Eating Healthy Not More Expensive Than Eating Junk Food (USDA May 2012 Study)

Most Americans are convinced junk food is cheaper than healthy food.  A new study by the United States Department of Agriculture Economic Research Service says that is not necessarily true.  It all depends on how we measure the price.  Here is the abstract for the study, titled  Are Healthy Foods Really More Expensive? It depends on How You Measure the Price

Most Americans consume diets that do not meet Federal dietary recommendations. A common explanation is that healthier foods are more expensive than less healthy foods.  To investigate this assumption, the authors compare prices of healthy and less healthy  foods using three different price metrics: the price of food energy ($/calorie), the price  of edible weight ($/100 edible grams), and the price of an average portion ($/average portion). They also calculate the cost of meeting the recommendations for each food group. For all metrics except the price of food energy, the authors find that healthy foods cost less than less healthy foods (defined for this study as foods that are high in saturated fat, added sugar, and/or sodium, or that contribute little to meeting dietary recommendations).

How did this government study define healthy foods?   Food items are defined as healthy if they

• Contain an amount of a food in at least one of the major food groups (vegetables, fruits, grains, dairy, and protein foods) equal to at least half  the portion size that the Dietary Guidelines for Americans 2010 uses for  measuring the nutrients in that food.
• Contain only moderate amounts of saturated fats, added sugars, and sodium. 

What were the major findings of the study?  How we define price determines whether eating healthy is more or less expensive than eating junk food.

• Foods low in calories for a given weight appear to have a higher price when the price is measured per calorie. For example, vegetables and  fruits, which are low in calories, tend to be a relatively expensive way to  purchase food energy. 
• Conversely, less healthy foods (called “moderation foods” in this report)—especially those high in saturated fat and added sugar—tend to be high in calories and to have a low price per calorie.
• When measured on the basis of edible weight or average portion size, grains, vegetables, fruit, and dairy foods are less expensive than most  protein foods and foods high in saturated fat, added sugars, and/or sodium. 
• In following the food group recommendations at ChooseMyPlate.gov, it is less costly to meet the grains, dairy, and fruit recommendations than those for vegetables or protein foods.

In other words, if you are like most Americans, you tend to eat too many calories.  That's why you're obese, morbidly obese or have super morbid obesity.   You eat too much junk food.   If you ate fewer calories you could still eat they same weight of healthy food and end up losing weight instead of packing on an extra 3-4 pounds every year.   It's time to start viewing the cheapest foods as those with the highest nutriment (not calories) at the lowest cost.  By that measurement, most healthy foods, including fruits and vegetables would be cheaper than most junk foods.

Many Americans claim they can't afford fruits and vegetables because they cost too much.  This study puts to rest the myth that eating healthy isn't affordable, especially if the cost of eating unhealthy included the additional cost of rapidly rising medical insurance premiums,  copays and deductibles for physician visits and hospital admissions that are directly attributed to the rising rates of obesity in this country.  We can cut our risk of diabetes, stroke, heart attack and cancer by 80% if we included a healthy diet as part of our healthy lifestyle.

Right now you have nothing to worry about.  If ObamaCare isn't struck down by the US Supreme Court, you'll be able to eat all the junk food you want and your accelerating premiums, copays and deductibles will be paid for by others.  However, you'll find a really hard time finding doctors to accept your Medicaid and that means longer hours waiting to get your diabetes medication filled in the ER.

That is if you plan on filling your prescriptions.  However, you'd  better think twice about  not filling your scipts because you won't want to be labeled as noncompliant when the government finds out you fall below the 80th% line for patient medication adherence.   That might categorize you as a high risk citizen that will trigger a pesonalized junk food tax that will penalize your bad food shopping habits.

Don't be a fool.  Eat your fruits and vegetables.

Citation:

Carlson, Andrea, and Elizabeth Frazão. Are Healthy Foods Really More Expensive? It depends on How You Measure the Price, EIB-96, U.S. Department of Agriculture, Economic Research Service, May 2012.

Baby Zach Thinks He's a Puppy Rolling Around In The Dog Bed (Cute Video)

Zach turned one year old last month and we have discovered how just how much he's absorbing and learning from experiences all around him. He may not seem like he's picking stuff up, but he is. In fact, we feel he may even be Marty and Cooper's Pack leader. He thinks he's a puppy, as you can see in this video below of him rolling around in the dog bed, just like his little puppy buddies!

You can see all the rest of Zachary's blog posts, videos and pictures too.

Baby Zach Taking His Puppy Dogs For a Walk (Video)

Baby Zachary can't wait to take his Marty and Cooper puppies for a walk.  Cute video of baby puppy love.

