Hospitals Sharing Patients Spreads Bacteria

This isn't funny, but I had to laugh about how ironic this is after having written this blog about hospital greed. With some hospitals now gaming the system, they are creating some of their own problems with bacteria that are antibiotic resistant. Although not part of this study, I now understand why Methicillin-resistant Staphylococcus Aureus (MRSA) is spreading so rapidly and a recent New York City Hospital outbreak became so severe. Maybe hospitals that are gaming the system will pay more dearly and not be able to keep up with the diseases they are spreading.


This study is about the spread of vancomycin-resistant enterococci (VRE) in regional California hospitals (Orange County) and how fast it spreads. Although slower in general than MRSA, it is spreading when hospitals share patients. Maybe it is time for the Centers for Medicare and Medicaid Services (CMS) to investigate and relax their 30-day readmission restriction. This might reduce the speed with which MRSA and VRE are being spread. Then the hospitals could worry more about bringing these back into their own hospitals.


The researchers obtained 2006-2007 patient level admission and transfer data for all 29 adult acute care hospitals (3 children's hospitals were excluded) in Orange County (serving a total population of 3.1 million). Of the 29 hospitals, five are long-term acute care facilities (LTACs), which primarily treat patients who have prolonged high-level medical needs. The data included length-of-stay (LOS), location where patient was admitted from or discharged to, and an encrypted patient identification code that allowed researcher to track patient movement between hospitals. The model was constructed using probabilities generated from this real-world data by calculating hospital-specific proportions of 2006 patients discharged to the community, transferred from each hospital, or readmitted within 365 days.


The full study may be read here. It is studies like this that can poke holes in what CMS does and makes rules harder to cut the number of readmissions to hospitals. Until CMS can get hospitals and other care facilities to increase their safety standards, we will continue to see the spread of more diseases and even more severe resistance to antibiotics. Until hospital boards get on board with safety measures, this will only get worse.


The safety standards are many, but one of the most common is the lack of hand sanitation by doctors, nurses, and other hospital employees. I will not say one group is worst than the other because they are all lax and seldom wash their hands. The next area is the lack of equipment sanitation. I have never seen a stethoscope, a blood pressure cuff, or other piece of equipment that is used patient after patient go through any sanitation or cleaning. I hate to think of the cost involved, but maybe patients will need to start asking to have this equipment be removed from a sealed cellophane container before it can be used.

A New National Sport – Doctor Bashing

One doctor feels she has a way to stop doctor bashing. I dislike having to tell her that doctors have opened themselves up to this and created their own problems by patient bashing to the point that there is no return. I don't like doctor bashing, but after having been the victim of patient bashing, I don't really care any more.


Yes, it is unfortunate that a profession whose members were once held in high esteem in their community has now become the new national sport called doctor bashing. In this era of new technologies and highly improved communication devices, it is a shame that communications between doctors and between doctors and patients has become so neanderthallistic. Doctors and patients alike, have been trying to blame the system, but I do not believe the system has any part in the bashing.


I think that the rapidly improving communication technologies, cell phones and the internet, are making people realize just how imperfect and human doctors are. This realization is causing the pedestals their own medical profession loves to make them think are built just for them, to come crashing down around them. When statistics show that annually, many thousands of medical errors happen to patients both inside the hospitals and outside in physician practices, we no longer have a need for the pedestals.


Dr. Carla J. Rotering, is right that the training, knowledge, and skills are higher than they were several decades ago when everyone thought well of their doctors. What she overlooks is the explosion of information in the last 15 years and the level of public communications improvements. When we think about television news channels, news programs, cell phones, and the internet social media and internet medical information, it is not surprising that we will no longer accept that doctors are slipping in their education and especially their continuing education to stay current with many of the illnesses and chronic diseases. By not referring complex patients to more knowledgeable doctors in many cases only adds fuel to the doctor bashing.


We as patients see and hear of doctors that are bad doctors, just moving from one state to another state and are back in operation. We even hear of doctors moving from one hospital to another hospital and continuing the same bad medical practices because the hospitals do not perform their due diligence. So is it any surprise that doctor bashing has become the national pastime. This is the only way we are able to apply pressure to rid ourselves of these doctors. I appreciate the TV shows that highlight the abuses of hospitals and physicians that feel they are above the law because they feel that the medical errors they caused are of no consequence to the overall grand scheme of things.


