Flu Shots for the 2014- 2015 Season

Flu vaccineOur offices supply of influenza vaccine has been delivered to the office this week and we will begin immunizing patients on October 1, 2014. The Center for Disease Control in its Morbidity and Mortality Report of August 15, 2014 recommended that all adults be immunized against influenza this year beginning at a time that is appropriate to the appearance of influenza in your community. We generally do not see any significant influenza in South Florida before Thanksgiving with the season usually lasting through March. It takes ten days for the vaccine to take effect and your body to develop the immunity to resist the flu invasion. Immunity after vaccination begins to fade at 3 months and is markedly reduced or absent in most individuals 65 years or older at 6 months. Most pharmacies locally will begin their vaccine campaign in September. If you receive the vaccine then there is the chance that your immunity will be decreasing by December. For this reason we prefer to vaccinate you on October 15 or later. Please call the office for an appointment.

We will be administering the senior high potency vaccine which is the usual trivalent inactivated influenza vaccine at four times the dosage given to younger patients. Research has shown that the higher dose is needed to get senior citizens immune response to work well. Despite the higher dose, there are no more side effects reported than in the usual dosage administered to younger individuals.

For individuals younger than 65 years we will be administering the recommended quadravalent vaccine which is also an inactivated viral product. We will be charging $35 for the shot. Patients with egg allergies are encouraged to obtain the trivalent recombinant influenza vaccine (RIV3, known as FluBlok). It is available in limited supplies at the Health Department and at Passport Health.

Feel free to call the office if you have any questions at 561.368.0191

Haste Makes Waste in Meeting Core Measures

Obamacare v1Once again Government regulators have put in place well-meaning rules without anticipating the consequences. We all hate sitting around in the Emergency Department waiting to be seen and to be treated. On October 15, 2014 as part of the new Affordable Health Care Act and the patient satisfaction portion, hospital ER’s will have about 180 minutes from the time you arrive and sign in to evaluate you , treat you and make a disposition or decision. The game starts on Oct. 15th but already hospital administrators have their systems operating to prepare to comply. If you fail to comply the hospital will be punished financially with fines and reductions in payments.

Take the case of LH who is 88 years old, demented and lives with her loving and nurturing son in South Florida. She went to the beach with her son on a hot humid day in August with temperatures in the 90 degree range and humidity of almost 80 percent for a feels like temperature of 110. While she sat under an umbrella for several hours, the beers she drank to celebrate her birthday did not react well with her medications for dementia. She stood up and swooned to the ground and ended up in the ER. Labs, EKGs and Chest X Rays were done and it was decided that she was dehydrated. She was given some fluids and sent home. Two days later a urine culture obtained at that visit became positive indicating an excessive number of bacteria and she was placed on an oral antibiotic for ten days.

Six days later she was still feeling weak and shaking when she stood up and moved about. Her son took her back to the ER concerned that she was having seizures. She was evaluated by the ER staff and noted to be running a fever. A Chest X Ray was taken and was read as left lower lobe pneumonia by the radiologist without comparing it to her film six days prior. As I was finishing up with my last morning patient I received a phone call from the ER physician advising me that my patient was there with pneumonia and fever and required admission. He told me he had obtained blood and urine cultures and started her on Rocephin. I reminded him she was already on an antibiotic trimethoprim/sulfamethoxazole for a urinary tract infection. I told him I could be there in about 30 minutes and asked him to keep her in the ER until I got there. He said that was fine. To meet the Core Measures need for a quick disposition I suggested that the patient be admitted to a medical floor on my service, be given a clear liquid diet and I would take care of the rest. He said that was fine.

In August, Boca Raton, Florida is a sleepy seasonal vacation town enjoying the offseason quiet with its two colleges and seasonal visitors off on holiday. Restaurants are never full. There are no lines at the movies. There are few if any traffic jams and beds are readily available in the hospital. The hospital is usually 1/3 to ½ full at best. Our brand new emergency room is bright, wonderfully equipped with digital and manual blood pressure cuffs, otoscopes and opthalmoscopes at each bedside in marked contrast to the paucity of them on the hospital inpatient floors. It is always easier to be thorough and complete in your exam in the emergency department where you are not wasting time looking for equipment to examine the patient. I arrived at the ER in 40 minutes and was met by the icy stare of the staff nurse who said, “She has a bed upstairs can I send her?” My response was, “Not until I have a chance to take a history from her and her son and examine her.” While I was taking the history and doing the exam my cell phone went off. It was another physician in the ER department calling to talk to me about another patient who was in the department having been sent there by his surgical specialty physician who had just examined him in his office for a problem. I excused myself and walked toward another section of the ER when my patients nurse asked, “are you finished can I send her up?” I again declined and informed her that Dr L in the urgent care session wished to talk to me about a patient now and I would be back. My patient was not critically ill. Antibiotics, food and fluids had been ordered. Taking a short break to speak to the other ER doctor would not jeopardize her care or safety.