 Make sure to catch all of Zachary's blog posts videos and pictures.

Show Me Your Tongue

Daddy does a complete neuro exam on his one year old Zachy. Show me your tongue, boy!

Make sure to catch all of Zachary's blog posts, videos, and pictures.

Baby Doves In a Nest With Their Mama Dove (Cool Pictures)

A while back I posted some backyard  pictures of a dove nesting in a tree.  Well, we discovered the baby doves have been born.  Here are the baby doves nesting in the tree with their mama. They were really calm.   How different they look from their mama dove.  We got up right within a couple feet and they didn't even flinch.   

 Really cool pictures, I think.  Enjoy.

Proportion of Days Covered (PDC) As a CMS Measure of Patient Medication Adherence: Big Brother Is Watching You!

I received a letter the other day from  MedicareBlue Rx (a Medicare Prescription Drug Plan) titled as an Adherence Improvement Opportunity. According to the letter I received:

The Centers for Medicare and Medicaid Services (CMS) recently added medication adherence measures to their reported patient safety measures.  CMS uses the Proportion of Days Covered (PDC), developed by Pharmacy Quality Alliance, to calculate adherence.  Based on this, a patient who has a PDC rate of at least 80 percent is considered to be adherent.

Here's a good link describing the methodology of the medication adherence measure using pharmacy claims data to calculate the proportion of days covered.  In other words, as I understand it,  CMS is trying to define how adherent you as a patient are to your prescription medications based on how often you fill them (using drug claims data linked with medical claims and enrollment data).

CMS currently calculates and reports on several patient safety measures, including Part D medication adherence to treatment for cholesterol (Statins), hypertension drugs (ACEi or ARB) and oral diabetes medications (Sulfonylureas, Biguanides and Thiazolidinediones).   According to the first link above, the medication adherence rate for all beneficiaries in Part D plans was just over 60%.  That's 60%.  That's not surprising to me given that research has shown just 10% of patients given free heart medications after an MI continued to fill them one year later. 

The letter I received continued:

In an effort to promote adherence, we used our pharmacy claims database to identify patients on select chronic medications with a PDC less than 80 percent for whom you have prescribed medication.  A profile for each of your patients is enclosed.

Lower medication adherence is a major cause of hospitalization, poor health outcomes (including death) and increased overall health care costs.  Higher adherence rates have been associated with lower health care costs and better health care outcomes.  One study found that patients with diabetes, hypertension or hypercholesterolemia with high medication adherence (80-100%) had reduced hospitalizations and lower health care costs compared to less adherent patients.

Reasons for non-adherence may include side effects of the drug, cost of the drug, lack of perceived benefit and/or forgetfulness.

In addition, studies have found that lower member cost share is associated with improved medication adherence.  When prescribing therapy, please consider the use of a generic drug.  Generic drugs cost less.  Your patients may benefit directly; most have a lower cost share for generic drugs.  This is especially true for patients who may enter the Part D 'Coverage Gap' and struggle to pay high prices for brand-name medications.

Medication adherence is an important factor in maintaining patient safety and containing health care costs.  Please evaluate the adherence rate of your patients in the attached profiles.  If  non-adherence is a significant issue, please discuss solutions to address non-adherence with your patient.

Note:  this information is not intended to replace your clinical judgement. Prescription claims data do not include many other patient-specific variables needed to completely interpret the appropriateness of a drug regimen.  Only you, in direct consultation with your patient, may determine a patient's true adherence to medication.

Sincerely,

Signed with a signature stamp

David E. Pautz, MD, FACP  Senior Medical Director, Government Programs

Along with this letter I received notification of one patient who had last filled their lisinopril over 6 months ago.  I presume this patient was  flagged for my review as not being adherent to their medication regimen.  I presume I was notified because I probably ordered this blood pressure medication when they were discharged from the hospital at some time in the past.

This letter was intriguing on so many levels.  The most concerning to me is that I am a hospitalist.  I am left wondering if Dr David Pautz needs to ask himself What is a hospitalist?  because where I'm sitting in the peanut gallery, hospitalists are not involved in the month to month management of medication adherence after the patient gets their formal hospital discharge summary sent to the primary care physician.  I'm sure most hospitalists have never heard of proportion of days covered (PDC).  And I'm pretty sure most hospitalists have no ability to counsel their discharged patients about medication adherence.  I can guarantee with 100% certainty that the only action most hospitalists will take with this letter is to throw it in  the trash.

