18 October 2013

This Blog Is Closing

It has been a short run this time, but my health if more important. I have enjoyed some of the topics and comments to them. I have really appreciated the emails and wish to thank those people.

I will keep my blog here up and operating, as long as I am able.


17 October 2013

Urgent Care Centers, We Really Need Them

Again, when something is needed, we see the primary care physicians (PCPs) lining up against them and in states with strong medical boards, they are being prevented from coming into existence. I am talking about urgent care centers (UCCs). With the shortage of primary care physicians, the strain on most hospital emergency departments (ED), and rising health care costs, these urgent care centers operate as a great convenience to non-emergency cases.

Since PCPs do not have evening office hours, this only seems reasonable that UCCs can fill a great need in caring for people not needing the services of the ED. In addition, costs are less than the ED. The PCPs are claiming that this is hurting their people and safety is an issue. Some providers believe urgent care centers disrupt coordination and continuity of care. I say to these providers, then have practices that are open 16 hours per day, 7 days a week and there would not be the need for UCCs.

Others believe the concerns of PCPs may be overstated, given urgent care’s focus on episodic and simple conditions rather than chronic and complex cases. In the future, health coverage expansions under the national health reform may lead to greater capacity strains on both primary and emergency care, causing even more growth of urgent care centers. Hospitals view urgent care centers as a way to gain patients, while health plans see opportunities of containing costs by steering patients away from costly emergency department visits.

UCCs are not designed to handle car accidents or resuscitate patients at death's door, but they do treat minor injuries such as cuts and minor fractures, as well as the ear infections and strep throats of primary care. The Urgent Care Association of America puts the number of UCCs at 9000, with physicians or physician groups owning 35% of them. In addition, corporations own 30%, hospitals own 25%, and non-physician individuals or franchisors own 7%.

Rapid expansion of UCCs is often attributed to such factors as long wait times for primary care appointments, crowded emergency departments and patient demand for more accessible care, including after-hours appointments. UCCs provide care on a walk-in basis, typically during regular business hours, as well as evenings and weekends, though not 24 hours a day. UCCs commonly treat conditions seen in primary care practices and retail clinics, including ear infections, strep throat and the flu, as well some minor injuries, such as lacerations and simple fractures.

UCCs generally are not equipped to deal with trauma, provide resuscitation or admit patients to a hospital, all reasons for seeking ED care. UCCs are typically staffed by physicians, generally with backgrounds in primary care or emergency medicine, and some have nurse practitioners or physician assistants working under physician supervision.

Patient demand for more convenient access to care reportedly has increased, prompting renewed growth in urgent care centers. According to a recent study, approximately 60 percent of patients with a usual primary care physician (PCP) reported that their PCP practices do not offer extended hours, suggesting a niche for urgent care centers to fill.

16 October 2013

Patients Hurt by Biased Research

Yes, this goes without saying. The actions of our pharmaceutical manufacturers is almost criminal, no it is criminal. I say this because once the drug is approved for one use; the drug reps are promoting it heavily for “off-label” uses. Then they get FDA approval for these “off-label” uses and doctors happily promote their use and even have the philosophy that more is better.

This blog by Dr. Kenneth Lin, carefully lays out how pharmaceutical manufacturers convince doctors to overuse many drugs often to the harm of patients. He uses two common drugs that this has happened to, anemia drugs (Epogen, Procrit, and Aranesp, which mimic the actions of the hormone erythropoietin) and the diabetes drug rosiglitazone (Avandia). These two drugs were featured in recent articles by Peter Whoriskey in the Washington Post. The anemia drugs were developed to spare dialysis patients with severe anemia the inconvenience and risks associated with periodic blood transfusions.

Whoriskey also found that pharmaceutical companies moved aggressively to put these drugs into use in a far greater patient population, including those less likely to benefit from them.

