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Friday, January 24, 2014

Paul Lee--a Washington healthcare lobbyist talks about why it's all good

A few nights ago I attended a dinner and lecture at the local dining venue where they served huge hunks of prime rib and sauteed snow peas from some far away place where it's Spring, and chocolate mousse and wild rice. Global warming increased just slightly due to our excess consumption, but my portion would have been wasted had I stayed home. Beside the food, I was curious to see what the healthcare lobbyist who spoke had to say about where healthcare reform is headed. I was surprised to find that he was almost entirely positive about what was going on and that in general he said things that I agreed with.

How could this be? Healthcare lobbyists generally want the industry they represent to get as much money as possible. I generally want the healthcare industry to rein in its excesses and be more conscientious and efficient. Clearly there is some agenda here that I don't understand. Either that or efficiency and reining in excesses is beginning to align itself with the success of the healthcare industry.

The Speech

Mr. Lee, the speaker, bravely faced an audience that included many doctors and administrators who believe that healthcare is going rapidly to the dogs and that the Affordable Care Act (or Obamacare as they prefer to call it) is the end of all that is good. His message was quite succinct and described a scenario in which the growth in healthcare expenditures would continue to slow and populations would become healthier and more people would be insured and access care in an environment that would include more non-physician caregivers and less specialists. His visit and presentations were paid for by the CEO's of the three local hospitals who seemed to approve of his message. He showed graphs of trends and briefly touched on the specific issues of rural hospitals, which all three of the local hospitals are. He talked about how new requirements for hospitals to curb complications would lead to a safer environment for patients and fewer unplanned readmissions.

Population Health

He also used a couple of terms that had the feel of buzzwords, but which were actually very interesting. He spoke of the inevitability of focusing on "population health." We presently do fee for service medicine, though not entirely (there are health care coops and other pre-paid models and quite a few physicians are salaried.) This means that we get paid when patients are sick. We are moving in the direction of being paid for how well we take care of patients, otherwise known as "pay for performance." According to Mr. Lee we are heading toward a goal of "population health" which he explained meant taking responsibility for the health of the entire community in which we practice, rather than just taking care of patients when they get sick. There is an article in the Journal of the American Medical Association this month which looks at exactly this. Emma Eggleston MD and Jonathan Finkelstein MD write about how population health could be attractive to the stakeholders who pay lots of money when people get sick, but might be less attractive to entities which make their money only through treating sick people. Also, if we focus on making everyone healthy there may be a dynamic of requiring people to do certain things that interfere with their individual rights, such as exercising and stopping unhealthy habits. This may not be universally acceptable to Americans.

How it works

I know that in our small community there could be some non-hospital interventions which might significantly reduce hospitalizations. If physicians or midlevel caregivers would see patients on an emergency basis in nursing homes and maintain good continuity of care with those patients and their families we would see fewer emergency room visits and hospitalizations. If there were a community crisis center that was robust and effective, we would have less emergency mental health visits. If acupuncture and massage were easily available and covered under insurance, we would likely have fewer pain medication prescriptions and fewer hospitalizations for complications of these medications. If our hospital was paid a certain amount of money per year to take care of the patients in the community regardless of whether they were admitted to the hospital, low cost ways to reduce hospitalizations would be very attractive, and the hospital would likely invest in them. If the hospital made money only when patients were admitted, they would not be inclined to do so. Mental health hospitalizations and emergency room visits are almost always a drain on hospital resources since we don't have a psychiatrist or mental health capabilities and can't hospitalize these patients. Traditionally these patients have also been poorly insured or uninsured as well, so there was no hope of reasonable reimbursement for the hours of care (however that may be defined) that they received in the emergency room. Hospitals such as ours might well save money by funding a community crisis center if it actually kept patients out of the emergency room.