In fact, I'm probably sure most primary care physicians will as well.   They simply  don't have the labor intensive time to discuss  the dozens of potential reasons why Mrs Smith was flagged by CMS for not taking her lisinopril as prescribed.  And CMS just doesn't want to pay for the time intensive resources necessary to adequately provide this consultation.  Between the ten complicated chronic  medical problems, the list of 25 medications and the last minute complaints of  "Oh, by the way  I'm tired, I have no energy and  I've been dizziness", outpatient internists and family medicine doctors simply don't have the time to pursue these labor intensive discussions being requested by David E. Pautz, Md, FACP, Senior Medical Director, Government Programs

What are my concerns with CMS tracking patient medication adherence rates?  It's Big Brother at its finest.  While the federal government investigates Google and Facebook for privacy concerns, they are deeply involved in their own crusade to define everything about you.  And you probably have no idea it's happening.

 Of course, the first question I must ask is who will have access to this data?  You may not know it but data about you is worth its weight in gold to someone somewhere. Whether you are in the category of 80% or higher in proportion of days covered or whether you are in the 20% is important to someone somewhere.  And whether we like it or not, that data will be bought and sold like anything else that carries intrinsic value.

What are some possible repercussions for you, the patient or for doctors carrying for these patients when this data does get into the hands of businesses who can use it to make or break their business model?  Someday, this data, like all data, can be used against you (or for you if you are determined to be compliant with your doctor's recommendations).  And if you think this data stops with Medicare, think again.  It will be used by your private medical insurance as well and sold as a revenue opportunity for insurance companies looking to increase alternative sources of revenue:

Consequences For Patients with low patient medication adherence and proportion of days covered. 

• You may be charged more for your Medicare or private insurance premiums or be required to pay higher copays and deductibles.
• You may be denied certain medications, treatments, procedures or surgeries, based on expected algorithmic complications of poor medication adherence.   
• Businesses may use this to increase collections efforts or to write it off as expected bad debt.
• You may be denied as a patient in doctors offices who will be financially penalized for having an overall patient population with low medication adherence rates.
• You may be denied health insurance (I would not expect medication adherence to be considered a preexisting medical condition), life insurance, credit cards, car loans, mortgages or you may even be denied opening a bank account based on your medication adherence rates and their actuarial defined association with credit risk.  
• You may be denied the right to foster children or gain custody of your children if you are considered unable to take your medications appropriately.
• You may be denied parole  or be considered a high risk re-offender for being a high risk of failing to comply with the rules.

Consequences for Doctors with low patient medication adherence and proportion of days covered.

• Doctors may be penalized by Medicare or their private insurance companies and receive lower payment for services provided if patient adherence rates are suboptimal
• In a bundled care and or  accountable care organization model, patients with lower medication adherence will require a higher utilization of resources  with a potentially higher risk of failure to meet defined thresholds of success and overall reduced profit potential when these goals fail (and they will because patients don't live in an ACO bubble).
• Physicians may get fired from their hospital owned jobs for having suboptimal patient medication adherence rates which will threaten hospital revenues. 
• Physicians may open up clinics on more affluent areas of a city to avoid being penalized with  low patient medication adherence rates, reducing critical access to inner city populations.

Consequences for Hospitals with low patient medication adherence and low proportion of days covered.  

• Like other ORYX measures, it may someday be used as a factor to determine how hospitals get paid by Medicare.  Look for hospital profit margins from Medicare to continue their assault downward.  
• Patient medication adherence rates may someday be used to deny payment for 30 day hospital  readmissions.  
• Hospitals may use this data to increase collections efforts or to deny assistance for their outrageous medical bills.
• Hospitals may close for their inability to control what patients do outside of the hospital.

When you have data like this that has profound implications across many aspects of American business, I can assure you that eventually, whether you are labeled as a patient with good medication adherence characteristics or not, will be used either to your benefit or to your detriment.  Discrimination against smokers and patients with super morbid obesity is just the beginning.  Be prepared for the next wave of making patients pay for the right not to accept personal responsibility for their actions.  Unfortunately, it's going to drag doctors and hospitals through the mud in order to get there. 

Baby Splashing In the Pool (Fun High Speed Splish Splash Pictures with Zachary)

We had some splish splash fun recently at the pool with one year old baby Zachary. I set the Canon EOS Rebel T2i on a really fast shutter speed and snapped away. I love baby Zach's expressions as the water droplets caught in suspended animation splashes on his face.  You can also view all of  Zachary's blog posts videos and slideshow pictures.  

 

Risk of Thrombosis For Mechanical Aortic Valves Managed Without Anticoagulation. A Case Study In Noncompliance.

