Pocket Ultrasound Machines: "Why doesn't everyone have one of these?"

For about 2 years now a tiny ultrasound machine has been part of my standard physical exam tools as I take care of patients in the hospital and in the outpatient clinic. In November of 2011 I first picked up an ultrasound transducer in a continuing medical education course on bedside ultrasound for emergency physicians. I am an internist, not an emergency physician, but I was interested in bedside ultrasound and it was the emergency physicians who were giving the most interesting course. It was transforming for me. I was able to see internal anatomy and physiology and eventually, with lots of practice, I was able to make diagnoses more quickly and accurately. I bought a pocket ultrasound machine so I could make bedside ultrasound a seamless part of my practice

It was an unexpected and welcome bonus that my patients and their families loved it. I would share the moving ultrasound pictures with them, often having them hold the machine so I could point out how beautiful their internal organs were and what we could see that helped give us a clue about their disease process. Many of these same patients also got full, detailed ultrasounds or other imaging by radiology technicians, but since the technicians aren't supposed to discuss findings with the patients and often they couldn't see the screen, it wasn't nearly as gratifying.

The most common comment I get from patients is, "Wow, that's really cool!"  "I agree!" I answer. Then they will ask, "Why doesn't everyone have one of these things?"

That is kind of a difficult question. "They're pretty expensive," I usually say. They are. At least for now. The little machines (Vscan, by GE) retail for over $8000, though you can buy them cheaper used or overseas. Physicians balk at spending this amount of money on a piece of equipment. Most of the expensive gadgets we use are owned by hospitals or by our group practices. Musicians, however, who make a fraction of what we do, buy their own musical instruments which often cost in excess of $10,000. I'm not sure the cost ought to be a serious consideration. Other doctors often ask me if I bill for my exams. I don't, because billing and the detailed documentation and posturing that would be necessary to prove to an insurance company that an ultrasound was necessary would take more time than I have. I report the results in my narrative of the physical exam, much as I do the findings of my ears or my hands or eyes. There are billing codes for limited ultrasounds, and if I were able to record and store my images easily I could probably boost my revenue, but that would make me feel just a little bit conflicted every time I did it. I would have to tell the patient that I was charging for it which would probably make them feel conflicted as well, or maybe choose to forgo the exam, which would mean that I would know less about what was going on and would be more likely to make a mistake.

"It also takes a long time to learn," I add. I have spent hundreds of hours in  learning from good teachers, mostly in person, but also online. I have done many thousands of exams and have reviewed a fair number with experts. But it is actually pretty quick to get good enough to be sure of a handful of different things that make a huge difference in making clinical decisions. After that, much like most of the things we do in medicine, learning expands exponentially with on-the-job experience. Many students in medical school now are learning how to use ultrasound at the bedside as part of their standard training, which is really the best way to do it.

"When did those things come out? I've never seen anything like it!" say my patients. The little pocket model I have has been available for at least 5 years, and there have been portable ultrasounds for considerably longer. The company that makes mine has not been aggressive in marketing it, even though it is potentially as huge a deal as the introduction of the stethoscope, and other ultrasound companies have been incredibly slow in developing competitive models. Maybe it's just difficult to develop the technology, but I think it's a little less wholesome than that. Ultrasound is a huge part of what radiology departments in hospitals and clinics do. It has grown as we have become aware of the dangers patients are incurring with the expanding use of imaging based on x-rays, such as CT scans. Full scale ultrasound exams are performed by radiology technicians using machines costing hundreds of thousands of dollars, are read by radiologists or cardiologists and billed out for thousands of dollars each. If physicians at the bedside are doing these exams for free, or even for cheap, this has the potential to negatively impact huge revenue centers. It is not in the financial interests of the whole industry for the manufacturers to produce an awesome pocket machine. A bedside ultrasound, which takes minutes, is hardly the same as a full scale ultrasound or echocardiogram which can take almost an hour to perform by a technician who does only this. In some cases we may order more ultrasounds because of what we see, or think we see, at the bedside, but for some questions our brief and focused exam will be enough and will supplant imaging by the radiology department.