A nearly viral piece of news this week was the fact that Utah has drastically reduced homelessness by giving the homeless homes. There is an initiative in Utah, begun 8 years ago, to reduce homelessness and poverty, which has several strategies for reducing costs related to chronic destitution. It costs a significant amount of money to treat the homeless in emergency rooms and intermittently put them in jail, and there is less of that if they live in apartments rather than on the street. Utah does not provide housing for free, but does make it very affordable, charging about 30% of government funded income. Utah also has programs to prevent homelessness including interventions to keep people in their homes who are at risk of losing them. President Obama's 2009 American Recovery and Reinvestment Act (the much derided "stimulus package") has been partly responsible for funding these projects. This is an excellent example of "population health." Not only does it reduce emergency room related costs, but the no-longer-homeless are much more likely to get and hold jobs than if they were on the streets.

Compressed Morbidity

The other term that our speaker, Mr. Lee, used at the end of his talk was "compressed morbidity." He explained that this was the overall goal of a good healthcare system. Most people, he asserted (and I agree) would like to be sick for the least amount of time possible, and die when they are not yet miserable or have only been so for a short time. The concept of compressed morbidity was first introduced by Dr. James F. Fries, now an emeritus professor of rheumatology at Stanford University, in 1980. He wrote a more comprehensive article on it in 2005. Dr. Fries noticed that almost everyone dies by the age of 110 and most people by the age of 85. As we get better at maintaining health, more people live to be older, but the true maximum age of a human doesn't increase much. With better prevention of disease, be it vaccination or quitting smoking, people live to ages that are closer to the maximum age and spend less of their lives sick and requiring medical care. He suggests active encouragement of all of the behaviors that we know make us stronger and smarter, including such revolutionary ideas as providing alternatives to nursing homes as people age. Although we will live longer if we do those things which slow disease and decline, we will overall use less medical resources. This goal is the end result of a "population health" approach.

I am mostly but not entirely excited about all of this. I personally would like to live healthy and then drop dead, or get eaten by a bear or something, while I remain mostly independent. But I still do respect the rights of people with different values to practice them. That sounds pretty good until I think about the rights of people to become addicted to injectable drugs, get HIV and multiple abscesses all over their body, spend years in the hospital and nursing homes lingering with their stroke related brain damage and chronic pain and eventually die after costing the system many millions of dollars. I suspect that it is not really up to me and does not rest on my sensibilities whether the US moves in the direction of population health and achieves progressive compression of morbidity. It will most likely be determined by how much money we are willing to spend on healthcare and what kind of outcomes we are willing to accept as being adequate for our money.

Friday, January 10, 2014

Ultrasound in South Sudan: what might it be good for?

Last month I spent 2 weeks in a small hospital in South Sudan and probably did about 100 bedside ultrasounds. The whole experience was very moving, and encompassed so much more than doing ultrasound, even though I had intended the trip to be primarily for teaching ultrasound applications. It turned out that I also had to learn as much tropical medicine as my aging brain could hold and clean up spider webs and feed people and put goop on rashes and sew up gashes and learn to say hello in Nuer and a number of other things which will occupy an important place in my heart for years.

But as an ultrasound nerd, there were many exciting nerdy moments. These were the moments that most ultrasound nerds experience when we realize, again, that this technology is totally cool and that we wish everyone could do it.

I have spent the last 2 years practicing hospital medicine and a little bit of primary care and doing thousands of bedside ultrasounds. I have taken classes and tests and spent free moments studying ultrasound anatomy books. I have taught students and shared pictures with specialists and attended meetings. I have ultrasounded friends and family members, my dog, taken a fellowship, bought 2 machines, given one away. All because ultrasound is cool. It is indescribably awesome to look inside a person's body without hurting them.

In the United States I use bedside ultrasound to answer pretty specific questions that are relevant to my practice. Is the heart function normal? Is there fluid in the belly or lungs which shouldn't be there? Do the kidneys and bladder empty properly? What do the great vessels say about hydration status?

In Africa I had less standard testing to help guide diagnosis, so the ultrasound got to tell me more information. Here are few ways it helped me:

1. Strong guy, walked in limping, having stepped on a thorn 5 days before. He was sure there was something in his heel. I hate getting foreign bodies out of heels. It really hurts and the flesh is so firm that it is nearly impossible to explore a heel. I had only the phased array transducer for visualizing large deep structures, but by using a rubber glove filled with water as a stand-off pad I was able to visualize an echogenic long thin thing about 2 cm down, numbed it up generously, sliced it open and pulled out a big thorn. Wow. Just like in the movies!

