[Reblog] In Medicine, More May Not Be Better

From the 23 October 2013 item at The Health Care Blog

 

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Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?

Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.

But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.

In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.

Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).

On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.

Consumer satisfaction is a metric that has been used extensively in other industries, and its increasing integration in healthcare may represent a desire to model medicine on industries that lead in efficiency, such as the technology, automobile or airline industries. But healthcare remains fundamentally different.

Consider Medicare’s initiative to have hospitals publicly report their patient outcomes and satisfaction data and have consumers compare them a la computers or SUVs. Of the 13 teaching hospitals within five miles of my apartment, the relationship between the quality of care and patient satisfaction was unclear. Within these hospitals, hospital mortality outcomes did not correlate with satisfaction ratings.

I’m a physician and I had difficulty making sense of the data, so how can we expect everyday people to use them in a meaningful way? Would they prefer a place where they or their relatives are likely to live longer, have a lower risk of readmission and have fewer infections, or a place where their pain would be better managed, their nurses more responsive and their bathrooms cleaner? Although ideally hospitals would score highly in both sets of measures, data suggest that is not necessarily always the case.

Patient visits can sometimes be like family dinners. They are probably not the best occasions to talk about Dad’s smoking habit or Mom’s Xanax addiction. But to maintain shared decision-making, clear and honest communication is vital. And in critical situations, most data suggests that patients want their physicians to be upfront about bleak issues such as life expectancy.

Yet a 2012 study by investigators in the Dana-Farber Cancer Institute found that patients who were better informed about the grim nature of their cancer and the goals of their treatment were less satisfied with their physicians. Such findings put a physician in a quandary: a more informed patient or a more satisfied one?

Emphasizing patient satisfaction and offering incentives to hospitals and physicians to keep their patients satisfied are laudable. But trying to transform patient satisfaction into a catch-all quality metric may not be the right approach. What is really needed is for physicians to take the time to help patients identify the things they need, not just what they want.

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Read the entire article here

 

A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)

 

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[Repost] Self-Rated Health Puts Aging, Health Needs On the Agenda

World Health Organization Regions (Photo credit: Wikipedia)

 

From the 23 October ScienceDaily article

 

mplementation of national surveys where the population can estimate and assess their own health may give policy makers important insights into the different health interventions that should be implemented. According Siddhivinayak Hirve, PhD student at Umeå University, this may include a simple tool that harmonizes the assessment of health in developing countries with the rest of the world.

When the World Health Organization, WHO, conducted a study of aging in a global context and health among adults, in 2007, they asked the simple question “In general, how would you rate your health today?” The results showed that every other elderly person, over 50, who lived in rural areas in India said that they felt very bad, bad, or moderate.

In his thesis, Siddhivinayak Hirve has examined the factors that influence the assessment of own estimated health in older individuals in the population in rural India. The thesis shows that women report worse health than men. Self-reported health also deteriorated with age. The effect of age in terms of self-rated health was affected by participants’ ability to move, ability to see, hearing, relationships, pain, sleeping problems, and more.

“Smoking and use of tobacco were factors that could be linked to at least one chronic disease, which in turn affected the self-reported health effects,” says Siddhivinayak Hirve. “Our studies also demonstrate that a large social network results in better self-rated health and also a higher quality of life.”

A four-year follow-up study that Siddhivinayak Hirve has conducted showed that the risk of dying was larger in those who reported poorer health compared with those who reported that they had good or very good health at the start of the study

…

Siddhivinayak Hirve concludes, based on his findings, that it is possible to use information on self-rated health from major national surveys, such as the planning of health care, even in small, isolated areas.

“My goal of this thesis has been to put aging on the agenda, both among scholars and policy makers,” says Siddhivinayak Hirve. “This is particularly important in countries where it has a rapidly aging population. The value of asking the simple question, “In general, how do you feel today?” Is very high and can be very helpful to identify health needs, and plan for targeted interventions in health. This is particularly true in developing countries.”

He also points out that measurements of self-rated health provides a driving force to strengthen research on health for the adult and aging populations in low-and middle-income countries that harmonize with international research.

Thesis is available for viewing at: http://umu.diva-portal.org/smash/record.jsf?pid=diva2:653335

 

Read the entire article here

 

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What Should You Know About E-Cigarettes?

Electronic Cigarette Model (Photo credit: planetc1)

On a personal note, my husband is very sensitive to e-cigarette vapors.
He finds he has to leave any room where they are being “smoked”.

 

From the 23 October 2013 ScienceDaily article

 E-cigarettes are becoming increasingly popular and widely available as the use of regular cigarettes drops. Recently, the Centers for Disease Control and Prevention (CDC) reported that e-cigarette use by children doubled from 2011 and 2012. The health effects of e-cigarettes have not been effectively studied and the ingredients have little or no regulation. Mayo Clinic’s Nicotine Dependence Center experts are available to discuss what people should know before trying e-cigarettes

Electronic cigarettes, often called e-cigarettes, are battery-operated devices that provide inhaled doses of a vaporized solution of either propylene glycol or vegetable glycerin along with liquid nicotine. An atomizer heats the solution into a vapor that can be inhaled. The process, referred to as “vaping,” creates a vapor cloud that resembles cigarette smoke. Some liquids contain flavoring, making them more appealing to users.

