pay for the drug.

The new bio-similar drugs and even some old drugs (like warfarin) may have a slightly different effect that depends on some minor manufacturing quirk.  Prescribers are well aware of these peculiar drugs and can easily make adjustments and do tests as needed.  Fortunately, small manufacturing differences for the vast majority of drugs is a distinction without a difference for the patient.

This principle needs to be considered in everyday terms.  The table salt at restaurants may come from separate and  distinct sources — it really makes no difference to the customer — salt is salt!  Marketing departments want you the think a generic is like coal and a brand-name is like diamond — intellectual garbage.

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Urinary Retention — 1 in 10 men over 70

urologybillboardOne ER visit is a red flag — more ER visits for the same problem become an example of  poor quality health care.

Urinary difficulty is something older men don’t like to talk about.  But, 1 in 10 men over the age of 70 will end up in the emergency room with urinary retention — an uncomfortable situation where they can not pass urine.  Urologists are aware of this frequent problem — see the billboard story.  It is a serious problem;  in third world countries it may be fatal.

The usual cause is enlargement of the prostate preceded by symptoms of slow and frequent urination.   Sometimes there are few symptoms until a painful inability to pass urine forces a rush to the emergency room.

The usual medical approach is to insert a tube (a catheter) into the bladder to relieve the pressure, start a medication to help urination, and 3 days later to remove the catheter.  50% of men can then pass urine adequately (for a while).  The quality issue is that 50% have a recurrence within a week — so is another ER visit the answer?

A friend of this blogger landed in the ER a total of 4 times with urinary retention.  Why is the ER the center of after-hours treatment for this problem — once identified as an issue why is the health care system making it a recurring emergency?

The solution is Urologists need to own the problem and provide adequate patient care 24 hours a day once a catheter is removed.  Yes, own the problem, not turn off the phone and let the ER solve it.  Does that mean the urologist must be at the clinic 24 hours a day?  No, but there must be an arrangement for immediate care — no waiting in the ER, no ER charges, no secondary consultations.  An arrangement with a 24 hour urgent care center may be enough but some back-up plan and patient education are essential.

The majority of men with urinary retention end up having a surgery to ream-out the prostate (TURP).  According to healthcare-salaries.com a suburban US urologist makes $500k to $1M each year.  This is another example of the decoupling of cost and quality caused by involving multiple providers with no common financial risk.

A proactive patient who has a catheter removed should ask the urologist “what is the plan if this does not work?”  and “is there some alternative to the ER since you have already evaluated me?”.  At least find out how to get in touch with the on-call urologist!

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The Most Powerful Treatment — walking

Moderate fitness is the most powerful treatment to prevent disease.  And, moderate fitness is easy to obtain.  Just walk 20 minutes a day.  People get very little extra benefit from more exercise than that!  The graph shows moderate fitness lowers your risk of death by about two thirds — and the extra years you get will have better quality.

The benefit of moderate fitness exceeds that of not having the following conditions:

  • smoking
  • high blood pressure
  • high cholesterol
  • family history of heart disease
  • overweight
  • pre-diabetes

So what worries you more?  Being a couch potato or having any of those conditions?  The couch potato is the worst.  This is not to say you should continue smoking — it means you need to BOTH exercise AND stop smoking.

The average American watches 5 hours of TV per day and many think the lack of activity it causes increases the death rate.  Just skip one TV show and walk instead to reverse the trend.

fitnessanddiseaseMany people say “I don’t have time” to walk 20 minutes a day.  The real question is “are those other things consuming your time really more important?”  If you are dead not much else matters.

A good primary care provider should ask you about your level of exercise and fitness at every visit.  A lack of fitness is the most severe health problem in the United States.  Health providers almost always check you blood pressure when in fact your level of activity is more important — let’s keep this in perspective.

Here is an absolutely wonderful YouTube video about fitness:

http://youtu.be/aUaInS6HIGo

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