I returned 10 minutes later to learn that the nurse had called the Nurse Practitioner working with the hospitalist service and she had written admitting orders in my absence to speed the process along the way. In the hospital’s view the most important issues were to move the patients along, get the medication reconciliation form filled out and get the form on preventing phlebitis and use of anticoagulants filled out so they can meet their Core Measures goals. I went into the patient and son , completed my exam, explained my findings and disappeared into the physician computer room to enter orders, dictate the admission summary after I had reviewed the nurse practitioner’s orders, reviewed the chest x ray and all the lab data. The computerized orders revealed the patient had been admitted to a medical floor, on antibiotics, on heparin for phlebitis and pulmonary embolus protection. They had missed the fact that the patient had executed a “Do Not Resuscitate “form and her son had brought it with him. This was not recorded in the orders. They had also missed the fact that the pneumonia or left lower lobe consolidation they diagnosed was the same on the x ray from 6 days prior and another from one year prior. I walked over to the radiology reading room and pointed this out to the radiologist who said what was being called a pneumonia was actually an innocent long standing hiatal hernia appearing behind the heart on x ray. Despite not having pneumonia, the patient was sick, weak, and febrile and needed admission to sort it out. I sat down at the computer and spent thirty minutes on the orders and admission notes and then spoke to the patient and family. At that point I allowed the ER nurse to call the transporter and bring the patient up to the floor. The nurse literally scowled at me and told me I was violating their Core Measures policy and their director would not be happy and would want to talk to me. I told her I had another patient to see and that if her director wanted to talk to me they knew where to find me since I have been on staff for 35 years. I reminded her Core Measures criteria did not officially start for three more months and that with an empty ER she needed to take a deep breath, count to ten slowly and relax. My comments were not appreciated.

Medicare Part D Open Enrollment For 2015

MedicareFrom October 15, 2014 through December 14, 2014 Medicare beneficiaries will have an opportunity to choose their 2015 prescription drug plan. These plans change annually. If you do nothing you will remain in your current plan in 2015 even though the price will change and the drugs covered will change.

On your computer go to http://www.medicare.gov . Choose prescription drug plans. You will be asked to put in your name, your Medicare ID number and your zip code. They will ask you to enter your favorite pharmacy and then all your medications by name, dosage and frequency of administration. You will then run the program and it will suggest the best plan for you. I suggest you choose the least expensive plan. There are elective add on features which pay your drug deductible and even cover the donut hole for a higher fee.

If you have any questions feel free to call us. If you cannot use a computer and need our help please let us know.

Small Medical Practices Result in Fewer Hospital Admissions

Quantity-v-QualityThe American College of Physicians and the Affordable Care Act or “Obamacare”, are blatantly trying to make small independent medical practices obsolete. Under a barrage of rules, regulations and requirements all punishable by fines and or a reduction of payment for Medicare payments, the government is herding small practices into selling their practices to large hospital or health care systems. The goal is to provide more complete care in a paperless, seamless system of coordinated care. The American College of Physicians has gone as far as to aggressively push medical practices to become a Patient Centered Medical Home. This is all being done at the expense of mom and pop practices that have long term relationships with their patients but lack the resources to build and maintain the infrastructure that government and insurers demand from health care providers today.

It must have come as quite a shock to the ACP and the Center for Medicare Services (CMS) when a study published in Health Affairs and reviewed in the 08/21/2014 MedPage Today discussed a survey which showed that smaller primary care practices with fewer than 10 physicians had fewer preventable hospital admissions among their Medicare beneficiaries than larger practices.

The data was obtained between 2007 and 2009 and its publication produced the expected response from CMS and the ACP. They theorized that Patient Centered Medical Homes were just getting started and speculated that if the data from today was reviewed it would tell a different story. The problem is that when one looks at data from small medical practices, such as the data presented by the MDVIP concierge group from their small practices nationwide, you see exactly the same trend. Not only do the small practices hospitalize less but they score higher on quality measures designed by the government and insurers themselves.

The authors of the current study noted that 83.2% of US office based physicians are practicing in small practices of 10 or less physicians. Small practices in which physicians know their patients long term and are accessible and available clearly outperformed the larger health system and government sponsored mega groups.

Think about that the next time you look for a doctor. Which health care setting do you want your insurance plan to cover?

