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Monday, June 27, 2011

Antibiotics for appendicitis, heparin for burns and other stories of wonder

In the recent batch of throw away journals, several articles reported on findings that are at least moderately exciting.

The first was from the annual meeting of the Central Surgical Association in Detroit. An analysis of several studies pointed out that many cases of CT scan proven appendicitis can be effectively treated with intravenous antibiotics.  In the past, when I was trained in medicine and surgery, appendicitis was diagnosed entirely on clinical grounds. Exquisite tenderness in the right lower quadrant, fever, elevated white blood cell count and a story of diffuse abdominal pain gradually focusing on the lower abdomen were sufficient evidence to operate on a suspected acute appendicitis. Cases without all of these findings were also operated on, and removing a normal appendix was considered part of the cost of preventing a catastrophic appendix rupture with the associated spillage of fecal matter into the sterile abdominal space. Now classic cases of appendicitis as described here will usually be corroborated with an abdominal and pelvic CT scan which will show a characteristic swelling of the appendix. When appendicitis is treated with antibiotics, 20% of patients can avoid an appendectomy and will be able to walk home without an incision in their belly and without the risk of surgical and anesthesia complications.

The British Medical Journal online is said to have reported on a New Zealand study showing that  in a randomized controlled trial of nearly 40,000 patients, women who took a somewhat low dose of calcium and vitamin D, 1 gram and 400 IU, had about 1.2 times the risk of women not taking calcium and vitamin D of having heart attacks and strokes.  Other studies show similar findings for calcium alone.  To truly evaluate the risks and benefits of calcium, one would need to know if calcium and vitamin D supplements in normal women actually prevent the condition they are prescribed for, that is osteoporotic fractures.  When last I heard, proof of a positive effect of calcium on bone strength was lacking and vitamin D supplementation was only definitely good for fracture prevention in the frail elderly. I am not entirely sure what to do with this information, other than inform my patients of the depth of our ignorance regarding these supplements.

At the international conference of the American Thoracic Society, researchers reported that daily treatment with the antibiotic azithromycin could postpone exacerbations of chronic lung disease for nearly 100 days compared to patients not treated with the antibiotic.  Azithromycin, because of how well tolerated it is and how it can be given in a very short course due to its persistence in the body, is one of the most overused antibiotics in my experience. It is pretty much good for what ails you: hang nails, mosquito bites, colds and flu. It is even generic. Using it daily on patients with chronic lung disease will undoubtedly cause an increased resistance of community bacteria to the drug, making it useless for others who might need it. Clearly this is an intervention that needs to be chosen after much consideration, and for patients who really have very little lung reserve.

A rheumatological meeting at New York University reported that treatment of gout with medications that reduce uric acid  levels can decrease heart related mortality by nearly 50%.  Patients with gout have elevated levels of uric acid in their blood streams, related to diet, genetics, kidney function and medications they take.  Many patients have elevated uric acid levels without getting gout (a very painful inflammation of joints and soft tissues, especially in the legs.) These patients also will benefit from lowering the uric acid levels.  The medication used most commonly to lower uric acid is allopurinol. It is very inexpensive and sometimes causes an allergic rash or hair loss. In general it is very well tolerated and very affordable.  There are many medications that can control gout symptoms but only the medications that reduce uric acid levels are helpful to the heart.  Allopurinol and it's new cousin Febuxostat work, as do the two ancient gout drugs probenicid and sulfinpyrazone which make a person eliminate uric acid in the urine. This study will help me counsel patients on what medicine to take to prevent gout.

The proceedings of the National Academy of Science apparently reported on a slight reduction of the effectiveness of SSRI antidepressants such as Prozac (fluoxetine) in patients (and mice) treated with certain medications for pain, specifically NSAIDs such as ibuprofen and naproxen.  The effect is small, but certainly worth thinking about if a patient doesn't respond to antidepressant medications.  Of course, if they give up their effective pain medication, which may reduce their exercise, depression may rear its head in another way.

The British Medical Journal reported in May that using beta blocker medications along with asthma inhaler medications for chronic obstructive lung disease actually improves survival. I had always been convinced that use of a beta blocker in a patient who wheezed was a very bad idea and would reduce the effectiveness of a drug that stimulated beta receptors, such as albuterol. In fact I would often scoff at the silliness of doctors who would have their patients on both beta blockers and beta stimulators. I'm thinking now that I was probably wrong.

