Archive for category The Proactive Patient
Many patients take too many medications which leads to unnecessary side effects, drug interactions and high cost. Yet physicians sometimes fight just to get patients to take necessary medications. Two examples:
- Provider: How many medications are you taking?
Patient: Including vitamins I think fifteen.
Provider: What? I only have two medications on my list.
Patient: I restarted all the medications I was taking before you hospitalized me plus all the new prescriptions from when I left the hospital and I added some vitamins.
- Patient: I stopped that medication because I thought it was causing my hair to fall out.
Provider: Your heart medication does not cause hair to fall out. And, even if it did you could die without it.
The medications you take should be reviewed at each visit so you and the provider consider which are truly needed and why. The provider who gives the patient a prescription is responsible to make sure there is no interaction or duplication with ongoing treatment. Yes, that means cardiologists and dentists also. A proactive patient should simply ask, “Is that new medication compatible with all of my existing medications and does it replace one of the existing medications?”
The highest risk situation for evaluation of medications happens when alternate providers become involved. Like a hospital doctor, an ER doctor or a specialist. They tend to add medications without fully considering the existing medications, often thinking the primary provider will resolve any drug issues — too bad when a fill-in primary provider steps into the mix.
An article in the Washington Post January 28, 2017 by Dr. Ranit Mishori advises the following questions for providers and patients to consider together about medications:
● What is this medication, and why am I taking it?
● Are there non-pharmacologic options to treat this condition?
● How long do I need to be on it?
● What are the benefits of continuing to take it?
● What are the possible harms of using that medication?
● Do any of my medications interact with any another?
● Can I lower the doses of any of these medications?
● Which of my medications are more likely to be nonbeneficial considering my age, my other medical conditions and my life expectancy?
● Are there any medications I can get off completely?
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):
- What difference will it make?
- How much improvement is expected?
- 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“.
DON’T GET AN ANNUAL EXAM. The data are clear — see the recent article in the New England Journal of Medicine and the op-ed in the New York Times — perhaps you missed this counter-intuitive health advice?
Mechanical devices need preventative maintenance. The aircraft mechanic in the illustration prevents engine failure by checking and replacing parts before they go bad. He knows the MTBF (mean time between failures) for the various engine components. You would think this is how the human body works but THAT’S NOT TRUE. You don’t take out an appendix like a spark plug just because they sometimes go bad — you fix it only when needed because surgery hurts and has complications.
One third of the US adult population get annual physical exams and primary care doctors spend 10% of office visits doing those exams. Sound research shows the annual physical is not needed and worse yet, may be harmful because of false positives (tests that say something is wrong but later are proven wrong). It’s the very essence of a false positive — an abnormal test in a healthy person! You know where that leads: “we need to do some additional tests or a biopsy” — just hope it’s not a brain biopsy.
The US healthcare system needs the wasted 10% of primary care time elsewhere. It’s totally crazy — doctors doing unnecessary annual exams that clog up the appointment calendar and make it hard for people with actual problems to get an appointment. And, a large number of people have health problems who don’t see health care providers when they should (but that’s another story)!
Doctors like to do annual physicals — it’s nice to visit with patients and not have to make any hard decisions. And, they make a lot of money doing the exams under the guise of “maintaining a relationship”. But, the exams are not needed.
A proactive patient would make health care appointments as needed for the following:
- Annual flu shot
- Tetanus vaccination every 10 years.
- Cholesterol test every 5 years
- For women over 40 a pap smear every 3 years and a mammogram every 2 years.
Do you really need to have a health care provider tell you the following things, or is this list enough?
- DO keep weight in normal range (BMI below 25)
- DO walk 30 minutes every day
- DO wear seat belts
- Don’t use drugs or alcohol
- Don’t smoke
- DO Check blood pressure every year (automated checks are just fine)
- DO see a health care provider if you have a health problem.
Keep in mind this discussion is about an exam for nothing in particular — just a “check-up” — which you don’t need. On the other hand, a patient needs visits with a health care provider to treat and monitor abnormal conditions. You need routine visits to adjust blood pressure medications, to treat diabetes, to treat acne and to evaluate arthritis.
Kudos to Consumer Reports for the article on the over-use of antibiotics “How to Stop a Superbug” in the August 2015 issue. One of the most common reasons people see primary care doctors is cough. And, as it turns out, most of those coughs should NOT be treated with antibiotics. Of course, it does not mean they do not need treatment — just not with antibiotics since the cause is usually a recent viral infection. Antibiotics do nothing for viral infections.
Doctors who inappropriately treat a cough with antibiotics often do so just to get the patient out of the office as quickly as possible. Statements like “could be early pneumonia” or “I hear some pneumonia” or “you have bronchitis” is the politically correct version of “you will get over it, take this pill and don’t bother me”.