“As of right now, there is no long-term safety data showing the impact of repeated inhalation of propylene glycol or vegetable glycerin on lung tissue,” cautions Jon Ebbert, M.D., associate director at Mayo Clinic’s Nicotine Dependence Center. “There is some short-term data suggesting that e-cigarettes may cause airway irritation, but until we have long-term safety data, we are not recommending e-cigarettes for use among cigarette smokers to help people stop smoking.”

So, what is known about electronic cigarettes?

*Manufacturers claim that electronic cigarettes are a safe alternative to conventional cigarettes.

*The Food and Drug Administration (FDA) has questioned the safety of these products.

*FDA analysis of two popular brands found variable amounts of nicotine and traces of toxic chemicals, including known cancer-causing substances (carcinogens).

*The FDA has issued a warning about potential health risks associated with electronic cigarettes, but is not yet regulating their use or standards of manufacture.

“It’s an amazing thing to watch a new product like that just kind of appear. There’s no quality control,” says Richard Hurt, M.D., director of Mayo Clinic’s Nicotine Dependence Center. “Many of them are manufactured in China under no control conditions, so the story is yet to be completely told.”

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[Repost] Long Term Care — Five Things Physicians and Patients Should Question

I am especially grateful for #4.

From the ABIM fact sheet

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[Repost] Most Frequent Procedures Performed in U.S. Hospitals, 2011

From Statistical Brief #165 at Healthcare Cost and Utilization Project (HCUP)

Anne Pfuntner, Lauren M. Wier, M.P.H., and Carol Stocks, R.N., M.H.S.A. Introduction When hospitalized, patients may undergo procedures for surgery, treatments (e.g., blood transfusions), or for diagnostic purposes (e.g., biopsy). The principal procedure is the procedure performed for definitive treatment. Hospitalizations usually involve multiple procedures, which together constitute the all-listed procedures performed during a hospital stay. Data on inpatient hospital procedures can help hospital administrators, health practitioners, researchers, and others understand how hospital care, including care related to diagnosis and treatment, is currently provided and what changes or consistencies in care delivery have occurred over time. The present Statistical Brief presents 2011 data on the most common all-listed procedures performed during hospital stays in the United States, overall and by patient age. Changes between 1997 and 2011 in the number of stays and in the rate of hospitalizations with these procedures are also presented. All differences between estimates noted in the text are statistically significant at the .001 level or better. Findings Most frequent all-listed procedures performed during hospital stays, 2011 Table 1 shows the all-listed procedures that were performed most commonly during hospital stays in 2011, as well as the change in the rate of hospitalizations with these procedures since 1997. Procedures were performed in 63 percent of hospital stays in 2011. The hospitalization rate for stays with procedures remained stable since 1997 at 780 per 10,000 population. Blood transfusion was the most common procedure performed during hospitalizations in 2011 (12 percent of stays with a procedure); the rate of hospitalizations with blood transfusion more than doubled since 1997. Respiratory intubation and mechanical ventilation was the third most common procedure performed, occurring in 7 percent of stays with a procedure in 2011. The hospitalization rate for stays involving respiratory intubation and mechanical ventilation increased 56 percent since 1997.

Highlights Procedures were performed in 63 percent of hospital stays in 2011.The hospitalization rate for stays with procedures remained stable since 1997 at 780 per 10,000 population. Between 1997 and 2011, the hospitalization rate for stays with hemodialysis increased 68 percent. The hospitalization rates for stays with a blood transfusion increased 129 percent for adults aged 18-44 years and 45-64 years, 111 percent for adults aged 65-84 years, and 97 percent for adults aged 85 years and older. The hospitalization rate for stays with Cesarean section increased 39 percent between 1997 and 2011. Between 1997 and 2011, the most rapidly growing procedure was indwelling catheter—the rate of hospitalization for stays with this procedure more than tripled. Adults aged 65-84 years accounted for more than half of the total number of stays with knee arthroplasty in 2011; their hospitalization rate increased 59 percent since 1997.

Six of the most frequent procedures performed were associated with pregnancy, childbirth, and newborns. When combined, they accounted for 30 percent of stays with a procedure in 2011: prophylactic vaccinations and inoculations, repair of current obstetric laceration, Cesarean section, circumcision, artificial rupture of membranes to assist delivery, and fetal monitoring. Cesarean section was the most common major operating room procedure performed in 2011 (41 stays per 10,000 population); the hospitalization rate for stays with Cesarean section increased 39 percent since 1997. Four cardiovascular procedures also were among the most frequently performed in 2011, constituting almost 15 percent of all stays with a procedure: diagnostic cardiac catheterization, coronary arteriography; hemodialysis; diagnostic ultrasound of the heart (echocardiogram); and percutaneous transluminal coronary angioplasty (PTCA). Between 1997 and 2011, the hospitalization rate for stays with hemodialysis increased 68 percent, but the rate fell 24 percent for stays with diagnostic cardiac catheterization.

