Artificially Sweetened Beverages, Stroke and Dementia Risk

An observational study in the Journal “ Stroke, A Journal of Cerebral Circulation” examined the question of whether there is an a relationship between consuming “ diet” beverages with artificial sweeteners and the development of a stroke or dementia using data from the Framingham Heart Study Offspring Cohort. They looked at 2888 individuals older than 45 years of age for the development of strokes and 1484 participants over age 60 for the development of dementia. They followed the group for ten years and were able to gauge their intake of artificially sweetened beverages from food questionnaires filled out at exams. After making adjustments for age, sex, education, caloric intake, diet quality, physical activity, and smoking they found that higher consumption of artificially sweetened beverages was associated with a higher risk of strokes and dementia. This was not seen in individuals drinking sugar sweetened beverages.

In a comment section, the author acknowledged that diabetic patients had a higher risk of stroke and dementia than the general public and they consumed more artificially sweetened beverages than others. While the study did not show cause and effect it does leave us wondering just how safe these diet drinks are?

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Hospital Discharges and the Handoffs

Fred Pelzman, M.D. is an experienced internist who practices in the NY Metropolitan area and trains young doctors at a well-deserved renowned academic medical center. His corporate behemoth medical system tries to engage in the latest and greatest business practice models for care, using technology and staff generally unavailable to the mom and pop medical practices that once dotted America.  Meanwhile, Dr. Pelzman cares for people compassionately while training his young disciples in an ever changing and complicated health care environment. I love reading his blog posts discussing his thoughts, concerns and efforts.

This week’s article or “post” is about the difficulty and danger entailed when a patient leaves the hospital, after being cared for by hospital based physicians, and returns to their homes and the care of their outside doctor’s. I give Dr. Pelzman much credit for taking ownership of the problem and attempting to solve it. I think there is a much simpler solution to his problem than creating a fast track computer program for patients who need to be seen quickly post discharge. It is called the telephone.

There was a time when physicians actually picked up the phone and called their colleagues and discussed the transfer of care before initiating it. During my internship and residency at the University of Miami Jackson Memorial Program; when a patient was being transferred, the receiving physician received a page resulting in a phone call from the transferring physician to discuss “the case.” The transferring physician wrote a transfer summary in the chart to be reviewed by the receiving physician. When patient’s went home, especially non-private patient’s, the handoffs were inadequate since often there was no receiving physician to communicate with.

After finishing my training and entering private care in a suburban community, the transfer of care was quite simple because most physicians cared for their own patients in the hospital and in the community so the transfer of care was smooth and seamless. This changed with the institution of “managed care” run by insurers at the request of employers and by the development of hospitalist physicians.

Employed hospital based physicians were the idea of Robert Wachter, M.D., the father of hospitalist medicine and the current director of hospital physician training at University of California in San Francisco. When he was completing his training in internal medicine he noticed that general internists in private medicine were not being paid very well in the field. He also noticed that his academic teachers, who were required by Medicare and insurers to actually spend time taking a history, doing a physical exam and writing a progress note on each patient on their teaching service if the facility was going to get paid for their care hated actually interacting with patients. They preferred to be in their research labs or teaching students and future doctors.

Hiring someone to do that work and creating a specialty gave them the freedom to go back to what they wanted to do. It also gave administration a certain amount of control over the tests ordered, medications ordered, length of stay and costs. At the same time this was occurring, “administrative and management experts” were out in the community, convincing private physicians that the solution to their low reimbursement was to stay in the office and see more patients and give up caring for hospital patients. It was deemed inefficient to cancel or delay patients in your office or clinic so you could run to the hospital or emergency room to see an acutely and seriously ill patient.

As hospitalist medicine took hold, medical and surgical specialties decided it was more efficient to use their services than to take the time to admit the patients with issues they were best trained to care for. Orthopedic surgeons stopped admitting patients to the hospital with fractures that needed surgical repair. They asked the hospitalist to do it. Oncologists stopped admitting patients with fevers and infections and abnormal blood counts as a consequence of their cancer or treatment of cancer. They asked the hospitalist to do it. Gastroenterologists stopped admitting acute gastrointestinal bleeders who needed endoscopy and cardiologists stopped admitting acute heart failure and pulmonary edema and heart attacks. These specialists preferred to be “consultants” and let the hospitalists perform the tedious medication reconciliation, admitting orders and mandated quality metrics forms and the deep vein thrombosis prevention forms. The hospitalists became their interns and medical students performing the time consuming , bureaucratic, labor intensive low paid administrative work so the specialist could arrive like the cavalry and just do their procedure and leave.

The problem is that the hospitalist didn’t know the patient. The referring doctor never called the hospitalist or ER physician to send the records and explain why the patient was coming and there was little if any communication. The same occurs when the patient leaves the hospital and is sent for post hospital care. No one coordinating care in the hospital contacts those responsible for the patient’s outpatient care to discuss a care plan. The fault lies with both the inpatient and outpatient physicians who don’t take the time to communicate.

Above anything else, the patient must come first. Picking up the phone and calling the receiving physician and discussing the nuances of the necessary care and creating a plan which is explained to the patient is in the patient’s best interests. All care givers need to remember this and create local environments, climates and systems that encourage communication between hospital-based physicians and community physicians.