Patients with mechanical heart valves are routinely treated with life long anticoagulation.  Therapy is usually in the form of warafarin or trade name Coumadin therapy.  Why?  Why do we manage mechanical aortic (and mitral) heart valves with anticoagulation?  For the same reason we manage atrial fibrillation with vitamin K antagonists.  We "thin the blood" in order to reduce the risk of clot formation on the metallic foreign body and subsequent  risk for systemic embolization, particularly stroke.

What is the risk of systemic clot embolization  in patients with a  mechanical heart valve? Here are the numbers:

• While on warfarin therapy:  0.7-1% per patient per year.
• While on aspirin:  2.2% per patient per year.
• While on no therapy: 4% per patient per year.
• Patients with mitral valve are double the risk than patients with aortic valves.
• Some medical societies recommend all patients with a mechanical heart valve should also take 75-100 mg of aspirin per day, unless contraindicated.  

Coumadin is a nasty drug that can be very difficult to manage.  The Joint Commission has safety standards for anticoagulation managment in the hospital.  That does not mean they can dictate how physicians order warfarin.  But maybe they should.

As a hospitalist, I see an incredible clinical variation in how to initiate Coumadin therapy.     Sometimes failure to adequately dose Coumadin correctly can lead to INR/Hgb ratios that are out of this world.  And when that point has arrived, I may be forced to place subclavian central lines in fully anticoagulated patients.  Interestingly enough, none of my central lines in these folks have ever had procedural related bleeding.  That is because they are in  hypovolemic shock.

In my opinion, physicians are often either too lazy, to ignorant or to arrogant to appropriately manage warfarin therapy in the safest possible way.   I don't blame them.  The drug is difficult to predict and has so many confounding clinical variables that standardizing its management is the only way to safetly administer it across populations of hospital patients who's drug profiles and nutritional status's change rapidly on a day to day basis.  Doctors who think they are smarter than  Coumadin are a danger to patient health. Don't touch me or my family.  I would choose a pharmacist driven warfarin management protocol over a physician directed concept of a care plan every day of the week.

With the dangers of coumadin readily established, I must also point out the dangers of bridging anticoagulation using heparin or Lovenox.  Since warfarin often takes up to five days or more for the coagulation cascade to be adequately suppressed, physicians will bridge with these other drugs while waiting for the INR of Coumadin therapy to reach therapeutic goal. 

Unfortunately, even these drugs come with potentially devastating and life threatening complications, including severe bleeding and shock  (I particularly see a fair amount of retroperitoneal bleeding from Lovenox therapy) as well as H.I.T. positive antibody related thrombosis.  Does the risk of heparin or Lovenox bridging outweigh the risk of thrombosis from not providing bridging and allowing the INR to rise over several days in the post operative period in patients with mechanical heart valves?

The ACC/AHA, in their published 2008 guidelines gave guidance for bridging anticoagulation management in patients with mechanical heart valves in the perioperative period.   Their recommendations are pretty aggressive.   In high risk patients, they recommend restarting warfarin and bridging heparin as soon after surgery as bleeding stability permits (Class I Recommendation).  They define high risk as an patient with a mechanical mitral valve or any mechanical aortic valve patient with at least one risk factor (atrial fibrillation, previous thromboembolism, left ventricular dysfunction, a hypercoagulable state, older generation thrombogenic valves, a mechanical tricuspid valve, or multiple valves.)

This recommendation seems a bit counter intuitive to me.  Why?  The stated risk of thrombosis for mechanical aortic valves is 4% per patient per year.  That is a daily risk of thromboembolism of approximately 0.011%. Based on my decade of hospitalist clinical experience, I get a clinical sense that my short term risk  of complications from bridging heparin is greater than the 0.011% daily risk of thrombosis off all treatment.

You won't find many doctors or patients these days willing to test the limits of avoiding anticoagulation with mechanical valves.  We have been scared into anticoagulation submission, driven by fear and aggressive Society guidelines that leaves little room for clinical interpretation. I have difficulty understanding how a 4% yearly  risk of thrombosis off all therapy translates into such an aggressive clinical standard for perioperative bridging. 

Especially when we hit the non compliant research jackpot that provides insight into real life experience that would  never get past today's strict ethical standards.  Take, for example,  the 52  year old Hispanic roofer who decided two years prior to stop taking his warfarin for his mechanical aortic valve.    It was too much of a hassle getting his blood drawn and avoiding his favorite foods. Oh yeah, and the falls off the ladder kept giving him bruises.   To his credit, two years and four falls later he was doing just fine. Would you stop taking your Coumadin and play Russian roulette with your heart valve?  Some folks do.  And apparently some will do just fine.  

