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Healthcare Costs: Under-Thinking Leads To Over-Testing

Jul 08, 2009 - 14 comments
Tags:

healthcare

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healthcare costs





My mother-in-law just had a CT scan of her head in the Emergency Department of her local hospital. My husband called me to ask if I could “talk to her about her headache.”

Severe headaches in the elderly are indeed worrisome, and I wondered if she had fallen recently - if she might have a bleed in her brain requiring immediate surgery. Of course, she’d need a CT scan to rule that out… I was prepared for the worst. But what I learned by simply talking to Mrs. Zlotkus was unexpectedly revealing - not only about her diagnosis but about our healthcare system in general.

As it turns out, Mrs. Zlotkus had been having severe headaches for about 3 months. She was taking Vicodin daily to “take the edge off.” When I asked her about the location of the pain, she said that it was “just on one side of my head, from the top of my neck to the top of my head.” I asked her if the pain sometimes traveled to the other side, or if it involved her eye. “Never,” was her quick response. She also told me that she’d been seeing a physical therapist for 2.5 months for neck stretching exercises.

Mrs. Zlotkus told me her CT scan was negative, and that her blood tests didn’t show any “temporary arthritis.” (That’s temporal arteritis, I presume.)

“Well,” I said, “There’s only one thing left that I can think of that will give you a headache in the exact area you’re describing - and that’s shingles. Did you notice any scabs or painful bumps on your scalp when the headaches first started?”

“Why, yes!” Said Mrs. Zlotkus. “About 3 months ago I noticed some very painful, crusty scabs on my scalp. I thought for sure it was because my hairdresser used extra strong chemicals on my hair. I scolded her for it. She told me to put tea tree oil on it.”

Oh, boy. There it was - a diagnosis as plain as the nose on her face.

“Um… Well did you tell the ER docs about the scabs?”

“No. They never asked me about it and I didn’t see what my hairdresser’s chemical burn had to do with my severe headaches.”

My mother-in-law’s work up (ER visit, CT scan, several doctor visits, pain medicines), misdiagnosis (neck muscle stiffness), and mistreatment (physical therapy) for shingles probably cost upwards of $10,000. Worse than that, she did not get anti-viral treatment early enough in her outbreak to prevent a long-lasting pain syndrome (called post-herpetic neuralgia). Now that she has this shingles-related headache, it’s very hard to treat. And taking lots of acetaminophen-rich medications (Vicodin) is the last thing her liver needs right now.

So how did the healthcare system fail Mrs. Zlotkus? In my opinion, this is a great example of the “failure of synthesis” that Evan Falchuk discusses on his See First blog (http://www.seefirstblog.com/2009/06/03/is-this-really-how-we-should-measure-quality/). Somehow, the physicians involved in Mrs. Zlotkus’ care didn’t take the time to think about her symptoms, to ask the right questions, and to put all the puzzle pieces together. Instead, they just ruled out the potential emergency issues (a stroke/hemorrhage, or temporal arteritis) and gave her a follow up appointment with a neurologist (who couldn’t fit her in their schedule for 2 months). They didn’t take a full history - they just dumped her in the most likely diagnostic category (neck stiffness) and let some other specialist follow up. Shameful.

I’ve described more egregious examples of hasty medical care on this blog - consider the case of an elderly woman (the mother of a friend of mine) who was misdiagnosed with “end stage dementia” (http://www.getbetterhealth.com/lack-of-quot-continuity-of-care-quot-can-kill/2008.02.01) when she really had acute delirium from an overdose of diuretics… Or the case of my girlfriend who was mistaken in the ER for a drug seeker when she was suffering from a kidney stone (http://www.getbetterhealth.com/the-benefit-of-the-doubt-have-healthcare-professionals-lost-it/2007.11.08).

Sometimes I feel as if I have to keep an eye on all my friends and family before they set foot in a hospital, ER, or doctor’s office. I’m afraid that those providing their care will be so rushed and thoughtless that my loved ones will wind up with a huge bill, the wrong diagnosis, and perhaps even a near-death experience. I am seriously afraid for them.

The bottom line is that we have to stop rewarding providers for volume over quality. We have to value the history and physical exam beyond the CT scan and lab tests. We have to give doctors the chance to think about their patients - rather than turn up the speed dial on the clinical treadmills as a means to reduce costs.

