Archive for July, 2008

Washington diary: Body shock

Monday, July 14th, 2008

I have spent the past two weeks recovering from foot surgery and so I have had ample time to reflect on the marvels of (private) US health care and the misery of a body in decline.

By sheer coincidence my medical issues started as soon as I landed in the US four years ago.

Only 48 hours after getting off the plane in Washington I was seized by numbing pain in my upper jaw and rushed to a smart dental clinic near the White House.

I pointed to a throbbing molar and was puzzled to find the unusually monosyllabic nurse taking an X-ray of every single tooth in my mouth with quiet and unflinching determination.

She returned half an hour later with the maestro of the clinic who pinned 36 or so stamp sized X-rays on a back-lit board as if they were part of an avant-garde art project and then gave a PowerPoint presentation entitled something like “My vision for your mouth”.

“What about the tooth that hurts?” I asked innocently.

“Thas juss the beginning,” said Dr Harrison, a southern gent with a pencil-thin moustache arching over a blindingly white smile.

“We are gonna work together for three years to get everything in perfect order! An I promise, I won’t have to see ya more than once a month.”

When the doctor had exited in a swoosh of fluttering white to “work with” the next patient, the nurse leant over as if in deep confidence and added: “You are SOOO lucky to be working with Dr Harrison! He is the beeeast!”, making “best” sound like “beast”.

I never returned after my root canal operation. I chose to become a dental fugitive, hounded every six weeks by increasingly urgent letters reminding me of the doctor’s vision and my empty promises. I am certain that my mouth is on a blacklist somewhere.

Flatulent joints

Two months later the next chapter of bodily woes was opened. One day, out of the blue, without warning and for no apparent reason, my neck felt as if I had survived a garrotting.

I ventured into the hitherto unknown world of chiropractors.

Dr Schweinstein X-rayed everything above my shoulders and explained to me that – among other things – I had too much gas in my joints, which is why I would soon hear a flatulent noise as he took my neck into a half nelson.

As I contemplated the notion of farting joints, the chiropractor’s fleshy hands fastened around my head, yanking it left and then right as if I was an extra in some martial arts movie. I heard the advertised noise and felt instantly better as the pain seeped away.

“Thank you, Dr Schweinstein,” I said with genuine relief and admiration for the healing profession. “That will be it then?” I added for good measure, heading for the door.

The doctor fixed me with watery blue eyes.

“Actually,” he intoned with a flat, yet authoritative voice, “this is just the prologue, you might say. What I have in mind for you is a two-year programme… a standard course of chiro-therapy to get your neck back in shape. The good news is: shouldn’t need you here more than once a week! Your insurance should cover some, if not most of it.”

The cost of this healing process to the uninsured would have been $150 a week. I wondered how the estimated 50m Americans who have no private medical insurance cope. They don’t, of course.

But they weren’t on my mind at this stage. I was planning another getaway. A fugitive from medicine… twice over.

Midlife crisis

Four months later I was reading the New York Times and my then seven-year-old son asked me: “Dad, why are you holding the newspaper like that?”

“Like what?”

“Like that… so far!” he said and stretched his little arms straight out.

I hadn’t even noticed how my reading arm had got longer and longer.

So my eyes were next. At least the optician was a “walk-in”. No appointments, no waiting room, no dog-eared copies of last month’s Time Magazine and Yachting Monthly.

The verdict: long sighted.

“Why?” I asked the optician, whose name escapes me. “I have always had perfect vision!”

His nose crinkled and I knew I should have kept my mouth shut. No optician believes in perfect vision. It’s presumptuous and it’s not good for business.

“How old are you?” he asked.

“Forty-one,” I replied.

“Ahhhhh,” he said in a voice oozing pity, understanding and wisdom all coated in glee. “It’s the age.”

And with those three words my midlife crisis started.

The healthcare industry had officially declared me fair game, easy prey, a rich seam of never-ending profits.

I left the opticians and stumbled, diminished, into the glare of a Washington summer’s day.

I walked down the road fingering my new glasses – frames so sleek, lenses so petite they were almost invisible – almost – when I felt my Blackberry buzz to life in my trouser pocket.

I put on my new specs clumsily, half enjoying this pompous new prop, and allowed them to slide professorially to the tip of my nose. I glanced down at the tiny screen. It was a joy to see so clearly.

An e-mail flashed up from someone called Kevin. I assumed it was work and clicked to open.

“Need Viagra, Cialis, Levitra?” Kevin asked. “We can help! You can perform!” It wasn’t the Kevin I thought it was.

Metatarsal hell

I had hit rock-bottom. What could possibly be next? A few months later I got the answer: my feet.

I have always had feet so wide they defied even the most comfy Hush Puppies. To me, Birkenstocks felt like winkle-pickers.

The pain was beginning to make me hobble and I was about to learn a new word: podiatry.