We as patients can no longer rely on state medical boards to do their due diligence when complaints are lodged because of the protection they provide to all doctors. So is it any surprise that television stations and newspapers are provided information so that they can investigate and possibly uncover more than one patient can discover.


The following are some of her suggestions for those that feel healthcare is getting a bad rap:


#1. Have the courage to speak up and promote the positives about our system, hospitals, and providers. This is difficult when we see the greed in our hospital systems and our medical insurance carriers. They are both seeking higher and higher profits by their administrators and CEOs so that they can ask for higher and higher salaries and bonuses. They often dictate the actions of physicians.


#2. Continue to express compassion to friends and family who have suffered disappointments with their healthcare providers without joining the bash. The blameless apology works really well. “I’m so sorry you had such a painful experience.” A great idea, providing it is well placed and rightly justified. Most may well be justified, but be sure that there is nothing more to be concerned about. If this is an isolated case, no problem, but if you are hearing a pattern, proceed with caution.


#3. Promote empathy for the challenges physicians face. Help to educate others about the pressures on physicians in today’s turbulent environment. Also a great idea, provided that the physician is doing their best to stay current and when they are not current, referring patients to doctors that are current instead of doing what many doctors do by thinking they are all that the patient needs and follow bad advice from the organizations they listen to. Example: Diabetes for which doctors have a difficult time staying current and so follow the American Diabetes Association and stack one oral medication on top of another oral medication when the patient might be better served by using insulin.


#4. Thank, appreciate and recognize those physicians who exemplify the Hippocratic Oath and are truly patient-centered in their approach. If the doctor is truly patient centered and doing no harm, then this is the proper thing to do and I support this as well.


#5. Do your part in making your organization a caring community in which everyone, including physicians, feels supported. If everything else is positive, then do your part to be positive and supportive of the physicians.


In many cases, it is possible to be positive. I have recently experienced some of the downsides in physician actions and therefore I am probably over cautious.

Salsalate for Diabetes?

Part 3 of 3 parts


This is in three parts because there are too good points and some information that is not being given out in the high praise for diabetes and this will be necessary for your doctor to determine before you could be given salsalate, if the FDA approves it for diabetes. It is currently being used to treat cancer, osteoarthritis and rheumatoid arthritis, which gives us a plethora of information.


In October 2010, I wrote a blog about salsalate in which I did find a lot to be concerned about and why it may not be right for diabetes. Again, the same researcher at Joslin Diabetes Center, Dr. Allison Goldfine, has another article out on research she has been doing on salsalate. In the first study for 14 weeks, she could only get a 13 percent improvement in blood glucose readings for people with type 2 diabetes. C-reactive protein concentrations (a marker of inflammation) showed improvement of 34 percent. In Stage 2, she is saying salsalate has a 37 percent improvement in blood glucose results in 48 weeks.


Salsalate is an inexpensive means of treating and/or reducing the risk for diabetes in obese young adults by reducing glycemia and lowering inflammation. This is one of the largest benefits. It will be interesting if it can pass the heart disease progression tests which FDA will want proof of before granting its use for diabetes. The highest dosage given in the both stages is 4 grams per day of salsalate.


Stage 1 of TINSAL-T2D (Targeting Inflammation Using Salsalate in Type 2 Diabetes) evaluated varying doses of salsalate in 108 participants with type 2 diabetes for 14 weeks. This study was reported in the Annals of Internal Medicine in 2010. The current findings are based on Stage 2 of TINSAL-T2D, which evaluated 286 participants with type 2 diabetes for 48 weeks. The subjects' blood glucose was inadequately controlled on current diabetes medications. Participants were randomized into salsalate and placebo groups. All patients were continued on the medications they entered the study taking. Participants in both trials using insulin, thiazolidinediones, glucagon-like peptide-1 agonists, NSAIDs, warfarin, or uricosuric agents were not eligible for the study. Reading the warnings shows that these would have severe adverse effects on the study participants.