My mother-in-law just spent $10,000 of our tax dollars on a diagnosis that could be made in 5 minutes of thoughtful questioning over the telephone. Multiply that cost by the number of other Medicare beneficiaries who are suffering similar misdiagnoses in this country and we’re talking serious money.

Under-thinking leads to over-testing. Has the CBO taken that into consideration in its scoring of various reform plans? I don’t think so. To me, this is yet another reason why we need physicians at the table in healthcare reform - we see the real cost drivers that others might not think of - even if some of us are too busy to diagnose shingles correctly!

Counterfeit Drugs: A Growing Global Health Crisis

Jun 21, 2009 - 4 comments
Tags:

medications

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drugs

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Counterfeit Drugs

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malaria

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counterfeit

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antibiotics



    "A resistant strain of bacteria –created by partially effective counterfeit antibiotics – doesn’t need a VISA and passport to get to the U.S."

-    Paul Orhii, National Agency for Food and Drug Administration and Control, Nigeria

I attended a conference in DC yesterday called, “The Global Impact of Fake Medicine.” Although I had initially wondered if homeopathy and the supplement industry would be the subjects of discussion, I quickly realized that there was another world of medical fraud that I hadn’t previously considered: counterfeit pharmaceuticals.

Just as designer goods have low-cost knock-offs, so too do pharmaceuticals and medical devices. Unfortunately, counterfeit medical products are a higher risk proposition – perhaps causing the death of hundreds of thousands of people worldwide each year (http://www.aei.org/book/930).

It is difficult to quantify the international morbidity and mortality toll of counterfeit drugs – there have been no comprehensive global studies to determine the prevalence and collateral damage of the problem.  But I found these data points of interest (they were in the slide decks presented at the conference):

-    Pfizer Global Security raids resulted in seizure of 11.1 million counterfeit tablets, capsules and vials in 42 countries in 2008. Pfizer seizure of counterfeit drugs in 2008 were up 28.9% over 2007.

-    Within a 7 day period, 250 different Internet-based Viagra purchases were seized in a single mail center. After chemical testing, it was determined that 100% of the tablets were counterfeit.

-    Anti-malarial counterfeit tablets are common in East Asia and Africa, threatening to derail the US goal of decreasing malaria mortality by 50% in 15 countries (http://www.usaid.gov/our_work/global_health/id/malaria/index.html). Chemical testing in Africa revealed that 20-67% of chloroquine failed content quality checks, and 75-100% of sulfadoxine-pyrimethamine tablets (for pregnant women) was not absorbable. Tests conducted in Cambodia in 2003 demonstrated that 27% of anti-malarials were counterfeit with quinine being 77% counterfeit and tetracycline 20% counterfeit.

-    Some “Canadian” mail order pharmaceutical prescriptions have very circuitous routes of manufacture, packaging, and delivery. One batch was manufactured in China transported to Dubai, then to London, then filled in Bahamas, sent to the UK, and then mailed to the US.

-    Counterfeit drugs are estimated to make up 30% of Kenya’s total pharmaceutical products, 20% of India’s, 10% of Russia’s, and $70 billion by 2009. India and China have much less stringent safety and regulatory standards, which provides fertile soil for counterfeiters.

-    25 years ago, most counterfeit medications were placebos. Today’s counterfeits have some active ingredients because sophisticated counterfeiters are looking for repeat business.

This conference provided a sobering account of the counterfeit pharmaceutical industry, tracking its exponential growth over the past two decades. That growth appears to be fueled by the outsourcing of pharmaceutical manufacturing plants to countries with limited regulatory oversight, and the sale of medications via the Internet.  So far, poor quality and contaminated prescription drugs are rarely found in US pharmacies – but that could certainly change. The FDA, US Department of Commerce, and US Agency for International Development are calling for an international public-private partnership to stem the tide of counterfeit drug manufacturing. But with little to lose (fines for counterfeit drug manufacturing are notoriously light) and much to gain (a slice of a multi-billion dollar industry), it’s unlikely that the counterfeiters are going anywhere anytime soon.

