The Affordable Care Act – Choice Still Matters

Affordable Care ActThe Affordable Health Care Act (aka “ObamaCare”) has led to the purchase of physician practices as hospitals and health care systems organize narrow networks of health care providers to cash in on the influx of newly insured patients.  The insurers are contracting with the health systems at discounted rates to provide care. The insurers are requiring the newly insured to see physicians who are in their contracted network and sacrifice choice.  This week in an article published on the front pages of the NY Times insurance company executives were discussing how having a choice is over rated and unimportant. They are beginning to develop a public relations and marketing campaign to sell that idea to the public that having a choice of physicians to perform your surgery or radiation therapy is unimportant.

I have practiced adult medicine for 35 years now and let me, without reservation, tell you that is simply not true. My 85 year old golf and tennis playing patient survived replacement of two heart valves riddled with infection because he was sent to the Cleveland Clinic in Ohio where statistics show patients survive more often with fewer complications. I have three survivors of multiple myeloma treated at Dana Farber Cancer Center in Boston, University of Arkansas in Little Rock and Moffit Cancer Center in Tampa. I have scores of athletic seniors dancing and running and home from the hospital in 48 hours after having their hips replaced with the minimally invasive anterior approach by surgeons with 2000 or more of these under their belts rather than just a few. Then there are the lymphoma survivors from MD Anderson and Dana Farber Cancer Center who survived multi-drug treatment regimens at places that perform these services more frequently than other places.

Some physicians and medical centers are better than others. Some are the experienced researchers and teachers who show the rest of us how to handle difficult diseases so our patients can benefit from their experience.  Choice matters! Do not let your human resources person, employer or health insurance marketing guru sell you on price over choice. It will cost you or your loved one your life or your health if you do!

Testosterone Therapy in Low T Syndrome in Veteran’s tied To Higher Cardiovascular Risk.

Cardiovascular RiskMedPage Today is reporting a Veteran’s Affair study which indicates that men with and without coronary artery disease who received testosterone supplements had a higher risk of death, heart attack and stroke.  The current study looked at 8709 veterans who underwent coronary angiography between 2005 and 2011 and had a testosterone level less than 300 ng/dL.  These findings surprised researchers who had looked at a previous VA study that suggested that testosterone therapy reduced cardiovascular risk.

Steven Nissen, MD of the Cleveland Clinic, a world respected cardiologist felt the study was a “red flag” that “demands attention from not just physicians but also from regulators.”  He is concerned about the “increasingly commonly prescribed (testosterone replacement therapy) “practice which is largely “fueled by direct to consumer advertising that’s urging men to get tested for low testosterone and then to seek replacement.” Nissen pointed out that in both men and women a drop in hormone levels is a normal part of aging and it is not necessarily a disease. “Making it into a disease may end up causing more harm than good.”

Anne R. Coppola, MD of the University of Pennsylvania in an editorial noted that “what is missing from the literature are data from randomized trials that include a sufficient numbers of men for an adequate amount of time to assess the long term benefits and risks of testosterone therapy.”   She cited a small study called the Testosterone Trial in Older Men which had to be stopped early because of a higher rate of cardiovascular events “in the group taking testosterone.

In our market you cannot turn on a sports talk radio show or ride down an Interstate highway without seeing ads for “Low- T Syndrome.”  It is a highly profitable cash business being fueled by testimonials and word of mouth rather than well planned medical studies. Legitimate research is ongoing at Harvard Medical School but it is difficult for others to obtain funding when the producers of the product can make so much money based on here say and nothing else. The number of prescriptions for testosterone products has increased since 2000 from 5.3 million to 1.6 billion.  The American College of Endocrinology has clear and strict guidelines on when supplementation in young men is appropriate. There is a large anti-aging medical community who feel that even if you are older and have normal levels you will feel better and benefit from supplementation. This research questions that feeling and begs for regulators to step in and stop an unproven possibly dangerous practice until we have more data.

 

Biphosphonates Raise the Risk of Atrial Fibrillation

Atrial FibBiphosphonate drugs such as Fosamax, Boniva and Actonel are used commonly to treat osteoporosis and to prevent the progression of bone disease from low mineralization or osteopenia to osteoporosis. The most common side effect we normally see is gastrointestinal upset with inflammation of the esophagus and stomach especially when the pill is not swallowed with sufficient liquids.  Patients receiving biphosphonates are cautioned to take the pill with sufficient liquid, while remaining upright for 45 minutes to an hour.  Biphosphonates have revolutionized the prevention of and treatment of osteoporotic bone disease.