There is also abundant controversy about adding routine ultrasound to the way we practice medicine. It is a "disruptive technology" which means that it potentially changes things in far reaching ways, many of which can't be adequately predicted. We may see things inside patients that are best left unseen or are difficult to interpret. We may thus end up chasing findings that are nothing and costing patients more money and anxiety than we should. I have not found this to be true, however. Imaging of all kinds, especially the detailed kind that comes out of radiology departments, is often misleading and anxiety provoking. Think about the majority of mammogram abnormalities that turn out to be nothing or adrenal "incidentalomas," the small meaningless lumps we see on the adrenal glands when CT scanning the abdomen. Combining bedside imaging with examining the patient, talking to them and reviewing laboratory data has been much less likely to lead me to misdiagnoses than to appropriate ones.

Many older physicians are trying to adjust to changes that make them feel that they are losing the profession that they used to practice skillfully in the past. We are asked to learn to use computer systems to document patient visits, review medical histories and order treatments. We start to become data entry technicians, and we aren't very good at it. We are asked to learn continually changing algorithms for treating a myriad of diseases. We are required to provide excellent preventive medicine for our patients so they don't have heart attacks or strokes or get cancer, when research on the proper way to do this makes what was wise one day stupid the next. On top of this people like me with our tiny little ultrasound machines come along and say "Hey...there's this other thing you should do too..." But I would love for my overworked and stressed out colleagues to know that this is different. Data entry is not inherently fun. Robots or trained monkeys could probably stay on top of the preventive to-do list better than we do, and algorithms don't give us much job satisfaction, even if they do help us deliver evidence based treatments. Bedside ultrasound, though, is terrifically fun and despite the time and effort required, brings back some of the joy of being a real doctor. I say this after a quarter of a century of practicing internal medicine. I am an "older physician."

So, "Yes," I tell my patients. "I agree. It is incredibly cool. We are looking at the inside of your body together and learning things. It's unusual now, but I'm pretty sure it's not going to be too long before it's part of what most of us do."

America's New Guidelines for Cholesterol Lowering Drugs: What do European Doctors Say?

In November of last year the American Heart Association released new recommendations on who should be taking "statins" (drugs like lipitor/atorvastatin), the most common medicines we use to control cholesterol levels. High cholesterol levels are associated with higher risk of heart attacks and strokes, and taking statins, which lower cholesterol, can reduce those risks. The drugs have pretty significant side effects, though, and not everyone with high cholesterol or other cardiac risks will actually have a heart attack or stroke, so it seems clear to most of us that not everyone should take statins.

The American Heart Association's 2013 guidelines
The new recommendations departed from prior ones in saying that we should prescribe statin drugs to patients with higher risk of heart attacks rather than just patients with high cholesterol. I wrote about the new recommendations here. It actually kind of makes sense, since even patients with relatively normal cholesterol levels may have lower risk of heart attacks when they take statins, and patients who have high cholesterol but no other risk factors may be vanishingly unlikely to have a heart attack regardless of whether they take the drugs. So, theoretically, the new recommendations would allow some people who have been taking statins entirely because of high cholesterol levels to stop taking them, which would be nice.

More statins: good idea or bad idea?
There has been considerable debate since these recommendations were released since they actually significantly increase the number of people who doctors may encourage to take statins. The data on whether giving statins to patients who have never had heart attacks will reduce their risk of heart attack or stroke is pretty weak, and it appears that statin therapy in this group of people does not reduce the risk of death or other disability. (Check out the audio discussion by Dr. John Abramson of Harvard University at The British Medical Journal online since the printed version costs money to read.) Statins appear to be significantly more effective in preventing heart attacks in patients who have already had coronary artery disease, including heart attacks or angina ("secondary prevention"). Almost all of the data we have on how effective statins might be has been financed, at least in part, by the manufacturers of the drugs, whose primary responsibility is to make money for their shareholders by selling statins, not to make patients live longer and healthier lives. The new recommendations would result in many patients without medical illnesses being starting on medications, what we call "primary prevention." Patients who are calculated (using a risk calculator) to have a 10 year risk of heart attack or stroke that is greater than 7.5% would be encouraged to take statin drugs.