2. Two women came in very short of breath after long journeys. Tuberculosis is endemic in South Sudan. Both had pericardial tamponade with moderate effusions and calcified pericardia, probably indicative of chronic tuberculous effusion. TB is treatable, but definitively treating pericardial tamponade was not practical. Diagnosing the condition was interesting from an imaging point of view, but the two ladies died anyway.

3. A couple of patients had kidney failure. By history it seemed likely that it was not new, but ultrasound was helpful in ruling out obstruction and the kidneys of both were echogenic suggesting that the condition was not likely to improve much.

4. One patient appeared quite short of breath, but it was unclear if she had asthma or pneumonia or something else. There is no x-ray machine. The ultrasound showed bilateral pleural effusions which strongly supported a diagnosis of tuberculosis. This was treated effectively with anti-tuberculosis medications and steroids. Her pleural effusions nearly disappeared within a few days of treatment.

5. An old man had been discharged for presumed congestive heart failure. He was clearly going to die, and his daughter had taken him to a hut in the village before taking him home. His ultrasound showed a huge tumor in his chest cavity displacing his heart, which otherwise functioned just fine. His heart medications could be stopped.

6. A young woman had come in to the hospital with a premature delivery and post-partum hemorrhage. She was anesthetized and the retained placenta was manually extracted, but it was not clear that it had been completely removed. Ultrasound showed an empty uterus, allowing her to go home when she had stabilized.

7. Other women with vaginal bleeding could either go home if they were stable, with a completed miscarriage, or could be counseled to rest if a pregnancy could be visualized.

8. There were leg infections which were slow to heal, some with pus collections that had been drained. Ultrasound could tell us if they needed repeated drainage.

9. A woman with a suspected ovarian cancer had a painfully huge belly from ascites. She responded pretty well to therapeutic paracentesis, but the ultrasound was very helpful in allowing us to dodge the large peritoneal tumor masses that might have caused bleeding.

10. Evening clinic often brought babies who were under the weather. Doctors in South Sudan see enough untreated congenital heart disease that they could be reasonably certain of a diagnosis of ventricular septal defect. Still, seeing the hole in the heart on ultrasound and the degree of heart enlargement was very useful. Some babies can make it to Khartoum, the capital of Sudan, and may be eligible for free heart surgery.

...and also so many reassuringly normal or near normal ultrasounds.

How and who to teach in this setting is a good question. Caregivers have varying backgrounds and must actively develop new competences when patients are sick and demand is high. It is interesting that the ability to visualize a person's internal organs with ultrasound and correlate those pictures with previously learned anatomy does not necessarily spring from an extensive medical education. Some people are just good at it. I encouraged the people I taught to ask specific questions rather than looking for weird things like tumors. Finding a normal fetal heartrate, determining fetal presentation and estimating fetal age are very useful and not hard to learn. These will be possible to learn and practice with a little bit of supervision. Finding fluid in the belly is easy and potentially very useful. Detecting fluid in the lungs will take a little more work, but should be easy eventually. Looking for a full or empty bladder should not be too hard to master. Most hearts will be normal, so detecting that there is something wrong should come with a little practice. Diagnosing exactly what is wrong is quite a bit trickier. Protocol driven diagnostics and treatments have been very effective in resource poor settings, so a more complete training course should probably include a protocol of when to do ultrasound and what questions are reasonable to ask.

Thursday, January 9, 2014

Smoking: A half century of knowing we should quit

In 1950 Ernst Wynder MD and colleagues began to produce convincing data that cigarette smoking caused lung cancer. Over the ensuing many years evidence has arisen linking cigarette smoking to many different cancers and conditions, chronic lung disease and heart attacks. In 1964 the surgeon general reported that cigarette smoking was the most important risk factor for development of lung cancer and that quitting smoking reduced that risk. Since that time a concerted effort to reduce tobacco smoking has been one of the most important public health agenda items for the medical profession. Since this is the 50th anniversary of organized tobacco control, the Journal of the American Medical Association has devoted an entire issue to the subject of tobacco and health.