The last and most fascinating drug story came to me in the form of a high school friend whose father, a family practitioner, I knew from childhood. She visited me unexpectedly last weekend and told me his story and showed me his website. He, Michael Saliba MD, worked in La Jolla and did some research early on at UC San Diego medical school on treatment of burns.  He found that a common and inexpensive medication that we use for treating blood clots, heparin, was a very powerful stimulator of skin healing in burned or otherwise denuded skin.  He was able to try this on humans and over the years has successfully treated people with quite severe burns with heparin.  He applies the solution by dripping it on a wound in the case of small wounds, and intravenously and as a subcutaneous injection of high doses in much more significant burns.  He found that not only did it dramatically speed healing but it also nearly completely relieved pain, and patients often healed without much scarring. Most of the centers which use heparin are overseas, however, and the routine has never caught on in the US. Although there have been more studies reported, some showing dramatic successes and reductions in associated costs, there are none of the large multi-center studies that usually herald a major change in therapeutics.  Some explanations include the fact that heparin has been a generic medication for so long that it doesn't financially benefit anyone to study it, that high doses of heparin worry physicians due to perceived risk of major bleeding (which actually only happens if there are bleeding injuries in the first place) and possibly due the fact that our standard treatments of very large burns is very big business, supporting all kinds of medical industry. Or he could just be making it up. Having known Dr. Saliba for as many years as I have, his overall kindness and trustworthiness are strong enough that I doubt that his claims are exaggerated.  I think I will try it for the next burn wound I see. Besides being a very inexpensive treatment, what excites me most of all is the potential to treat burn pain which is so difficult to manage with oral medications.

Wednesday, June 8, 2011

Accountable Care Organizations--some perils and pitfalls

It is ever more widely accepted that fee for service medicine, that is payment for individual services that medical professionals provide, by patients or by insurers, is a bad idea. If a physician is paid to deliver a specific service, such as seeing a patient in the office, removing his or her gallbladder or doing a colonoscopy, the physician will perform more of these services, regardless of whether this improves the health of the patient. Ethically a doctor may make appropriate choices, but financially the reward will be for quantity of services not quality of care. If a health care provider is paid to take care of a patient, a flat fee per patient per year for instance, the incentive will be to keep that patient as healthy as possible with as little medical intervention as possible and to prevent costly disease. This is known as "capitation" (literally paying by the head.)

Capitation has been tried and used in many situations over many years in medicine. Staff model health care cooperatives such as Kaiser and Group Health operate this way. Many states pay flat fees to providers to serve their medicaid populations. Outcomes are often better because this system focuses on continuity of care with members assigned to specific doctors, and usually involves better coordination of aspects of care by the different providers involved. It sometimes irritates patients because choices of specialists and medications are often limited due to the staff model and to money saving drug formularies. In cooperatives, a governing board which includes patients help make decisions about what kinds of care are provided, which makes them somewhat more responsive to consumers' needs.

The present model (outlined in the Affordable Care Act) that attempts to get away from fee for service medicine is called the Accountable Care Organization (ACO). A group of physicians, often in cahoots with a hospital, can contract with medicare to provide service to at least 5000 medicare patients, and if they can provide that care for cheaper than benchmarks, while documenting good quality as measured by various things that organized medicine thinks is important such as lab test numbers and hospital admissions, they can have a share of the saved loot. There are various reasons why this is not a great solution. First of all, the creation of accountable care organizations is driving a big push by hospitals to employ physicians, which may make medicine more corporate, placing yet another entity between the patient and the provider. If a physician is employed, the rules of practice will likely be defined by the employer, and if that employer is interested entirely in saving money, convenience and the human touch may well be lost. Also, these much larger organizations may, by controlling more of the care that is delivered, have enough power to actually push costs up by monopolizing care.

Another problem with the present model of an ACO is that it would not end fee for service at all, and so the administrative hassles involved in making lists of diagnoses for each patient and matching them up with fees for units of service will continue to eat up our time. More non-patient time will be eaten by the documentation of quality. It is not entirely bad to be required to demonstrate that our care works, but the devil is in the details, and getting cholesterol numbers just right may not be the thing that my patients actually value.

Finally, in my personal world, ACOs are impractical because a community the size of mine, around 20,000 people, is too small to have 5000 medicare beneficiaries as is required by the Affordable Care Act. We could potentially hook up with other communities, but having meetings and communicating would be a nightmare, given the density of population around here.

I do think that physicians need to be more involved in providing care for patients that contributes to their actual health and happiness instead of simply providing units of service. I think that a system that rewards good care and encourages creative ways of delivering it are part of a successful future for medicine. It is vitally important in all of this that we continue to care for our patients and remain committed to the give and take relationship that allows us to share our knowledge while respecting what our patients value. Having a third party, an insurance company, pay for our services already negatively affects this intimate partnership. It is my hope that in reforming our present payment system we do not introduce yet another financially motivated entity into the exam room.

Thursday, June 2, 2011

How to get more gifted physicians to practice primary care

It is entirely clear that too few medical graduates go into primary care. Although the number of family physicians is increasing modestly, there are very few internal medicine residents becoming primary care doctors. This year there will be only about 200 new internal medicine doctors entering the workforce from training programs, which will not even begin to cover the attrition of older and more efficient physicians, and due to improvements in access with the affordable care act, demand will be increasing significantly.  The main reason that very few physicians are choosing primary care is that specialty fields are just about as rewarding personally and way more rewarding financially.

