June 19, 2015

What Is Happening at Joslin Diabetes?

Not only has Joslin Diabetes Center continued to (in most cases) shield the person writing the blog, but also they have moved away from much of the mainstream diabetes information and are concentrating for the last several months of promoting their own agenda and departments within Joslin. This makes me wonder if they are in need of more advertising because their patients are not finding value in the Diabetes Center.

Over the last month, many of the blogs have been repeats of prior blogs. Does this mean that the blog is on the way out and will shortly be disappear? I would not be surprised if this happens. It seems obvious that they no longer have employees willing to support the blog and are willing to write a blog.

I have noticed that many other hospital and diabetes blogs supported in the past by progressive diabetes centers are slowly disappearing or are losing the content interest they had at one time. Even the Mayo Clinic diabetes blog is heading downhill with many repeats and not being issued as often.

I used to find many blog ideas from these two sources and read them regularly. Now I look at them and often go on to another source. When I recognize a repeat, I now hit the delete key and the email is gone.

Could these blogs be a victim of 'less is more'? Or are they now low-value for the reader? I would have to answer yes to both questions.

With the internal changes happening in our nation's hospitals and clinics, much of the value in healthcare is disappearing because of time constraints as each person is working harder to reap more of the financial pie and pride is no longer a factor. What many of the hospital employees and other healthcare employees have not realized yet is the fact that the financial pie is smaller because the administrators are taking a larger slice of it.

Even many Accountable Care Organizations (ACOs) that are now required by law are also causing their employees the same problem because the ACO administrators are gobbling up larger and larger slices of the financial pie.

June 18, 2015

Doctors Need to Learn When to Stop a Medication

Being in the age range for geriatrics, this blog really hit home and means that I will need to pay attention to what the doctors say and be alert to any new medications prescribed to avoid duplication. I will also need to be more alert as I age to question my doctors about what medications may no longer be necessary.

This will be difficult for the doctor and me. This is because the blankety blank researchers are afraid of the elderly and multiple conditions, exclude us from clinical trials because they have no experience with us, and feel it is a waste of money to have clinical trials that might include us. Yet they will waste more money on faulty clinical trials of no meaning and think they are doing things of importance.

The blog from GeriPal - Geriatrics and Palliative Care Blog talks about when to stop medications in people with advanced dementia. The author talks about her training and says, “Throughout medical training, we devote extensive time learning when to start medications. We memorize the pharmacology, indications for use, side effects, and sentinel trials showing their efficacy. Yet, not until my fellowship training in Geriatrics, did I learn another key part of medication prescribing: when to stop.”

Why are many patients with advanced dementia still taking medications of questionable benefit? Stopping a medication may seem straightforward, and clinicians know that stopping a medication is frequently more difficult than starting a medication. Clinicians generally lack the knowledge and more importantly, the evidence to help clinicians know when to discontinue medications.

Stopping medications involves discussing the risks and benefits with the patients and their families, which if often difficult as they are of the opinion and hope that the medication will stop or significantly slow the progression of the disease. They often will not accept the disease has advanced beyond the point where medication is helpful.

Many clinicians are uncomfortable taking away medications, as they are trained to always 'do' something, which usually prescribing. Stopping medications does not mean they stop caring for the patient, they shift their focus of what the patient needs.
This means for a patient, a focus is made on hand-feeding and skin care, quality time spent with his or her family, and focus on activities the patient still enjoys. The author concludes by stating that learning and studying when to stop medications, can help us start taking better care of our patients.

While this is redundant, I would like to refer you back to my last blog and the blog by Leslie Kernisan, MD, and how she handles stopping or reducing medications for treating hypertension. Dr. Kernisan's procedure can easily be adapted to other medications.

June 17, 2015

The “Less Is More” Medical Campaign – Part 6

In the last blog, research was encouraged to discover harms when more medicine is practiced, but not when less medicine is practiced. This is one of the weaknesses of the 'less is more' medical campaign. This is why as a conclusion I would encourage you to read these two blogs, 1) a blog by Rocky Bilhartz, MD and 2) a blog by Leslie Kernisan, MD who rightly poke holes in the 'less is more' advocated so openly by many doctors.

Both use some statistics to show why and urge caution when thinking 'less is more' when dealing with the people over the age of 65. They also reference the lack of research that does not happen for people in this age group and Dr. Bilhartz says that population medicine (medicine for all ages) is not always what should be followed. He correctly states that many doctors only want you to believe that less is always more in public medicine. This takes the individual out of medicine and often harms the individual when the full medical history is not given the attention it deserves. They prefer that you should only do for the individual in medicine what is best for the entire group as seen from their perspective. And, they are wrong about that.

What does not make good sense is that even the few clinical trials that do include the people over the age of 65 are very restrictive of who is included in the trials. This makes many of them unreliable for use in comparing them for the average patient over 65. Many of the over 65 patients have multiple conditions (comorbidities) that affect their health and make healthcare more complicated. Some of these conditions or diseases can include – diabetes, multiple sclerosis, cardiovascular disease, hypertension, and many, many others. This is just one more reason that the individual medical history is important and should trump 'less is more' medicine. Granted this does not mean that more is always better, but the individual needs to be front and center and not lumped into the general population.

Dr. Kernisan deals with the topic of hypertension and blood pressure medications. She works with elder patients and often sees patients that are over medicated. In the process of reviewing patient history, she often discovers that patients are being prescribed more hypertension medications than necessary to manage blood pressure.