How many Dutch people would be on statins?
A group of physicians from the department of epidemiology at Erasmus University in Rotterdam, the Netherlands, did a very clever study to look at what effect implementing these new recommendations might have had on a group of random Dutch people (average age 65 or so) they have been following since 1997. Using the data they had collected they found that 100% of the men and 65% of the women would have been recommended to take statins based on risk level. On average the men were calculated to have a 21.5% 10 year risk of heart attack or stroke based on the calculator and the women 11.6%. They were able to actually look at who had these events, and it turned out, at least for this population, the calculator seriously overestimated the risks. Only 12.7% of the men and 7.9% of the women actually had a heart attack or stroke. (Perhaps Dutch people have lower risk of heart attacks because they ride bicycles more. Physical activity is not entered into the risk calculator.) The authors conclude that using the risk calculator to determine whether to prescribe statins is inaccurate in their population and basically unnecessary over the age of 65 since nearly everyone would receive qualifying scores. They ask if the present guidelines are really advocating a blanket prescription for statins based on age.

Putting it all together
Statins may or may not make us live longer. If they do, it is a pretty small effect unless we have had prior heart attacks or coronary artery disease. They do have side effects. About 1 in 5 people who take them develop some problem, often just muscle pains and weakness but sometimes diabetes and probably thinking and memory problems. The new recommendations released in 2013 by the American Heart Association would have us encourage the majority of people over the age of 65 to take these drugs, as well as quite a few healthy younger people. Since drug companies are major players in funding research on statins, we may never get truly unbiased information about their risks and benefits. Healthy diet, regular exercise and not smoking are far more powerful ways to reduce risk of heart attack and overall death and disability due to all causes, but advertising this makes nobody any money. It is possible that guidelines which increase the use of statins will also make us just a little weaker, achier, stupid and diabetic.

Mammograms are not as awesome as we said they were: Damage control articles published in JAMA

A few weeks ago I wrote a blog which addressed a newly released study of the effectiveness of mammograms. This article, in the the British Medical Journal, looked at women who were followed over a 25 year period as part of a Canadian study, found that there was no evidence that mammograms reduced deaths from breast cancer. Most women who will die of breast cancer do so regardless of whether that cancer was diagnosed by a mammogram, and the few who are saved because their cancers were diagnosed earlier than they would have been if only clinical exam were used may have been canceled out by the far more significant number of women who were harmed by overdiagnosis, that is being diagnosed with a breast cancer that would never have troubled them had they not had mammogram screening.

I was concerned that this didn't set off a huge discussion among doctors and all of the rest of us about whether we should really continue to do regular screening mammograms. Our lives, health and billions of dollars rest partially on the answer to this question. The fact that it is so important is probably why the conversation has been so slow to start. Not doing the tremendous number of screening mammograms we now do would be very destabilizing since hospitals and surgeons and radiologists depend heavily on this revenue stream. Women's health centers at hospitals are primarily about mammograms and breast cancer diagnosis and treatment. These employ nurses and administrative assistants and social workers and counselors. There are ongoing and yearly campaigns designed to get women to get mammograms. A major change in policy has the potential to free up a great deal of financial and human resources, but at the same time jobs will be lost and budgets broken. If we accept that mammograms have lead to substantial overdiagnosis, this will have a huge emotional impact on women who have been diagnosed with breast cancer as a result of mammogram screening.

So it is not surprising that the response to this Canadian study was measured.

Today two articles were published in the Journal of the American Medical Association one addressing mammograms in general and the other mammograms in women over the age of 74. These articles have been published less than two months after the BMJ article and are already getting lots of press and lots of discussion. The article about the overall risks and benefits of mammography is a review of multiple studies, including the BMJ article, and is really interesting to read. It delicately steps around some strong evidence that mammograms have no particular value in saving womens' lives and comes up with numbers that nevertheless make preventative mammogram screening look unattractive. The conclusions are that mammograms do reduce breast cancer deaths, but on the order of 1-50 per 10,000 women screened for 10 years, depending on age. A total of around 300 will be diagnosed with breast cancer and up to a third of these cancers will be overdiagnosed, resulting in women presumably being treated with radiation, surgery and chemotherapy for tumors that would not have caused harm. Six-thousand of the 10,000 screened with mammography, fully 60%, will be called back during this 10 years for abnormal mammograms that will need further workup, including more imaging and biopsies. Still, the conclusion is that mammograms reduce breast cancer mortality, but only a little bit.