In October’s issue of Chest Medical Journal Dr. Abhishek Sarma, MD, of Maimonides Medical Center in Brooklyn, N.Y. shows that biphosphonate use is associated with an increased risk of developing the arrhythmia atrial fibrillation.  Atrial fibrillation is a disorderly rhythm of the upper chambers of the heart leading to ineffective blood flow and increased risks of clots forming in the heart chambers and disseminating causing strokes. Older adults, the same patient population that is at risk for osteoporosis, is the patient group who when they develop atrial fibrillation require the use of blood thinners such as warfarin or xarelto or elliquis to prevent clot formation and strokes. Dr. Sharma performed a review of existing randomized controlled and observational studies.  He concluded there was a 27% increased risk of developing atrial fibrillation if you were taking biphosphonates. They looked at six observational studies with almost 150,000 participants and six randomized controlled trials with 41,000 patients. The increased risk occurred in patients taking the biphosphonates by mouth or by intravenous infusion. They postulated that biphosphonate use triggers an inflammatory protein that effects intracellular calcium and leads to arrhythmias.

The study clearly requires follow-up. If you stop the biphosphonates will the patient return to a normal rhythm on their own or if chemically or electrically shocked back into a normal rhythm?  It is clear that we need to prevent and treat osteoporosis but it is now important for us to determine what this new finding means to a person’s long term health. If you are taking biphosphonates speak to your physician about this new finding and how or if it relates to you.

Where Do You Go To Die?

Question Mark v3A long-time patient in his mid-nineties, who lived an independent and full life style, became acutely ill six weeks ago. He lost his equilibrium and was unable to get up from a chair without having his blood pressure plummet and him faint.  When we could keep his blood pressure up, and he tried to walk, he ambulated like an intoxicated individual, swaying from side to side slapping his feet down like Goofy in Disney World.  CT scans of the brain, neck and spine, MRI scans of the brain, neurological testing, cardiac testing and multiple consultants in cardiology, neurology, and endocrinology could not find the cause of his problems. He did develop an aggressive and fastidious urine infection which improved with antibiotics.  It was hoped that with time, good nutrition and help from a team of occupational and physical therapists at a skilled nursing facility, we could return this sweet gentleman to his previous state of life. It did not work out that way.  Instead of improving he declined. He refused to eat or drink. He refused to consider intravenous nutrition or a feeding tube. He was judged by psychiatry to be sane and competent to make those decisions.   Trials of mood and appetite stimulants did not work. The decline occurred over a five day period at the SNF during which I called on him at least daily.

The patient and I had discussions about end of life issues yearly which we documented on his chart. The last discussion in January 2013 revealed that he did not want to be kept alive by machines but was not ready to sign a Do Not Resuscitate (DNR) order. He was against artificial feeding measures such as NG tubes and PEG’s.  As he declined clinically, I reintroduced that discussion to his wife and children.  I suggested we execute a DNR form and begin comfort measures. I asked them to consider a consult with Hospice but assured them we could provide comfort measures without them as well. They declined all help saying they were beginning to consider it but were not quite ready yet to make a decision. The SNF charge nurse was present at one of these discussions and to my surprise called me aside and said, “That man cannot die here. People cannot die here unless they execute a DNR or are in a hospice bed.”   I could not believe what I was hearing. We were in an old age home in a geriatric community with multiple custodial care patients plus the post-hospital rehab type patients.  The charge nurse then brought in the administrator who emphasized the same message. “He cannot die here.”

If the patient’s demise was imminent, the SNF wanted him transferred to the acute care hospital or else they threatened to call 911.    Where then are deteriorating patients supposed to die?  Hospice has become a bureaucracy unto itself and, while their efforts and works are admirable, the cost to Medicare is extraordinary.  Why can’t a deteriorating patient who is not uncomfortable or in distress expire quietly surrounded by family in a SNF?  Ideally this patient should be at home but sometimes the family just cannot provide the support and care in their home?  Is the only alternative an acute care hospital via 911 or Hospice?

Low Dose Aspirin Cuts Colon Cancer Risk in Women

AspirinNancy Cook, SCD of Brigham and Women’s Hospital in Boston and colleagues reported in the July 16, 2013 issue of the Annals of Internal Medicine that data from the Women’s Health Initiative including 39,876 women 45 years or older, who were randomly assigned to take 100 mg of aspirin every other day for ten years, experienced a 20% reduction in the risk of colorectal cancer. The study did not show that there was an all-cause reduction in mortality .

The very conservative US Preventive Services Task Force currently recommends aspirin in Women 55 – 79 only if potential benefits are greater than harms. The aspirin group did have more bleeding from peptic ulcers and gastrointestinal bleeding. The article was accompanied by an editorial comment by Peter Rothwell, MD, PhD of the University of Oxford. He felt that the risk of bleeding and the fact that there was no all-cause mortality reduction, or risk in all cause cancer reduction, should result in a tempering of suggestions for widespread use of aspirin in healthy middle-aged women. MedPage Today, the online Journal of the University Of Pennsylvania School Of Medicine, ran a comment from Dr. Randal Burt, MD, a gastroenterologist at the Huntsman Cancer Institute who felt that this was one more piece of evidence that aspirin can reduce colorectal cancer.