What is surprising is that patients up to age 75 were included in both Stage 1 and Stage 2 of the study. This will be valuable information for clinicians when the trials are completed and if FDA gives an approval. Maybe, just maybe, some researchers are seeing the need to include the elderly.


Dr. Goldfine is currently leading a heart disease study named TINSAL-CVD to evaluate how salsalate impacts coronary artery plaque volume in patients with established coronary artery disease. The trial results should be available in two years and then we may know if salsalate is a safe drug for use as a diabetes medication. It will be interesting if it can pass the heart disease progression tests which FDA will want proof of before granting its use for diabetes.


Dr. Goldfine was kind enough to send me copies of both studies which is helpful in understanding the more than the Medical News Today was saying that the studies may provide additional evidence that salsalate may be an effective drug to treat type 2 diabetes. One aspect of this is that very few other diabetes medications will match up for stacking medications.


I am looking forward to the end of the latest trial and just how it will fare, which other oral medications it will be allowed to be used with, and if doctors will be issued enough information to prevent problems.

Salsalate for Other Diseases and More Cautions

Part 2 of 3 parts


Because salsalate if being required to undergo testing for cardiac safety, it seems obvious that this has not been done for prior approvals for other diseases. These diseases and health conditions include cancer, knee pain, rheumatoid arthritis, osteoarthritis,bursitis, foot pain, and arthritis. It is also used to treat pediatric Crohn's disease and inflammatory bowel disease (IBD).


Salsalate (Amigesic, Salflex, Argesic-SA, Marthritic, Salsitab, Artha-GDisalcid, Disalcid)(Note: Disalcid is no longer available in the U.S.) is a nonsteroidal anti-inflammatory medication (NSAIDs). Never use these NSAIDs when a woman is considering pregnancy or pregnant unless prescribed by a doctor and under a doctor's close supervision. Nursing mothers should stop nursing while taking salsalate or use alternate drugs. This is because salicylic acid appears in breast milk at levels close to maternal blood levels and this may cause adverse effects in the infant.


Yes, I have repeated some information from part 1 because this is important. Presently salsalate is as strong as aspirin in reducing inflammation, but it has less effect on blood clotting than aspirin does. Salsalate is available by prescription in tablets of 500 mg and 750 mg.


Store salsalate at room temperature (59 to 86 degrees F.) and it is wise to store it in a dry place, meaning bathrooms and kitchens are out. The usual dose is 3000 mg daily and this is done two to four times over the day. Always take salsalate with food to reduce stomach upset. Do not add aspirin to salsalate as this will cause salicylic acid toxicity.


Nonsteroidal anti-inflammatory drugs (including salsalate) may rarely increase the risk for a heart attack or stroke. This effect does not apply to low-dose aspirin. The risk may be greater in people with heart disease or increased risk for heart disease (e.g., due to high blood pressure, diabetes), or with longer use. This drug should not be taken right before or after heart bypass surgery (CABG). Also, this drug may infrequently cause serious (rarely fatal) bleeding from the stomach or intestines. This bleeding can occur without warning symptoms at any time during treatment. Stop taking this medication and seek immediate medical attention if you notice any of the following rare but very serious side effects: chest pain, severe dizziness, weakness on one side of the body, sudden vision changes, slurred speech, black stools, persistent stomach/abdominal pain, vomit that looks like coffee grounds. Bold on diabetes above is my emphasis and helps explain why it is going through the additional cardiac testing.


This medication may interfere with certain laboratory tests (including certain urine glucose tests, thyroid hormone levels), possibly causing false test results

Salsalate Warning and Cautions

Part 1 of 3 parts


This is in three parts because there are many good points and some information that is not being given out in the hype for potential use for treatment of diabetes. This will be necessary for your doctor to determine before you could be given salsalate; if the FDA approves it for diabetes, (This is at least more than two years or more from now). We are fortunate that this has been around for centuries and in wide use in the last century, because we are aware of the side effects. It is currently being used (FDA approved) to treat cancer, osteoarthritis and rheumatoid arthritis which gives us a plethora of information.


This source covers the side effects and what to be alert for with salsalate. These are important enough to quote:
“Before taking this medicine
Tell your doctor…

• If you are allergic to anything, including medicines, dyes, additives, or foods.
  