Even the study she uses was not totally accurate because the fall situation prior to the study was not disclosed. Dr. Kernisan says that people aged 70+ are more at risk of falls by being treated for high blood pressure than is recognized by clinicians and patients. She also notes that real-world Medicare beneficiaries often have more chronic conditions that the older adults who are enrolled in randomized trials of blood pressure treatment.

Dr. Kernisan does state that preventing or reducing the risk of cardiovascular events is laudable, but it has been hard to prove a benefit for medicating most people to keep blood pressure below 150/90. She firmly believes that doctors should be especially careful when it comes to patients who seem prone to falls, or who are experiencing blood pressure levels well below the target of 150/90.

The following is important enough to quote from her blog. “Because right now, when it comes to treating high blood pressure in older adults, we are often not careful. Meaning that many clinicians don’t:
  • Ask about falls or near-falls before starting or adjusting blood pressure meds.
  • Get more blood pressure data points before making an adjustment in therapy. The convention is to treat at a visit based on the blood pressure that the staff just obtained. It would be better to base treatment on multiple readings, preferably taken in the patient’s usual environment.
  • Check on blood pressure soon after making an adjustment in therapy. Often patients have their meds adjusted and nobody checks on things until the next face-to-face visit…which might be 6 months away.
  • Find out what the patient is actually taking before making adjustments. When looking at a given BP number, we should confirm that the patient is actually ingesting the meds we think they are, at the dose we think they are. Needless to say, this isn’t always the case! Also occasionally important to have figured out when medications were taken relative to when the BP was checked.
  • Act to reduce BP meds in vulnerable elders. If a frail older person on BP meds sits in front of me and registers SBP of less than 120, I generally look into things a little more. (I ask about falls, and I check orthostatics.) Why? Because now we seem to be fair ways below my usual target SBP of 140s. Is this person on more medication than they need? Are they dropping their BP into worrisome low range when they stand up?”

Both blogs are important, Dr. Bilhartz covers one aspect, and Dr. Kernisan covers another aspect.

June 16, 2015

The “Less Is More” Medical Campaign – Part 5

What the writers say in this segment is true, but – yes, there can always be one of these – why does high-value care always need to be high-cost care.

Delivering high-value healthcare in the U.S. will require increasing the availability and affordability of needed care and decreasing waste and unnecessary care, much of which is harmful. But there are considerable barriers to reducing unnecessary and potentially harmful care.

One of the many barriers to care that quality care is the perception that more care is better medicine. The United States Preventive Services Task Force (USPSTF) recommendation in 2009 advising that mammography posed more harms than benefits for women between the ages of 40 to 50 and this was not well received nor understood as it was intended. Was the message well stated? No. The USPSTF did not emphasize that screening these women leads to net harms.

It is true that less healthcare creates fears of rationing, but that is a topic for another blog and I have written about this in the past as well. Withholding care simply to save money sometimes seems irrational. Currently many doctors and hospitals earn more money when they do more and this is a common tactic of many hospitals in addition to overcharging the system.

Many physicians and lay persons have written to thank MedPage Today for talking about this important issue and for encouraging more research into the harms of tests, procedures, and treatments. This last part of encouraging more research into the harms of tests, procedures, and treatments needs more emphasis and is seldom seen in the mainstream media, to say nothing about medical newsletters and journals – even MedPage Today seldom says enough.

Unfortunately, awareness of the harms of overuse of medical care probably isn't enough to achieve the "less is more" goal. According to the article authors, “We are very encouraged to see that many new efforts are underway to reduce overuse, including educational initiatives, computer-based alerts, and decision support tools, peer review and feedback, and system changes supported by implementation and behavioral sciences.”

Important changes are occurring in the U.S. healthcare system, moving away from fee-for-service medicine, which rewards high-volume care regardless of appropriateness, towards bundled payments, accountable care organizations, and capitated systems that can better align incentives towards high-value care. I do need to wonder if all the changes are for the better and if rationing will become too common place to the harm of patients.

June 15, 2015

The “Less Is More” Medical Campaign – Part 4

About two-thirds of the doctors surveyed have tied the 'less is more' approach to care by limiting "low-value" tests or procedures.  The doctors report pushback from patients and said that patients resisted their efforts and requested more tests and other procedures even though they had been advised otherwise.

Nearly 390 doctors completed the survey for MedPage Today from May 4 to 15.  The survey is not a true representation of the medical community, but it still shows how some doctors balance providing healthcare to patients who think they need certain procedures or tests.  Unnecessary testing is a serious problem and this is identified by 85 percent of the survey respondents.

If we are to believe the survey report, it says more than 80 percent of the physicians say they are trying to limit what the view as “low-value” procedures.  According to the 80 percent, CT scans, MRIs, and x-rays are the three most common tests as providing low value for the costs or risk.  What they fail to say is that occasionally the use of these three tests are absolutely necessary.  I can agree that they are overused, but if they are attempting to eliminate these tests, many people will not be diagnosed properly.

Most of the doctors quoted in the MedPage Today article were adamant that they work with patients to avoid unnecessary procedures and tests that will not add to the value of their care.  I actually like this, “Knowing when a screenings are necessary can come down to experience,” said Michael Rothstein, MSN, FNP, who works at the New York College of Podiatric Medicine.  "I tell my students that 'you have to know when to limit so you're not doing the million-dollar workup unnecessarily," he said.

From the different articles that comprise the group of 'less is more' series, it is fairly obvious that many hospitals and some doctors do more tests and procedures than needed to determine what is ailing a patient.  It has been interesting that more examples were not used, but this will not be the last blog in this series.