Patient Safety and the Joint Commission

Two of my local hospitals just invested $3 – $4 million dollars in preparation for an inspection of the facilities by the Joint Commission on Accreditation of Hospitals (JCAHO). The cost of the inspection runs in the $10 million dollar range after the preparation costs. The inspection is a high stress situation for the administration because if you fail, or lose your accreditation, the private insurers will void their contract with you and you won’t get paid for the work done.

Medicare through the Center for Medicare Services (CMS) is preferential to JCAHO so much so that they perform 80% of the inspections of hospitals in America. When JCAHO was initially formed it was in response to poor care in small private hospitals in non-urban nonacademic centers. They cleaned that up.

The current version uses up a great deal of money, creating a legion of hospital administrators running around with clipboards and computer tablets without making any meaningful dent in mistakes and outcome results. In a recent study published in the British Medical Journal the outcomes and re-admissions rate for the same problem within 30 days of discharge were compared at hospitals which rely on state surveys of quality and safety as opposed to the JCAHO ten million dollar survey. They found that there was no statistically significant difference.

In a related report hosted by the journal Health Affairs, a review of the 1999 report of the National Academies of Sciences, Engineering and Medicine entitled, “To Err is Human, Building a Safer Health System” was discussed. That controversial report claimed that 44,000 to 98,000 deaths per year occur due to medical errors. They discussed the work of Linda Aiken, PhD, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. Her research looked at safety at 535 hospitals in four large states between 2005 and 2016. She called the results disappointing noting improvement based on suggestions in the 1999 report in only 21% of the hospitals surveyed and worsening in 7%. Most of her work involved the staffing and role of nurses which is critical to the quality of the care an institution provides.

Staffing or the ratio of patients cared for per nurse per shift is a critical component of safe patient care. Once a nurse on a non-critical care unit is asked to care for more than four patients the time spent at the bedside nursing diminishes. You cannot recognize problems, complications or changes in your patient’s condition if you are not spending time with them.

It seems to me as a clinician caring for patients in the outpatient and inpatient setting for 40 years that the more time nurses get to spend with patients the better the patients do. Maybe it’s time for government to separate the insurer’s ability to pay hospitals and JCAHO accreditation. Maybe the millions of dollars spent per inspection would be better spent on hiring more nurses per shift plus giving them the clerical and technical support they need to spend more time and care for their patients?

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Inflammation and Increased Risk of Cardiovascular Disease

For years, experts have noted that up to 50% of men who have a heart attack do not have diabetes, high blood pressure, high cholesterol, do not smoke and are active. This has led to an exploration of other causes and risk factors of cardiac and cerebrovascular disease.

In recent years, studies have shown an increased risk of cardiovascular disease in patients with rheumatoid arthritis, in untreated psoriatic arthritis and in severe psoriasis. We can also add atopic eczema to the list of cardiovascular risk factors.

In a publication in the British Medical Journal, investigators noted that patients with severe atopic eczema had a 20% increase risk in stroke, 40 – 50% increase risk of a heart attack, unstable angina, atrial fibrillation and cardiovascular death. There was a 70% increased risk of heart failure. The longer the skin condition remained active the higher their risks.

The study looked at almost 380,000 patients over at least a 5 year period and their outcomes were compared to almost 1.5 million controls without the skin conditions. Data came from a review of medical records and insurance information in the United Kingdom.

It’s clear that severe inflammatory conditions including skin conditions put patients at increased risk. It remains to be seen whether aggressive treatment of the skin conditions with immune modulators and medications to reduce inflammation will reduce the risks?

It will be additionally interesting to see what modalities cardiologists on each side of the Atlantic suggest we should employ for detection and with what frequency? Will it be exercise stress testing or checking coronary artery calcification or even CT coronary artery angiograms? Statins have been used to reduce inflammation by some cardiologists even in patients with reasonable lipid levels? Should we be prescribing statins in men and women with these inflammatory skin and joint conditions but normal lipid patterns?

The correlation of inflammatory situations with increased risk of vascular disease currently raises more questions with few answers at the present time.

PPI Use and Death Risk

In recent weeks we have seen articles linking the long term use of proton pump inhibitors such as Nexium (esomeprazole), Protonix ( Pantoprazole), Aciphex (Rabeprazole), Prilosec ( Omeprazole) with an increased risk of community acquired pneumonia, kidney disease, bone disease, cognitive dysfunction and increased risk of clostridia difficile infection (antibiotic related colitis). These drugs are commonly used short-term for the treatment of ulcers, gastro esophageal reflux disease, Barrett’s Esophagus, upper GI bleeding and H Pylori infections.

Often, after the prescribed treatment period, physicians try to discontinue the use of PPI’s but the patients have a return of their symptoms. With these medications now being sold over the counter, it is very difficult to get a symptomatic individual to curtail therapy even if the long-term risk is daunting.

I often attempt to switch patients to “old fashioned” antacids such as Tums, Rolaids, Mylanta, Gaviscon or even the H2 receptor blockers such as Tagamet and Zantac (Cimetidine and Ranitidine). All too frequently the response is that “my symptoms returned and only get better with the PPI.”

A study published in the British Medical Journal looked at data from the Veterans Administration data base for a period of two years, and selected a representative group of PPI users and non-users. They then followed them for 7-8 years.