But what about the Canadian study published in February? This looked at women aged 40-59 who were screened with either clinical examination (examination of the breast by a trained health care provider) or mammograms plus clinical examination over the 5 year study period and then followed for 25 years. The only difference in the groups at 25 years is that the mammogram group had more breast cancer. There was no mortality difference. Did the Canadian women in the BMJ study play catch-up and get mammograms after the study was done and so reap all of the mortality benefit? If so, they appear to have also avoided a certain amount of overdiagnosis by taking their 5 year holiday. There are many ways to study the efficacy of mammogram screening, and none of the many studies that have been analyzed and meta-analyzed was really able to do a gold standard approach. Because of the fact that we have embraced mammogram screening as our standard of care, we have not done the definitive study.  Ideally we would compare a group of women who were denied access to mammograms for 25 years and only received clinical breast exams or breast self examination to a group who had mammograms at varying frequencies, say every 1-4 years, along with their clinical breast exams. No such experiment has been done so we rely on evidence gleaned from huge populations over many years but with less than ideal designs.

The other article in today's JAMA tackles the question of mammogram screening in patients older than 74. No actual studies have been done on this population and many countries stop recommending mammography for patients aged 70-75 years of age. In the US a significant proportion of women getting mammograms are over 74. Today's article concludes, based on extrapolating the data we have based on younger patients' data, that there would be a mortality benefit of mammogram screening if the women in question were expected to live 10 or more years. That is such a can of worms. I have very warm and respectful relationships with many older women who are my patients and I find it very difficult to admit to myself, much less them, that I expect they will die before 10 years elapse. That also assumes that I have any reasonable idea. The most important predictor of being alive tomorrow is being alive today, which is the message I like patients to take with them.

In a delightful juxtaposition, Dr. Mary Tinetti, an academic geriatrician, wrote an article about how extrapolating benefits of interventions from younger to older patients is often inaccurate. She doesn't address the mammogram issue, but her article is well placed. We really don't know what good or harm mammogram screening will do for our patients beyond the ages we have studied. It does appear, however, that overdiagnosis increases with age (see the BMJ article), so more women in their final decades will be diagnosed with breast cancers that would never have caused them harm if we continue to subject them to screening mammograms. I have watched my elderly patients suffer through radiation and chemotherapy and it is a lousy way to enjoy retirement.

So this kerfluffle about whether to do mammograms or not is a really big deal, and there is much damage control going on. It is interesting to look at this from the sidelines, and I am sure there is much that I am not perceiving. Many well meaning people are highly invested in the prevention of breast cancer and much good work is being done. Mammography is definitely not going away. It is a reasonable way to detect breast cancer, and detecting breast cancer comes before treating it, and we have improved tremendously in our ability to effectively treat and cure it. Mammogram screening for patients at high risk yields a whole different set of numbers than what I have quoted. There may also be ways to augment mammogram screening with other testing to make sure that the breast cancers we treat actually need to be treated. It is past time, though, that we question the wisdom of pushing for regular mammograms in unselected women over the age of 50.

Principles of Critical Care Medicine for Non-Intensive Care Specialists: Harvard Medical Education at its best

I just got back from Boston where I visited friends and went to a really good and useful Harvard Medical school continuing medical education course. Harvard is one of the few institutions that I have found to have consistently good classes for practicing physicians, with a few exceptions. This Spring I wanted to get myself to Boston and so I went to the online list of Harvard CME courses, which is more exciting than a candy store. In the time block that I had available they offered two delicious options. One was a week long course on everything anyone ever wanted to know about internal medicine which would have earned me over 60 hours of credit while crushing my soul with 10 hour days of densely packed information mainly intended to help practicing physicians pass their board exams. The other was the course that I chose which delivered almost 20 hours over 2 1/2 days, leaving me time to walk along the waterfront and eat a little lobster and even frolic with my friends.

The course, the 2nd Annual Principles of Critical Care Medicine for Non-Intensive Care Specialists was designed with the knowledge that much of the intensive care delivered in the United States is by physicians who don't do intensive care medicine as their main thing, and haven't received fellowship training in it. Many of us have become pretty good at it, but we sure can benefit from hearing what highly intelligent and rigorously educated intensivists have to say. Three intensive care and pulmonary medicine specialists from Harvard's Beth Israel-Deaconess, Drs. J. Woodrow Weiss, Jeremy Richards and Peter Clardy, along with guest speakers, shared information that was geared to what I really needed to learn. They gave us "evidence based" recommendations, but more importantly they told us how things worked in their hospital's intensive care unit, what they had done to improve patient care and outcomes and what that actually looked like. They focused on some of the most deadly diseases, sepsis and acute respiratory distress syndrome, and about some relatively dismal long term outcome information for the patients who are saved from their dread diseases in intensive care units, often to be faced with long term physical and mental disability. They taught us to manage ventilators more skillfully and to actually engage our brains by remembering how human physiology is reflected in some of the data which is presented to us so copiously in critically ill patients. They taught us how we might prevent delirium in patients who frequently become confused and have a very hard time coming out of it. We were gently encouraged to give blood products only to patients who could really benefit from them, which is still a bit of a moving target.