It is clear that there are multiple studies showing that aspirin can reduce the risk of colorectal cancer. There are studies showing it reduces the risk of a stroke in women as well.

Like all decisions to take or prescribe a medication, the risks and benefits must be examined first. It is clear to me that in a woman with a strong family history of colorectal cancer, and little or no history of gastrointestinal or systemic bleeding, an aspirin with close monitoring should seriously be considered.

Women and Cardiovascular Disease – There is A Difference Between Men and Women

Front view of woman holding seedlingThe American Society of Preventive Cardiology presented an educational seminar recently in Boca Raton, Florida to educate physicians, nurses and health care providers that cardiovascular disease in women can be very different than in men.  Failure to recognize these differences has resulted in women being under diagnosed, under treated and suffering worse outcomes.

The difference is first noticeable in pregnancy when the development of elevated blood pressure, super elevation of lipids and the development of gestational diabetes predispose young mothers to earlier, more serious, cardiovascular risk later in life. The faculty noted that women of child bearing age tend to use their obstetrician as their primary care doctor.  They suggested that women with pregnancy related diabetes, hypertension and lipid abnormalities should be referred to a medical doctor knowledgeable in preventive cardiology, post-delivery, for ongoing care.

For reasons that are unclear, women are less likely to be treated to recommended guidelines for lipids, diabetes and hypertension.  Diabetic women have a far worse prognosis with regard to cardiovascular disease as compared to men. They are less likely to be treated with aspirin, which while not as effective in preventing MI in women, is apparently protective against stroke.

Women about to have a heart attack have different symptoms the weeks, to months, before the event. They are more likely to have sleep disturbances, unexplained fatigue, weakness and shortness of breath than the standard exertional angina seen in men.   When they do have a heart attack they are as likely to have shortness of breath and upper abdominal fullness and heartburn as they are to have chest pain. They are more likely to have neck and back pain with nausea than men are.  

Since women have different symptoms than men they are more likely to be sent home from the emergency room without treatment.  They are less likely to have bypass surgery than men, less likely to be treated with the anticoagulants and antiplatelet medications that men are treated with and, they are less likely to be taken to the catheterization lab for diagnosis and intervention as compared to men.

The faculty was comprised of world-class researchers, clinicians and educators who happened to be outstanding speakers as well, bringing a vital message to our community.  They pointed out the different questions and diagnostic tests we should be considering in evaluating a woman as opposed to a man.

This was my first educational seminar through the American College of Preventive Cardiology and I thank them for the message they delivered to the medical and nursing community at probably one of the finest seminars I have had the privilege to attend.

Hope for HIV Prevention and Treatment

HIV is a disease that has evolved during our lifetime. As a clinician, during my years of training I saw men and women present to the Jackson Memorial Hospital emergency room with a strange overwhelming lung infection and a shutdown of the body’s immune response to infection. Even with aggressive treatment they failed and succumbed to the disease quickly. We had no idea what the process was back in the early 1970’s and were privileged to be around to see pioneers like Margaret Fischl, MD at the University of Miami Miller School of Medicine, begin to take on this dreaded disease in a population no one else would care for.

Hard work and millions of dollars in expense for research coupled with courageous patients has led to announcements like the one released by Michael Martin , MD of the Center for Disease Control that a drug called tenofovir, administered to high risk intravenous narcotic users, significantly reduced the risk of catching the disease. One pill a day In the 2400 volunteers, from 17 drug treatment centers in Thailand, taking one dose of tenofovir per day reduced the risk by almost half. The results were so striking amongst IV drug users that the author recommended beginning a once a day tenofovir program as a pre-exposure prophylaxis in all the high risk groups. He defined the high risk groups as men who have sex with men, heterosexual individuals and heterosexual couples where one person is HIV positive and the other HIV negative.  The drug was surprisingly well tolerated with only 8% of the patients experiencing episodes of nausea.

The purpose of discussing this article is to fan the hope among all individuals, providers and citizens, who have seen the ravages of this disease and did not believe a treatment, prevention or cure would occur in our lifetime. The presence of newer medications for prevention should not allow any of us to let our guard down and eliminate using the tried and true methods that prevent transmission of the disease.  Practicing safe sex by using condoms, avoiding sharing needles when injecting medication and being aware that when you are sexually active you are exposing yourself to your partner’s entire sexual past history will still need to be the cornerstone of prevention.

 

The Beat Goes On

Graduates Lifting MortarboardsLast month, I attended the University of Miami Miller School of Medicine graduation for the class of 2013. It had special meaning for me since this was the last group of students, at the University of Miami Miller School of Medicine/ Charles M Schmidt Florida Atlantic University (FAU) joint venture, to pass through my tutelage prior to the Boca Raton program becoming solely an FAU program.