Table 1. Number of stays, stays per 10,000 population, and percentage change in rate of the most frequent all-listed procedures for hospital stays, 1997 and 2011
All‐listed Clinical Classifications Software (CCS) procedures	Number of stays with the procedure in thousands		Number of stays with the procedure per 10,000 population		Change in rate, %
	1997	2011	1997	2011	1997-2011
All stays (with and without procedures)	34,679	38,591	1,272	1,239	-3
All stays with any procedure	21,257	24,312	780	780	0
Stays with a procedure, %	61	63
Blood transfusion*	1,097	2,929	40	94	134
Prophylactic vaccinations and inoculations	567	1,860	21	60	187
Respiratory intubation and mechanical ventilation	919	1,635	34	52	56
Repair of current obstetric laceration	1,137	1,315	42	42	1
Cesarean section	800	1,272	29	41	39
Diagnostic cardiac catheterization, coronary arteriography	1,461	1,261	54	40	-24
Upper gastrointestinal endoscopy, biopsy	1,105	1,225	41	39	-3
Circumcision	1,164	1,108	43	36	-17
Artificial rupture of membranes to assist delivery	747	948	27	30	11
Hemodialysis	473	909	17	29	68
Diagnostic ultrasound of heart (echocardiogram)	632	869	23	28	20
Fetal monitoring	1,002	780	37	25	-32
Arthroplasty knee	329	718	12	23	91
Enteral and parenteral nutrition	277	586	10	19	85
Percutaneous transluminal coronary angioplasty (PTCA)	581	560	21	18	-16
Colonoscopy and biopsy	531	525	19	17	-13
Laminectomy, excision intervertebral disc	425	525	16	17	8
Spinal fusion	202	489	7	16	112
Incision of pleura, thoracentesis, chest drainage	349	476	13	15	19
Hip replacement, total and partial	291	467	11	15	40
* The number of stays with blood transfusion does not reflect the number of units of blood transfused. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS), 1997 and 2011

 

 

 

 

Read the entire report here

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[Reblog] The Environmental Factors That Influence Our Children’s Illnesses

POSTED ON OCTOBER 23, 2013 BY BABYGREENSERIES

 

© Ampyang | Dreamstime Stock Photos & Stock Free Images

In general, we know that most illnesses and diseases are caused by an interplay of genetics and environmental factors. While there is little we can do to alter genetic susceptibility, understanding what and how environmental factors exacerbate if not trigger illnesses and diseases can help you keep your child safe and healthy.

First, note that there are disease agents – chemical and biological – that your child is exposed to through ingestion, inhalation and dermal contact with soil, food, water and the air. That’s called direct exposure. The opposite, indirect exposure, involves contact with disease agents through interactions with parents and caretakers. For instance, if the father who works in the construction industry comes home and holds his baby, the baby may inhale industrial fumes from his work clothes or chemical residue from the father’s worksite may be transferred from the father’s skin to the baby. Through both modes, children absorb disease agents that alter hormones and disrupt metabolic processes thereby triggering a number of childhood illnesses. It’s also important to recognize that exploratory behavior for children includes putting objects in the mouth, hand-to-mouth contact, which increases the risk for exposure to environmental disease agents.

The chart below lists a number of common childhood illnesses, an associated environmental agent and potential direct and indirect sources of exposures. Use this list to determine if there are any sources of disease agents that you should keep away from your child.

Presenting Problem	Environmental                  Agent	Potential Exposures
Abdominal Pain	Lead	Batteries, smelting, painting, ceramics, enameling, welding, plumbing
Acute Psychoses	Lead Carbon disulfide mercury	Fungicide, maternal infection, wood preserving, removing paint from old houses, viscose rayon
Angina	Methylene chloride Carbon monoxide	Improperly vented indoor combustion sources, traffic exhaust, car repair, furnaces, water heaters, gas grill, foundry, wood finishing
Asthma	Formaldehyde Pet dander Tobacco smoke Toluene diisocyanate	Plastics, textiles, lacquer, playing with pets, polyurethane kits
Cardiac Arrhythmia	Fluorocarbons Solvents	Refrigerator repair, automobile emissions, cigarette smoke, paint thinners, propane gas
Dermatosis	Solvents Soaps Caustic alkali Metals	Plastics, metal cleaning, electroplating, machining, housekeeping, leather tanning
Headache	Carbon monoxide Solvents	Unvented kerosene, tobacco smoke, firefighting, dry cleaning, wood finishing, gas grill, water heaters, furnaces, automobile exhaust, improperly vented indoor combustion mechanisms
Hepatitis	Halogenated hydrocarbons	Healthcare workers, lacquer
Pulmonary Edema	Cadmium Nitrogen oxides Phosgene Halogen gases	Farming, welding, smelting, chemical operations

 

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