In skills workshops which were wound into the lecture and small group problem solving sessions we had a chance to use ultrasound to practice procedures and image the hearts of a few live volunteers. We were taught the standard bedside echocardiographic views and used "phantoms" to practice placing central venous catheters and sampling fluid in the abdomen and chest.  Having attended many specific ultrasound training workshops I was a little disappointed in the cursory nature of these workshops, but the course was short and there truly was not enough time to cover everything that people should learn. The fact that bedside ultrasound was a part of the course means that the organizers not only feel that it is part of what should be done in intensive care units, but also that it is at the core of what anyone who practices intensive care medicine should be able to do, even (or maybe especially) at small community hospitals. This is a good message.

The course was small enough that it was possible to talk to all of the speakers and ask individual questions. The folks who attended were an interesting mix: we were primarily physicians who managed patients in hospitals where there were no intensivists, but we were also emergency physicians and advanced nurse practitioners and physician's assistants. It is unusual to run into many of these people at conferences because they are often too busy to attend, and we are a small minority of physicians in the US.

There was a feeling in the course of trying to make sure every recommendation was based on some kind of reputable research. Since only a minority of interesting questions have been addressed adequately by reputable researchers, this approach was impractical, and as the course wore on we more often treated to experience, deduction, good sense and critical questioning. There was a nice mix of research results and practical recommendations.

The course was held in the World Trade Center on the water in South Boston, where not too long ago only warehouses and fishing boats lived. It is near a beautiful museum of contemporary art, is served by $3 ferries to all sorts of destinations on the Boston Harbor, and has easy walking access to excellent restaurants. There is a very long foot path called the Harbor Walk which makes it easy to get exercise at the edge of the water. The Seaport Hotel where conference attendees stayed was large, well appointed, expensive but not ridiculously so. The World Trade Center was also hosting the Boston Flower and Garden Show, so parking would have been terrible, but renting a car was superfluous so it didn't matter. The show was really interesting, if you like that sort of thing, and it was possible to walk in from the conference without paying the $20 entrance fee, which was probably not intentional, but did not appear to be forbidden.

What I learned is readily usable. I look forward to treating my next intensive care patients to what is presently the cutting edge at one of America's best hospitals and sharing some really great ideas with my doctor colleagues.

Tranexamic acid--why you may be less likely to bleed to death in Britain than in the US if you get injured

The other day at an interdisciplinary rounds meeting at the hospital, one of our nurses who is also an emergency medical technician mentioned that in Britain injured patients receive tranexamic acid before arriving at the hospital because it reduces death from bleeding. "What's that?" I said. I kind of barely remembered hearing this medication's name associated with the treatment of a rare disease, but not treatment of trauma. So I was guessing that this was some drug that was invented long ago which had been found to be quite effective in other countries, but has not been really optimally used in the US because it is generic and therefore unlikely to make drug companies money.

Bingo.

Here's the story, as far as I can determine.

Tranexamic acid is a relatively simple cyclic molecule that blocks the fibrinolytic process, that is the natural breakdown of blood clots in the body. In the setting of any injury, especially severe ones, fibrinolysis is intensified, leading to a condition of excess bleeding in trauma victims. This is hardly ideal, and tranexamic acid can help reverse this. It also appears to have an effect on reducing inflammation, which may be even more significant. There have been a couple of major studies in the last 3 years showing significantly better outcomes in patients who have traumatic injury and who are treated with tranexamic acid intravenously soon after injury. The most recent study, published in the Archives of Surgery, looked at 896 patients injured in the military from registries in the UK and the US and identified the subset treated with tranexamic acid. Although this group was generally more severely injured, the mortality rate was significantly lower, 6.5% lower, than the group that had not received the drug. In very seriously injured patients, those who received massive transfusion of blood products, the difference in survival was nearly 14%. It is not often that we see an effect this powerful, especially in a group like this who are healthy and will likely have long and productive lives after being saved. An earlier study, published in 2011 in the Lancet entitled CRASH-2 showed similar results in civilian trauma victims, with a double blind prospective design.