Hostility Towards Scientists And Jenny McCarthy’s Latest Video

May 30, 2009 - 33 comments
Tags:

Autism

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vaccination

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anti-vaccination



I’ve been fairly quiet about Jenny McCarthy’s campaign against childhood vaccinations, partly because Dr. David Gorski has covered the issue so thoroughly already, and partly because of my “do not engage” policy relating to the deeply irrational (i.e. there’s no winning an argument with “crazy.”) But this week I was filled with a renewed sense of urgency regarding the anti-vaccinationist movement for two reasons: 1) I received a personal email from a woman who is being treated with hostility by her peers for her pro-science views on vaccines and 2) a friend forwarded me a video of Jenny McCarthy speaking directly to moms, instructing them to avoid vaccinating their kids or giving them milk or wheat because of their supposed marijuana-like addictive properties.

Anti-Vaccination Views Are A Status Symbol?

I was surprised to discover that some pro-science moms are being mocked by peers who are uninterested in evidence, choosing to believe any dubious source of health information that questions the “medical establishment.” This concerned mom writes:

    "I am the mother of two young children, and I live in the trenches of the anti-vax woo.  In my circle of about 14 mothers, my anecdotal analysis is that the rate of complete vaccination hovers around 60%.  The mothers in this group are all very well educated, middle-class or affluent, predominantly stay-home mothers. One problem is what they consider reliable sources of information.  They rely on anecdotes and dismiss scientific evidence in part because they are very anti-medical establishment.  The group is self-validating and many shared values (and myths) increase in intensity over time.

    Many of the mothers practice “Natural Family Living” which has some appealing aspects, but also harbors elements of a cult.  In this environment, anti-vaccination becomes a very powerful status symbol… I have lost friendships and been partially ousted from this circle because of my views."

This note struck a chord with me, since I experienced similar hostility in the past for voicing my concern about pseudoscience and misleading consumer health information. I was accused of being “paternalistic, narrow-minded, a dinosaur - part of a dying breed, a racist against complementary and alternative medicine, and a Bible school teacher, preaching evidence-based medicine,” insulted for my desire to be accurate about what was known and not known about treatment options, and my expertise, training, and academic credentials were called into question publicly on many occasions. I endured all of this primarily at the hands of someone who supposedly believed in “natural healing” and the “art of kindness” as an integral part of patient care.

I am troubled by the mounting antagonism towards those of us who’d like to use critical thinking and scientific reasoning to learn what we can about medicine and our health. I’m not sure what to do about it except to encourage one another to stand strong for science and reason – to expect all manner of attacks and insults, and to be firmly committed to the objective quest for truth. It shall set us free.

Jenny McCarthy – Inaccurate, Unhelpful And Dangerous Advice

Although I find Jenny McCarthy’s advice and opinions painful to watch, I committed myself to viewing her recent video at my friend’s request. In order to spare you similar discomfort, let me simply summarize what she said so you can get a high level overview of the sort of bizarre and misinformed claims she promotes (feel free to check out the video for yourself at http://www.generationrescue.org/media/Biomedical-101.html).

    "Autism is not primarily a genetic disorder, but caused by vaccine-related toxins (including mercury, aluminum, ether, anti-freeze ,and human aborted fetal tissue) and pesticides."

    * A recent study (http://www.nature.com/nature/journal/v459/n7246/full/nature07953.html) published in Nature links genetic alternations in DNA that codes for neuronal cell adhesion molecules to autism spectrum disorders.
    * A mercury-autism link has been fully debunked (http://www.cdc.gov/vaccinesafety/concerns/thimerosal.htm).
    * An aluminum-autism link has been disproven (http://www.webmd.com/parenting/news/20040129/aluminum-in-vaccines-poses-no-harm).
    * There is no ether, anti-freeze or human tissue in vaccines (http://scienceblogs.com/insolence/2007/11/cries_the_antivaccinationist_why_are_we.php).
    * There is no conclusive evidence of a link between pesticides and autism.

    “Kids get ‘stoned’ by wheat and dairy toxins. Giving them wheat or dairy proteins is like giving children marijuana.”

    * There is currently no evidence (http://www.mayoclinic.com/health/autism-treatment/AN01519) that any diet improves or worsens the symptoms of autism spectrum disorders.  In fact, whole grains and dairy products are an important part of a healthy diet for most children.

    “Food allergies are like Iran and Iraq. Glial cells (they’re like chef cell) provide food to the neuron kings. Glial cells can turn into Rambo to fight Iran and Iraq. If a child is allergic to everything, the Rambo cells stop feeding the neurons and the neurons starve. That causes the symptoms of autism.”