The trouble would arise as the drug makers won FDA approval for vastly expanded uses, pushing it in larger doses, for milder anemia and for patients with a wider array of illnesses. Very quickly, the market included nearly all dialysis patients, not just the roughly 16 percent who required blood transfusions. The size of average doses would more than triple. And over the next five years, the FDA would approve it to treat anemia in patients with cancer and AIDS, as well as those getting hip and knee surgery.”

Doctors became motivated to give more doses of these drugs because the pharmaceutical companies were offering greater incentives, estimated between $100,000 and $300,000 annually for an oncologist. This created a seductive atmosphere and caused doctors to think if some of the drug was good, more had to be better. No checks were done and over prescribing continued.

Not until 14 years later did an independent researcher obtain access to the complete study report from the FDA and conclude that the NEJM authors had used statistical slight-of-hand to obscure an increased risk of heart attacks and death in the normal-hematocrit group. In the meantime, lobbyists working for the drug manufacturers successfully blocked efforts by Medicare administrators to stop paying for the higher (harmful) doses.”

This was the same tactic used by Glaxo Smith Kline in their promotion of Avandia and the manufacturer successfully stalled regulatory action in the US for three years, during which thousands of new patients were prescribed the drug.

This leads to the conclusion that the role of FDA members were to blame and let huge conflicts of interest stand in the way of protecting the public. The system of rotation from FDA to the pharmaceutical industry and them back to the FDA needs to stop and this should be outlawed with severe penalties for employees that do this. The next issue is passing a law that pays the salary of the FDA employees and pays for the supplies and operations to prevent pharmaceutical companies from having to kick in large sums of money to pay for the approval of their drugs. This practice also needs to be against the law with larger fines levied. These fines should be large enough to prevent companies from bribing FDA officials.

15 October 2013

Hospital Protocols Hinder Care

Hospital protocols do hinder and actually harm patients. I had a hard time believing the first part of this doctor's blog until I realized he was not joking. My next thought was why a hospital would treat a doctor in this manner. I would have guessed that a doctor and even a doctor's family would be expressed to the head of the line. I am happy to see that they receive the same poor treatment as the rest of us.

It is a shame that a few patients have required the need for hospitals to enforce strict protocols such as name and personal information before treatment can start. I understand the need for medical information to avoid allergic reactions and medical complications with medications the person is already taking. Yet, patients often arrive unconscious and unable to communicate and they are treated. I can appreciate the need for triage as the most serious patients should go to the head of the treatment line and that should never be disputed. Even this gets complaints from those that feel they are totally privileged and better than the rest.

In a way, it is probably the most fun way to spend a day sitting in an emergency department. It is surprising what happens and does not happen. This happened by accident one day when my daughter injured herself and my wife had taken her to the emergency department. I got there as soon as I was notified, but was refused to see my daughter because she was in treatment. After treatment was completed, I did not see my wife and daughter being moved to the hospital room since the exit used by patients was not visible from the waiting area, which I had been moved into.

This was before cell phones. There were mobile phones, but few people could afford them. So there I was, probably less than 40 feet from my wife and daughter and unable to have anyone look for them. In some ways, this seemed to be a hospital trick to keep families separated. Finally two of us decided to leave the emergency department and go into the hospital since we had not seen any of our families leave. Yes, both of our families had members admitted and we were not notified. For some reason they would admit that my daughter had been admitted to the hospital, but would not tell me which room. If it were not for my wife entering the hallway and upon seeing me, coming to get me, neither of us would have known. It turned out that his wife was in the same room as my daughter.

After some time we were able to convince our wives that we had been there since before noon and been told that we would see them later. The other fellow even guessed that they had been told that they would be informed when we arrived. I finally had to take my wife and his son down to show them the room where we had been kept. Still waiting were five other people that had been there at the time we were there. My wife knew one of the individuals and where his son was in the hospital and the rest were advised to start looking elsewhere in the hospital.

