Managing the Transition from Hospital to Home

For the elderly and especially the elderly with diabetes in the United States, this is a real problem. Today, most primary care doctors do not make rounds in a hospital and often are not aware that a patient of theirs is in the hospital. Fact is, most hospitals do not contact the patient's doctor to let them know they are in the hospital even when requested by the patient.

This is the reason that transitions from the hospital to home are so difficult for many of the elderly. If they don't have someone available to be a caregiver for them and see to it that they get to their primary care doctor, often that does not happen and the person ends back up in the hospital.

The divide between outpatient and inpatient medicine seems to be growing, highlighting the importance of managing care transitions as an outpatient-only physician, according to this article published in Medical Economics.

According to the article, primary care doctors can play a major role in preventing transition gaps for their hospitalized patients. Lines of communication should remain open between hospital-based clinicians and primary care doctors, via electronic medical records and other modes of communication. Yet, many hospitals are not doing this.

Primary care doctors can have the greatest influence on continuity after patient discharge. Follow-up visits should include assessment of patient recovery and review of the post-discharge care plan and medication regimen. How can the primary care doctor do this when hospitals will not communicate.

The shift to a hospitalist model of care can be unnerving for elderly patients, and it is important to notify patients of this change. Courtesy visits to the hospital allow primary care physicians to stay involved in patient care without being the caregiver in the hospital, and are important for patients. Many primary care doctors will not visit the hospital because they are not reimbursed for doing this. So it is a two way disconnect because most primary care doctors expect their patients to present themselves at their office.

Yet, when a few hospitals have contacted doctors that do make house calls or reach agreements with nurses to see discharged patients from the hospital, primary care doctors become upset and raise all sorts of issues that they are the ones their patient should see. Yeh, right doctors, the patient may not be capable of travel or does not have transportation available to come to your office. This is a catch-22 for some elderly patients.

Vaccination Recommendations Not Followed By People with Diabetes

This is alarming. I have seen recommendations promoted before and blogged about it here. National guidelines for hepatitis B, influenza, and 23-valent pneumococcal polysaccharide vaccines, according to a study published in Clinical Diabetes are not being followed by people with diabetes.

The latest in Endocrinology Advisor says that patients with diabetes, considered to be at increased risk for infection and infectious complications are not being vaccinated. This is serious and people with diabetes, any type, need to get current with their vaccinations. I will need to get mine in the coming three years and one will come due in each of the coming years. In addition, I will also be receiving two or three additional shots that are due.

23-valent pneumococcal polysaccharide vaccines is one that many people just don't get and I don't know why. The CDC has several pages about this and I suggest that you read them and follow other links as well.

The researchers identified extensive nonadherence to immunization recommendations for all three vaccines among patients considered to be at increased risk for infection and infectious disease complications because of their history of diabetes. For the hepatitis B vaccination, nonadherence to the 2011 Advisory Committee on Immunization Practices' recommendation was pervasive.

Allocation of health care resources to increase vaccine coverage should remain a priority, with a focus on spreading awareness of the hepatitis B vaccine recommendation for people with diabetes. This should be a no-brainer, but for some reason, people with diabetes elect to avoid this vaccination.

I finally arrived at a compromise with my VA doctor. She has been pushing very hard to have me get the flu shot. I complain that the mercury is hard on my system and if they would get the vaccine without the mercury, I would take it. Two winters ago, they had one, but before my appointment, they had an individual that was allergic to mercury and needed the flu shot, so I did have the regular shot. The same happened last fall and I said I would pass and in the future, they needed to order two. So, I will see what happens this fall. I am fortunate to have never had the flu, but the odds are mounting against me.

Soybean Oil Causes Obesity

If you don't believe in rodent studies, you may want to skip this blog. I don't either, but felt that this study needs to be reproduced in humans – highly unlikely. It does raise some interesting ideas and even Tom Naughton covers this in his blog here.