    * I don’t know what to say about this strange analogy - clearly no science-based information here.

    “To treat autism, you need to give your child supplements to fight off the yeast in their bodies. I recommend Super Nathera, Culturelle, Cod Liver Oil, Caprylic Acid, CoQ10, Calcium, Vitamin C, Selenium, Zinc, Vitamin B12, B6, and Magnesium.”

    * There is no evidence of efficacy for any of these supplements in the treatment of autism.

    “You need to consult with a DAN! Practitioner.”

    * DAN! Practitioners recommend chelation therapy for the treatment of autism. There is no evidence (http://www.mayoclinic.com/health/autism-treatment/AN01488) that chelation therapy has any benefit for children with autism, and in fact, can be fatal.

    “Whatever you think becomes your reality. Imagine your child going to his/her prom and he’ll be cured.”

I think it’s pretty clear that Jenny McCarthy’s recommendations range from ineffective (imaginary healing) to harmful (malnutrition related to absent dairy and wheat in the diet, excessive levels of vitamins) to deadly (chelation therapy with DAN! Practitioners). Will mothers watching her new show on Oprah fall for her pseudoscience and poor advice?

I was pleased to see this open letter to Oprah (http://shirleywho.wordpress.com/2009/05/11/an-open-letter-to-oprah/) from one concerned mom. Here’s an excerpt:

    "To me, it is clear that a significant number of people look up to you, and trust your advice and judgment. That is why it is such a huge mistake for you to endorse Jenny McCarthy with her own show on your network.

    Surely you must realize that McCarthy is neither a medical professional nor a scientist. And yet she acts as a spokesperson for the anti-vaccination movement, a movement that directly impacts people’s health. Claims that vaccines are unsafe and cause autism have been refuted time after time, but their allure persists in part because of high-profile champions for ignorance like McCarthy. In fact, ten of the thirteen authors of the paper that sparked the modern anti-vaccination movement retracted the explosive conclusions they made due to insufficient evidence. Furthermore, it is now clear that the study’s main author, Andrew Wakefield, falsified data to support these shaky conclusions.

    We have come close to eradicating life-threatening and crippling illnesses because of vaccines, but are now struggling to prevent outbreaks because of parents’ philosophical beliefs that vaccines are harmful. Realize this: when someone chooses not to vaccinate their child, they aren’t just putting their own child at risk, they are putting everyone else around them at risk. Diseases with vaccines should normally be of little concern even to unprotected individuals due to herd immunity – with the majority of the population immune, unprotected individuals are less likely to come into contact with the pathogen. Unfortunately, herd immunity disintegrates as fewer people are vaccinated, putting everyone who hasn’t yet been vaccinated at greater risk for infection. Now, the rates of infection by diseases for which we have safe and effective vaccines are climbing, thanks to anti-vaccination activists like Jenny McCarthy.

    You reach millions of people everyday and your words and endorsements carry an incredible amount of weight. If you say to buy a certain book, people will buy it. If you do a segment on a certain charity, people will contribute. And if you say that what Jenny McCarthy is saying has merit, people will believe you…"

Conclusion

A certain segment of society appears to be emotionally invested in medical beliefs that are not based on science, but rather anecdotes, conspiracy theories, and magical thinking. Those who recommend a more objective method of inquiry may be subject to ridicule and hostility by that segment. Nonetheless, it is important (for public health and safety purposes and the advancement of science) for critical thinking to be promoted and defended. While some celebrities, like Jenny McCarthy, are committed to misinforming the public about their children’s health - parents who recognize the deception are speaking out against it. Perhaps the best way to combat Jenny’s propaganda is to boycott Oprah. Refusing to support the promotion of dangerous pseudoscience may be our best defense.

Nurses Dish On Communication Lapses That Harm Patients

Apr 07, 2009 - 3 comments
Tags:

nurses

,

nurse



Network technology giant Cisco Systems, Inc. invited nurses to offer focus group feedback on a recent study that showed that 92% of nurses believe that communications lapses adversely affect patient safety.  I joined five nurses in a cozy break out room at the HIMSS convention center and asked about their real-life experience with communications lapses in the hospital. Here are the highlights:

1. Technology Isn’t Perfect - although some hospitals have instituted bar code scanners and wireless computers to help to reduce errors, these devices often drop their connections. One nurse said that the devices actually slow down the process of distributing medications, and bypassing the system simply results in a loss of automated medication cross-checking. The devices don’t perform well in the case of an electrical surge, and nurses often waste time finding computers on wheels (affectionately known as “COWs”) that have a full battery.

