Archive for category Patient Satisfaction

Over prescribing — high risk for the elderly

hugsnotdrugs

Elderly patients are taking too many drugs.  And, in most cases the drugs can be stopped.  This surprising idea was highlighted by Dr. Ezekiel J. Emanuel in his New York Times article 11/22/15.  He backed up his statements with a study from 2010 (JAMA).  The figures that follow are from that study.

The first figure is the logic diagram for stopping medications in elderly patients who have several chronic diseases.  The second figure is the list of medications that were stopped in the study.  Only 2% of the stopped medications eventually had to be restarted.  The cost savings alone is huge and the reduction in the risk of side effects is likewise tremendous.  “Less is more”.

Health care providers often prescribe drugs intended for younger healthier patients to older sicker patients.  Often the drug testing originally done to approve drugs excludes older sicker patients due to the risks of side effects.  A drug might add many years of life to a 50 year old but that’s not likely for an 80 year old with multiple problems.   In fact, over medicating elderly patients may hasten death — this has been proven in many studies.

Dr Ezekiel suggests asking the following questions to the health care providers who prescribe medications, tests or treatments to elderly patients (or perhaps any patients):

  1. What difference will it make?
  2. How much improvement is expected?
  3. How likely and severe are the side effects?

Evaluate the answers carefully, if the answers are: small difference, not much improvement, and fairly likely side effects then perhaps that drug, test or treatment is not needed.

Dr. Emanuel favors the advice of teaching hospital doctors like him, but it’s just not practical or necessary for patients to get a university consultation.  Stopping medications is not rocket science.  As the graphic says, it may be better for many elderly patients to get “hugs not drugs“.

 

Figure 1

drugstop

 

 

Figure 2

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More Clinic Visits for Diabetics — use the phone

stringphoneJune 3rd 2015 Kaiser Health News reported the ACA seemed to cause more provider visits for management of diabetes “More Patients, Not Fewer, Turn To Health Clinics After Obamacare”.   This is both good and bad.

The “good”:  more attention to a patient’s condition is likely to result in better diabetic management, fewer complications, fewer hospitalizations and longer life.

The “bad”:  since clinic visits can be billed to insurance, clinics make appointments and make money for each visit.  The payment for visits rather than outcome is expensive and a known problem in US healthcare (fee for service).  Diabetes can be managed over the phone in many, if not most cases — but there is no money for the provider in that approach.  Phone care has a much higher value for the healthcare system and the patient; but, low-cost high-quality (high value) care is not getting the incentive.

The care of diabetics is further compromised by the pharmacy.  A key piece of equipment for a diabetic is a glucose meter.  The manufacturer almost gives away the meter so they can make huge profits by selling the disposable test sticks.  The sticks are not interchangeable, not generic, sold in small lots, each lot sold with a co-pay, each lot requiring a visit to the pharmacy, and the use of gasoline to make the trip.  If you don’t have much money the speed-bump turns into a mountain.

The solution:  every few years mandate a generic test stick that manufacturers of glucose meters must support.  “Uncouple” the meter maker form the test stick maker.  And, sell the sticks in lots that last for at least 90 days, and that are sent to the patient by mail.   Adjust the payment to providers so that they must contact diabetics by phone to adjust medications at least 2 times per month in order to bill for a medium or high level clinic visit.  Also, each provider must obtain patient satisfaction data to prove the adequacy of service.

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Addendum:  Here is a link to an interesting court case about glucose meters

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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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Prescriptions — the missing manual

samplerx

The above prescription example comes from Medical School Headquarters intended as an example of what doctors should NOT do — that is to issue handwritten prescriptions.  There are just so many possibilities for error mostly coming from illegibility.  Also, errors from inadequate information provided to the pharmacist and the patient.

Electronic prescribing is unquestionably the best solution.  Patients should choose prescribers who use computer software to send prescriptions to the pharmacy.  In fact, prescribers who don’t use computers to do this are dinosaurs soon to be extinct — perhaps it would be a good time to leave that office practice and find something more modern.