While only an N=1 case report, it makes one pause about how aggressive our recommendations really are for perioperative anticoagulation management in mechanical valves and whether those recommendations reduce thrombosis from the valve at the expense of complications from bridging therapy on a short term basis. Or even long term basis.   Is any of this research looking at the big picture?

 What's the benefit of a 3% yearly reduction in stroke if you increase your risk of a major bleeding complication by 5%?   Would you rather die from a stroke or an intracranial hemorrhage.  Pick your poison.  Us hosptialists, we'll take care of you either way.  Although, to some degree, membership in the patient noncompliance club may have its benefits.  

If you're on Coumadin or warfarin, here are some resources you might find helpful:

• The Coumadin (Warfarin) Help Book: Anticoagulation Therapy to Prevent and Manage Strokes, Heart Attacks, and Other Vascular Conditions
• The Coumadin Cookbook: A Guide to Healthy Meals When Taking Coumadin

Do Intensive Care Units (ICUs) Save Lives? Not Really. But, If We Build It, They Will Come.

Do intensive care units save lives?  That's a great question to ask in today's rapidly changing hospital payment environment.  We must continue to be diligent in asking ourselves if the care we are providing is the least resource intensive cheapest care possible without sacrificing outcomes. 

If you get admitted to a hospital, most facilities will determine which floor or unit you go to based on your presenting diagnosis as well as how  intensive your nursing needs will be.  Are you a dialysis patient?  You may go to a dialysis floor.  Are you a heart failure patient?  You may go to the cardiac floor.  Are you old and weak?  You will probably go to the hallway in the basement holding area near the hospital's centralized utility system near the social worker's break room.

We don't want these low paying social admits (and 17 other reasons you don't need to be admitted to the hospital) taking up high margin surgical beds.  Those doctors make a lot of money for hospitals.  We can't make them wait.  I have provided a much greater discussion about hospital floor plan layout design for interested parties.  

Intensive care units can even be subspecialized into medical units, surgical units and even subspecialty surgical units (like cardiac or transplant ICUs).  ICU nurses often train along side other ICU nurses for many months before they are free to practice on their own.  I met Mrs Happy when she was training as an ICU nurse.  Her final test?  She had to win at  ICU Bingo before she was free to see patients on her own.  And of course, the nurses climb all over themselves to try and  get paid that whole extra dollar an hour to be the preceptor of the day.

How are decisions made for patients to be  transferred to the intensive care unit?  Hospitalists and other physicians often write the order to admit a patient to the ICU as a direct admission from an outside ER or other inpatient hospital stay or they may transfer a patient to the ICU if their clinical condition deteriorates during their hospital stay.

Why would a physician transfer a patient to the intensive care unit?  For many hospitals, the ICU is the only place that allows certain monitoring, procedures or interventions to be performed.  From a resource utilization standpoint, use of  ventilators, arterial lines, central venous pressure monitoring, titration of continuous medication drips and frequent nursing vital signs are all excellent reasons for patients to be admitted or transferred to the intensive care unit.  

Physicians will also admit or transfer patients to the intensive care unit who are experiencing a rapid deterioration in their clinical condition.  Things like hypotension, acute respiratory failure, rapid gastrointestinal blood loss, severe sepsis or septic shock  and any other number of conditions that require intensive and continuous technological monitoring and bedside nursing care and carry a high probability of necessary interventions that require ICU status (see above).

And then there are established  hospital policies and procedures which state that certain objective data points (such as defined lab values) require the patient to be ICU status.  Things like committee defined critical potassium levels of 6.0 (or 6.1 or 6.2 or 6.3) or blood sugars greater than 500 (or 600 or 700 or 800) or sodiums less than 115 (or 110 or 105 or 100) often lead to ICU admissions or transfers by default, independent of the lack of clinical  decompensation   and often without any allowable  input of the attending physician.  These are hospital defined parameters that committees have determined to be in the patient's best interest, even though no data exists that such policies are medically necessary.  

These are the three main ways patients end up in the intensive care unit.  Intensive care units are expensive for patients, insurance companies and hospitals. So I ask the question again, "Do ICUs save lives?"   Do we overutilize intensive care units?  Have they become really expensive nursing homes and end of life hospice houses at many institutions?  Those are questions  Paul Levy (ex Boston hospital CEO) eludes to in reference to his post  last month in his blog Not Running a Hospital.  This discussion was in reference to an Archives of Internal Medicine  titled:

Intensive Care Unit Bed Availability and Outcomes for Hospitalized Patients With Sudden Clinical Deterioration.