• If you have any medical conditions such as asthma, nasal polyps, allergies, high blood pressure, kidney disease, liver disease (including hepatitis), stroke, high cholesterol, diabetes, or heart disease. These conditions increase the risk of side effects from or reactions to salsalate.
  
• If you have ulcers or other stomach problem. Salsalate can worsen these conditions.
  
• If you drink more than 3 alcoholic drinks per day. This can increase your risk of side effects while taking salsalate.
  
• If you have gout. Salsalate may worsen it and also decrease the effects of some medicines used to treat gout.
  
• If you have congestive heart failure or fluid retention (swelling, usually of the legs and feet). Salsalate may worsen this problem.
  

If you are pregnant, trying to get pregnant, or if there is any chance of pregnancy. There may be an increased risk of harm to the fetus if a woman takes this drug during pregnancy, especially during the last few months.

• If you are breast-feeding. Salsalate passes into breast milk and can affect the baby.
  
• About any other prescription or over-the-counter medicines you are taking, including vitamins and herbs. In fact, keeping a written list of each of these medicines (including the doses of each and when you take them) with you in case of emergency may help prevent complications if you get sick.”
  

Interactions with other drugs – “this is serious:
#1. Taking salsalate while using "blood thinners" (such as warfarin and heparin) can increase your risk of serious bleeding.
#2. If you take salsalate while taking lithium, your lithium level may go up. This can increase your risk of toxic effects from lithium. You may need more frequent checking of lithium levels while on salsalate.
#3. Taking salsalate along with other non-steroidal anti-inflammatory drugs that are used for pain, inflammation, or fever, such as ibuprofen, naproxen, diclofenac, fenoprofen, indomethacin, and ketaprofen, can increase your risk of bleeding or other side effects.
#4. Taking salsalate along with other salicylates (or medicines containing salicylates) such as aspirin, trisalicylate, bismuth subsalicylate, etc., can result in a dangerous overdose of salicylates. See "Precautions" section for more details.
#5. Medicines for gout may not work properly while taking salsalate.
#6. Alcohol may increase your risk of stomach irritation or bleeding while taking salsalate. Steroids such as prednisone may also increase this risk.
#7. Pills that are used for diabetes (oral hypoglycemic drugs) may have more effect if taken with salsalate. This can increase your risk for low blood sugar.
#8. If you are taking medicine to make your urine less acid, salsalate may not work as well because it will be removed from the body more quickly.
#9. If salsalate is taken with antacids or drugs that block stomach acid, it may absorb too quickly and cause stomach irritation.”


Please check with your doctor, nurse, or pharmacist about whether other medicines, vitamins, herbs, and supplements can cause problems with this medicine. Presently there are no known serious interactions with food. It is advised to always tell all doctors, dentists, nurses, and pharmacists that you are taking this drug.


Salsalate is a tablet or capsule, which is normally taken by mouth with food or a full glass (8 ounce) of water or milk. It is not to be taken with antacids. The dose will depend on why you are taking and how many times per day you are taking it (2 or 3 times). This is an often heard direction, but I will emphasize this in bold because it is so important for this medication. Take this drug exactly as directed by your doctor. Keep salsalate in a tightly closed container, away from heat, moisture, and out of the reach of children and pets.


Yes – first approved before 1984 (FDA cannot verify dates of drugs approved before 1984.)


This is a disclaimer: This information does not cover all possible uses, actions, precautions, side effects, or interactions. It is not intended as medical advice, and should not be relied upon as a substitute for talking with your doctor, who is familiar with your medical needs.


I urge you to read the source as I only covered part of it. Other warnings and cautions should be read here and here. There are other good sources, which you may wish to read about salsalate by typing it into your search engine and reading those of interest.

The Over 65 Project

The Over 65 Blog was an interesting find for me. It speaks to many ideas that I can relate to at age 71 and I am not afraid to admit it. Yes, there are some ideas that are difficult to agree to and this is as it should be. We all need to be aware of some of the thorny issues facing us as seniors and be prepared to agree or disagree.