Insurance companies in our present, primarily fee for service, payment system, pay generously for operations and procedures, but much less for complex interactions such as counseling patients on their multiple medical problems, medications, and managing their many diseases. A cataract operation is reimbursed at around $1500 or more, and an ophthalmologist can perform one of these in less than an hour. A similar hour of seeing patients will net a physician a small fraction of that amount of money, and will require many more decisions and neuron firings. Many other procedures have similar high reimbursement for very low amounts of work. If a physician specializes in a field that involves many procedures, he or she can make truly absurd amounts of money if there are sufficient numbers of patients who need that procedure.

Because of the shortage of primary care doctors, more and more people are getting their primary care from nurse practitioners and physician's assistants, who have many fewer years of education than a physician. These providers are paid less than physicians and are more plentiful. Many of them are very competent, but patients often prefer an MD over a PA because the MD has a greater depth of knowledge. A primary care visit is often a combination of counseling about psychological issues, medications and interactions, review of tests, recommendations about prevention and careful examination (at its best). MDs can be very good at this.  Midlevel practitioners are often quicker, having been trained to treat urgent problems more than chronic ones.

Training to be a primary care physician requires at least 7 years after completing a bachelors or higher level college degree. The first year is spent learning basic science and physiology, the second involves absorbing huge amounts of information about human beings in health and disease. The third and fourth years bring the student in direct contact with patients, providing supervised clinical care along with classes and individual teaching by practicing physicians and academics. After these 4 years we have an MD degree, and must pass a licensing exam that assures a certain level of competence in all fields of medicine. At this point we can still choose to become surgeons, radiologists, pathologists or go on to academic medicine or research.  Those of us who intend to be primary care docs then spend at least 3 years in residency, taking care of patients under the supervision of more experienced physicians, with an increasing level of independence. When we finish these residency years we are broadly competent in taking care of most of what can go wrong with a human, with fresh and extensive knowledge of psychiatry, critical care, well patient care and the vast variety of other illnesses we have been exposed to.  After those residency years we have the opportunity to take another year or more of specialty training in fields such as cardiology, oncology, infections disease or rheumatology. Most physicians who specialize limit their practices to specific diseases and no longer do general medicine.

Nurse practitioners and physicians assistants must complete 2-3 years of training after getting their undergraduate degrees and in most states are then certified to practice independently. Although they are often gifted and become increasingly capable with years of practice, they do start out with considerably less training than physicians and the programs that train them are significantly less competitive.

So what would a midlevel practitioner be really excellent at doing? In what kind of a situation would a provider with less extensive experience and education really shine? Procedures. A midlevel such as a nurse practitioner or physicians assistant could learn to do an excellent cataract extraction or colonoscopy. Advanced level nurses already act as surgical assistants and have been providing anesthesia services at a high level for longer than MDs have done. In developing countries with less medical regulations, it is often the janitors or former patients who learn to do operations and act as surgeons when the foreign trained doctors are not available. I have read that some of the most skillful surgeons for vaginal fistulas, a very delicate and specialized condition of women who have had disastrous labors, are lay people.

What else would midlevels really excel at? Already much of diabetes care is delivered by nurse practitioners who limit themselves to issues related to that disease. They do an excellent job, often better than MDs. Specific disease states, as are now managed by subspecialists, would be perfect for nurse practitioners and PAs. In fact, this is already starting to gain momentum.

How would shifting procedural work to midlevel providers affect the health care equation? If less well paid providers did this work market forces would drive down costs, which would make procedure rich specialties less desirable. Health care costs would also go down, and if cognitive specialties such as primary care were even somewhat better reimbursed it would increase the number of talented folks choosing those careers.

A recent article in the New England Journal of Medicine obliquely addressed this question. Here is the link:

http://www.nejm.org/doi/full/10.1056/NEJMoa1009370

In this article authors looked at the success of treatment of hepatitis C by specialists vs primary care doctors after an online course in treating this common and deadly disease.  Primary care providers were slightly more successful than the gastroenterology clinic which trained them in curing the disease. This does, of course, involve MD providers in both cases, but gives very strong support for the idea that specialization can be taught effectively and quickly.

A move in this direction will be very unpopular among just those who are most needed to make it work, the MDs who make their livings doing procedures. These folks have years of practical experience and have skills that are not available in books or videos. Excellent surgeons will always be necessary and appreciated. A supremely skilled surgeon is an artist and deserves money and acclaim. Wise subspecialists will always be needed and appreciated in taking care of patients with diseases that are rare or so complicated that primary care physicians are just not enough. But we are now grossly out of balance, with a truly inadequate number of primary care physicians to take care our our growing needs, and appropriate use of midlevels could be a solution to the problem.