High Dose Flu Vaccine Works Better

Shot, PatientIn a brief article in the August 14th issue of the New England Journal of Medicine, Carolos DiazGranados, M.D. reports that the high dose flu vaccine is more effective in preventing influenza in senior citizens over 65 years of age when compared to the other vaccines on the market. The vaccine was created because the immune systems of seniors are less responsive to a vaccine dosage than younger people. Many received the standard flu shot but never developed the immunity or protection expected. With that in mind a vaccine was created with 4 times the immune system stimulating material than a traditional flu shot.

Dr. DiazGranados studied 31,803 patients over two flu seasons and compared the high dose shot to the quadrivalent formulation. He found that not only was the high dose vaccine more effective but that it had the same number of side effects as all the other preparations suggested for flu protection.

We will be beginning g our flu shot program on October I, 2014 with the vaccine already in the office. I will be recommending the high dose vaccine to all my patients 65 years and older. All others will be given the quadrivalent product. Influenza vaccination is recommended in all adults.

Call the office 561 368 0191 to set up an appointment for your flu shot.

No Need For Routine Pelvic Exams?

Woman Sitting with Tea CupThe American College of Physicians created controversy and discord with the American College of Obstetrics and Gynecology by stating that women without symptoms of pelvic disease and of average risk” do not benefit from pelvic exams as part of routine care.” This recommendation received major media coverage. ACP panelist Russell Harris MD of the University of North Carolina in Chapel Hill in an interview with the University of Pennsylvania on line journal MedPage Today added further confusion to the recommendations by saying that “Our guidelines really have to do with women who do not have symptoms, who do not have a discharge or bleeding or pain. Our guidelines talk about screening of asymptomatic women who are not pregnant. Those women simply don’t need the exam. It’s not something that is useful for them.” The article goes on to say that “the guideline also does not apply to women who are due for cervical cancer screening.”

The concern is that the exam is intrusive in a private area and most findings lead to evaluations that lead one down an investigative path that is expensive, invasive and studies show very little yield in terms of finding preventable disease. This is based on the groups’ review of 52 published studies between 1946 and 2014.

Once again organized medicine has shown a way to be confusing, divisive and contributing to the appearance that the right hand does not know what the left hand is doing. The ACP and the American College of Obstetrics and Gynecology should have discussed this issue and released a joint recommendation which makes sense. The ACP guidelines suggest we should be visually inspecting the cervix which requires a speculum exam and using cervical swabs for cancer and or human apillomavirus. How much extra time and cost is involved if the clinician with the patient’s pre approval digitally and manually palpates the uterus, ovaries and rectum for the presence of unsuspected anatomical abnormalities? Is this, in fact, another effort by the American College of Physicians, and the American Board of Internal Medicine, to dumb-down and accelerate the training of future physicians? If we do not perform a certain number of pelvic exams on normal individuals how is one going to recognize an abnormal exam? This is the same type of short sighted thinking that led to the Institute of Medicine and US Preventive Task Force recommending that we do not teach women how to perform breast self -examination to detect breast irregularities? It reminds me of the recommendations years ago to stop doing chest x rays on smokers for the detection of lung disease and lung cancer because it was low yield and not cost effective. Funny how 20 years later the recommendations now call for screening low dose CT Scans of the Chest on smokers 55 years or older who have been smoking for many years.

I will continue to discuss the issue of a pelvic exam with my patients and suggest they discuss it with their gynecologist as well. I believe that 15 -20 years down the road the guidelines will once again insist on examinations of the uterus and ovaries when the politics of the times is not solely set on reducing health care costs! Hopefully those new suggestions will not be fueled by an increase in advanced gynecological cancer due to 20 years of no one examining their patients.

Are Older Women Receiving Too Much Calcium?

CalciumThe June issue of Menopause, a peer reviewed medical journal, carried an original research article by Margery Gass, MD and colleagues which indicated that older women are taking too much Vitamin D and Calcium. She conducted a randomized and placebo controlled trial of 163 women with low Vitamin D levels. The age range of the study group was 57 to 90. They were given Vitamin D and Calcium citrate tablets to reach the recommended daily amount of 400 to 4800 IU per day of Vitamin D and 1200 mg of calcium per day. Follow-up lab studies revealed that almost 10% of the women developed elevated blood calcium levels. More disturbing was the fact that 31% developed elevated levels of calcium in their urine predisposing them to kidney stones.

The lead author suggested that every patient calculate how much calcium they are getting daily in their normal diet before supplementing it with extra calcium. Her group pointed out the benefits of clinicians periodically measuring patients 24 hour urine calcium level. Those with a level > 132 mg were at much higher risk of developing hypercalcemia and its complications and need to reduce their supplemental calcium intake. We will begin suggesting 24 hour urine collection in our patients in the near future.

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