Articles Posted in Outpatient Care

commty care ncHospitals and health systems are making stark choices between offering models to assist their communities and reduce medical costs−or raking in profits, no matter how outrageous and shame-provoking their charges might be. Evidence of the extremes came this week in reports about alternative realities.

Let’s start with the positive view, recognizing exemplary efforts in the Charlotte, N.C.-area to both help patients and to sharply cut medical costs. Forward-looking health policy experts decided to dive into the highest Medicaid users of emergency services, discovering, for example, that just one patient, a homeless alcoholic man, visited the ER 223 times in 15 months and had undergone 150 redundant and needless X-rays or other scans. Many of the top 100 “frequent flyers,” poor and repeat ER patients, took an exceedingly costly route to fill prescriptions or to seek pregnancy or other routine tests; 86 of these individuals were known to have behavioral woes, including depression or bipolar disease. The experts found that these individuals visited multiple ERs on the same day, sometimes crossing a street or two to do so. They appeared on hot or cold days, suggesting their real need might not be medical but for shelter.

Community Care North Carolina — an umbrella group, with cooperation and support from hospitals, social workers, nurses, and social service agencies — searched out the heaviest using Medicaid-ER patients. They needed to comb the streets, jails, and even a strip club. They helped the patients find responsive primary care doctors, and other assistance, for example, in managing chronic illnesses and conditions. They connected them with social service agencies for assistance with existing housing, nutrition, jobs, and transportation programs. As the Charlotte Observer reports:

Medicare CardTwo new case studies show how hard it is to cut the gigantic costs of America’s medical industry. The first concerns how tinkering with Medicare payment incentives can drive up some already soaring drug costs. The other revisits how retail clinics that have popped up at chain drug stores affect health care spending.

Medicare drug incentives

The Obama Administration “touched off a tempest,” the New York Times said, by proposing to experiment with finances affecting some drugs covered under Medicare Part B. Patients get them in doctors’ offices and hospitals to treat cancer, rheumatoid arthritis and other conditions. The paper observed that:

Hypodermic-NeedleIt’s one thing when the makers of sodas or breakfast cereals tweak their packaging to maximize their profits. But Big Pharma deserves a slap for its practice, newly spotlighted by researchers, of putting out over-sized dosages of cancer fighting drugs. This ensures that $3 billion in already costly drugs get tossed out and wasted each year.

Nurses and physicians have no choice about using jumbo size packages of these injectable drugs. They typically give the shots in offices and clinics, and they toss out unused portions to avoid transmitting one patient’s germs to the next patient. Some of the one-size-fits-all vials, the New York Times said, contain a dose, based on patients’ weight and height, that’s suitable for an NFL linebacker or an NBA forward.

As the co-author of the study on this mendacious packaging said: “Drug companies are quietly making billions forcing little old ladies to buy enough medicine to treat football players, and regulators have completely missed it. If we’re ever going to start saving money in health care, this is an obvious place to cut.”

Here’s another device you probably don’t need. Or do you?

That’s the question Austin Frakt, who writes for the New York Times, tried to answer for himself when his cardiologist told him that one of his heart’s chambers sometimes pumped when it shouldn’t. The doctor had been “99.9% certain” that it wasn’t worrisome, and doctor advised against additional tests and visits.

But even though he’s a health economist, and knows that many commonly prescribed tests aren’t necessary, Frakt is only human. “As a patient,” he acknowledged in his story in The Times, “I’m not confident I know which ones.”

Earlier this year, both patients and providers were shocked when a rash of hospital patients got seriously ill or died after medical devices used to examine their gastrointestinal tracts infected them because they were not sufficiently cleaned after previous use. 

Now, it seems, inpatients aren’t the only ones who need to worry about contaminated medical instruments — according to an advisory issued by the Centers for Disease Control and Prevention ( CDC) and FDA, a wide range of reusable diagnostic instruments used in doctors’ offices and other outpatient facilities are vulnerable to the same risk of carrying other patients’  bacteria.

And last week, the FDA followed up that notice with a warning that bronchoscopes specifically can transmit infections if not adequately cleaned — 109 such adverse events have been recorded by the agency in the last five years, according to Bloomberg.com. Bronchoscopes are instruments inserted into the mouth or nose and through the windpipe (trachea) to examine the lungs’airways.

Here’s another story with a satisfying ending and the take-home lesson that it’s a bad idea to cheat taxpayers and abuse medical resources.

A chain of hospices agreed to settle a lawsuit over its overbilling of Medicare, and driving up payments by providing care to patients for whom it wasn’t appropriate. St. Joseph Hospice, which operates in four states will pay $5.9 million, reported Associated Press (AP).

Hospice care is for people with terminal illnesses, and generally provides palliative services, which address symptoms, not curative care. Hospice patients usually receive the care in their homes, enabling them to die where they are most comfortable, instead of in a hospital or other care facility. Doctors prescribe hospice care only for people who are not expected to live longer than six months.

People who have suffered kidney stones say there’s nothing more painful. But according to new research, for a disturbing number of patients, treating them can cause complications requiring emergency follow-up. All the more reason to heed some good advice about how to prevent them in the first place.

Kidney stones are small, hard pebbles formed in the kidneys from minerals and acid salts. They pass through the urinary tract, from the kidneys to the bladder. Before passing them painfully during urination, victims often suffer from extreme pain in the back, side, abdomen and/or groin. Sometimes there’s nausea and vomiting. As horrible as it to have kidney stones, generally they cause no permanent damage.

As reported in the journal Surgery, researchers from Duke Medicine have determined that as many as 1 in 7 patients receiving treatment for kidney stones experience complications requiring emergency care.

The relatively new hospice industry is a needed and important part of end-of-life care. But it has grown too quickly for the relatively minor oversight it gets, and that has caused heart-wrenching patient harm.

That’s the take-home message of a recent exposé in the Washington Post. “Hospices,” it says, “are among the least inspected organizations in the U.S. health-care system, with most operating for years before an inspector calls. Malpractice suits and other legal claims against hospices are difficult to pursue, attorneys said, because for such patients, death is expected. Finally, many families may be unaware of what kind of nursing care hospices are obliged to provide, experts say.”

Hospice care focuses on comfort rather than cure. It discourages invasive treatment in favor of enabling people to die at home, which most Americans with serious illness say they prefer.

We know a lot more than we used to about diagnosis mistakes in hospitals, but a new study says that every year, at least 1 in 20 adults gets the wrong diagnosis in a doctor’s office.

For more than 6 million U.S. patients a year, according to the authors of the study published in the journal BMJ Quality & Safety, these misdiagnoses can have major consequences and can amount to medical malpractice.

“The question is, can we eliminate human error, and the answer is no,” Hardeep Singh, lead author of the paper, told The Boston Globe. “We have just now begun to understand what [these errors] are and what we can do.”

Intensive care in hospitals includes extreme measures that can induce delirium in many patients, and that, doctors are now discovering, don’t necessarily go away when the patient leaves the ICU.

About 3 in 4 ICU patients develop delirium, according to a story in the Philadelphia Inquirer, and delirium is associated with poorer survival rates and worse long-term outcomes.

It has long been known that ICU delirium sometimes includes delusions and hallucinations. Some ICU patients have believed that that they were being assaulted or imprisoned; that their nurses were plotting to kill them; that the walls were covered in blood; that huge spiders were riding bicycles in the room.

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