The Cochrane Collaboration, a group of researchers who review randomized controlled trials concluded that tranexamic acid was safe and effective in reducing mortality in trauma patients without increasing adverse events.

So maybe it's actually very expensive, then. I called our hospital pharmacy to ask about that. Apparently a gram of it costs about $44. The usual protocol for trauma is 1 gram intravenously right away and then another gram over the next 8 hours. So $88 times 100 equals $8800 to save 6.5 lives (using the data from the military study), $1353 per life saved. That's pretty cheap. And since it probably reduces the severity of illness in the rest of the patients treated, it may end up reducing overall treatment costs.

Presently the only FDA (Food and Drug Administration) approved indication for this drug in the US is an oral formulation to be used for women with heavy periods and intravenously for prevention of dental bleeding in hemophiliacs. It is also used, off label, to reduce transfusion requirements in total joint surgeries (that's why we have it in our pharmacy), also in some places for prostate surgery, general surgery, gastrointestinal hemorrhage, bleeding around pregnancy and delivery and bleeding within the eye. It reduces the frequency of attacks of swelling in a condition called hereditary angioedema, which is rare, and was why I had even heard of it in the past. It has been available over the counter for years in Europe, marketed for heavy menstrual bleeding. The injectable formulation is also on the World Health Organization's list of 350 essential medicines which are considered safe and effective and necessary worldwide.

So what are its side effects? It may increase the risk of blood clots in the legs and lungs, but studies have shown this to be far less of an issue than one might guess, and it looks like the lives saved far outweigh this risk.  The CRASH-2 study showed that there might be a slight risk of increasing mortality if it was given to trauma patients more than 3 hours after their injury.

Why is it not FDA approved for reduction of bleeding in trauma and other similar situations for which there is ample evidence of safety and efficacy? The FDA approves drugs and devices when approval is requested, and usually the drug or device manufacturers who stand to make money from an FDA approved indication are the ones to make the request. I suspect there has been no request for approval for these other indications. Just because it is not FDA approved to reduce bleeding in trauma and surgery doesn't mean it can't be used, but physicians have a certain hesitance to use unfamiliar drugs "off label."

So the story of tranexamic acid is another excellent example of how simpler, cheaper and sometimes more effective treatments are not being widely used in the US, even though our patients may receive exorbitantly expensive medications and treatments of dubious or minimal benefit. This is because we allow powerful pharmaceutical companies to inform our practice. Sometimes this actually works, when companies produce groundbreaking innovations and encourage us to adopt them. It is unlikely, though, to help us find creative uses for inexpensive drugs that have been around a long time. This dynamic may mean that 6 or so people of the 100 who are probably just now being involved in accidents with bleeding will die when they would not have if use of this drug part of our routine practice.

Critical Access Hospitals--the 96 hour rule and other ridiculous and self defeating requirements in Medicare's payment for small hospitals

My home hospital is small. In a town of just over 20,000 people, this hospital has 25 beds and is designated "critical access" by Medicare because it is felt to be necessary to the health care of the community. Critical access is a designation which was introduced in 1997 when modernization of Medicare payment systems threatened to close a large proportion of hospitals in small communities which were unable to benefit from economies of scale. A small hospital needs to remain capable of providing services to small but significant floods of patients when everyone gets sick at once, and maintain skills and staff to care for a variety of different diseases. This can make such a hospital less financially efficient (though various other factors can partly offset this) and the critical access program spares my hospital some of the Medicare belt tightening that would make admitting Medicare insured patients prohibitively unprofitable.

Most larger hospitals are now paid for their Medicare insured patients according to the Prospective Payment System, in which a fixed amount of money is paid to the hospital according to what disease the patient has. This means that if a patient presents with pneumonia the hospital will get maybe $8,000 for all of the expenses involved in treating the patient, excluding doctor fees which are billed separately. If the patient does very well and only stays in the hospital 2 days, the hospital does very well and if the patient languishes and requires more resources, the hospital loses money. It is designed, ideally, to work out so the hospital survives, covers its costs and makes a profit. This encourages hospitals to make patients well as soon as possible by making sure that they don't profit from taking poor care of patients. It's generally a good system. Small hospitals, though, are very sensitive to individual patient disasters, and if a patient or two uses more resources than the Prospective Payment covers, the hospital can fail. For this reason critical access hospitals are paid "fee for service". Medicare pays 101% of its allowable fee for each service a patient uses in the hospital. Overall, this can end up costing Medicare more per patient, but it does keep small hospitals afloat.