Articles include a survey of smoking prevalence around the world: US residents smoke less than people in Europe, especially Eastern Europe. Although many Africans smoke, they don't smoke much, Women generally don't smoke as much as men, except possibly in Eastern Europe. There were a pair of articles discussing eCigarettes, the nicotine delivery devices that look vaguely like cigarettes but don't burn tobacco. One article expressed the strong conviction that eCigarettes should be regulated by the Food and Drug Administration (FDA) because their long term safety has not been studied, especially in adolescents, their public use makes people accept a smoking-like activity in public places where it is now prohibited and many people who smoke eCigarettes also smoke tobacco so perhaps the delivery of nicotine allows ongoing addiction. The other article suggested that eCigarettes might be a "disruptive technology" and might entirely replace burning tobacco, with its associated health risks. Digital photography was a similar disruptive technology and has successfully nearly replaced film photography due to its competitive cost and improved convenience and adaptability. The authors felt that increased regulation of eCigarettes might serve to bolster the market share of the tobacco industry, with significant negative impact on the health of the smokers who are likely to abandon tobacco for a cheaper and more convenient alternative.

Other articles looked at the usefulness of two drugs, bupropion and varenicline, to promote and support cigarette abstinence. These drugs have been available for years, along with nicotine replacement, to help smokers quit and have been moderately helpful.

The most thought provoking article of the collection was written by two authors, Andrea L. Smith and Simon Chapman, of the Public Health School of the University of Sydney in Australia. They point out that the vast majority of patients who have quit smoking have done so entirely unassisted. No support groups, no drugs, no counseling. In a 2013 Gallup poll, 48% of successful quitters stopped "cold turkey" because they decided it was time. 5% used nicotine replacement and only 3% used drugs. The authors noted that the Australian government spends a vast amount more money on the drugs prescribed to help patients quit than on social marketing campaigns which would make them want to quit. Apparently the US is not alone in its belief that we need pharmaceuticals to make us well. Buying drugs which don't work and require that patients visit doctors for prescriptions and counseling is revenue generating. Successfully quitting "cold turkey" is not.

In 1964 Americans first got the message from the surgeon general that they should quit smoking to reduce their risk of lung cancer. The response to this message was huge. In 1964 42.7% of adults smoked and today that number is 18.1%. Average daily cigarette consumption among smokers has also dropped, from 20 to 13. We have seen a significant reduction in death rates associated with smoking related diseases. The vast majority of smokers consider themselves to be addicted and would like to quit. The huge number of patients who have successfully quit have reduced their risk of heart attack, stroke, cancer and lung disease significantly. A group out of Yale University modeled the number of premature deaths prevented by tobacco cessation since 1964 and they estimate that 8 million lives were saved. These were people who didn't get cancer, didn't need oxygen tanks, didn't have to undergo radiation treatment or chemotherapy, have bypass operations, struggle to walk up hills due to shortness of breath or heart pain. What a lot of people need thanks for this: doctors who diligently nagged patients, researchers who followed up leads conscientiously, advocates who countered tobacco company rhetoric, public health specialists who made the story interesting, and most of all smokers who decided to quit, because it was time.

Monday, January 6, 2014

Hypertension: New (Joint National Committee 8) Recommendations for Treatment

Doctoring is a practice based in science, but at its best, attempts to treat whole complex humans to achieve goals such as health and happiness which have no good scientific definition. Good doctors practice outside of boxes, and our success or failure is scrutinized closely according to very subjective criteria by our patients and colleagues. It is nice, in this situation, to have aspects of our work be based on clearly measurable variables; blood pressure, for instance.

The concept of high blood pressure as a clinical diagnosis began to be accepted at the beginning of the last century, correlated with the invention of the blood pressure cuff. It turns out that the pressure of blood in the arteries, when elevated, can lead to heart attacks, strokes, aneurysms and kidney failure and can be an indication of other serious medical illnesses including tumors of the adrenal gland and pituitary as well as narrowing of the blood vessels to the kidneys. Controlling the blood pressure has been effective in reducing heart attack and stroke rates, historically. Blood pressure elevations are usually related to genetic factors as well as obesity, high salt diet, excessive alcohol intake. Lifestyle changes to reduce salt intake and obesity and increase activity significantly reduce blood pressure. The first consistently tolerable blood pressure medicine was produced in the late 1950's and that class of medications (thiazide diuretics) is still one of the most widely used and effective ones available.