I read this intriguing study.  From 2007 to the end of 2009, consecutive hospitalized patients (excluding cardiac surgery and coronary care units) in Calgary, Alberta, Canada were selected based on their sudden clinical deterioration triggering medical emergency team activation . The intensive care units in this study were closed units staffed by intensivists. (What is an intensivist?)  

A total of 3494 patients were selected based on the above criteria.  The attending physician requested the ICU bed without routine notification of whether ICU beds were available or not (no beds, one bed, two beds, more than two ICU beds).  The primary outcome was ICU admission within 2 hours of emergency team activation. Four secondary outcomes were also evaluated:

1. Change in patient goals of care(resuscitative, medical, or comfort) within 24 hours of emergency activation
2. Hospital mortality
3. Health care resource use
4. ICU admission during the remainder of the hospitalization

Results of the study concluded that patients were less likely to be transferred to an ICU within 2 hours of a medical emergency team activation if ICU bed availability was reduced. In fact, when no ICU beds were available, patients were 33% less likely to be to be admitted to the ICU. And when no ICU beds were available, patients were nearly 90% more likely to change the goal of care from resuscitative to medical or comfort care.    Interestingly, the odds ratios for hospital mortality did not change across all four groups based on ICU bed availability (approximately 33% mortality for all groups)

What does this data suggest?   How available our ICU beds are can determine processes of care in the hospital but it does not appear to change mortality.  In other words, if we build it, they will come. And if we set up archaic hospital policies to transfer patients to the ICU, we can then capture these charges  because that's the policy we have in place. But it won't make them better or save their lives

If we have big ICUs with lots of  beds, we are more likely to fill those beds with patients that don't necessarily require ICU monitoring and who's care in the ICU will not change their outcomes.  And given that most physicians have no formal training to  determine which patient is appropriate for the ICU and which isn't, and making the decision to transfer a patient to the ICU is a highly individualized process that is decided on a case by case issue between doctors and nurses as well as outdated hospital policies and procedures.  

This is not to say that ICUs are not an important component that can provide necessary care.  Just that we probably use them a lot more often than we need to because we lack a formal process to define their role.  Now the question becomes, how do we start using intensive care units in a more cost effect way?

This sounds like a perfect opportunity to create another evidence based ICU checklist  process for hospitals to  define who is appropriate for the ICU and who isn't. Perhaps the Society of Hospital Medicine could tackle this process, if they haven't already.    This is also a good opportunity for hospitals to reevaluate their old school voodoo medicine ICU criteria that hasn't been evaluated (or probably ever  validated) and to rid hospital policies and procedures filled with honky tonk  rules that do nothing for patient care but increase cost and inconvenience for patients and create an unnecessary paper trail the size of Texas for nurses stuck in the middle.  

Far too often the ICU is a place of convenience for doctors, nurses and patients who falsely believe that ICU care is better than non ICU care.  This data may be telling us that is not the case.   As I suspect to be true  in so  much of what we do, less is more.

What Do I Say To A Patient Demanding Opiates/Narcotics For Unreasonable Pain Control Management?

As physicians we are often asked to treat pain in patients with no physiological explanation for pain or a pain syndrome that is not treated as a standard of care with opiates. Internist Dr Centor recently discussed this with his rant on our opiate culture and the tyranny of pain with regards to a NYT article about the no-win situation ER physicians often find themselves in.

One of my favorites quotes

The most bothersome aspect of this story involves the "patient satisfaction" component. How do we balance between patient expectations (for pain meds, or CT scans or referral to subspecialists) against the high value cost conscious care that we aspire to give. If I appropriately refuse to order a CT scan, and the patient relates that he/she is not satisfied with my doctoring, have I done a good thing or a bad thing. If I suspect a drug abuse problem, should I worry about patient satisfaction or being a good steward of my responsibility to prescribe opiates appropriately?

I agree and have written extensively about this problem in the recent past.  No where in the Constitution does it say we have a right to be pain free.  Being free of pain is no more a right than is being free of debt.  Some lawmaker somewhere probably had a bad experience with untreated pain in their end-of -life full code great grandmother and decided to make it their mission to make pain free hospital existence a right for all Americans.    

Unmanaged expectations lead to irrational patient demands.  The customer is always right sacrifices our personal dignity for money.  I cringe at patient requests that interrupt nursing and physician work flow in other more critical patient needs because of the perceived right to all comfort all the time.  For example, I was once interrupted dead in my work up tracks to address the pain of a canker sore.  A canker sore.  

A canker sore.  