First, I would name the individuals behind the over 65 project. They include:

• James Sabin, M.D.
  Clinical Professor of Psychiatry
  Harvard Medical School
  

• Sherwin Nuland, M.D.
  Professor of Surgery Emeritus
  The Yale School of Medicine
  

• Daniel Callahan
  President Emeritus
  The Hastings Center
  

• Susan Gilbert
  Public Affairs & Communications Manager
  The Hastings Center
  

The most challenging point for me is in their introduction. When they are talking about the current technology hungry model that feeds that system and consumes a large share of resources this is quite a challenge. They continue, “That model has put an unbridled pursuit of cure, not care, in the saddle, a balance that must now shift to a better balance in the direction of care. It has made end-of-life decisions more difficult, blurring the line between living and dying and offering seductive hope that death can be indefinitely overcome. The latter is both damagingly expensive and often an affront to human dignity and a peaceful death. The present over 65 generation, as well as the aging baby boomers, will be caught in the throes of the necessary revolution. They need a strong voice. Their own welfare is at stake, and their wisdom and insight are necessary for the good of all. ”


Since I am older than the baby boom generation, it will be on many of us to prepare people in the baby boomer generation to know how to be heard and to be able to speak to the problems we are facing. Presently, there are approximately 40 million Americans over the age of 65. By 2030 the predicted number is 72 million.


The Over 65 Project has five goals. No one said they would be simple goals, but they are goals that we can embrace and generally support. I have quoted them because of their importance.


#1. A stronger role for seniors: “A much livelier, wider, more articulated, and stronger role for the elderly must be initiated to address the future of Medicare and related health and economic problems of old age. That aim will require a dialog among themselves, with their physicians, and with legislators. All three will be important.”


#2. Self determination: “The importance of self-determination in seniors’ lives needs to be strengthened and clarified, not only for end-of-life care but also for the managing of their health and illness in general. Yet that self-determination will only become meaningful if they have had many occasions early in their elder years to talk with other elders about how to discover and shape their personal values about illness and their inevitable mortality. Many seniors come into old age without a well-defined set of values about how they might best think of their aging and making medical decisions, particularly in the face of complicated, life-threatening, chronic illness. Even when they do have some well-formed values, they can encounter complexities that were unforeseen or resistance from doctors or family members in following their wishes. Understanding oneself, and one’s aging, takes work, experience, and some help.”


#3. More care, less technology: “The balance between cure and care is now too heavily weighted to an unbridled pursuit of cure, even when the potential for cure is vanishingly small. The health care system needs more care and less technology. The present system is beset with excessive and costly diagnostic tests, the use of treatments with poor evidence to support them, and doctors too inclined to respond to illness with technological fixes and desperate “last ditch” interventions at the expense of compassion and a good doctor-patient relationship. Seniors need to support comparative- and cost-effective research, which is a powerful way to determine the value of various technologies. Armed with that information, they can learn when to say no to tests and treatments that are not beneficial and to embrace those that fit with their needs and values.”


#4. Confronting the cost problem: “At the heart of the present Medicare debate is the high and increasing cost of that program. Those costs must be attacked by adherence to evidence-based, efficient care, some reduction in prices, as well as some combination of reducing benefits and raising taxes. There will be no painless way to avoid making these changes. Seniors should be part of that debate, not simply resisting the painful reforms. A central, but neglected, issue for discussion should be that of intergenerational responsibility. What do the young owe the old and what do the old owe the young? Medicare is a pay-as-you go system. That means that the cost of the present Medicare beneficiaries is borne by the younger generation of workers today and future generations tomorrow. How heavy a burden can be asked of them by those who are old? What is a reasonable obligation of the young to the old? What are the reasonable obligations of the old to the young?”


#5. The economic and family needs of the over 65 generation: “A large proportion of the baby boom generation will go into their late 60s and 70s with inadequate financial resources, estimated on average to be only 40% of their retirement income. Those pressures will in too many cases be exacerbated by the need to be family caretakers for their spouses or partners. Even now, most people over 65 are responsible for at least one spouse, parent, or other relative of an advanced age. That burden can all too often be financially and emotional overwhelming (notably in the case of Alzheimer’s). The burden they in turn will place on their baby boom children will be no easier—and many more will have to bear it in the future. That certainty not only touches directly on intergenerational obligation but no less on what family members owe to each other—and to what extent they can ask for government help to lighten the pressure on them.”