My podiatrist, a tower of a man who wears disconcertingly orange clogs with his blue surgical jump suit, eased me into the wonderful world of podiatry.

“No surgery, yet, Matt. Foot surgery is a serious business… we’ll give you some orthotics first.”

These specially moulded soles were the most expensive shoes I have ever bought and they didn’t work. Six months later the pain was so bad that I had to go under the knife.

I would like to say that I have joined the hallowed order of the broken metatarsal, just in time for the World Cup.

Rooney, Beckham, Owen, Frei… even if I was nursing MY metatarsal on the sofa watching them test theirs on the pitch. But unfortunately I shared my pain with the other Beckham, not David, Victoria.

And it wasn’t the metatarsal per se… it was metatarsal-related. I am talking about an excrescence of the bone resulting in a serious realignment of the toes. I am talking about a… bunion.

Posh Spice has one, a whopper that sticks out of her golden lace thong sandals like a raw pink golf ball. And I have two. One on each foot.

Hobbling hordes

“Bunion?” Isn’t that what women get for wearing the wrong shoes?” a friend asked. True.

About 50% of American women get bunions, a statistic that didn’t make me feel any better. I owe mine to my mother. Yes, they are hereditary and no, I have never worn stilettos.

“Bunion?” I asked the doctor. “Is there no fancier word? Something in Latin perhaps. Something complicated, more interesting?”

“Well, bunion is the ancient Greek word for turnip. Does that help?” the doctor with the orange clogs asked. (*)

No, it didn’t.

The worst thing is that the surgery necessary to remove a “turnip” is long, complicated, painful and could end in failure.

It involves hobbling around for eight weeks with a surgical boot that could have been invented by a workshop of medieval torturers on attachment to the Ministry of Funny Walks.

I hit my low point last week. I was waiting in the surgery for my post operation check-up.

I was surrounded by middle-aged women wearing the same boot. My fellow patients. The hobbling regiment of hop-alongs.

A lady with a magenta rinse turned to me and said: “Honey, I feel so sorry for you. You are the wrong age and the wrong gender to have a bunionectomy!”

She recommended I check out an internet talk show called Life Beyond Bunions. I didn’t know whether to feel flattered or flattened.

*bunion: medical condition known as hallux valgus. Origin early 18th century, unknown origin, perhaps Old French buignon, from buigne, bump on the head (Oxford English Dictionary)

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Pulmonary Hypertension in Interstitial Lung Disease

Wednesday, July 9th, 2008

Treatment of Pulmonary Hypertension in Interstitial Lung Disease

Limited data suggest that the treatment of pulmonary hypertension in ILD is beneficial. Enough oxygen to limit exercise and nocturnal hypoxemia should be a focus of care.

Trakada et al.[11] studied 38 patients with ILD and oxygen saturation above 90% at rest during the daytime with nocturnal polysomnography. They observed that all 38 (100%) experienced nocturnal hypoxemia to an oxygen saturation at least below 85%, and they suggested that screening for nocturnal hypoxemia should be standard in these diseases.

There are some theoretic risks to vasodilation in patients with ILD. If pulmonary artery vasodilation leads to improved blood flow into areas of fibrotic lung, then worsening of ventilation perfusion mismatch may result. This would be manifested by lower oxygen concentrations either at rest or with activity. Whether significant worsening of hypoxemia occurs with oral or systemic vasodilators remains to be shown in larger clinical trials. Small studies have suggested that hypoxemia may occur. This has been shown in some scleroderma patients with ILD who were treated with epoprostenol.[15] Ghofrani et al.[16] administered inhaled nitric oxide, intravenous epoprostenol, or oral sildenafil to 16 patients with pulmonary hypertension and ILD. Although all three agents decreased pulmonary vascular resistance, the patients receiving intravenous prostacyclin experienced decreased arterial oxygen tension, largely because of an increase in shunt fraction. By contrast, inhaled nitric oxide and sildenafil maintained ventilation perfusion matching and decreased pulmonary vascular resistance without a decrease in arterial oxygen tension.

There is a theoretic benefit in matching ventilation and pulmonary vasodilation with an inhaled medication such as iloprost. In a pilot study by Olshewski et al.,[17] eight patients with ILD and severe pulmonary hypertension were given epoprostenol, inhaled nitric oxide, or inhaled iloprost. Systemic arterial pressure, arterial oxygen saturation, and pulmonary right-to-left shunt flow, measured by multiple inert gas analysis, were not significantly changed; however, pulmonary vascular resistance fell and was associated with significant clinical improvement in some of the patients.