Patients taking PPI drugs regularly had a 25% increased risk of death. There was no apparent reason why these medications led to a higher death risk. Further studies will be needed. The conclusion is take them for as short a period of time as possible.

Fish Consumption and Reduction of Risk of Developing Breast Cancer

Fish v2MedPage, the online medical journal of the University of Pennsylvania School Of Medicine reviewed an article published in the British Medical Journal concerning a relationship between consumption of marine fish oil from fish and a reduction in the risk of developing breast cancer. The study was published by Duo Li, MD, a professor of nutrition at Zhejiang University in Hangzhou, China. They reviewed data from 21 “prospective cohort studies involving nearly 900,000 people”. According to their data, eating just one or two portions a week of salmon, sardines, mackerel or other fish rich in marine n-3 polyunsaturated fatty acids is associated with a 1 % reduced risk of breast cancer in later life. Their data came from questionnaires that asked about patients’ intake of fatty acids and from blood levels measured in several studies. When they looked at similar fatty acids which come from plants not fish, such as alpha linoleic acid, they could not see a similar protective effect.

The study was critiqued by Alice H Lichtenstein, DSc, director for the cardiovascular nutrition lab at Tufts University. She had numerous questions and concerns about the methodology and conclusions but did support the need for future prospective studies to examine this question. While I have neither the credentials nor experience of Dr. Lichtenstein in evaluating this type of data I believe strongly in the KISS (keep it simple stupid) principle. Fleshy fish provides fish oils which are felt to be beneficial to our health. The same cannot be said for fish oils which you receive in pills and preparations.

My advice is to eat fish two or three times per week. Prepare it simply in a Mediterranean diet style and obtain the benefits that research seems to consistently show for this eating pattern.

Coffee Consumption May Lead to Safer Driving Trips

CoffeeIt is no secret that for decades men and women have been drinking caffeinated beverages to wake up or stay awake. This is especially pertinent when it comes to driving an auto or a truck and trying to stay alert and awake. Researchers in Australia decided to take a look at the question of whether ingesting caffeine in the form coffee or tea led to fewer accidents. Lisa Sharwood, PhD, of the University of Sydney reported in the British Medical Journal that long haul truckers who reported consuming caffeine to stay awake had a 63% reduced likelihood of crashing than control subjects. Their study looked at 530 long-haul truck drivers who had an accident between December 2008 and May 2011 in Australia. They compared them to 517 controls that had no accidents in the same 12 month period.

Case drivers drove about 1,700 miles in the week before their accident. Controls drove somewhat more, about 2,400 miles, in the week before their interview. 43% of the case drivers admitted to drinking caffeinated beverages specifically to stay awake. Only 3% admitted using illegal substances such as amphetamines or cocaine to stay awake.

The practical side of the study is that if you must operate a motor vehicle and you feel fatigued then stopping for a caffeine containing beverage definitely helps reduce the likelihood of a crash.

Too Much Calcium May Be Harmful For Women

Front view of woman holding seedlingThe Swedish Mammography Cohort, a population based group that includes 61,433 women born between 1914 and 1948 with a median follow-up of 19 years was used to answer the question of whether calcium intake can be harmful? The research team analyzed food intake by questionnaires and estimated the total calcium intake from food and supplements in the study group. Participants were divided into groups based on total daily calcium intake. One group consumed less than 600 mg of calcium per day. A second group consumed between 6000 and 999 mg a day. Group three consumed 1,000 to 1,399 mg per day. The last group consumed more than 1400 mg a day or the equivalent of drinking five 8 ounce glasses of cow’s milk.

The study was led by Karl Michaelsson, MD, of Uppsala University in Sweden and published in the online edition of the British Medical Journal. They found that the group consuming 1400 mg or more per day of calcium had a higher risk of death from cardiovascular disease, ischemic coronary disease and all causes than expected. The high calcium intake did not however increase the risk for strokes. At the other end of the spectrum were those individuals on an extremely low calcium diet with less than 600 mg per day. They were found to have an increased risk of death as well from all the causes mentioned above plus stroke.

Once again this appears to be a call for moderation in one’s diet. Too much or too little of anything is associated with consequences. At the current time postmenopausal women are advised to consume 1600 mg of calcium a day between diet and supplements. It may be time to look at that number and see how it applies to North American women as opposed to Swedish women who participated in this project.

Screening for Cervical Cancer- The Pap Smear

Cervical Cancer is easily prevented and detectable by having regular pap smears performed by your obstetrician-gynecologist or your primary care physician. In many cases the physician will add the HPV (Human Papilloma Virus) test to look for the presence of a virus associated with cervical and oral cancers.

It is recommended that all women begin receiving annual pap smears at age 21 or within three years of having sex, whichever occurs first. These tests should be repeated annually.  If a woman has her cervix surgically removed as part of a hysterectomy it is no longer necessary to have pap smears.  Older women who have had normal pap smears for several years in a row and have the same monogamous sexual partner for many years or are now sexually inactive , may be able to eliminate having pap smears.  Women over 30 years old with several normal pap smears and the same sexual partner may be able to spread out the pap smears from an annual event to one every two – three years.

A recent study in Sweden, published in the British Medical Journal, confirmed that women who had regular pap smears were detected with cervical cancer much earlier than those women who were not tested, and they survived the disease at a much higher rate.  While this type of test is invasive and involves extremely private anatomical areas, the data is clear that this is one screening procedure that saves lives!