Scientists at the University of California, Riverside have found that mice on a high soybean oil diet showed increased levels of weight gain and diabetes compared to mice on a high fructose or high coconut oil diet. The scientists fed male mice a series of four diets that contained 40 percent fat, similar to what Americans currently consume.

1. In one diet, the researchers used coconut oil, which consists primarily of saturated fat.
2. In the second diet about half of the coconut oil was replaced with soybean oil, which contains primarily polyunsaturated fats and is a main ingredient in vegetable oil.
3. The other two diets had added fructose, comparable to the amount consumed by many Americans.
4. All four diets contained the same number of calories and there was no significant difference in the amount of food eaten by the mice on the diets.

Yes, the study is on rodents. Will it give the same results in homo sapiens? While the statistics are interesting, something says it will not be the same in humans.

In the U.S. the consumption of soybean oil has increased greatly in the last four decades due to a number of factors, including results from studies in the 1960s that found a positive correlation between saturated fatty acids and the risk of cardiovascular disease. As a result of these studies, nutritional guidelines were created that encouraged people to reduce their intake of saturated fats, commonly found in meat and dairy products, and increase their intake of polyunsaturated fatty acids found in plant oils, such as soybean oil.

Implementation of those new guidelines, as well as an increase in the cultivation of soybeans in the United States, has led to a remarkable increase in the consumption of soybean oil, which is found in processed foods, margarines, salad dressings and snack foods. Soybean oil now accounts for 60 percent of edible oil consumed in the United States. That increase in soybean oil consumption mirrors the rise in obesity rates in the United States in recent decades.

During the same time, fructose consumption in the United States significantly increased, from about 37 grams per day in 1977 to about 49 grams per day in 2004.

The study also includes extensive analysis of changes in gene expression and metabolite levels in the livers of mice fed these diets. The most interesting results were those showing that soybean oil significantly affects the expression of many genes that metabolize drugs and other foreign compounds that enter the body. This suggests that a soybean oil-enriched diet could affect one's response to drugs and environmental toxicants, if humans show the same response as mice.

The UC Riverside researchers also did a study with corn oil, which induced more obesity than coconut oil but not quite as much as soybean oil. They are currently doing tests with lard and olive oil. They have not tested canola oil or palm oil.

Advocacy Blogger Does Not Understand “Death Panel”

This blog author would like us to believe that the death panel discussion is over and that all it took was a change in 'end of life discussions' that the Centers for Medicare and Medicaid Services is now set to reimburse doctors for now. He seems to conveniently forget that it was never about end-of-life palliative care. It was, and remains, about the Independent Payment Advisory Board (IPAB), its power, and its non-accountability.

Sorry, I am on a rant, but I really don't like this discussion by Bob Doherty of the

The ACP Advocate Blog. He is a Washington insider and obviously needs to protect some people in his advocating. In comments to his blog here, all are agreeing with him, but when another publication picked his blog to write about, the comments are basically my thoughts from the last sentence in the first paragraph.

I attempted to put my comment on his blog, but after four days, I know it will not be published because he controls the comments like I do. I can agree with several statements in his blog, and especially this - “Advance care planning allows a person with decision-making capacity to develop and indicate preferences for care and choose a surrogate to act on his or her behalf in the event that he or she cannot make health care decisions.”

I don't agree that the death panel was ever about discussing advance care planning with their patients, physicians would then pressure patients to give up on treatment and end their lives. It has always been about the Independent Payment Advisory Board (IPAB), it's power, and it's non-accountability. The IPAB would not answer to anyone and could make recommendations without having to worry about any ramifications or even lawsuits. This was what was correctly labeled as the “death panel.”

Recently the House of Representatives passed a bill to prevent the IPAB from existing, but the Senate has refused to discuss this and not even allowed it to be assigned to a committee, thanks to Senate majority leader Mitch McConnell, R-KY.