You might think electronic prescribing solves all the problems, NOT SO.  Just ask any patient taking a few medications on a regular basis!  Here is what they say:

  • My office appointments never match when prescriptions expire –so I either have to change appointment times or hope the office will renew the prescription early — always involves a phone call and wastes my time.
  • I had no idea the doctor prescribed a brand name drug instead of a generic and I got hit with an unnecessary huge bill.
  • The doctor has no idea how much medications cost.
  • I need 90 day prescriptions for some things and 30 day prescriptions for other things but they can’t get it straight.
  • My doctor’s computer system can’t send things to my mail order pharmacy
  • I have to send prescriptions to my mail order pharmacy myself — usually they are the handwritten type and sometimes the pharmacy can’t read them.
  • If my doctor issues a duplicate prescription so it will last until my next visit sometimes I get more medication (and cost) than I need.
  • Often generic medications are less expensive if I purchase them without involving insurance — the pharmacist sure does not tell me that!

Here are some prescription suggestions for PATIENTS:

  • ALWAYS take a list of prescriptions with you to health care appointments (or just take the bottles, but there is a risk of loosing expensive medications in the process).
    • Your record should include the name of the medication (brand name if appropriate) and generic name
    • Dose — that means the size (mg) of the pills and number taken, or amount of liquid (ml) or strength (%) of a cream or ointment
    • How often taken and whether scheduled or as needed
    • Why the medication is taken
    • Number of doses of medication prescribed AND exactly how many days that covers (like 30 day supply)
    • When that medication will expire and need refill
    • The pharmacy phone number and FAX number (the latter is very important for mail order pharmacies)
  • ASK if a new medication is generic and if not if a suitable generic is available.  Or, if a suitable generic in the same drug family is available.
  • ASK if the medication is short term or long term.  If it is long term usually ask for 90 day supply with 3 refills (if insurance will approve).  And, use mail order services advised by the insurance company since they are usually less expensive.
  • BEFORE leaving the prescribers presence ask if the number of refills on a new prescription will last until next appointment?  And, ask for an extension of refills for older prescriptions that will expire before the next scheduled visit (otherwise you get the fun of calling the nurse for refills)
  • If a specialist prescribes a medication ASK if the specialist plans on long term follow-up and providing refills — if not what communication with primary care will convey the needed prescription information.  But, if the specialist plans on managing the medication expect a full review of all medications to avoid duplicate prescribing and adverse drug interactions.

Here are some prescription suggestions for PRESCRIBERS:

  • Consider the cost of medications — you can’t do that if you don’t find out how much they cost, especially the brand name drugs
  • Prescribe the lowest cost alternative.  Before prescribing a brand name drug ask if you are sure there is a real cost benefit over an older generic.  If you don’t know, find out.
  • Don’t prescribe antibiotics for viral infections
  • Think about refills, don’t just write some arbitrary number.  Make sure the patient has enough refills and will not have to call your nurse to get them.  Contrary to popular belief patients do not like to go the the pharmacy — give 90 day prescriptions where possible.
  • Have a patient Internet portal to deal with medication refill issues.
  • Although it’s nice to compute the number of pills a patient will need it is sometimes better for insurance reasons to say the number of days of medication is needed ( 7 days, 90 days etc.)
  • To avoid duplicate prescriptions when the patients prescription will not last until the next scheduled visit the following statement is helpful “extend existing active prescription so refills last until ____ “(e.g. a year from today).  Sometimes: “stop refills on current active prescription.  This is a replacement so note the changes.”
  • Most mail-order pharmacies will take either electronic prescriptions or faxed prescriptions — it is not rocket science to get those numbers into the electronic prescribing system — make it happen.