So what is going on? A virus irritates the lining of the bronchial tubes. The tubes become inflamed and overly sensitive, causing the symptom of coughing. Coughing is bothersome, it keeps people awake at night, makes noise at work and after a while it hurts the ribs and chest — it’s super irritating — please get rid of it!
The bottom line is that a virus infection causes a temporary form of asthma. Doctors have hesitated to make that diagnosis because once you say “asthma” it is like a life-long diagnosis — in fact, it could have been a reason for an insurance company to deny coverage in the past. So, by avoiding the “a”-word adequate treatment is not offered. Anti-asthma treatment really works! and it is almost always a temporary treatment (unless the person really does have typical asthma).
Why a researcher would do such an experiment is not clear but they have compared the benefit of antibiotic treatment versus an asthma inhaler for “acute bronchitis” and found the inhaler works better — duh — treating a virus with an antibiotic is a placebo treatment.
Cough after a viral infection, particularly influenza, can last a long time, sometimes months, even though the virus itself is gone. And, when people have a long-term cough other diseases need to be considered. A cough that lasts for more than a few weeks usually needs to be evaluated with a chest x-ray as a precaution.
Many times a long term cough is the result of ineffective treatment — the failure to prescribe adequate inhaled medication to begin with. Sometimes, it is the failure of the patient to have the prescription for the inhaled medication filled (it’s expensive) and sometimes it is a failure to take the inhaled medication correctly.
Very few doctors explain how to take an inhaled medication — it just takes too long, and they expect the pharmacist to do that. Sadly, the pharmacy tech who hands out prescription has no idea how an inhaler should be used — and the pharmacist is not much better. Proper technique (click on the link) is critical for the medication to work.
What inhaler is best? — there are several to choose from. Check your insurance formulary for a combination product containing both a steroid and a bronchodilator. There are no generics in this class of prescription drugs and that is another story! Some choices include Dulera, Advair, and Symbacort (there may be others depending on what country you live in).
Again, thanks to Consumer Reports. But, they did omit the obvious question for a cough: if you don’t take an antibiotic for a cough, exactly what do you do? If it’s mild, cough-drops and nasal decongestants are helpful, but if it is a bigger problem an anti-asthma inhaler is often a huge help. Be proactive, tell you doctor you don’t want an antibiotic for your cough but you do want an asthma medication — bring this article with you.
One 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!
Hospitals 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).
- 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.
- Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
- Educate staff that IV fluid is not a cure-all. Fluid would help a dehydrated patient but not others.
- 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.
- 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?
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!
- 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.
If 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:
- Serum Creatinine (Cr) as measured on a blood sample.
- Your age (in years)
- Your race (black or not-black)
- 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 calculator. The 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.|
|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.
Slow the progression.
Find and treat complications.
|Check hemoglobin and Iron — keep in satisfactory range.|
|Check calcium, phosphate and PTH — keep in satisfactory range.|
Referral to nephrologist.
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.
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.
Nancy Morden MD MPH with others from the Dartmouth Institute for Health Policy and Clinical Practice published a nice “Perspective” in NEJM 3694;4:299-302. The essence of the article is the observation that published goals of treatment which don’t specify how to reach the goal lead to prescribers” jumping the gun” with strong expensive medications rather than a prudent step by step approach.
A good example from the article is controlling blood pressure. Guidelines state the desired blood pressure goal is less than 140/90. Prescribers tend to skip dietary management, skip lowering the salt intake, skip reducing alcohol consumption and jump right to strong blood pressure medications (with the attendant drug allergies, risks and costs).
Another criticism is stopping a medication too soon. The example is beta-blocker medication after a heart attack. It is not enough just to start the medication. The medication must be continued indefinitely. Too often the medication is stopped because the reason for starting it is forgotten.
Here are the areas the authors found problematic:
- Blood pressure control
- Cholesterol management
- Diabetes control
- Clot prevention for occlusive vascular disease
- Lipid control for coronary artery disease
- Long term beta-blocker after heart attack
- Avoidance of antibiotics for acute bronchitis
- Drug use generally in the elderly
From the patient standpoint: if a health care provider says you have some condition or diagnosis make sure to ask for a step-wise approach to treatment. In other words, ask for simple or less expensive things to be tried first. Then insist on follow-up to see if the first steps work. If the simple things work, you win. Make sure to research the diagnosis on the internet to exhaust the simple and low cost alternatives. Later, if the simple things are not enough move on to the next step.
There are obviously situations where a slow cautious approach is not correct. If you are having a heart attack or a stroke or a blood clot it’s too late to do simple things.
Make sure to understand how long a medication might be needed — if it is “until something better is found” then stick to it and make sure the providers give a good reason for stopping (particularly if you change providers).