Articles Posted in Clinical guidelines

mal200x267In the battles between lawyers and doctors over malpractice lawsuits filed by patients harmed while seeking medical services, it may be worth heeding economists’ prescription for caregivers: Physicians, heal thy selves.

Aaron Carroll, a pediatrician and health policy expert at Indiana University, has written in the “Upshot” column of the New York Times that research shows that so-called tort “reforms”—including current initiatives on medical malpractice by the Republican-controlled Congress—may be misguided.

That’s because advocates committed to greater patient safety and improved care may find more impressive results on the medical not the legal side of “reforms,” Carroll argues. He points to persuasive data from Florida and Texas hospitals and how they fare with lawsuits and their rankings with Patient Safety Indicators (PSIs).

D-vitaminsThe health care pendulum appears to have taken a bad swing to the extreme with vitamin D.  Too many Americans may be taking unnecessary tests to see if they’re deficient of this important nutrient. Too many of us are taking unneeded amounts of it.

Federal experts report that blood tests for vitamin D among Medicare beneficiaries, most 65 and older, increased 83-fold from 2000 to 2010. Testing rates rose 2.5-fold from 2009 to 2014 among those with commercial insurance.  Among a recent sample of 800,000 patients in Maine, nearly one in five had at least one test for blood levels of the vitamin over a three-year period. More than a third got two or more tests, often for vague complaints like malaise or fatigue. Labs and doctors are telling patients who have undergone tests and who have readings in the normal range of 20 to 30 nanograms of the vitamin per milliliter of blood that they suffer a deficiency.

This all is leading to what some experts are terming a “pandemic” of over-testing, faulty diagnosis, and excess consumption of a nutrient, based on sparse evidence and misplaced belief that, as the New York Times reports, “vitamin D can help turn back depression, fatigue, and muscle weakness, even heart disease or cancer. In fact, there has never been widely accepted evidence that vitamin D is helpful in preventing or treating any of those conditions.”

Prostate-e1492269148971-483x1024A burst of bad headlines and not so great news reports may have confused some men. But to put it in lay terms:  The use of the common test for routine prostate cancer screening got a dim grade of C for many men, up from a dismal D, in a re-evaluation by independent experts who assess the nation’s preventive medical services.

That blunt review of regular prostate-specific antigen (PSA) tests, despite some reports to the contrary, keeps with how the influential U.S. Preventive Services Task Force (USPTF) looked at annual  screening for this most common form of cancer for men when it issued its first guidelines in 2012, notes healthnewsreview.org.

The health information site says the USPTF earlier had surprised many, downgrading routine prostate cancer screening to a D, and noting, “There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” It now says it rates a C for many men younger than 70, meaning physicians should “Offer or provide this service for selected patients depending on individual circumstances,” and that “There is at least moderate certainty that the net benefit is small.”

end-of-life-800-300x198Many hospitals and doctors rightly have campaigned to get more patients to provide information in advance about their end-of-life care choices, but doesn’t that mean that the choices when made should be respected? And if they’re not, what role do the courts have?

Paula Span, a New York Times columnist who writes on aging issues, reports that a growing number of patients and families have sued hospitals, doctors, and nurses for disregarding or overriding advance directives. There are various kinds of these legal documents. But they often become part of patients’ medical records, directing caregivers, for example, that an individual does not want extreme measures taken to resuscitate them or to sustain their lives.

This can go against deep traditions in medicine, especially for caregivers accustomed to crisis responses in difficult, exigent circumstances. They think of themselves as life changers and life savers. At the same time, patients have insisted that their rights and choices demand respect. Many physicians and hospitals have recognized and encouraged this, as has the U.S. health care system more generally, for example, via Medicare.

rheumatoid-arthritis-hands-2-300x200More than 50 million Americans struggle with arthritis: Three in 10 of them find that stooping, bending, or kneeling can be “very difficult.” One in five can’t or find it tough to walk three blocks, or to push or pull large objects. Grown-ups with arthritis are more than twice as likely to report fall injuries.  Arthritics have lower employment rates, and a third of them 45 and older experience anxiety or depression. So what to do about this leading cause of disability, a painful condition whose woes will only grow as the nation ages and already is responsible for $81 billion in direct annual medical costs?

Experts from the Centers for Disease Control and Prevention recommend that those with the most common arthritis forms—osteoarthritis, rheumatoid arthritis, gout, lupus, and fibromyalgia—avoid a reflexive reach for pain-killing pills. Instead, they must keep moving. “Physical activity,” CDC experts said in a new study, “is a proven strategy for managing arthritis. …” It also “has known benefits for the management of many other chronic conditions” that also afflict those with arthritis—including heart disease, diabetes, and obesity.