I just can't wrap my mind around this incredible pendulum swing towards a patient's right to demand comfort and satisfaction at all times.  Where does this expectation come from?  Why do patients have a right to pain free existence?  At what point does satisfaction end and just putting up with the daily annoyances of life begin?  So  what if it's 3 am and you have heart burn or constipation.  Why must you force your nurse  to make your minor annoyances of life turn  into a trail of intensive documentation.   

We know higher patient satisfaction scores are associated with higher patient mortality.  I have my own thoughts on how to improve patient satisfaction scores and they have nothing to do with providing health care, opiates or unnecessary CT scans.  It's all about FREE=MORE.   At the extreme interpretation of patient satisfaction goals, some institutions might even mandate the AIDET method in circumstances where a little spine and backbone from health care providers is instead the right medical therapy for the patient. 

We have to accept that what patients want in the name of patient satisfaction is often not what the need.  Higher quality care does not equal happy patients  anymore than low quality care equals dissatisfied patients.  I have seen lots of highly satisfied patients who have received  sub optimal treatment and I have seen  lots of upset patients who had everything done perfectly by the book.  I have not experienced an obvious  correlation between satisfaction and quality.   Nor do I believe this correlation exists. 

When patients ask for opiates by name we can either give it to them in the name of patient satisfaction or we can tell them no and deal with the consequences.  Me?  I prefer to deal with these situations on a patient by patient basis and I have found, through a decade of experience, that not all drug addicts are the same, but most carry a lot of mental baggage that complicates their insight into their addiction as well as their willingness to seek treatment.

In patients whom I have strong evidence of opiate seeking behavior  or have lots of  red flags to drug seeking behavior or the very specific action of a patient faking a seizure in the ER,  I will nicely explain to the patient "I am not your drug dealer" and if they are angry I won't provide them with a fix, I calmly explain to them that assaulting a physician is a felony.  It turns out not all druggies carry a calm collected demeanor to them, like the guy who lobbed to me the strangest insult ever in a fit of anger.  Or, perhaps, it was meant as a compliment.  Sometimes, I just can't tell.

How do you handle situations involving suspected drug seeking patients without compelling medical indication for opiates?

just like daddy! Like Father. Like Son.

just like daddy ! Like father. Like son.

   

Make sure to catch all Zachary's blog posts, videos and slideshow pictures.

Assaulting Doctors and Nurses In Nebraska Is Now A Felony (2012 Law LB 677). What Makes Us So Special?

Consider this Happy's public service announcement for any patient visiting a Nebraska hospital or medical clinic. Don't assault your health care professionals. Gov.  Dave Heineman signed legislation (LB 677) on March 7th, 2012  introduced  by Sen Steve Lathrop (D-Omaha) that would classify assaulting of a health care professional as equivalent to assaulting a police officer.

That's right folks, if you are a patient in a hospital or medical clinic in the State of Nebraska and you cause bodily injury to your doctors and nurses, you can be charged with a felony.  What are the specific details of Nebraska's felony assault legislation?  How does LB 677 define a health care professional?

"A health care professional means a physician or other health care practitioner who is licensed, certified, or registered to perform specified health services consistent with state law who practices at a hospital or a health clinic." 

I think that covers just about every licensed provider from doctors and nurses to respiratory therapists and physical therapists.  Unfortunately, I don't think this legislation covers the elderly volunteers passing out books or the dedicated men and women from janitorial services who are right in the thick of the action.

Patients can be charged with a first degree assault (Class ID felony) if

• He or she intentionally or knowingly causes serious bodily injury and the the offense is committed while the health care professional is on duty at a hospital or a health clinic.

Patient can be charged with a second degree assault (Class II felony) if

• He or she intentionally or knowingly causes bodily injury with a dangerous instrument and the offense is committed while the health care professional is on duty at a hospital or a health clinic.

Patients can be charged with a third degree assault (Class IIIA felony) if

• He or she intentionally, knowingly, or recklessly causes bodily injury and the offense is committed while the health care professional is on duty at a hospital or a health clinic.

Every hospital and health clinic will be required to display, in a prominent place, a printed sign with a minimum height of 20 inches and a minimum width of 14 inches with each letter to be a minimum of one-fourth inch in height and shall read the following

WARNING: ASSAULTING A HEALTH CARE PROFESSIONAL WHO IS ENGAGED IN THE

PERFORMANCE OF HIS OR HER OFFICIAL DUTIES IS A FELONY.