In order to be critical access, a hospital must have 25 or fewer beds, though it can also have separate units for rehabilitation or psychiatric services, at 10 beds each. It must be 35 miles by primary road or 15 miles by secondary road from another hospital, or 15 miles in mountainous terrain. Up until 2006, it was also possible for the states to designate a hospital as a "necessary provider." Hospitals so designated remain critical access, though this loophole is no longer available. The 2014 budget will address this definition again, proposing to remove critical access status from hospitals within 10 miles of another hospital.

Because critical access hospitals don't have the usual built in incentives of the prospective payment system to limit the length of hospital stays, theoretically they can just make more money by keeping patients longer. Thus the 96 hour rule. Originally it was stipulated that critical access hospitals couldn't keep patients longer than 4 days. Since this was patently ridiculous, the law was changed to allow hospitals to average no more than 96 hours, which was a wee bit better.

So why do we even want to have little hospitals? They don't have very many medical specialists, they don't have dialysis units or cancer centers or cardiac cath labs. Sometimes they can't do MRI scans or nuclear stress tests, and the littlest ones can't even do surgeries. When you put all critical access hospitals (there are about 1300 in the US) in a big pot and average their results they have a higher mortality for many diagnoses than the bigger hospitals. Some of these hospitals are probably not good. But so are many larger hospitals. Communities often depend on the existence of hospitals. Businesses don't want to locate themselves far from a hospital. When a local hospital closes, the chronically ill and the poor who have trouble with transportation are prohibitively far from health care. Small hospitals support the work of primary care doctors with labs and radiology suites and emergency services. Communities without a hospital often have only very few and basic outpatient providers. Small hospitals often provide more appropriate care for patients because everyone knows everyone else, so we remember what happened last time, what worked, what didn't. The nurses know who drinks on the sly or is abused by their husband. The specialists and the hospital physicians know each other well and also know and share patients which makes care more personal and makes patients feel more secure. Communication is excellent and things get done right away. For those patients who have problems that are beyond the scope of a small facility, the emergency department can stabilize and transport. In our hospital we have a heliport on the roof and our patients can be up and out and at the major referral center that is 90 miles away in next to no time. The very old and very sick who want comfort rather than life prolonging procedures can get that right near home, with physicians who know them and often know their family and friends, and share their concerns.

So I guess I am a fan of good little hospitals. But I am not necessarily a fan of the critical access system. Our hospital is occasionally so full we need to turn away patients, but we have more actual physical room and could definitely squeeze in a few more patients if we weren't limited to 25 beds. Also the fee for service system really does not encourage us to develop innovations that make patients get better faster. I think we do a great job at my local hospital of reducing over-testing and over-treatment, but there is no financial incentive to do so since we make more money if we do more. We would be better at creative thriftiness if it actually saved us money. Our creativity is stifled by the need to be little and by being paid fee for service.

Lately we are being encouraged to take the "96 hour rule" more seriously. We need to certify when we admit a patient that they will only require 96 hours in the hospital. If we think they are likely to be in our hospital longer than that, we theoretically need to transfer them to the larger hospital 90 miles away. Seriously? And if we think they will only need 96 hours but we are wrong, theoretically we should then transfer them. So our dear sweet 96 year old who is admitted with diarrhea and turns out to have a small bowel obstruction and then develops pneumonia would need to take an ambulance ride or a $40,000 helicopter ride on day 4 just as we have her really nicely stabilized. The alcoholic with pancreatitis who never gets better in 4 days but is perfectly appropriate for our level of care would go straight from the emergency room to the tertiary care facility. The overworked doctors at those hospitals are so definitely not going to love that, as they deal with their own sick patients. I've been on both sides of this situation, as the doctor transferring a patient and as the one receiving the patient. If a patient is being transferred solely because it is difficult to design an appropriate discharge, it is more difficult to do that from a hospital 90 miles away from their home. It is also extremely likely that subtleties of the history will be lost and that procedures and tests and mistakes will be repeated. Transfer to a different hospital is necessary if the patient's recovery is stalled because of lack of expertise or technology, but if it is only to save the payer (Medicare) money, I expect it will do the opposite.