2. Where’s The Patient? - the group of nurses all agreed that poor coordination of care inside the hospital can harm patients. Some nurses expressed frustration at having proceduralists and radiology teams remove the patients from their rooms without scheduling it with the nurses. They explained that nurses give out medications at specific times, and when the patients are taken to another part of the hospital without their knowledge, then they can’t plan to give them their medications appropriately. Missed doses or missed meals (for patients with diabetes for example) can result in dangerous hypoglycemic episodes, syncope, and various other harms.

3. Where’s The Pharmacist? - easy access to hospital pharmacists is critical for all clinical staff. One nurse relayed the shocking story of a med tech who was unable to get in touch with a hospital pharmacist to confirm I.V. zinc dosing in the NICU, and gave such an overdose that one of the premature babies died.

4. Where’s The Doctor? -during an audience poll at the Cisco booth, most nurses rated physicians as the hardest staff to get a hold of in the hospital setting. There is regular confusion about who’s on call, and there is often no direct line to call the physicians.

5. Where Are The Nurses Aides? - when it comes time to transfer patients (who are often very heavy) or move them in bed, nurses often have no way of finding peers to help them lift the patients safely. This results in wasted time searching for staff to assist, or even worse, can result in low back injury to the staff or patient falls.

6. Language Barriers - when patients are transitioned home from the hospital, they are often given complex instructions for self-care. These instructions are particularly hard to follow for patients whose native tongue is not English. Nurses see many re-admissions based on language-based miscommunications.

7. Decision Support Systems - one of the nurses suggested that a recent study showed that the number one source of clinical information for nurses was their peers. That means that nurses turn to other nurses for educational needs more often than they turn to a textbook or peer-reviewed source of information. Nurses would like to have better access to point-of-care decision support tools for their own educational benefit and the safety of patients.

8. Change of Shift - nurses identified shift changes as a primary source of communication errors. Technology that enables medication reconciliation is critical to safe continuation of inpatient treatment. One nurses said: “shift changes is when all the codes happen.”

And so I asked the nurses what their ideal technology would do for them to help address some of the communications problems that they’re currently having. This is what they’d like their technology to do:

1. All-In-One - nurses don’t want more devices to carry around. They want one simple device that can do everything.

2. Call a code - with one press of the button, the nurses would like the device to contact all staff who should participate in resusscitating a crashing patient.

3. Lab Values - nurses would like the device to alert them of all critical lab values on the patients under their care.

4. Clinical Prompts - nurses would like reminders of clinical tasks remaining for individual patients (e.g. check blood pressure on patient in bed 3)

5. Call and Locate Colleagues - the device should function as a full service cell phone with pre-programmed staff names/numbers and team paging lists

6. Locate Equipment -nurses would like to be able to track and locate wheelchairs, electronic blood pressure cuffs, and other equipment throughout the hospital.

7. Translate Verbal Orders To Written Orders - verbal orders are more prone to errors than written ones. An ideal device would have a voice recognition system in it that would translate physician orders to text.

Is there such a device on the market today? There are many different devices that have the capability to do some of above, but to my knowledge there is no device that can do it all yet. Companies like Cisco are working hard to provide integrated solutions for nurses - and the Nurse Connect phone is an important first step. What technologies would you recommend to nurses?

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More information about the phone (from press release):

Cisco Nurse Connect is a newly introduced solution that integrates nurse call applications, including Rauland-Borg’s Responder product lines, with Cisco Unified Wireless IP 7925G Phones to deliver nurse call alerts to mobile caregivers.

The Cisco 7925G Phone was specifically designed with the features necessary to support the unique safety and biohazard requirements of hospitals, including a battery that supports up to 13 hours of talk-time, ruggedized and hermetically sealed, and Bluetooth support for hands-free use.

The Nurse Connect Solution offers many benefits. For example, by reaching nurses on their mobile devices, the need to continually walk back to nursing stations or patient rooms is greatly reduced. Nurses can also have two-way communications with patients and send immediate requests to different levels of personnel after talking with the patient.