At that point, a nurse came by and asked that everyone be seated and quiet. I am afraid I was less than polite when I asked why we were being denied access to our families. I was told that they did not want too many people in the exam rooms. I said that we were still kept in the dark when our families were moved into the hospital. They were told they would be notified when we arrived, when we had been here for some time. At that point one of the doctors walked by and could tell we were very upset. He wanted to know what was happening. My wife spoke up and said the nurses were causing family stress by separating us from our families. Instead of notifying us when discharged from the ER or admitted to the hospital, those that had been diverted to this room were not informed.

One of those was an executive for a large area corporation and large employer and said that all contributions to this hospital would stop immediately. Several others wanted to know who was responsible for this and that the nurses on duty should all be removed from their jobs. To this, I added the nurses that would not tell us where our families were in the hospital. The doctor finally got quiet and called the administrator to the room. It took another hour to sort things out and supposedly get protocols corrected. The executive said that he was sticking by his word since people were not being held accountable for the mess and with the attitude of the staff could not be ignored. The administrator wanted a private meeting, but the executive said this would be an attempt to hide things from these families. Everyone was taken to the nurse station to find out if their relatives were admitted and even with the administrator telling them to get the information; it took almost 30 minutes, as it was clear, they were dragging their feet.

The local newspapers were notified and six months later, the hospital was sold to another hospital and policies changed. It was fortunate that our family did not need to use that hospital again and moved to another town about four months later.

I would encourage everyone to read the blog by the doctor here and another doctor about that doctor's blog here. It is a shame the protocols established by some hospitals cause more stress and harm to families than good will.

14 October 2013

Is All the Dementia Screening Necessary?

Before getting into this blog, I would like to include some points that the World Health Organization (WHO) has in their guidelines about assessing the value of a screening test.

#1. The condition should be an important health problem.
#2. There should be a treatment for the condition.
#3. Facilities for diagnosis and treatment should be available.
#4. There should be a latent stage of the disease.
#5. There should be a test or examination for the condition.
#6. The test should be acceptable to the population.
#7. The natural history of the disease should be adequately understood.
#8. There should be an agreed policy on whom to treat.
#9. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
#10. Case finding should be a continuous process, not just a “once and for all” project

The above are guidelines worthy of remembering and applying to many topics about screening. In the US, professional medical organizations and government agencies are making the determination of what screenings should be accomplished and many times when they are to be done. In my research, I have not discovered where the WHO says to harm patients to do the screening, create a stereotype that mandates screening, or order very costly screening for the sake of screening with little or no scientific evidence to back the screening.

Yet we have screenings happening based on the three items mentioned above that professional organizations and government agencies think need to be done. Other types of screening are not done because government is not mandating them and many of the doctors would not be current enough to know what to do if the screening result was positive.

The latest screening being mandated seems to be for dementia. This screening includes all types. I have to agree with one author that many of these screenings are poorly designed, poorly thought through, and often damaging or harmful to the frailest patients. However, with the government behind this and several of the medical associations, this will be difficult to stop.

11 October 2013

Urban Gardening, The Challenges

As more of us people with diabetes are told to eat more fresh produce, our supermarkets know that we are looking for fresh produce. Even then, the produce is several days old and not truly fresh as the grocery chains would like us to believe. Three or more days old are not fresh any longer. What are we to do if we don't live on an acreage and do our own gardening?

I wish I could do just that and be able to garden, but apartment living does not allow this to happen. Even the owner of the building won't allow gardening in the manicured lawns. No one near us will allow gardening and this means traveling to surrounding farms, which even many of them don't want. I finally located one farmer where we can get fresh eggs and some produce during the summer, but not enough to satisfy a family of two. Plus, the selection is limited to what they don't or can't process and not what some of our choices would include. This means no beans, no peas, and many other of my choices of vegetables. Plus many of the selections are past their prime when we are notified to come and harvest.