The advancement of therapies for pulmonary hypertension in ILD will require carefully designed clinical trials that will focus on both short-term and long-term endpoints. Although survival may ultimately be affected, short-term studies of gas exchange, exercise tolerance, and quality of life should be sufficient to speed therapies to the bedside of these difficult-to-treat patients.  Printer- Friendly Email This

Reduction of High-Risk Polypharmacy Drug Combinations

Wednesday, July 2nd, 2008

Abstract and Introduction

Abstract

Study Objectives: To enhance physician and patient awareness of polypharmacy; to decrease the risks, drug costs, and waste resulting from polypharmacy; and to make the business case for reducing misuse, overuse, and underuse of drugs by reducing polypharmacy.
Design: Longitudinal, time series cohort.
Setting: Outpatient, managed care, integrated delivery system.
Patients: A total of 195,971 patients who received health care from the Henry Ford Medical Group and had health insurance coverage from the Health Alliance Plan.
Measurements and Main Results: Two identical interventions separated by 1 year were conducted in patients at high risk of harm from polypharmacy based on five categories of high-risk drug combinations (referred to as polypharmacy events). Six months of pharmacy claims data were reviewed before and after each intervention to identify these patients. The intervention program consisted of clinical pharmacists performing drug therapy reviews, educating physicians and patients about drug safety and polypharmacy, and working with physicians and patients to correct polypharmacy problems. Prescription cost/member/month, number of prescriptions/member/month, and rates of polypharmacy events/1000 members were measured before and after each of the two interventions. After the first intervention, the overall rate of polypharmacy events decreased from 29.01 to 9.43/1000 patients (67.5% reduction). The number of prescriptions/member/month decreased from 4.6 to 2.2 (52.2% reduction), prescription cost/member/month decreased from $222 to $113 (49.1% reduction), and overall institution drug cost was reduced by $4.8 million. Six months after the second intervention, the overall rate of polypharmacy events was reduced from 27.99 to 17.07/1000 (39% reduction), the number of prescriptions/member/month decreased from 4.5 to 4.0 (11.1% reduction), and prescription cost/member/month decreased from $264 to $239 (9.5% reduction). Overall institution drug costs were reduced by $1.3 million. Sustained effects were seen for all measures of polypharmacy (p=0.001).
Conclusions: These interventions reduced drug costs and numbers of prescriptions in a managed care cohort of patients at high risk for adverse drug events due to polypharmacy. By providing clinical information, decision support, patient self-management support, and care delivery redesign some of the problems resulting from polypharmacy can be solved.Introduction

A national survey of noninstitutionalized American adults indicated that more than 40% of persons aged 65 years or older take five or more different drugs/week, with 12% taking 10 or more.[1] Polypharmacy, however, may not only be appropriate but is often necessary to improve health outcomes and prevent disease progression in older persons with chronic conditions. However, overuse, underuse, and misuse of drugs have all been linked to serious health problems, disabilities, hospitalizations, and death.[2-4]

The term polypharmacy suggests that more drugs are prescribed and taken than are warranted clinically. Patients at greatest risk of polypharmacy consequences are the elderly, patients taking five or more concurrent drugs, those with multiple physicians and pharmacies, patients with concurrent comorbidities or impairments in vision or dexterity, and individuals who have recently been hospitalized.[5] According to one study, nearly one in four noninstitutionalized elderly Americans is taking potentially dangerous prescription drugs.[3]

Researchers who evaluated a cohort of older ambulatory persons estimated that as many as 27.6% of adverse drug events are preventable and occur most commonly with cardiovascular drugs, diuretics, nonopioid analgesics, antidiabetic agents, and anticoagulants.[6] Preventable drug-related morbidity is the fifth most costly health condition. In 2000, the United States spent $133 billion on drugs and an estimated $177 billion managing drug-related problems.[7] For every $1.00 spent on drug therapy, as much as $1.30 may be spent managing drug-related problems.[7] These concerns have prompted calls to action by numerous organizations, including the Centers for Medicare and Medical Services, the Institute for Health Care Improvement, the Institute for Health Care Quality, the National Committee for Quality Assurance, the National Quality Forum, and the Institute for Safe Medication Practices. Oversight of pharmaceutical care by clinical pharmacists has proven effective in improving quality and lowering cost of care in various venues.[8-14]

The goal of our longitudinal study was to improve drug safety through the reduction of polypharmacy in managed care patients. In patients receiving polypharmacy, we performed two identical interventions that consisted of clinical pharmacists performing drug therapy reviews, educating physicians and patients about drug safety and polypharmacy, and working with physicians and patients to correct polypharmacy problems. The intervention integrated the practice of pharmaceutical care with data extracted from pharmacy claims. Primary objectives were to enhance physician awareness of polypharmacy within our managed care network, decrease rates of selected high-risk polypharmacy combinations, and reduce drug costs resulting from polypharmacy.

Our secondary objective was to develop the business case for expanding the polypharmacy intervention program to all patients receiving health coverage from our institution. According to some authors, an intervention can be said to fulfill a business case for quality if it leads to a financial return on the investment needed to implement the intervention in a reasonable time and with a reasonable rate of discounting.[15] This return may consist of profit, reduced losses, or avoided costs. For a polypharmacy intervention to be sustainable, it must satisfy the business case for quality.