What to do? I'm thinking that the whole critical access system needs to be reconsidered. Managing all small community hospitals the same way doesn't make sense. Clearly little hospitals need support in order to survive, but giving them arbitrary rules and paying them fee for service is hardly the way to make them function better and certainly doesn't encourage creative innovation.

The Hospital Dependent Patient--some people will be in and out of the hospital despite our best efforts to make them well

This week the New England Journal of Medicine published an article by David Reuben MD and Mary Tinetti MD, both academic gerontologists, about patients who are unable to stay out of the hospital. The two physicians study the problems of old people, and are of the opinion that most of these "hospital dependent" patients are elderly. Certainly some of them are, but in my experience a surprising number are just chronically ill, usually also poor and with home situations unequal to their vast medical needs. Drs. Tinetti and Reuben are apparently studying these patients, thinking about solutions and now focusing us on this special population.

Hospitals potentially risk not being paid for patients who return to the hospital with new or persistent diseases within a short time of discharge. (I wrote an article on the history of this several months ago which points out some of the same issues that Dr. Reuben and Dr. Tinetti mention as well as how this fits in with the history of Medicare. Not as dry as it sounds. You should check it out.) Physicians who readmit patients after less than a 30 day hiatus are made to feel that they have participated in some sort of failure of management. Sometimes they have, but sometimes that isn't the case at all. If a patient is readmitted with an illness that is still troublesome, but clearly improving out of the hospital, for which the patient has visited the emergency department only for reassurance, this is a failure of management, due to unfamiliarity with the patient's history, often because the doctors in charge haven't really read the chart, reviewed the history or talked to the patient. If a patient is readmitted because treatment has lead to a preventable complication, that is a failure of management. If the readmission could have been prevented by a timely visit to an outpatient physician, this is a system failure of some kind and potentially avoidable. If the patient returns, however, because he or she is just too sick and fragile to remain well outside of a hospital, there is no failure, other than that expectation of success was overly optimistic.

The reason that we have hospital dependent patients is that our hospitals are really quite good at keeping people alive, even when they are balanced on a knife edge of medical stability. Twenty-four hour attentive nursing and frequent visits by physicians, respiratory and physical therapists, dietitians, patient educators and social workers along with spare-no-cost life saving technology is wondrously effective at shoring up the nearly dead. For many people, though, life without all of this is hard or impossible, so after a few days at home or in a nursing home, they will return to the hospital to be saved again.

Solutions involve difficult decisions. Is it worth the staggering amount of cash it takes to keep people in marginal health marginally healthy? How can one enter into the discussion of allowing natural death with a patient who feels mostly pretty good with ordinary hospital care? Herein lies the fallacy: once we get to this point, hospital dependency, it is hard to back off. The trick is to not get there in the first place.

Most people who are independent and in full possession of their faculties do not want to be a burden on others. There are many moments between this point and full dependency when decisions could be made to withhold life prolonging medical care, and it is important that we present patients with these options without making them feel that they need to at least try what we have to offer. Although we as physicians are becoming more accepting of withdrawing life support or at least not intensifying it as people become desperately ill, most of us feel justified in allowing natural death only in people who have become truly miserable. Our patients, however, would usually prefer not to be truly miserable ever.

Many of our hospital dependent patients have survived some last ditch attempt at keeping them alive. Given the opportunity to do it all again, from the standpoint of their well selves, many would say no.  It is interesting, though, that from the standpoint of being rescued and now dependent, many patients will continue to undergo painful and progressively disabling medical treatments until at last nothing will work.

I'm wondering if it is possible to end our love affair with medicine that defies death in our waning years. Might it be acceptable, at least sometimes, to allow our patients to die without a diagnosis? No cause of death. Death certificates could say "old age" or "natural causes" without further clarification. When death comes knocking, sometimes, if the time is ripe, we might let him in the front door, bid our loved ones goodbye and depart. Or have we as a society really decided that lengthening life is pretty much always a good thing? If we have, hospital dependent patients will be increasingly part of our jobs. Shaming ourselves when they are readmitted is misguided and very unlikely to change anything.