May I am just used to too many years of good fruits and vegetables harvested at their prime and canned or frozen beyond what we consumed in our daily meals. Mother and Dad always planned the plantings to spread out the harvest and prolong what we had fresh for the daily meals. Plus the canner was always kept busy once harvest started and the prime picking was for the daily meals or frozen.

This article was a pleasant surprise to find; however, many will not gain from this, but still is an interesting article even with the hazards it brings out. The concept of local food and urban gardening is gaining popularity as urban agriculture, with its benefits and obstacles, and is coming to many cities.

The benefits of urban agriculture are many. Urban gardens are often built on previously unused lots, increasing the beauty and value of the neighborhood. They provide recreation opportunities and a social network for the gardeners involved. Urban food production also means that healthy, fresh produce is readily available to city dwellers.”

The challenges that organizers and growers face need to be understood and conquered if urban gardens are to take hold and even be profitable. Many of the obstacles, planners and growers face include soil contaminants, water availability, and changes in climate and atmospheric conditions.

Of the contaminants found in urban soils, lead is the most prevalent. Even though there is concern about plants taking up lead from the soils, research shows plants take up very little and in fact, it is less than we are exposed to from drinking water. Practices such as washing food before eating and covering soils with mulch can decrease these risks. Finding reliable and safe water sources can be difficult for urban gardeners. Using drip irrigation that will deliver water where and when it is needed can conserve water.

10 October 2013

Can You Deal With the Elephants in the Exam Room?

First, it is necessary to identify the elephants that a discussion is hard for providers and patients to talk about with ease.

#1. Sex
#2. Costs of care
#3. Alternative treatments
#4. Advanced directives
#5. Digital technologies

I find I have no trouble in discussing any of the above or more, but studies show that they are often difficult for providers and patients to talk about and many just won't consider talking about them.

The first item above is important for both men and women with diabetes for a variety of reasons. Men often have sexual dysfunction or erection dysfunction quite often and this can affect how they feel about diabetes. In looking for studies, there are a few, but not worth the time because most are less than 10 men. Women have other problems and often dislike having sex because of yeast infections and often dryness making sex painful.

The second item above is very difficult to get providers to talk about because often they are not totally aware of what the actual costs are when providers are employed by the hospital. Hospitals have so many extras that are tacked on to a charge to get more from the insurance companies and/or Medicare/Medicaid. There are at least three free apps, which address health care costs.

The third item above is more difficult for patients because they are afraid of the reactions they will receive from their provider. Once the diagnosis is received by the patient, some will consider having the treatment prescribed by their provider, but others would like to consider complimentary treatment, which may include holistic, neuropathic, or homeopathic regimens. Often they won't discuss these with the doctor because they know from past experience that the doctor will ridicule them and dismiss the treatment. Often they just take the prescription or prescribed treatment and go to another doctor that will provide these.

The fourth item above is probably one of the more contentious topics as many providers just hand out papers to have the patient check the boxes for the advance directives for end of life care to meet federal mandates. In these situations, many patients just ignore these. If they are like me, I have seen physicians, hospitals, and families ignore the wishes of the patient and do what they want done, even with the advance directives on file. I have even seen family ushered out of a parent's room so they can follow their own policies against the directives.

The fifth and final item above is about mobile technologies. These can improve the doctor-patient relationship, but even then, doctors do not want them around and will ignore their use. Many patients use the internet and this often causes physicians to see this as a threat to them and upsetting the balance of their relationship with the patients. Fortunately, times are changing and with both shared decision making and digital health technology in present popularity, physicians are often forced to deal with this or lose patients.

Now it becomes necessary to state that both providers and patients need standards that medical app developers can follow. If they are reliable and effective digital tools, they can help prevent the elephants from being in the exam room discussion instead of making the elephants presence larger.

While the above discussion may not include all the elephants, often once they are recognized and the provider brings them up with the patient, they disappear and the tension is relieved. Often a partner or a caregiver can be the one to start the conversation and they can be the ones to carry these discussions. Read a doctors interpretation and thoughts about this topic here.