Several Happy points to consider from this important legislation

• I cringe at the hours of labor cost that went into debating the size of these mandated notification signs that must be placed in a prominent place to be compliant with these legislative mandates. 
• I'm still confused.  Why should assaulting an officer or assaulting a doctor or nurse carry any different weight or require any different legislative standard than assaulting the Walmart checkout clerk or the cable man.  Every life is equal and none should carry any more weight than another with special legislative punitive action.  These rules perpetuate a double life standard that places a greater value on some lives over others. 
• If you are a patient in the hospital angry at your hospitalist for not giving you what you want, even at the risk of bad patient satisfaction scores, you might want to consider stalking the poor unsuspecting elderly volunteer passing out the feel good arts and crafts.  Apparently, their lives are not as worthy for a felony assault charge as the doctors and nurses.  
• Or if you really want to get your doctor or nurse, an easy way around this felony legislation is to go outside for your smoke break (nobody follows these hospital smoking ban policies and nobody is enforcing them either) between 7-7:30 am or pm and wait for your nurse or hospitalist to walk in the front door for their shift change.   Since these health care professionals aren't technically on duty yet, assaulting them before or after their shift waives their right to a felony charge against you.
• Tell the judge and your lawyer "the last thing I remember was getting an IV".  Then claim you had a bad  reaction to a drug ordered by a physician and administered by a nurse.  That way you can claim your assault was an iatrogenic result of the treatment plan your doctor had ordered. Then watch the DA drop the case like a  hot potato as any defense attorney could find any number of doctors to get on the stand for $500 an hour and claim that the patient had a bad reaction to a drug given to them in the hospital.  At this point, The Joint Commission might feel compelled to get involved in the interest of patient safety.  We shouldn't be allowing our patients to go around punching doctors and nurses.  That's the rationale that will be handed down and if we don't have policies in place to prevent it, we should.   A smart defense lawyer and patient might even try to counter sue the hospital, doctor and nurse for pain and suffering as a direct result of their negligence in administering a drug that caused them harm.

I'm not even sure why we are having this conversation.   Everyone know the patient is always right, even though we know higher patient satisfaction scores are associated with higher mortality.    What happened to our team spirit?  We need to make sure our patient satisfaction scores do not suffer under the weight of this legislative  action that is sure to upset a few of our violent patients.  Even patients who assault us have a right to rate our service for them.  And I can assure you, if we press charges against them for assault, they aren't going to give us glowing reviews.  The last time I checked, assault was not an exclusion criteria for throwing out bad patient satisfaction scores.

And since our hospital payments by Medicare are determined by a measly 300 patient discharges out of tens of thousands, we should not risk our good scores over minor issues like nurses and doctors getting punched in the face, spit on or bitten in a rage of anger that we caused by our own defense attorney discovered negligence. We just need to let it go for the good of the organization.  If we want to collect our Medicare money, we need to learn how to better pick our battles like we do with our rules on how to qualify for EHR stimulus funds. 

Dentist Pulls Out All Teeth Of Ex-Boyfriend In Revenge Attack (Anna Mackowiak of Poland)

If you are a dentist and you are looking to get revenge on your ex-boyfriend, what better way to make him pay than to pull out all his teeth.  That's exactly what 34 year old Polish dentist Anna Mackowiak is reported to have done by the International Business Times, where she describes her ordeal in jaw dropping detail.

You are probably wondering  how a dentist could get her bastard ex-boyfriend to sit still long enough to get all 34 of his teeth pulled.  This guy, after already dumping his dentist girlfriend, decides to see her for a toothache. Mistake number one.   That's when she apparently took the opportunity to exact her reported revenge.   To make matters worse, the guy got dumped by his new girlfriend who said she couldn't date a guy with no teeth.   

There are some days were some people feel like pulling out all their teeth.  This lady took that emotional instability to the extreme and used her medical education as her weapon.  I feel sorry for the guy. I don't know what he did to her, but having all your teeth pulled out in revenge seems unjustified by any standard.  To make matters worse,  I can't even use my joke on him that  I use for my patients with missing teeth.  

Happy:  You have summer teeth.
Patient:  What are summer teeth?
Happy:  Summer there and some aren't.  

This dentist is being investigated for malpractice and could face up to three years in prison.  I don't know about you, but if I was a dentist wondering how to get even with my crazy ex, I probably wouldn't have choosen the full dental extraction root!  I suspect her action did not  get to the root of her problems!

Dove Nesting In a Tree (Close-Up Backyard Pictures)

In addition to robins carrying grub worms, we discovered we also have a dove nesting in one of our backyard trees this year.  Plant a tree and the birds will come.  Beautiful creatures these doves are.  It was a good week for nature pictures in our backyard.  I even caught a bunny rabbit making a run for it. Makes for exciting times for Marty and Cooper.

Addendum:  The baby doves have been born.  Here are some pictures of the baby doves nesting in our backyard with mama dove!