Some Doctors Argue for More Statins

Doctors are doubling down on their right to be wrong and do more harm to patients. With Rosuvastatin/Crestor the only statin still under patent, all of the other statins have lost patent protection, and so the world has changed. It is now cheaper to use the generic statins and doctors now feel that the benefits of low cost far outweigh the harms caused by statins. These doctors are promoting statins for more of the population and this means that the complications of statins will be affecting more people.

Recommendations now state that statins, which decrease low-density lipoprotein (LDL) cholesterol, may be prescribed if lifestyle changes aren’t enough. In 2013, the American College of Cardiology and American Heart Association, in collaboration with NIH’s National Heart, Lung, and Blood Institute (NHLBI), released new clinical practice guidelines on cholesterol treatment to reduce ASCVD (atherosclerotic cardiovascular disease) risk. Among the recommendations was that people 40 to 75 years of age without clinical ASCVD and diabetes should take statins if they have an LDL cholesterol level of 70 to 189 mg/dl and an estimated 10-year ASCVD risk of 7.5% or more. The guidelines also included methods for making this risk estimate.

A group led by Drs. Ankur Pandya and Thomas A. Gaziano at the Harvard T.H. Chan School of Public Health developed a computer model to project the lifetime health outcomes and cardiovascular disease–related costs of 1 million hypothetical U.S. adults. They used data from the nationally representative National Health and Nutrition Examination Survey (NHANES) and several other published sources.

The team found that the health benefits conferred by the current ASCVD risk threshold of 7.5% or higher were worth the incremental costs, according to commonly accepted “willingness-to-pay” public health standards. Lowering the threshold for statin treatment to 3% or 4% could avert another 125,000 and 160,000 cardiovascular events, respectively. Depending on assumptions about benefits and risks, these risk thresholds might also be considered cost-effective options. These estimates can help inform future decisions about balancing costs with quality years of life.

A group led by Dr. Udo Hoffmann at Massachusetts General Hospital and Harvard Medical School studied whether the new guidelines improved the efficiency and accuracy of the previous ones. The group drew on data from nearly 2,500 adults in the Framingham Heart Study. Participants underwent testing to detect coronary artery calcification, an early sign of coronary artery disease.

About 39% of the participants were eligible to receive statins under the ACC/AHA guidelines, compared to 14% under the previous 2004 guidelines. The new guidelines proved more accurate and efficient at identifying people at increased risk of both cardiovascular disease and subclinical coronary artery disease. The findings were consistent for men and women. They were particularly important for people at intermediate risk, for whom deciding when to begin statin therapy is challenging. The researchers estimated that between 41,000 and 63,000 cardiovascular events would be prevented over a 10-year period by adopting the ACC/AHA guidelines compared to the previous guidelines.

The new cholesterol treatment guidelines have been controversial, so our goal for this study was to use the best available evidence to quantify the tradeoffs in health benefits, risks, and costs of expanding statin treatment. We found that the new guidelines represent good value for money spent on health care, and that more lenient treatment thresholds might be justifiable on cost-effectiveness grounds even accounting for side effects such as diabetes and myalgia.

Now we have Big Pharma and a new class of drugs for treatment of LDL called Praluent (PSCK9), which in the USA has been limited by the FDA to treat only people at extreme risk for heart disease from cholesterol. Not that this will slow things as these doctors will just elevate the number of people at high risk and prescribe the drugs anyhow.

In addition, the side effects of Praluent include itching, swelling, pain or bruising at the injection site, nasopharyngitis and flu. Allergic reactions, such as hypersensitivity vasculitis and hypersensitivity reactions requiring hospitalization, have been reported.  Please read this blog by Dr. Malcolm Kendrick for more information on the drug class PSCK9.

If you would like to do more research about statins, I suggest you read the Great Cholesterol Con by Dr. Malcolm Kendrick. This is important if you even think that doctors are doing you a favor by prescribing statins to you.