There are many classifications of drugs that can lower blood pressure and the production of new ones has been a staple of the pharmaceutical industry for many years. Since blood pressure medications frequently have unpleasant side effects or don't lower the blood pressure very effectively, it was easy to produce new drugs that promised superior blood pressure lowering effects or less side effects or a more convenient dosing schedule. A pleasingly simple and mutually enjoyable office visit for a patient and primary care physician in my experience included measuring the blood pressure, finding it to be just a bit too high, going to the sample closet, finding an attractively packaged new blood pressure medication with the placebo effect still firmly attached to the brightly colored capsules, giving it to the patients with instructions to come back in two weeks to see how well it worked. Unfortunately the shiny new medications were ridiculously expensive and usually too new to have been extensively tested to determine if they actually worked to reduce the target issues, stuff like strokes, heart and kidney damage, as opposed to just lowering the blood pressure. Guidelines emerged from organizations such as the National Heart Lung and Blood Institute (NHLBI) to address which medicines to use and what blood pressure was too high and which patients to treat. There has been abundant research on blood pressure control and outcomes in different populations, fueled by both drug companies which wanted to prove their new blockbusters to be effective and experts in the field who wanted to find out what actually worked. Committees have attempted to digest this research, some good and some suspect, and come up with recommendations to guide practice.

This week the Journal of the American Medical Association published the Joint National Committee's eighth set of guidelines, ten years after the last set of guidelines came out. Guidelines are taken quite seriously by physicians and now by the people who pay us, who often scrutinize our adherence to them as a basis for performance based pay. These guidelines were 5 years in the making, I read, and were scrupulously discussed, based only on randomized controlled trials, and were delightfully succinct. There were three editorials in the same issue, generally approving them, though admitting that there is room for debate and improvement.

Briefly, and it is possible to be brief with these recommendations, the new guidelines recommend:

  1. Treat all patients over the age of 60 with lifestyle recommendations plus medications if their blood pressure is over 150 systolic or 90 diastolic, aiming for a blood pressure just below this goal. Previous guidelines recommended a goal of 140/90 in this group. Patients who feel fine and are on medications with blood pressure significantly below this goal may remain on the same medications.
  2. Patients between the ages of 18 and 60, start treatment with lifestyle measures and medications if the blood pressure is over 140 systolic or 90 diastolic, with a goal blood pressure of under 140/90.  This same recommendation is true for patients in this age group with diabetes or kidney disease (which increase the risks associated with hypertension.)
  3. Use drugs in only 4 classes to start, including diuretics, angiotensin converting enzyme inhibitors or angiotensin receptor blockers or calcium channel blockers such as diltiazem and amlodipine. Beta blockers are absent from the list of recommended drugs because of one well done study which showed an increase in death for patients on beta blockers, primarily due to strokes. Drugs can be started singly or in combination. For African Americans use only thiazides or calcium channel blockers unless they have significant kidney disease, in which case angiotensin active medications are probably effective. Be sure to use doses of these drugs that are adequate but not toxic (there is a nice table.)
  4. For patients with blood pressure above the goal after starting initial therapy, add another of the drugs in one of the 4 classes, but do not combine angiotensin receptor blockers with angiotensin converting enzyme inhibitors. If blood pressure still is not controlled, drugs in another class may be added, though it is unclear from evidence that this will make a difference in outcome.

These recommendations are not meant to entirely squelch creativity and do not address control of blood pressure in patients who have established heart disease, who may take other medications that control issues other than just the blood pressure and may interact with blood pressure medications.

I am generally very happy with these new guidelines. The fact that blood pressure goals for patients over the age of 60 are looser will significantly reduce the burden of treatment for these people, and reduce the number of fruitless visits in which both patients and physicians feel like failures because a number refuses to climb as low as we would wish. The standardization of blood pressure goals for patients younger than this, returning to the historical 140/90 as a goal of treatment will also simplify things. The treatment of blood pressure with reduction of disabling strokes and heart attacks that has been associated with this is a major success of modern medicine and simplifying treatment will probably make both patients and physicians more motivated to do it right.