Finally, sloppy prescribing causes patient injuries, provider law suits, extra time, and extra costs for both the patient and the prescriber.  Electronic prescriptions are a step in the right direction but they are now mostly geared for pharmacists and not the real-world problems of patients.  The integration of pharmacies within care delivery systems (e.g. an ACO) is an urgent need.

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What Do You Like About Doctors?

lookout

Everybody complains about doctors or other health care providers.  But, according to a survey by Consumer Reports last year 75% of 49,000 people surveyed were very satisfied with their doctors.  If you search the Internet that view is not obvious (go ahead, try a search).

So, it should be easy to see what people like about health care providers since so many people like what they do (or at least some things they do).

Leave a comment about a very specific thing your health care provider, or surgeon, or specialist, or hospital or clinic really does well.

Ok, just a few rules:

don’t include names, don’t include things like personality or appearance or grooming

do include things that seem efficient, things that seem professional, a process that solved a problem quickly, comments that made you feel better, or anything that made you say WOW.

The intent is to let other people know what really good care looks like.

I will start the ball rolling — the first comments are mine.

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Shared Decision Making — shared with whom?

sharing

What is Shared Decision Making (SDM)?  It is a process for patients to make good decisions about tests, medications, surgeries and just about anything health care providers might suggest.  What it is, and what it is not — some examples:

A patient has frequent headaches and has a visit with a provider.

Scenario 1:  The provider says “a CT scan of the brain is needed, so get that done and come back for a follow-up visit.”  (Old school, doctor knows best)

Scenario 2:  The patient wonders if a CT scan of the brain would be a good idea to make sure there is no brain tumor.  The provider says “sure, the nurse will schedule it tomorrow.”  (Consumerism, do what the patient wants)

Scenario 3:  The provider says “there are a number of options including a trial of migraine medications or getting a CT of the brain.”  Then the provider gives the patient a handout that lists independent sources for additional information.  And, says “I will call you on Monday, after you have had a chance to review the information so we can decide what to do”  (Shared Decision Making)

Group Health Cooperative in Washington State has made a big push to support SDM.  The Group has made information available on the Internet to assist the patient for many common situations.  91% of patients who used the system found it “very important” or “extremely important”.  Click to see an Example of shared decision-making by Group Health Cooperative.

Pros and Cons:

  • The process takes longer than just doing what the provider says
  • Usually the SDM comes to a decision the patient will support, so they will follow instructions and treatments more than an average patient.
  • As long as the information reviewed by the patient is based on evidence based guidelines (well researched advice) then good decisions are possible.  And, usually the decisions are less invasive and less costly.

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Satisfaction VS Quality

The following is extracted from data presented by the Dartmouth Atlas.

 

Data about high ranking academic medical centers is plotted above.  On the vertical axis is the patients rating of their experience at the hospital — the higher the percent the better.  On the horizontal is the rate of a severe infection complication of tubes put in the veins (which should be taken out periodically) — the lower the rate the better.  The hospitals in the lower right have the highest rate of undesirable “line” infections AND the lowest rating by patients.  The hospitals in the upper left have the lowest rate of such infections AND the highest satisfaction.

The point is:  the hospitals are all over the map (poor reliability).  Worse yet, patients seemed to give some hospitals high marks for poor performance.   To be fair, very few patients actually get line infections so the negative effect on overall satisfaction is small.  It would be interesting to evaluate  satisfaction of patients who had line infections (if they survive).

So, you say, hospitals need to work harder.  That would be true but where are the guidelines for removing these problematic vascular catheters?  The CDC and others describe how to care for the catheters but leave it to “judgement” when to take them out.  The problem is “judgement” is not conducive to reliability.

Make a rule and follow the rule!  Sure there are exceptions, like it’s the last vein the patient has — judgement is when you state why you are not following the rule.  The specter of malpractice litigation is here.   Although the rule of law is doctors are not held responsible for a well considered judgement (which later may prove to be wrong) it often does not work that way in court.   So,  a good defense would be that a national guideline was followed — if it existed.

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