Although arthritis commonly is associated with seniors, the majority of adults with the condition, more than 32.2 million Americans, are younger than 65. Arthritis is much more common among women than men, and much less so among Hispanics and those of Asian descent that among whites. It afflicts those with a high school or less education more than those who completed college or higher.

cdc-logo-300x226When it comes to the nation’s health, the Trump Administration and the GOP-dominated Congress seem determined to prove they know how to do penny-wise and pound-foolish. They’re amply demonstrating this with proposed slashes in the nation’s basic budget for public health. They’re calling for a $1 billion cut for the Centers for Disease Control and Prevention, notably in the agency’s funding to combat bioterrorism and outbreaks of disease, as well as to battle smoking and to provide critical medical services like immunizations. Their target is the Prevention and Public Health Fund, set up under the Affordable Care Act, aka Obamacare. With the ACA under fire by partisans who want to repeal and replace it, the fund was already imperiled. GOP lawmakers, determined to cut domestic spending, seem disinclined to come up with substitute sums.

Andy Harris, a Maryland Republican congressman, physician, and House appropriations health subcommittee member, has been quoted as calling the public health money, “a slush fund.” He argued that, “It’s been used by the secretary [of health and human services] for whatever the secretary wants. It’s a misnomer to call it the Prevention and Public Health Fund, because it’s been used for other things, and it’s about time we eliminated it.”

The Obama Administration did embarrass Congress by tapping the fund to provide emergency aid last summer to Florida, Puerto Rico, Hawaii, and other states battling tropical infections, including Zika and dengue fever. Congress took a long recess vacation, as states clamored for help for mosquito eradication and vaccine development to deal with Zika, a virus that can cause severe birth defects and other harms.

consent-300x170Modern medicine has become so complex, bureaucratic, and forbidding that it’s little wonder that patients—already ailing—don’t grasp the risks and consequences of treatments they prescribe. Overwhelmed patients also don’t demand that doctors fully brief them.

And shame on physicians for failing to help patients more in this critical area of caregiving, two doctors have written in an excellent New York Times Op-Ed column. The doctors—Mikkael Sekeres, director of the leukemia program at the Cleveland Clinic, and Timothy Gilligan, director of coaching, Center for Excellence in Healthcare Communication, at the Cleveland Clinic—deserve credit for calling out colleagues while describing the vital health care concept of informed consent.

My firm has detailed information on this important patient right in health care (click here to see).

Back-Pain-300x188Back pain is one of Americans’ leading debilitating complaints, prompting us to spend billions of dollars annually for relief and costing more than $100 billion, especially in lost work and wages. But an influential physicians’ group, joining a growing number of other experts, now recommends that we buck up, exercise, keep moving—and stay away from a reflexive reach for drugs, especially powerful painkillers, to deal with aching backs.

The American College of Physicians, with guidelines published in the Annals of Internal Medicine, concedes it is breaking with longstanding medical views on treating low back pain. But the group’s experts said they conducted a “systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain.”

They found that many patients with low back pain recovered over time “regardless of treatment,” and these individuals might benefit most from heat, rest, exercise, and over the counter, non-steroidal medications. Another group of back pain sufferers might need physical therapy, stress reduction, acupuncture, yoga, or ta-chi. Only after patients have not found relief with “non-pharmacological therapy,” should doctors consider giving non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen. If these don’t work, tramadol (Cymbalta) or duloxetine (Ultram) might be considered.

prescription-bottles-1-300x170Some diligent, grown-up sons and daughters may want to check in on mom, dad, and grandma, grandpa, all the aunties and uncles, too. That’s because there’s yet another warning that too many doctors are whipping out their prescription pads all too readily and writing scripts for retirement-age Americans, who now take on average three psychiatric drugs without any mental health history.

Research published in the JAMA Internal Medicine shows that over-prescribing of powerful psychotropic drugs, including sleeping pills, painkillers, and anti-depressants may be more common than believed. The study was based on an analysis of data from a big number of doctors’ office visits, with researchers finding the number of “polypharmacy” incidents (cases in which seniors received scripts for multiple drugs) increased between 2004 and 2013 from 1.5 million to 3.68 million.

This doubling resulted from seniors’ greater openness in talking with their doctors about mental health issues, and, in instances where visits were related to “anxiety, insomnia, or depression,” the researchers write. But, in disturbing fashion, a high number of women and rural patients were involved in cases where multiple psychotropics were prescribed, and many of the prescriptions were for painkillers.

HouseGregoryHouse-276x300Doctors, nurses, and hospitals should stop ignoring colleagues who act like jerks because obnoxious physicians—think of  Dr. Gregory House, the TV internist—may hurt patients, especially in surgery.

Researchers, who published a study in the JAMA Surgery, looked at two years of quality care data from seven medical centers, involving 800 surgeons and 32,000 adult patients. They also had information on physicians with “unsolicited patient observations,” meaning complaints from those undergoing care and their friends and families.

Stat, the online health information site, summarizes what the researchers found:

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