One of the graduates visited my office weekly for two years and then once per quarter the following year.   He came to me as a first year student to learn how to take a history and do a physical exam after being out in the world working for a few years, post-college, as a psychiatric nurse.  He was extremely nervous about being able to remember how to study and succeed at test taking with the younger more academic students.  He brought a mature determined attitude to his mission and was now finishing at the top of the class. 

Also among the graduates was my niece who liked the small class size of the program, the early introduction of patient contact and the ability to develop strong relationships with the faculty. Despite being a mature 23 year-old future pediatric emergency room physician , at 56 inches and 85 lbs. she still got “carded” when she ordered white wine at a post ceremony celebration. 

Then there was “Mike” a young enthusiastic African American student who I met for the first time last year while “chaperoning” a community service health screening in an impoverished section of Fort Lauderdale. My first year student is his best friend and he sent Mike over to me because his mentor was not present.  “I have this middle aged woman with a butterfly rash and all the signs and symptoms of lupus. I have never seen lupus before so how do I help her.”  Mike was correct in his diagnosis and then became her supporter and advocate in helping her gain access to medical care and follow up. 

At the post ceremony reception we met Adam, the son of a colleague, who gave my wife a big hug because she was his teacher in 3 year-old preschool and he remembered her because she taught him to love education and learning.

The President of the University of Miami, and former Secretary of Health and Human Services, Donna Shalala, presided over the ceremonies and reminded the new physicians of what an exciting time this was to be entering the field of medicine.  These young physicians will be at the forefront of the changes in health care delivery in medicine.  They have been given the best of training over four years in evidence based medicine and all the latest technology without forgetting the importance of the personal touch and humanism.  The caring and compassion for others putting the patients’ needs first was the theme hammered home all night by the talented and accomplished faculty and guest speakers. 

I left the ceremonies with a new sense of optimism looking at a diverse but already accomplished group of young physicians.  I feel comfortable they will steer patient care in the correct direction and I feel fortunate that I was able to play a very small role in their nurturing and education.

Unique Stroke Symptoms in Women

Stroke - NIHIn a previous blog I have discussed the need to recognize stroke symptoms rapidly so that an individual can be transported to an approved stroke center quickly and receive treatment within 60 minutes of arrival and hopefully within 3 hours of the onset of the symptoms. The classical symptoms include:

  • Sudden numbness, weakness or paralysis of your face, arm or leg usually on one side of your body
  • Abrupt onset of difficulty speaking or understanding speech
  • Sudden vision change with blurring, double or decreased vision
  • Sudden dizziness, loss of balance or loss of coordination
  • The onset of a severe sudden headache which may be associated with a stiff neck, facial pain, vomiting or pain between your eyes
  • Sudden change in mental status or level of consciousness
  • Sudden confusion, loss of memory or orientation or perception.

New research shows that women often delay seeking help. It is believed this occurs because women often exhibit different warning signs in addition to the traditional ones. Women having a stroke may exhibit:

  •  Loss or consciousness or fainting
  • Shortness of Breath
  • Falls or Accidents
  • Seizures
  • Sudden pain in the face, chest, arms or legs

No CPR Policy at California Independent Living Facility

Young Man Doing Chest Compressions on Elderly ManLast month, an 87 year old resident of a California senior living facility dropped to the floor suddenly with no spontaneous respirations or heart beats. A nurse on duty immediately called 911 to summon medical assistance. The 911 operator instructed the nurse to begin cardiopulmonary resuscitation. The nurse refused stating that the facility had a policy of calling for help but not providing any medical help. The 911 operator begged the nurse to begin CPR or at least call another resident or worker to begin the CPR policy. She refused per institutional policy. When the paramedics arrived a few minutes later, the 87 year old was clinically dead.

The facility took the position that its residents or their health care surrogates knew of the “NO CPR” policy in advance and were comfortable with it. The family of the woman said they were aware of the no CPR policy in advance and were comfortable with the care and compassion the patient had received while a resident. The incident caused a national furor and outcry over the “NO CPR” policy.

In the State of Florida, those residents requesting a NO CPR or Do Not Resuscitate status need to fill out and display the yellow Do Not Resuscitate form # 1896. It is a two-part form. The larger part should be displayed prominently in one’s home, usually on the refrigerator. The smaller copy should be placed in one’s wallet and be available at all times. Your doctor will be required to sign both forms. Your physician should be given a copy for their records as well.

When you enter a hospital electively or emergently you will need to inform the staff that you have a State of Florida DNR form #1896 and they will make a copy and place it on your medical record chart. You may rescind this order and request full resuscitation status if you so desire at any time!

 

It is important before you enter or contract with a senior facility to live there that you learn what their policy is for providing all types of care. You will need to agree with the policy or you should choose to live elsewhere.