I will have more in future blogs and add some of my thoughts to these from the patient's perspective of type 2 diabetes as we age.

Health Care Rationing, Why Should the Elderly Support It?

This is a catch 22 situation if I ever heard of one. Dr. James Sabin, writing blogs for “Over 65” makes some excellent points. I think he admits if what he is proposing is done wrong, it will not be a good thing. In reading and rereading his blog here, I am inclined to agree with many of his ideas. Yet in the back of my brain, I keep going back to a discussion I had with a now deceased doctor who said there is too much rationing for the sake of rationing. He said he hated to give up on a patient unless the patient asked him to. As a doctor of oncology, he would not give up easily. He was not afraid of trying different treatments and did discover a lot of drug combinations that were successful for cancer. He never sought credit for his work and all he cared for was the well-being of his patients.


A point that Dr. Sabin makes, but does not emphasize hard enough (although this is done in the introduction for the over 65 project), is all the money wasted on cures for the diseases of the elderly when some of this could better be used to care for the elderly. Not only care for the elderly, but also to develop preventive medicine which could alleviate the pain and suffering many of the elderly experience.


Dr. Sabin does make four excellent points which need consideration. While I have some reservations, I would urge everyone to read his blog. His first point as to why we should support health care rationing is improved health. While moving money to infrastructure investments such as housing, social services, and transportation could help many people, I am afraid that putting more people into care facilities too early is not an answer. Yet, I see this all around me and many people do not last long when confined in care facilities.


First, social services is not made part of this care, more often excluded if possible, and transportation is often limited for lack of funds and normally this is reserved for trips to the doctor or the hospital. I do not know what assisted living facilities are like in other parts of the country, but here they seem more like confining facilities that restrict the residents like cattle and only allow them freedom within the facility.


Then we can discuss retirement homes which are purchased and the residents can come and go just like it was their residence, medical facilities exist on the site of up to 25 plus retirement homes and is available to the residents during certain hours and available to others of elderly public for certain hours. Medical personnel are on call to the retirement home residents 24/7 and they may be transferred to hospitals when needed.


The second point in the blog is improved access. This means doing this for the poor elderly populations. This would include access to primary care and geriatric care. If a patient is hospitalized, then these two cares would ensure proper care and/or oversee care when discharged to ensure there is minimal readmission to the hospital. This will prevent the hospitals from gaming the system to apply more and more tests not needed on the elderly.


The third point is improved medical care. This is a powerful point as it could prevent health care rationing. By preventing hospital after hospital readmission, much of the wasteful interventions would not happen and therefore costs could be contained rather than continue to rise. When it comes to the elderly, often less treatment is better and less harm is inflicted on the elderly because of the over treatment which hospitals and many physicians are wont to do.


The fourth and last point Dr. Sabin presents is the need for improved intergenerational equity. This is probably the weakest of the points. I say this because until the over treatment waste is removed from the equation, care is taken to not always use the latest and most costly treatments, the coming expansion of the over 65 population will continue to put a severe drain on the resources for elderly care; and rationing will become a necessity whether we like it or not.


To make Dr. Sabin's points workable, those of us over 65 now need to help point the way and work to see that rationing does not become a reality. I am often accused of being too harsh in my expression of hospital greed, but this is a large part of what will drive rationing for those needing more care at times. What I am unable to justify is the millions of dollars taken out of hospitals by hospital administrators and some administrator staffs for their salaries and bonuses. This is a large part of the drivers behind all the tests conducted by hospitals that are not necessary and considered wasteful and harmful for elderly patients.


To keep salaries and bonuses increasing, staff reductions are common among the nurses and overtime is forbidden among the overworked staff. Unnecessary tests are ordered and hospitalists are directed to see that tests are done. Several investigations around the country are being done in hospital emergency departments where doctors have been ordered to find ways to admit patients to the hospital so that more tests could be done, which in turn could stretch the hospital stay of the patients.


This blog is applicable to what hospitals are doing to cause readmissions. This is a large area for concern if we are to prevent health care rationing.